2018-05-10T13:56:44-07:00 2017-09-30 990 2016-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786323420 242 Green Street Gardner MA 01440 Robert Crosby Sr VP of Finance, Treasurer, CFO 9786323420 2018-04-30 2016 2022-09-23 18:48:47Z Heywood Hospital Robert Crosby 242 Green Street Gardner MA 01440 123353683 0 X www.heywood.org X 1907 MA To be our community's trusted choice for exceptional patient centered care. 20 17 1180 111 0 0 2617675 1783646 112270215 116121685 849075 943308 1663344 1433260 117400309 120281899 170445 156414 0 0 59566652 61677293 84000 56000 528560 52789952 55787633 112611049 117677340 4789260 2604559 95194844 96090126 41566485 41756567 53628359 54333559 To be our community's trusted choice for exceptional patient centered care. 0 0 109334305 156414 116121685 Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health care needs of the under-served and collaborating with others to enhance quality and contain the growth of the community health care costs. Details to this are published in "The Community Benefit Report of Heywood Hospital - Fiscal year 2015" filed with the MA Attorney General's Office. 0 0 0 109334305 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 1 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 1 0 1 181 0 1 1180 1 0 0 0 0 0 1 1 0 0 0 0 X 20 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MA X Robert Crosby 9786306157 242 Green Street Gardner MA 01440 X Daniel Asquino Trustee 0.2 0 X 0 0 0 Winfield Brown President/CEO 40 0 X X 851290 0 70930 Cheney Castine Treasurer 0.2 X 0 0 0 Robert Chauvin Vice Chairman 0.2 0 X 0 0 0 Joyce Fletcher Trustee 0.2 0 X 0 0 0 John Flick Trustee 0.2 0 X 0 0 0 James Garrison Trustee 0.2 0 X 0 0 0 Glenn Hunt Chairman 0.2 0 X 0 0 0 Roy Lake 2nd Vice Chairman 0.2 0 X 0 0 0 James Meehan Trustee 0.2 0 X 0 0 0 Don Mruk Trustee 0.2 0 X 0 0 0 Elizabeth Nottleson Trustee 0.2 28 X 700 274992 19205 Michele Parker Trustee 0.2 0 X 0 0 0 JoAnne Parks Trustee, Clerk 0.2 0 X 0 0 0 Kenneth Pierce Trustee 0.2 0 X 0 0 0 Benjamin Prentiss Trustee 0.2 36 X 900 414710 40424 Tina Sbrega Trustee 0.2 0 X 0 0 0 Joel Shaughnessy Trustee 0.2 0 X 0 0 0 John Skrzypczak Trustee 0.2 0 X 0 0 0 Craig Twohey Trustee 0.2 0 X 0 0 0 Rebecca Bialecki VP of Community Health Relations 40 0 X 171493 0 44693 Tina Santos VP of Patient Care Services 40 0 X 275728 0 38209 Carol Roosa Chief Info Officer / VP of Info Services 40 0 X 186573 0 50621 Dawn Casavant VP of External Affairs 40 0 X 157505 0 49690 Tina Griffin Athol Chief Nursing Officer/VP of Pat. Care Svcs. 40 0 X 230256 0 47332 Robert Crosby Sr VP of Finance / CFO 40 0 X 324813 0 57218 Bruce Bertrand Chief Medical Officer 40 0 X 293679 0 37538 Rose Kavalchuck VP of Prof. Services 40 0 X 257104 0 46995 Andrew Cocchiarella Director of Anesthesia Services 50 0 X 709381 0 43870 Steven Yerid Chief of ER Medicine 40 0 X 460655 0 43543 Ellen Ray Chief of ER Medicine 40 0 X 362861 0 56257 Sarah Gilbert ER Physician 30 0 X 341885 0 50913 Marc DeBell ER Physician 30 0 X 325512 0 39292 Michael Grimmer VP of Support Services 40 0 X 261351 0 53040 Karen McArdle-Coggins HMG President 40 0 X 186194 0 30075 5397880 689702 819845 103 1 1 0 Quartulli & Associates PO Box 423 Gardner MA 01440 Physical Therapy 2701572 Alliance Healthcare Services 18201 Von Karman Ave Suite 600 Irvine CA 92612 MRI 1479605 Quest Diagnostics 5763 Collection Center Dr Chicago IL 60693 Lab contracted services 1037269 New England Inpatient Specialists 120 Waters St North Andover MA 01845 Hospitalists 934501 Diversified Clinical Services 28525 Network Place Chicago IL 60673 Wound management services 812210 37 0 0 73920 12035 1604897 92794 0 1783646 Ancillary O/P Services 622110 72194724 72194724 0 0 Ancillary I/P & Routine Services 622110 37377267 37377267 0 0 HMG Patient Revenue (net) 621111 3483649 3483649 0 0 Contracted Services Revenue 900099 2996926 2996926 0 0 Lifeline Service Revenue 624120 34660 34660 0 0 34459 34459 0 0 116121685 414796 0 0 414796 0 0 0 0 0 0 0 0 427553 0 0 0 427553 0 427553 0 0 427553 3240067 217335 2921162 7728 318905 209607 528512 0 0 528512 84512 73920 142894 -58382 0 -58382 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722310 