2011-04-26T09:17:00-07:00 2010-09-30 990 2009-10-01 042103581 HENRY HEYWOOD MEMORIAL HOSPITAL HENR 9786303420 242 GREEN STREET GARDNER MA 01440 Robert Crosby 9786306157 2011-04-29 2009 2016-02-24 21:20:13Z ROBERT CROSBY 242 GREEN STREET GARDNER MA 01440 100971490 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 reflects the views and adeals of, and is upheld by, our trustees, incorporators, employees, physicians and volunteers. 21 20 1011 278 0 0 1243719 2930001 90905166 95394047 -1266241 167930 1069987 1133754 91952631 99625732 50000 50000 0 0 47089606 48844530 11021 1196 107753 44540726 45560571 91691353 94456297 261278 5169435 88289608 93803027 44175900 47803730 44113708 45999297 A community oriented and supported not-for-profit acute care hospital serving those who work and live in the area. 0 0 89674163 50000 95394047 Heywood Hospital is dedicated to the community benefit goals of improving the health status of our community, addressing the special health care needs of the underserved 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 2010" filed with the MA Attorney General Office on February 0 0 0 89674163 1 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 146 0 1 1011 1 0 0 0 0 0 0 0 0 0 0 0 0 0 21 20 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 Daniel Asquino 0 X 0 0 0 Gerald Bankowski 0 X 0 0 0 JoAnne Parks 0 X 0 0 0 Kenneth Pierce 0 X 0 0 0 James Faust 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 Paul Harasimowicz DMD 0 X 0 0 0 Stephen Hemman 0 X 0 0 0 Glenn Hunt 0 X 0 0 0 Brian Knuuttila 0 X 0 0 0 Anthony Kraskouskas 0 X 0 0 0 Janet Latour 0 X 0 0 0 John Mulqueen 0 X 0 0 0 Michele Parker MD 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 Edmund Taylor 0 X 0 0 0 Daniel P Moen 40 X X X 359483 0 26643 Robert Crosby 40 X 0 0 0 James Mullen 40 X 199469 0 26459 Thomas Cady 40 X 159517 0 22721 Rose Kavalchuck 40 X 143002 0 20808 Lorie Martiska 30 X 106482 0 10934 Theresa Koehler 40 X X 161079 0 14752 Jeffrey Blake 32 X 0 436126 27273 Robert Terlato 32 X 0 412653 26838 Peter Brassard 32 X 0 401802 23525 Michael Stauder 32 X 0 375090 26143 Francis Garofalo 32 X 0 324814 69223 1129032 1950485 295319 35 1 1 0 William A Berry & Sons 99 Conifer Hill Drive Danvers MA 01923 Construction Services 12885084 Quartulli & Associates PO Box 423 Gardner MA 01440 Physical Therapy 2720684 Bay State Emergency Med 44 Crosby Road Ashburnham MA 01430 Emergency Rom Physicians 2534967 Alliance Healthcare Services 100 Bay View Circle Newport Beach CA 92660 MRI 1221673 Quest Diagnostics 5763 Collection Center Drive Chicago IL 60693 Contracted Services 755533 33 0 0 38466 0 232305 2659230 0 2930001 Ancilary O/P Services 900099 52898989 52898989 0 0 Ancilary I/P & Routine Patient Services 900099 41777271 41777271 0 0 Contracted Service Revenue 900099 309434 309434 0 0 HMG Patient Revenue 900099 260086 260086 0 0 Lifeline 900099 68619 68619 0 0 79648 79648 0 0 95394047 265284 0 0 265284 13857 0 0 13857 0 0 0 0 33623 0 0 0 33623 0 33623 0 0 33623 1134762 64556 1168772 141757 -34010 -77201 -111211 0 0 -111211 28950 38466 35229 -6279 0 0 -6279 0 0 0 0 0 0 0 0 0 0 0 0 Meals Revenue 900099 806592 0 0 806592 Purchase Discounts 900099 163546 0 0 163546 Medical Record Copies 561499 20374 0 0 20374 115898 0 0 115898 1106410 99625732 95394047 0 1301684 50000 50000 0 0 0 0 0 0 1303283 358037 945246 0 0 0 0 0 39589926 38072570 1456126 61230 632277 596789 34669 819 4416703 4179956 235867 880 2902341 2744411 153217 4713 0 0 0 0 55269 17550 37719 0 95900 0 95900 0 0 0 0 0 1196 1196 0 0 0 0 10899606 10899606 0 0 91299 87483 3816 0 14149807 13976168 170636 3003 624505 624505 0 0 0 0 0 0 1729037 1712089 16948 0 40626 39928 698 0 0 0 0 0 51082 34572 16510 0 395434 395434 0 0 0 0 0 0 3393143 3365437 27706 0 771235 738635 32600 0 Professional Fees 5160342 4083318 1041112 35912 Provisions for Bad Debt 3600086 3600086 0 0 Free Care 2557514 2557514 0 0 Subscriptions and Dues 422694 97740 324954 0 Laundry and Uniforms 464555 464555 0 0 1058437 977780 80657 0 94456297 89674163 4674381 107753 2960833 2453099 0 0 4558140 4601826 10849981 9520061 0 0 0 0 527502 235927 1663924 1677640 1323069 1357529 95538591 41470807 31602555 54067784 16838220 15174420 1965870 2306506 15999514 2408235 0 0 0 88289608 93803027 13957479 16865672 0 0 0 0 25253612 26264155 0 0 0 0 1346692 1052456 0 0 3618117 3621447 44175900 47803730 X 36681914 38407900 6425905 6585434 1005889 1005963 44113708 45999297 88289608 93803027 X 1 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 15452016 4875 749235 0 225000 0 15981126 16606107 5250 -659341 0 500000 0 15452016 0.94 0.06 0 0 0 0 125271 125271 0 29929038 18164941 11764097 0 0 0 0 0 32503006 23305866 9197140 0 32981276 0 32981276 54067784 Capital