2014-08-14T09:12:13-05:00 2013-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2012-10-01 030183721 Windsor Hospital Corporation WIND 8026746711 289 County Road Windsor VT 05089 David C Sanville 8026746711 2014-08-13 1 Barbara J McGuan CPA P00219457 2077752387 2014-08-13 2012 2015-11-30 17:44:51Z Mt Ascutney Hospital & Health Center Kevin Donovan 289 County Road Windsor VT 05089 54717456 0 X www.mtascutneyhospital.org X 1933 VT To improve the lives of those we serve. Our activities include providing healthcare. 15 13 588 67 92804 47357 1045106 995526 42721756 47969559 517785 656866 112344 24214 44396991 49646165 0 0 0 0 29167348 28907533 0 0 220754 18701283 19754508 47868631 48662041 -3471640 984124 39840458 42487151 28978605 26022626 10861853 16464525 X Mount Ascutney Hospital and Health Center's mission is to improve the lives of those we serve. 0 1 34762874 47876755 Mt. Ascutney Hospital and Health Center (MAHHC) operates a not-for-profit critical access hospital which provides primary and secondary health care. MAHHC's primary service area includes Windsor, Claremont, Woodstock, Hartland, Springfield, and Brownsville. The hospital provides essential healthcare services including emergency department, med/surg inpatient, med/surg outpatient, ancillary diagnostic tests, imaging/radiology procedures, and wellness/prevention services. MAHHC staffs a total of 25 acute med/surg beds and 10 acute rehabilitation beds. MAHHC also had 25 extended care beds until it ceased operations of its nursing home on August 30, 2013. During the year there were 995 inpatient discharges, 1,540 outpatient surgeries, 84,411 outpatient lab tests, and 11,682 outpatient imaging procedures. MAHHC identified access to primary care as a central community need and is committed to providing the physician services of family practice, internal medicine and pediatrics in Windsor and Woodstock. During the year there were 33,694 primary care patient visits. MAHHC's service area includes a significant proportion of residents who are uninsured, underinsured, or dependant on Medicare/Medicaid benefits. MAHHC provides free care to patients who meet certain criteria. Foregone charges furnished under MAHHC's free care policy amounted to $794,724. 34762874 1 1 0 1 0 0 0 0 0 1 1 0 0 1 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 1 0 0 0 1 67 0 1 588 1 1 1 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X David Sanville 8026747240 289 County Road Windsor VT 05089 Shelley Seward 1.00 X X 0 0 0 Nancy Loux 1.00 1.00 X X 0 0 0 Harold Pyke 1.00 0.50 X X 0 0 0 Susan Plausteiner 1.00 X X 0 0 0 Paul Buff 1.00 X 0 0 0 Beach Conger MD 1.00 X 97970 0 24471 Larry Frazer 1.00 X 0 0 0 Michael Newbold 1.00 0.50 X 0 0 0 Jane Osgood 1.00 X 0 0 0 Lynn Peterson MD 1.00 X 0 0 0 Alan Cummings 1.00 X 0 0 0 Nancy Formella 1.00 X 0 0 0 Hon Donna Sweaney 1.00 X X 0 0 0 Steven Smith MD 1.00 0.50 X 168782 0 61091 Donna VanFleet 1.00 X 0 0 0 Mary Joyce MD 1.00 X 173569 0 21346 Mary Bell 1.00 X 0 0 0 Vincent Fusca III 1.00 1.00 X 0 0 0 Rev David Jones 1.00 0.50 X 0 0 0 Kevin Donovan 40.00 1.00 X 262127 0 63985 Jill Lord 40.00 0.50 X 154208 0 719 Catherine Schneider MD 40.00 X 224149 0 16565 David Sanville 40.00 0.50 X 97883 0 0 Paul Calandrella 40.00 X 104371 0 0 Christopher Connor MD 40.00 X 346834 0 17551 Peter Rauert MD 40.00 X 240313 0 26155 Andrew Robinson MD 40.00 X 233061 0 0 Perry Nelson MD 40.00 X 222076 0 0 Heidi Cruz MD 40.00 X 214606 0 29308 2539949 0 261191 36 0 1 1 Dartmouth-Hitchcock One Medical Center Drive Lebanon NH 03756 Professional and Physician Services 1411203 Emergency Services of New England PO Box 12 Chester VT 05143 Physician Asst. for Emergency Room 1187805 Sodexo Inc & Affiliates PO Box 360170 Pittsburgh PA 152516170 Mngmt & Support Staff - Envrnmntl Srvcs 449149 Huntzinger Management Group 670 North River Street Suite 401 Plains PA 18705 Consultant srvcs for new EMR system 342135 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Physician Coverage for Hospital 306487 11 28042 474054 493430 12548 995526 Patient Services 900099 75309104 75309104 Program & Misc Other 900099 3302259 3209455 92804 DHS/VAHHA Revenue 900099 207671 207671 Provision for Doubtful Accounts 