2023-08-15T15:05:38-05:00 2022-09-30 010523282 Berry Dunn McNeil & Parker LLC 2211 Congress St Portland ME 04102 990 2021-10-01 020280367 Androscoggin Valley Hospital Inc ANDR 6037522200 59 Page Hill Road Berlin NH 03570 Matthew Streeter System CFO 6037522200 2023-08-15 1 Matthew Streeter 999009999 Barbara J McGuan CPA P00219457 2077752387 2023-08-15 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z Michael Peterson 59 Page Hill Road Berlin NH 03570 83231308 0 X www.avhnh.org X 1971 NH Critical Access Hospital 13 11 443 60 0 0 9128809 2584058 65847300 74261440 1832387 684763 119123 85890 76927619 77616151 588388 692569 0 0 36379964 40204428 0 0 0 29886900 34227643 66855252 75124640 10072367 2491511 96834885 74030462 56712041 37838892 40122844 36191570 Delivering the best healthcare experience for every patient, every day. 0 0 55670105 692569 65565425 Androscoggin Valley Hospital is a critical access hospital. The Hospital provides a broad range of inpatient and outpatient services to meet the health needs of the upper Androscoggin Valley and surrounding communities. With a commitment to the highest quality surgical care - AVH is leading the way to a healthier future for our health care community. 258784 334176 Educational programs offered by AVH include childbirth classes, babysitting course, wellness fairs, lecture series, CPR and first aid courses, nutritional counseling, and a variety of support groups. 7189144 8361839 Other community benefits provided by the Hospital include the provision of care to the underinsured; the promotion of good health for children through participation in the healthy kids program; and the sponsorship of numerous clinics and programs supporting good health in the community. 63118033 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 120 0 1 443 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Matthew Streeter CFO 6033265610 8 Clover Lane Whitefield NH 03598 Brianne Teaboldt Medical Staff President 1.00 0.00 X 0 0 0 Donna Goodrich Chair 1.00 1.50 X X 0 0 0 Jay Poulin Vice-Chair 1.00 0.50 X X 0 0 0 Thomas McCue Treasurer 1.00 1.00 X X 0 0 0 Martha Laflamme Secretary 1.00 0.50 X X 0 0 0 Lynn Beede Director 1.00 0.00 X 0 0 0 Javier Cardenas Director 40.00 0.00 X 446241 0 54911 Alta Chase Director 1.00 1.00 X 0 0 0 Jessica Foster-Hebert Director 1.00 39.00 X 0 108222 15925 Julie King Director 1.00 0.00 X 0 0 0 Daniel Van Buren Director 1.00 0.00 X 0 0 0 Sarah Verney Frechette Director 1.00 0.00 X 0 0 0 Tyler White Director 1.00 0.00 X 0 0 0 David Backler Past Director 1.00 0.00 X 0 0 0 Joseph Dupuis Past Director 1.00 0.00 X 0 0 0 Tim Godin Past Director 1.00 0.00 X 0 0 0 Eric Johnson Past Director 1.00 0.00 X 0 0 0 Joan Merrill Past Director 1.00 0.00 X 0 0 0 Jerry Rittenhouse MD Past Director 40.00 0.00 X 600971 0 0 Sarah Baillargeon Past Director 1.00 0.00 X 0 0 0 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 Peterson President 40.00 2.00 X 413676 0 46019 Keith Shute MD Chief Medical Officer 39.50 0.50 X 506394 0 50256 Mahlon Bradley Orthopedic Surgeon 40.00 0.00 X 620388 0 56738 Glenn M Hall General Surgeon 40.00 0.00 X 537671 0 30970 Krzysztof Plociennik MD Provider 40.00 0.00 X 500368 0 62917 Arthur A Ruediger ED Physician 40.00 0.00 X 397652 0 57217 Stephen G Kraunz Physician 40.00 0.00 X 395795 0 34858 Richard Werkowski Former Interim CFO 0.00 0.00 X 120750 0 0 4539906 952825 475945 70 1 1 1 North Country Healthcare Inc 8 Clover Land Whitefield NH 03598 Management Services 2885314 Weeks Medical Center 173 Middle Street Lancaster NH 03584 Contract Labor/Purchased Services 854202 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Physician Contract Labor 832647 Navin Haffty & Associates PO Box 88597 Milwaukee WI 532888597 Contract Labor/Purchased Services 809357 Granite State GI Consultants 6 Tsienneto Road Suite 301 Derry NH 03035 GI Contract Labor 723627 15 43678 2016716 523664 2584058 Patient Revenue 621400 99159035 99159035 Miscellaneous Revenue 621400 2112739 1785996 326743 Contractual/Char. Adj. 621400 -27010334 -27010334 74261440 484153 484153 104591 0 104591 104591 104591 5797066 5575193 21263 221873 -21263 200610 200610 0 43678 18701 -18701 -18701 77616151 73934697 0 1097396 X 692569 692569 2118287 1764367 353920 30259219 23647710 6611509 728408 569517 158891 5211559 3512741 1698818 1886955 1473463 413492 162799 162799 129421 129421 96943 96943 12999237 11269818 1729419 83925 83925 1234619 