2013-08-15T15:05:06-05:00 2012-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2011-10-01 030183721 Windsor Hospital Corporation WIND 8026746711 289 County Road Windsor VT 05089 David C Sanville 8026746711 2013-08-15 1 Barbara J McGuan CPA P00219457 2077752387 2013-08-15 2011 2016-02-25 16:41:14Z Mt Ascutney Hospital & Health Center Kevin Donovan 289 County Road Windsor VT 05089 45535123 0 X www.mtascutneyhospital.org X 1933 VT To improve the lives of those we serve. Our activities include providing healthcare. 15 12 610 145 0 0 290914 1045106 44423161 42721756 406880 517785 144149 112344 45265104 44396991 0 0 0 0 28702159 29167348 0 0 207652 17125303 18701283 45827462 47868631 -562358 -3471640 39107257 39840458 26322561 28978605 12784696 10861853 X Mount Ascutney Hospital and Health Center's mission is to improve the lives of those we serve. 0 0 34086857 42721756 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, 10 acute rehabilitation beds, and 25 extended care beds. During the year there were 1,000 inpatient discharges, 550 outpatient surgeries, 76,100 outpatient lab tests, and 8,700 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 38,00 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 $744,400. 34086857 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 60 0 1 610 1 0 0 0 0 0 0 0 0 0 0 X 15 12 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Theresa Kohler 8026747240 289 County Road Windsor VT 05089 Harold Pyke 1.00 X X 0 0 0 Nancy Loux 1.00 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 22.00 X 92500 0 23477 Larry Frazer 1.00 X 0 0 0 Michael Newbold 1.00 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 Shelley Seward 1.00 X X 0 0 0 Nancy Formella 1.00 X 0 0 0 Hon Donna Sweaney 1.00 X 0 0 0 Steven Smith MD 40.00 X 159782 0 61091 Donna VanFleet 1.00 X 0 0 0 Andrew Robinson MD 40.00 X 0 0 0 Catherine Schneider MD 40.00 X 151510 0 24464 Kevin Donovan 40.00 X 257905 0 17976 Bennett Beres 40.00 X 133671 0 33547 Jill Lord 40.00 X 146112 0 852 Wayne Bennett 40.00 X 190504 0 18665 David Sanville 24.00 X 0 0 0 Paul Calandrella 40.00 X 0 0 0 Christopher Connor MD 40.00 X 347347 0 35514 Peter Rauert MD 40.00 X 279724 0 27792 Glenn Neale MD 40.00 X 286988 0 40439 Laura Manfield 40.00 X 220771 0 26810 Heidi Cruz 40.00 X 189682 0 45763 2456496 0 356390 34 0 1 1 Dartmouth-Hitchcock One Medical Center Drive Lebanon NH 03756 Provide Professional and Physician Servi 1948706 Emergency Services of New England PO Box 12 Chester VT 05143 Physician Assistance for Emergency 1006837 Valley Regional Hospital 243 Elm Street Claremont NH 03743 Provide Surgeons for Hospital 278283 CPSI PO Box 850309 Mobile AL 366850309 Service/Maintenance Contract 242585 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Provide Physician Coverage for Hospital 232687 12 469251 575855 22405 1045106 Patient Services 900099 69735554 69735554 Program & Misc Other 900099 868142 868142 DHS/VAHHA Revenue 900099 302698 302698 Uncollectable Provisio 900099 -2177808 -2177808 Contractual & Charity 900099 -26006830 -26006830 42721756 325519 325519 69744 0 69744 69744 69744 1311895 2233 1121862 0 190033 2233 192266 192266 58870 16270 42600 42600 44396991 42721756 0 630129 935670 115978 819692 21406032 19183459 2055974 166599 1530566 1116280 414286 3685905 3061538 624367 1609175 1174706 434469 37547 6242 31305 30604 30604 4244236 2490014 1742820 11402 81240 3766 74449 3025 48681 32931 14949 801 1045859 339374 706485 77964 48878 29064 22 446166 446166 2096367 2096367 598738 353337 245401 Contracted Wages 2970987 2445016 525971 Medical Supplies 2441620 2422996 18600 24 Dues/Fees/Taxes 2234707 228142 2006278 287 General Supplies 631394 248268 378026 5100 1715173 815932 878849 20392 47868631 34086857 13574122 207652 1601 2040 5796450 4310274 542045 5437430 4943761 14037 20653 606056 537845 399107 147056 33694489 19376034 13639227 14318455 9618618 11218112 1714139 1873054 1880592 1927163 39107257 39840458 4360185 6011590 8937741 8731471 1030739 1743586 11993896 12491958 26322561 28978605 X 6690592 4628155 464786 441032 5629318 5792666 12784696 10861853 39107257 39840458 X -3471640 1548797 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 19779 19779 0 Explanation of Lobbying Activities: Part II-B, Line 1: The Hospital paid $18,081 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 $1,698 in the form of dues to the American Hospital Association (AHA). 