2020-07-29T04:32:29-05:00 2019-09-30 861065772 DELOITTE TAX LLP TWO JERICHO PLAZA JERICHO NY 11753 990 2018-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION INC SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON PRESIDENT/CEO 5089417000 2020-07-28 1 CHRISTINE KAWECKI P00743140 5169187000 183.83.136.238 2020-07-28 06:55:51 US P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 1BA7F11F8C184D0CB166ED8A071ADA6BBBB853D3 2018 2021-01-29 14:40:06Z SIGNATURE HEALTHCARE KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 35150985 0 X WWW.SIGNATURE-HEALTHCARE.ORG X 1890 MA TO OPERATE EXCLUSIVELY FOR THE BENEFIT OF BROCKTON HOSPITAL, INC. AND ITS (SEE SCHEDULE O) AFFILIATED ORGANIZATIONS, INCLUDING MEDICAL CENTERS, HEALTH CARE CENTERS, NURSING CENTERS, LABORATORIES, CLINICS AND OTHER MEDICAL, SURGICAL OR DENTAL FACILITIES, IN THE CONDUCT OF THEIR CHARITABLE, EDUCATIONAL AND SCIENTIFIC FUNCTIONS. 22 17 0 196 0 0 2324859 1303015 651231 234900 515302 384677 -41276 -33744 3450116 1888848 0 0 0 0 0 0 57614 22832 640610 843337 851740 900951 874572 2549165 1014276 11297502 11938623 0 0 11297502 11938623 X SEE SCHEDULE O. 0 0 80453 234900 SOLICIT, RECEIVE, INVEST AND HOLD CONTRIBUTIONS RECEIVED FROM ANY AND ALL SOURCES FOR THE BENEFIT OF ITS NON-PROFIT AFFILIATE BROCKTON HOSPITAL, INC. 80453 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 X 22 17 1 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 MA X X KIM HOLLON 5089417000 680 CENTRE STREET BROCKTON MA 023023395 JOSEPH DRIER III CHAIRMAN 1.00 1.00 X X 0 0 0 DAVID M OFFUTT VICE CHAIRMAN 1.00 1.00 X X 0 0 0 KIM N HOLLON PRESIDENT/CEO 1.00 41.00 X X 0 792516 29184 LUKE MCCABE TRUSTEE (START 12/31/18) 1.00 1.00 X 0 0 0 TIMOTHY CRUZ TRUSTEE 1.00 1.00 X 0 0 0 MICHAEL L DERN MD TRUSTEE 1.00 41.00 X 0 441483 25664 DAVID DRINKWATER MD VICE PRESIDENT SPECIALTY CARE 1.00 41.00 X 0 619743 31141 DAVID F ENGELKEMEYER TRUSTEE 1.00 1.00 X 0 0 0 MARIA FERNANDES TRUSTEE (START 2/28/19) 1.00 1.00 X 0 0 0 DAVID FRENETTE TRUSTEE 1.00 1.00 X 0 0 0 ROBERT S GREENBERG MD TRUSTEE 1.00 41.00 X 0 275874 10420 REV CHERYL HARRIS TRUSTEE 1.00 1.00 X 0 0 0 STEVEN LANE MD PRES MEDICAL STAFF 1.00 1.00 X 0 0 0 JAMES LEARY TRUSTEE 1.00 1.00 X 0 0 0 EUGENE MARROW TRUSTEE 1.00 1.00 X 0 0 0 FRED NICCOLI CHAIRMAN DEV OFF BD OF GOVRNRS 1.00 1.00 X 0 0 0 WALLACE PECKHAM III TRUSTEE (END 12/31/18) 1.00 1.00 X 0 0 0 PATTI ROLAND TRUSTEE 1.00 1.00 X 0 0 0 MICHAEL SULLIVAN TRUSTEE 1.00 1.00 X 0 0 0 ROBERT SULLIVAN TRUSTEE 1.00 1.00 X 0 0 0 PATRICIA TORTORELLA TRUSTEE 1.00 1.00 X 