2013-08-09T10:08:13-05:00 2012-09-30 346565596 Ernst & Young US LLP 55 Ivan Allen Jr Blvd Suite 1000 Atlanta GA 30308 990 2011-10-01 060966963 Natchaug Hospital Inc NATC 8604561311 189 Storrs Road Mansfield Center CT 06226 PAUL V MALONEY 8604561311 2013-08-09 0 Chad D Franks P01071312 4048748300 2011 2016-02-24 21:20:13Z Stephen W Larcen PHD 189 Storrs Road Mansfield Center CT 06226 47430564 0 X WWW.NATCHAUG.ORG X 1954 CT To provide inpatient and outpatient psychiatric healthcare services. 15 13 663 53 0 0 195250 132429 44920212 47287791 17780 10344 0 0 45133242 47430564 0 0 0 0 36405653 38561375 0 0 41848 9166667 7850394 45572320 46411769 -439078 1018795 17348692 19504685 9307210 11646884 8041482 7857801 X To provide a continuum of accessible, community-based services for those living with psychiatric illness and chemical dependency or emotional and related educational disabilities, with a commitment to the dignity and privacy of those needing service, empowering them to participate in their own care, education and recovery. 0 0 16690284 17500833 Inpatient TreatmentNatchaug Hospital provides a full range of inpatient psychiatric and substance-abuse treatment for children, adolescents and adults at our 57-bed Mansfield Center facility. The highly qualified, experienced and dedicated professional staff of Natchaug Hospital provides expert care in a supportive, therapeutic setting - helping people regain their stability and return as soon as possible to their own homes. The hospital serves Medicare and Medicaid subscribers and provides care without regard to ability to pay.Intermediate Care (ICC)An acute level of care for a longer length of stay for persons living with prolonged and severe mental illness. Historically, people from Eastern Connecticut who were in need of an extended length of stay were referred to Cedarcrest Hospital in Newington. Natchaug Hospital ICC provides this much-needed care for persons from the Eastern Region, closer to the communities where they live and work. United Services and the Southeastern Mental Health Authority are the Local Mental Health Authorities (LMHA's) responsible for authorizing admission to the Intermediate Care Program. The above includes the authorization of Department of Mental Health and Addiction Services (DMHAS) funds to pay for care in the event the patient is medically indigent, has exhausted his/her Medicare benefit, or has no Medicare hospitalization coverage. Patients are most likely to be referred from Eastern Region hospital inpatient units when it becomes clear that the patient will not be able to safely return to the community following an acute care stay. Upon admission, each patient is assessed by a psychiatrist, a registered nurse and a primary therapist, and a treatment plan is developed. The treatment team works closely with the client, their family and community providers to develop a discharge plan and ensure that community supports are in place.In-Patient Treatment Programs Treats 57 clients on a daily basis at the Mansfield location. Inpatient treatment includes: Comprehensive bio-psycho-social assessment Formulation of a treatment plan developed with the client/family which may include the use of medications Group therapy (a primary treatment approach) Family therapy and individual therapy Formulation of a discharge/aftercare plan Case management services Client referral to in-patient programs: Majority (over 80%) come from emergency rooms Self-referral via phone call or walk-in Referral from a Natchaug Program (PHP, IOP, school) Referral from community providersTypical client experience: The majority of our clients arrive via ambulance through the ambulance entrance. All clients receive an initial assessment by a registered nurse and psychiatrist which is completed within 8 hours of admission. Clients are oriented to the unit, the milieu, and the schedule. Our clients are closely monitored for the first 24-48 hours, depending on presentation and symptoms. Groups are scheduled from morning through evening. In addition, the clients meet with their Primary Therapist and Psychiatrist regularly.Contact with the family/guardian is during the admission process or within the following 48-72 hours. Family meetings are scheduled by the Primary Therapist. The clients on the child and adolescent units attend school in the building for 5 hours per day, with groups during the day, after school, and in the evening. Staffing pattern: Each inpatient unit is staffed 24-7 with: Registered NursesPsychiatristsMental Health Workers Licensed Practical Nurses (Adult Unit only) Also on the clinical treatment team are:Nurse Manager Licensed Primary TherapistsCase Manager (Adult Unit Only)Unit ClerkDieticianCertified Occupational Therapists (COTA)Occupational Therapist (OT)Family Practice Physician on site M-FInpatient Units: Adult rooms all semi-private plus one four-bed room. Child/Adolescent rooms are all private Units include group room space Meals are served in the dining roomOther points:Licensed by Connecticut Department of Public Health.Surveyed by Joint Commission under the Hospital StandardsSurveyed by the Center for Medicaid Services (federal program) 8243375 8419516 Joshua CentersPartial Hospital Program (PHP) The Partial Hospital Program provides four hours of intensive psychiatric support daily for up to five days per week. This is a morning program for adults and an after-school program for children and adolescents. The program can eliminate the need for a hospital stay, and/or help with the transition back to home and regular school after a period of inpatient care.Intensive Outpatient Program (IOP) The Intensive Outpatient Program is somewhat less intense than the PHP, providing three hours of intensive treatment each day for up to five days each week. This program is offered both in the morning and during the evening for adults, after-school for children and adolescents. The IOP program is designed to help continue progress with behavioral health stabilization and recovery.Extended Day Treatment (EDT)This special program, partially