2016-08-12T10:34:18-05:00 2015-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2014-10-01 020222118 Valley Regional Hospital Inc VALL 6035427771 243 Elm Street Claremont NH 03743 Jean Shaw CFO 6035427771 2016-08-09 1 Barbara J McGuan CPA P00219457 2077752387 2016-08-09 2014 2016-09-27 15:27:22Z Peter Wright 243 Elm Street Claremont NH 03743 39238765 0 X www.vrh.org X 1893 NH Critical Access Hospital 19 15 415 32 0 0 201019 41950 37721546 34864772 2053504 4131389 -26770 3749 39949299 39041860 0 0 0 0 21304708 21597628 0 0 0 19004578 18693941 40309286 40291569 -359987 -1249709 64279099 59416328 37958812 39543423 26320287 19872905 X The mission of Valley Regional Hospital, Inc. is to foster optimal and sustainable population health. Our vision is to provide compassionate, affordable, evidence-based, high quality care in partnership with the community. 1 0 32442669 34864772 Valley Regional Hospital is a provider of health services with facilities in the Claremont, NH area. The Hospital grants credit to patients, substantially all of whom are local residents. The Hospital also provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. The Hospital does not pursue collection of amounts determined to qualify as charity care. The Hospital maintains records to identify and monitor the level of charity care it provides. For the year ending September 30, 2015 charges forgone for services and supplies furnished under the charity care policy were approximately $1,092,000. The estimated cost of those services and supplies was approximately $747,000.In addition, the Hospital provides a number of other services to benefit certain poor and elderly patients. Medicaid and state programs do not cover the full cost of the Hospital incurred cost of providing medical care to patients. The hospital provides services to residents throughout the region. Those services include health evaluations, screenings, and flu vaccine administration at community events and in the workplace. Health education, wellness, chronic disease management, fitness, and ergonomic programs are also widely offered. For these services, and many other community services, the hospital receives little or no payment.Other community benefits can't be quantified or assigned a value. For example, the hospital provides committee and board participants and expertise to address community needs; to support community health initiatives; to advocate for and support individuals who are socially, economically and physically challenged; and to collaborate with the local public safety organizations. 32442669 1 1 0 1 0 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 50 0 1 415 1 0 0 0 0 0 0 0 0 0 0 X 19 15 0 0 0 0 1 1 1 1 1 0 0 1 1 1 0 1 1 1 1 0 NH X Jean Shaw 6035427771 243 Elm Street Claremont NH 03743 Peter Wright President & CEO 38.40 1.60 X X 0 246174 22356 Robert Porter Trustee 0.90 0.10 X 0 0 0 Alison Raymond Trustee 0.90 0.10 X 0 0 0 Lisa Richmond Trustee 0.90 0.10 X 0 0 0 Bernard Rosen MD Trustee 0.90 0.10 X 0 0 0 Jim Wimberg Trustee 0.90 0.10 X 0 0 0 Michael O'Connell Chair 0.90 0.10 X X 0 0 0 Michael Satzow Trustee 0.90 0.10 X 0 0 0 Robert Cricco MD Trustee 39.90 0.10 X 100232 0 1552 Michael Fuerst Trustee 0.90 0.10 X 0 0 0 Oliver Herfort MD Trustee 39.90 0.10 X 266010 0 31596 Sherwood Moody Trustee 0.90 0.10 X 0 0 0 James Borchert Trustee 0.90 0.10 X 0 0 0 Charlene Lovett Vice Chair 0.90 0.10 X X 0 0 0 Patricia Putnam Treasurer 0.90 0.10 X X 0 0 0 Charles Sawyer MD Trustee 39.90 0.10 X 467331 0 21095 Allan Berggren MD Secretary 0.90 0.10 X X 0 0 0 John Tomlinson Trustee 0.90 0.10 X 0 0 0 Deanna Howard Trustee 0.90 0.10 X 0 0 0 Michael L Prozzo Jr Past Trustee 0.90 0.10 X 0 0 0 Allen Damren Past Trustee 0.90 0.10 X 0 0 0 Steven Monette Past VP of Finance 37.20 2.80 X 0 175720 898 Jean Shaw Interim CFO 35.00 5.00 X 78232 0 25029 Jeffrey A Hanissian Physician 36.00 0.00 X 341025 0 35215 Carl E Tetirick Physician 20.00 0.00 X 283942 0 23123 Clifford B Langweiler Physician 36.00 0.00 X 425052 0 29595 Ivar L Frithsen Physician 35.00 0.00 X 218147 0 25377 Robert L Bassett Physician 32.00 0.00 X 546381 0 32932 2726352 421894 248768 20 0 1 1 MedHost 2739 Momentum Place Chicago IL 606895327 IT System & Service 556841 CompHealth PO Box 972651 Dallas TX 753972651 Locum Tenens 460357 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Locum Tenens 381308 Alliance Healthcare Services Inc PO Box 6600 Newport Beach CA 