2019-04-26T14:42:10-07:00 2018-09-30 990 2017-10-01 042126583 ATHOL MEMORIAL HOSPITAL ATHO 9782493511 2033 Main Street Athol MA 01331 Robert Crosby CFO 9786306503 2019-04-10 209.160.147.198 2017 2020-01-14 16:20:31Z Robert Crosby 242 Green St Gardner MA 01443 29062927 0 X www.atholhospital.org X 1918 MA Our vision is to be one of the best independent community hospitals in America. Our mission is to be our communities' trusted choice for exceptional patient-centered care. 21 18 239 12 0 0 1167664 727446 27791416 28004029 -57958 2611 256988 313211 29158110 29047297 5105 4155 0 0 9930551 10245253 56000 51333 152128 16759394 17047855 26751050 27348596 2407060 1698701 13520928 23777812 5124396 15607652 8396532 8170160 Our mission is to be our communities' trusted choice for exceptional patient-centered care. 0 0 25079892 4155 28004029 Athol Memorial Hospital is a critical access hospital (CAH) serving the nine towns of North Quabbin Region. The areas relatively small population is dispersed over a large geographic area. Inherent in the Hospital mission of providing healthcare services are efforts to help improve the health and lives of our community. This intent is the framework for our community benefits activities. 0 0 0 25079892 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 56 0 1 239 1 0 0 0 0 0 1 1 0 0 0 0 X 21 18 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 MA X Heywood Hospital Robert Crosby 9786306157 242 Green Street Gardner MA 01440 Glenn Hunt Chairman 0.2 X 0 0 0 Robert Chauvin Trustee 0.2 X 0 0 0 Roy Lake Trustee 0.2 X 0 0 0 Cheney Castine Esq Treasurer 0.2 X 0 0 0 JoAnne Parks Clerk 0.2 X 0 0 0 Daniel Asquino Trustee 0.2 X 0 0 0 Joyce Fletcher Trustee 0.2 X 0 0 0 John Flick Esq Trustee 0.2 X 0 0 0 James Garrison Trustee 0.2 X 0 0 0 James Meehan Trustee 0.2 X 0 0 0 Donald Mruk MD Trustee 0.2 X 0 0 0 Michele Parker MD Trustee 0.2 X 0 0 0 Kenneth Pierce Trustee 0.2 X 0 0 0 Tina Sbrega Trustee 0.2 X 0 0 0 Joel Shaughnessy Trustee 0.2 X 0 0 0 John Skrzypczak MD Trustee 0.2 X 0 0 0 Craig Twohey Trustee 0.2 X 0 0 0 Albert Rose Trustee 0.2 X 0 0 0 Winfield Brown President/ CEO 0.2 40 X X 0 894266 72206 Elizabeth Nottleson Trustee/Family Physician 0.2 28 X 0 279752 19337 Benjamin Prentiss Trustee/Family Physician 0.2 36 X 0 393972 41565 Robert Crosby VP of Finance 0.2 40 X 0 394327 60454 Tina Griffin VP/CNO 40 0 X 0 233418 48604 Dawn Casavant VP of External Affairs 0 40 X 0 201795 52371 Rose Kavalchuck VP of Professional Services 0 40 X 0 213869 47679 Carol Roosa CIO 0 40 X 0 218744 48708 Carole Vaidulas ER RN 36 0 X 114593 0 11440 Leticia Hebert RN 32 0 X 112283 0 11212 Michele Munger Xray Coordinator 40 0 X 110582 0 18069 Kathy Ledford ER RN 40 0 X 110466 0 23493 Bethany Maselli ER RN 40 0 X 108137 0 26117 Michael Grimmer VP of Support Services 0 40 X 0 234587 40741 Rebecca Bialecki VP of Community Health Relations 0 40 X 0 168794 47096 556061 3233524 569092 10 1 1 0 Quartulli & Associates PO Box 423 Gardner MA 01440 PT & OT Services 940723 New England Inpatient Specialists 120 Water Street North Andover MA 01845 Hospitalists Physicians 742056 Quest Diagnostics 12436 Collections Center Dr Chicago IL 60693 Clinical Laboratory Services 286087 TelePhysicians PC 1768 Business Center Drive Reston VA 20190 Telemedicine Services 288726 Favorite Healthcare PO Box 803356 Kansas City MO 64180 Medical Staffing Services 178280 10 0 0 11580 1000 403402 311464 0 727446 Ancillary OP Services 622110 20578542 20578542 0 0 Ancillary IP & Routine Services 622110 7261744 7261744 0 0 Anesthesia Patient Revenue 622110 163743 163743 0 0 0 0 0 0 28004029 2611 0 0 2611 0 0 0 0 0 0 0 0 103061 0 0 0 103061 0 103061 0 0 103061 0 0 32445 11580 15630 16815 0 16815 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722310 121078 0 0 121078 Gift Shop 453220 22547 0 0 22547 Occupational Health 900099 21582 0 0 21582 28128 0 0 28128 193335 29047297 28004029 0 315822 X 1755 1755 2400 2400 0 0 0 0 0 0 0 0 0 0 0 0 8186081 8077301 108780 0 67437 65814 1623 0 1325751 1294778 30973 0 665984 660530 5454 0 0 0 0 0 25492 0 25492 0 4334 0 4334 0 0 0 0 0 51333 51333 0 0 0 0 5273727 5131798 139064 2865 28822 28822 0 0 2913864 2863309 49052 1503 232668 232668 0 0 0 0 0 0 561038 527184 33854 0 16287 13431 2856 0 0 0 0 0 12662 11815 812 35 3208 3208 0 0 0 0 0 0 845317 839291 6026 0 87055 66633 