2012-08-13T09:00:15-07:00 2011-09-30 990 2010-10-01 060646696 JOHNSON MEMORIAL HOSPITAL INC JOHN 8606844251 201 Chestnut Hill Road Stafford Springs CT 060760860 John Grish 8606848150 2012-08-13 2010 2016-02-24 21:20:13Z David Morgan 50 Pleasantview Drive Somers CT 06071 61508343 0 X www.jmmc.com X 1912 CT Johnson Memorial Hospital provides needed medical care to the community regardless of any individuals ability to pay. Services include inpatient routine, inpatient ancilliary, and outpatient care in support of the hospitals healthcare mission. 11 10 724 122 -19959 0 252845 26249 61336091 59092708 134029 123908 34824592 2265478 96547557 61508343 0 0 0 0 34409728 32505138 0 0 0 34763840 29359136 69173568 61864274 27373989 -355931 46957303 41290011 38223343 32673891 8733960 8616120 Johnson Memorial Hospital provides needed medical care to the community regardless of any individuals ability to pay. Services include inpatient routine, inpatient ancilliary, and outpatient care in support of the hospitals healthcare mission. 0 0 55880089 14192 59112667 Inpatient and Outpatient Care: Expenses related to services performed for patients of Johnson Memorial Hospital contribute importantly to it's expempt purpose because the expenses are incurred in the diagnosis, cure, mitigation, treatment and prevention of disease and for medical purposes affecting the structure or function of the human body. (80,067 Outpatient visits and 15,614 Inpatient days) 0 0 0 55880089 1 1 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 116 0 724 1 1 1 0 0 0 0 0 X 11 10 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Thomas Blazejowski 8606848133 201 Chestnut Hill Road Stafford Springs CT 060760860 Gary J Roman 2 X 0 0 0 James A Baum 2 X 0 0 0 Evelyne A Parizek 2 X 0 0 0 Richard P Dobson SR 2 X 0 0 0 John Larabee 2 X 0 0 0 Patrick Mahon 2 X 0 0 0 James Makuch 2 X 0 0 0 Joan C Smith 2 X 0 0 0 Peter J Betts 50 X 0 0 471897 David Morgan 50 X 338553 0 23364 John Grish 50 X 294915 0 21971 Dr Michael S Woods 50 X 276724 0 21390 Michelle Urban 50 X 145997 0 17216 Dianne Malsbury 40 X 116768 0 16279 James Clyburn 40 X 114316 0 16200 Andrew McFarlin 40 X 113580 0 16177 Brian Nyberg 40 X 113547 0 16176 Maria Ayson 40 X 109344 0 16042 1623744 0 636712 28 0 1 0 Somers Anesthesiology Associates inc C/O IPMS 99 East River Drive 5th Floor East Hartford CT 06108 Professional Services 421491 CRG Partners Group LLC 2 Atlantic Avenue Boston MA 02110 Financial Consulting 384824 Marcum LLP 555 Long Wharf Drive 12th Floor New Haven CT 06511 Audit Services 222115 Murphy Security Service LLC PO Box 356 New Britain CT 06050 Security 167814 AMF Property Management Corporation 855 Sullivan Avenue South Windsor CT 06074 Real Estate Rentals 142790 6 0 0 0 0 14192 12057 0 26249 Inpatient and Outpatient Revenues 622000 59092708 59112667 -19959 0 0 0 0 0 59092708 123908 0 0 123908 0 0 0 0 0 0 0 0 0 0 0 0 0 Equity Investment in Joint Venture 900099 -12760 0 0 -12760 Prior Period Adjustment 900099 1094678 0 0 1094678 Disportionate Share Payments 900099 619650 619650 0 0 563910 563910 0 0 2265478 61508343 60296227 -19959 1205826 0 0 0 0 0 0 0 0 1140130 0 1140130 0 0 0 0 0 25152915 23276488 1876427 0 431137 380022 51115 0 3808308 3509138 299170 0 1972648 1795843 176805 0 1856097 1384200 471897 338736 0 338736 0 97397 0 97397 0 0 0 0 0 0 0 0 0 0 0 4865877 4865877 0 0 0 0 0 0 0 0 0 0 1060532 1060532 0 0 0 0 0 0 4201851 4201851 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1554584 1554584 0 0 0 0 0 0 3243262 3243262 0 0 1390635 0 1390635 0 Patient Supplies 6946973 6946973 0 0 Bad Debt 2141072 2141072 0 0 Misc other expenses 1662120 1520247 141873 0 61864274 55880089 5984185 0 4142245 884889 8177399 8443038 1154583 1216494 1147109 901400 58139738 37256964 23070812 20882774 4124507 4009963 2868975 2856650 2271673 2094803 46957303 41290011 21585647 17096845 14132699 13072582 2504997 2504464 38223343 32673891 X 4607130 4285194 0 321617 4126830 4009309 8733960 8616120 46957303 41290011 X -355931 238091 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 841760 0 0 0 0 0 841760 841760 0 0 0 0 0 841760 841760 0 0 0 0 0 841760 0 1 0 0 0 406997 0 406997 23615088 0 11992695 11622393 1276173 0 1009263 266910 32312419 0 24109978 8202441 529061 0 145028 384033 20882774 Investment in Joint Venture 2856650 C 2856650 Property under Capital Leases 410496 Deferred Financing, other 1057581 Due from Affiliates 626726 2094803 0 Self-Insurance Liability 1269265 Due to Third Parties 542256 Other Long Term Liabilities 307910 Pension Obligation 385033 2504464 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Principal is permanently restricted by donors and income is available for operations. The income related to this principal is recorded on Part VIII line 3 1 1 1 X 1 X 1 1 1 0 0 491 191306 0 191306 0.003 10773 8011006 3988567 4022439 0.065 0 0 0 0 0 0 11264 8202312 3988567 4213745 0.068 12 3335 145385 0 145385 0.002 4 115 69577 170 69407 0.001 0 0 0 0 0 0 0 0 0 0 0 0 3 46 9949 0 9949 0.0001 19 3496 224911 170 224741 0.0031 19 14760 8427223 3988737 4438486 0.0711 0 0 0 0 1 0 275 138 137 0 1 132 101 0 101 0 0 0 0 0 0 0 0 0 1 274 2487 0 2487 0.00001 0 0 0 0 0 1 349 0 349 0 4 406 3212 138 3074 0.00001 1 889187 62245 16754590 19817679 -3063089 X 1 1 1 1 Johnson Memorial Hospital Inc

