2019-08-13T15:14:18-05:00 2018-09-30 010494526 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2017-10-01 020222157 Monadnock Community Hospital MONA 6039247191 452 Old Street Road Peterborough NH 03458 Richard D Scheinblum VP of Finance/CFO 6039247191 2019-08-08 1 Nicholas E Porto P01310283 2078792100 2019-08-08 208.105.168.164 2019-08-08 16:33:28 ED P 3452BD8595D9AC820B41F271E29CE8BF50AD3EDC 86AD5A998A217BD7885303F5109AB5202568ED7D 2017 2019-02-21 02:37:17Z Cynthia K McGuire 452 Old Street Road Peterborough NH 03458 125466255 0 X www.monadnockcommunityhospital.com X 1919 NH Critical access hospital serving the Monadnock region of the State of New Hampshire 20 13 761 123 0 539 664145 1019530 86764929 92947961 1240746 7773593 1558 6252 88671378 101747336 21025 32136 0 0 41855046 44704519 0 0 457898 45119963 48859814 86996034 93596469 1675344 8150867 122356088 130171265 53621930 52257757 68734158 77913508 X Monadnock Community Hospital is committed to improving the health and well-being of our community. We will elevate the health of our community by providing accessible, high quality and value based care. 0 0 83706789 32136 92947961 The primary purpose of Monadnock Community Hospital (MCH) is to ensure access to quality health care for patients in our community, regardless of their ability to pay. The following is a summary of the services MCH provides in an effort to fulfill its mission, together with key program statistics for fiscal year 2018.Inpatient Services - Includes: intensive care unit, adult stays, maternity/births, and skilled nursing. During the fiscal year, the Hospital admitted 1,451 patients and recorded 4,510 patient days. Emergency Services - MCH offers health services 24 hours per day, 7 days per week. Responsible for the immediate treatment of any medical or surgical emergency; for initiating life saving procedures in all types of emergency situations; and for providing emergency and initial evaluations and treatment for other conditions including minor illnesses and injuries, and sub-acute medical problems. During the year, there were 14,429 visits to the ER. Physician Practices - Family health services, programs, and education are integral components of healthcare at MCH. Inpatient and outpatient primary care includes: medical, surgical, psychological and specialist services, provided by physicians and mid-level practitioners. These are located at the Hospital and its four satellite practices located in Antrim, Jaffrey, New Ipswich, and Rindge. During the year, 69,834 primary care office visits were recorded. Surgical Services - Includes same day and short-term inpatient surgery. MCH provides surgery in the areas of orthopaedics, general surgery, OB/GYN, ophthalmology, urology, ENT, and podiatry. In addition, the Hospital offers some non-surgical procedures including colonoscopies, gastroscopies, and pain management injections. During the fiscal year, 3,333 procedures were performed. Radiology and Diagnostics - MCH provides advanced radiological technology and extensive imaging services including: bone density, MRI, CT, nuclear medicine, ultrasound, mammography, and other diagnostic procedures, both inpatient and outpatient. During the fiscal year, 32,309 exams were performed. Rehabilitation Services - Additionally, MCH serves the people of the Monadnock Region through its medical rehabilitation and fitness services. MCH offers rehabilitation programs for cardiac and diabetic rehabilitation, along with pulmonary fitness, which feature educational and exercise components. We also provide physical and occupational therapy, as well as speech rehabilitation. During the fiscal year 57,340 procedures were recorded for these services. Wellness Services - Community members wanting to improve and maintain their health have access to an award-winning, medically-based fitness facility. During the fiscal year, 19,649 member months were recorded.Monadnock Community Hospital's Financial Grant Program provides assistance with hospital and/or physician bills for qualifying patients. In fiscal year 2018, the Organization recorded $1,734,000 in charges foregone based on established rates. The estimated cost incurred to provide these services was $887,455. In addition, Monadnock Community Hospital provided other services to the community at no cost or reduced cost, such as screenings and clinics. The cost of providing these services was approximately $3,350,000 in 2018. 83706789 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 1 1 1 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0 1 1 0 0 0 1 137 0 1 761 1 1 1 0 0 0 0 1 1 0 0 0 0 X 20 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X Nicole Humphrey 6039247191 452 Old Street Road Peterborough NH 03458 X Anne Baddour Trustee 3.00 0.00 X 0 0 0 Robert Boyd Trustee 3.00 0.00 X 0 0 0 James Callahan Esq Trustee 3.00 0.00 X 0 0 0 Peter Cerroni DMD Trustee 3.00 0.00 X 0 0 0 Elizabeth Cooley MD Ex-Officio (voting) 50.00 0.00 X 233490 0 24698 Jeffry Crocker Trustee 3.00 0.00 X 0 0 0 Barbara R Duckett RN Trustee 3.00 0.00 X 0 0 0 Paul Faber Trustee 3.00 0.00 X 0 0 0 William James Jr Trustee 3.00 0.00 X 0 0 0 Gregory Kriebel MD Ex-Officio (voting) 50.00 0.00 X 296786 0 27609 Leslie Lewis Trustee 3.00 0.00 X 0 0 0 Terrence McNamara DO Ex-Officio (voting) (end 1/18) 50.00 0.00 X 445442 0 25799 Fay Migotsky MD Ex-Officio (voting) 50.00 0.00 X 169723 0 22383 Joseph Pepe MD Trustee 3.00 49.00 X 0 859974 299412 Pat Shuster Trustee 3.00 0.00 X 0 0 0 Sheldon Spector Ex-Officio (voting) 3.00 0.00 X 0 0 0 Alexander Walker Esq Trustee 3.00 42.00 X 0 535049 179536 Marcia Ober Chair 3.00 1.00 X X 0 0 0 Steven H Reynolds Chair (end 1/18) 8.00 0.00 X X 0 0 0 Michael Shea Vice Chair 3.00 0.00 X X 0 0 0 Thomas S Bates CPA Treasurer 3.00 0.00 X X 0 0 0 Jamie Trowbridge Treasurer (end 1/18) 3.00 0.00 X X 0 0 0 Norman A Makechnie Esq Secretary 3.00 0.00 X X 0 0 0 Cynthia McGuire Chief Executive Officer 55.00 1.00 X X 370746 0 64052 Richard D Scheinblum VP Finance/CFO 50.00 0.00 X 198332 0 13667 Ronald Michalak MD Physician 50.00 0.00 X 479012 0 24639 Shawn Harrington MD President-Medical Staff 50.00 0.00 X 429376 0 24299 Robert C Knowles MD Physician 50.00 0.00 X 401165 0 26009 William White MD Physician 50.00 0.00 X 354732 0 19801 Michael Lindberg MD Physician 50.00 0.00 X 326658 0 16843 3705462 1395023 768747 53 0 1 0 Catholic Medical Center 195 McGregor Street Manchester NH 03102 Contract Physician and Lab