20422 0 Professional Fees 4866283 3160531 1609360 96392 Bad Debt 1307626 1307626 0 0 Free Care 487604 487604 0 0 Laundry/Linen Services 86679 86679 0 0 295189 216715 78474 0 27348596 25079892 2116576 152128 1967773 1635468 0 0 943244 751598 2854570 3174036 0 0 0 0 0 11439300 396384 332803 200601 281651 16006386 11562313 5650273 4444073 0 1503083 1518883 195000 0 5000 5000 13520928 23777812 2542740 3658329 0 0 72332 116960 0 0 0 0 0 0 40868 10111097 0 0 2468456 1721266 5124396 15607652 X 5950205 5899679 1042764 843084 1403563 1427397 8396532 8170160 13520928 23777812 X 1698701 23763 0 0 0 -1948836 X 0 1 X 1 0 X 1503083 705622 25302 0 713855 1269 1518883 1370811 706454 63874 0 636832 1224 1503083 1391453 94080 18408 0 133124 6 1370811 1546049 63274 -139376 0 78492 2 1391453 1559197 54696 -2219 0 65622 3 1546049 0 0.94 0.06 0 0 0 104490 104490 0 7464729 4574880 2889849 0 0 0 0 0 8056520 6824868 1231652 0 380647 162565 218082 4444073 Donor Restricted Investments 1518883 F 1518883 0 Estimated third party settlements 1716266 Estimated malpractice liability 5000 1721266 X Schedule D, Part V, Line 4 The Organization's endowment includes both donor restricted endowment funds and funds designated by the Board of Trustees to function as endowments. As required by GAAP, net assets associated with endowment funds, including funds designated by the Board of Trustees to function as endowments, are classified and reported based on the existence or absence of donor- imposed restrictions. The Organization has interpreted state law as requiring realized and unrealized gains of permanently restricted net assets to be retained in a temporarily restricted net asset classification until appropriated by the Organization's Board of Trustees and expended. State law allows the Board to appropriate as much of the net appreciation of permanently restricted net assets as is prudent considering the Organization's long and short-term needs, present and anticipated financial requirements, expected total return on investments, price-level trends, and general economic conditions. Schedule D, Part X, Line 2 Heywood Healthcare, Heywood Hospital, Athol, HMGI, Charitable Foundation, Quabbin and NMTC have been determined to be not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code"), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Code. All of the entities are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Under ASC 740, an organization must recognize the financial effects of a tax position taken for tax return purposes when it is more likely than not that the position will not be sustained upon examination by a taxing authority. The Organization does not believe it has taken any material uncertain tax positions, and accordingly, it has not recorded any liability for unrecognized tax benefits. Additionally, the Organization has filed IRS Form 990 information returns, as required, and all other applicable returns in jurisdictions where so required. For the years ended September 30, 2018 and 2017, there were no interest or penalties recorded or included in the consolidated statements of operations. X X X X X X X 1 JNB & Associates 21 Water Street Amesbury MA 01913 Consultant 0 0 51333 -51333 0 51333 -51333 MA Golf Classic 44025 11580 32445 0 4637 5520 4371 0 1102 0 0 44025 11580 32445 0 4637 5520 4371 0 1102 15630 16815 1 1 1 X 1 X 1 1 1 0 1 1 0 0 451197 325242 125955 0.0048 0 0 6631492 6325316 306176 0.012 0 0 0 0 0 0 0 0 7082689 6650558 432131 0.0168 0 0 255617 0 255617 0.0098 0 0 91625 0 91625 0.0035 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8680 0 8680 0.0003 0 0 355922 0 355922 0.0136 0 0 7438611 6650558 788053 0.0304 0 0 0 0 0 0 0 0 78 0 78 0 1546 0 1546 0.0001 2090 0 2090 0.0001 464 0 464 0 108 0 108 0 40 0 40 0 0 0 4326 0 4326 0.0002 1 320829 0 7461848 7756733 -294885 X 1 1 1 1 Athol Memorial Hospital 2033 Main Street Athol MA 01331 www.atholhospital.org 2226 X Athol Memorial Hospital 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X www.atholhospital.org/about/community-benefit X www.nqcc.org/; https://www.chna9.com/resources.html X X 1 18 1 www.atholhospital.org/about/community-benefit 0 0 1 X 150 300 1 1 X X X X 1 X atholhospital.org X atholhospital.org/for-patients-and-visitors/patient-financial-services X atholhospital.org X X X X X X 1 X X 