936621 297998 1373834 1359364 14470 65280 51342 13938 39129 29564 9565 115646 115646 3314529 3314529 1103165 1103165 Patient Care Supplies 7703230 7703230 MET Tax 3157218 3157218 Intercompany Allocation 2513852 2341944 171908 Other Expenses 134816 75225 59591 75124640 63118033 12006607 0 X 4243 4193 30535132 11969545 7037374 5942551 944479 1005558 696872 409563 63834539 41554208 19877486 22280331 26116089 22146687 11623210 10272034 96834885 74030462 6536633 5443251 5344700 4317205 8492 44822216 28078436 56712041 37838892 X 40122844 36191570 40122844 36191570 96834885 74030462 X 2491511 -4516741 -1906044 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 9494 9494 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. 198192 198192 25632384 23049718 2582666 359449 359449 0 32011706 16688264 15323442 5632808 1456777 4176031 22280331 Due from Affiliates 637306 Other Receivables 2134631 Deferred Compensation 7483913 Investment in Affiliate 16184 10272034 Deferred Compensation 7483913 Estimated Third Party Payor Settlements 19867021 Due to Related Parties 727502 28078436 72279390 -4516740 -4516740 76796130 96943 723078 820021 77616151 74304619 0 74304619 96943 723078 820021 75124640 Part XI, Line 4b - Other Adjustments: Gift Shop Expenses 22,678. Auxiliary Expenses 7,831. Contribution Expense 692,569. Part XII, Line 4b - Other Adjustments: Auxiliary Expenses 7,831. Gift Shop Expenses 22,678. Contribution Expense 692,569. Golf Tournament 43678 43678 700 6300 7400 2000 2301 43678 43678 700 6300 7400 2000 2301 18701 -18701 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 320545 320545 0.00430 13871352 10414002 3457350 0.04600 14191897 10414002 3777895 0.05030 78840 610 78230 0.00100 82174 82174 0.00110 5301668 4459006 842662 0.01120 692569 692569 0.00920 6155251 4459616 1695635 0.02250 20347148 14873618 5473530 0.07280 0 1521416 23265876 23176945 88931 X 1 0 1 1 Androscoggin Valley Hospital Inc 59 Page Hill Road Berlin NH 03570 www.avhnh.org 00050 X X X X Androscoggin Valley Hospital 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X https://avhnh.org/community-health-needs-assessment/ X 1 21 1 https://avhnh.org/community-health-needs-assessment/ 1 0 1 X 300.000000000000 300.000000000000 X X X 1 1 X X X X 1 X https://avhnh.org/patients-visitors/financial-information/ X https://avhnh.org/patients-visitors/financial-information/ X https://avhnh.org/patients-visitors/financial-information/ X X X X X X 1 X 0 X X X X 1 X 0 0 Androscoggin 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. Androscoggin Valley Hospital Part V, Section B, Line 6a: The Hospital's CHNA was conducted along with Weeks Medical Center and Upper Connecticut Valley Hospital. Androscoggin 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. Androscoggin Valley Hospital Part V, Section B, Line 11: Please see attached CHNA and Implementation Strategy. Schedule H, Part V, Section B, Line 22: All patients are charged the same amount for services and procedures performed, regardless of whether they were insured or uninsured. The net amount due to the hospital is based upon contractual adjustments for insured patients and administrative adjustments for uninsured patients, which may include free care, charity care, and discounted care. 8 1 - AVH Surgical Associates 7 Page Hill Road Berlin NH 03570 Physician Practice Office 2 - Androscoggin Valley Hospital 133 Pleasant Street Berlin NH 03570 Outreach Clinic/Lab Services 3 - Androscoggin Valley Hospital 2 Broadway Avenue Gorham NH 03581 Outreach Clinic/Lab Services 4 - Androscoggin Valley Hospital 181 Corliss Lane Colebrook NH 03576 Outreach Clinic/OB, Neuro, Cardio, GS, AUD, ENT, Pulm, Sleep, URO, and Pain 5 - Androscoggin Valley Hospital 173 Middle Street Lancaster NH 03584 Outreach Clinic/Sleep, ENT, Audiology, OB, Pulmonology, and Urology 6 - NCH Outreach Clinic 167 Main Street Gorham NH 03581 Outreach Clinic/PT/Rehab 7 - NCH Outreach Clinic 1976 White Mountain Highway North Conway NH 03860 Outreach Clinic/ENT, Pain, and Sleep 8 - Saco River Medical Group 15 US Route 302 Glen NH 03838 Sleep and Cardiology Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. The ratio was derived from Worksheet 2. Part I, Line 7g: All costs reported on Part I, Line 7g are attributable to a physician clinic. Part III, Line 4: Please see pages 8-12 of the attached audited financial statements. Part III, Line 8: The Organization used a cost report as the