2011-08-08T10:58:03-05:00 2010-09-30 SASLOW LUFKIN & BUGGY LLP TEN TOWER LANE AVON CT 06001 990 2009-10-01 060646678 THE CHARLOTTE HUNGERFORD HOSPITAL CHAR 8604966728 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 Susan M Schapp 8604966728 2011-08-01 1 Beth Thurz 8606789200 2009 2016-02-24 21:20:13Z Susan M Schapp 540 LITCHFIELD STREET PO BOX 988 TORRINGTON CT 067900988 113824222 0 X WWW.CHARLOTTESWEB.HUNGERFORD.ORG X 1917 CT TO PROVIDE QUALITY, COMPASSIONATE AND COST EFFECTIVE HEALTHCARE TO THE COMMUNITY OF NORTHWESTERN CONNECTICUT. 15 15 1053 170 2115129 0 3782338 3509677 100568164 105888350 -174726 2066888 202657 607983 104378433 112072898 16000 12000 0 62125908 65975270 0 447846 41435164 43904798 103577072 109892068 801361 2180830 114560220 117822296 54204378 59139886 60355842 58682410 THE CHARLOTTE HUNGERFORD HOSPITAL PROVIDES QUALITY MEDICAL HEALTHCARE REGARDLESS OF RACE, CREED, SEX, NATIONAL ORIGIN, HANDICAP, AGE, OR ABILITY TO PAY. OUR MISSION IS TO SERVE THE COMMUNITY WITH RESPECT TO PROVIDING HEALTHCARE SERVICES AND HEALTHCARE EDUCATION. IN KEEPING WITH THE HOSPITAL'S COMMITMENT TO SERVE ALL MEMBERS OF THE COMMUNITY, FREE CARE AND/OR SUBSIDIZED CARE, CARE PROVIDED TO PERSONS COVERED BY GOVERNMENTAL PROGRAMS AT BELOW COST, HEALTH ACTIVITIES AND PROGRAMS TO SUPPORT THE COMMUNITY WILL BE CONSIDERED WHERE THE NEED AND/OR AN INDIVIDUAL'S INABILITY TO PAY COEXIST. THESE ACTIVITIES INCLUDE WELLNESS PROGRAMS, COMMUNITY EDUCATION PROGRAMS, SPECIAL PROGAMS FOR THE ELDERLY, HANDICAPPED, THE MEDICALLY UNDERSERVED AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. 0 0 82646261 12000 104179591 DURING FY 2010 THE HOSPITAL CONTRIBUTED OVER 21,000 HOURS TOWARD THE COMMON PURPOSE OF SERVICING THE HEALTHCARE NEEDS OF THE COMMUNITY. THE VALUE OF THIS CONTRIBUTION IS APPROXIMATELY $168,000, WHICH IS GIVEN BACK TO THE COMMUNITY THOUGH LOWER COSTS IN BOTH PATIENT SERVICES AND OTHER "WELLNESS" PROGRAMS. IN ADDITION THE HOSPITAL GRANTED CHARITY CARE IN THE AMOUNT OF $1,421,695 DURING FISCAL YEAR 2010. THE CHARLOTTE HUNGERFORD HOSPITAL RENDERED THE FOLLOWING SERVICES DURING FY 2010:INPATIENT SERVICES:DISCHARGES 6,438PATIENT DAYS 27,979 SPECIAL SERVICES: OPERATING ROOM CASES 4,031 AMBULATORY SURGERY CASES 3,357 ENDOSCOPY CASES 1,026 AMBULATORY MEDICAL CASES 2,791 POST ANESTHESIA CARE UNIT CASES 2,589 DELIVERY ROOM DELIVERIES 412RESPIRATORY THERAPY TREATMENTS 35,061 PULMONARY REHAB TESTS 5,801PULMONARY FUNCTION LAB TESTS 1,680 CARDIO DIAGNOSTIC EXAMS 12,800EEG EXAMS 1,643PHYSICAL THERAPY TREATMENTS 23,149 CARDIAC REHAB TREATMENTS 3,704 SPEECH THERAPY TREATMENTS 672 OCCUPATIONAL THERAPY TREATMENTS 1,418 SLEEP STUDY TESTS 585 DIAGNOSTIC RADIOLOGY EXAMS 29,415 MAMMOGRAPHY EXAMS 9,366 NUCLEAR MEDICINE EXAMS 1,304 ULTRASOUND EXAMS 8,515 C.A.T. SCAN EXAMS 12,786 P.E.T. SCAN EXAMS 60 M.R.I. EXAMS 850 SPECIAL PROCEDURES (RADIOLOGY) EXAMS 1,281 RADIATION THERAPY TREATMENTS 8,683 LABORATORY TESTS 673,270 PSYCHIATRIC CLINIC VISITS 34,512 PHP-ADULT/ADOLESCENT VISITS 4,282 RENAL DIALYSIS VISITS 509 EMERGENCY DEPARTMENT VISITS 31,939 EMERGENCY DEPARTMENT PHYSICIAN VISITS 4,348 OUTPATIENT DIABETES PROGRAM VISITS 1,579 WALK IN CENTER BLOOD DRAWING VISITS 1,964 WALK IN CENTER VISITS 11,519 HOSPITALIST CONSULTS 9,525WINSTED HEALTH CENTER: CARDIAC REHAB TREATMENTS 1,521 DIAGNOSTIC RADIOLOGY EXAMS 4,762 LABORATORY TESTS 22,047 EMERGENCY DEPARTMENT VISITS 6,654 EMERGENCY DEPARTMENT