2016-08-03T12:07:37-07:00 2015-09-30 990 2014-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786323420 242 Green Street Gardner MA 01440 Robert Crosby Sr VP of Finance, Treasurer, CFO 9786306157 2016-05-04 2014 2016-12-15 16:53:06Z Robert Crosby 242 Green Street Gardner MA 01440 116174970 0 X www.heywood.org X 1907 MA To be our communities' trusted choice for exceptional patient-centered care. 22 18 1143 166 0 0 2425672 2266318 104118171 107888356 761780 1116944 1252666 1346159 108558289 112617777 125000 131414 0 0 54557727 56128843 0 0 416846 50617334 50119456 105300061 106379713 3258228 6238064 97123339 96147072 44445106 42620658 52678233 53526414 To be the community's trusted choice for patient-centered care. 0 0 99075396 131414 107888356 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 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 Generals Office. 0 0 0 99075396 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 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 1 149 0 1 1143 1 0 0 0 0 0 1 1 0 0 0 0 X 22 18 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 Daniel M Asquino Trustee 0.2 0 X 0 0 0 Winfield Brown President /CEO 40 0 X X 762630 0 70661 Cheney Castine Treasurer - Trustee 0.2 0 X 0 0 0 Robert Chauvin Trustee 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 A Hunt Vice Chairman -Trustee 0.2 0 X 0 0 0 Craig Twohey Trustee 0.2 0 X 0 0 0 Roy Lake Trustee 0.2 0 X 0 0 0 James Meehan Trustee 0.2 0 X 0 0 0 Donald Mruk Trustee 0.2 0 X 0 0 0 Elizabeth Nottleson Trustee/Physician 0.2 24 X 0 197141 15119 Michele Parker Trustee 0.2 0 X 0 0 0 JoAnne Parks Trustee 0.2 0 X 0 0 0 Kami Phillips Trustee/Physician 0.20 0 X 0 171601 14416 Kenneth J Pierce Chairman-Trustee 0.2 0 X 0 0 0 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 Robert Crosby Sr VP of Finance / CFO 40 0 X 315426 0 53216 Michael Grimmer VP of Support Services 40 0 X 281402 0 50042 Bruce Bertrand Chief Medical Officer 32 0 X 257739 0 30725 Rose Kavalchuck VP of Quality Services 40 0 X 237262 0 45595 Tina Griffin Athol VP of Patient Care 40 0 X 165316 0 25795 Dawn Casavant VP of External Affairs 40 0 X 174562 0 46399 Karen McArdle-Coggins HMG President/VP of Physician Recruiting 40 0 X 233164 0 16407 Rebecca Bialecki VP of Community Initiatives 40 0 X 30069 0 5218 Tina Santos VP of Patient Care Srvcs/CNO 40 0 X 266200 0 35163 Carol Roosa VP of Information Services/CIO 40 0 X 184438 0 47197 David Gill Staff Psychologist 40 0 X 241709 0 31791 Christian Heinis ER Physician 30 0 X 255901 0 44322 Steven Yerid Chief of Emergency Medicine 40 0 X 497073 0 49667 Ellen Ray Emergency Physician 40 0 X 338442 0 38807 Sarah Gilbert ER Physician 30 0 X 268520 0 41898 Thomas Cady Former VP of Human Resources 0 0 X 179174 0 35836 4689027 368742 698274 94 1 1 0 Quartulli and Associates Inc PO Box 423 Gardner MA 01440 Physical Therapy 2612526 Alliance Healthcare Services 100 Bay View Circle Newport Beach CA 92660 MRI 1420708 Quest Diagnostics Inc 5763 Collection Center Drive Chicago IL 60693 Lab Contracted Services 885754 Spine & Pain Center 242 Green Street Gardner MA 01440 Pain Management Physician 791542 New England Inpatient Specialists 120 Waters Street North Andover MA 01845 Hospitalists 696667 30 0 0 101362 0 1954279 210677 0 2266318 IP Ancillary & Routine Revenue 621110 40533864 40533864 0 0 OP Ancillary Revenue 621110 63843344 63843344 0 0 Contracted Service Revenue 900099 2279979 2279979 0 0 HMG Patient Revenue (Net) 621111 1111990 1111990 0 0 Lifeline 624120 44664 44664 0 0 74515 74515 0 0 107888356 321364 0 0 321364 0 0 0 0 0 0 0 0 314305 0 0 0 314305 0 314305 0 0 314305 4243507 42158 3469429 20656 774078 21502 795580 0 0 795580 20460 101362 67108 -46648 0 -46648 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722310 755047 0 0 755047 Purchase Discounts 900099 199516 0 0 199516 Lab Revenue 900099 39596 0 0 39596 84343 0 0 84343 1078502 112617777 107888356 0 2463103 X 131414 131414 0 0 0 0 0 0 3112103 1067881 1874943 169279 0 0 0 0 44281339 42583596 1603713 94030 945729 806099 118290 21340 4125400 3697439 390035 37926 3664272 3434170 214774 15328 0 0 0 0 305029 25161 279868 0 114630 0 114630 0 0 0 0 0 0 0 0 0 0 0 10687791 10687791 0 0 207849 196610 11090 149 14707002 14543381 157870 5751 1753700 1713452 40248 0 0 0 0 0 2083735 2056445 27290 0 113139 69907 39825 3407 0 0 0 0 119650 81799 31751 6100 735589 735589 0 0 0 0 0 0 4224555 4198422 26039 94 769427 576300 193127 0 Professional Fees 5880188 4694615 1132149 53424 Bad Debt 4409585 