Services 2898389 Monadnock Region Emergency Physicians PL 380 Lafayette Road Hampton NH 03842 Contract Emergency Physician Group 2250796 Monadnock Anesthesia Association c/o Surgical Suite Peterborough NH 03458 Contract Anesthesia Group 1473879 Sodexo Inc & Affiliates PO Box 360170 Pittsburgh PA 15251 Dietary/EVS Service Management 798933 Hutter Construction Corporation PO Box 257 New Ipswich NH 03071 General Contractor 747011 24 42230 25087 952213 9280 1019530 Net Patient Service Revenue 621400 82827389 82827389 Other Operating Revenue 621400 5565150 5565150 Disproportionate Share Funding 621400 4100348 4100348 Cafeteria/Vending Machine 722210 340042 340042 Employee Pharmacy Sales 446110 115032 115032 92947961 823207 823207 30652397 23702011 6950386 6950386 6950386 23160 42230 16908 6252 6252 101747336 92947961 0 7779845 22920 22920 9216 9216 1789911 1207760 582151 34492114 31039079 3212277 240758 476362 404483 69744 2135 5622457 4853070 724154 45233 2323675 2064798 241056 17821 111561 111561 60000 60000 166620 166620 7276988 6856955 420033 86371 86371 2658296 1310371 1323035 24890 1143078 999983 137715 5380 2813606 2508514 305092 72976 48765 20703 3508 140344 66424 44672 29248 1078378 21558 1056820 4388428 4195999 192429 515518 448673 66845 Med & Pharm Supplies 13461606 13459599 2007 0 Med Exp/Service Contrac 5531995 4974811 493893 63291 Provision for Bad Debt 4966097 4966097 0 0 NH Medicaid Enhancement 3613664 3613664 0 0 774288 547679 200975 25634 93596469 83706789 9431782 457898 7780 7779 19809720 13302423 436457 295658 8766705 9473219 12390 293587 201592 1414052 1410000 953606 1103571 96837507 59587116 36914281 37250391 48582166 61664565 4499777 4819945 665567 642122 122356088 130171265 8606850 8829522 24876967 24233041 378946 189132 19759167 19006062 53621930 52257757 X 56457118 64496464 3557821 4377657 8719219 9039387 68734158 77913508 122356088 130171265 X 8150867 212058 816425 X X 0 1 X 1 0 X 0 0 0 0 0 1 13587 1 360 0 0 13947 0 Part II-B, Line 1: Monadnock Community Hospital is a member of the NH Hospital Association and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of Monadnock Hospital in furtherance of its exempt purpose. Monadnock Hospital does not directly perform any lobbying activities. NHHA, Portion of dues available for lobbying: $10,066 AHA, Portion of dues available for lobbying: $3,521 In addition, MCH hosts an annual legislative breakfast, which is a bipartisan event to which legislators, local politicians, and other public officials are invited to discuss health care issues in New Hampshire. Discussion topics for the 2018 breakfast focused on the current and proposed healthcare legislation, its impact on MCH, and collaboration to advocate for the growing health needs of the Monadnock region. The cost of this forum was $360. 12277040 493404 1411813 765213 13417044 11739947 205969 1073757 742633 12277040 11053734 498812 708687 521286 11739947 11410548 1026702 489797 1873313 11053734 10304146 526809 924772 345179 11410548 0.00000 0.67370 0.32630 1 0 964622 964622 31964604 20147602 11817002 1114598 633975 480623 62793683 38805539 23988144 37250391 Interest Rate Swap Agreements 1177576 Estimated Third-Party Settlements 17828486 19006062 X 102151301 212058 816425 1028483 101122818 166620 457898 624518 101747336 92971951 0 92971951 166620 457898 624518 93596469 Part V, Line 4: Temporarily restricted assets are available for health care services, including the purchase of equipment and providing health education and programs. The income and dividends on permanently restricted net assets are generally used to support health care services and for capital purchases of property and equipment. Part X, Line 2: The Hospital is a not-for-profit corporation as described in Section 501(c)(3) of the Internal Revenue Code (the Code) and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Management evaluated the Hospital's tax positions and concluded the Hospital has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying financial statements. Part XI, Line 2d - Other Adjustments: Increase in fair value of interest rate swap agreement 816,425. Part XI, Line 4b - Other Adjustments: Fundraising Expenses 457,898. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 457,898. MCH Golf Classic 65390 42230 23160 240 4465 5515 4848 0 1840 65390 42230 23160 240 4465 5515 4848 1840 16908 6252 1 1 1 X 1 X 1 1 0 1 1 887455 887455 0.01000 8036927 6717774 1319153 0.01490 8924382 6717774 2206608 0.02490 809000 809000 0.00910 3000 3000 0.00000 2310000 2310000 0.02610 228000 228000 0.00260 3350000 3350000 0.03780 12274382 6717774 5556608 0.06270 1 2542288 71360 27159673 26967769 191904 X 1 1 1 1 Monadnock Community Hospital 452 Old Street Road Peterborough NH 03458 02507 X X X X Monadnock Community Hospital 1 0 0 1 X X X X X X X X X 17 1 0 0 1 X see Part V, Section C X 1 16 1 See Part V, Section C 1 0 1 X 200.000000000000 400.000000000000 X X X 1 1 X X X X 1 X See Part V, Section C X See Part V, Section C X See Part V, Section C X X X X X X 1 X 0 X X X X X 1 X 0 0 Monadnock Community Hospital Part V, Section B, Line 5: Monadnock Community Hospital (MCH) used a methodology that was highly focused on identifying needs among underserved populations. The approach used was designed to elicit perspective from a broad range of community stakeholders, especially those representing higher risk groups. MCH used a multi-phased methodology to achieve the objectives of the assessment. The methodology included the following stages: establishing a leadership team to provide project guidance and insight regarding local health resources and perspectives of community needs; strategic secondary research; conducting qualitative research through group discussions and surveying community stakeholders representing high-risk populations in the service area; and needs prioritization process. Establishing a Leadership Team: MCH benefits from having a highly stable group of community leaders, many of whom have participated in CHNA processes and worked collaboratively with MCH to address prioritized need for many years. The benefit is that a broad section of the MCH region service providers remain engaged and highly insightful about emerging needs, as well as the impact of existing strategies. The Leadership Group: Retaining a core group of highly experienced participants is continually enhanced with the addition of new participants who bring creative insight and unique perspectives. The