2022-11-10T10:07:06-06:00 2021-12-31 010494526 Baker Newman & Noyes PO Box 507 Portland ME 04112 990 2021-01-01 222504349 St Mary's Health System STMA 2079071233 93 Campus Avenue PO Box 7291 Lewiston ME 042437291 Steven Jorgensen President & CEO 2079071233 2022-11-02 1 Steven Jorgensen 999009999 Connor Smart P02285543 2078792100 2022-11-02 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z Steven Jorgensen 93 Campus Avenue PO Box 7291 Lewiston ME 042437291 3810829 0 X www.stmarysmaine.com X 1983 ME As an entity, St. Mary's Health System provides administrative oversight, management resources, and supportive services to advance comprehensive, preventative, and healing services for the patients, employees, and the local business community of its affiliated organizations. 9 6 22 7 0 0 59672 88000 2835190 3076907 32510 -63285 290280 367719 3217652 3469341 0 0 0 0 2137206 2381716 0 0 0 1193268 907957 3330474 3289673 -112822 179668 10638200 11831173 25177498 26211436 -14539298 -14380263 X As an entity, St. Mary's Health System provides administrative oversight, management resources, and supportive services to advance comprehensive, preventative and healing services for the patients, employees, and the local business community of its affiliated organizations. The Prevention & Wellness / Take Charge Community Health Risk Screening Program was developed to provide a cost effective way for individuals, particularly underserved populations, to learn more about their health. 0 0 2566620 0 3076907 Safety and Employee Health, and Affiliated Services: a program to provide screening and injury management for its employees and the business community. 2566620 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 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 1 0 0 0 1 4 0 1 22 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 ME X X Donald Bevers Jr Treasurer & CFO 2079071233 93 Campus Avenue PO Box 7291 Lewiston ME 042437291 Jeffery Davila MD Director 0.10 40.20 X 0 748298 4958 Anne Brown MD Director 0.10 40.20 X 0 158929 37041 Steve Jorgensen President & CEO 0.10 40.30 X X 0 526409 33283 David Geiger Esq Director 0.10 0.20 X 0 0 0 Ralph Harder MD Director 0.10 0.20 X 0 0 0 Lena Hartley Director 0.10 0.20 X 0 0 0 Kathy McManus Director 0.10 0.20 X 0 0 0 John Murphy MD Director (end 12/2021) 0.10 0.20 X 0 0 0 Steve Ouellette Director 0.10 0.20 X 0 0 0 Mark Anthoine Chair 0.10 0.20 X X 0 0 0 Stephen Grubbs Covenant Health President & CEO 0.10 45.00 X 0 909317 36190 Jeffrey Hundman Treasurer & VP Finance (end 9/2021) 0.10 40.20 X 0 272695 31319 Joan Daigneault Secretary (end 7/2021) 0.10 40.20 X 0 41886 22839 Angela White Secretary 0.10 40.20 X 0 28123 5132 Michael Hendrix Interim CFO (end 12/2021) 0.10 40.70 X 0 345986 41692 Alan Bean MD Physician 40.00 0.00 X 107968 0 16836 Rosanne Marquis Nurse Practitioner 40.00 0.00 X 101116 0 11209 Jonathan Torres Medical Director 40.00 0.00 X 110465 0 0 319549 3031643 240499 3 0 1 0 Covenant Health Inc 100 Ames Pond Drive Tewksbury MA 01876 Management services 116844 1 88000 88000 Health Plans & Care 621110 3076907 3076907 3076907 22111 22111 623811 256092 367719 367719 367719 85396 -85396 -85396 -85396 3469341 3076907 0 304434 1068971 885749 183222 11446 9484 1962 1223121 1013478 209643 78178 64778 13400 116844 116844 193 193 162551 155210 7341 25466 6372 19094 5279 5041 238 81225 77557 3668 74 71 3 4384 4186 198 371208 206249 164959 50674 48386 2288 Drugs/medical supplies 90059 90059 3289673 2566620 723053 0 3878 1832 2930528 2744473 105884 161528 41115 103625 9475178 4640378 5229029 4834800 1520721 1607677 807045 2377238 10638200 11831173 398037 133464 24779461 26077972 25177498 26211436 X -15213792 -15142757 674494 762494 -14539298 -14380263 10638200 11831173 X 179668 -33633 13000 X X 0 1 X 1 1 1 X X 1 Covenant Health Inc 222484505 10 1 116844 3172829 1 116844 3172829 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 Part I, Line 12g, Column (vi), Other Support: St. Mary's Health System (SMHS) provides administrative oversight, management resources, and supportive services to advance comprehensive, preventative, and healing services for the patients, employees, and