2023-08-15T15:32:17-05:00 2022-09-30 010523282 Berry Dunn McNeil & Parker LLC 2211 Congress St Portland ME 04102 990 2021-10-01 020276210 Upper Connecticut Valley Hospital UPPE 6032374971 181 Corliss Lane Colebrook NH 03576 Matthew Streeter System CFO 6032374971 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 Scott Colby 181 Corliss Lane Colebrook NH 03576 32773092 0 X www.ucvh.org X 1969 NH Upper Connecticut Valley Hospital strives to improve the well-being of the rural communities it serves by promoting health and assuring access to quality care. 14 10 162 14 0 0 3182506 1482685 22463460 26393144 1680028 1059454 0 142420 27325994 29077703 95909 140045 0 0 11685553 13868190 0 0 0 10384323 12591581 22165785 26599816 5160209 2477887 46987886 40304391 18179317 11536994 28808569 28767397 Upper Connecticut Valley Hospital strives to improve the well-being of the rural communities it serves by promoting health and assuring access to quality care. 0 0 20524240 140045 26393144 Upper Connecticut Valley Hospital provided hospital care and inpatient and outpatient services on a region-wide basis. The net charity care provided by the Hospital for the year-ended September 30, 2022 was $407,478. 20524240 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 66 0 1 162 1 0 0 0 0 0 0 0 0 0 0 0 0 X 14 10 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 Lynn Brewer Chair 39.00 1.00 X X 5481 0 0 Morgan Wade Vice Chair 1.00 0.00 X X 0 0 0 James Wells Treasurer 1.00 0.00 X X 0 0 0 Eric Stohl Secretary 1.00 1.00 X X 0 0 0 Jeannine Burns Director 1.00 0.00 X 0 0 0 Fr Craig Cheney Director 1.00 0.00 X 0 0 0 E Harlan Connary Director 1.00 0.00 X 0 0 0 Robert Dawson President of Medical Staff 1.00 39.00 X 0 1191 0 Gail Fisher Director 1.00 0.00 X 0 0 0 Maggie Fitzgerald Director 1.00 0.00 X 0 0 0 Edward Laverty PA-C Chief Medical Officer 40.00 0.00 X 307048 0 46990 Laura Mills Director 1.00 0.00 X 0 0 0 David Thatcher Director 1.00 0.00 X 0 0 0 Sharon Ellingwood White Director 1.00 0.00 X 0 0 0 Odette Crawford Past Chair 1.00 1.00 X X 0 0 0 Avis Brosseau Past Director 1.00 0.00 X 0 0 0 Scott Colby President/CEO 40.00 0.00 X 312238 0 37870 Thomas Mee System CEO 1.00 45.00 X 0 677301 39588 Matthew Streeter System CFO 1.00 45.00 X 0 167302 26546 Thomas Cochran Physician 40.00 0.00 X 374597 0 37287 Darin C Brown ED Services Provider 40.00 0.00 X 322342 0 36818 Arnold Albert DNP 40.00 0.00 X 177899 0 10715 Lindsay Lea CNO 40.00 0.00 X 156969 0 16696 Robert Gooch Pharmacist 40.00 0.00 X 133984 0 33076 Celeste Pitts Former CFO 16.00 24.00 X 77712 116567 38926 1868270 962361 324512 13 1 1 0 North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 Management Services 1438424 Medical Solutions LLC 1010 N 102nd St Omaha NE 68114 Clinical Staff 796835 Catholic Medical Center 100 McGregor St Manchester NH 03102 Clinical Staff 556778 BE Smith LLC PO Box 74007636 Chicago IL 60674 Clinical Staff 352138 NH Imaging Services One Pillsbury St Concord NH 03301 Imaging Services 254650 10 1371868 110817 1482685 Patient Service Revenue 621400 35833462 35833462 Miscellanous Revenue 624100 250414 172570 77844 Contractual/Char. Adj. 621400 -9690732 -9690732 26393144 359092 359092 142420 0 142420 142420 142420 4395751 3695389 700362 700362 700362 29077703 26315300 0 1279718 X 140045 140045 709627 359519 350108 10754131 8413323 2340808 146216 115538 30678 1658999 1112595 546404 599217 459507 139710 140793 58408 82385 97675 97675 131820 131820 4151783 3215179 936604 6495 6495 247548 44637 202911 15013 11835 3178 571888 493151 78737 48555 35338 13217 2949 2949 14707 14707 1730050 1730050 362026 362026 Patient Care Supplies 2331940 2321911 10029 MET Tax 1053483 1053483 Intercompany Allocation 909236 909236 Other Expenses 775620 594746 180874 26599816 20524240 6075576 0 X 1274943 1146241 7499598 4653666 4305894 2444717 329622 349994 324920 251470 28574264 13517524 13314512 15056740 19386567 15608358 551830 793205 46987886 40304391 2662968 1479140 148983 282848 0 316401 15367366 9458605 18179317 11536994 X 28479341 28477452 329228 289945 28808569 28767397 46987886 40304391 X 2477887 -3532465 1013406 X 1 X 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4825 4825 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. 