result is an MCH-led CHNA Leadership Group that is highly effective, quickly transitions "assessed needs" to implementation strategies, and is sensitive to evolving needs and opportunities for improving health and wellbeing. The Group offered critical feedback on the project work plan, critiqued quantitative data, helped to refine the list of community needs, helped develop the database of available resources, and participated in quantitative and qualitative research methods to build the prioritized list of identified community needs. Qualitative (Primary) Research: Leadership meetings and one-on-one interviews were conducted with a broad range of MCH leaders, community stakeholders, other community service providers, and healthcare consumers in the service area. The primary research also included quantitative and qualitative feedback provided from 33 community leaders and stakeholders via an electronic survey. The research approach was designed to "cast a broad net and engage underserved populations and other stakeholders highly knowledgeable about resources and service gaps that those communities face. The research goals were (1)to flesh out a high-level list of community needs, and (2)to gain insight and granularity regarding specific subpopulations impacted by higher priority needs. The discussion group included leaders from community service providers who represent at-risk groups such as (but not limited to) adults and children suffering from behavioral health problems, chronic disease patients and those at-risk of acquiring a chronic condition, economically challenged populations including children living in poverty and/or near-poverty, homeless individuals and families, individuals and families in engaging in risky lifestyles, populations requiring integrated care service, senior citizens, and other frequent users of the healthcare system. Monadnock Community Hospital Part V, Section B, Line 11: Please see attached implementation plan for how the Hospital is addressing (or any needs it is not addressing and why) the significant needs of the community in which it serves. Monadnock Community Hospital Part V, Section B, Line 16j: The complete financial assistance policy is available upon request and in the waiting rooms. Instructions on how to find out more about financial assistance are posted on the Hospital's website, on the back of all billing invoices, and published in a brochure that is available around the Hospital and in the admissions office.Interpreter services are available for limited English proficient individuals and for the hard of hearing and/or visually impaired. Monadnock Community Hospital Part V, Section B, Line 20e: The Hospital Patient Financial Services (PFS) Department shall develop and implement billing and collection procedures designed to maintain an adequate cash flow, keep accounts receivable at an acceptable level, and identify and write-off bad debts in a timely fashion. Monadnock Community Hospital contracts with an agency to process all self-pay accounts and self-pay after insurance balance statements/letters. I. Self-pay accounts and self-pay balances remaining after insurance adjudication shall be transferred to the agency on a weekly basis. The cycle for collections is three (3) statements and/or letters and two phone call series spaced approximately thirty (30) days apart. The statements shall include: a. Previous balance (unless this is the first statement). b. Activity since last statement (except those accounts that went to a $0.00 balance). c. Current balance due. d. Telephone number(s) for inquiries concerning the statement. e. Status or reminder message where appropriate. f. Availability for the use of a credit card for payment. g. Information regarding Financial Assistance and Medication Bridge Programs. h. Return envelope.II. In the event that statements or letters are returned by the postal service as undeliverable for reasons such as "moved, left no forwarding address," "forwarding order expired, or "no such address" the agency will indicate on the daily report "mail returned." PFS staff will review system for the correct address and will make corrections within the computer system and correspondence will be re-mailed. If no correct or current information can be obtained, the specific account(s) shall be flagged for referral to an outside collection agency equipped to handle this type of situation (see bad debt processing footnote).In addition, on a weekly basis, the FAP staff run system reports to identify emergency room visits classified as self-pay. Based on the information in these reports, the guarantor of each visit is sent a financial assistance application in the mail. Determination of eligibility is contingent upon receiving a completed application and required documentation from the patient and/or guarantor. Schedule H, Part V, Section B, Line 7a & 10a: The most recent CHNA is available at the Hospital's facility's website:https://monadnockcommunityhospital.com/wp-content/uploads/2018/12/2018-CHNA-Report-FINAL-1.pdfThe Hospital's 2016 Implementation Strategy, which was in effect during the filing period for this return, is available at:http://monadnockcommunityhospital.com/wp-content/uploads/2019/06/Monadnock-Community-Hospital-Implementation-Plan-REPORT-2016.pdfThe Hospital's most recent Implementation Strategy, which was implemented in conjunction with the fiscal year 2018 CHNA but after the close of the filing period covered by this return, is available at: http://monadnockcommunityhospital.com/wp-content/uploads/2019/06/MCH-Implementation-Plan-2019.pdf Schedule H, Part V, Section B, Line 16b: The complete financial assistance policy is available upon request and in the waiting rooms. Instructions on how to find out more about financial assistance are posted on the Hospital's website, on the back of all billing invoices, and published in a brochure that is available around the Hospital and in the admissions office.The Hospital's Financial Assistance Policy is available on the Hospital's website at:http://monadnockcommunityhospital.com/wp-content/uploads/2019/04/MCH-FAP-Policy.pdfThe Hospital's Financial Assistance Policy Application is available at:https://monadnockcommunityhospital.com/wp-content/uploads/2018/11/MCH_FAP_Application.pdfThe Hospital's Financial Assistance Plain Language Summary is available at:http://monadnockcommunityhospital.com/wp-content/uploads/2019/04/FAP_Plain_Language_Summary-2019.pdf 