funded by the Connecticut Department of Children, supports children and adolescents who have emotional or behavioral health issues that put them at risk of needing psychiatric residential or inpatient care. The Extended Day Treatment program is particularly helpful for children with special needs who are in foster care.Child & Adolescent Treatment Programs:- Treat about 250 children and adolescents daily in all programs/locations- May prevent hospitalization- Aids in transition back to the community following hospitalization- Transportation to PHP, IOP & EDT: Most of this transportation is provided by Natchaug Hospital staff, driving the Hospital vans that pick up clients from their school or home. - Average length of stay in PHP/IOP program, 6 - 8 weeks; EDT and IICAPS, 6 months.Joshua Program treatment services include: - Comprehensive bio-psycho-social assessment- Group Therapy (the primary treatment approach)- Family and individual therapy- Medication management- Occupational and creative rehabilitation therapy- Comprehensive aftercare/discharge planningPartial Hospital Program (PHP): four hours of treatment for up to five days per week Intensive Outpatient program (IOP): three hours of treatment up to five days per week Extended Day Treatment (EDT) is a specialized therapeutic after-school support program that provides structured groups for three hours a day up to five days per week to learn and practice social skills such as group interaction, listening, cooperative leisure activities. Intensive In-Home Child & Adolescent Psychiatric Services(IICAPS): developed and monitored by the Yale University Child Study Center, provides in home services 2-3 times per week to help meet the needs of families with children with persistent psychiatric disorders. Client referral to a Child/Adolescent Treatment Program:- Referred from an inpatient program in Connecticut- Community providers (Child & Family Services; United Children & Families; Emergency Rooms)- School systems- Private providers (community psychiatrists or therapists)- Family and friendsTypical client experience in a Child/Adolescent Program:Initial referral phone call results in an intake appointment with a masters level clinician to complete a bio-psycho-social assessment. The client must be accompanied by their parent/guardian. After admission to the Program, the client/guardian meets with the psychiatrist/APRN for treatment planning and medication management.In a treatment day, clients arrive after being picked up from their school (or home) in one of Natchaug Hospital vans and will attend four groups in PHP and three groups in IOP. Groups include a psychotherapy group, educational groups and an activity group. The activity group is led by a Mental Health Worker or a CRS Staff member; all other groups are led by a masters level clinician. Education groups might include managing emotions; dangers of substance abuse; handling relationships, etc. Natchaug Hospital Group Levels: Psychotherapy/Process Group: is based on exploration and analysis of the interaction of a person's thoughts, feelings & beliefs and the group process for the purpose of facilitating an interpersonal change process and is led by a mental health professional with a graduate degree in a clinical discipline. Educational/Skills Group: Involves the acquisition of knowledge and/or skills, improved coping responses, or the sharing of experiences (such as Goals or Wrap-up Group). Group goals are to reduce stress, improve problem solving and learn new coping behaviors. This group is led by a staff member with documented training and/or experience in group leadership. The group includes: Registered Nurses, Certified Occupational Therapy Assistants, Mental Health Workers, Pharmacists, and Dieticians, CRS staff (music, art or recreational therapists).Leisure Activity Groups: involve the client/patient/student within a meeting/group format in order to practice the development of healthy social relationships. This may include a specific activity (art, music, games) planned with the goal of improving attention and/or social interactions; led by a staff member with the desire and supervisor-determined competency to lead a leisure activity group.Other points:Surveyed by Joint Commission using Behavioral Health Standards; PHP/IOP licensed by the Department of Public Health; EDT is licensed by the Department of Children & Families. 9834494 10967294 EducationClinical Day Treatment School Programs (CDT)Natchaug's clinical day treatment programs, which are approved by the Connecticut Department of Education, offer special education services to students in grades 1 - 12 whose social, emotional or behavioral health problems prevent them from functioning successfully in a regular school environment. Each student's individual academic and clinical treatment plan is designed to address their special needs and return them to their regular schools as soon as possible. Natchaug Hospital schools operate in Enfield, Danielson, Mansfield, Norwich, Montville and Windham. Natchaug is also the contracted operator of two schools for the town of Norwich.Natchaug Hospital's Board of Directors serves a number of functions similar to a Board of Education, with responsibilities for the oversight and the implementation of certain State statutes and Federal legislation.Natchaug Hospital School Programs- Each school day, an average of 200 students attend Natchaug Hospital's school programs- Approved by the Connecticut Department of Education: Inpatient School Journey House School Clinical Day Treatment School in six sites - Natchaug contracts with the Norwich Public Schools to provide services located at: Deborah Tennant-Zinewicz Hickory Street SchoolStudents come to the Inpatient School on an emergency basis, and for non-educational reasons; school staff determines if the student receives special education services, and if there is an Individual Education Plan (IEP) to be implemented. Students come to the Journey House School on a planned basis and for non-educational reasons. Each student's school