Campaign Fund 618731 F Ret. & AD&D Policy 1687775 C 2306506 Funds Held by Trustee 2408235 C 2408235 0 Est. Settlement with 3rd Party 3621447 3621447 SchD_P05_S00_L04 Schedule D, Part V, Line 4 Perm endow funds established by donor restricted gifts and maintained to provide a permanent source of income. The principal of which is kept in perpetuity. Board Designated endow funds are established by the governing body to fund capital projects and/or improvements of the organization. SchD_P10_S00_L00 Schedule D, Part X Footnote: The Hospital and HMG 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 IRS 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 private 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 position. Tax years from 2006 through the current year remain open for examination by federal and state taxing authorities. Golf Classic 67416 38466 28950 2100 4054 13014 14368 0 1693 0 0 67416 38466 28950 2100 4054 13014 14368 0 1693 35229 -6279 1 1 X 1 X 1 X 1 1 1 0 1 1 1764142 994467 769675 0.0085 12583724 11311505 1272219 0.014 0 0 0 0.00 0 0 14347866 12305972 2041894 0.0225 667928 71646 596282 0.0066 161859 0 161859 0.0018 0 0 0 0 0 0 0 0 112694 0 112694 0.0012 0 0 942481 71646 870835 0.0096 0 0 15290347 12377618 2912729 0.0321 0 0 0 0.00 0 0 0 0 0 0 0 0 68662 0 68662 0.0007 0 0 0 0 52647 0 52647 0.0006 2903 0 2903 0 152338 0 152338 0.0017 0 0 0 0 0 0 276550 0 276550 0.0030 1 1654142 75000 26470164 25061183 1408981 X 1 1 Henry Heywood Memorial Hospital

242 Green Street Gardner MA 01440

X X X 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. The provision for Bad Debt in the amount of $3,600,086 that was reported in Part IX, Line 25, Column A was removed from the total expenses prior to calculating the percent of total expense on the Schedule H, Part I, Line 7, column f. The text to the footnote in our financial statements pertains to the Allowance for Doubtful Accounts: "The Organization provides an allowance for doubtful accounts equal to estimated bad debt losses. The losses are based upon historical collection experience together with a review of the current status of the existing receivables." The costing methodology used for lines 2 was based on the cost to charge ratio dervied from the supplied Worksheet 2 in the IRS Schedule H instructions. The methodlogy used to arrive at the number on 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 FY10. This amounted to approximately 4.5% which was applied against the number on line 2. It is our belief that $75,000 amount of bad debt should be included as community benefit. 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 qulaity patient care available to all in our community, regardless of their economic means, qualifies bad debts as a community benefit. The Allowable costs on Line 6 were obtained from our FY2010 Medicare cost report, Worksheet D schedules. Heywood Hospital provides patients with information about financial assistance programs that are available through the Commonwealth of Massachusetts 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, Heywod 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 determine 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 Hospital 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 throught the Virtual Gateway, which is an internet portal designed by the MA Executive Office of Health and Human Services. The Virtual Gateway manages the applciation process from the programs listed above, which is available for children, adults, seniors, veterans, homeless and disabled individuals. Heywood Hospital specifically assists the patient in completing the application and securing the necessary documentation required by the applicable financial assistance program. Heywood Hospital will then submit this documentation to the Commonwealth Office of Medicaid and assist the patient in securing any additional documentation if such is requested by the Commonwealth after completing the application. All Virtual 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. Part I, Line 6B: 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. We filed this years report on April 1, 2011. Heywood Hospital co-chairs the Joint Coalition on Health which undertakes comprehensive assessments of community needs and assets every 3-5 years. The Coalition released an 88 page report on March 18, 2009 entitled The Mental Health and Substance Abuse Assessment of North Central Massachusetts. This report was the work of a committee from the coalition and a paid consultant who was funded through Heywood Hospital and other partners in the Coalition. This report included quantitative and qualitative data, including focus groups, interviews and surveys to identify