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 5-Athol Memorial Hospital In 2018, Athol Hospital conducted a comprehensive Community Health Needs Assessment (CHNA). A priority of the health assessment is to understand the needs of under-resourced populations and to identify and prioritize health issues and related socio-economic determinants of health. Throughout the assessment, special attention was paid to "communities within communities", health disparities and health equity. Information and perceptions from under-represented racial/ethnic, socioeconomic and geographic groups were collected from 596 Surveys, 17 Focus Groups, and 12 Healthcare Professional Interviews to supplement the quantitative data gathered. Schedule H, Part V, Section B, Line 6a-Athol Memorial Hospital The CHNA was a collaborative effort conducted by Athol Hospital and Heywood Hospital. The assessment focuses on the 15 primary communities served by Heywood and Athol Hospitals. The data was analyzed and presented in three ways the Heywood Healthcare total service area of 15 communities, the Heywood Hospital service are of 6 communities and the Athol Hospital service area of 9 communities. Schedule H, Part V, Section B, Line 6b-Athol Memorial Hospital It was a collaborative between the Montachusett Regional Planning Commission (MRPC); UMASS Memorial Health Alliance Clinton Hospital; The Community Health Network of North Central MA (CHNA 9) Group; and John Snow, Inc. Quantitative data sources came from Massachusetts Community Health Information Profile (MassCHIP) data from the Massachusetts Department of Public Health (MassDPH); the Youth Risk Behavior Survey (YRBS) data; U.S. Census data (including data from the American Community Survey); and other Commonwealth and Federal Government organizations and agencies. Staff at MRPC was responsible for conducting research and analysis efforts. The Community Benefits Leadership Team made up of department heads from Athol and Heywood Hospitals, the North Quabbin Community Coalition, the CHNA-9 Group and other relevant community partners provided input into the process and assisted with analyzing and reviewing the report. Other organizations and individuals also contributed to the assessment, including: North Quabbin Recovery Planning Group; Jail to Community Task Force; Children's Health and Wellness; Multicultural Task Force; Gardner Area Interagency Team; Substance Abuse Task Force; Greater Gardner Religious Council; Schwartz Center Rounds; Greater Gardner Chamber of Commerce; Heywood Senior Team ; Regional Behavioral Health Collaborative; Gardner MENders Support Group; Montachusett Suicide Prevention Task Force; North Quabbin Community Coalition; Community Health Connections Board; Montachusett Public Health Network; and CHNA-9 CHIP Breakfast . Schedule H, Part V, Section B, Line 7d-Athol Memorial Hospital Part V, Sec B, Line 7d Hospital staff presented the CHNA findings with community members, stakeholders, and partners and solicited input in response to the CHNA to help inform the development of a Community Health Improvement Plan (CHIP). A link to the assessment and a summary of the findings was presented at the following committee meetings: Multicultural Task Force; Gardner Area Interagency Team; Substance Abuse Task Force; Greater Gardner Religious Council; Schwartz Center Rounds; Heywood Leadership Team ; Regional Behavioral Health Collaborative; Athol and Heywood Hospital Medical Ethics; Athol and Heywood PFAC; Montachusett Suicide Prevention Task Force; North Quabbin Community Coalition; Heywood Charitable Foundation Community Investment Committee and CHNA-9 Schedule H, Part V, Section B, Line 11-Athol Memorial Hospital The Community Health Improvement Plan (CHIP) developed from the Community Health Needs Assessment, prioritizes significant health focus areas, targets at risk populations, and outlines the strategies and resources within the community that the hospital will partner with to respond to the health needs. Athol Hospital's approach to addressing the critical health needs identified by the CHNA is to actively participate in and collaborate with cross-sector coalitions, healthcare and behavioral health providers, community, and faith-based organizations and businesses to develop and implement our plan, goals, and strategies. Through our engagement