files are evaluated for proper placement in school. Girls who receive special education, Section 504, and regular education all are educated at the Journey School. Students come to the six CDT sites via a Planning and Placement Team (PPT) Meeting from their home school district. They may be placed on a diagnostic basis with PPT meetings every two weeks while psychiatric, psychological and educational assessments are performed. Students also may enter the program already receiving special education services with an IEP (Individualized Education Plan) in place.Students come to the Hickory Street School and DTZ School by placement by the Norwich Board of Education. All students are identified as special education and have an IEP in place.Transportation to all day school programs is provided by the Local Education Authority (LEA) that placed the student; however, transportation during the school day for field trips is often provided using Natchaug vans with school staff driving; sometimes school field trips are transported by outside vendors. Student Referral to the Inpatient and Journey Schools - Placement for non-educational reasons (inpatient or residential treatment admission)Student Referral to the six CDT sites - These are only made by the Local Education Authority (LEA), which is designated by the state to be the "town of nexus," which takes numerous requirements into consideration, such as where the parent resides. Referral to the Hickory and DTZ schools - These are only made by the Norwich Board of EducationDescription of typical day:A typical day in the Inpatient and Journey House School is a five-hour day that covers all academic areas, including electives of Art and PE. A typical day in the CDT schools is similar to any traditional school day, with academic subjects in addition to psycho-educational groups led by school clinicians. 10196936 10400148 Natchaug Hospital provides inpatient acute behavioral health services for patients at its main site in Mansfield Center. Natchaug Hospital also operates a number of structured day programs providing partial hospital, intensive outpatient, extended day treatment, and outpatient services for persons with behavioral health and substance abuse treatment needs. These programs are provided at a variety of sites throughout eastern Connecticut. The Hospital also provides specialized residential treatment to adolescent girls in the care of the Connecticut Department of Children and Families. 10196936 10400148 44965089 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 52 0 1 663 1 0 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 0 X Paul V Maloney 8604561311 189 Storrs Road Mansfield Center CT 06226 X Colin K Rice 2.00 X 0 0 0 Antoinette Ellzey 2.00 X 0 0 0 Rev Laurence AM LaPointe 2.00 X 0 0 0 Harriotte W Wilson 2.00 X 0 0 0 William E Anderson Jr 2.00 X 0 0 0 Edward S Sawicki MD 2.00 X 0 0 0 Carol A Wiggins PHD 2.00 X 0 0 0 Judith M Caracausa 2.00 X 0 0 0 Pedro J Johnson 2.00 X 0 0 0 Karla Harbin Fox Esq 2.00 X 0 0 0 Stephen W Larcen PHD 40.00 X X 0 467346 69180 Kimberly A Colfer Esq 2.00 X 0 0 0 Elizabeth B Ritter 2.00 X 0 0 0 Dana R McGee Esq 2.00 X 0 0 0 Nancy A Brouillet Esq 2.00 X 0 0 0 James E Watson MD 2.00 X X 0 0 0 Michael G Pallein CPA 2.00 X 0 0 0 Carolyn S Drescher 2.00 X 0 0 0 Michael Kurland 2.00 X 0 0 0 Michael C Nee MD 2.00 X 0 0 0 Bernice Szafarek DMD 2.00 X 0 0 0 David Klein PHD 40.00 X 169142 0 37367 Paul Maloney 40.00 X 0 149772 29582 Deborah Weidner 40.00 X 267841 0 32582 Paul Weigle 40.00 X 172375 0 22604 Jonathan L Chasen 40.00 X 217384 0 35544 Pamela Shuman 40.00 X 193631 0 36751 Teodora Andrei 40.00 X 217736 0 38293 Paul G Pentz 40.00 X 177007 0 34207 1415116 617118 336110 30 0 1 0 Aetna Insurance 25 Great Arrow Ave STE 23 Buffalo NY 14207 Insurance Services 818690 Staff Care Inc PO Box 281923 Atlanta GA 30384 Medical Services 401870 United Community & Family Services 34 East Town St Norwich CT 06360 Medical Services 319571 Mansfield Family Practice Mansfield Professional Park Storrs CT 06268 Medical Services 218743 Anthem Blue Cross Blue Shield 370 Bassett Road North Haven CT 06473 Insurance Services 121322 5 132429 132429 Net Patient Revenue 624100 47287791 47287791 47287791 9844 9844 500 0 500 500 500 47430564 47287791 0 10344 1528759 474658 1054101 27908002 27885560 22442 1785386 1699657 84530 1199 5034042 4987349 42410 4283 2305186 2261698 41771 1717 418741 418741 91700 91700 71879 71879 18441 18441 1895848 1885789 10059 53930 53930 1930405 1928257 2148 670302 670302 139790 139790 41772 41772 225786 225786 887474 887474 472702 472702 Medical Supplies 524485 524485 Repairs & Maintenance 289735 289735 Dues & Subscriptions 88300 88300 Education/Tech Training 29104 29104 46411769 44965089 1404832 41848 7250 8749 894437 1863528 241282 19168 4253960 6058802 127971 121434 477762 137645 18278799 7143662 11177564 11135137 53611 168466 106611 17348692 19504685 5723526 7999515 3234650 2809866 349034 837503 9307210 11646884 X 7868019 7647801 173463 168000 42000 8041482 7857801 17348692 19504685 X 1018795 -1202476 X X 1 0 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 18441 0 0 18441 0 Explanation of Lobbying Activities: Part II-B, Line 1: Natchaug Hospital paid Kenneth L. Przybysz LLC and Connecticut Hospital Association (CHA) for their lobbying efforts on behalf of the organization during the fiscal year. Both CHA and Mr. Przybysz lobbies Connecticut State Legislators in the interest of a group of specialty hospitals in the State of Connecticut. 195897 195897 13085151 4319938 8765213 1145517 240310 905207 2908705 1944566 964139 943529 638848 304681 11135137 Due To Affiliates 269467 Professional Liability 568036 837503 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 201464 201464 0.00430 14980067 12097736 2882331 0.06210 1892874 1661564 231310 0.00500 17074405 13759300 3315105 0.07140 464464 464464 0.01000 173130 8000 165130 0.00360 629508 629508 0.01360 220786 220786 0.00480 1487888 8000 1479888 0.03200 18562293 13767300 4794993 0.10340 0 758212 189553 3998115 4948303 -950188 X 1 1 1 1 Natchaug Hospital