4409585 0 0 Free Care 1477686 1477686 0 0 Subscriptions & Dues 785070 301706 478556 4808 1744831 1586348 153273 5210 106379713 99075396 6887471 416846 4790919 3931381 0 0 2183922 1139222 12412717 13485224 0 0 0 0 141938 122696 1293977 1599887 1136493 1152865 108738813 57784555 51835665 50954258 20325016 20554685 502992 417530 139610 145902 0 0 2360090 2643422 97123339 96147072 14129444 13259267 0 0 601026 245096 23948559 23581586 0 0 0 0 109342 249040 0 0 5656735 5285669 44445106 42620658 X 47224241 49424721 4447768 3095407 1006224 1006286 52678233 53526414 97123339 96147072 X 6238064 -1920860 0 0 0 -3469023 X 1 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 20170666 18245 -665620 0 -854491 0 20377782 18078764 100 1729112 0 -362690 0 20170666 17128384 2200 2044839 0 1096659 0 18078764 11897431 5683 1966503 0 -3258767 0 17128384 17367013 5000 -128702 0 5345880 0 11897431 0.88 0.05 0.07 0 0 0 170871 170871 0 66902136 25082422 41819714 0 0 0 0 0 39999350 31531879 8467471 0 1666456 1170254 496202 50954258 0 Est. Settlements with Third Party Payors 2684439 Est Insurance Claims 1646001 Deferred Comp 955229 5285669 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 Heywood Healthcare, Heywood Hospital, Athol and HMGI, and the 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. . The Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial position. Tax years from 2011 through the current year remain open for examination by federal and state taxing authorities. Golf Classic 106970 86510 20460 0 3564 18487 22924 0 6959 Ride of Your Life 14851 14851 0 0 3314 2644 1280 0 7936 0 121821 101361 20460 0 6878 21131 24204 0 14895 67108 -46648 1 1 1 X 1 X 1 1 0 1 1 1307958 726236 581722 0.0055 20030178 17770285 2259893 0.0212 0 0 0 0.0 0 0 21338136 18496521 2841615 0.0267 1251257 34311 1216946 0.0114 353971 0 353971 0.0033 0 0 0 0.00 0 0 0 0.0 79971 0 79971 0.0007 0 0 1685199 34311 1650888 0.0154 0 0 23023335 18530832 4492503 0.0421 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160849 0 160849 0.0015 0 0 0 0 335707 0 335707 0.0032 0 0 0 0 0 0 496556 0 496556 0.0047 1 1684489 8086 25724713 23736111 1988602 X 1 1 1 1 Henry Heywood Memorial Hospital 242 Green Street Gardner MA 01440 www.heywood.org 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.jointcoalitiononhealth.org X 1 15 1 www.heywood.org 0 0 1 X 100 400 1 1 X X X X 1 X www.heywood.org X www.heywood.org X X X X X 1 1 X X 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. 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, Black African Americans, Latinos, Brazilians, Hmong, LGBTQ, elders, young adults, homeless individuals, veterans and adults with major mental illness. The Community Health Needs Assessment is made available on the hospital website and a summary of key findings went out in The Healthy You, a hospital publication mailed to 55,000 residents in our primary and secondary service area. Presentations were given to the Hospital Board of Trustees, Joint Coalition on Health, CHNA 9, Regional Behavioral Health Collaborative, Gardner Area Interagency Team and North Quabbin Community Coalition. Feedback elicited from these groups informed the development of the Hospitals implementation strategy. The following lists the Hospitals key focus areas and goals to address the needs identified in the CHNA: Goal: To develop community-wide behavioral health strategies and systems that improves mental health and substance abuse infrastructure in the region. Goal: To reduce the incidence and prevalence of suicide in the region. Goal: To introduce innovative strategies to improve access to health services. Goal: To develop population health management programs and support changes to policy and environmental conditions that support healthy settings, where our patients, live, work and play. Goal: To strengthen primary care service delivery to support improved patient health outcomes, patient satisfaction and the reduction of health care costs. Goal: To work in partnership with community organizations and coalitions to address the social determinants on health. Schedule H, Part V, Section B, Line 5-Henry Heywood Memorial Hospital Hospitals included in the development of the 2012 Community Health Needs Assessment are Heywood Hospital, Gardner, MA; HealthAlliance Hospital, Leominster, MA; and Clinton Hospital, Clinton, MA. Schedule H, Part V, Section B, Line 6a-Henry Heywood Memorial Hospital Athol Memorial Hospital 1033 Main Street Athol MA 01331 Schedule H, Part V, Section B, Line 6b-Henry Heywood Memorial Hospital Athol Memorial Hospital 1033 Main Street Athol MA 01331 Schedule H, Part V, Section B, Line 11-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. 