with community-based organizations, our Patient and Family Advisory Committee, and the Community Benefits Advisory Committee we can ensure that our CHIP has input from persons who represent the broad interests and special knowledge of the significant health needs of our community. Schedule H, Part I, Line 7 The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c was based on the cost to charge ratio derived from the supplied Worksheet 2, in the IRS schedule H instructions. Schedule H, Part II The Athol Hospital's Community Benefits Mission Statement is "Athol Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health needs of the under-served and collaborating with others to enhance quality and contain the growth of community healthcare costs." Schedule H, Part III, Section A, Line 2 The costing methodology used for line 2 was based on the cost charge ratio derived from the supplied worksheet 2 in the IRS Schedule H instructions. Schedule H, Part III, Section A, Line 3 The methodology used for line 3 was to take the percentage of financial assistance applications that were due to inadequate documentation divided by the total applications received for FY 2018. This amounted to approximately 0% which was applied against the number on line 2. As a tax exempt hospital, we must provide necessary services regardless of the patient's ability to pay for the service provided. As a not for profit, patient care is provided to all, regardless of ability to pay for that care, making quality patient care available to all in our community, regardless of their economic means, qualifies bad debts as community benefit. Schedule H, Part III, Section A, Line 4 The footnote can be found on Page 11 of the financial statements - under "Allowance of Doubtful Accounts". Schedule H, Part III, Section B, Line 8 The allowable costs on line 6 were obtained from our FY 2018 Medicare Cost Report, Worksheet D schedules. Schedule H, Part III, Section C, Line 9b Athol Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of MA or through Athol Hospital's own financial assistance program, which may cover all or some of their unpaid hospital bills. For those patients that request such assistance, Athol Hospital assists patients by screening them for eligibility in an available public program and assisting them in applying for the program. These programs include but are not limited to MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net and others. It is the patient's obligation to provide Heywood Hospital with accurate and timely information to determine of the patient is eligible to apply for certain health insurance programs. If the patient of guarantor is unable to provide the necessary information Athol Hospital may make reasonable efforts to obtain any additional information from other sources. Information the Heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for public health insurance program is done through Virtual Gateway, which is an internet portal designed by the MA Executive Office of Health and Human Services. The Virtual Gateway manages the application process from the programs listed above, which is available for children, adults, seniors, Veterans, homeless and disabled individuals. Athol Hospital specifically assists the patient in completing the application and secure the necessary documentation required by the applicable financial assistance program. Athol Hospital will then submit this document to the Commonwealth Office of Medicaid and assist the patient in any additional documentation if such is required by the Commonwealth after completing the application. All Virtual Gateway applications are reviewed and processed by the Commonwealth of MA, Office of Medicaid. Special circumstance applications are reviewed and approved by the MA Division of Health Care Finance and Policy. Hospitals have no role in determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing decisions made by the Commonwealth to ensure accurate and timely adjudication of all hospital bills. If the patient does not comply with the request for documentation, then our standard collection procedures apply. Schedule H, Part VI, Line 2 In addition to conducting the CHNA, the organization monitors hospital data and actively engages with the Community Benefits Leadership team and Community Benefits Advisory