2017-05-08T13:30:02-07:00 2016-09-30 990 2015-10-01 042126583 ATHOL MEMORIAL HOSPITAL INCORPORATED ATHO 9782493511 2033 Main Street Athol MA 01331 Robert Crosby CFO 9786305008 2017-04-25 2015 2021-01-29 14:40:06Z Robert Crosby Heywood Hospital 242 Green St Gardner MA 01440 26904663 0 X www.atholhospital.org X 1918 MA Our vision is to be one of the best independent community hospitals in America. Our mission is to be our communities' trusted choice for exceptional patient-centered care. 20 17 257 22 0 0 824733 1690173 22536620 25046682 -11057 1250 554748 147250 23905044 26885355 0 14867 0 0 9560732 8862206 0 0 62818 14695160 16163708 24255892 25040781 -350848 1844574 10349937 13071779 7774238 7154509 2575699 5917270 Our mission is to be our communities' trusted choice for exceptional patient-centered care. 0 0 23156101 0 25048682 Athol Memorial Hospital is a critical access hospital (CAH) serving the nine towns of North Quabbin Region. The areas relatively small population is dispersed over a large geographic area. Inherent in the Hospital mission of providing healthcare services are efforts to help improve the health and lives of our community. This intent is the framework for our community benefits activities. 0 0 0 23156101 1 1 0 0 0 0 0 0 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 60 0 1 257 1 0 0 0 0 0 0 0 0 0 0 X 20 17 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 1 0 MA X Heywood Hospital Robert Crosby 9786306157 242 Green Street Gardner MA 01440 Kenneth Pierce Chairman 0.2 X 0 0 0 Glenn Hunt Vice Chairman 0.2 X 0 0 0 Roy Lake Treasurer 0.2 X 0 0 0 Cheney Castine Esq Treasurer 0.2 X 0 0 0 JoAnne Parks Clerk 0.2 X 0 0 0 Daniel Asquino Trustee 0.2 X 0 0 0 Robert Chauvin Trustee 0.2 X 0 0 0 Joyce Fletcher Trustee 0.2 X 0 0 0 John Flick Esq Trustee 0.2 X 0 0 0 James Garrison Trustee 0.2 X 0 0 0 James Meehan Trustee 0.2 X 0 0 0 Donald Mruk MD Trustee 0.2 X 0 0 0 Michele Parker MD Trustee 0.2 X 0 0 0 Tina Sbrega Trustee 0.2 X 0 0 0 Joel Shaughnessy Trustee 0.2 X 0 0 0 John Skrzypczak MD Trustee 0.2 X 0 0 0 Craig Twohey Trustee 0.2 X 0 0 0 Winfield Brown President/ CEO 0.2 40 X X 0 782320 73748 Elizabeth Nottleson Trustee/Family Physician 0.2 28 X 0 327410 20721 Kami Phillips Trustee/Family Physician 0.2 24 X 0 28430 1422 Robert Crosby VP of Finance 0.2 40 X 0 312908 56616 Michael Grimmer VP of Support Services 0 40 X 0 256070 52195 Rebecca Bialecki VP of Community Health Relations 0 40 X 0 132623 26430 Tina Griffin VP/CNO 0 40 X 0 198861 30503 Dawn Casavant VP of External Affairs 0 40 X 0 167495 48415 Carol Roosa CIO 0 40 X 0 178925 49077 Rose Kavalchuck VP of Professional Services 0 40 X 0 199198 45924 Bruce Bertrand Chief Medical Officer 0 40 X 0 263226 36548 Mark Wu Surgeon 40 0 X 280687 0 19422 Jordan Bergeron Director of Nursing 40 0 X 108197 0 26147 388884 2847466 487168 2 0 1 0 Quartulli & Associates PO Box 423 Gardner MA 01440 PT & OT Services 891746 New England Inpatient Specialists 120 Water Street North Andover MA 01845 Hospitalists Physicians 606654 Quest Diagnostics 12436 Collections Center Dr Chicago IL 60693 Clinical Laboratory Services 173569 St Vincent Physician Services 123 Summer Street Worcester MA 01608 ER & Hospitalist Physicians 150000 Littler Mendelson PC PO Box 45547 San Francisco CA 94145 Legal Services 123108 5 0 0 32826 0 419262 1238085 0 1690173 Ancillary OP Services 622110 17799055 17799055 0 0 Ancillary IP & Routine Services 622110 7010054 7010054 0 0 Anesthesia Patient Revenue 622110 109468 109468 0 0 MRI Scan Income 622110 82346 82346 0 0 Occupational Health/CPR Classes 622110 30526 30526 0 0 15233 15233 0 0 25046682 2573 0 0 2573 0 0 0 0 0 0 0 0 650 0 0 0 650 0 650 0 0 650 0 3711 0 5034 0 -1323 -1323 0 0 -1323 8552 32826 14274 -5722 0 -5722 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722212 100244 0 0 100244 Refunds/Settlements 900099 13781 0 0 13781 Gift Shop/Auxilliary 453220 34538 0 0 34538 3759 0 0 3759 152322 26885355 25046682 0 148500 X 14367 14367 500 500 0 0 0 0 0 0 0 0 0 0 0 0 7239838 7145745 94093 0 57752 56566 1186 0 988370 969657 18713 0 576246 570706 5540 0 0 0 0 0 107176 1219 105957 0 11177 0 11177 0 0 0 0 0 0 0 0 0 0 0 4604047 4604047 0 0 25264 25264 0 0 2634901 2578420 56481 0 0 0 0 0 0 0 0 0 367968 367968 0 0 14965 12320 2645 0 0 0 0 0 25851 24797 