790294 0 0 790294 Purchase Discounts 900099 165850 0 0 165850 ACLS Training 611710 27800 0 0 27800 80145 0 0 80145 1064089 120281899 116121685 0 2376568 X 156414 156414 0 0 0 0 0 0 3404144 1199931 1994226 209987 0 0 0 0 47910954 45486646 2253487 170821 957761 797924 136474 23363 5459864 5005720 416393 37751 3944570 3691886 228922 23762 291943 0 291943 0 138845 8389 130456 0 176353 0 176353 0 0 0 0 0 56000 56000 0 0 0 0 14607953 14607953 0 0 341401 329696 10763 942 16121646 15910669 203933 7044 1693012 1559544 124030 9438 0 0 0 0 2022133 1873071 149062 0 85692 51152 34507 33 0 0 0 0 184211 127509 56702 0 701692 701692 0 0 0 0 0 0 3985859 3967202 18180 477 629660 542041 87619 0 Professional Fees 6101206 5163143 951839 -13776 Bad Debt 4309281 4309281 0 0 Free Care 1884788 1884788 0 0 Subscription & Dues 830629 345858 483172 1599 1681329 1613796 66414 1119 117677340 109334305 7814475 528560 4760131 4104361 0 0 528176 579630 13114002 14299711 0 0 0 0 33251 4000 1636151 1583424 1114913 741878 107811240 62298110 48335048 45513130 22690343 25904430 527550 675397 152684 158908 0 0 2302595 2525257 95194844 96090126 12113071 14536533 0 0 252045 228863 22853204 20989321 0 0 0 0 366311 237595 0 0 5981854 5764255 41566485 41756567 X 49949292 50289068 2672715 3038068 1006352 1006423 53628359 54333559 95194844 96090126 X 2604559 2970385 0 0 0 -4869744 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 22460789 2504 2793312 0 -343327 0 25599932 20377782 0 1888246 0 -194761 0 22460789 20170666 18245 -665620 0 -854491 0 20377782 18078764 100 1729112 0 -362690 0 20170666 17128384 2200 2044839 0 1096659 0 18078764 0.89 0.04 0.07 0 0 0 210871 210871 0 67164046 28467712 38696334 0 0 0 0 0 38639675 32516445 6123230 0 1796648 1313953 482695 45513130 0 Est. settlements with third party payors 3283311 Est. Malpractice liability 1195000 Deferred Compensation 1285944 5764255 X Schedule D, Part V, Line 4 Permanent Endowment funds are established by donor restricted gifts and maintained to provide a permanent source of income. The principal of which is kept in perpetuity. Board Designated Endowment funds are established by the governing body to fund capital projects and/or improvements of the organization. Temporary Restricted funds are established by donor restricted gifts that maintain a source of income for a specific period of time. Schedule D, Part X, Line 2 Tax Status footnote per Audited Financials: Heywood Healthcare, Heywood Hospital, Athol, HMGI, and Charitable Foundation 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. Quabbin Healthcare has filed for its exempt status under Section 501(c)(3) of the Code. The Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2013 through the current year remain open for examination by federal and state taxing authorities. X X X X X X X 1 JNB & Associates 21 Water St Amesbury MA 01913 Consultant 0 0 56000 -56000 0 56000 -56000 MA Golf Classic 86570 52820 33750 2000 13782 13927 26457 4450 9477 Winter Affair 45100 21100 24000 0 385 4280 13184 5500 11702 2 26762 0 26762 0 487 2026 3045 4798 27394 158432 73920 84512 2000 14654 20233 42686 14748 48573 142894 -58382 1 1 1 X 1 X 1 1 0 1 1 0 0 2052325 672369 1379956 0.0122 0 0 23995784 19483949 4511835 0.0398 0 0 0 0 0 0 0 0 26048109 20156318 5891791 0.0520 0 0 1240923 918 1240005 0.0109 0 0 394791 132 394659 0.0035 0 0 0 0 0 0 0 0 0 0 0 0 0 0 212793 0 212793 0.0019 0 0 1848507 1050 1847457 0.0163 0 0 27896616 20157368 7739248 0.0683 0 0 1152 0 1152 0 0 0 0 0 0 0 0 0 7451 2399 5052 0 0 0 50 0 50 0 0 0 0 0 0 0 0 0 11095 0 11095 0.0001 0 0 3269 0 3269 0 0 0 409750 0 409750 0.0036 0 0 0 0 0 0 0 0 432767 2399 430368 0.0037 1 2084236 20217 26060927 25313067 747860 X 1 1 1 1 Henry Heywood Memorial Hospital 242 Green St Gardner MA 01440 www.heywood.org 04-2103581 X Henry Heywood Memorial Hospital 1 0 0 1 X X X X X X X X X X 15 1 1 1 1 X www.heywood.org X www.jointcoalitionhealth.org X 1 15 1 www.heywood.org 0 0 1 X 150 300 X 1 1 X X X X 1 X www.heywood.org X www.heywood.org X X X X X X 1 X X 0 X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Henry Heywood Memorial Hospital The 2015 Community Health Needs Assessment of North Central Massachusetts was a joint