PHYSICIAN VISITS 614 PULMONARY REHAB TESTS 2,376 82646261 1 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 186 0 1 1053 1 1 1 0 0 0 0 0 0 0 0 15 15 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 CT X SUSAN M SCHAPP 8604966728 540 LITCHFIELD STREET TORRINGTON CT 06790 EDWARD ARUM 2.50 X 0 0 0 RICHARD DUTTON MD 1.00 X 0 0 0 GLADYS CERRUTO 1.00 X 0 0 0 DAVID J FRAUENHOFER 1.00 X X 0 0 0 JAMIE GREGG 1.00 X 0 0 0 PAUL GROSSMAN 1.00 X 0 0 0 KENDRICK HOM MD 1.00 X 0 0 0 JOHN JANCO 1.00 X X 0 0 0 NANCY SULLIVAN HODKOSKI 1.00 X 0 0 0 JOHN LAVIERI 2.50 X X 0 0 0 DIANE LIBBY CPA 1.00 X 0 0 0 MARVIN MASKOVSKY 1.00 X 0 0 0 JAMES O'LEARY 1.00 X 0 0 0 CHARLES W RORABACK 1.00 X 0 0 0 ALFRED J FINN MD 1.00 X 0 0 0 DANIEL J MCINTYRE 60.00 X 388725 0 75240 GARY J DEPAUL 60.00 X 282305 0 91815 JOHN J CAPOBIANCO 60.00 X 214507 0 33737 MARK PRETE MD 60.00 X 331731 0 61309 RAYMOND J ELLIOTT 60.00 X 181398 0 36858 STEVEN SINGER MD 60.00 X 290910 0 55344 ELZBIETA LACH-PASKO MD 60.00 X 390719 0 59395 roberta meltzer md 60.00 X 184858 0 45637 SUSAN SCHAPP 60.00 X 150218 0 35722 MARIA BAIULESCU MD 60.00 X 196507 0 29436 KAREN O'FLYNN MD 60.00 X 181202 0 32842 STACY TAYLOR MD 60.00 X 192806 0 34997 ASMA QAMAR 60.00 X 189665 0 28234 RAHUL MAGAVI MD 60.00 X 224919 0 30822 3400470 0 651388 55 0 1 0 mayo collaborative services po box 9146 mineapolis MN 554809146 labORATORY TESTS 1302761 NWCT EMERGENCY SERVICES 80 S MAIN STREET WEST HARTFORD CT 06107 MEDICAL 524946 PORTAL HEALTHCARE SOLUTIONS LLC 5885 TRINITY PARKWAY SUITE 210 CENTERVILLE VA 20120 TRANSCRIPTION SERVICES 405848 NEW MILFORD LAUNDRY 40 COMMONS COURT WATERBURY CT 06704 LAUNDRY/LINEN SERVICES 405782 TORRINGTON RADIOLOGIST PC 57 COMMERCIAL BLVD TORRINGTON CT 06790 MEDICAL 389664 26 22160 2348497 1139020 3509677 NET PATIENT REVENUE 900099 91292922 91292922 LABORATORY SERVICES 621500 12895994 10911033 1984961 OTHER HOSPITAL SERVICE 900099 2130065 2130065 SURGICAL ASSOC OF LITC 621110 -430631 -430631 105888350 1409742 1409742 717405 441203 276202 276202 276202 1880894 1137861 85887 743033 -85887 657146 657146 75640 22160 29087 46553 46553 93009 57286 35723 35723 MEDCONN 561499 129912 129912 GAIN FROM EQUITY METHO 900001 119337 119337 CT HOSPITAL LAB NETWOR 621500 256 256 249505 112072898 104179591 2115129 2268501 12000 12000 2510765 1883074 627691 47820509 35679264 11929112 212133 6039532 4507316 1506761 25455 6071267 4530999 1514679 25589 3533197 2636833 881473 14891 1499116 1118794 374004 6318 276581 206413 69002 1166 119165 88933 29730 502 9716409 7251377 2424080 40952 661548 493715 165045 2788 374566 279539 93448 1579 1191966 889567 297375 5024 2232949 1666455 557083 9411 179610 134043 44810 757 374299 279340 93381 1578 6177041 4609939 1541067 26035 1867148 1393456 465822 7870 SUPPLIES 15611524 11650914 3894812 65798 PROVISION FOR BAD DEBT 2413649 2413649 PHYSICIAN FEES 1154344 865758 288586 HOSPITAL AUXILIARY EXPE 54883 54883 109892068 82646261 26797961 447846 4295 4615 4167900 5577511 280200 282069 9892274 9573985 1838456 1902704 1162270 1678690 138148361 96586131 45555251 41562230 49551991 54362578 2107583 2877914 114560220 117822296 8429178 7460667 4555000 3475000 4218334 3880641 37001866 44323578 54204378 59139886 X 41852805 39309707 2944647 3000453 15558390 16372250 60355842 58682410 114560220 117822296 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED Part I-A, Line 1: Organizations Direct and Indirect Political Campaign Activities: THE HOSPITAL PAID DUES TO THE CONNECTICUT HOSPITAL ASSOCIATION. SOME PORTION OF THESE DUES MAY HAVE BEEN USED FOR LOBBYING EXPENSES ON BEHALF OF ITS' MEMBERS. 