2013-05-09T19:48:30-07:00 2012-09-30 990 2011-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786323420 242 Green Street Gardner MA 01440 Robert Crosby 9786306157 2013-04-17 2011 2016-02-24 21:20:13Z Robert Crosby 242 Green Street Gardner MA 01440 112251996 0 X www.heywood.org X 1907 MA Heywood Hospital is a community oriented and supported not-for-profit acute care hospital governed by a local Board of Trustees. Our mission is to be our communities' trusted choice for exceptional patient-centered care. 20 19 988 289 0 0 995825 3474560 98848732 100862323 -135263 1034227 1044642 967815 100753936 106338925 231428 118567 0 0 52620474 52430754 21806 12925 102038 49068941 49513662 101942649 102075908 -1188713 4263017 86669292 91777100 44191517 46158901 42477775 45618199 Heywood Hospital is a community oriented and supported not-for-profit acute care hospital governed by a local Board of Trustees. Our mission is to be our communities' trusted choice for exceptional patient-centered care and to be one of the best independent community hospitals in America. 0 0 96309728 118567 100862323 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 2012" filed with the MA Attorney Generals Office. 0 0 0 96309728 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 0 0 1 0 0 0 0 1 1 1 1 0 1 121 0 1 988 1 0 0 0 0 0 0 X 20 19 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 Winfield Brown 40 X X 176640 0 16189 Gerald L Bankowski 0 X 0 0 0 Robert Chauvin 0 X 0 0 0 Laura Chen 0 X 0 0 0 Joyce Fletcher 0 X 0 0 0 John Flick 0 X 0 0 0 James Garrison 0 X 0 0 0 Stephen Hemman 0 X 0 0 0 Glenn A Hunt 0 X 0 0 0 John Kerney 0 X 0 0 0 Anthony P Kraskouskas Jr 0 X 0 0 0 Janet Latour 0 X 0 0 0 Michele Parker 0 X 0 0 0 JoAnne Parks 0 X 0 0 0 Kenneth J Pierce 0 X 0 0 0 Henri Sans 0 X 0 0 0 Tina Sbrega 0 X 0 0 0 John Skrzypczak MD 0 X 0 0 0 Karl Sorenson MD 0 X 0 0 0 Daniel P Moen 40 X X X 970645 0 22811 Daniel M Asquino 0 X 0 0 0 Robert Crosby 40 X 248789 0 26834 Michael Grimmer 40 X 57021 0 8417 Tina Santos 40 X 66466 0 5476 Thomas Cady 40 X 178896 0 28127 Rose Kavalchuck 40 X 192100 0 25255 James Mullen 40 X X 317386 0 28802 Lorie Martiska 30 X X 160059 0 11793 David Gill 40 X 256112 0 27681 Sheila Ebert 24 X 190343 0 14449 Alice Vaine 30 X 139559 0 12682 Tina Griffin 40 X 132463 0 23587 Laura Duffy 32 X 128659 0 27120 Dianne Cormier 32 X X 126373 0 11791 3341511 0 291014 56 1 1 0 Quartulli and Associates Inc PO Box 423 Gardner MA 01440 Physical Therapy 2984257 Bay State Emergency Medical Inc 44 Crosby Road Ashburnham MA 01430 Emergency Room Physicians 2664370 William A Berry & Sons Inc 99 Conifer Hill Drive Danvers MA 01923 Construction Services 2315189 Alliance Healthcare Services 100 Bay View Circle Newport Beach CA 92660 MRI 1165811 Quest Diagnostics Inc 5763 Collection Center Drive Chicago IL 60693 Lab Contracted Services 938278 26 0 0 53825 0 2140981 1279754 704524 3474560 Ancillary O/P Service 622110 56606353 56606353 0 0 Ancillary I/P & Routine 622110 43392280 43392280 0 0 Contracted Services 900099 545101 545101 0 0 HMG Patient Revenue (net) 621111 198519 198519 0 0 Lifeline 624120 63052 63052 0 0 57018 57018 0 0 100862323 234823 0 0 234823 58 0 0 58 0 0 0 0 37698 0 0 0 37698 0 37698 0 0 37698 6622412 42905 5847011 18960 775401 23945 799346 0 0 799346 29800 53825 47100 -17300 0 -17300 0 0 0 0 0 0 0 0 0 0 0 0 Meal Revenue 722212 688968 0 0 688968 Purchase Discounts 900099 149217 0 0 149217 Medical Record Copies 561499 23235 0 0 23235 85997 0 0 85997 947417 106338925 100862323 0 2002042 118567 118567 0 0 0 0 0 0 1719868 645244 1074624 0 0 0 0 0 41676026 40185854 1422189 67983 717163 616079 100044 1040 4978986 4695442 269816 13728 3338711 3163695 170398 4618 0 0 0 0 295717 15394 280323 0 97342 0 97342 0 0 0 0 0 12925 12925 0 0 0 0 11768420 11762885 5535 0 70570 61964 8606 0 13897473 13658197 237532 1744 1245383 1201322 44061 0 0 0 0 0 1687518 1668009 19509 0 78719 67184 11535 0 0 0 0 0 61883 39642 22241 0 894164 894164 0 0 0 0 0 0 4560863 4546910 13953 0 732925 691200 41725 0 Professional Fees 5015772 3650088 1365684 0 Bad Debt 4274050 4274050 0 0 Free Care 2555954 2555954 0 0 Subscriptions & Dues 623491 203849 419642 0 1653418 1594035 59383 0 102075908 