1054 0 34303 34303 0 0 0 0 0 0 946606 943787 2819 0 148809 40905 107904 0 Professional Fees 4721516 3316250 1342448 62818 Bad Debt 1397114 1397114 0 0 Free Care 636688 636688 0 0 Outside Repairs 104380 104380 0 0 382943 311098 71845 0 25040781 23156101 1821862 62818 881817 1570114 0 0 0 1049267 2529286 2935877 0 0 0 0 0 0 348237 342920 175940 157277 15394541 9754028 4790013 5640513 0 0 1604644 1370811 0 0 0 0 20000 5000 10349937 13071779 5158156 4878060 0 0 8126 45171 0 0 0 0 0 0 636159 77920 0 0 1971797 2153358 7774238 7154509 X 1184246 3497193 69734 1081080 1321719 1338997 2575699 5917270 10349937 13071779 X 1844574 17349 0 0 0 1479648 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1391453 94080 18408 0 133124 6 1370811 1546049 63274 -139376 0 78492 2 1391453 1559197 54696 -2219 0 65622 3 1546049 1428736 15816 1091 0 -113554 0 1559197 968215 359388 137402 0 36269 0 1428736 0 0.977 0.023 0 0 0 104490 104490 0 6260321 4364429 1895892 0 0 0 0 0 7402304 5389599 2012705 0 1627426 0 1627426 5640513 0 0 Donor Restricted Investments 1370811 F 1370811 0 Estimated Third Party Settlements 2148358 Estimated Malpractice Liability 5000 2153358 X Schedule D, Part V, Line 4 The Organization's endowment includes both donor restricted endowment funds and funds designated by the Board of Trustees to function as endowments. As required by GAAP, net assets associated with endowment funds, including funds designated by the Board of Trustees to function as endowments, are classified and reported based on the existence or absence of donor-imposed restrictions. The Organization has interpreted state law as requiring realized and unrealized gains of permanently restricted net assets to be retained in a temporarily restricted net asset classification until appropriated by the Organization's Board of Trustees and expended. State law allows the Board to appropriate as much of the net appreciation of permanently restricted net assets as is prudent considering the Organization's long and short-term needs, present and anticipated financial requirements, expected total return on investments, price-level trends, and general economic conditions. Schedule D, Part X, Line 2 Heywood Healthcare, Heywood Hospital, Athol, HMGI,Charitable Foundation, and Quabbin Healthcare have been determined to be not-for-profit corporations as described in Section 501(c)(3) of Internal Revenue Code(the "Code"). and the Realty Corp. has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Code. All of the entities are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2012 through the current year remain open for examination by federal and state taxing authorities. Additionally, the Organization has filed all applicable returns, as required, in jurisdictions where so required. For the years ended September 30, 2015, there were no interest or penalties recorded or included in the statement of operations. Golf Tournament 41378 32826 8552 0 1622 5210 3844 0 3598 0 0 41378 32826 8552 0 1622 5210 3844 0 3598 14274 -5722 1 1 1 X 1 X 1 1 1 0 1 1 348662 221456 127206 0.0051 6076660 5822504 254156 0.0101 0 0 0 0 0 0 6425322 6043960 381362 0.0152 390535 0 390535 0.0155 2860 0 2860 0.0001 0 0 0 0 0 0 0 0 13517 0 13517 0.0005 0 0 406912 0 406912 0.0161 0 0 6832234 6043960 788274 0.0313 0 0 0 0 0 0 0 0 225 0 225 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 225 0 225 0 1 466766 0 6187651 6139983 47668 X 1 1 1 1 Athol Memorial Hospital 2033 Main Street Athol MA 01331 www.atholhospital.org 2226 X Athol Memorial Hospital 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X www.atholhospital.org X www.jointcoalitiononhealth.org X 1 15 1 www.atholhospital.org 0 0 1 X 100 400 X 1 1 X X X X 1 X www.atholhospital.org X www.atholhospital.org X X X X X 1 X X 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 3-Athol 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-Athol Memorial Hospital Athol 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-Athol Memorial Hospital Hospitals included in the development of the 2015 Community Health Needs Assessment are Athol Hospital, Athol, MA; Heywood Hospital, Gardner, MA; HealthAlliance Hospital, Leominster, MA. Schedule H, Part V, Section B, Line 6b-Athol 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-Athol Memorial Hospital