926580000 MRI Services 301416 American Healthcare Staffing Association PO Box 945 Traverse City MI 496850000 Contract Staffing 256814 12 4660 14362 22928 41950 Patient Service Revenue 621400 58899412 58899412 Other Revenue 900099 1394224 1249931 144293 Provision for Bad Debts 621400 -3113834 -3113834 Charity/Contractual Adjustment 621400 -22315030 -22315030 34864772 636528 636528 156621 152872 3749 3749 3749 3495017 19317 0 19473 3495017 -156 3494861 3494861 24560 4660 24560 0 39041860 34720479 0 4279431 X 991077 908467 82610 15891463 12994994 2896469 165365 134731 30634 3434602 2837345 597257 1115121 918748 196373 11231 11231 59938 59938 194639 194639 6650925 5778908 872017 351664 289736 61928 805198 663403 141795 2149621 1771073 378548 26946 22200 4746 1073720 1073720 2130271 1755130 375141 340516 340516 Medical Supplies 2673463 2202666 470797 Medicaid Enhancement Ta 1882003 1882003 Miscellaneous 221748 182701 39047 Dues & Subscriptions 122058 100564 21494 40291569 32442669 7848900 0 X 474190 179189 11151864 9379138 3170444 3633953 634981 666268 394330 470813 46247975 28635975 18927874 17612000 23051682 22085835 3976203 3621100 181893 167738 2315638 1600294 64279099 59416328 3834040 4148232 80774 79404 24775000 24240000 9268998 11075787 37958812 39543423 X 20765173 14770901 1325017 1227010 4230097 3874994 26320287 19872905 64279099 59416328 -1249709 -5197673 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 10997 10997 0 Part II-B, Line 1: The Organization pays dues to local associations, a portion of which are attributable to lobbying activities. 5350477 0 -400894 847 4948736 4934551 63 416864 1001 5350477 4685173 67 250258 947 4934551 4044562 72 640539 4685173 4115180 355 -58567 12406 4044562 0.00000 0.78300 0.21700 0 0 250667 250667 16750441 9117000 7633441 148235 124387 23848 27917802 18703547 9214255 1180830 691041 489789 17612000 Beneficial Interest in Perpetual Trusts 3621100 F 3621100 Due To Affiliates 104620 Estimated Third-Party Payor Settlements 7688161 Interest Rate Swaps 2594474 Reserve for Self-Funded Insurance 663006 Deferred Compensation 25526 11075787 33817109 -5197673 177432 -5020241 38837350 194640 9870 204510 39041860 40264491 177432 177432 40087059 194640 9870 204510 40291569 Part V, Line 4: The Organization uses its endowment funds in support of health care services, purchases of equipment, health education, and indigent care. Part XI, Line 2d - Other Adjustments: Rental Expenses 152,872. Fundraising Expenses 24,560. Part XI, Line 4b - Other Adjustments: Other Nonoperating Expenses Included in Revenue 9,870. Part XII, Line 2d - Other Adjustments: Rental Expenses 152,872. Fundraising Expenses 24,560. Part XII, Line 4b - Other Adjustments: Other Nonoperating Expenses Included in Revenue 9,870. Golf Tournament 29220 4660 24560 4920 5825 1881 11934 29220 4660 24560 4920 5825 1881 11934 24560 0 1 1 X 1 X 1 X 275.000000000000 1 1 0 1 1 2554926 1845526 709400 0.01760 6727904 4200566 2527338 0.06270 9282830 6046092 3236738 0.08030 268287 44312 223975 0.00560 154820 154820 0.00380 233246 233246 0.00580 12313 12313 0.00030 668666 44312 624354 0.01550 9951496 6090404 3861092 0.09580 3000 3000 0.00010 58746 58746 0.00150 21698 21698 0.00050 3500 3500 0.00010 86944 86944 0.00220 1 1918122 11396435 11396435 X 1 1 1 1 Valley Regional Hospital Inc 243 Elm Street Claremont NH 03743 www.vrh.org 00007 X X X X Valley Regional Hospital Inc 1 0 0 1 X X X X X X X X X 14 1 1 0 1 X www.vrh.org X X 0 0 1 X 200.000000000000 275.000000000000 X X X X 1 1 X X X 1 X www.vrh.org X www.vrh.org X X X X 1 X 0 X X X 1 X 0 0 Valley Regional Hospital, Inc. Part V, Section B, Line 5: During the period March through July, 2015, a Community Health Needs Assessment in the Valley Regional Hospital service area of New Hampshire was conducted by Valley Regional Hospital in partnership with New London Hospital, Alice Peck Day Memorial Hospital, Dartmouth-Hitchcock, and Mt. Ascutney Hospital and Health Center. Information gathering utilized in the assessment included the following: 1. Area residents survey made available through direct mail and website links 2. Physical surveys and survey collection boxes in public places throughout the region - chamber of commerce offices, physicians' offices, libraries 3. Survey of key community stakeholders who are agency, municipal, or community leaders, including: - Dr. Karen Baranowski, Executive director Connecticut Valley Homecare and