45533758 690138 3824302 774452 49273746 47240328 1043719 -1532480 1217809 45533758 0.60720 0.33230 0.06050 0 0 155467 155467 75462132 45067826 30394306 57056080 47428989 9627091 5474682 4089316 1385366 41562230 INVESTMENTS HELD IN TRUST FOR ESTIMATED SELF-INSURANCE LIABILITIES 4042373 F UNDER BOND INDENTURE AGREEMENT-HELD BY OTHERS 277118 F BENEFICIAL INTEREST IN ASSETS HELD IN TRUST BY OTHERS 12619869 F LONG-TERM INVESTMENTS 30690384 F DONOR RESTRICTED ASSETS 6732834 F 54362578 CAPITAL LEASE OBLIGATIONS 21204 ESTIMATED AMOUNTS DUE TO THIRD PARTY REIMBURSEMENT AGENCIES 2034000 OTHER CURRENT LIABILITIES 5718436 ESTIMATED SELF-INSURANCE LIABILITIES 2554405 ACCRUED PENSION LIABILITY 33995533 44323578 112072898 109892068 2180830 2027450 -5881712 -3854262 -1673432 114100348 2027450 2027450 112072898 0 112072898 109892068 0 109892068 0 109892068 Part V, Line 4: Description of Intended Use of Endowment Funds: THE ENDOWMENT FUNDS WILL BE USED PRIMARILY FOR CAPITAL PURCHASES, INDIGENT CARE AND OTHER USES AS APPROVED BY THE BOARD IN ACCORDANCE WITH DONOR RESTRICTIONS. Part X: Description of Uncertain Tax Positions Under FIN 48: THE HOSPITAL ACCOUNTS FOR UNCERTAIN TAX POSITIONS WITH PROVISIONS OF FASB ASC 740, "INCOME TAXES" WHICH PROVIDE A NEW FRAMEWORK FOR HOW COMPANIES SHOULD RECOGNIZE, MEASURE, PRESENT AND DISCLOSE UNCERTAIN TAX POSITIONS IN THEIR CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. THE HOSPITAL DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS AS OF SEPTEMBER 30, 2010 AND 2009. AS OF SEPTEMBER 30, 2010 AND 2009, THE HOSPITAL DID NOT RECORD ANY PENALTIES OR INTEREST ASSOCIATED WITH UNCERTAIN TAX POSITIONS. Part XI, Line 8 - Other Adjustments: PENSION RELATED CHANGES OTHER THAN NET PERIODIC PENSION COSTS: -5216819. NET ASSETS RELEASED FROM RESTRICTIONS: -774452. RECLASSIFICATION OF TEMPORARY RESTRICTED NET ASSETS: 109559. GOLF TOURNAMENT 75640 75640 3795 22455 2837 FASHION SHOW 9330 9330 6 12830 12830 97800 22160 75640 3795 22455 2837 29087 46553 1 1 1 X 1 X 1 1 0 1 1 1372 784776 23828 760948 0.00690 33148 15271377 14008178 1263199 0.01150 8039 4233350 2779329 1454021 0.01320 42559 20289503 16811335 3478168 0.03160 93 3574 109654 0 109654 0.00100 12 12000 0 12000 0.00010 16215934 15659217 556717 0.00510 93 3586 16337588 15659217 678371 0.00620 93 46145 36627091 32470552 4156539 0.03780 1 2413649 38976426 39192673 -216247 X 1 1 ADVANCED MEDICAL IMAGING OF NORTHWEST CT LLC IMAGING CENTER 0.50000 0.00000 0.50000 MEDCONN COLLECTION AGENCY LLC PATIENT COLLECTION AGENCY 0.20000 0.00000 0.00000 SURGICAL ASSOCIATES OF LITCHFIELD COUNTY LLC SURGICAL SERVICES 1.00000 0.00000 0.00000 UROLOGY CENTER OF NW CT UROLOGY CENTER 0.62500 0.00000 0.37500 LITCHFIELD COUNTY HEALTHCARE SERVICE CORP PHYSICIANS PRACTICE 1.00000 0.00000 0.00000 NORTHWESTERN CT DIALYSIS LLC (DISSOLVED 32410) RENTAL REAL ESTATE 0.50000 0.00000 0.00000 CHARLOTTE HUNGERFORD HOSPITAL

540 LITCHFIELD STRRET TORRINGTON CT 06790

X X X X HUNGERFORD EMERGENCY MEDICAL CENTER

115 SPENCER STREET WINSTED CT 06098