0 0 0 DAVID WOLOHOJIAN TRUSTEE 1.00 1.00 X 0 0 0 STEPHEN BORGES INTERIM CFO (START 4/19/19) 1.00 41.00 X X 0 224425 28802 JAMES PAPADAKOS SENIOR VP/CFO (END 4/19/19) 1.00 41.00 X 0 426403 25282 0 2780444 150493 0 0 1 0 0 293296 1009719 63267 1303015 RENT FROM AFFILIATES 900099 234900 234900 234900 85649 85649 117021 0 117021 117021 117021 33371567 33072539 299028 299028 299028 38833 293296 189598 -150765 -150765 1888848 234900 0 350933 X 22832 22832 78729 72431 6298 FUNDRAISING EXPENSES 617778 617778 TRANSPORTATION EXPENSES 66429 66429 ADMINISTRATIVE EXPENSES 30626 8022 22604 SCHOLARSHIP EXPENSES 6000 6000 52178 52178 874572 80453 153509 640610 41025 39176 1782234 1429990 3209414 4053978 0 10195 4502298 2053311 2526259 2448987 3738570 3956297 11297502 11938623 0 0 X 5997092 6909099 3680468 3409582 1619942 1619942 11297502 11938623 11297502 11938623 X 1014276 904709 -384678 -893186 X 0 1 X 1 0 X X 2 BROCKTON HOSPITAL INC 222472997 3 1 505048 0 SIGNATURE HEALTHCARE MEDICAL GROUP INC 043306782 10 0 234900 0 2 739948 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE A, PART IV, SECTION A, LINE 1: MEMBERSHIP COMPOSITION OF THE BOARD OF TRUSTEES FOR THE ORGANIZATION AND ITS TAX EXEMPT AFFILIATE BROCKTON HOSPITAL, INC. ARE THE SAME. THE ORGANIZATION HAS THE POWER TO APPOINT THE BOARD OF DIRECTORS FOR ITS TAX EXEMPT AFFILIATE SIGNATURE HEALTHCARE MEDICAL GROUP, INC. WHICH HAS BEEN GRANTED CERTAIN MANAGERIAL POWERS SUBJECT TO THE PRIOR APPROVAL OF THE ORGANIZATION. SCHEDULE A, PART IV, SECTION C, LINE 1: MEMBERSHIP COMPOSITION OF THE BOARD OF TRUSTEES ("BOT") FOR SHC AND ITS NON-PROFIT AFFILIATE BROCKTON HOSPITAL, INC. ARE THE SAME BUT DIFFERS FROM THE BOT OF IT'S NON-PROFIT AFFILIATE, SMG. SHC IS THE SOLE MEMBER OF SMG AND AS SUCH HAS ALL RIGHTS AND POWERS CONFERRED ON MEMBERS OF NON-PROFIT CORPORATIONS UNDER THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS INCLUDING BUT NOT LIMITED TO THE POWER TO APPOINT THE BOT FOR SMG. SUBJECT TO THE RIGHTS OF SHC THE SMG BOT HAS AND MAY EXERCISE ALL THE POWERS OF SMG RELATING TO AND IN CONNECTION WITH THE PRACTICE OF MEDICINE BY SMG, MAKE PHYSICIAN HIRING AND FIRING DECISIONS, CONDUCT PEER REVIEW SUBJECT TO SHC'S CREDENTIALING STANDARDS, OVERSEE PRACTICE STANDARDS AND QUALITY OF CARE DELIVERED THROUGH SMG, OVERSEE OPERATIONS AND PATIENT CARE POLICIES SUBJECT TO SHC'S POLICIES, AND OVERSEE OTHER CERTAIN MANAGERIAL POWERS SUBJECT TO THE PRIOR APPROVAL OF SHC. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4717908 116735 4834643 4502193 25000 190715 4717908 4090994 411199 4502193 3763490 1539 325965 0 0 0 4090994 4017169 82461 -288537 0 47603 0 3763490 0.00000 0.71000 0.29000 1 1 1 1069674 1069674 3044685 1665886 1378799 387939 387425 514 2448987 BOARD-DESIGNATED INVESTMENTS 307473 F DONOR-RESTRICTED INVESTMENTS 3648824 F 3956297 PART V, LINE 4: THE ORGANIZATION INTENDS TO USE ITS ENDOWMENT FUNDS TO SUPPORT ITS NOT-FOR-PROFIT AFFILIATE BROCKTON HOSPITAL, INC. IN FURTHERING ITS TAX EXEMPT PURPOSE OF PROVIDING HIGH QUALITY HEALTH CARE SERVICES TO THE RESIDENTS IN THE COMMUNITIES IN WHICH IT SERVES AND TO SUPPORT BROCKTON HOSPITAL'S SCHOOL OF NURSING. X X X X X X X 1 BLACKBAUD SYSTEMS INC 2000 DANIEL ISLAND DRIVE CHARLESTON SC 29492 ANALYSIS OF CONTRIBUTORS 0 0 17332 -17332 CRESCENDO INTERACTIVE INC 110 CAMINO RUIZ CAMARIELO CA 93012 PLANNED GROUP SERVICES 0 0 5500 -5500 22832 -22832 MA RING OF CHAMPIONS 56920 45460 11460 720 23429 500 13405 CANCER WALK 179446 170234 9212 2518 0 0 115827 1 95763 77602 18161 5973 18256 0 8970 332129 293296 38833 9211 41685 500 138202 189598 -150765 X X X X X 0 1 0 0 0 0 0 0 0 KIM N HOLLON PRESIDENT/CEO 0 681531 0 104230 0 6755 0 0 0 29184 0 821700 0 0 MICHAEL L DERN MD TRUSTEE 0 435983 0 0 0 5500 0 0 0 25664 0 467147 0 0 DAVID DRINKWATER MD VICE PRESIDENT SPECIALTY CARE 0 614243 0 0 0 5500 0 0 0 31141 0 650884 0 0 ROBERT S GREENBERG MD TRUSTEE 0 195374 0 75000 0 5500 0 0 0 10420 0 286294 0 0 STEPHEN BORGES INTERIM CFO (START 4/19/19) 0 191922 0 19100 0 13403 0 0 0 28802 0 253227 0 0 JAMES PAPADAKOS SENIOR VP/CFO (END 4/19/19) 0 357218 0 55000 0 14185 0 0 0 25282 0 451685 0 0 PART I, LINE 4B DURING THE YEAR ENDED 12/31/2018 THE ORGANIZATION MADE 457(F) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN CONTRIBUTIONS FOR ELIGIBLE PLAN PARTICIPANTS. THE PLAN WAS CREATED BY SIGNATURE HEALTHCARE FOR THE PURPOSE OF PROVIDING DEFERRED COMPENSATION FOR A SELECT GROUP OF EMPLOYED PHYSICIANS UPON MEETING THE ELIGIBILITY REQUIREMENT OF COMPLETING TWO YEARS OF PLAN SERVICE. FOR YEARS IN WHICH THE ORGANIZATION MEETS ITS OPERATIONAL MARGIN GOAL THE ORGANIZATION WILL CONTRIBUTE TO THE PLAN. THE ORGANIZATION MAY CREDIT TO THE ACCOUNT OF EACH PARTICIPANT UP TO 4% OF THE PARTICIPANT'S TOTAL CASH COMPENSATION FOR THE PRIOR PLAN YEAR. PARTICIPANT'S REMAIN PARTICIPANTS IN THE PLAN UNTIL FORFEITURE OR DISTRIBUTION OF HIS/HER ACCOUNT. COMMENCEMENT OF DISTRIBUTIONS BEGIN UPON THE LAPSE OF FORFEITURE RISK AND ARE MADE IN SINGLE LUMP-SUM DISTRIBUTIONS NET OF APPLICABLE FEDERAL AND STATE WITHHOLDING TAXES. NO DISTRIBUTIONS WERE MADE FROM THE