costing methodology to determine the amount of allowable Medicare costs. Part VI, Line 2: Every 3 years, Androscoggin 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: Androscoggin Valley Hospital offers many financial assistance and referral programs to ensure that cost will not be a barrier to patients getting the healthcare services they need. If payment of healthcare expenses could create a financial hardship, Hospital staff will work with patients to apply for financial assistance. Information regarding financial assistance policies is available at the Hospital's entrances and patient registration and on the Hospital's website. As part of the financial counseling application process, the Hospital will assess eligibility for health insurance coverage through federal or state programs such as New Hampshire Medicaid and assist in the application process. Part VI, Line 4: The geographic area served by Androscoggin Valley Hospital is the Berlin service area. The Berlin service area is composed of the city of Berlin, and the towns of Gorham, Shelburne, Milan, Randolph, Dummer, Errol and Stark. These communities are within the boundaries of Coos County, which is bordered by the State of Maine to the east, the State of Vermont to the west and Quebec, Canada to the north. The city of Berlin defines much of the region as the largest community in the County with a population of 10,025. The total population of the Berlin service area is 16,121. The changing economic landscape and the closing of paper and pulp mills over the last decade in the Coos County have significantly impacted the area's unemployment rate and population compared to those experienced by the overall state of New Hampshire. Part VI, Line 5: Androscoggin Valley Hospital is the leading provider of healthcare to thousands of families in the small-town communities of New Hampshire's North Country. As a Critical Access Hospital, AVH offers 24/7 emergency care, in-house treatment of most medical issues, and an arrangement for treatment of all other problems with the nearest tertiary-care facility.Over the past decade, AVH has invested significantly in expanding and improving our facilities and services, and enhancing our team of dedicated, highly trained doctors, nurses and other staff. The result is a hospital that more effectively contributes to the health of our communities than ever before. Our new location in North Conway, NH offers comfortable and private treatment rooms for pain procedures as well as some elective treatments. Recent renovations have taken place to update the Obstetrics and Gynecology space offering an improved patient experience through open reception and more natural flow for patients as well as closer proximity to the inpatient women's services area. At the end of the day, our top priority is to ensure the highest level of quality healthcare to those that we are so fortunate to serve.In an effort to continue to provide a high quality of healthcare for all patients in the North Country, the hospitals of Coos & Grafton County came together to explore collaboration. We, the boards and senior management of Androscoggin Valley Hospital, Upper Connecticut Valley Hospital, and Weeks Medical Center realize that significant national, state and local economic pressures are jeopardizing local access, quality and sustainability. We have therefore formed North Country Healthcare (NCHC) with the stated objective of working collaboratively to better serve the healthcare needs of North Country patients. This collaborative effort will work to:1. Ensure access to quality care within the communities in which our patients live2. Provide local and high quality care with positive outcomes to our patients in the North Country 3. Control the cost of care through innovative programs and the use of shared resourcesNational healthcare reform demands lower costs and higher quality from all hospitals, requiring collaboration in patient care across all providers: from primary care to specialist, from ambulance to hospital, from hospital to rehabilitation to home care, from local hospital to tertiary (specialty hospital) care. Therefore, Androscoggin Valley Hospital, Upper Connecticut Valley Hospital, and Weeks Medical Center have formed this joint venture to identify and implement sustainable opportunities for our future. The NCHC and its member hospitals are prepared to manage costs and coordinate