Committee to continuously monitor and assess any changing or emerging community and healthcare needs. Schedule H, Part VI, Line 3 Role of Hospital Certified Financial Counselors and other Finance Staff: The hospital will try to identify available coverage options for patients who may be uninsured or underinsured with their current insurance program when the patient is scheduling their services, while the patient is in the hospital, upon discharge, and for a reasonable time following discharge from the hospital. The hospital will direct all patients seeking available coverage options, or those that the hospital determines may be eligible, to the hospital's patient financial counseling to screen for eligibility in an appropriate coverage option. The hospital will then assist the patient in applying for the appropriate coverage options that are available or notify them of availability of financial assistance through the hospital's own internal financial assistance program, if available. Notification Practices: Individual printed notices are available by contacting a Financial Counselor or through the Patient Accounts Office. Notices indicate the criteria used to determine eligibility for MassHealth and the Health Safety Net Trust Fund and where or how patients may apply. The goal of these notices is to assist patients in applying for coverage within a financial assistance program such as MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, and Health Safety Net. When applicable, the hospital may also assist patients in applying for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. When a patient contacts the hospital, Patient Accounting, Financial Counseling or Social Service Staff will attempt to identify if a patient qualifies for a public financial assistance program or payment plan. Patients who are already enrolled in a public financial assistance program, such as MassHealth or Health Safety Net, may qualify for certain federal, state and private assistance agencies. Patients may also qualify for additional assistance based on the hospital's own internal criteria for financial assistance, or qualify for coverage of services as a Medical Hardship based on the patient's documented income and allowable medical expenses. The following items outline more specifically the notification process, criteria, and availability of information beyond the signs that are posted in the hospital. 1. The hospital will provide an individual notice of the availability of financial assistance programs and other programs of public assistance to a patient expected to incur charges for which he/she will be personally responsible, exclusive of personal convenience items or services that may not be paid in full by third party coverage. 2. The hospital or its agents will include a notice or statement about Eligible Services to Low Income Patients and other programs of public assistance in its initial bill and subsequent correspondence with the patient. All correspondence will direct the patient where and how they can receive more information or additional assistance and will inform the patient that they may apply or reapply for financial and public assistance before, during or after care, or after collection agency assignment if their situation changes. 3. The hospital will include a notice regarding the availability of financial assistance and other programs of public assistance to Low Income Patients in all written collection actions. The hospital will notify the patient that it offers a payment plan if the patient is determined to be eligible for MassHealth or free care/uncompensated care through the Health Safety Net Trust Fund as a low income patient or due to Medical Hardship. These payment plans are consistent with 1016 CMR 6613.08 (1)(f)(4). The hospital will also offer payment plan options for those individuals who do not qualify for Low Income Patient status. 4. Heywood Hospital will include language on its written notices that reads: "You may be eligible for assistance through our Financial Assistance Program. For eligibility information, please contact our Customer Services Department at 1-800-305-6757." Verbiage may change to accommodate changes of department information. 