900099 -3175557 -3175557 Contractual and Charity Allowance 900099 -27673918 -27673918 47969559 281008 281008 67435 49930 17505 17505 17505 5368412 8019 4980092 20481 388320 -12462 375858 375858 27497 28042 20788 6709 6709 49646165 47876755 92804 681080 1471235 547228 924007 21586459 19102554 2348813 135092 234073 208402 24145 1526 4013475 3561522 438166 13787 1602291 1383165 209487 9639 71971 71971 38073 38073 3277927 1668319 1589627 19981 50548 5723 42093 2732 89613 53638 35237 738 844893 117067 720826 7000 1254310 495488 758822 64665 44616 19789 260 538743 538743 2626771 2626771 630247 355459 273553 1235 Contracted Wages 4331996 3746034 585962 Medical Supplies 2767378 2756909 10461 8 Dues/Fees/Taxes 1867661 191850 1675567 244 Miscellaneous Expenses 656964 414430 220727 21807 642748 110470 525573 6705 48662041 34762874 13678413 220754 2013099 1616084 2299215 2776146 542045 429120 4943761 7181442 20653 5045 537845 511134 147056 212564 33867307 21665391 14318455 12201916 11218112 11088456 1873054 1952321 1927163 4512923 39840458 42487151 6011590 4820843 8731471 8514646 1743586 2764463 12491958 9922674 28978605 26022626 X 4628155 10098630 441032 509713 5792666 5856182 10861853 16464525 39840458 42487151 X 984124 213273 4405275 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16127 16127 0 Explanation of Lobbying Activities: Part II-B, Line 1: The Hospital paid $13,891 in the form of dues to the Vermont Association of Hospitals and Health Systems (VAHHS). VAHHS is a member-owned organization devoted to improving the health status of communities throughout Vermont through activities which include advocacy, policy development, education and research. The Hospital also paid $2,236 in the form of dues to the American Hospital Association (AHA). 5880406 79267 5959673 5705958 174448 5880406 5787015 -81057 5705958 5710296 76719 5787015 5634030 76266 5710296 0.00000 0.98260 0.01740 0 0 75418 75418 12329034 7850366 4478668 12722291 8905391 3816900 8740564 4909634 3830930 12201916 Deposits 5560 Other Assets 131155 Deferred Financing Costs, net 62556 Equity in Subsidiary 1874998 Other Receivables 85847 Medicare and Meaningful Use Receivable 2352807 4512923 Other Liabilities 1076357 Post-Retirement Benefit Obligation 3828918 Interest Rate Swap 550258 Estimated Settlements with Third-Party Payors 4467141 9922674 51782100 213273 4475993 4689266 47092834 38073 2515258 2553331 49646165 46179428 70718 70718 46108710 38073 2515258 2553331 48662041 Description of Intended Use of Endowment Funds: Part V, Line 4: In general, the amount of the original gift and any required accumulations by the donor are not expendable. However, the market value of the fund may fall below that amount depending on current financial conditions in the underlying investments. Under the policy of the Hospital, the endowment assets are invested moderately with the intent of providing a predictable stream of funding to the Hospital. The Hospital invests in equity funds, bond funds and money market investments to achieve its long-term return objectives within limited risk constraints. Actual returns in any year may vary from budgeted amounts due to market fluctuations. Part XI, Line 2d - Other Adjustments: Unrealized Gain on Interest Rate Swap 239,289. Equity in Income of Subsidiaries 178,347. Change in Funded Status of Pension Plan 3,908,372. Unrealized Appreciaton in Charitable Remainder Trust 15,752. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts 63,515. Fundraising Expense 20,788. Rental Expenses 49,930. Part XI, Line 4b - Other Adjustments: Expenses from Discontinued Operations 2,515,258. Part XII, Line 2d - Other Adjustments: Fundraising Expense 20,788. Rental Expenses 49,930. Part XII, Line 4b - Other Adjustments: Expenses from Discontinued Operations 2,515,258. 2013 MAH Golf Classic 55539 28042 27497 756 6416 7093 6523 55539 28042 27497 756 6416 7093 6523 20788 6709 1 1 1 X 1 X 1 1 1 0 1 1 818566 818566 0.01680 6680675 3561612 3119063 0.06410 7499241 3561612 3937629 0.08090 274420 274420 0.00560 59206 59206 0.00120 9432248 5903874 3528374 0.07250 8000 8000 0.00020 9773874 5903874 3870000 0.07950 17273115 9465486 7807629 0.16040 1 1842786 17660130 17822162 -162032 X 1 1 1 1 Windsor Hospital Corporation