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, Black African Americans, Latinos, Brazilians, Hmong, LGBTQ, elders, young adults, homeless individuals, veterans and adults with major mental illness. The Community Health Needs Assessment is made available on the hospital website and a summary of key findings went out in The Healthy You, a hospital publication mailed to 55,000 residents in our primary and secondary service area. Presentations were given to the Hospital Board of Trustees, Joint Coalition on Health, CHNA 9, Regional Behavioral Health Collaborative, Gardner Area Interagency Team and North Quabbin Community Coalition. Feedback elicited from these groups informed the development of the Hospitals implementation strategy. The following lists the Hospitals key focus areas and goals to address the needs identified in the CHNA: Goal: To develop community-wide behavioral health strategies and systems that improves mental health and substance abuse infrastructure in the region. Goal: To reduce the incidence and prevalence of suicide in the region. Goal: To introduce innovative strategies to improve access to health services. Goal: To develop population health management programs and support changes to policy and environmental conditions that support healthy settings, where our patients, live, work and play. Goal: To strengthen primary care service delivery to support improved patient health outcomes, patient satisfaction and the reduction of health care costs. Goal: To work in partnership with community organizations and coalitions to address the social determinants on health. 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 II, Line 6 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 II, Line 8 Heywood Hospital serves a medically underserved population area, because of this, the Hospital is constantly working to recruit and search for physicians to serve our community. 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 2014. This amounted to approximately .48% which was applied against the number on line 2. It is our belief that the $8,086 amount of bad debt should be included as a community benefit. 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". Schedule H, Part III, Section B, Line 6 The allowable costs on line 6 were obtained from our FY 2015 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 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 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 2011 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 2011 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 2011 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 2011 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 2011 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 Mechanic St Leominster MA 01453 042551175 501(c)(3) 51414 0 home care - elderly and disabled home care - elderly and disabled Heywood Healthcare Charitable Foundation 242 Green Street Gardner MA 01440 222720562 501(c)(3) 59960 0 Support local organizations. Comm Foundation No Central Mass 9 Leominster Connect Leominster MA 01453 043537449 501(c)(3) 10000 0 Mental Health Issues awareness House of Peace and Education 20 Barthel Ave Gardner MA 01440 043300490 501(c)(3) 10000 sponsorship United Way North Central Mass 649 John Fitch Highway Fitchburg MA 01420 042233021 501(c)(3) 10000 annual appeal 5 0 Schedule I, Part I, Line 2 Montachusett Home Care Corp and the Community Health Network of MA file an annual report with the Office of Healthy Communities that contains a summary of how the funds are allocated. X X 0 0 X X X X X X 1 0 0 0 0 1 0 0 0 Winfield Brown President /CEO 452447 0 52728 0 257455 0 22600 0 48061 0 833291 0 0 0 Robert Crosby Sr VP of Finance / CFO 274728 0 38228 0 2470 0 22700 0 30516 0 368642 0 0 0 Michael Grimmer VP of Support Services 232786 0 32897 0 15719 0 20621 0 29421 0 331444 0 0 0 Bruce Bertrand Chief Medical Officer 226668 0 29250 0 1822 0 17500 0 13224 0 288464 0 0 0 Rose Kavalchuck VP of Quality Services 205076 0 29440 0 2746 0 21624 0 23971 0 282857 0 0 0 Karen McArdle-Coggins HMG President/VP of Physician Recruiting 152719 0 79999 0 446 0 4375 0 12032 0 249571 0 0 0 Tina Santos VP of Patient Care Srvcs/CNO 233011 0 32489 0 700 0 21354 0 13809 0 301363 0 0 0 Carol Roosa VP of Information Services/CIO 