5. There is no primary language other than English that is spoken by 5% or more of the hospital's service area. Signage and other documentation will be provided in English. The hospital provides translator services for several other languages and this service may be accessed for those individuals whose primary language is not English or Spanish. 6. For cases where the hospital continues to determine eligibility for free care/uncompensated care through the Health Safety Net Trust Fund application, then MassHealth will provide written notice of determination that the patient is or is not eligible within 30 days of receiving a completed application and the required supporting documentation. The vast majority of patients will however be screened via the common intake process and processed through the Virtual Gateway and MA-21 system. 7. Whether the hospital is using the MassHealth application process through the Virtual Gateway or submitting a MassHealth application directly, the hospital will assist the patient in completing the application or intake process for enrollment and eligibility screening. Schedule H, Part VI, Line 4 Athol Hospital's nine (9) communities include Athol, Orange, Phillipston, Petersham, New Salem, Royalston, Warwick, Irving and Wendell. Athol Hospital is a Federally designated Critical Access Hospital, also holding a Medically Underserved Population designation as well as a Federal Primary Care Health Provider Shortage Area (HPSA) designation. Communities in the Service Area vary greatly in terms of their demographic, social and economic factors. Some communities are more rural while others are more urban; others are considered more affluent while others are considered to be economically disadvantaged, and some are more racially/ethnically diverse while others are considered more homogenous. Due to these factors, the health disparities and inequities experienced by people in the region vary widely from community to community. The overall population of the Service Area has grown a modest 6% since 2000. This rate is less than the US overall (9.7%), but double that of the Commonwealth of MA (3.1%). It is important to note the change in racial makeup over time and the growth of the Hispanic/Latino population between 2000 and 2016, especially in Athol. The Service Area has a median age nearly 9 years higher than the State and Nation including a greater number of those age 65 and older living alone and increased 7% between 2010 and 2016. The rural nature of Athol Hospital's communities and the social isolation of older adults living alone make it more difficult to access basic daily needs. The Social and Economic inequities experienced by people in the region vary widely from community to community. There are lower poverty rates overall throughout the Service Area compared to the State and Nation, but pockets of poverty persist throughout. Athol, Wendell, and Orange have the highest poverty rates at 17%, 16.1%, and 13.7% respectively, compared to MA rate of 11.4%. Athol's childhood poverty rates have increased 6.4% respectively since the last CHNA in 2015 with data from 2013 and 2016. Overall, wages in the Service Area have increased by nearly $200 million since 2000, but wages have decreased significantly in select communities. Veterans in the Service Area are better off when compared to the State and Nation when it comes to health outcomes and financial stability. However, disparities in unemployment and disability compared to non-veterans are prevalent throughout the Service Area. In four communities in the Service Area, the unemployment rate for veterans reaches beyond 10%; Warwick (10.5%), Athol (10.9%), Orange (11.5%), and Royalston (12.1%) compared to MA (7.3%). Schedule H, Part VI, Line 5 Athol Hospital's approach to addressing the critical health needs identified by the CHNA is to actively participate on and collaborate with cross-sector coalitions, healthcare and behavioral health providers, community, and faith-based organizations and businesses to develop and implement our plan, goals, and strategies. Partners include: North Quabbin Community Coalition; Valuing our Children; Franklin Hampshire North Quabbin Opiate Prevention Task Force; The Regional Behavioral Health Collaborative; Athol and Royalston Boards of Health; Suicide Prevention Task Force; Athol YMCA; Athol Public School District; Athol, Erving, and Winchendon Senior Center; Life Path; Phillipston Congregational Church; Salvation Army. Schedule H, Part VI, Line 7 The Community Benefit Report is filed with Attorney General's Office, State of Massachusetts. 