12 1 - Bond Wellness Center 458 Old Street Road Wellness Center Peterborough NH 03458 Fitness center and rehabilitation services 2 - Monadnock Orthopaedic Associates 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice 3 - Jaffrey Family MedicinePT Satellite 82 Peterborough Road Jaffrey NH 03452 Physician practice with PT services 4 - Monadnock Regional Pediatrics 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 5 - Monadnock Internal Medicine 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 6 - Monadnock Family Care 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 7 - Monadnock Surgical Associates 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice 8 - Antrim Medical Group 12 Elm Street Antrim NH 03440 Physician practice 9 - Rindge Family Practice 145 US Route 202 Rindge NH 03461 Physician practice 10 - Monadnock Behavioral Health 458 Old Street Road Wellness Center Peterborough NH 03458 Physician practice 11 - New Ipswich Family Medicine 821 Turnpike Road New Ipswich NH 03071 Physician practice 12 - Neurology 454 Old Street Road MAB Building Peterborough NH 03458 Physician practice Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: Charity care and means tested programs use the cost to charge ratio as their methodology. This Hospital calculates the ratio in a manner consistent with worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of cost to charges. Part I, Line 7g: Included in the subsidized health services activities reported for fiscal year 2018 are unreimbursed costs of $479,000 attributed to an outpatient behavioral health practice and $1,743,000 related to emergency and trauma services. Part I, Ln 7 Col(f): The Bad Debt expense included on Form 990, PartIX, Line 25(A), but subtracted for purposes of calculating the percentage in this column is $4,966,097. Part II, Community Building Activities: See previous footnotes. Part III, Line 2: The amount reported on Part III, Line 2 was derived by applying the cost to charge ratio against the amount of bad debt expense reported on Form 990, Part IX, Line 25, Column (A) ($4,966,097). Accounts written off to bad debt include gross charges being written off less any payments received against those charges. Any cash collected on accounts previously written off is included as an offset to bad debt expense as recoveries of bad debt. The Hospital calculates the ratio in a manner consistent with Worksheet 2, patient care charges to patient care expenses, to arrive at the ratio of costs to charges. Part III, Line 3: The estimated amount of charity care included in bad debt expense is based on the number of applications for charity care denied due to lack of complete documentation against the average charity care write off at cost per qualified patient. We believe the amount is minimal based on our extensive efforts to educate patients and staff about our various payment plans and financial grant programs to ensure that patients who qualify for any of our programs utilize them. Depending on the specific circumstances, a patient may be eligible for charity care, discounted care, payment programs, or a combination of the above. Due to these efforts, we believe that amounts written off to bad debt that could qualify as charity care is minimal. Part III, Line 4: Please see footnote 1 on page 8 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs for the Medicare cost report are reported in accordance with CMS guidelines using the cost to charge ratio methodology. Part III, Line 9b: As of 9/30/2011 Monadnock Community Hospital has a written credit and collection policy. Described within that policy are the collection practices and bad debt processes that are followed for patients who are known to qualify for charity care or financial assistance. The Organization maintains a Financial Assistance Program (FAP) database which is maintained by the Social Services Department of MCH. The Patient Financial Services (PFS) staff reference this database for approval status and eligibility amounts, identifying any account(s) where the discount will apply. Internal FAP insurance plans are applied to those accounts and related discount amounts are adjusted in the billing system. Remaining balances are expected to be paid in full by the patient. Payment plans may be requested by the patient and are established by the Financial Grant Coordinator based on the patient's available income and assets. Accounts are annotated to reflect payment arrangements. During bad debt processing, designated staff evaluate accounts listed as collection review for potential bad debt write off. This process includes an examination of account history for indication of FAP application. Part VI, Line 2: The State of NH, under RSA 7:32-f, requires every healthcare charitable trust, either alone or in conjunction with other healthcare charitable trusts in its community, to conduct a Community Health Needs Assessment to assist in determining the activities to be included in its community benefits plan. The needs assessment process includes consultation with members of the public, community organizations, service providers, and local government officials in the entity's service area to identify and prioritize the community needs that the health care entity can address directly or in collaboration with others. The Community Health Needs Assessment is updated at least every three years, most recently in 2018 (tax year 2017). In 2007, the Regional Community Benefits Steering Committee was first formed to prepare a single Community Benefits Needs Assessment for the Monadnock Region. The work group consisted of representatives from multiple organizations, including Monadnock Community Hospital. Based on the needs assessment and community engagement process, the priority needs and health concerns of the community MCH serves include access to care - driven by financial barriers and/or availability of primary care, availability of behavioral health care, general socioeconomic issues, and transportation services. This collaboration is continued today, through a similar process for the CHNA. In mid-2018, MCH completed its most recent CHNA and successfully identified and prioritized service gaps in the region. Utilizing a consulting group along with community organizations, the team collaborated to not only identify these gaps but to work together to identify and implement a plan to decrease these service gaps and improve