201 Chestnut Hill Road Stafford Springs CT CT 06076

X X X Johnson Memorial Hospital Inc 1 1 1 10890 1 43560 1 X X X X X X X 1 1 X X X 1 X X X 1 X X X X X X 1 X 0 0 5 Johnson Memorial Hospital DBA Johnson Surgery Center

148 Hazard Avenue Enfield CT 06083

Outpatient Surgery Center and Diagnostic Imaging Center with Lab draw stations and Cardio Pumonary Johnson Memorial Hospital

151 Hazard Avenue Enfield CT 06083

Physical Therapy Services Johnson Memorial Hospital

7 Elm Street Enfield CT 06083

Cardiac Rehab Services Johsnon Memorial Hospital DBA Tolland Medical Specialists

384L Merrow Road Tolland CT 06084

Physician Session Space with Lab and Xray services Johnson Memorial Hospital

15 Palomba Drive Enfield CT 06086

Lab Draw Station SchH_P01_S00_L07 Schedule H, Part I, Line 7 Ratio of Cost to Charges was utilized. Also actual accumualted costs with overhead allocations based on recent Medicare Cost studies. SchH_P02_S00_L00 Schedule H, Part II Johnson Memorial Hospital helps promote the health of the communities it serves through community building activities by addressing the socioeconomic indicators of health including local economic development, workforce development, youth education, and collaborative partnerships to address public health. Specifically in FY11 JMH participated in activities including volunteering at local schools during American Education Week to encourage literacy, presenting at local schools and to the unemployed about careers in health care, participating in local community coalitions aimed at promoting heart health and excercise and nutrition, and supporting local nonprofits in their effort to promote local business. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 There is no footnote in the Audited Financial Statements pertaining to Bad Debts. Gross charges written to bad debt were reduced to cost by applying applicable (updated quarterly) ratio of Cost to Charges. The Director of Patient Accounts reviewed detailed reports and estimated that 7% of self pay may have been Charity Care. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 Line 6 was computed from the 2011 Medicare Cost Study (D) worksheets. The shortfall from Medicare contributes importantly to the welfare and and benefit of our community by providing high quality healthcare at affordable prices. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b Patients who can demonstrate that payment of their outstanding hospital bill would be a hardship for them may apply for financial assistance. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 Patients apply for financial assistance in accordance with Financial Assistance Policy SchH_P06_S00_L02 Schedule H, Part VI, Line 2 JMH is expected to finish it's first community health needs assesment (CHNA) in Spring 2013. Once the organization completes its community health needs assessment, programs to address identified needs and target populations will be created. The assessment will also allow Johnson Memorial Hospital to formally evaluate its community benefits program. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 The Johnson Memorial Hospital has a position dedicated to informing and educating patients for assistance. This position is the "Entitlement Coordinator". The position functions as a resource to both the patient and hospital to evaluate, faciltate, and track Medicaid applications for the self pay patients that present. If a patient is not seen during their stay the Coordinator contacts them to see if they qualify for Medicaid or any of our assistance programs. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 The Johnson Memorial Hospital (JMH) is an acute-care hospital which primarily serves the communities in North Central Connecticut. The towns in JMH's service are are part of either Tolland or Hartford County, which are included in the Hartford-West Hartford-East Hartford, CT Metropolitan Statistical Area. The service area has a population of about 150,000 and is suburban to the city of Hartford. The average household income is in the $80,000 range. Approx. 