effort between Heywood Healthcare's Heywood Hospital and Athol Hospital, Health Alliance Hospital, Community Health Connections FQHC, the Montachusett Public Health Network (MPHN), MA Department of Public Health's Community Health Network Area of North Central Massachusetts (CHNA 9) and the Joint Coalition on Health. The assessment is designed to provide information and analyses relative to the health status, issues, concerns and assets of the North Central Region of Massachusetts. The assessment includes 30 cities and towns which are primary service areas of the three hospitals-Heywood Hospital, Athol Hospital and Health Alliance Hospital. The data was presented and analyzed in four ways including, the entire region, Heywood Healthcare Service Areas, Health Alliance Service Areas, and the MPHN Service Areas. Comparisons were made between the different service areas and to Massachusetts as a whole. All data was gathered systematically utilizing standards which guided the methodologies. The quantitative data collected came from the Massachusetts Community Health Information Profile, the Massachusetts Department of Public Health, the US Census Bureau, the MA Department of Workforce Development, the MA Department of Elementary and Secondary Education, the Youth Risk Behavior Survey (YRBS) Data, and the CD Behavioral Risk Factor Surveillance System (BRFSS). Qualitative data was gathered through 16 focus groups and 26 key informant interviews representing diverse communities and populations in the region, such as illness, Black African Americans, Latinos, Brazilian's, Hmong, LGBTQ, elders, young adults, homeless individuals, veterans and adults with major mental illness. They were conducted in cooperation with Westwinds Clubhouse; North Quabbin Community Coalition; Veterans Homestead Inc; 15 West Teen Coffeehouse; Clinton Hospital; Montachusett Opportunity Council; New Hope Baptist Church; Hope Center; Fitchburg Senior Center; Goodrich Academy Alternative High School; and Regional Behavioral Health Collaborative. Priority Health Issues identified from the CHNA are Mental Health and Substance Abuse; Suicide Prevention; Chronic Disease and related risk factors; Nutrition Issues including Obesity and food insecurity. As well as addressing health disparities that exist in our region and improving access to care for populations adversely affected by social determinants of health. Schedule H, Part V, Section B, Line 5-Henry Heywood Memorial Hospital Heywood Hospital's 2015 Community Health Needs Assessment took into account input from person's who represent the community. This input was gathered through 16 focus groups and 26 key informant interviews representing diverse communities and populations in the region, such as Black African Americans, Latinos, Brazilians, Hmong, LGBTQ, elders, young adults, homeless individuals, veterans, and adults with major mental illness. Schedule H, Part V, Section B, Line 6a-Henry Heywood Memorial Hospital Hospitals included in the development of the 2015 Community Health Needs Assessment are Heywood Hospital, Gardner, MA; Athol Hospital, Athol, MA; HealthAlliance Hospital, Leominster, MA. Schedule H, Part V, Section B, Line 6b-Henry Heywood Memorial Hospital Other organizations involved in the development of the 2015 Community Health Needs Assessment was Community Health Connections FQHC, the Montachusett Public Health Network (MPHN), MA Department of Public Health's Community Health Network Area of North Central Massachusetts (CHNA 9) and the Joint Coalition on Health. The focus groups were conducted in collaboration with the Westwinds Clubhouse; North Quabbin Community Coalition; Veterans Homestead Inc; 15 West Teen Coffeehouse; Clinton Hospital; Montachusett Opportunity Council; New Hope Baptist Church; Hope Center; Fitchburg Senior Center; Goodrich Academy Alternative High School; and Regional Behavioral Health Collaborative. Schedule H, Part V, Section B, Line 11-Henry Heywood Memorial Hospital Heywood 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: CHNA9; Montachusett Public Health Network; Gardner Area Interagency Team (GAIT); Suicide Prevention Task Force; Regional Behavioral Health