the overall health of the community. Monadnock Community Hospital uses this information to help focus its Community Benefit efforts to meet the priority needs identified in the Community Benefit Plan. In addition, other needs or services not specifically identified in the Community Health Needs Assessment, but addressed under the Organization's Community Benefit Plan include availability of dental or oral health care (via the Organization's Monadnock Healthy Teeth to Toes program which focuses on dental hygiene and care, nutrition, and daily physical activity for children ages kindergarten to third grade) and availability of prescription medication (via the Organization's Medication Bridge program designed to help eligible patients apply for assistance programs that provide free or discounted prescription medications). Pursuant to State of NH RSA 7:32-c-1, a Community Benefits Reporting Form is filed annually with the Office of the Attorney General Charitable Trusts Unit. Part VI, Line 3: MCH is committed to providing quality healthcare to anyone in need of services, regardless of ability to pay. We understand patients may not have the finances to pay for their healthcare services and medications, and do not want this to prevent anyone from receiving necessary treatment. As part of the Hospital's mission to the communities we serve, we have developed programs to help meet the needs of our patients who meet income eligibility. Through our Financial Assistance and Medication Bridge Programs, we have been providing financial assistance to those qualifying for many years. We reach out to our patients in many different ways to ensure they are aware that help is available and to guide them through the process. Brochures and signage are posted in high traffic areas and all employees of MCH are informed about the Financial Assistance Program during orientation. When a patient goes through the registration process at the Hospital the staff are trained to inform uninsured or underinsured patients about the Monadnock Community Hospital Financial Assistance and the New Hampshire Health Access programs and that there is assistance available within the Hospital to help with the application process. In addition, any time a patient calls customer service, the representative is trained to help identify and offer support to patients who may require financial assistance. Patients may qualify for free care, discounted care, payment plans or a combination of the above. Assistance is also provided in applying to federal and state programs for those who qualify. Part VI, Line 4: The Hospital's primary service area consists of 13 towns, including Antrim, Bennington, Dublin, Francestown, Greenfield, Greenville, Hancock, Jaffrey, New Ipswich, Peterborough, Rindge, Sharon, and Temple. The Hospital serves the general population of the primary service area referenced above. Part VI, Line 5: Monadnock Community Hospital is a critical access hospital located in the Monadnock Region of NH. Our mission is to improve the health and well-being of our community. The Hospital is served by a board of trustees consisting of local citizens active in their community and its organizations. The majority of the board is not employed by the Hospital and consists of local community and business representatives as well as medical staff. Each year, MCH seeks to make the Monadnock Region a healthier place to live by identifying new and changing healthcare needs, then developing a strategy to address some of the most pressing issues. In addition, no one is turned away who is in need of medical care. Our mission is to provide health care for everyone in our community, regardless of their ability to pay. The Hospital is committed to giving back to the community to the greatest extent possible. Monadnock Community Hospital supports thousands of individuals and families with free or reduced-fee services and programs. Our Financial Assistance Program administered by the Social Services Department helps families and individuals in need with access to health care and other available community services such as catastrophic care, fuel assistance, meals on wheels, food banks, and visiting nurses. Other examples of the Hospital's effort to reach our patients beyond traditional hospital services include access to free or reduced cost medications through our Medication Bridge program; educating children on the importance of good oral hygiene through our Monadnock Healthy Teeth program which helps children in preschool through high school to get off to a good start regardless of family access to dental health care; training for community agencies such as local volunteer fire and rescue personnel; offering prevention and wellness education including nutrition, smoking cessation and dealing with stress; providing regular community seminars regarding timely health topics; screenings and clinics for important health issues such as breast cancer; offer behavioral health (substance use & mental health) trainings to the community through Be The Change; and offer space for community organizations to meet, including local support groups. These are just a few of the many areas where we are reaching out to others to assure they are cared for well. Part VI, Line 6: GraniteOne Health is a non-profit, New Hampshire-based healthcare system consisting of Catholic Medical Center (CMC) in Manchester, Huggins Hospital (HH) in Wolfeboro, and Monadnock Community Hospital (MCH) in Peterborough. GraniteOne Health draws on the resources and expertise of these strong, trusted hospitals to enhance collaboration, strengthen clinical partnerships and meet the health needs of the communities by providing greater access to high-quality care and a seamless patient experience. The organization will enable the hospitals to grow their clinical relationships, build economies of scale, and improve value to patients.Both Huggins and Monadnock have long-standing clinical relationships with CMC in specialty areas such as cardiology and vascular care. GraniteOne allows the hospitals to explore further collaborations in clinical areas as well as other services that could benefit from economies of scale, all while maintaining a seamless patient experience.GraniteOne Health offers access points throughout New Hampshire to advanced clinical services such as open heart surgery, angioplasty, minimally invasive heart valve and vascular surgery, cancer care, comprehensive weight loss management, orthopedics, innovative maternal health services and over 30 other medical and surgical subspecialties. GraniteOne Health gives patients access to high-quality, coordinated care across the continuum of health. Part VI, Line 7, Reports Filed With States NH 1 Town of Peterborough 1 Grove Street Peterborough NH 03458 Government 22500 Cash contribution for the benefit of the Peterborough Ambulance. 