2023-08-15T15:34:33-05:00 2022-09-30 010523282 Berry Dunn McNeil & Parker LLC 2211 Congress St Portland ME 04102 990 2021-10-01 020300637 North Country Home Health & Hospice Agency Inc NORT 6034445317 536 Cottage Street Littleton NH 03561 Matthew Streeter System CFO 6034445317 2023-08-15 1 Matthew Streeter 999009999 Joseph R Byrne P01289281 2077752387 2023-08-15 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z Tiffany Haynes 536 Cottage Street Littleton NH 03561 10335443 0 X www.northcountryhomehealth-hospice.org X 1971 NH To provide quality home health and hospice care, utilizing a holistic approach, while working in collaboration with all community resources, to meet the comprehensive needs of the clients and their families, in a cost effective manner. 12 9 96 31 0 0 760620 743488 8299303 9551973 9114 13666 33891 26316 9102928 10335443 0 0 0 0 5700811 5863699 0 0 0 3160918 2914942 8861729 8778641 241199 1556802 5198676 6015233 2452979 1972579 2745697 4042654 To provide quality home health and hospice care, utilizing a holistic approach, while working in collaboration with all community resources, to meet the comprehensive needs of the clients and their families, in a cost effective manner. 0 0 6777155 9578289 Home care: provides home health, hospice, and health promotion services to residents of upper Grafton and Coos Counties of New Hampshire. 6777155 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 17 0 1 96 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Matthew Streeter 6033265610 8 Clover Lane Whitefield NH 03598 Chrissy Smith Chair 1.00 0.00 X X 0 0 0 Roxie Severance Vice Chair 1.00 1.00 X X 0 0 0 Patrick Kelly Treasurer 1.00 0.00 X X 0 0 0 Mell Brooks Secretary 1.00 0.00 X X 0 0 0 Darrell Bodnar Trustee 1.00 40.00 X 0 254388 32958 JJ Bujeaud Trustee 1.00 1.00 X 0 0 0 Greg Eastman Trustee 1.00 0.00 X 0 0 0 Kimberly Force Trustee 1.00 0.00 X 0 0 0 Ann Hebert Trustee 1.00 39.00 X 0 4253 128 Holly McCormack Trustee 1.00 0.00 X 0 0 0 Brian O'Hearn Trustee 1.00 40.00 X 0 229636 48726 Chad Sterns Trustee 1.00 0.00 X 0 0 0 John Starr Past Trustee 1.00 0.00 X 0 0 0 Tiffany Haynes President/CEO 40.00 0.00 X 141833 0 28381 Thomas Mee System CEO 1.00 45.00 X 0 677301 39588 Matthew Streeter System CFO 1.00 45.00 X 0 167302 26546 Michael J Counter Past President/CEO 40.00 0.00 X 167637 0 5877 Kevin Botelho APRN 40.00 0.00 X 132542 0 25741 Jessica C Foster-Hebert Director of Clinical Services 39.00 1.00 X 108222 0 15925 Ashley A Horwy Hospital Coordinator 40.00 0.00 X 106833 0 3404 Amy L Remick Physical Therapy Manager 40.00 0.00 X 104959 0 14941 Alyssa Lennon Director of Hospice 40.00 0.00 X 103067 0 23931 865093 1332880 266146 7 0 1 0 Berry Dunn McNeil & Parker 1000 Elm St 4th Floor Manchester NH 03101 Audit, Billing & Coding 405150 MAS Medical Staffing 156 Harvey Road Londonderry NH 03053 Clinical Staff 301829 McBee Associates PO Box 823519 Philadelphia PA 19182 Accounts Receivable Mgmt 176365 North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 Management Services 170282 4 630912 112576 743488 Home Health Care 621610 9551973 9551973 9551973 13666 13666 26316 0 26316 26316 26316 10335443 9551973 0 39982 343728 343728 4241240 3813120 428120 74436 67348 7088 889769 769284 120485 314526 263547 50979 47391 47391 6000 6000 30000 30000 6 6 726597 296345 430252 56060 46974 9086 124597 104402 20195 209130 175234 33896 45230 37899 7331 277541 271818 5723 19683 16493 3190 24728 20720 4008 108013 90504 17509 57476 48160 9316 Patient Care Supplies 588762 588762 Loss on Disposals 443101 90826 352275 Other Expenses 75719 75719 Intercompany Allocation 74908 74908 8778641 6777155 