189 Storrs Rd PO Box 260 Mansfield Center CT 06250

X Natchaug Hospital Inc 1 1 1 250.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X X X 1 0 1 X X 0 0 9 Care Plus

1353 Gold Star Highway Center Groton CT 06340

Day Treatment Center Clinical Day Treatment Windham

345 Jackson Street Willimantic CT 06226

Day Treatment Center Joshua Center-Northeast

934 North Main St Danielson CT 06239

Day Treatment Center Joshua Center-Enfield

72 Shaker Road Suite 7 Enfield CT 06082

Day Treatment Center Joshua Center-Montville

20 Maple Ave Uncasville CT 06382

Day Treatment Center Quinebaug Day Treatment Center

320 Pomfret Street Putnam CT 06260

Day Treatment Center Rivereast Day Treatment Center

428 Hartford Tpke Vernon CT 06066

Day Treatment Center Thames Valley Clinical Day Program

One Ohio Avenue Norwich CT 06360

Day Treatment Center Joshua Center-Shoreline

5 Research Parkway Old Saybrook CT 06475

Day Treatment Center Part I, Line 3c: Natchaug Hospital used Federal Poverty Guidelines to determine eligibility. Part I, Line 7: The organization used cost to charge ratio as determined by the Medicare Cost Report. Part I, Line 7g: No physician clinic costs were included in the Subsidized Health Services cost calculations. Part I, L7 Col(f): The organization reported bad debt expense in accordance with Generally Accepted Accounting Principles (GAAP) Provision for Bad Debt ASU 2011-07. The provision require certain health care entities to present the provision for bad debts associated with patient services revenue as a deduction from patient service revenue rather than as an operating expense. Part III, Line 4: For FY12 Natchaug Hospital, Inc., was not separately audited, however the parent entity Hartford HealthCare Corp. included Natchaug's financial results in its Consolidated Audited Financial Statement. The HHC's financial statements were provided in accordance with Generally Accepted Accounting Principles (GAAP). GAAP does not require a footnote for bad debt expenses, however, the charity care footnote reads as follows: "A patient is classified as a charity patient by reference to the established policies of the Hospital. Essentially, these policies define charity care services as those services for which no payment is anticipated. In assessing a patient's inability to pay, the Hospital utilizes the generally recognized poverty income levels for the State of Connecticut, but also includes certain cases where incurred charges are significant when compared to patients' incomes." In the event a patient fails to qualify for financial assistance or fails to pay their portion of discounted charges, and the patient does not pay timely their obligation to the Hospital, the Hospital reserves the right to institute and pursue collection actions and to pursue any remedies available at law or in equity, including but not limited to, imposing wage garnishments or filing and foreclosing on liens on primary residences or other assets, instituting and prosecuting legal actions and reporting the matter to one or more credit rating agencies. In the event the Hospital is unable to collect, the outstanding amounts are written off as bad debt. For those patients who qualify for financial assistance and are cooperating in good faith to resolve outstanding accounts, the Hospital may offer extended payment plans and will not impose collection efforts described above.For FY 2011, the amount reported on Part III, Line 3 was determined by reviewing the demographics as well as the insurance plans of the patients for whom accounts were written off as bad debt during the year and extrapolating likelihood that they would be eligible under the hospital's charity care program. For FY 2012, the hospital applied a ratio using the FY 2011 calculations. This ratio ( 25%) was applied to the current year bad debt expense to calculate the estimated amount for 2012.The hopsital received many incomplete Financial Assistance Package applications; if they were complete they would likely have counted as financial assistance. Part III, Line 8: Providing care for those in need, including Medicare and Medicaid patients, and serving all patients regardless of ability to pay are an essential part of the community benefit standard, as well as our mission in our community. We serve these patients without regard to the payment shortfall. Therefore, Medicare shortfall should be considered a community benefit.The organization used a cost to charge ratio as determined by the Medicare Cost report. Part III, Line 9b: The following is included in the Natchaug Hospital's Financial Assistance Policy: For those patients that qualify for financial assistance and who are cooperating in good faith to resolve the Hospital's outstanding accounts, the Hospital may offer extended payment plans to eligible