the local business community of its affiliated organizations. SMHS is part of the Covenant Health Inc. (CH) System; CH, a related organization and sole corporate member of SMHS, is the supported organization of SMHS. While SMHS may not directly transfer funds to or compensate CH, all of SMHS's activities and expenditures are in furtherance of both its own mission and the charitable purpose and mission of the Covenant Health System as a whole. Accordingly, 100% of SMHS's 2021 expenditures, other than those paid directly to Covenant Health Inc. for management services, have been classified as Other Support, as these costs were either paid on behalf of or in participation to the overall Covenant Health system and mission. Part IV, Section A, Line 1: The Organization was organized to operate exclusively for the benefit of, to perform the functions of, or to carry out the purposes of Covenant Health, Inc., other organizations within or affiliated with the Covenant Health System that are exempt as 501(c)(3) public charities under Section 501(a)(1) or 509(a)(2), and/or other organizations that are exempt as 501(c)(3) public charities under Section 501(a)(1) or 509(a)(2). But for the existence of the Organization, Covenant Health, Inc. would be responsible for the activities and services performed by St. Mary's Health System. While Covenant Health, Inc. is specifically named in the Organization's governing documents, many of the affiliated entities within the broader Covenant Health System are not explicitly listed. However, as outlined in the preceding paragraph, Covenant Health, Inc. is the parent of the Covenant Health System. Any benefits provided to any entity within the System, either directly or indirectly, also benefit Covenant Health, Inc., the named Supported Organization. Therefore, while not all organizations that received support from the Organization are listed in the Organization's governing documents, any organization receiving support is part of a charitable class of supported organizations named in the Organization's governing documents through their affiliation, membership, and common-control relationship with Covenant Health, Inc. 674494 88000 762494 1514616 59672 -468620 431174 674494 1132332 389567 7283 1514616 1253952 130783 -113722 138681 1132332 1271448 137950 36680 192126 1253952 0.00000 0.98960 0.01040 0 0 883298 883298 8295013 4390807 3904206 296867 249571 47296 4834800 Investment in Maine Health 5000 F Investment in Synernet 549661 F Investment in Covenant Health Investment Trust 1053016 F 1607677 Due from affiliates 2257238 Security deposits 120000 2377238 Due to affiliates 23802268 Security deposits 1625 Professional liability loss reserve 2037736 Deferred fixed asset expense obligations 236343 26077972 X Part V, Line 4: The System's Endowment Funds, in conjunction with any revenues generated from the Funds, are used to further the System's exempt mission and operations, which includes the following uses: administrative oversight; management resources; and supportive services to advance comprehensive, preventative and healing services for the patients, employees, and the local business community of the System's affiliated organizations. Part X, Line 2: Covenant and its member organizations are considered not-for-profit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. Tax-exempt organizations could be required to record an obligation for income taxes as the result of a tax position they have historically taken on various tax exposure items including unrelated business income or tax status. Under guidance issued by the Financial Accounting Standards Board, assets and liabilities are established for uncertain tax positions taken or positions expected to be taken in income tax returns when such positions are judged to not meet the "more-likely-than-not" threshold, based upon the technical merits of the position. Estimated interest and penalties, if applicable, related to uncertain tax positions are included as a component of income tax expense. The System has evaluated the position taken on its filed tax returns. The System has concluded no uncertain income tax positions exist at December 31, 2021. 