96309728 5664142 102038 1853123 2438924 0 0 3023263 2398884 10745265 10258616 0 0 0 0 59961 72338 1366412 1371294 1024514 1080396 101611889 46904976 56055833 54706913 11923586 17190937 493046 489451 124289 129347 0 0 0 1640000 86669292 91777100 13381637 13297762 0 0 0 0 26230945 26312766 0 0 0 0 812024 729023 0 0 3766911 5819350 44191517 46158901 X 36836852 40274861 4634890 4337245 1006033 1006093 42477775 45618199 86669292 91777100 X 4263017 -1122593 X 1 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 11897431 5683 1966503 0 -3258767 0 17128384 17367013 5000 -128702 0 5345880 0 11897431 16786738 4875 958017 0 382617 0 17367013 18164728 5250 -686973 0 696267 0 16786738 0.86 0.06 0.08 0 0 0 125271 125271 0 64667161 20961879 43705282 0 0 0 0 0 35983796 25943097 10040699 0 835661 0 835661 54706913 0 Est Settlement with 3rd Party 4336350 Est Insurance Claims 1483000 5819350 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Perm Endow 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 Funds are established by the governing body to fund capital projects and/or improvements of the organization. Temp Restricted funds are established by donor restricted gifts that maintain a source of invomce for a specific period of time. SchD_P09_S00_L00 Schedule D, Part IX 1. Investment in purchased coalition = $157,000 2. Insurance recovery receivable = $1,483,000 SchD_P10_S00_L02 Schedule D, Part X, Line 2 The Hospital and HMG (as of April 2006) have been determined to be not-for-profit corporations as described in Section 501(c)(3), and the Realty Corp has been determined to be a not-for-profit corporation as described in Section 501(c)(2) of the Internal Revenue Code (the "Code") and are exempt from federal income taxes on related income pursuant to Section 501(a) of the code. The IRS has also previously determined that the hospital is not a provate foundation because it is an organization described under the IRC section 170(i)(A)(iii). Any income not substantially related to these Organizations' exempt purposes may be considered unrelated business income under IRC Section 511 and, as such, subject to tax at normal corporate rates. In accordance with generally accepted accounting principles, the Organization annually evaluates its tax status and tax positions taken with respect to its operations and financial positions. Tax years from 2008 through the current year remain open for examination by federal and state taxing authorities. Golf Classic 83625 53825 29800 0 2172 15720 19593 400 9215 0 0 83625 53825 29800 0 2172 15720 19593 400 9215 47100 -17300 1 1 X 1 X 1 X 1 1 1 0 1 1 2056615 1157204 899411 0.0092 15867678 13653014 2214664 0.0225 0 0 0 0 0 0 17924293 14810218 3114075 0.0317 966837 89597 877240 0.009 427465 6407 421058 0.0043 0 0 0 0 0 0 0 0 24714 0 24714 0.0003 0 0 1419016 96004 1323012 0.0136 0 0 19343309 14906222 4437087 0.0453 386 0 386 0.00 0 0 0 0 1957 0 1957 0 1100 0 1100 0 0 0 0 0 125354 0 125354 0.0013 58434 16998 41436 0.0004 294802 0 294802 0.0031 0 0 0 0 0 0 482033 16998 465035 0.0048 1 2006886 130435 30181944 26705266 3476678 X 1 1 1 1 Henry Heywood Memorial Hospital

242 Green Street Gardner MA 01440

X X X Henry Heywood Memorial Hospital 1 1 1 100 1 400 1 X X X 1 1 X X X X X X 1 X 1 X X X X X X 1 X 0 0 SchH_P01_S00_L06a Schedule H, Part I, Line 6a The Organization makes it's annual Community Benefit Report available to the public by transmitting the report electronically to the Attorney General's Community Benefit office which then makes it public on their website. SchH_P01_S00_L07 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. The costs for lines 7e through 7i were actual costs incurred. SchH_P02_S00_L00 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 underserved and collaborating with others to enhance quality and contain growth of community healthcare costs." Sch H, Part II, line 1: The Hospital took part in building a community vegetable garden. This garden was established to assist the Veteran's Outreach Ceter to provide individuals with food, increased sense of productivity and fulfillment, as many of these individuals are disabled and cannot work full-time jobs. Sch H, Part II, Line 3: The Hospital has