X Part I, Line 3c: Care will be provided free for those uninsured who qualify as uninsured and verification has determined that their annual income is less than 200% of the Federal Income Poverty Level. Care will be provided at Hospital cost, as established by the Office of Health Care Access (OCHA), for those uninsured patients who request assistance and verification has determined that their annual income is between 200% and 250% of the FPL. Care will be discounted by 30% for those unisured patients who request assistance and verification has determined that their annual income is between 250% and 400% of the FPL. The hospital will also consider the total medical expenses faced by a family and the family's ability to pay for those expenses, and will consider offering greater assistance when possible to those families facing castastrophic medical expenses. Part I, Line 7: A cost to charge ratio based on charity care charges and expenses. Part III, Line 4: The rationale for reporting bad debt expense directly from the trial balance is that accounts have already been discounted prior to being classified as a bad debt expense. Part III, Line 8: The reported amounts for Medicare revenue received and Medicare costs are derived directly from the Medicare cost report. Part III, Line 9b: The hospital attempts to have individuals fill out all paper work required for charity care. If the person is not capable of doing this or is known to be unable to do this (such as a known homeless person), then the financial assistance committee will adjust the account to charity care and it will not be reported as bad debt. If an account has been reported as bad debt and information comes forth indicating an inability to pay, then the account would be removed from bad debt and moved to charity care. Part VI, Line 2: The hospital offers free health screenings, free health education and lectures at various community events including fairs, expos, private companies, public municipalities, and public gatherings. This helps the community assess their medical needs. In addition to the above items, the hospital distributes free medical summary cards which allow patients to track their medications. Part VI, Line 3: The hospital counsels all self pay patients either by meeting with a financial counselor or if he or she is an inpatient, meeting with a social worker. All statements received by patients include financial counseling information. Signs are posted throughout the hospital including in the emergency room which state the charity care policies and financial assistance information. Part VI, Line 4: The Charlotte Hungerford Hospital is a 109 bed, general acute care hospital located in Torrington, Connecticut, serving a twelve town primary service area comprised of approximately 100,000 persons. Part VI, Line 6: All board of directors members reside in the community served by the Charlotte Hungerford Hospital and are not employees of the hospital nor are they independent contractors doing business with the hospital. The hospital extends medical staff privileges to all qualified physicians who apply for such privileges. The hospital establishes an annual capital budget to add or replace patient care equipment and facilities. Medical education is provided to physicians through conferences on a monthly basis. CT 1 HEALTHCARE SCHOLARSHIPS 12 12000 Other Information: Part IV: THE CHARLOTTE HUNGERFORD HOSPITAL AUXILIARY AWARDS SCHOLARSHIPS IN THE AMOUNT OF $1,000 EACH TO STUDENTS PURSUING HEALTHCARE EDUCATIONS. THE STUDENTS MUST LIVE IN THE AREA SERVED BY THE