1 0 Peter L. Gosline Scholarship 4 6000 Dr. Mark Luedke Scholarship 2 3216 Part I, Line 2: During the fiscal year ending September 30, 2018, the Hospital made contributions to a governmental entity, the Town of Peterborough. Additionally, during the fiscal year, the Hospital continued to support the Peter L. Gosline Employee Education Scholarship to support professional growth of Hospital employees. Both full and part-time employees are eligible to submit an application. The applicant must be a current Hospital employee in good standing who has been employed at MCH for at least 12 months. The applicant must also be currently enrolled in a degree or certificate program, provide a letter of recommendation from their current Hospital manager, as well provide a copy of their current college transcript. In 2018, the Hospital established the Dr. Mark Luedke Memorial Scholarship Fund in memory of the organization's Radiology Medical Director. The fund is to support clinical education and certification for members of MCH's Radiology Department, and is disbursed with the input of the Director of Radiology, the Chief Nursing Officer, and VP of Human Resources. X X X 0 1 0 0 0 0 0 1 0 Elizabeth Cooley MD Ex-Officio (voting) 232200 0 0 0 1290 0 4749 0 19949 0 258188 0 0 0 Gregory Kriebel MD Ex-Officio (voting) 295921 0 0 0 865 0 5400 0 22209 0 324395 0 0 0 Terrence McNamara DO Ex-Officio (voting) (end 1/18) 427377 0 4935 0 13130 0 5400 0 20399 0 471241 0 0 0 Fay Migotsky MD Ex-Officio (voting) 166271 0 0 0 3452 0 3058 0 19325 0 192106 0 0 0 Joseph Pepe MD Trustee 0 634968 0 185279 0 39727 0 266339 0 33073 0 1159386 0 0 Alexander Walker Esq Trustee 0 375639 0 107483 0 51927 0 126396 0 53140 0 714585 0 0 Cynthia McGuire Chief Executive Officer 241206 0 106575 0 22965 0 40375 0 23677 0 434798 0 17500 0 Richard D Scheinblum VP Finance/CFO 184327 0 13555 0 450 0 3794 0 9873 0 211999 0 0 0 Ronald Michalak MD Physician 478562 0 0 0 450 0 5400 0 19239 0 503651 0 0 0 Shawn Harrington MD President-Medical Staff 428926 0 0 0 450 0 5400 0 18899 0 453675 0 0 0 Robert C Knowles MD Physician 387250 0 0 0 13915 0 5400 0 20609 0 427174 0 0 0 William White MD Physician 352752 0 0 0 1980 0 0 0 19801 0 374533 0 0 0 Michael Lindberg MD Physician 324678 0 0 0 1980 0 254 0 16589 0 343501 0 0 0 Part I, Line 4b Cynthia McGuire, President & CEO, participates in a 457(f) plan with Monadnock Community Hospital. After a three year vesting period, amounts previously contributed to her by Monadnock Community Hospital are reported as part of her W-2 wages. In calendar year 2017, a total of $35,000 was deposited into Ms. McGuire's 457(f) plan account, which is included in the amount reported on Schedule J, Part II, Column C for this current fiscal year Form 990 filing. Additionally, $20,985 of compensation is reported in Column B(iii), which represents the vested 2014 contribution of $17,500 and earnings of $3,485. The following individuals take part in a section 457(f) forfeitable nonqualified deferred compensation plan administered by Catholic Medical Center, their employer, which is a related organization. The amounts listed represent calendar year 2017 contributions for many years of service: Joseph Pepe: $244,989 Alexander Walker: $110,346 Part I, Line 7 MCH compensates physicians utilizing productivity targets based on RVU (relative value units). In addition, the Compensation Committee recommends to the full board, annually, the variable pay award that may be issued to the Hospital's CEO. The payment of the award is discretionary and is subject to meeting the pre-determined goals of the Organization. A NHBFA Revenue Bonds Series 2013 021304598 2013-01-01 27240000 refinance existing Series 2007 and 2009 bonds 0 0 0 A 27240000 27057466 182534 2013 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 1 0 0 0 0 A 0 Schedule K, Part III, Line 9, Part IV, line 7 and Part V: Although formal policies are not in place in regards to the remediation of our bond, the monitoring requirements of section 148, and procedures to ensure that violations are timely identified and corrected, Mondanock Community Hospital has compliance checks in place that substantiate these requirements. Below is a list of all compliance checks that Monadnock Community Hospital has in place to monitor the 2013 Bond Issue: 1. Covenant calculations performed monthly as part of the Financial Scorecard preparation which is reviewed by the MCH Board of Trustees; 2. Covenant calculations are performed for each quarter and reported to the bond issuer, TD Bank; 3. Covenant certificate is signed each quarter by the CFO and reported to the bond issuer, TD Bank; 4. Financial statements and statistical reports are sent to the bond issuer, TD Bank, on a quarterly basis; 5. Annual Operating and Capital budgets are reported to the bond issuer, TD Bank; 6. A No Event of Default certificate is signed by the CFO annually and reported to the bond issuer, TD Bank; 7. Annual Audited Financial statements are reported to the bond issuer, TD Bank. Each of these items that are reported to TD Bank has a specific deadline for completion as outlined in the bond documents. Robert C Knowles MD FACS Highest Compensated EE Malpractice Tail Coverage X 60000 0 0 1 1 Connie Cerroni Wife of Board Member 34909 Connie Cerroni is employed in part by Monadnock Community Hospital. She receives wages of $12,092 and benefits of $22,817, for a total of $34,909 in compensation. Connie Cerroni is the wife of Peter Cerroni, who serves on the Board of Trustees for MCH. 0 Michael Shea Lessor of Rental Property 131838 Mr. Shea is president and part owner of Belletetes, Inc. Monadnock Community Hospital leases a building in Jaffrey, NH for the Jaffrey Family Medicine Practice which is owned by Belletetes, Inc. Terms are at arms-length. The total amount reported in Column C represents rental payments ($105,492) as well as payments for property taxes and common area maintenance. 