Hospice - Elyse Crossman, ED Greater Claremont Chamber of Commerce - Ella Casey, ED Newport Chamber of Commerce - Dr. Middleton McGoodwin (and staff), Superintendent of Schools SAU #6 - Dr. Cindy Gallagher (and staff), Superintendent of Schools SAU #43 - Nancy Merrill, Administrator, City of Claremont - Dr. Aurora Drew, Public Health Advisory Council - Jessie Levine, Sullivan County Manager - Deborah Mozden, ED Turning Points Network - Maggie Monroe-Cassel, ED TLC - Corey Gagnon, ED Community Alliance - Dr. Richard Root, Valley Regional Healthcare - Curtis Harvie, APRN, Valley Regional Healthcare - Tracy Pike, RN, Emergency Department Manager 2. community member discussion groups convened at soup kitchens, homeless shelters, recovery communities 3. review of available population demographics and health status indicators. Valley Regional Hospital, Inc. Part V, Section B, Line 6a: Valley Regional partnered with the following other local hospitals: - New London Hospital - Alice Peck Day Memorial Hospital, - Dartmouth-Hitchcock Medical center - Mt. Ascutney Hospital and Health CenterThere is significant overlap in service area among these organizations; the CHNA identified both regional and community-specific needs. Valley Regional Hospital, Inc. Part V, Section B, Line 7d: The CHNA was widely distributed in traditional ways (hard copy mailings, website, handouts at community meetings, etc) as well as via a recorded community access cable television program. Valley Regional Hospital, Inc. Part V, Section B, Line 11: CHNA Implementation StrategyThe issues identified through the Community Health Needs Assessment far outstrip the ability of a single entity to ameliorate those issues. Valley Regional Healthcare (VRH) is an active partner in determining ways to address every one of the identified issues; we are doing so across the healthcare system, in collaboration with many other local non-profit groups.Cost of prescription drugs and access to enough, affordable health insurance:The uninsured rate in the VRH service area (13%) is higher that the NH state average (10.5%). Our implementation strategy to address this indicator is as follows:1. VRH advertises that its Case Management staff will work with any community member or patient to help with insurance issues - completing forms, identifying options, and providing the avenue for uncompensated care. That information is on our website and published in multiple media. 2. VRH staff works closely with other agencies - Service Link, DHHS, local schools - to provide assistance and financial aid.Access to dental health care:1. Sullivan County Oral Health Collaborative (SCOHC) was established in March of 2004 to identify oral health needs and create access to dental care in Sullivan County. This collaboration of community leaders includes the Claremont Dental Initiative, Pathways of the River Valley, West Central Behavioral Health, Valley Regional Hospital, New London Hospital, United Way of Sullivan County, Claremont Kiwanis, and representatives from the dental community and public. 2. SCOHC creates access, while uniquely serving those most in need. As a non-profit, all profits from private and public payments go back into the business to create more access for all. 3. VRH supports SCOHC's efforts by loaning two senior staff members to provide financial and operational oversight. The "Loaned Trustee" concept is an expressed expectation of all senior managers, in support of smaller local non-profits.Access to primary health care:1. As part of the VRH business plan, an increase in primary care providers is a priority. Expanding services with the establishment of a new practice, Valley Primary Care, along with heavy marketing to educate the community about the availability of providers, has been a recent focus.2. Special fundraising has been done to support access to primary care for Sullivan County's 236 homeless school-aged children.Smoking/tobacco use:1. VRH has offered broadly advertised free smoking cessation classes, through its education department2. Tools to help people quit smoking are widely distributed at health fairs throughout the year.Poor nutrition/unhealthy food:1. VRH has partnered with the Claremont Soup Kitchen on a number of initiatives, including the creation of a community garden on hospital grounds. VRH also helps to orchestrate a free health clinic at the Soup Kitchen.2. VRH dietitians provide free