care in a way that is financially sustainable, while continuing to provide local access to quality care throughout the county and beyond. The hospitals of the North Country must work together as critical parts of our economy and community. Part VI, Line 7, Reports Filed With States NH 1 Coos County Family Health Services 133 Pleasant Street Berlin NH 03570 020350051 501(c)(3) 475000 0 Community Benefit Grant Foundation for Healthy Communities 125 Airport Road Concord NH 03301 020275078 501(c)(3) 205345 0 Governor's Commission on Alcohol & Other drugs to support substance abuse prevention, treatment, and recovery efforts. Great Northwoods Community Foundation 59 Page Hill Road Berlin NH 03570 020452547 501(c)(3) 10000 0 General Support 3 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. The Hospital has entered into an agreement with Coos County Family Health Services (CCFHS) whereby the Hospital will provide funding in the form of a community benefit grant. The terms of the agreement require that the Hospital provide CCFHS with the agreed-upon community benefit grant on July 1 of the grant year. The amount of the community benefit grant to be awarded is determined on an annual basis in accordance with the terms of the agreement. 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 Mahlon Bradley Orthopedic Surgeon 578635 0 39377 0 2376 0 19000 0 37738 0 677126 0 0 0 Jerry Rittenhouse MD Past Director 600971 0 0 0 0 0 0 0 0 0 600971 0 0 0 Glenn M Hall General Surgeon 439855 0 97493 0 323 0 15600 0 15370 0 568641 0 0 0 Krzysztof Plociennik MD Provider 482805 0 15283 0 2280 0 19500 0 43417 0 563285 0 0 0 Keith Shute MD Chief Medical Officer 426052 0 59500 0 20842 0 17200 0 33056 0 556650 0 0 0 Javier Cardenas Director 432559 0 11306 0 2376 0 14865 0 40046 0 501152 0 0 0 Michael Peterson President 315540 0 88652 0 9484 0 19500 0 26519 0 459695 0 0 0 Arthur A Ruediger ED Physician 382893 0 13931 0 828 0 15594 0 41623 0 454869 0 0 0 Stephen G Kraunz Physician 392458 0 2797 0 540 0 14102 0 20756 0 430653 0 0 0 Matthew Streeter System CFO 0 157136 0 10000 0 166 0 0 0 26546 0 193848 0 0 Richard Werkowski Former Interim CFO 120750 0 0 0 0 0 0 0 0 0 120750 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 organization - 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. Form 990, Part VII, line 5: Jerry Rittenhouse, Past Director, was compensated by a third party, Mystic Valley Urology, LLC for services rendered to the Organization. Mystic Valley Urology received $600,971 from the filing Organization for services rendered. A 2012 New Hampshire Health and Education Facilities Authority Revenue Bonds 020279866 2012-03-29 14500000 Refinancing existing bonds, terminate interest rate swap contract 0 0 0 A 10182795 14500000 125386 14374614 2012 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 1 A 0 Mystic Valley Urology LLC Entity controlled more than 35% by Jerry Rittenhouse, Past Director 600971 Independent Contractor Agreement for Medical Services Rendered 0 Form 990, Part VI, Section A, line 6 Effective April 1, 2016, North Country Healthcare (NCH) became the Sole Member of Androscoggin 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 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 Purchased Services: Program service expenses 3,349,573. Management and general expenses 431,030. Fundraising expenses 0. Total expenses 3,780,603. Contract Labor: Program service expenses 7,920,245. Management and general expenses 1,298,389. Fundraising expenses 0. Total expenses 9,218,634. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Androscoggin Valley Hospital 59 Page Hill Road Berlin, NH 03570 EIN 02-0280367 Androscoggin Valley Hospital is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Form 990, Part XI, line 9: Transfer to Affiliate -1,906,044. North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 812225283 Healthcare Management NH 501(c)(3) Line 12a, I N/A 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 Upper Connecticut Valley Hospital Corliss lane Colebrook NH 03576 020276210 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 1 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 1 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 1 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 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 Northcare Inc D 518580 FMV Androscoggin Valley Hospital Foundation M 130971 FMV