299038 -39283 259755 263236 35802 299038 240915 24066 1745 263236 232266 13836 5187 240915 233884 3524 5142 232266 0.00000 0.66630 0.33370 0 0 69700 69700 12582952 3846146 8736806 14370491 9536372 4834119 1551121 135006 1416115 15056740 Estimated Third-Party Payor Settlements 8869097 Due to Related Parties 589508 9458605 25275291 -3532465 -3532465 28807756 131820 138127 269947 29077703 26329869 0 26329869 131820 138127 269947 26599816 Part V, Line 4: The Organization's endowments are used for staff education, nursing projects and indigent care. Part XI, Line 4b - Other Adjustments: Community Benefit Expense 138,127. Part XII, Line 4b - Other Adjustments: Community Benefit Expense 138,127. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 1426632 1426632 0.05360 3449821 2682082 767739 0.02890 4876453 2682082 2194371 0.08250 3298147 3144309 153838 0.00580 138127 138127 0.00520 3436274 3144309 291965 0.01100 8312727 5826391 2486336 0.09350 1 453649 8807730 8771583 36147 X 1 1 1 1 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 www.ucvh.org 00592 X X X X Upper Connecticut Valley Hospital 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X https://www.ucvh.org/community-benefits-report/ X 1 21 1 https://www.ucvh.org/community-benefits-report/ 1 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X https://www.ucvh.org/patients-visitors/financial-information/ X https://www.ucvh.org/patients-visitors/financial-information/ X https://www.ucvh.org/patients-visitors/financial-information/ X X X X X 1 X 0 X X X X 1 X 0 0 Upper Connecticut Valley Hospital Part V, Section B, Line 5: An electronic survey was sent to a select group of local experts that included information from well-respected secondary sources on the current state of health care in the community. Individuals and agencies involved in Public Health and State & Local Health were included as were individuals from priority populations, chronic disease groups and other community members. Upper Connecticut Valley Hospital Part V, Section B, Line 6a: The Hospital's CHNA was conducted along with Weeks Medical Center and Androscoggin Valley Hospital. Upper Connecticut Valley Hospital Part V, Section B, Line 6b: The Hospital's CHNA was conducted along with Coos County Family Health and North Country Home Health & Hospice Agency. The first is a local FQHC. Upper Connecticut Valley Hospital Part V, Section B, Line 11: Please see attached CHNA and Implementation Strategy. Part I, Line 7: The Hospital uses a cost-to-charge ratio. The cost-to-charge ratio was derived from the Form 990 Schedule H worksheet 2, Ratio of patient care cost-to-charges Part I, lines 7E-I. The Hospital determines cost by combining direct expenses identified by its accounting system with an estimated overhead allocation. Part I, Line 7g: Specialty Care Providers & Emergency Department Part II, Community Building Activities: The community building activities undertaken by UCVH consist of supporting local government and other health care providers, coordination of disaster drills, emergency preparedness, and support of other local organizations within the community. In addition, in an effort to provide the necessary health care services for the population within a reasonable driving distance, UCVH has entered into a collaboration with the other two Coos county hospitals to provide necessary primary care, behavioral health, and specialty services for the UCVH service area. Part III, Line 2: The Hospital uses a cost-to-charge ratio. The cost-to-charge ratio was derived from the Form 990 Schedule H worksheet 2, Ratio of patient care cost-to-charges. The CCR was then applied to bad debt expense at charge value in order to arrive at the estimated expense reported. Part III, Line 4: Please see pages 8-12 of the attached audited financial statements. Part III, Line 8: Allowable costs come from the filed cost report. Over the past years, due to Sequester, UCVH has operated at a loss from Medicare. Sequester was discontinued during the Public Health Emergency and therefore in Fiscal 2021 there was no loss from Medicare. Normally this shortfall was treated as a community benefit as there are no other funds available to subsidize the loss. Part III, Line 9b: If known to qualify for charity or financial assistance, patients are given the assistance needed. Part VI, Line 2: Every 3 years, Upper Connecticut Valley Hospital participates in a community needs assessment with three other members of the community's health care system. Using information from that assessment allows the Hospital to provide healthcare services to the North Country community on an ongoing basis. Part VI, Line 3: UCVH has a patient financial counselor who is responsible for working with patients and any who may be billed for their care to determine their eligibility, on a case by case