0 Schedule L, Part II: The Hospital has entered into loan agreements with several physician employees. Two physicians listed in Form 990, Part VII have been involved in the loan program, though the Hospital has loans with other physician employees as well. In all instances, the loans were a part of a written policy that was pursuant to a written contract and approved by the board. The board also reviews on an annual basis the status of all physician loans not more than 180 days after the fiscal year end. Each loan will accrue interest at a rate of prime plus 1% or 2%. The loans will be forgiven over the terms of the notes. The amount of loan forgiveness, along with imputed interest, will be included in the recipients' IRS Form W-2 or IRS Form 1099-MISC as taxable compensation in the year forgiven. The details of the loan forgiveness which is reported on Schedule J, Part II, Column B(iii) for the respective recipients as follows:Dr. Knowles - $12,520 (inclusive of $520 of interest)Dr. McNamara also received loan forgiveness in the amount of $12,520 (inclusive of $520 interest) in calendar year 2017. His loan balance at the beginning of fiscal year 2018 was $0, so details of his loan were reported on the prior year Form 990, Schedule L, Part II and are not included on Schedule L, Part II in the current year pursuant to IRS instructions. Schedule L, Part IV: Form 990, Part VI, Section A, line 6 The sole Member of MCH shall be GraniteOne Health, a New Hampshire voluntary corporation that is exempt from taxation under section 501(c)(3) of the Internal Revenue Code. Form 990, Part VI, Section A, line 7a GraniteOne Health shall elect the elected members of MCH's Board of Trustees who are nominated as set forth in Article II of MCH's governing documents. GraniteOne Health shall also have the powers reserved to it as described in the following narrative for Form 990, Part VI, Line 7b. Vacancies on the Board of Elected Trustees occurring prior to the end of any Elected trustee's term shall be elected by GraniteOne Health from nominations by either vote of the Board at a meeting of the Board, for which notice has been given of the nomination process, or by GraniteOne Health if the vacancy is from the group of Elected Trustees nominated by GraniteOne Health. Form 990, Part VI, Section A, line 7b The following actions initiated by MCH shall require GraniteOne Health's approval: a. Adoption of the annual capital and operating budgets, provided that the expenditure of any of the cash reserves, board-designated reserves, surplus assets and other assets held by MCH on the Affiliation Date and recorded on MCH's financial statements as unrestricted assets, as well as certain parcels of real estate not required for the operation of MCH (the "Pre-Affiliation Assets") contemplated by such budgets and proposed in accordance with those powers reserved to MCH, will not be subject to the approval of GraniteOne; b. Approval of any strategic plans or material nonclinical programming and marketing plans, including material modifications thereof; c. Authorization of debt incurred, assumed, or guaranteed by the hospital in excess of Five Hundred Thousand Dollars ($500,000.00), other than as provided for in any approval annual capital or operating budget; d. Authorization of any material acquisition, disposition, formation, organization or investment by MCH of or in any other corporation, partnership, limited liability company, other entity or joint venture, other than an acquisition funded with Pre- Affiliation Assets proposed in accordance with those powers reserved to MCH will not be subject to the approval of GraniteOne; e. Authorization of the sale, disposition, mortgage, or encumbrance of any assets dedicated to the operations of MCH involving assets of Five Hundred Thousand Dollars ($500,000.00) or more, with the exception of real estate identified prior to the Affiliation; f. Authorization of MCH to enter into any merger, consolidation or joint venture; or to sell or dispose of substantially all of the assets of MCH or any of its respective subsidiaries; or to create or acquire any subsidiary organization; g. Authorization of MCH to institute any bankruptcy, insolvency or reorganization proceedings for itself or any subsidiary; h. Authorization of a capital investment by MCH or any of its subsidiaries in any individual entity or project in the form of cash or either tangible or intangible property in excess of Five Hundred Thousand Dollars ($500,000.00), except as provided in any approved annual capital or operating budget or to the extended funded by the Restricted Assets or the Pre-Affiliation Assets; i. Authorization to develop, implement or terminate clinical programs and clinical procedures by MCH or its subsidiaries; j. The amendment of the Articles of Agreement or Bylaws of MCH or its subsidiaries to the extent that it would (a) impact the Reserved Powers; or (b) reasonably be expected to have a material strategic, competitive or financial impact on the System or any of its members; and k. The MCH Board of Trustees' appointment or reappointment of the MCH CEO and the determination of the CEO's compensation. Form 990, Part VI, Section B, line 11b The Hospital's Form 990 is prepared with assistance by an independent public accounting firm. A draft of the Form 990 is initially reviewed in detail by key finance employees. Thereafter, the final draft is made available to the full board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c On an annual basis, the Organization provides all administrators/directors/managers, Board Members, and medical staff members with the conflict of interest policy. Said individuals are required to complete a new conflict of interest disclosure on an annual basis. Any conflicts of interest noted are reviewed by the Chair of the Board, in conjunction with the Corporate Compliance Officer. If the conflict of interest appears to meet the policy definitions requiring full Board review, the Chair of the Board takes this to the full Board meeting, and it is discussed, and appropriate action is taken (in compliance with state and federal requirements). The conflict of interest statement requires signatories to inform the Hospital of any conflict of interest that occurs at any time throughout the year. If a conflict of interest arises during the year, it is reviewed by the Compliance Officer, and if necessary, is taken to the Board Chair/Board. The Compliance Officer confers with legal counsel with regard to conflicts of