1 0 0 0 0 0 0 0 0 Stephen Grubbs Covenant Health President & CEO 0 851411 0 30924 0 26982 0 8700 0 27490 0 945507 0 0 Jeffery Davila MD Director 0 744428 0 0 0 3870 0 3515 0 1443 0 753256 0 0 Steve Jorgensen President & CEO 0 483808 0 18094 0 24507 0 8700 0 24583 0 559692 0 0 Michael Hendrix Interim CFO (end 12/2021) 0 324148 0 8509 0 13329 0 7349 0 34343 0 387678 0 0 Jeffrey Hundman Treasurer & VP Finance (end 9/2021) 0 228197 0 3948 0 40550 0 3002 0 28317 0 304014 0 0 Anne Brown MD Director 0 158139 0 0 0 790 0 4784 0 32257 0 195970 0 0 Part I, Line 3 Any compensation paid to the trustees, directors, officers or key employees of the Organization is subject to the oversight and decisions of Covenant Health, a related tax-exempt organization. Every two-to-three years the Compensation Committee of the Covenant Health Board of Directors engages an external consultant to provide competitive market data from various survey sources, which is then used to develop recommendations for changes to the compensation program. Since 2003, the Compensation Committee has engaged a human resources consultant to conduct this analysis. Objectives of the analysis are to assess the compositeness of the total cash compensation levels of the senior leadership team, develop market based competitive salary ranges for all executive positions, and ensure that the annual incentive opportunities, if there are any, are competitive and reasonable. Part I, Line 4a During the 2021 tax year, Jeffrey Hundman served as the Treasurer and VP of Finance for St. Mary's Regional Medical Center of Lewiston, Maine, and other affiliated organizations within the Covenant Health System operating in the greater Lewiston-Auburn region and community. Jeffrey Hundman was paid directly by Covenant Health Inc., the parent of the System, for his services. In September, 2021, Jeffrey Hundman ended his term of service and employment with the System. As part of his separation from Covenant Health, Jeffrey Hundman received severance compensation in the amount of $39,045 in the 2021 tax year, which was included in his 2021 Form W-2 wages. In accordance with IRS Instructions, Jeffrey Hundman's severance compensation is reported on this Schedule J, Part II, within his column B(iii), Other Compensation total. Form 990, Part VI, Section A, line 6 Covenant Health, Inc. is the sole corporate member of the Organization. Form 990, Part VI, Section A, line 7a As the sole corporate member of the Organization, Covenant Health, Inc. retains the ability to elect and remove the Organization's board of directors with or without cause. Form 990, Part VI, Section A, line 7b As the sole corporate member of the Organization, Covenant Health, Inc. has the following powers and rights over the Organization and its subsidiaries as outlined in the Organization's bylaws: 1. To approve any change in the written statements of philosophy and mission; 2. To amend and to repeal the organizing and governing documents; 3. To elect the Board of Directors or remove them with or without cause; 4. To appoint and remove the president; 5. To ratify the Board of Director's election of the Chair of the Board; 6. To approve all plans of merger, consolidation, reorganization, dissolution, or the sale, lease assignment, or transfer of substantially all of the assets, or the purchase or acquisition of an interest in any corporation, partnership, joint venture, or other entity; 7. To approve all long-range strategic plans before implementation; 8. To approve the acquisition, sale, or encumbrance of any real estate valued in excess of an amount set by the Member in writing; 9. To approve all capital budgets and non-budgeted expenses in excess of an amount set by the Member in writing; 10. To approve all debt in excess of limits set by the Member in writing; 11. To appoint the auditors; 12. To approve the sale, assignment, or transfer of any equity interest or membership interest in any subsidiary; 13. To approve any reclassification or other change of any capital stock or other equity security; and, 14. To approve the issuance of, or the creation of any obligation to issue, any