Collaborative; Minority Health Coalition; Health Disparities Collaborative; Community Health Connections FQHC; GVNA Healthcare; Community Health Link; LUK, Inc; AED Foundation; SHINE Initiative; Gardner Community Action Team (GCAT); and Montachusett Opioid Prevention Coalition (MOPC); Gardner Religious Council; Unitarian Church; Gardner CAC; HOPE House; Peoples Place Tobacco Cessation Group; Gardner, Ashburnham, Winchendon and Westminster Public School Districts; Montachuset Vocational Technical High School; The Winchendon School; Mount Wachusett Community College; Fitchburg State University; Framingham State University; University of New Hampshire; Bates College; Gardner Rotary Club; Hannaford Key Accomplishments of Reporting Year: * Provided nutrition education to 1,120 individuals through cooking classes and interactive presentations promoting wellness and managing chronic disease with good nutrition. * Robust partnership with the Gardner and Ashburnham-Westminster schools offering nutrition education and physical activities to 248 elementary students and provided food assistance to 220 low- income and at-risk youth through a weekend backpack food program. * Provided health information about heart disease and diabetes to over 185 individuals by participating in community health fairs and events reaching vulnerable populations. * Offered wellness instruction and self-care techniques to 980 individuals to manage symptoms associated with having a mental health and/or substance use disorder. * Provided training on Opioid Overdose Prevention and Narcan Administration to 473 community members and QPR Gatekeeper training for 135 increasing knowledge on signs and symptoms of a suicide crisis and substance use and how to respond. * Provided health and financial insurance information and enrollment assistance to 4,048 individuals reducing financial barriers to accessing healthcare. * Offered free psychosocial support to 58 community members looking for information and referrals on issues related to housing, food, transportation, behavioral and substance abuse. * Assisted and paid for legal services (such as healthcare proxy, guardianship, advanced directives) for 27 patients who did not have the means to pay. * Assisted 61 patients with transportation and as a result was able to follow up with their healthcare and prevented missed appointments. * Provided 5,876 hours of mentorship to 207 students pursuing careers in healthcare. * Lead several multi-sector coalitions and actively participated on community boards and committees to collaboratively address community health needs and gaps in services. * Distributed $119,874 grants to 25 local organizations that provide programs in line with the hospital's community benefit areas of focus and reach the targeted population. Schedule H, Part I, Line 6a Heywood's approach to Community Benefits has been to collaborate with others through the Joint Coalition on Health and other coalitions to develop our plan, goals and strategies. Partners include the Joint Coalition on Health, Gardner Interagency Team, the CHNA, The Minority Coalition, Montachusett Opportunity Council, Mount Wachusett Community College, the Community Health Connections Health Centers, North Central Human Services, Luc, Inc., Community Health Link, Gardner, VNA, the Gardner Public Schools, the Winchendon Public Schools, the Health Foundation of Central MA, Kresge Foundation, the Department of Public Health, AHEC, and others. At this time we continue to focus our efforts on mental health and substance abuse, insuring those without jobs and/or insurance, addressing the needs of under-served populations, focusing on the needs of youth and children, and targeting adults and children with overweight and obesity issues which lead to chronic diseases and diabetes. 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 Heywood Hospital's Community Benefits Mission Statement is "Heywood 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 4 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. 