2001486 0 X 725330 2745264 401574 405061 2311291 1685349 28359 35329 2064165 1222557 1362395 841608 291915 238288 77812 64334 5198676 6015233 1254104 871390 5840 5840 759569 645174 433466 450175 2452979 1972579 X 2405810 3752120 339887 290534 2745697 4042654 5198676 6015233 X 1556802 -60958 -198887 X 1 X 1 X 1 0 X 970356 434101 1216713 760620 743488 4125278 5189207 7832461 7651151 8299303 9551973 38524095 6159563 8266562 8867864 9059923 10295461 42649373 0 0 0 42649373 3782 6123 7958 40804 39982 98649 3782 6123 7958 40804 39982 98649 30506 33246 2201 65953 6163345 8303191 8909068 9102928 10335443 42813975 0.99620 0.99630 0.00230 0.00180 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 319611 -51310 6 268295 265950 56620 2959 319611 250092 18327 2469 265950 245018 7476 2402 250092 240272 6249 1503 245018 0.15690 0.84310 0.00000 0 0 168203 168203 1136921 787580 349341 747155 434977 312178 11886 11886 841608 Due to Related Parties 43336 CARES Act Provider Relief Funds 406839 450175 X 10261001 -60958 -13478 -74436 10335437 6 6 10335443 8778635 0 8778635 6 6 8778641 Part V, Line 4: All income of the endowment assets earned is to be used for the general operations of the Agency. Part X, Line 2: The Agency is a public charity under Section 501(c)(3) of the Internal Revenue Code (IRC). As a public charity, the Agency is exempt from state and federal income taxes on income earned in accordance with its tax exempt purpose. Unrelated business income is subject to state and federal income tax. Management has evaluated the Agency's tax positions and concluded that the Agency has no unrelated business income or uncertain tax positions that require adjustment to the financial statements. Part XI, Line 2d - Other Adjustments: Change in fair value of perpetual trust -13,478. 0 1 0 0 0 0 0 1 0 Thomas Mee System CEO 0 538642 0 126000 0 12659 0 5597 0 33991 0 716889 0 0 Darrell Bodnar Trustee 0 194186 0 52020 0 8182 0 7736 0 25222 0 287346 0 0 Brian O'Hearn Trustee 0 182130 0 39500 0 8006 0 8000 0 40726 0 278362 0 0 Matthew Streeter System CFO 0 157136 0 10000 0 166 0 0 0 26546 0 193848 0 0 Michael J Counter Past President/CEO 114880 0 45000 0 7757 0 2943 0 2934 0 173514 0 0 0 Tiffany Haynes President/CEO 134387 0 1690 0 5756 0 2996 0 25385 0 170214 0 0 0 Kevin Botelho APRN 125307 0 4500 0 2735 0 3875 0 21866 0 158283 0 0 0 Part I, Line 3 North Country Healthcare, a related organization, uses the following methods to establish compensation for the top management official of the filing organization: - Compensation committee - Independent compensation consultant - Form 990 of other organizations - Written employment contract - Compensation survey or study - Approval by the board or compensation committee Part I, Line 4b Thomas Mee, System CEO, participated in a 457(f) plan administered by North Country Healthcare, a related organization. Part I, Line 7 Michael Counter's amount of $45,000 was based on achievement of his performance goals and agency performance. It was approved by NCHHH Board of Directors. The bonuses for both Tiffany Haynes and Kevin Botelho were productivity bonuses. Form 990, Part VI, Section A, line 6 North Country Healthcare, Inc. is the sole member. Form 990, Part VI, Section A, line 7a Each member of the Corporation Board shall be nominated by action of an Affiliate Board, or by the Corporation Board, as the case may be, in accordance with the nomination powers indicated in the Corporation's Bylaws. Form 990, Part VI, Section A, line 7b The Corporation Bylaws include Major Matters which include specific duties and responsibilities which are shared by the Corporation Board and the