289 County Road Windsor VT 05089

X X X X Skilled nursing facility Windsor Hospital Corporation 1 1 X X X X X X X 12 1 1 1 X X X X X X X X X X 1 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X 1 1 X X 1 0 X X 1 X 0 0 Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. Part I, Line 7g: Physician Clinic costs included within Subsidized Health Services are $4,293,056 of the total Community Benefit Expenses and $2,972,398 of the Direct Offsetting Revenue. Part III, Line 4: 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 and historical 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 accounts receivable. The costing methodology used above was the cost to charge ratio. Part III, Line 8: The shortfall represents the PPS reimbursement difference on the Rehab and SNF units. Since the reimbursement does not cover the costs of these units, a subsidy is created. Because the Hospital determined that these services are important to our service area, the Hospital covers the subsidy. Part III, Line 9b: MAHHC's collection policy and charitable care policies are consistently applied to all patients. Our collection policy applies to any balance owed by the patient whether it is a balance after insurance, a balance with no insurance, or a balance after an adjustment for partial charitable care. Statements, credit reporting, collection efforts, and write-off criteria are the same for all like balances, regardless of the reason for the balance and regardless of whether it is a balance after charitable care or not. Patients who qualify for financial assistance receive the appropriate adjustment on their bill. If a balance remains after that adjustment, they are billed according to the collection policy, for the remainder. Windsor Hospital Corporation Part V, Section B, Line 3: Data that informed this needs assessment report was collected through a number of data-gathering activites:- Secondary data gathering: Health, economic, and education data from sources including Youth Risk Behavior Survey, the Behavioral Risk Factor Surveillance System, other public health and hospital discharge data, census data, and NECAP data. In some cases, issues were highlighted that have received local attention or which have emerged or intensified since the last secondary data surveys were conducted (examples include oral health, prescription drug misuse, housing assessments, reductions in availability of appropriate mental health services, etc.).- First informed stakeholders' forum: Perceptions of informed regional stakeholders on the nature and causes of potential community needs were gathered through a community forum.- Stakeholders' survey: Opinion data from informed regional stakeholders using an online opinion poll of regional leaders in health, public health, education, municipal governments, public safety, and social service providers; 67 informed stakeholders responded to this survey.- Focus group discussions: Focus group data collected from 6 focus groups largely consisting of lower-income consumers of health/welfare services. - Residents' survey: Opinion data from residents collected through community listservs, individual interviews at human service organizations, and focus groups. These surveys targeted both economically stable and lower-income households; 196 residents responded to surveys.- Second informed stakeholders' forum: Perceptions of informed regional stakeholders on the results of Items 1 to 5 above were gathered through a second community forum. Windsor Hospital Corporation Part V, Section B, Line 4: Other facilities were Dartmouth Hitchcock Medical Center and Alice Peck Day Hospital. Windsor Hospital Corporation Part V, Section B, Line 5c: A benefit report was prepared and made available and distributed through the Mt. Ascutney Community Foundation and the Windsor Area Community Partnership.The CHNA and all information generated in the needs assessment process will be available for stakeholders participating in the process, and will also be available electronically and printed summaries will be make public. Part VI, Line 3: The Hospital posts its charity care policy on its website. Part VI, Line 4: MAHHC's