Athol Hospital's approach to addressing the critical health needs identified by the CHNA is through outreach, education, and support to the communities we serve. Hospital members actively participate on and collaborate with cross-sector coalitions, healthcare and behavioral health providers, community, and faith-based organizations and businesses to develop and implement our plan, goals, and strategies. Partners include: North Quabbin Community Coalition; Valuing our Children; Franklin Hampshire North Quabbin Opiate Prevention Task Force; The Regional Behavioral Health Collaborative; Athol and Royalston Boards of Health; Suicide Prevention Task Force; Athol YMCA; Athol Public School District; Athol, Erving, and Winchendon Senior Center; Phillipston Congregational Church; Salvation Army. Key Accomplishments of Reporting Year: * Partnered with the Athol Schools to address food insecurity by providing food assistance to 50 low- income and at-risk youth through a weekend backpack food program. * Promoted healthy summer habits for youth by educating over 225 youth and their families on Lyme disease, benefits of exercise and healthy eating, sun safety and skin cancer detection. * Provided health information about heart disease and offered free blood pressure screenings to over 50 individuals. * Promoted wellness by providing flu prevention education in community settings and free flu vaccinations to 75 individuals. * Promoted mental health awareness and substance use prevention by educating 135 community members and business leaders on recognizing signs and symptoms of substance abuse; sponsoring free disposal of sharps and needles; and supporting men to gain self-care techniques to better manage their behavioral health and/or addiction issues. * Provided 2,421 individuals with counseling on health insurance coverage and financial assistance. Completed 620 health insurance applications and made 367 referrals to reduce barriers to accessing health care and social supports. * Assisted 149 patients with transportation and as a result were able to follow up with their healthcare and prevented missed appointments. * Actively participated on community boards and committees including, the North Quabbin Community Coalition, Athol YMCA Diabetes Prevention Advisory Board, Valuing our Children, Franklin Hampshire North Quabbin Opiate Prevention Task Force, and the Regional Behavioral Health Collaborative, to collaboratively address community health needs and gaps in services. Schedule H, Part I, Line 7 The costing methodology used to calculate the amounts reported in the table in Part I, for lines 7a through 7c was based on the cost to charge ratio derived from the supplied Worksheet 2, in the IRS schedule H instructions. Schedule H, Part II The Athol Hospital's Community Benefits Mission Statement is "Athol Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the specific health needs of the under-served and collaborating with others to enhance quality and contain the growth of community healthcare costs." Schedule H, Part III, Section A, Line 2 The costing methodology used for line 2 was based on the cost charge ratio derived from the supplied worksheet 2 in the IRS Schedule H instructions. Schedule H, Part III, Section A, Line 3 The methodology used for line 3 was to take the percentage of financial assistance applications that were due to inadequate documentation divided by the total applications received for FY 2016. This amounted to approximately 0% which was applied against the number on line 2. As a tax exempt hospital, we must provide necessary services regardless of the patient's ability to pay for the service provided. As a not for profit, patient care is provided to all, regardless of ability to pay for that care, making quality patient care available to all in our community, regardless of their economic means, qualifies bad debts as community benefit. Schedule H, Part III, Section A, Line 4 The footnote can be found on Page 8 of the financial statements - footnote #2 under "Allowance of Doubtful Accounts". 