equity security. Form 990, Part VI, Section B, line 11b The Form 990 is provided to the governing body for their review and approval prior to filing. Form 990, Part VI, Section B, line 12c This process is the responsibility of the Compliance Officer. A conflict of interest disclosure form is submitted to all leadership, board members, board committee members, employed physicians, medical directors and certain employees in key positions annually to be completed. Reminders are sent to all persons of interest to ensure that all conflict of interest disclosure forms are completed and collected. Form 990, Part VI, Section B, line 15 Any compensation paid to the trustees, directors, officers or key employees of the Organization is subject to the oversight and decisions of Covenant Health, a related tax-exempt organization. Every two-to-three years the Compensation Committee of the Covenant Health Board of Directors engages an external consultant to provide competitive market data from various survey sources, which is then used to develop recommendations for changes to the compensation program. Since 2003, the Compensation Committee has engaged a human resources consultant to conduct this analysis. Objectives of the analysis are to assess the compositeness of the total cash compensation levels of the senior leadership team, develop market based competitive salary ranges for all executive positions, and ensure that the annual incentive opportunities, if there are any, are competitive and reasonable. Form 990, Part VI, Section C, line 19 The Organization's Form 990, governing documents, conflict of interest policy, and financial statements are made available to the public upon request. The Organization's Form 990 is also made available on the website of its parent organization, Covenant Health, at the following web address: https://www.covenanthealth.net/financial-information/financial-information Form 990, Part XI, line 9: Recoveries of bad debts 13,000. Form 990, Part XII, Line 2c: The audit process has not changed from the prior year. Alternative Health Services 360 Broadway Bangor ME 04402 010422885 Home health and hospice ME 501(c)(3) Line 10 St Joseph Healthcare Foundation 0 CHS of Waltham Inc dba Maristhill Nursing & Rehab Center 66 Newton Street Waltham MA 02453 043333609 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 CHS of Worcester Inc dba St Mary Care Center 39 Queen Street Worchester MA 01610 043419625 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 Community Clinical Services PO Box 7291 Lewiston ME 04243 010409788 Physician practice ME 501(c)(3) Line 10 St Mary's Health System 1 Covenant Health Foundation Inc 100 Ames Pond Drive Tewksbury MA 01876 800199674 Charitable foundation MA 501(c)(3) Line 12a, I Covenant Health Inc 0 Covenant Health Investment Trust 420 Bedford Street Lexington MA 02420 046835128 Investment trust MA 501(c)(3) Line 12a, I Covenant Health Inc 0 Covenant Health Inc 100 Ames Pond Drive Tewksbury MA 01876 222484505 Health care management and resource organization MA 501(c)(3) Line 10 N/A 0 Fanny Allen Corporation Inc 790 College Parkway Colchester VT 05446 222495808 Charitable foundation VT 501(c)(3) Line 12a, I Covenant Health Inc 0 Fanny Allen Holdings Inc 790 College Parkway Colchester VT 05446 030181052 Real estate holding company VT 501(c)(3) Line 12a, I Covenant Health Inc 0 Helping Hands of St Marguerite Inc 799 Concord Avenue Cambridge MA 02138 800199674 Private home-care health services MA 501(c)(3) Line 10 Covenant Health Inc 0 M & J Company 360 Broadway Bangor ME 04402 222480150 Lease holding company ME 501(c)(2) St Joseph Healthcare Foundation 0 Mary Immaculate Guild Inc 172 Lawrence Street Lawrence MA 01841 463073987 Supporting grants and donations MA 501(c)(3) Line 12a, I Covenant Health Inc 0 MI Adult Day Health Care Center Inc 189 Maple Street Lawrence MA 01841 042921888 Adult day care services MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Management Inc 172 Lawrence Street Lawrence MA 01841 042857794 Assisted living services MA 501(c)(3) Line 12a, I Covenant Health Inc 0 MI Nursing Restorative Center Inc 172 Lawrence Street Lawrence MA 