primary service area includes Windsor, Claremont, Woodstock, Hartland, Springfield, and Brownsville. Part VI, Line 5: The Windsor Community Health Clinic at Mt. Ascutney Hospital was established to serve members of our community who are not covered by Medicaid, VHAP, and private insurance, and who do not have the financial resources to pay for healthcare services. The Clinic offers free clinic appointments to members who have no insurance, or are under-insured and meet certain income requirements. X X X X 0 0 0 0 0 0 0 1 0 Steven Smith MD 157382 0 9000 0 2400 0 0 0 61091 0 229873 0 0 0 Mary Joyce MD 171552 0 1000 0 1017 0 6631 0 14715 0 194915 0 0 0 Kevin Donovan 250012 0 0 0 12115 0 44358 0 19627 0 326112 0 0 0 Jill Lord 153028 0 0 0 1180 0 0 0 719 0 154927 0 0 0 Catherine Schneider MD 223833 0 0 0 316 0 9023 0 7542 0 240714 0 0 0 Christopher Connor MD 345802 0 0 0 1032 0 10000 0 7551 0 364385 0 0 0 Peter Rauert MD 239761 0 0 0 552 0 5714 0 20441 0 266468 0 0 0 Andrew Robinson MD 193061 0 40000 0 0 0 0 0 0 0 233061 0 0 0 Perry Nelson MD 221836 0 0 0 240 0 0 0 0 0 222076 0 0 0 Heidi Cruz MD 214366 0 0 0 240 0 8766 0 20542 0 243914 0 0 0 Part I, Line 7 Steven Smith, MD received a bonus which was based upon being a preceptor. Mary Joyce, MD and Richard White, MD received bonuses which were based upon Relative Value Units (RVU's). Andrew Robinson, MD received a bonus which was based upon longevity. Supplemental Information Part III Steven Smith MD, Trustee, was paid $218,473 in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for his services as physician. The Organization reimburses Dartmouth Hitchcock for the cost of his services. He was not compensated for his duty as trustee. Kevin Donovan, CEO, was paid $319,512 in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for his services as CEO. The Organization reimburses Dartmouth Hitchcock for the cost of his services. David Sanville, CFO, was paid $97,883 in compensation by Gifford Medical Center, an unrelated organization, for his services as CFO. This compensation includes Base Compensation, Employer Paid Deferred Compensation, Employer Paid Nontaxable Benefits and Payroll Taxes. The Organization reimburses Gifford Medical Center for the cost of his services. A Vermont Educational and Health Buildings Financing Agency 237154467 2010-02-05 9244000 Refinancing of 2004 and 2005 Bonds 0 0 0 A 729354 9244000 128133 9115867 2010 1 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 1 1 TD Bank NA 18.000000000000 0 0 0 0 0 A 0 Changes in Program Services Form 990, Part III, line 3 Mt. Ascutney Hospital and Health Center (MAHHC) ceased operations of its nursing home facility on August 30, 2013. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed and approved by the Finance Committee of the Board. The Board receives a copy of the final version and it is discussed at the Board meeting. Form 990, Part VI, Section B, line 12c The Finance and Audit Committees monitor and report to the Board of Directors. Form 990, Part VI, Section B, line 15 The Executive Committee of the Board meets annually to review compensation for the CEO, using independent surveys of area compensation for executives of various sized hospitals. Other officers and key employees salaries are determined, by the HR department, using comparable market data. Form 990, Part VI, Section C, line 19 All internal policies, governing documents, and financial statements are made available upon request Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Unrealized Gain on Interest Rate Swap 239,289. Equity in Income of Subsidiaries 178,347. Change in Funded Status of Pension Plan 3,908,372. Unrealized Appreciation in Charitable Remainder Trust 15,752. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts 63,515. Historic Homes of Runnemede 40 Maxwell Perkins Lane Windsor VT 050891206 237396147 Providing Services for the Aging VT 501(c)(3) Line 9 Windsor Hospital Corporation 1 Mount Ascutney Hospital Community Health Foundation Inc 289 County Road Windsor VT 05089 030300481 To provide healthcare services to the Windsor, Vermont community VT 501(c)(3) Line 3 Windsor Hospital Corporation 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0