basis. For any government programs, such as Medicaid or the UCVH financial assistance program all staff at UCVH, particularly registration staff who will be the first ones to notice if a patient does not have insurance, are trained to refer the patient to the financial counselor. In addition, brochures are available, as is contact information on the website. Part VI, Line 4: UCVH is the smallest critical access hospital in New Hampshire that serves the largest geographic service area (over 850 square miles) including communities in the states of New Hampshire, Vermont, and Maine. According to the New Hampshire state health profile, our residents are the most fragile of all citizens in New Hampshire as it relates to health outcomes and economic conditions. UCVH is dependent on public funding and disproportionate share funding to subsidize the care provided to the patients we serve. Part VI, Line 7, Reports Filed With States NH 1 Foundation for Healthy Communities 125 Airport Road Concord NH 033017300 020275078 501(c)(3) 96127 0 Substance Abuse prevention, treatment & recovery The Bowler-Bartlett Foundation 7 North State Street Concord NH 03301 237425858 501(c)(3) 40000 0 Mobile Medical Unit 2 0 Part I, Line 2: The Hospital was mandated by the State of NH to contribute funds to the Alcohol and Drug Prevention Treatment Fund in order to continue the Medicaid Expansion Program. These funds go towards various programs surrounding recovery, treatment and prevention for substance misuse in New Hampshire. Additionally, each of the Hospitals affiliated with North Country Healthcare elected to participate in an initiative with the Bowler-Bartlett Foundation to purchase a mobile medical unit to be made available for use throughout New Hampshire. 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 Thomas Cochran Physician 369437 0 2400 0 2760 0 7707 0 29580 0 411884 0 0 0 Darin C Brown ED Services Provider 319314 0 2200 0 828 0 967 0 35851 0 359160 0 0 0 Edward Laverty PA-C Chief Medical Officer 287910 0 18310 0 828 0 8516 0 38474 0 354038 0 0 0 Scott Colby President/CEO 238929 0 57600 0 15709 0 7040 0 30830 0 350108 0 0 0 Celeste Pitts Former CFO 71930 107895 1000 1500 4782 7172 1870 2804 13701 20551 93283 139922 0 0 Matthew Streeter System CFO 0 157136 0 10000 0 166 0 0 0 26546 0 193848 0 0 Arnold Albert DNP 172609 0 2200 0 3090 0 4952 0 5763 0 188614 0 0 0 Lindsay Lea CNO 148275 0 2600 0 6094 0 4774 0 11922 0 173665 0 0 0 Robert Gooch Pharmacist 127166 0 5414 0 1404 0 2880 0 30196 0 167060 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 Part of the compensation program overseen by the Compensation Committee and approved by the Corporation Board and Affiliate Boards includes variable incentive compensation for executives. This variable compensation is a withhold of total compensation and earned back by executives based on strategic goal performance. Shari Parker Family member of Board Secretary Eric Stohl 119554 EmploymentWages: $93,242Benefits: $26,292 0 Form 990, Part VI, Section A, line 6 As the Parent Organization, North Country Healthcare (NCH) is the Sole Member of Upper Connecticut Valley Hospital. 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 18 UVCH makes its 990 available upon request. 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 IX, line 11g Contract Labor: Program service expenses 2,082,120. Management and general expenses 732,590. Fundraising expenses 0. Total expenses 2,814,710. Other Professional Fees: Program service expenses 1,133,059. Management and general expenses 204,014. Fundraising expenses 0. Total expenses 1,337,073. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook, NH 03576 EIN: 02-0276210 Upper Connecticut Valley Hospital is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Form 990, Part XI, line 9: Contribution received in the acquisition of Indian Stream Health Center 1,719,370. Equity transfer to North Country Healthcare, Inc. -705,964. 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 Inc 59 Page Hill Road Berlin NH 03570 020280367 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 North Country Home Health & Hospice Agency Inc 536 Cottage Street Littleton NH 03561 020300637 Home Health Agency NH 501(c)(3) Line 10 North Country Healthcare 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 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 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 Organization NH 501(c)(3) Line 12a, I Weeks Medical Center 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 1 1 0 1 0