patients, will not impose wage garnishments or liens on primary residences, will not send unpaid bills to outside collection agencies and will cease all collection efforts. Natchaug Hospital, Inc. Part V, Section B, Line 13g: Policy is posted on internet Natchaug Hospital, Inc. Part V, Section B, Line 19d: Part V, Section B, Linde 19b: Natchaug Hospital is in the process of adopting proposed 501r regulations. Once the regulations are final, the hospital will be in compliance. Part VI, Line 2: In addition to the formal Windham County health needs assessment, Natchaug Hospital assesses data from the Connecticut Hospital Association (CHA) and providers throughout the state regarding bed availability and days in emergency departments while awaiting admission. Data from health needs assessments conducted by Backus Hospital, Lawrence & Memorial Hospital and the United Way is also reviewed. Needs are also assessed through Systems of Care meetings, and by tracking waiting lists for admission to programs. Natchaug utilizes all this data to respond to the needs of community served. Part VI, Line 3: Natchaug informs and educates patients about their eligibility for financial assistance in a number of ways. Natchaug's financial assistance policy is available on the hospital's web site and signage is posted in admissions and waiting areas. The policy is also available upon request. Additionally, Natchaug employs three Financial Counselors who meet with patients to review payment options or process financial assistance applications. Part VI, Line 4: Natchaug Hospital admits residents of, on average, 150 of Connecticut's 169 towns and six states each year. Natchaug Hospital's service area is comprised of 62 towns, primarily east of the Connecticut River, which together represent approximately half the State's land area. Natchaug Hospital's clients represent urban, suburban and rural areas. Admissions reflect the demographics and prevalence of behavioral health illnesses of the region: during FY 2012, admissions were composed of 54.5% female, 45.5% male; 1.04% American Indian or Alaskan Native, .38% Asian, 7.15% African American, 86.57 Caucasian, .05% Native Hawaiian, 4.8% other or unknown; 61.68% of clients were age 19 or older, 28.41% were between 12 and 18 years of age, 9.91% were age 4 to 11. The majority of Natchaug Hospital clients (approximately 76%) are financially stressed, as measured by the number of students meeting Federal free/reduced lunch criteria and the number of clients overall who are un insured or participating in a public support plan such as HUSKY, Medicaid or Medicare. Part VI, Line 5: Natchaug Hospital staff actively contributes to the community. For example, Natchaug Hospital's Director of Pharmacy, Jose Scarpa, serves on the Experiential Education Advisory Board of UConn's School of Pharmacy, staffs a Migrant Farmers Clinic, serves on the Accreditation Council for Pharmacy Education, and more; Program Director Peter DeRosa serves on the Eastern Connecticut Chamber of Commerce's Health Advisory Committee and as a Chamber Trustee; Natchaug's Director of School Programs, Jill Bourbeau, serves as the Past President of CAPSEF, where she also sits on the Strategic Planning, Finance and Membership committees; Paul Kindall, Program Director of Natchaug's Enfield Joshua Center, serves on Healthy Enfield; two Natchaug staff serve on their local Boards of Education; at least three Program Directors serve their region's Systems of Care; and the Human Services Advisory Board for the Mansfield Town Council includes a representative from Natchaug.Natchaug Hospital provided seven Professional Development seminars on behavioral health topics for professionals working with school-age youth (school nurses, guidance counselors, teachers, etc), for free. The goals of these seminars are to 1) help identify treatable behavioral conditions as early as possible and 2) to improve awareness of effective classroom management of behaviorally-challenged youth.All members of the Board of Directors reside in our service area and are neither employees, family members, nor contractors of the Hospital. The Hospital extends medical staff privileges to all qualified physicians in its community. The Hospital uses its surplus funds to provide additional benefits to its patients and the community it serves. Part VI, Line 6: Natchaug Hospital is an Affiliate of Hartford HealthCare Corporation (HHC). HHC strives to provide compassionate care designed to deliver the necessary health services needed by the community. The Strategic Planning and Community Benefit Committee of the HHC Board of Directors ensures the oversight for these services by each hospital community. In addition, HHC continues to take important steps toward achieving its vision of being "nationally respected