counseling, demonstrations and classes, highlighting cooking techniques and healthy food choices. Lack of physical activity:1. VRH works with the Recreation Department and local schools to support all local outdoor activities such as 5k runs. We also provide a staff person who works as trainer for sports teams at Stevens High School.2. In order to model the behaviors we hope to change, VRH offers its employees many opportunities for physical activity, including classes and free use of the VRH rehab gym.Mental illness and access to mental health care:1. This is a top concern for community and state leaders. Lack of treatment options and residential treatment options means that the Emergency Department becomes a place where people need treatment are often stuck, awaiting placement. The utilization of our ED for mental health conditions far exceeds the state average.2. VRH has developed protocols to safely care for those patients who are awaiting placement; included service might be round-the-clock security (unreimbursed).3. A feasibility study and grant proposals have been underway for months; the business plan that will unfold will hopefully determine the financial efficacy of creating an involuntary psych unit here, to address the acute need.4. In terms of outpatient treatment and long term support for these individuals, there are not many resources, either financial or human, to address the problems. We work closely with many local organizations, including West Central Behavioral Health, and on many local wellness committees, in order to pool resources.Cancer:1. VRH's implementation strategy is two-fold:2. Prevention includes free screenings at health fairs, educational materials widely distributed, and public presentations by providers to help insure early detection and treatment.3. 3D Mammography screening is available, and has been financially supported philanthropically to insure women's access to screening.4. Our business plan for better patient care has moved us to re-establish an oncology practice at the hospital. Planning will come to fruition in the next year, when a newly trained infusion nurse will provide chemotherapy, and an oncologist will be on site a few days a week, saving cancer patients from needing to travel to receive treatments and other care.Income, poverty and family stress:1. While this issue is largely outside the purview of VRH, we are a large, local employer with a pay structure that reflects fair market, despite the depressed real estate market in most of Sullivan County. We also provide senior staff to work on local committees through the city, county, and Chambers of Commerce, with a goal of economic development.Care for seniors:1. VRH provides respite care and long term skilled nursing care at rates below those we charge for acute-stay rooms. 2. VRH providers work in partnership with senior centers and long-term care facilities in the area, providing screenings, clinics and educational opportunities. Alcohol and drug misuse:1. This is another area of conscious, consistent collaboration. At least three area-wide community groups are working to provide access to care and education for patients and families alike. VRH representatives act as leaders and committee members for all three groups.2. VRH has implemented SBIRT (Screening and Brief Intervention) into its primary care and pediatric practices, training providers and office staff to identify, intervene and refer when drug or alcohol issues are noted in teenagers.3. VRH hosts weekly Al-Anon meetings.Heroin and misuse of pain medications:1. Rate of ED use for substance abuse is more than double the rate for NH overall. 2. Community coalitions for wellness see this as the top priority. Recovery programs are viewed as an important area of focus.3. Senior staff participate fully in all community groups. VRH supports the various recovery programs both financially as well as through educational and professional partnerships. Valley Regional Hospital, Inc. Part V, Section B, Line 20e: Applications are offered to all self-pay patients along with education regarding NHHP and expanded Medicaid. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Valley Regional Hospital, Inc. Part V, Section B, line 16a website: www.vrh.org Valley Regional Hospital, Inc. Part V, Section B, line 16b website: www.vrh.org 1 Kane Oncology Center 243 Elm Street Claremont NH 03743 Oncology Center Part I, Line 3c: It is the policy of Valley Regional Hospital to provide financial assistance to those patients who are unable to pay for all or part of the cost of their care that is not covered by other sources of funding. Valley Regional Hospital's Financial Assistance Program is a program that assists uninsured and under-insured patients who meet specific income, geographical and Valley Regional Hospital guidelines.The Hospital will cover up to 100% of the cost of care for patients depending on the patient's level of income and family size. The Hospital also is a participating provider with the NH Health Access Network. Part I, Line 7: The Organization used an overall cost to charge ratio for lines 7a and 7b. Amounts listed on lines 7e, 7f and 7i were derived from internal financial/cost accounting systems. Part II, Community Building Activities: Valley Regional Healthcare believes the skills and knowledge of its employees are the most critical assets to building a strong and healthy community. VRH employees participate on a wide variety of local boards serving or participating in health and wellness missions, including dental health, domestic violence, higher education, school boards, chambers of commerce, United Way, public transportation, elder health, and substance abuse. Employees also participate on state level boards and within elected government, working to improve policy and practice on a broad spectrum. Local businesses rely upon collaborations with VRH to provide education and expertise in community building activities such as through public and private health fairs. VRH takes advantage of public chamber activities, such as the Chili and Apple Festivals, Winter Carnivals, and Spring Home Show to provide tables of health information and free screening activities. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance based on its assessment of individual accounts andhistorical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable.In evaluating the collectibility of accounts receivable, the Hospital analyzes past results 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 dataabout these major payor sources in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary. For receivables associated with self-pay patients (which include both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a provision for bad debts in the period of service based on past experience, which indicates that many patients are unable or unwilling to pay amounts for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated or eligible) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged against the allowance for doubtful accounts.During 2015, the Hospital decreased its estimate from $3,041,148 to $2,950,622 in the allowance for doubtful accounts relating to self-pay patients and during 2014 the Hospital decreased its estimate from $3,489,423 to $3,041,148 in the allowance for doubtful accounts relating to self-pay patients. During 2015, self-pay write-offs decreased from $4,597,314 to $3,188,142 and during 2014 self-pay write-offs decreased from $4,825,886 to $4,597,314. Such changes in write-off amounts resulted from trends experienced in the collection of amounts from self-pay patients.The Organization used a cost-to-charge ratio as its methodology for reporting bad debt expense at cost. Part III, Line 8: Medicare costs approximate Medicare revenue. The Organization does not anticipate a Medicare shortfall or that any such shortfall should be considered as community benefit. Part III, Line 9b: Patients who are known to qualify for financial assistance file a financial assistance determination application with the Hospital. If the application is approved, the patient's account shall be written off, in accordance to the level of adjustment the applicant was qualified to receive. The patient write-off guidelines are as follows:1. The determination is valid for 6 months from the date of signature for all applications except those individuals who demonstrate that they are on a fixed income (i.e. Social Security, retirment, disability), in which case approval is for 1 year from the date of signature.2. Patient qualifies according to the established Financial Assistance income guidelines3. Account notes must indicate what payor that the balance is due to (appropriate payor write-off codes to be utilized). Part VI, Line 2: The purpose of the assessment was to identify community health