11% of residents under 65 for all income levels are uninsured. JMH provided Charity Care in the amount of $465,816 in Fy2011. Eastern Connecticut Health Network, Saint Francis Hospital and Medical Center also provide services in JMH's service area. Baystate Medical Center, located in Massachusetts, also provides services to this area. SchH_P06_S00_L07 Schedule H, Part VI, Line 7 CT X X X X X 1 0 0 0 0 0 0 0 0 Peter J Betts 471897 0 0 0 0 0 0 0 0 0 471897 0 0 David Morgan 338553 0 0 0 0 0 0 0 23364 0 361917 0 0 0 John Grish 294915 0 0 0 0 0 0 0 21971 0 316886 0 0 0 Dr Michael S Woods 276724 0 0 0 0 0 0 0 21390 0 298114 0 0 0 Michelle Urban 145997 0 0 0 0 0 0 0 17216 0 163213 0 0 0 SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Peter Betts received a severence package in the amount of $188,998 which is included in the $471,894 on Part ll line 1e of Schedule J. These amounts were paid by Johnson Memorial Hospital to Peter J. Betts, Inc. The severence period was 3 months and David Morgan, previously COO, succeeded Peter Betts as Interim President/CEO on April 22, 2011. Patrick Mahon Vice Chairman of Board 103893 Insurance coverage 0 F990_P06_S0A_L04 Form 990, Part VI, Section A, Line 4 The Parent Corporation changed it's name effective Oct.4, 2010 (formerly The Johnson Memorial Corporation). As part of this change the new "Johnson Memorial Medical Center" and the Johnson Memorial Hospital Inc.'s Bylaws were Ammended and Restated on January 17, 2011. F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 Article 3of the Johnson Memorial Medical Center Bylaws stipulates that there will be not less than 30 nor more than 60 members F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a Members are elected by the Board as recommended by the Governance and Nominationg Committee. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Board policy provides that Members of the Finance Committee are provided the opportunity to review and comment to Executive leadership before the 990 is filed. All members of the Board have access to any copy of the Form 990 and the Chief Financial Officer provides a summary of the 990 at the Board meeting following the filing of Form 990. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c An annual disclosure statement is required. Executives, Managers, and Board members are required on an ongoing basis to disclose interests that may give rise to conflict of interests. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 A Board Committee reviews compensation annually for the Executive team and recommends compensation for Board approval. Comparability data is reviewed and may include industry surveys, documented compensation of similiar positions in similiar organizations, and expert compensation schedules. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 The Johnson Memorial Medical Center maintains these documents in Administration and are available for viewing upon request during normal business hours. This is inlcudes the Johnson Memorial Hospital. F990_P11_S00_L05 Form 990, Part XI, Line 5 Changes in Temp. Restricted Assets (for Capital) -321617, Unrealized Gains or Losses 80376, Fund Balance Trasfers Misc 3150 Johnson Memorial Medical Center 201 Chestnut Hill Road Stafford Springs CT 06076 222541974 Parent Corporation CT 501 (c) (3) 11 N/A Johnson Evergreen Corporation dba Evergreen Health Care Center 205 Chestnut Hill Road Stafford Springs CT 06076 223012385 Nursing Home CT 501 (c) (3) 3 N/A Johnson Development Fund 201 Chestnut Hill Road Stafford Springs CT 06076 222541977 Fund Raising CT 501 (c) (3) 11 N/A Home and Community Health Services 101 Phoenix Avenue Enfield CT 06083 060646620 Visiting Nurse Association CT 501 (c) (3) 9 N/A Johnson Health Care Inc 201 Chestnut Hill Road Stafford Springs CT 06076 222541981 Occupational Medicine CT 501 (c) (3) 9 N/A Wellcare Inc 201 Chestnut Hill Road Stafford Springs CT 06076 222541983 Inactive CT N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 Johnson Evergreen Corporation dba Evergreen Health Care Center j 180000 reasonable cost Johnson Evergreen Corporation dba Evergreen Health Care Center p 693475 Reasonable allocation Johnson Memorial Medical Center j 494992 Reaonable cost Johnson Health Care Inc p 53088 Resonable allocation Home and Community Health Services p 384600 Reasonable allocation Not Applicable