for excellence in patient care and most trusted for personalized, coordinated care."HHC affiliation creates a strong integrated health care delivery system with a full continuum of care across a broader geographic area. This allows the small communities easy and expedient access to the more extensive and specialized services the larger hospitals are able to offer. This includes continuing education of health care professionals at all the affiliated institutions through the Center of Education, Simulation and Innovation located at Hartford Hospital, the largest of the system hospitals.The affiliation further enhances the hospitals' abilities to support their missions, identity, and respective community roles. This is achieved through integrated planning and communication to meet the changing needs of the region. This includes responsible decision making and appropriate sharing of services, resources and technologies, as well as cost containment strategies. Reports Filed With States Part VI, Line 7 CT X X X X 0 0 0 0 0 0 0 0 0 Stephen W Larcen PHD 0 338963 0 63228 0 65155 0 45900 0 23280 0 536526 0 0 David Klein PHD 147974 0 21143 0 25 0 11109 0 26258 0 206509 0 0 0 Paul Maloney 0 142905 0 6619 0 248 0 15271 0 14311 0 179354 0 0 Deborah Weidner 258910 0 8906 0 25 0 12250 0 20332 0 300423 0 0 0 Paul Weigle 160931 0 0 0 11444 0 0 0 22604 0 194979 0 0 0 Jonathan L Chasen 211046 0 3422 0 2916 0 11526 0 24018 0 252928 0 0 0 Pamela Shuman 189410 0 0 0 4221 0 9696 0 27055 0 230382 0 0 0 Teodora Andrei 216611 0 1100 0 25 0 11100 0 27193 0 256029 0 0 0 Paul G Pentz 176982 0 0 0 25 0 11038 0 23169 0 211214 0 0 0 See Part V See Part V 154349 See Part V 0 Business Transactions Involving Interested Persons: (a) Name of Person: William E. Anderson, Jr. (b) Relationship Between Interested Person and Organization: Director(c) Amount of Transactions: $154,349(d) Descrption of Transactions: Mr. Anderson is a board member at Natchaug Hospital. Mr. Anderson is currently an executive at the Savings Institute Bank & Trust. The bank does business with Windham Community Memorial Hospital and Natchaug Hospital. The Hospital paid the bank $154,349 for interest and principal payments on an outstanding loan.(e) Sharing of Organization's Revenue? No Form 990, Part VI, Section A, line 1 There were some board members whose term expired in June, 2012. As a result, they were not considered voting members at the end of the tax year. Form 990, Part VI, Section A, line 6 Natchaug Hospital is organized as a non-stock not for profit entity. Hartford HealthCare Corporation is the sole member. Form 990, Part VI, Section A, line 7a The sole member of the organization has the authority to approve/deny members of the governing body. Form 990, Part VI, Section A, line 7b The sole member of the organization has the right to review, approve, disapprove and deny significant transactions such as mergers, acquisitions, dissolutions etc. Form 990, Part VI, Section B, line 11 The Form 990 was prepared by Hartford HealthCare Corporation's Tax Department. It was then reviewed by an independent accounting firm. It was then forwarded to the organization's top management including the CFO for review. The Form was then made available to the board for review. Once the entire review process was completed, the form was signed by the CFO and then filed with the Internal Revenue Service. Form 990, Part VI, Section B, line 12c The hospital's board has adopted the policy of the member, Hartford HealthCare Corporation (HHC). All directors, officers and senior management of the organization complete and sign a Conflict of Interest statement. The statement includes an itemization and description of any actual or potential conflict of interest and all material facts related thereto for such director, officer or senior manager by virtue of his or her activities or the activities of related persons. Directors, officers and senior managers are urged to be inclusive in this disclosure since the disclosure of potential and actual conflicts of interest is essential to ensuring discussion of the conflict. Conflict of Interest disclosure statements are returned to the HHC Office of Compliance, Audit & Privacy (OCAP). All disclosures are reviewed by OCAP under the direction of legal counsel and the HHC Executive Compliance Steering Committee (ECSC), who shall exercise good faith judgment as to whether a conflict exists. Legal counsel and the ECSC shall be responsible for monitoring transactions or arrangements in which a director, officer and senior management may have a conflict of interest and for assuring that the director, officer or senior management serves the hospital's best interests. OCAP, legal counsel and/or the ECSC may consult with any director, officer or senior manager and obtain information necessary