HOSPITAL. THEY MUST ALSO PROVIDE EVIDENCE OF HAVING BEEN ACCEPTED INTO A COLLEGE PROGRAM OR THEIR CURRENT GRADES IN COLLEGE. RECIPIENTS OF THE SCHOLARSHIPS MUST SUBMIT LETTERS OF RECOMMENDATION FROM THEIR TEACHERS AND ALSO FROM NON-FAMILY PERSONS. X X X 0 0 0 0 0 0 0 0 0 DANIEL J MCINTYRE 388725 0 0 0 0 0 29093 0 46147 0 463965 0 0 0 GARY J DEPAUL 282305 0 0 0 0 0 58302 0 33513 0 374120 0 0 0 JOHN J CAPOBIANCO 214507 0 0 0 0 0 8272 0 25465 0 248244 0 0 0 MARK PRETE MD 331731 0 0 0 0 0 21928 0 39381 0 393040 0 0 0 RAYMOND J ELLIOTT 181398 0 0 0 0 0 15324 0 21534 0 218256 0 0 0 STEVEN SINGER MD 290910 0 0 0 0 0 20809 0 34535 0 346254 0 0 0 ELZBIETA LACH-PASKO MD 390719 0 0 0 0 0 13012 0 46383 0 450114 0 0 0 roberta meltzer md 184858 0 0 0 0 0 23692 0 21945 0 230495 0 0 0 SUSAN SCHAPP 150218 0 0 0 0 0 17889 0 17833 0 185940 0 0 0 MARIA BAIULESCU MD 196507 0 0 0 0 0 6108 0 23328 0 225943 0 0 0 KAREN O'FLYNN MD 181202 0 0 0 0 0 11331 0 21511 0 214044 0 0 0 STACY TAYLOR MD 192806 0 0 0 0 0 12108 0 22889 0 227803 0 0 0 ASMA QAMAR 189665 0 0 0 0 0 5718 0 22516 0 217899 0 0 0 RAHUL MAGAVI MD 224919 0 0 0 0 0 4121 0 26701 0 255741 0 0 0 Form 990, Part VI, Section B, line 11 A COPY OF FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS BEFORE IT IS FILED WITH THE IRS. THIS ENABLES THE BOARD TO ASK QUESTIONS, AND TO APPROVE THE DISCLOSURES MADE IN THE RETURN. Form 990, Part VI, Section B, line 12c THE HOSPITAL DISTRIBUTES A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY TO ITS BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND PURCHASING AGENTS. Form 990, Part VI, Section B, line 15 Compensation for senior staff is determined using the following steps: - A market survey based on CT Hospital Association is used as a starting point. - Adjustments are then made based on the candidate's current salary and prior experience. - The compensation figure is then presented to the board of directors for approval. Form 990, Part VI, Section C, line 19 THE HOSPITAL MAKES ITS GOVERNING POLICIES AVAILABLE TO THE PUBLIC UPON REQUEST. A CONFLICT OF INTEREST QUESTIONNAIRE IS DISTRIBUTED TO THE BOARD OF DIRECTORS, ALL MANAGEMENT PERSONNEL, AND THE PURCHASING AGENTS FOR THE HOSPITAL. AN ANNUAL REPORT OF THE OPERATIONS OF THE HOSPITAL INCLUDING FINANCIAL INFORMATION IS PUBLISHED EACH YEAR AND IS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C: THE HOSPITAL'S AUDIT COMMITTEE ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND THE SELECTION OF AN INDEPENDENT ACCOUNTANT. THESE FUNCTIONS AND PROCESSES HAVE NOT CHANGED FROM THE PRIOR YEAR. SURGICAL ASSOCIATES OF LITCHFIELD COUNTY LLC 538 LITCHFIELD STREET SUITE 201 TORRINGTON CT 06790 200796298 SURGICAL SERVICES CT -430631 0 THE CHARLOTTE HUNGERFORD HOSPITAL ADVANCED MEDICAL IMAGING OF NW CT LLC 57 COMMERCIAL BLVD TORRINGTON CT 06790 061594854 MAGNETIC RESONANCE IMAGING CT N/A RELATED 671685 287171 0 0 UROLOGY CENTER OF NW CT LLC 538 LITCHFIELD STREET TORRINGTON CT 06790 582674029 EQUIPMENT RENTAL CT N/A RELATED 34725 47782 0 0 NORTHWESTERN CONNECTICUT DIALYSIS LLC 540 LITCHFIELD STREET TORRINGTON CT 06790 061491220 RENTAL REAL ESTATE CT N/A RELATED -2819 0 0 LITCHFIELD COUNTY HEALTHCARE SERVICE CORPORATION 540 LITCHFIELD STREET TORRINGTON CT 06790 061227655 MANAGEMENT SERVICES CT THE CHARLOTTE HUNGERFORD HOSPTIAL C 505 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ADVANCED MEDICAL IMAGING OF NW CT LLC R 661000