160072 0 23627 0 738 0 20110 0 27088 0 231635 0 0 0 Dawn Casavant VP of External Affairs 152314 0 21946 0 301 0 19523 0 26877 0 220961 0 0 0 Tina Griffin Athol VP of Patient Care 157252 0 7317 0 747 0 3283 0 22512 0 191111 0 0 0 Thomas Cady Former VP of Human Resources 54401 0 0 0 124773 0 10043 0 25793 0 215010 0 0 0 Elizabeth Nottleson Trustee/Physician 0 151062 0 26400 0 19679 0 3375 0 11744 0 212260 0 0 Kami Phillips Trustee/Physician 0 137361 0 15118 0 19121 0 3154 0 11263 0 186017 0 0 Ellen Ray Emergency Physician 334438 0 0 0 4004 0 5200 0 33607 0 377249 0 0 0 Sarah Gilbert ER Physician 267570 0 0 0 949 0 14625 0 27274 0 310418 0 0 0 Steven Yerid Chief of Emergency Medicine 419458 0 77000 0 614 0 22200 0 27468 0 546740 0 0 0 Christian Heinis ER Physician 255541 0 0 0 360 0 13194 0 31128 0 300223 0 0 0 David Gill Staff Psychologist 239119 0 0 0 2591 0 5050 0 26740 0 273500 0 0 0 Schedule J, Part I, Line 1a Housing allowance provided to Michael Grimmer, VP of Support Services, per contract. This is paid through his weekly salary. Social Club Membership dues provided to Mr. Brown, CEO, per contract. Schedule J, Part I, Line 1b There was no written policy for the housing allowance provided to Michael Grimmer; it was part of his employment contract. There was no written policy for the Social Club Membership dues; it was part of his employment contract. Schedule J, Part I, Line 4 Thomas Cady, former VP of Human Resources, received severance payments in the amount of $124,199 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 annually. A MA Health and Educational Facilitiy Authority 042456011 57586EGT2 2009-03-31 17785000 Funds used for new Watkins Bldg project 0 0 0 B MA Health and Educational Facility Authority 042456011 57586C7E9 2008-06-19 6715000 Refunding and new Watkins Bldg 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 1-03/31/2009 17,785,000 MA Health and Educational Facilitiy Authority The rebate computation was performed on October 9, 2015. Schedule K, Part IV, Line 2c-03/31/2009 17,785,000 MA Health and Educational Facilitiy Authority 03/31/2009 17,785,000 MA Health and Educational Facilitiy Authority - Rebate computation was performed on October 8, 2013. Schedule K, Part IV, Line 2c-06/19/2008 6,715,000 MA Health and Educational Facility Authority 06/19/2008 6,715,000 MA Health and Educational Facility Authority - Rebate computation was performed on October 8, 201 Kaitlin Fletcher family member - Joyce Fletcher, Trustee 61175 employment 0 Jaime Griffin family member - Tina Griffin - Officer 10921 employment 0 Eliot Nottleson family member - Elizabeth Nottleson - Trustee 84628 employment 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 final review. Once reviewed, the 990 is received by the Board of Trustees. The 990 is then approved by the board, and submitted by the accounting department. Form 990, Part VI, Section B, Line 12c Annually, a Conflict of Interest Form is sent out to the manager, 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. Mr. 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 IX, Line 11g Included in Fees for services (non-employees) other expenses are: Physician Fees: $5,429,435 Outside Clinical Fees: $5,105,637 Temporary Employees: $140,077 Medical Staff: $12,642 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 and transfers to inter-corporate related organizations to support their operations. Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 employ physicians MA 501(c)(3) 9 Heywood Healthcare 0 Heywood Hospital Realty Corporation 242 Green Street Gardner MA 01440 043327447 property holding company MA 501(c)(2) Heywood Healthcare 0 Athol Memorial Hospital 2033 Main Street Athol MA 01331 042126583 Hospital MA 501(c)(3) 3 Heywood Healthcare 0 Heywood Healthcare Inc 242 Green Street Gardner MA 01440 222720658 Parent Corp MA 501(c)(3) 7 N/A 0 Heywood Healthcare Charitable Foundation 242 Green Street Gardner MA 01440 222720562 Charitable Foundation MA 501(c)(3) 7 Heywood Healthcare 0 HHMH Aid Association 242 Green Street Gardner MA 01440 042198019 raise funds for the Hospital MA 501(c)(3) 9 N/A 0 Winchendon Health Foundation 87 Central Street Winchendon MA 01475 042113276 supporting organization MA 501(c)(3) PF N/A 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 Heywood Hospital Realty Corporation j 90153 actual cost Heywood Hospital Realty Corporation q 244316 actual cost Heywood Hospital Realty Corporation r 218000 actual cash Granted an extension from the IRS.