for an ordinarily prudent person to make a judgment as to whether a conflict exists and each director, officer or senior manager shall cooperate with such requests. OCAP, legal counsel and/or the ECSC shall provide guidance to the director, officer or senior manager and to the board of directors as to the appropriate course of action. Legal counsel and the ECSC shall seek the advice and approval of the full Board of Directors in determining whether a conflict of interest exists and that the director, officer or senior manager serves the organization's best interests. When a conflict of interest is discovered, such director, officer or senior manager with the conflict will be required to refrain from participating in any discussion or action concerning such conflicted situation in accordance with policy. If, after completing and signing the annual disclosure statement, an actual or potential conflict arises, the director, officer or senior manager with the conflict shall promptly notify OCAP in writing. Form 990, Part VI, Section B, line 15b The CEO and CFO scales are reviewed annually against surveys and reviewed and approved by the Hartford HealthCare Corporation Compensation Committee. These executives are compensated by Hartford Hospital, a related organization. Other executives are reviewed annually against market using Connecticut Hospital Association (CHA) data, Hartford Hospital (HH) data and appropriate published compensation surveys periodically and reviewed with the Hospital's independent Executive Committee of the Board annually. Form 990, Part VI, Section C, line 19 Form 990 and Form 1023 and its attachments are available upon request. The Hospital's governing documents, financial statements and Conflict of Interest statements are also made available upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Unrealized Pension Plan -1202476. Total to Form 990, Part XI, Line 5: -1202476. Part XII, Lines 2 a & c The organization's financial statement was not audited by an independent accounting firm. However, its operating results were including the the consolidated audited financial statement of the parent company. In addition, the parent organization has a committee that assumes responsibility for oversight of the audit of its financial statements. Average Hours Per Week Form 990 Part VII, Column B Certain employees listed on Part VII of Form 990 share their time between Natchaug Hospital and other related organizations. These are all full time employees that average 40-60 hours per week. Their hours and salaries are allocated between Hartford Hospital and Natchaug Hospital for expenditure purposes. Form 5471 Disclosure DISCLOSURE STATEMENT RELATED TO FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, FILED ON BEHALF OF THE TAXPAYER UNDER THE CONSTRUCTIVE OWNERSHIP RULES OF IRC SECTIONS 958(A) AND (B), THE TAXPAYER IS REQUIRED TO FILE FORMS 5471, INFORMATION RETURN OF U.S. PERSONS WITH RESPECT TO CERTAIN FOREIGN CORPORATIONS, AS A CATEGORY 5 FILER WITH RESPECT TO CERTAIN CONTROLLED FOREIGN CORPORATIONS (CFCS). THESE FILING REQUIREMENTS ARE OR WILL BE SATISFIED THROUGH THE FILING OF FORMS 5471 FOR THESE CFCS BY OTHER U.S. TAXPAYERS IDENTIFIED BELOW WHO HAVE THE SAME FILING REQUIREMENT. TAXPAYER NAME: HARTFORD HOSPITAL ADDRESS: 80 SEYMOUR STREET, PO BOX 5037 HARTFORD, CT 06102-5037 IDENTIFYING NUMBER OF U.S. TAX RETURN WITH WHICH THE FORMS 5471 WERE OR WILL BE FILED: 06-0646668 IRS SERVICE CENTER WHERE U.S. TAX RETURN WAS OR WILL BE FILED: E-FILED Hartford Hospital 80 Seymour Street Hartford CT 06102 060646668 Health Services CT 501 (c) (3) 3 Hartford HealthCare Corp 1 Windham Community Memorial Hospital 112 Mansfield Avenue Willimantic CT 06226 060646966 Health Services CT 501 (c) (3) 3 Hartford HealthCare Corp 1 Windham Hospital Foundation Inc 112 Mansfield Avenue Willimantic CT 06226 562546632 Supporting Organization CT 501 (c) (3) 11 (a) Windham Community Memorial Hospital 1 Midstate Medical Center 435 Lewis Avenue Meriden CT 06451 060646715 Health Services CT 501 (c) (3) 3 Hartford HealthCare Corp 1 Hartford HealthCare Corp 80 Seymour Street Hartford CT 06102 222672834 Support and Management Svcs. to Hartford Hospital and Affiliates CT 501 (c) (3) 11 (c) N/A 1 VNA Health Care Inc 103 Woodland Street Hartford CT 06105 060646938 Home Healthcare CT 501 (c) (3) 7 Hartford HealthCare Corp 1 Rushford Center Inc 883 Paddock Avenue Meriden CT 06450 060932875 Substance Abuse Healthcare Services CT 501 (c) (3) 7 Hartford HealthCare Corp 1 Hartford Hospital Auxiliary co Hartford Hospital 80 Seymour Street Hartford CT 06115 066040747 Fundraising CT 501 (c) (3) 11 (c) Hartford Hospital 1 Connecticut Health System Inc 80 Seymour Street Hartford CT 06102 222779421 Coordination of Health Delivery CT 501 (c) (3) 11 (c) N/A 1 Institute of