key issues, concerns and assets with respect to mental health and substance abuse in the region. The Joint Coalition also worked collaboratively with two other coalitions to complete The Comprehensive Health Assessment of North Central Massachusetts. This 173 page report includes demographic information, health status indicators, racial and ethnic disparity data and information on social determinants of health, as well as qualitative information gathered through a consultant and the Minority Coalition of North Central Mass. A pdf file of this report is attached. Heywood has a very aggressive and comprehensive program called GHAP to inform patients and members of the community about their eligibility for assistance and to assist them with enrollment and access to care. The goal is to inform the community about insurance options before they present to the Hospital for care. Many referrals come from area physicians to the program. The GHAP program was begun at Heywood in 1998 to connect uninsured patients with insurance and care. In addition to postings within the Hospital, the GHAP program is marketed throughout the community and self-pay patients who present to the ED receive a follow-up call from GHAP staff to offer assistance. In addition, the GHAP program does outreach to community organizations and presents information monthly to the newly un-employed at the local unemployment office. GHAP also works collaboratively with Patient Accounts to assist patients who have difficulty paying their bill. GHAP has been nationally recognized by AHA and is part of a five-organization network model for patient access that has received state grant funding. In 2010, GHAP enrolled 4,500 patients into health insurance and assisted a total of 15,000 patients with information and applications. 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 close to 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 activities, and provides the GHAP program onsite at HealthAlliance. Environmental Improvements - Heywood Hospital works diligently to remove environmental hazards and waste from the community. In June 2010, Heywood Hospital began removing pharmaceutical wastes from the regular waste stream. For FY2010, there was 374 gallons of this waste removed as hazardous waste. The Hospital is working on implementing this service Hospital wide, currently it is just used in our pharmacy. Other hazardous wastes removed from the normal waste stream consist of batteries, computer parts, microwaves, CPU units, and various medical wastes. Coalition Building - Heywood Hospital is a leader in several community coalitions, including the Joint Coalition on Health, Community Health Network Area (CHNA) and the Minority Coalition. This leadership and technical support have helped leverage more than $7 million in outside funding for community health initiatives over the past 5 years. Community Health Advocacy - Heywood Hospital is a member of the Gardner Area Interagency Team "GAIT". The Gait Team is committed to the coordination and improvement of health and human services in the Greater Gardner Area. The purpose is to provide an opportunity for networking, communication and collaborations between area concerned citizens and the Community at large. To promote the development and enhancement of health and human Services in our area. To advocate on behalf of consumers seeking, receiving or in need of health and human services in our area. Heywood Hospital also provides staff for various healthcare training and enrollment sessions to the public. Workforce Development - One of the most critical benefits of a Hospital is to attract well qualified primary care physicians and specialists to the region. Heywood has a strong, collegial and supportive medical staff that provide many important services for the community outside of the hospital. Heywood Hospital has a community board of trustees consisting of community members from Gardner and surrounding towns. In addition, Hospital surpluses and philanthropic funds are invested into the provision of technologically sophisticated care and services and to maintain a modest amount of reserve. Community Benefit Mission Statement - Heywood Hospital has a long tradition of providing healthcare and other services that improve not only the health but also the quality of life in our community. Heywood Hospital dedicates our organization to the community benefit goals of: -Improving the health status of our community. -Addressing the special health problems of minorities, the poor, uninsured and other underserved populations. -Containing the growth of community helathcare 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 President/CEO/ -Specific goals and