interest, if there is any question regarding the potential conflict. Form 990, Part VI, Section B, line 15 The Organization has a written executive compensation policy and procedure. Under this policy, the Compensation Committee, comprised of delegated representatives of the Board of Trustees, has the power and responsibility to determine the Hospital's approach to executive compensation and review the performance of the CEO. The Compensation Committee has the responsibility to set, monitor and review the base salary of the CEO. The Committee maintains minutes of sessions and final recommendations and determinations in accordance with the Board of Trustee guidelines. Annually, market data is reviewed by the Committee to determine the appropriate salary for the Hospital's CEO based upon identified standards. At the end of the time period, the Committee reviews to what extent stated goals were met and recommends an amount for the variable pay award to be approved by the full board. Form 990, Part VI, Section C, line 19 Monadnock Community Hospital files audited financial statements annually with the New Hampshire Attorney General's Charitable Trust Unit and informs the Director of Charitable Trusts of pecuniary benefit transactions that have occurred between MCH and a board member or officer. Notices of such transactions of $5,000 or more are also published in the local newspaper in accordance with NH RSA 7:19-A, II(D). Current copies of the bylaws, conflict of interest policy and Form 990 are on file with the Charitable Trust Unit. The Hospital also makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part VII, Section A, Column D: Director Compensation The 2017 compensation reported for Dr. Cooley, Dr. Kriebel, Dr. McNamara, and Dr. Migotsky was paid by Monadnock Community Hospital for their services as physicians. No part of their compensation was remuneration for their services as an ex-officio voting members of MCH's Board of Trustees. Form 990, Part XI, line 9: Change in fair value of interest rate swap agreements 816,425. Form 990, Part XI, Line 2c: Audit Review Process The Audit Committee oversees the audit process for Monadnock Hospital. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for the fiscal years ended 9/30/17 and 9/30/18. Form 990: On December 30, 2016, Monadnock Community Hospital became affiliated with Catholic Medical Center (CMC), a 330-bed acute care hospital in Manchester, New Hampshire, and Huggins Hospital (HH), a 25-bed critical access hospital in Wolfeboro, New Hampshire, through the formation of a common parent, GraniteOne Health (GraniteOne). GraniteOne is a New Hampshire voluntary corporation that is recognized as being a Section 501(c)(3) tax-exempt and "supporting organization" within the meaning of Section 509(a)(3) of the Internal Revenue Code of 1986, as amended (the Code). GraniteOne serves as the sole member of the Hospital and HH and co-member of CMC, along with CMC Healthcare System, Inc. GraniteOne is governed by a thirteen member Board of Trustees appointed by each of the respective hospitals within the GraniteOne system. The GraniteOne Board of Trustees governs the GraniteOne system through the existence and execution of reserved powers to approve certain actions by the Boards of Trustees of each of the hospitals. Through GraniteOne, this more integrated healthcare system enhances the affiliated hospitals' ability to coordinate the delivery of patient care, implement best practices, eliminate inefficiences and collaborate on regional planning. These efforts strengthen the hospitals' ability to meet the healthcare needs of their respective communities and provide for a more seamless patient experience across the continuum of care. The Hospital has engaged in various transactions with GraniteOne and CMC. The Hospital recognized revenue from these related parties of approximately $340,000 for the year ended September 30, 2018 and $215,000 from the date of affiliation, December 30, 2016, through September 30, 2017, which is reflected within other revenue in the accompanying statements of operations. The Hospital also incurred expenses to these related parties of approximately $3.1 million for the year ended September 30, 2018 and $2.2 million from the date of affiliation, December 30, 2016 through September 30, 2017, which is reflected within operating expenses in the accompanying statements of operations. The effect of these transactions resulted in a net amount due to related parties of approximately $187,000 and $437,000 as of September 30, 2018 and 2017, respectively, which is reflected within accounts payable and accrued expenses in the accompanying balance sheets. Alliance Ambulatory Services 100 McGregor Street Manchester NH 03102 020519436 Ambulatory Surgical Center NH 501(c)(3) Line 10 CMC Healthcare System 0 Alliance Health Services 100 McGregor Street Manchester NH 03102 611508839 Practices NH 501(c)(3) Line 10 CMC Healthcare System 0 Alliance Resources 100 McGregor Street Manchester NH 03102 020398138 Real Estate NH 501(c)(3) Line 12b, II CMC Healthcare System 0 Catholic Medical Center 100 McGregor Street Manchester NH 03102 020315693 Hospital NH 501(c)(3) Line 3 GraniteOne Health 0 CMC Healthcare System 100 McGregor Street Manchester NH 03102 010568516 Parent NH 501(c)(3) Line 12b, II N/A 0 CMC Physician Practice Associates 100 McGregor Street Manchester NH 03102 020460245 Practices NH 501(c)(3) Line 10 CMC Healthcare System 0 GraniteOne Health 100 McGregor Street Manchester NH 03102 814663563 Supporting Organization NH 501(c)(3) Line 12a, I N/A 0 Huggins Hospital 240 South Main Street Wolfeboro NH 03894 030223332 Hospital NH 501(c)(3) Line 3 GraniteOne Health 0 Monadnock Health Services - INACTIVE 452 Old Street Road Peterborough NH 03458 020420789 Inactive NH 501(c)(3) Line 12a, I Monadnock Community Hospital 1 St Peter's Home 100 McGregor Street Manchester NH 03102 020222228 Day Care Services NH 501(c)(3) Line 10 CMC Healthcare System 0 Alliance Urgent Services 100 McGregor Street Manchester NH 03102 831238167 Health Care Services NH N/A Bedford Ambulatory Surgical Center LLC 11 Washington Place Bedford NH 03110 020519727 Surgical Center NH N/A Alliance Enterprises 100 McGregor Street Manchester NH 03102 020386795 Real Estate NH N/A C 0 Doctors' Medical Association Inc 100 McGregor Street Manchester NH 03102 020340690 Medical Office Building NH N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0