a Domestic Violence Task Force which helps the community in violence prevention. Also, a Substance Abuse Support Group was established for the community to reach out and help families. Sch H, Part II, Line 4: New this year, the Hospital established the Heywood Hospital Green Team. This group held Earth Day events which included a mercury thermometer exchange for new, non-mercury thermometers. Also, they held an electronic recycling day at no charge. This recycling project removed about 1,000lbs of electronic recycling from the community. Sch 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, Greater Gardner Interagency Team, the CHNA, the Minority Coalition, Montachusetts Opportunity Council, Mount Wachusetts Community College, the Community Health Connections Health Centers, North Central Human Services, Luk, Inc, Community Health Link, Gardner VNA, the Gardner Public Schools, the Winchendon Public Schools, the Health Foundation of Central MA, Kresge Foundation, the Dpt 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 underserved 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. Sch H, Part II, Ln 7: Heywood Hospital had representation at a Community Service Health Fair on Oct 25, 2011. Additionally, Heywood Hospital Emergency Department includes a community health promotion advocate under the SBIRT project. This advocate screens emergency room patients and community members for health risks and substance abuse, and makes appropriate referrals. Sch 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 out physicians to serve our community. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 Footnote: "Allowance for Doubtful Accounts - Accounts Receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Organization analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data baout these major payor sources of revenue in evaluating the sufficiency of the allowance for doubful accounts. For receivables associated with services provided to patients who have third-party coverage, the Organization records a provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts." The costing methodology used for line 2 was based on the cost to charge ratio derived from the supplied worksheet 2 in the IRS sch H instructions. The methodology used for line 3 was to take the percentage of financial assistance applications that were denied due to inadequate documentation divided by the total applications received for FY12. This amounted to approximately 6.5% which was applied against the number on line 2. It is our belief that $130,435 amount of bad debt should be included as community benefits. 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 debt as a community benefit. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The allowable costs on line 6 were obtained from our FY2012 Medicare Cost Report, worksheet D schedules. SchH_P03_S0C_L09b 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 determin if the patient is eligible to apply for certain health insurance programs. If the patient or guarantor is unable to provide the necessary information, Heywood Hospital may make reasonable efforts to obtain any additional information from other sources. Information that heywood obtains will be maintained in accordance with applicable federal and state privacy and security laws. The screening and application process for a public health insurance program is done through the 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, homless and disabled individuals. Heywood specifically assists the patient in completing the application and securith 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 Viertual 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 the determination of program eligibility made by the Commonwealth, but at the patient's request may take a direct role in appealing or seeking information related to the coverage decisions. it is still the patient;s responsibility to inform Heywood Hospital of all coverage 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. SchH_P05_S0B_L17 Schedule H, Part V, Section B, Line 17 The Hospital posts general notices throughout the hospital about the financial assistance policy. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 Heywood Hospital co chairs the Joint Coalition on Health which undertakes comprehensive assessments of community needs and assets every three to five years. The Steering Committees of the JCOH and the CHNA, with support from the Minority Coalition of North Central MA, collaborate to finalize a comprehensive health assessment of a 27 town region in north central MA. After the addition of pertinent sections to the report originally completed in January 2011, a final report was made available to the public in the fall of 2011. It was published in hard copy and as an electronic file on the web sites of participating organizations. More than 20 focus groups and interviews were conducted by vendors who were responsible for the qualitative portion of the assessment. This data was gathered and analyzed by Blue Cross Blue Shield of MA. The Central MA Area Health Education Center intergrated the results of the qualitative work with the quantitative date to produce a final report. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 General Principles: For those patients who are uninsured or underinsured, Heywood Hospital will work with them to assist with applying for available financial assistance programs that may cover some or all of their unpaid hospital bills. In order to help uninsured and unnderinsured patients find available and appropriate financial assistance programs, Heywood Hospital will provide all patients with a general notice of the availability of programs in both the bills that are sent to patients as well as in general notices that are posted throughout the hospital. 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, Heywood 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. Heywood Hospital will provide, upon request, specific information about the eligibility process to be a Low Income Patient under either the Massachusetts Health Safety Net Program or additional assistance for patients who are low income through Heywood Hospital's own internal financial assistance program. Heywood Hospital will also notify the patient about available payment plans that may be available to them based on their family size and income. Role of Hospital Patient Finacnial Counselors and Other Finance Staff: Heywood 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 Heywood Hospital, upon discharge, and for a reasonable time following discharge from the hospital. The hospital registration and admission staff will direct all patients seeking available coverage options or financial assistance to the hospital's patient financial counseling office to determine if they are eligible and then to screen for eligibility in an appropriate coverage option. Heywood Hospital will then assist the patient in applying for the appropriate coverage options that are available or notify them of the availability of financial assistance through the hospital's own internal financial assistance program. Heywood Hospital will also provide information on how to contact the appropriate staff within the hospital's finance office to verify the accuracy of the hospital bill or to dispute certain charges. Notification Practices: Heywood Hospital will post a notice of availability of financial assistance in the following locations i. Service Delivery Areas such as Inpatient, Clinic and Emergency Department admissions and registration areas. ii. Patient Financial Counselor areas. iii. Central Admission and Registration areas and iv. Business office areas that are open to patients. Posting signs will be clearly visible and legible to patients visiting these areas. Heywood Hospital will also include a notice about the availability of financial assistance in all initial bills. When the patient contacts Heywood Hospital, the hospital finance staff will attempt to identify if a patient qualifies for a public financial assistance program or a payment plan. A patient who is enrolled in a public financial assistance program may qualify for certain plans. Patients may also qualify for additional assistance based on Heywood 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. For cases where Heywood Hospital is using the Virtual Gateway application, the hospital will assist the patient in completing the application for MassHealth, Commonwealth Care, Children's Medical Security Plan, Healthy Start, Health Safety Net or other forms of financial assistance programs, as they become part of the Virtual Gateway program. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Greater Gardner area, comprised of the City of Gardner and five surrounding towns, has a population of 60,000 people, a median income below the state average, and an unemployment rate above the state average. The community has been affected by the loss of the furniture industry over the past few decades, and by the current economic downturn. Mental Health and Substance Abuse are significant challenges for many residents of the area. the Hospital is the largest employer in the area, with around 1,000 employees. The community is largely white, non hispanic, but has a growing hispanic population. Gardner is one of three cities in the region, the others are Fitchburg and Leominster, which frequently collaborate for the betterment of the region. Heywood Hospital collaborates with the competing hospital in the Fitchburg Leominster area, HealthAlliance, on community health improvement acitivites. SchH_P06_S00_L05 Schedule H, Part VI, Line 5 The Heywood Hospital's Community Benefit Mission Statement states 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 collaborating with others to enhance quality and contain the growth of community healthcare costs. The Hospital dedicates our organization to the community benefit goals by improving the health status of our community; addressing the special health problems of minorities, the poor, uninsured annd other underserved populations; containing the growth of community health care costs. Such goals will be undertaken within the framework of a Community Benefit Plan which shall include such elements as commitment on the part of the Board of Trustees and CEO; specific goals and objectives; annual evaluation processes; commitment of hospital resources through normal budgeting process; consideration of community served in all operational and policy decisions; defined community; health status and needs assessment; opportunity for public input and comment; the promotion of cooperative and collaborative relationships with other providers and agencies in order to carry out a broad health agenda in our community. Such community benefit goals are elements and are herby adopted and endorsed by the Board of Trustees of Heywood Hospital. SchH_P06_S00_L06 Schedule H, Part VI, Line 6 not applicable SchH_P06_S00_L07 Schedule H, Part VI, Line 7 Heywood Hospital files an annual Community Benefit Report to the Attorney General's Community Benefit Office in Massachusetts. 1 Montachusett Home Care Corp 680 Mechanic Street Leominster MA 01453 042551175 501(c)(3) 51339 0 n/a n/a The funds will be used by the Community Health Network of North Central MA as support and collaborative community health assessment work. Montachusett Opportunity Council 133 Pritchard Street Fitchburg MA 01420 042401111 501(c)(3) 67228 0 n/a n/a The funds will be used by Joint Coalition on Health as support of operations, to provide Community Health grants in conjunction with identified priorities of the JCOH service area, and to support the Gardner Area InterAgency Team. 2 0 SchI_P01_S00_L02 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 X X X 1 0 0 0 0 1 0 0 0 Robert Crosby 225227 0 22441 0 1122 0 0 0 26834 0 275624 0 0 0 Winfield Brown 157667 0 15000 0 3972 0 0 0 16189 0 192828 0 0 0 Michael Grimmer 47867 0 6000 0 3154 0 0 0 8417 0 65438 0 0 0 Tina Santos 57908 0 8500 0 58 0 0 0 5476 0 71942 0 0 0 Thomas Cady 155361 0 22723 0 812 0 2398 0 25729 0 207023 0 0 0 Rose Kavalchuck 167709 0 23774 0 617 0 3479 0 21777 0 217356 0 0 0 David Gill 254821 0 0 0 1291 0 4900 0 22781 0 283793 0 0 0 Sheila Ebert 189238 0 0 0 1105 0 3807 0 10643 0 204793 0 0 0 Alice Vaine 139348 0 0 0 212 0 2843 0 9839 0 152242 0 0 0 Tina Griffin 131871 0 350 0 243 0 2754 0 20833 0 156051 0 0 0 Laura Duffy 101551 0 1609 0 25499 0 2187 0 24934 0 155780 0 0 0 Dianne Cormier 121588 0 4785 0 0 0 2412 0 9558 0 138343 0 0 0 Daniel P Moen 28403 0 0 0 942242 0 622 0 22189 0 993456 0 0 0 James Mullen 90766 0 23999 0 202621 0 3155 0 25647 0 346188 0 0 0 Lorie Martiska 75611 0 10956 0 73492 0 2020 0 9773 0 171852 0 0 0 SchJ_P01_S00_L04 Schedule J, Part I, Line 4 James Mullen, former CNO, and Lorie Martiska, former VP of Community Relations, both received severence payments in 2011. James Mullen's severence was a total of 148,456 and Lorie Martiska's severance was a total of 48,893. Laura Duffy, former Director of Emergency Services, received severance of 25,470. She was later rehired as an ER RN. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 Heywood Hospital accrues 6% of the CFO & VP's salaries for a bonus payment that is based off the financial conditions of the hospital once the fiscal year is completed. SchJ_P02_S00_L00 Schedule J, Part II There were changes to the Hospital's management team. The former president, Daniel Moen, terminated on January 24, 2011 and the new president, Winfield Brown, was hired on August 1, 2011. The former CNO, James Mullen, terminated on May 27, 2011 and the new CNO, Tina Santos, was hired on September 12, 2011. The VP of Community Relations terminated on August 25, 2011 and this position was not filled during the fiscal year. In addition, a VP of Support Services, Michael Grimmer, was hired on September 19, 2011. MA Health and Educational Facilitiy Authority 042456011 57586EGT2 2009-03-31 17785000 Funds used for new Watkins Bldg project 0 0 0 MA Health and Educational Facility Authority 042456011 57586C7E9 2008-06-19 6715000 Refunding and new Watkins Bldg project 0 0 0 0 0 66235 0 0 0 281690 0 0 17569545 0 0 2010 0 0 1 1 0 0 19154 0 0 0 329467 0 3597891 2806796 0 0 2008 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 1 TD Bank 18.7 0 0 0 0 1 0 1 1 Piper Jaffrey 18.7 0 0 0 0 1 X 1 704524 cost 0 0 1 0 F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b The Senior 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 approved and signed, copies are provided to the governing body at their monthly meeting. The 990 is then approved for finaly submission by the accounting department. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Annually, a Conflict of Interest form is sent out to the managers, trustees and employees with a broad discretionary authority. These forms are required to be signed and are monitored by the VP of Professional Services for completion. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 The CEO and Officer's salary is determined by the market data provided to the search committee by our search firm, an independent third party named Phillips DiPisa. This data supplemented the first hand knowledge of other comparable facilities in New England and that search firm had based on prior searches. Sources as the Massachusetts Hospital Salary Survey and Intimate knowledge of the going salaries for senior executives in healthcare also play a major role in determing salaries. F990_P06_S0C_L19 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 Executive Assistance, who provides copies upon request. F990_P11_S00_L05 Form 990, Part XI, Line 5 The amount that makes up the changes in net assets or fund balances is from gains and losses on investments, discounts on pledge receivables and transfers to Heywood Medical Group to help support the organization as they employ physicians that serve the Hospital. Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 employ physicians MA 501(c)(3) 9 N/A 1 Heywood Hospital Realty Corporation 242 Green Street Gardner MA 01440 043327447 property holding company MA 501(c)(2) N/A 1 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) 9 N/A 0 Heywood Physician Hospital Organization 242 Green Street Gardner MA 01440 043153119 Managed care contracted physicians MA 501(c)(3) 9 N/A 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 1 1 0 Heywood Affiliated Medical Group q 1584000 cash Heywood Affiliated Medical Group o 374195 actual cost Heywood Physician Hospital Organization p 224037 actual cost Heywood Hospital Realty Corporation p 179789 actual cost Heywood Affiliated Medical Group p 535180 actual cost Heywood Hospital submitted, and was granted, an extension on the 990 filing to 5/15/13.