1 0 0 0 0 0 0 0 0 Winfield Brown President/ CEO 0 501777 0 110549 0 281940 0 23400 0 48806 0 966472 0 0 Elizabeth Nottleson Trustee/Family Physician 0 262126 0 0 0 17626 0 5404 0 13934 0 299090 0 0 Benjamin Prentiss Trustee/Family Physician 0 373267 0 20108 0 598 0 7837 0 33728 0 435538 0 0 Robert Crosby VP of Finance 0 291843 0 57133 0 45351 0 23281 0 37174 0 454782 0 0 Michael Grimmer VP of Support Services 0 230848 0 0 0 3740 0 11419 0 29323 0 275330 0 0 Dawn Casavant VP of External Affairs 0 177371 0 23843 0 581 0 21735 0 30636 0 254166 0 0 Rose Kavalchuck VP of Professional Services 0 208093 0 0 0 5776 0 21101 0 26578 0 261548 0 0 Carol Roosa CIO 0 193314 0 25188 0 242 0 22014 0 26694 0 267452 0 0 Rebecca Bialecki VP of Community Health Relations 0 167261 0 0 0 1533 0 21496 0 25600 0 215890 0 0 Tina Griffin VP/CNO 0 201539 0 29980 0 1899 0 21133 0 27471 0 282022 0 0 Schedule J, Part I, Line 3 The CEO's compensation is paid by Heywood Hospital, a related organization and is determined by market data and analysis provided t the Hospital's Compensation Committee and Board of Trustees by an independent consultant engaged by the Board of Trustees annually. Schedule J, Part I, Line 4 Michael Grimmer, COO received a severance package when he terminated employment in April 2017 for 1 year severance. Form 990, Part VI, Section B, Line 11b The accountant for Athol Hospital prepares the Form 990 and provides it to the controller for review. The form is then sent to the CFO for a final review. Once reviewed, the 990 is received by the Board of Trustees. The 990 is then approved by the board and submitted to the IRS by the accounting department. Form 990, Part VI, Section B, Line 12c Annually, a Conflict of Interest Form is sent out to the managers, trustees and employees with broad discretionary authority. These forms are required to be signed and are monitored by the Corporate Compliance office for completion. Form 990, Part VI, Section B, Line 15 All Officers and the CEO's salaries are paid by Heywood Hospital. The CEO and Executive Staff's compensation is determined by market data and analysis provided to Heywood Hospital's Compensation Committee and Board of Trustees by an independent compensation consultant engaged by the Board of Trustees annually. Winfield Brown, CEO, and Robert Crosby, CFO, receive deferred compensation payments which are subject to multi-year vesting and incumbent upon fulfilling contractual obligations. Form 990, Part VI, Section C, Line 19 The Organization makes the governing documents, conflict of interest policy and financial statements available to the public by providing completed copies to the Administrative Assistant, who provides copies upon request. Form 990, Part IX, Line 11g Other Non-Employee Fees for Services consist of the following: Outside Physician Fees 4,064,551, Outside Clinical Fees 980,031, Temporary Employees 73,596, Medical Staff 9,000, Other Fees for Services 4,620 Form 990, Part XI, Line 9 The other changes in net assets relates to discounts on pledge receivables of (66,460) and (1,882,376) for a transfer to a related organization to support services. Heywood Healthcare Inc 242 Green Street Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 12b N/A 0 Heywood Healthcare Charitable Foundation Inc 242 Green Street Gardner MA 01440 222720562 Charitable Foundation MA 501(c)(3) 7 Heywood Healthcare Inc 0 Henry Heywood Memorial Hospital 242 Green Street Gardner MA 01440 042103581 Hospital MA 501(c)(3) 3 Heywood Healthcare Inc 0 Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 Multi-Specialty Physicians MA 501(c)(3) 10 Heywood Healthcare Inc 0 Heywood Realty Corp 242 Green Street Gardner MA 01440 043327447 Property Holding Corp MA 501(c)(2) n/a Heywood Healthcare Inc 0 Quabbin Healthcare Inc 242 Green St Gardner MA 01440 812053488 Behavioral Health MA 501(c)(3) 12b Heywood Healthcare Inc 0 Athol Memorial Hospital NMTC Holdings Inc 242 Green Street Gardner MA 01440 822171549 Support Athol Memorial Hospital MA 501(c)(3) 12a Heywood Healthcare Inc 1 0 0 0 1 0 0 0 1 0 1 0 0 1 1 1 1 1 0 1 Athol Memorial Hospital NMTC Holdings Inc d 1989838 Cash