Affiliate Boards. These Major Matters are further distinguished between Major Organizational Matters and Major Operational Matters. In both cases, the Bylaws contain the provisions for the approval of these matters including whether they are approved by a majority vote or super majority vote of all boards. In all cases, the Major Matters require approval by the Corporation Board and the Affiliate Boards. Form 990, Part VI, Section B, line 11b A copy of the Form 990 will be shared electronically with the entire NCH Board and Finance committee before filing, with adequate time for questions to be asked. Form 990, Part VI, Section B, line 12c Conflict of Interest Process: - Conflict of Interest Disclosure completed via BoardPaq (electronic means). - Results compiled into Conflict Matrix which is reviewed and approved by the Board. - Conflicts that meet the Pecuniary Benefit criteria are identified, shared with the Board and approved. - Disclosure notices are placed in local papers. - The NH Division of Charitable Trusts is notified of the Pecuniary Benefit and copies of the public notices are attached. Form 990, Part VI, Section B, line 15 The Compensation Committee is a subcommittee of the Finance Committee of the Corporation Board. This committee oversees the executive compensation policy and practices of the organization including the CEO, the Affiliate Presidents, and the CEO Cabinet which includes key executive positions for the organization. The Compensation Committee engages with an outside consultant to determine compensation benchmarks and best practices which guide the compensation processes for these executive positions. The comparison benchmark data and guidance are reviewed by the Committee and recommendations are made to the Corporation Board and Affiliate Boards. This is done on an annual basis. Form 990, Part VI, Section C, line 19 The Organization has implemented all policies and the governing documents and financial statements are available to the public upon request. Form 990, Part X, Line 10: Land, Buildings, and Equipment: Section 1.263(a)-3(n) Election: North Country Home Health & Hospice Agency, Inc. 536 Cottage Street Littleton, NH 03561 EIN: 02-0300637 North Country Home Health & Hospice Agency is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Form 990, Part XI, line 9: Change in interest of beneficial trust -13,478. Intercompany equity transfer -185,409. North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 812225283 Healthcare Management NH 501(c)(3) Line 12a, I N/A 0 Androscoggin Valley Hospital 59 Page Hill Road Berlin NH 03570 020280367 Critical Access Hospital NH 501(c)(3) Line 3 North Country Healthcare Inc 0 Upper Connecticut Valley Hospital Corliss Lane Colebrook NH 03576 020276210 Critical Access Hospital NH 501(c)(3) Line 3 North Country Healthcare Inc 0 Weeks Medical Center 173 Middle Street Lancaster NH 03584 020222242 Critical Access Hospital NH 501(c)(3) Line 3 North Country Healthcare Inc 0 Androscoggin Valley Hospital Foundation 59 Page Hill Road Berlin NH 03570 223035216 Management and Financial Support NH 501(c)(3) Line 12b, II Androscoggin Valley Hospital Inc 0 Northcare Inc 59 Page Hill Road Berlin NH 03570 521596952 Supporting Services NH 501(c)(3) Line 12b, II Androscoggin Valley Hospital Inc 0 Great Northwoods Community Foundation 59 Page Hill Road Berlin NH 03570 020452547 Healthcare Services NH 501(c)(3) Line 12b, II Androscoggin Valley Hospital Inc 0 Lancaster Patient Care Center 173 Middle Street Lancaster NH 03584 832130386 Supporting Services NH 501(c)(3) Line 12a, I Weeks Medical Center 0 0 0 1 0 1 0 0 0 0 1 1 0 1 0 1 0 0 1 0