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 2017. This amounted to approximately 1% 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. Line 4 explanation: Accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Organization analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about the major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Organization analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for uncollectible accounts, if necessary. For receivables associated with self-pay patients, the Organization records a provision for uncollectible accounts in the period of service on the basis of its past experience, which indicates that certain patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. Schedule H, Part III, Section B, Line 8 Line 6: The allowable costs on line 6 were obtained from our FY 2017 Medicare Cost Report, Worksheet D schedules. Line 8: There is no shortfall. Schedule H, Part III, Section C, Line 9b Heywood Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of MA or through Heywood Hospital's own financial assistance program, which may cover all or some of their unpaid hospital bills. For those patients that request such assistance, Heywood 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 Heywood 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. Heywood specifically assists the patient in completing the application and secure the necessary documentation required by the applicable financial assistance program. Heywood 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 Heywood Hospital collaborates with many local and state agencies and organizations to assess community health needs in the North Central region of MA. We continue to assess the health care needs of the community and collaboratively develop strategies to address these issues through our active participation with the following coalitions and organizations: Minority Coalition; Multicultural task force; Health Disparities Collaborative; Greater Gardner Religious Council; House of Peace and Education; Gardner Rotary; Community Health Connections; SHINE 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 The Heywood Hospital Service Area is comprised of the city of Gardner and five surrounding towns, Ashburnham, Westminster, Winchendon, Templeton and Hubbardston. The area has a population of approx. 57,000, a median income below the state average and an unemployment rate above the state average. The community is largely white, non Hispanic, but has a growing Hispanic population. Schedule H, Part VI, Line 5 Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the special health needs of the underserved and collaboration with others to enhance quality and contain the growth of community healthcare costs. Examples of activities the hospital participates in to promote the health of the community include: Provide nutrition education to through cooking classes, shopping tours and interactive presentations promoting wellness and chronic disease management.; Partner with the Gardner and Ashburnham schools offering nutrition education and physical activities and food assistance to low- income and at-risk youth through a weekend backpack program; Provided health information by participating at community health fairs and events at venues reaching vulnerable populations; offer free workshops promoting self care techniques such as meditation and Reikki; Provide insurance information and enrollment assistance to individuals reducing financial barriers to accessing healthcare; Offered free psychosocial support to community members looking for information on issues related to housing, food, transportation, behavioral and substance abuse. Schedule H, Part VI, Line 6 Heywood Hospital works closely with the community to promote health in areas identified by the 2015 Community Health Needs Assessment (CHNA) through a variety of means. The hospital works with area school systems to address childhood obesity and onset of adult diabetes through nutrition/fitness programs targeting young students K-2, in order to help develop healthy habits which may result in a reduction of chronic illness and obesity as indicated in the 2015 CNHA. Financial counselors help uninsured populations, including those recently unemployed and those experiencing financial hardship