objectives. -Annual evaluation process. -Commitment of hospital resources through normal budgeting process. -Consideration of community served in all operational and policy decision. -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 and elements are hereby adopted and endorsed by the Board of Trustess of Heywood Hospital. n/a 1 Montachusett Home Care Corp 680 Mechanical Street Leominster MA 01453 042551175 501(c)(3) 50000 0 The funds will be used by the Community Health Network of North Central MA as support and collaborative community health assessment work. 1 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 were allocated. X X X X X 0 0 0 0 0 0 0 0 0 Daniel P Moen 347401 0 0 0 12082 0 4900 0 21743 0 386126 0 466019 0 James Mullen 197537 0 0 0 1932 0 4273 0 22186 0 225928 0 245013 0 Thomas Cady 159012 0 0 0 506 0 1396 0 21324 0 182238 0 159040 0 Rose Kavalchuck 142503 0 0 0 499 0 2941 0 17868 0 163811 0 159271 0 Lorie Martiska 106326 0 0 0 156 0 2130 0 8804 0 117416 0 109746 0 Theresa Koehler 160962 0 0 0 117 0 0 0 14752 0 175831 0 54855 0 Jeffrey Blake 0 435149 0 0 0 977 0 0 0 27273 0 463399 0 461498 Robert Terlato 0 412039 0 0 0 614 0 0 0 26838 0 439491 0 435378 Peter Brassard 0 399030 0 0 0 2772 0 0 0 23525 0 425327 0 422384 Michael Stauder 0 374789 0 0 0 301 0 0 0 26143 0 401233 0 373321 Francis Garofalo 0 324291 0 0 0 523 0 50000 0 19223 0 394037 0 0 SchJ_P02_S00_L00 Schedule J, Part II Theresa Koehler was the CFO for Fiscal Year 2009 (October 2008 - September 2009), she terminated on October 23, 2009. Robert Crosby was hired in her place on January 4, 2010 as the new CFO, but had no 2009 earnings. Francis Garofalo is a new Urologist to Heywood Medical Group. He was hired on May 4, 2009. His $50,000 of deferred compensation is for a longevity bonus that was paid to him. MA Health & Educational Facility Authority 042456011 57586EGT2 2009-03-31 17785000 Funds used for new building project 0 0 MA Health & Educational Facility Authority 042456011 57586C7E9 2008-06-19 6715000 refunding and new building expense 0 0 66235 0 0 0 281690 0 17569545 2010 0 0 1 1 19154 0 0 0 329467 3597891 2806796 2008 1 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 1 0 1 1 TD Bank 18.7 0 0 1 0 1 1 Piper Jaffrey 18.7 0 0 1 F990_P06_S0B_L11 Form 990, Part VI, Section B, Line 11 The Staff Accountant prepares the 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. Then, the 990 is filed 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 broad discretionary authority. These forms are required to be signed and is monitored by the VP of Professional Services for completion. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Compensation for the CEO is negotiated between the CEO and the Board of Trustess based on the following: -Existing financial market conditions based on salary surveys from reputable organizations for similar positions & sized organizations. -Past accomplishments of strategic goals and objectives designed to fulfill the hospital's mission statement values. -Future strategic goals and objectives as agreed upon by the CEO and Board. -Financial capability of the organization to address existing market coditions and incumbent's expectation. Compensation for members of the Executive Team are predicated on the following: -Ability of the organization to financially meet the needs of incumbent or applicant. -The degree of responsibility and accountability to the President/CEO -Current market conditions as described in the survey data compiled by competent organizations. 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 Administration Assistant, who provides copies upon request. SchK_P01_S00_L00a Schedule K, Part I, Column a The bond issued on line B was a bond issued partially to refund a previous bond balance that was issued on November 9, 1999 and to pay for a portion of a new building. Heywood Affiliated Medical Group 242 Green Street Gardner MA 01440 043163589 contract physicians who provide service to Heywood Hospital MA 501(c)(3) 9 N/A Heywood Hospital Realty Corp 242 Green Street Gardner MA 01440 043327447 property holding corp which rents office space to physicians MA 501(c)(2) N/A 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 0 Heywood Hospital Realty Corp j 53999 Heywood Affiliated Medical Group o 479126 Heywood Hospital Realty Corp p 124863 Heywood Affiliated Medical Group p 123810 Heywood Hospital Realty Corp q 467420 Heywood Affiliated Medical Group q 2144483 On January 28, 2011 Heywood Hospital filed a form 8868 requesting an automatic 3 month extension of time, delaying the filing due date to May 15, 2011. An approval notice was submitted to Henry Heywood Memorial Hospital on March 21, 2011 accepting the May 15th deadline.