01841 042104851 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Residential Community Inc 189 Maple Street Lawrence MA 01841 042647207 HUD low income housing MA 501(c)(3) Line 10 Covenant Health Inc 0 MI Transportation Inc 189 Maple Street Lawrence MA 01841 042921889 Elderly transportation services MA 501(c)(3) Line 10 Covenant Health Inc 0 Mount St Rita Health Centre 15 Sumner Brown Road Cumberland RI 02864 050342330 Nursing home RI 501(c)(3) Line 10 Covenant Health Inc 0 Neighborhood Housing Initiative PO Box 7291 Lewiston ME 04243 010539730 Affordable housing services ME 501(c)(3) Line 10 St Mary's Health System 1 Penacook Place Inc 150 Water Street Haverhill MA 01830 237090088 Nursing home MA 501(c)(3) Line 10 Covenant Health Inc 0 Souhegan Nursing Association 24 North River Road Milford NH 03055 020222795 Home health and hospice NH 501(c)(3) Line 10 St Joseph Hospital of Nashua NH Inc 0 St Joseph Ambulatory Care Inc 360 Broadway Bangor ME 04402 222480373 Physician practice ME 501(c)(3) Line 10 St Joseph Healthcare Foundation 0 St Andre Health Care 407 Pool Street Biddeford ME 04005 010342399 Nursing home and restorative facility ME 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph Healthcare Foundation 360 Broadway Bangor ME 04402 222480149 Healthcare foundation ME 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph Hospital 360 Broadway Bangor ME 04402 010212435 Hospital and health care facility ME 501(c)(3) Line 3 St Joseph Healthcare Foundation 0 St Joseph Manor Health Care 215 Thatcher Street Brockton MA 02302 042565937 Nursing home and restorative facility MA 501(c)(3) Line 10 Covenant Health Inc 0 St Joseph's Hospital of Nashua NH Inc 172 Kinsley Street Nashua NH 03061 020222215 Hospital and health care facility NH 501(c)(3) Line 3 Covenant Health Inc 0 St Mary's D'Youville Pavilion PO Box 7291 Lewiston ME 04243 010211558 Nursing home and restorative facility ME 501(c)(3) Line 10 St Mary's Health System 1 St Mary's Regional Medical Center PO Box 7291 Lewiston ME 04243 010211551 Hospital and health care facility ME 501(c)(3) Line 3 St Mary's Health System 1 St Mary's Residences PO Box 7291 Lewiston ME 04243 222504356 Low income housing ME 501(c)(3) Line 10 St Mary's Health System 1 St Mary's Villa Nursing Home Inc 675 St Marys Villa Road Moscow PA 18444 232057177 Nursing home and restorative facility PA 501(c)(3) Line 10 Covenant Health Inc 0 The Surgicenter at St Joseph Hospital Inc 172 Kinsley Street Nashua NH 03061 020222215 Healthcare and surgery center NH 501(c)(3) Line 10 St Joseph Hospital of Nashua NH Inc 0 Youville Hospital and Rehabilitation Center Inc 1575 Cambridge Street Cambridge MA 02138 043239563 Hospital and health care facility MA 501(c)(3) Line 10 Youville Lifecare Inc 0 Youville House Inc 1573 Cambridge Street Cambridge MA 02138 043239593 Assisted living services MA 501(c)(3) Line 10 Youville Lifecare Inc 0 Youville Lifecare Inc 1575 Cambridge Street Cambridge MA 02138 042103582 Hospital and health care facility MA 501(c)(3) Line 10 Covenant Health Inc 0 Youville Place 10 Pelham Road Lexington MA 02421 043297834 Assisted living services MA 501(c)(3) Line 10 Covenant Health Inc 0 Campus Holding PO Box 7291 Lewiston ME 04240 010406049 Holding company ME St Mary's Health System C 1.00000 0 Covenant Health Insurance LTD PO Box 69 Grand Cayman CJ KY1-1102 043360127 Self-insurance company CJ N/A C 0 GNM Corporation 172 Kinsley Street Nashua NH 03060 020400550 Real estate holding company NH N/A C 0 SJ Physicians Services 172 Kinsley Street Nashua NH 03060 020522234 Physician practice NH N/A C 0 St Joseph Corporate Services Inc 172 Kinsley Street Nashua NH 03060 020405197 Holding company NH N/A C 0 Strauss Incorporated 360 Broadway Bangor ME 04402 010391369 Repairs and transcriptions ME N/A C 0 0 0 0 1 1 0 0 0 0 1 0 1 1 1 1 0 0 0 0 St Mary's Regional Medical Center D 1734271 Per book Community Clinical Services D 78033 Per book St Mary's Regional Medical Center E 23687560 Per book St Mary's Residences E 14498 Per book Community Clinical Services E 100210 Per book St Mary's Regional Medical Center L 3076907 Per book St Mary's Regional Medical Center M 3076907 Per book