Living 200 Retreat Avenue Hartford CT 06106 060646683 Psychiatric Services CT 501 (c) (3) 11 (c) Hartford Hospital 1 VNA Resources Inc 103 Woodland Street Hartford CT 06105 061161422 Home Healthcare CT 501 (c) (3) 9 VNA Health Care Inc 1 The Hatch Hospital Corp 112 Mansfield Avenue Willimantic CT 06226 066076412 Health Services CT 501 (c) (3) 3 Windham Community Memorial Hospital 1 WCMH Women's Auxiliary Inc 112 Mansfield Avenue Willimantic CT 06226 060677728 Fundraising CT 501 (c) (3) 11 (a) Windham Community Memorial Hospital 1 The Hospital of Central CT and Bradley Memorial 100 Grand Street New Britain CT 06050 060646768 Health Services CT 501 (c) (3) 3 Hartford HealthCare Corp 1 Central CT Senior Health Svcs dba Southington Care 45 Meriden Avenue Southington CT 06489 222635676 Sub-Acute & Long Term Healthcare CT 501 (c) (3) 9 Hartford HealthCare Corp 1 Bradley Health Services 100 Grand Street New Britain CT 06050 061367014 Health Services CT 501 (c) (3) 9 Hartford HealthCare Corp 1 Central CT Health Alliance 100 Grand Street New Britain CT 06050 222785033 Support and Management Svcs. to THOCC and Affiliates - Shell CT 501 (c) (3) 11 (b) Hartford HealthCare Corp 1 1 The Orchards of Southington 34 Hobart Street Southington CT 06489 061490803 Residential Services for Senior Citizens CT 501 (c) (3) 9 Central CT Senior Health Services Inc 1 Community Mental Health Affiliates 270 John Downey Drive New Britain CT 06051 060934544 Mental Health & Substance Abuse Treatment Provider CT 501 (c) (3) 7 Hartford HealthCare Corp 1 Mulberry Gardens of Southington LLC 58 Mulberry Street Plantsville CT 06479 820586577 Assisted Living & Adult Day Care Facility CT 501 (c) (3) 9 Central Ct Senior Health Services Inc 1 Midstate Medical Center Auxiliary 435 Lewis Avenue Meriden CT 06451 066063082 Fundraising CT 501 (c) (3) 3 Midstate Medical Center 1 HHC PhysiciansCare Inc 80 Seymour Street Hartford CT 06102 454456939 Practice Medicine and Provide Health Care Services to the Public CT 501 (c) (3) 9 Hartford HealthCare Corp 1 Hartford HealthCare Accountable Care Org Inc 200 Retreat Avenue Hartford CT 06102 460886367 To Manage and Coordinate Care for Medicare Beneficiaries CT 501 (c) (3) HHC PhysiciansCare Inc 1 Hartford HealthCare Corp Group (VEBA) 777 Main Street Hartford CT 06102 266671355 To Provide Medical Benefits to Employees CT 501 (c) (9) N/A Hartford HealthCare Corp 1 Central CT Sports Medicine Ctr LLC 15 Masairio Drive Suite 104 Berlin CT 06037 223196509 Physical Therapy CT N/A New Britain MRI Limited Partnership 100 Grand Street New Britain CT 06050 061271349 Magnetic Resonance Imaging CT N/A New Britain Occupational Health Center LLC 440 New Britain Avenue Plainville CT 06062 061484904 Occupational Healthcare CT N/A Hartford HealthCare Endowment LLC 80 Seymour Street Hartford CT 06102 454181103 Endowment Management CT N/A Ambulance Service of Manchester LLC 111 Founders Plaza East Hartford CT 06108 061557358 Ambulatory Services CT N/A Glastonbury Endoscopy Center LLC 300 Western Blvd Suite B Glastonbury CT 06033 261721234 Endoscopy Services CT N/A Glastonbury Surgery Center LLC 195 Eastern Boulevard Glastonbury CT 06033 262600828 Surgery Services CT N/A Hartford-Middlesex Clinical System LLC 80 Seymour Street Hartford CT 06110 061543605 Affiliate Support Services CT N/A Med East Assoc LLC 1703 West Main Street Willimantic CT 06226 061469575 Outpatient Care Clinic CT N/A Connecticut Imaging Partners LLC 111 Founders Plaza East Hartford CT 06108 134298940 Imaging Services CT N/A HHMOB Corporation & Subsidiary 80 Seymour Street Hartford CT 06102 061140244 Real Estate Parking CT N/A C CHS Insurance LTD 40 Church Street Hamilton BD Captive Insurance BD N/A C Windham Health Services Inc 112 Mansfield Avenue Willimantic CT 06226 061461101 Home Healthcare CT N/A C Windham Physician Hospital Organization 112 Mansfield Avenue Willimantic CT 06226 061441614 Medical Services CT N/A C Windham Family Medical Services 112 Mansfield Avenue Willimantic CT 06226 061491649 Medical Services CT N/A C CenConn Services Inc 100 Grand Street New Britain CT 06050 222836001 Investment Management CT N/A C Grand Indemnity Co LTD FB Perry Building 40 Church Street Hamilton BD 980609499 Professional Liability BD N/A C Hartford Physician Services PC 80 Seymour Street Hartford CT 06102 061254082 Medical Services CT N/A C Meriden Imaging Center 101 North Plains Industrial Road Meriden CT 06429 061541468 Imaging CT N/A S Hartford Physician Hospital Organization Inc 80 Seymour Street Hartford CT 06102 222785918 Physician & Hospital Support CT N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 1 0 Hartford Hospital O 139884 FMV Windham Community Memorial Hospital L 125092 FMV Windham Community Memorial Hospital N 202969 FMV Rushford Center Inc N 122640 FMV CHS Insurance Ltd Q 413129 FMV