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 2016. This amounted to approximately 0% which was applied against the number on line 2. As a tax exempt hospital, we must provide necessary services regardless of the patient's ability to pay for the service provided. As a not for profit, patient care is provided to all, regardless of ability to pay for that care, making quality patient care available to all in our community, regardless of their economic means, qualifies bad debts as community benefit. Schedule H, Part III, Section B, Line 6 The allowable costs on line 6 were obtained from our FY 2016 Medicare Cost Report, Worksheet D schedules. Schedule H, Part III, Section B, Line 8 There is no shortfall. Schedule H, Part III, Section C, Line 9b Athol Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of MA or through Athol Hospital's own financial assistance program, which may cover all or some of their unpaid hospital bills. For those patients that request such assistance, Athol Hospital assists patients by screening them for eligibility in an available public program and assisting them in applying for the program. These programs include but are not limited to MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net and others. It is the patient's obligation to provide Heywood Hospital with accurate and timely information to determine of the patient is eligible to apply for certain health insurance programs. If the patient of guarantor is unable to provide the necessary information Athol Hospital may make reasonable efforts to obtain any additional information from other sources. Information the Heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for public health insurance program is done through Virtual Gateway, which is an internet portal designed by the MA Executive Office of Health and Human Services. The Virtual Gateway manages the application process from the programs listed above, which is available for children, adults, seniors, Veterans, homeless and disabled individuals. Athol Hospital specifically assists the patient in completing the application and secure the necessary documentation required by the applicable financial assistance program. Athol Hospital will then submit this document to the Commonwealth Office of Medicaid and assist the patient in any additional documentation if such is required by the Commonwealth after completing the application. All Virtual Gateway applications are reviewed and processed by the Commonwealth of MA, Office of Medicaid. Special circumstance applications are reviewed and approved by the MA Division of Health Care Finance and Policy. Hospitals have no role in determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing decisions made by the Commonwealth to ensure accurate and timely adjudication of all hospital bills. If the patient does not comply with the request for documentation, then our standard collection procedures apply. Schedule H, Part VI, Line 2 Athol 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; North Quabbin Community Coalition; Multicultural task force; Greater Gardner Religious Council and Gardner Rotary. 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 Athol Hospital Service Area is comprised of the city of Athol and the surrounding towns of the North Quabbin region, Orange, Petersham, Phillipston, Royalston, New Salem, Wendell, Erving and Warwick. The designated rural area has a population of approx. 28,000, with a median income below the state average and an unemployment rate above the state average. The area has identified social determinants of health related to its rural nature, such as isolation, high unemployment, low wages, lack of transportation and access to healthcare. Schedule H, Part VI, Line 5 Athol 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: Partner with The Athol Royalston Regional School District to offer food assistance to low-income and at-risk youth through a weekend backpack food program; Provide health information by participating at community health fairs and events at venues reaching vulnerable populations; offer support groups for cancer survivors; Offer CPR and first aid training to community members unable to afford the classes; Educate the community and implement a program of safe disposal of sharps and 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 7 Community Benefit Report is filed with Attorney General's Office, State of Massachusetts. 