to enroll in appropriate programs to ensure healthcare coverage, an identified barrier to obtaining health care, as indicated in the 2015 CHNA. Community programs targeting nutrition and fitness are offered free and at reduced rates focusing on nutrition, healthy cooking and consistent exercise, focusing on the reduction of chronic disease including diabetes and cardiovascular disease in adults as indicated in the 2015 CHNA. Operation of a school-based health center which enrolls an average of 79% of all students in the school, providing nearly 1,000 behavioral health visits annually, addressing higher than normal suicide and substance abuse rate, as indicated in the 2015 CHNA. The Suicide Prevention Taskforce, which partners with approximately 100 area social service agencies, provides educational tools, and raises community and legislative awareness of significant area mental health and substance abuse issues, resulting in a Gardner suicide rate approximately twice the state average. Continue to work with the Minority Coalition, Joint Coalition of Health and other community agencies to raise awareness and skills among health providers to reduce disparities and strive for equal health. Schedule H, Part VI, Line 7 Community Benefit Report is filed with Attorney General's Office, State of Massachusetts. 1 Montachusett Home Care Corp 680 Mechanics St Leominster MA 01453 042551175 501(c)(3) 36414 0 cash home care -elderly & disabled Heywood Healthcare Charitable Foundation Inc 242 Green St Gardner MA 01440 222720562 501(c)(3) 120000 0 cash support local organizations 2 0 Schedule I, Part I, Line 2 Heywood Hospital has reporting systems in place to monitor grantee expenditures within each budget period and within the overall project period. This includes the requirements that grantees submit mid-year and end of year grant reports, to include a detailed report on the project budget expenditures. Heywood Hospital's Community Investment Committee reviews mid and end year reports for financial and operational compliance to assure that use of funds are consistent with the approved project and budget. Montachusett Home Care Corp files an annual report with the Office of Healthy Communities that contains a summary of how the funds are allocated. X X 0 1 X X X X X X 0 0 0 0 0 1 0 0 0 Winfield Brown President/CEO 480315 0 93000 0 277976 0 23300 0 47630 0 922221 0 0 Elizabeth Nottleson Trustee 0 260326 0 0 0 15365 0 5370 0 13835 0 294896 0 Benjamin Prentiss Trustee 0 374797 0 40215 0 598 0 7653 0 32771 0 456034 0 0 Robert Crosby Sr VP of Finance / CFO 280484 0 41602 0 2727 0 23300 0 33918 0 382031 0 0 0 Michael Grimmer VP of Support Services 222642 0 31562 0 7148 0 21458 0 31582 0 314392 0 0 0 Bruce Bertrand Chief Medical Officer 265122 0 24700 0 3857 0 23300 0 14238 0 331217 0 0 0 Rose Kavalchuck VP of Prof. Services 202888 0 51298 0 2918 0 20708 0 26288 0 304100 0 0 0 Karen McArdle-Coggins HMG President 185250 0 0 0 944 0 18000 0 12076 0 216270 0 0 0 Rebecca Bialecki VP of Community Health Relations 147933 0 22221 0 1338 0 21097 0 23596 0 216185 0 0 0 Tina Santos VP of Patient Care Services 240146 0 34800 0 782 0 22405 0 15804 0 313937 0 0 0 Carol Roosa Chief Info Officer / VP of Info Services 166900 0 18839 0 834 0 21523 0 29098 0 237194 0 0 0 Dawn Casavant VP of External Affairs 156998 0 0 0 508 0 21313 0 28377 0 207196 0 0 0 Tina Griffin Athol Chief Nursing Officer/VP of Pat. Care Svcs. 198927 0 29500 0 1829 0 21313 0 26019 0 277588 0 0 0 Andrew Cocchiarella Director of Anesthesia Services 676041 0 32500 0 840 0 0 0 43870 0 753251 0 0 0 Steven Yerid Chief of ER Medicine 399816 0 53809 0 7030 0 22300 0 21243 0 504198 0 0 0 Ellen Ray Chief of ER Medicine 311010 0 35735 0 16116 0 22059 0 34198 0 419118 0 0 0 Sarah Gilbert ER Physician 294628 0 46260 0 997 0 18455 0 32458 0 392798 0 0 0 Marc DeBell ER Physician 297646 0 27506 0 359 0 14994 0 24298 0 364803 0 0 0 Schedule J, Part I, Line 1a Travel expenses for the CEO's wife were paid through the hospital. Additionally, Social Club Membership dues provided to Winfield Brown, CEO, per his employment contract. Schedule J, Part I, Line 1b There was no written policy for the Social Club