concerns, priorities and opportunities for community health and health care delivery systems improvement. Working with The Community Health Institute/JSI, VRH and our partner hospitals brought together key healthcare, public service and community member stakeholders to collect both qualitative and quantitative data. The CHNA provides a clear blueprint for community outreach and collaboration opportunities, and also creates a timely benchmark against which to measure progress.The purpose of the research design was as follows: 1. To clearly define the VRH service area 2. To define measurement methodologies which can identify community needs 3. To create a prioritized list of community resources 4. To develop a catalogue of available healthcare resourcesThe following health issues were identified by survey respondents: 1. Cost of prescription drugs 2. Alcohol and drug misuse 3. Access to enough, affordable health insurance 4. Heroin and misuse of pain medications 5. Access to mental health care 6. Lack of physical activity 7. Access to dental health care 8. Poor nutrition/unhealthy food 9. Income, poverty and family stress 10. Access to primary health care 11. Smoking/tobacco use 12. Mental illness 13. Cancer 14. Care for seniors Part VI, Line 3: The Community Engagement department has created and posted signage throughout the hospital and clinics, and has posted information on the hospital's website. Part VI, Line 4: Valley Regional serves a rural region which includes the 15 towns of Sullivan County and portions of eastern Vermont, with a total resident population of 43,742. Spanning 552 spare miles, it is the 2nd least populous county in NH. 10% of individuals live below the poverty line; 12.6% are under the age of 18, 7.9% over 65. Part VI, Line 5: Valley Regional Healthcare recognizes its importance to the community - economically, as one of the largest local employers, and philosophically, as a large entity entrusted with community wellness. VRH leadership instills in employees the sense of responsibility to be involved in support of the community, on behalf of the hospital.VRH employees participate and lend expertise as board members of other non-profits, including those focused on dental health, community revitalization, higher education and school boards, elder issues, public transportation, domestic violence, substance misuse and abuse, and health and wellness initiatives. Employees also participate on state and Federal boards and committees as well as Chambers of Commerce and United Way, working to improve policy and practice in healthcare delivery.Business collaborations are a priority, particularly with large employers such as Sturm Ruger, Crown Point Cabinetry, the City of Claremont, Parks and Recreation, CoWorx, and many local banks. Our common goals include health education, health screenings, worker safety and employment opportunities. Part VI, Line 6: Valley Regiona Hospital is not affiliated with another healthcare system, but it collaborates voluntarily with other hospitals. Sharing resources, both material and human, participating in community groups, providing sponsorships to other non-profits whose missions are aligned, contributing to disaster and international relief efforts, partnering with the American Red Cross for blood drives - all these things represent community benefits. Additionally, we provide free physical space for groups like Alcoholics Anonymous, local non-profits, Rotary, and community groups like Healthy Vibrant Claremont. Our physicians and other providers offer free wellness programming at locations throughout the communities we serve - at senior centers, schools, recreation venues. Part VI, Line 7, Reports Filed With States NH 0 0 0 0 0 0 0 1 0 Peter Wright President & CEO 0 245994 0 0 0 180 0 14216 0 8140 0 268530 0 0 Oliver Herfort MD Trustee 254766 0 2114 0 9130 0 5227 0 26369 0 297606 0 0 0 Charles Sawyer MD Trustee 456377 0 0 0 10954 0 8038 0 13057 0 488426 0 0 0 Steven Monette Past VP of Finance 0 175129 0 0 0 591 0 0 0 898 0 176618 0 0 Jeffrey A Hanissian Physician 333681 0 0 0 7344 0 4489 0 30726 0 376240 0 0 0 Carl E Tetirick Physician 230182 0 31000 0 22760 0 5178 0 17945 0 307065 0 0 0 Clifford B Langweiler Physician 425052 0 0 0 0 0 7381 0 22214 0 454647 0 0 0 Ivar L Frithsen Physician 204256 0 10000 0 3891 0 0 0 25377 0 243524 0 0 0 Robert L Bassett Physician 532515 0 10000 0 3866 0 4029 0 28903 0 579313 0 