5705958 174448 5880406 5787015 -81057 5705958 5710296 76719 5787015 5634030 76266 5710296 0.00000 0.98500 0.01500 0 0 75418 75418 12096401 7430093 4666308 12627760 7500017 5127743 8894910 4445924 4448986 14318455 Other Liabilities 1062534 Post-Retirement Benefit Obligation 7647828 Interest Rate Swap 789547 Estimated Settlements with Third-Party Payors 2992049 12491958 44396991 47868631 -3471640 1254020 294777 1548797 -1922843 45931454 1254020 342784 1596804 44334650 30604 31737 62341 44396991 47854297 16270 16270 47838027 30604 30604 47868631 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 8 - Other Adjustments: Unrealized Loss on Interest Rate Swap -27,303. Equity in Income of Subsidiaries 116,649. Change in Funded Status of Pension Plan 46,516. Unrealized Appreciation in Charitable Remainder Trust -4,434. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts 163,349. Total to Schedule D, Part XI, Line 8: 294,777. Part XII, Line 2d - Other Adjustments: Equity in Income of Subsidiaries 116,649. Change in Funded Status of Pension Plan 46,516. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts 163,349. Fundraising Expense 16,270. Part XII, Line 4b - Other Adjustments: Unrealized Loss on Interest Rate Swap 27,303. Unrealized Appreciaton in Charitable Remaineder Trust 4,434. Part XIII, Line 2d - Other Adjustments: Fundraising Expense 16,270. Golf Tournament 58870 58870 650 5000 5805 4815 58870 58870 650 5000 5805 4815 16270 42600 1 1 1 X 1 X 1 1 1 0 1 1 471580 471580 0.00990 7322062 4162763 3159299 0.06600 7793642 4162763 3630879 0.07590 342261 342261 0.00720 95888 95888 0.00200 10730294 7942311 2787983 0.05820 3100 3100 0.00010 11171543 7942311 3229232 0.06750 18965185 12105074 6860111 0.14340 1 1270000 17441489 17680354 -238865 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 06 1 1 1 X X X X X X X X X X 1 1 1 200.000000000000 1 300.000000000000 0 1 1 X X 1 X X 1 X X X 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 $5,776,826 of the total Community Benefit Expenses and $4,482,511 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: Focus groups, surveys and stakeholder groups 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. 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 0 0 2400 0 0 0 61091 0 220873 0 0 0 Catherine Schneider MD 151396 0 0 0 114 0 0 0 24464 0 175974 0 0 0 Kevin Donovan 251305 0 0 0 6600 0 0 0 17976 0 275881 0 0 0 Bennett Beres 133445 0 0 0 226 0 5545 0 28002 0 167218 0 0 0 Wayne Bennett 190324 0 0 0 180 0 0 0 18665 0 209169 0 0 0 Christopher Connor MD 297101 0 50000 0 246 0 9800 0 25714 0 382861 0 0 0 Peter Rauert MD 279478 0 0 0 246 0 5697 0 22095 0 307516 0 0 0 Glenn Neale MD 267988 0 19000 0 0 0 0 0 40439 0 327427 0 0 0 Laura Manfield 213413 0 7142 0 216 0 2396 0 24414 0 247581 0 0 0 Heidi Cruz 189462 0 0 0 220 0 7768 0 37995 0 235445 0 0 0 Part I, Line 7 Christopher Conner, MD received a bonus which was based on Relative Value Units (RVU's). Laura Manfield, MD received a bonus which was a loan repayment. Glenn Neale, MD received a bonus which was based upon longevity. Supplemental Information Part III Steven Smith was paid $218,473 in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for his services as physician. He was not compensated for his duty as trustee. Kevin Donovan was paid 269,281 in compensation and benefits by Dartmouth Hitchcock Medical Center, an unrelated organization, for his services as CEO. Vermont Educational and Health Buildings Financing Agency 237154467 2010-02-05 9244000 Refinancing of 2004 and 2005 Bonds 0 0 0 512529 9244000 128133 9115867 2010 1 0 1 1 0 0 0 0 1 0 1 0 0 0 0 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 5: Net unrealized gains on investments: 1,254,020. Unrealized Loss on Interest Rate Swap -27,303. Equity in Income of Subsidiaries 116,649. Change in Funded Status of Post-Retirement 46,516. Unrealized Depreciation in Charitable Remainder Trust -4,434. Unrealized Appreciation in Beneficial Interest in Perpetual Trusts 163,349. Total to Form 990, Part XI, Line 5: 1,548,797. Form 990, Part XII, Line 2c The organization did not change its oversight or selection process during the tax year. 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 0 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 Mt Ascutney Hospital Community Health Foundation Inc P 19468 Historic Homes of Runnemede Inc P 90670