Membership dues; it was part of his employment contract. Schedule J, Part I, Line 6 Heywood Hospital accrues 15% of the executive team's salary as part of an incentive compensation program, and service goals are set by the Hospital's Trustees. A MA Health & ED Facility 042456011 57586EGT2 2009-03-31 17785000 Funds used for new Watkins Building project 0 0 0 B MA Health & ED Facility 042456011 57586C7E9 2008-06-19 6715000 Refunding used for new Watkins Building project 0 0 0 A 0 0 66235 0 0 0 281690 0 0 17569545 0 0 2010 0 0 1 1 B 0 0 19154 0 0 0 329467 0 3597891 2806796 0 0 2008 1 0 1 1 A 0 0 0 0 0 0 0 1 0 1 B 0 0 0 0 0 0 0 1 0 1 A 0 0 0 1 1 1 TD Bank 18.7 0 0 0 0 1 B 0 0 0 1 1 1 Piper Jaffrey 18.7 0 0 0 0 1 A 0 B 0 Schedule K, Part IV, Line 2c-03/31/2009 17,785,000 MA Health & ED Facility The rebate computation was performed on November 21, 2016. Schedule K, Part IV, Line 2c-06/19/2008 6,715,000 MA Health & ED Facility The rebate computation was performed on November 21, 2016. Heather Bialecki-Canning daughter of Officer-RB 51460 Salaries as NQCC Director 0 Brigitte Flick wife of Trustee J.Flick 29487 Salaries as philanthropy coor. 0 Eliot Nottleson husband of Trustee - EN 114998 Salaries as Phys. Assistant 0 Kaitlin Fletcher family member of Trustee - JF 66944 Salaries as RN 0 Form 990, Part VI, Section B, Line 11b The accountant at Heywood Hospital prepares the Form 990 and provides 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 The CEO and Executive Staff's compensation is determined by market data and analysis provided to the Hospital's Compensation Committee and Board of Trustees by an independent compensation consultant engaged by the Board of Trustees annually. Winfield Brown, CEO, also receives an annual contribution as payment for deferred compensation which is subject to a multi-year vesting schedule that is incumbent upon his ongoing employment. 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 VII, Section A, Line 1a Elizabeth Nottleson, Trustee to the Organization, received compensation from the organization as Medical Director and not for serving on the Board. Additionally, she received wages from a related organization for her employment as Family Practice Physician. Benjamin Prentiss, Trustee to the Organization, received compensation from the organization as Medical Staff President and not for serving on the Board. Additionally, he received wages from a related organization for his employment as Cardiology Physician. Form 990, Part IX, Line 11g Other Non-Employee Fees for Services consist of the following: Outside Physician Fees 8,981,290 Outside Clinical Fees 5,415,954 Temporary Employees 191,128 Medical Staff 19,581 Form 990, Part XI, Line 9 The amount that makes up the other changes in net assets or fund balance is from discounts on pledge receivables, $9,017, and transfers to related organizations to support their operations, $4,860,728. Heywood Healthcare Inc (HHI) 242 Green St Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 12b N/A 0 Athol Memorial Hospital 2033 Main St Athol MA 01331 042126583 Hospital MA 501(c)(3) 3 HHI 0 Heywood Medical Group 242 Green St Gardner MA 01440 043136589 Employ Physicians MA 501(c)(3) 10 HHI 0 Quabbin Healthcare Inc 242 Green St Gardner MA 01440 812053488 Behavioral Health Services MA pending pending HHI 0 Heywood Realty Corp 242 Green St Gardner MA 01440 043327447 Property Holding Co MA 501(c)(2) HHI 0 Heywood Healthcare Charitable Foundation 242 Green St Gardner MA 01440 222720562 Charitable Foundation MA 501(c)(3) 7 HHI 0 HHMH Aid Association 242 Green St Gardner MA 01440 042198019 Raising funds for Hospital MA 501(c)(3) 10 HHI 0 Winchendon Health Foundation 87 Central St Winchendon MA 01475 042113276 supports organization MA 501(c)(3) PF N/A 0 0 0 1 0 0 0 1 0 1 1 1 1 1 1 1 1 1 1 1 Heywood Realty Corp k 92810 cost per sq ft Heywood Realty Corp l 208500 contract Heywood Realty Corp o 111291 actual cost Schedule R, Part II Quabbin Healthcare Inc. is a newly established corporation in our FY 2016. We are still in process of filing for exemptions which is why the status is "pending". This corp will be Behavioral Health and Addiction Recovery services.