0 0 Part I, Line 3 Valley Regional Healthcare, Inc., a related organization, establishes the compensation for the Organization's CEO & CFO. Valley Regional Healthcare, Inc. uses a variety of resources to establish compensation as follows: 1. Form 990 of other organizations 2. Written employment contract 3. Compensation survey/study 4. Approval by the board/compensation committee Part I, Line 7 Individuals listed with Incentive Bonus amounts are physicians who under their employment agreements/contracts have a provision for Incentive Bonus based on their Relative Value Units (RVU) of services exceeding a target amount. Form 990, Part VII, line 5: Peter Wright, CEO is paid by Mary Hitchcock Memorial Hospital, an unrelated organization via a professional services agreement. A breakdown of Mr. Wright's 2014 compensation is as follows: Salary: $246,174 Benefits: $22,356 A State of New Hampshire Business Finance Authority 521304598 64468KBJ4 2008-06-02 26260000 Financing for Buildings and Structures 0 0 0 A 2020000 26260000 325806 25934194 2010 0 1 1 1 A 0 0 0 0 0 0 1 A 0 0 1 1 1 1 Morgan Stanley & RBS Citizens 20.000000000000 0 0 0 0 0 A 0 Date Rebate Computation Performed Issuer Name: State of New Hampshire Business Finance Authority Date the Rebate Computation was Performed: 06/02/2016 Form 990, Part III, line 2 In September of 2015 Valley Regional Hospital opened an urgent care center. Form 990, Part VI, Section A, line 6 The sole member of the Organization is Valley Regional Healthcare, Inc. Form 990, Part VI, Section A, line 7a The Organization's directors are nominated and elected by the Organization's member at the annual meeting of the Corporation. Form 990, Part VI, Section A, line 7b The following actions and undertakings involving the business of the Organization are subject to the ratification by the member: adoption of operating budget; adoption of capital budgets; adoption of strategic plans; initiation of significant fund-raising activities; implementation of institutional affiliations, mergers, consolidations or other reorganizations; material modification of service and business offerings; material acquisitions or dispositions of assets; changes in certified public accountants, fiscal year or material accounting practices; incurrence of material indebtedness; material changes in insurance programs and arrangements; material changes in employee benefits plans; adoption of quality improvements plans; election of directors; selection of the president/CEO; amendment of the Organization's bylaws; and amendment of the articles of association. Form 990, Part VI, Section B, line 11 The Organization's CFO reviews the draft Form 990 prior to its filing. The CFO then goes over the document with the board's finance committee. Form 990, Part VI, Section B, line 15 The executive committee of the board of trustees convenes on an annual basis to review the compensation of the CEO. The amount of compensation shall be reviewed by the D-H independent compensation consultant for purposes of determining compliance with the rebuttable presumption, if necessary. The CEO compensation is tied to the strategic planning goals of the Organization. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy and financial statements available to the public upon request. Form 990, Part IX, line 11g Physician Fees: Program service expenses 1,699,102. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,699,102. Purchased Services: Program service expenses 3,791,463. Management and general expenses 810,386. Fundraising expenses 0. Total expenses 4,601,849. Other Professional Fees: Program service expenses 288,343. Management and general expenses 61,631. Fundraising expenses 0. Total expenses 349,974. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Valley Regional Hospital, Inc. 243 Elm Street Claremont, NH 03743 EIN: 02-0222118 Valley Regional Hospital, Inc. is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Valley Regional Healthcare Inc 243 Elm Street Claremont NH 03743 020397338 Healthcare supporting organization NH 501(c)(3) Line 11b, II N/A 0 George H Stowell Trust 295 Windsor Rd Claremont NH 03743 Charitable Trust NH T 53637 1624242 1.00000 0 Clarence H Martin Trust 243 Elm St Claremont NH 03743 Charitable Trust NH T 1962379 0.66670 0 McGuire Endowment 243 Elm St Claremont NH 03743 Charitable Trust NH T 34478 1.00000 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0