1 Athol Royalston Middle School 1062 Pleasant St Athol MA 01331 046006370 11567 Camera Equipment Capital equipment donation 1 0 Schedule I, Part I, Line 2 Athol Hospital purchased the donated equipment. 0 0 0 0 0 0 0 1 0 Mark Wu Surgeon 258980 0 18849 0 2858 0 2914 0 16508 0 300109 0 0 0 Winfield Brown President/ CEO 0 459347 0 52728 0 270244 0 23200 0 50549 0 856068 0 Elizabeth Nottleson Trustee/Family Physician 0 311718 0 15326 0 366 0 6000 0 14721 0 348131 0 0 Robert Crosby VP of Finance 0 271280 0 39000 0 2628 0 23300 0 33316 0 369524 0 0 Michael Grimmer VP of Support Services 0 217471 0 18818 0 19781 0 21281 0 30914 0 308265 0 0 Tina Griffin VP/CNO 0 197106 0 0 0 1754 0 5963 0 24540 0 229363 0 0 Carol Roosa CIO 0 154834 0 23515 0 575 0 21288 0 27789 0 228001 0 0 Dawn Casavant VP of External Affairs 0 147098 0 20161 0 236 0 21107 0 27308 0 215910 0 0 Bruce Bertrand Chief Medical Officer 0 257653 0 751 0 4822 0 22996 0 13551 0 299773 0 0 Rose Kavalchuck VP of Professional Services 0 196386 0 0 0 2812 0 21110 0 24814 0 245122 0 0 Rebecca Bialecki VP of Community Health Relations 0 119571 0 12500 0 552 0 4896 0 21534 0 159053 0 0 Schedule J, Part I, Line 3 The CEO's compensation is paid by Heywood Hospital, a related organization and is determined by market data and analysis provided to the Hospital's Compensation Committee and Board of Trustees by an independent compensation consultant engaged by the Board of Trustees annually. Schedule J, Part I, Line 7 Dr. Mark Wu has an employment contract with Athol Hospital for a Physician Bonus Award. This contract states "In each year, your bonus will be calculated based upon Employer receiving net receipts in excess of the Physician Base Salary. In addition, the Employer will be entitled to recoup up to $30,000 in Personal Insurance Benefits prior to the processing of the Bonus Award. After the Base Salary and the above mentioned Personal Insurance Benefits, the incentive will be split 40% for the Hospital and 60% for the Physician". For the period of January 1, 2015 through December 31,2015, Dr. Wu earned $18,849 for a bonus incentive. The entire amount was paid in Fiscal year 2015. Form 990, Part VI, Section B, Line 11b The Accountant for Athol Hospital prepares the form 990 and provides it to the Senior Accountant and Controller for review. The form is then sent to the CFO for final review. Once approved and signed, form 990 is placed on the Hospital Cyber Board for the Board of Trustees' review. Form 990 is then approved by the Board and submitted by the Accounting Department. Form 990, Part VI, Section B, Line 12c The Board of Trustees review the Organization's Conflict of Interest policy annually in order to ensure that the Organization's Board of Trustees, Officers, and Employees are regularly and consistently monitoring and enforcing it. Form 990, Part VI, Section B, Line 15 Salaries are determined by the Board of Directors considering comparable salary information for Officers of other entities of similar size and level of activity. 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 Executive Assistant, who provides copies upon request. Form 990, Part IX, Line 11g The expenses that make up this line are as follows: Physician Fees of $3,365,436, Outside Clinical fees of $903,300. Temporary Employees of $324,911, Medical Staff of $9,000 and Other Contracted Services of $1,400. Form 990, Part XI, Line 9 The other changes in net assets relates to discounts on pledges receivable of $(23,976) and $1,503,624 from a related organization to support operations. Heywood Healthcare Inc 242 Green Street Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 11b N/A 0 Heywood Healthcare Charitable Foundation Inc 242 Green Street Gardner MA 01440 222720562 Charitable Foundation MA 501(c)(3) 7 Heywood Healthcare Inc 0 Henry Heywood Memorial Hospital 242 Green Street Gardner MA 01440 042103581 Hospital MA 501(c)(3) 3 Heywood Healthcare Inc 0 Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 Multi-Specialty Physicians MA 501(c)(3) 9 Heywood Healthcare Inc 0 Heywood Realty Corp 242 Green Street Gardner MA 01440 043327447 Property Holding Corp MA 501(c)(2) Heywood Healthcare Inc 0 Quabbin Healthcare Inc 242 Green St Gardner MA 01440 812053488 Behavioral Health MA Pending Pending Heywood Healthcare Inc 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 1