PLAN TO ANY LISTED PERSONS DURING THE YEAR. X SUPPLIES 169 61852 OTHER X GIFT CARDS 16 1415 OTHER 0 0 1 1 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING BASED ON THE NUMBER OF ITEMS RECEIVED. PART I, LINE 32B: STAFF OF SHC'S NON-PROFIT AFFILIATE, BROCKTON HOSPITAL, SOLICIT NONCASH CONTRIBUTIONS TO BE USED AT FUNDRAISING EVENTS HELD FOR THE BENEFIT OF HEALTHCARE RELATED PROGRAMS AND SERVICES OFFERED BY BH. FORM 990, PART III, LINE 1 TO BE THE LEADING COMMUNITY BASED HEALTHCARE DELIVERY SYSTEM IN SOUTHEASTERN MASSACHUSETTS PROVIDING THE FULL RANGE OF PRIMARY CARE, SPECIALTY CARE, HOSPITAL CARE AND RELATED ANCILLARY SERVICES ON A COORDINATED BASIS. SIGNATURE HEALTHCARE PHYSICIANS AND SIGNATURE HEALTHCARE BROCKTON HOSPITAL STRIVE TO BE RECOGNIZED AS THE "PROVIDERS OF CHOICE" BY STAFF, PATIENTS AND THE COMMUNITY. FORM 990, PART VI, SECTION A, LINE 2 TIMOTHY CRUZ, DAVID FRENETTE, PATTI ROLAND, ROBERT SULLIVAN, DAVID WOLOHOJIAN, WALLACE PECKHAM, III, JOSEPH DRIER, III, JAMES LEARY, MICHAEL SULLIVAN, PATRICIA TORTORELLA, REV. CHERYL HARRIS, EUGENE MARROW, FRED NICCOLI, ROBERT S. GREENBERG, M.D., DAVID DRINKWATER, M.D., KIM N. HOLLON, MICHAEL L. DERN, M.D., DAVID ENGELKEMEYER, DAVID OFFUTT, MARIA FERNANDES, LUKE MCCABE AND STEVEN LANE HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER AS THEY ARE ALSO TRUSTEES OF BROCKTON HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 4 THE CORPORATION'S BYLAWS WERE AMENDED TO REFLECT THE FOLLOWING CHANGES: (1) THE NUMBER OF ELECTED TRUSTEES REMAINED UNCHANGED AND WAS AMENDED TO INCLUDE AT LEAST TWO MEMBERS OF THE GREATER BROCKTON COMMUNITY (DESIGNATED "CONSUMER TRUSTEES") WHO ARE EITHER CONSUMER ADVOCATES OR HAVE CONSUMED HEALTH CARE SERVICES DELIVERED BY THE CORPORATION THROUGH ITS AFFILIATES. (2) ALL TRUSTEES OF THE CORPORATION, WITH THE EXCEPTION OF THE CONSUMER TRUSTEES, ARE REPRESENTATIVES OF PROVIDERS PARTICIPATING IN THE SIGNATURE ACCOUNTABLE CARE ORGANIZATION (''ACO"). (3) THE POWERS AND PRINCIPAL FUNCTIONS OF THE CORPORATION WERE AMENDED TO INCLUDE TO GOVERN THE ACO. (4) THE QUALITY IMPROVEMENT COMMITTEE WAS ESTABLISHED TO BRING COMBINED EXPERTISE AND QUALITY OVERSIGHT BY THE CORPORATION OF THE ACO, AND THE ACTIVITIES OF ITS AFFILIATES AND CONSISTS OF THOSE INDEPENDENT TRUSTEES SERVING ALSO FROM TIME TO TIME AS MEMBERS OF THE BROCKTON HOSPITAL QUALITY IMPROVEMENT COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S FORM 990 IS PREPARED BY AN OUTSIDE INDEPENDENT CERTIFIED PUBLIC ACCOUNTING FIRM AND IS PRESENTED TO AND REVIEWED BY THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER AND COPIES OF FORM 990 ARE PROVIDED TO EACH MEMBER OF THE BOARD OF TRUSTEES PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES SHALL BE SUBMITTED TO THE PRESIDENT OR HIS DESIGNEE BY DECEMBER 1ST, PRIOR TO THE BEGINNING OF EACH CALENDAR YEAR. THE PRESIDENT OR HIS DESIGNEE SHALL, IN WRITING, ADVISE MEMBERS (TRUSTEES, SENIOR MANAGEMENT, DEPARTMENT MANAGERS AND PHYSICIANS) AND INDIVIDUALS ON THE MEDICAL EXECUTIVE COMMITTEE WHO ARE NOT MEMBERS, OF THE CONFLICT OF INTEREST POLICY AND REQUEST THAT EACH INDIVIDUAL COMPLETE AND SUBMIT TO THE PRESIDENT OR HIS DESIGNEE, A QUESTIONNAIRE OUTLINING ANY POSSIBLE CONFLICTS OF INTEREST OR INDICATING THAT NO SUCH CONFLICT OF INTEREST EXISTS. THE PRESIDENT OR HIS DESIGNEE SHALL REVIEW ALL CONFLICT OF INTEREST QUESTIONNAIRES AND AT LEAST ANNUALLY DISCLOSE TO THE EXECUTIVE COMMITTEE THE RESULTS OF THE QUESTIONNAIRES. AT LEAST ANNUALLY THE PRESIDENT OR HIS DESIGNEE SHALL REQUEST A COMMITTEE OF THE BOARD TO REVIEW STANDARD RELATIONSHIPS WITH LOCAL BANKS, INSURANCE FIRMS, VENDORS AND OTHER ENTITIES SERVING THE INSTITUTION TO ASSURE THAT THE RELATIONSHIP IS IN THE BEST INTEREST OF THE INSTITUTION AND IS OTHERWISE CONSISTENT WITH THE TERMS OF THE CONFLICT OF INTEREST POLICY. ANY MEMBER HAVING A POSSIBLE CONFLICT OF INTEREST ON ANY MATTER SHOULD NOT VOTE, USE HIS/HER PERSONAL INFLUENCE OR MAKE AN ADMINISTRATIVE DECISION ON THE MATTER, AND IN THE CASE OF A TRUSTEE, SHOULD NOT BE COUNTED IN DETERMINING THE QUORUM FOR THE ACTION OF THE MATTER. THE MINUTES OF THE MEETING SHOULD REFLECT THAT A FULL AND ACCURATE DISCLOSURE WAS MADE, THAT THE MEMBER ABSTAINED FROM VOTING OR DECISION MAKING AND THE QUORUM OTHERWISE PRESENT. THE CONFLICT OF INTEREST POLICY SHALL BE REVIEWED ANNUALLY BY THE MEMBERS AND EACH NEW MEMBER SHALL BE ADVISED OF THE POLICY PRIOR TO THE INDIVIDUAL'S SELECTION AS A MEMBER, AND SHALL BE REQUIRED TO FILE WITHIN 30 DAYS THEREAFTER A COMPLETED QUESTIONNAIRE. FORM 990, PART VI, SECTION B, LINE 15 THE STANDING COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE FILING ORGANIZATION IS EMPOWERED TO REVIEW AND APPROVE ALL MATTERS PERTAINING TO COMPENSATION AND SHALL REPORT ALL ACTIONS TAKEN BY IT ON THESE MATTERS TO THE BOARD OF TRUSTEES. ANNUALLY, THE COMPENSATION COMMITTEE ENGAGES AN INDEPENDENT COMPENSATION CONSULTING FIRM TO PREPARE AN EXECUTIVE COMPENSATION ANALYSIS WHICH INCLUDES A COMPETITIVE ASSESSMENT OF THE TOTAL COMPENSATION PROGRAM FOR THE ORGANIZATION'S EXECUTIVE POSITIONS (CEO, CFO AND VICE PRESIDENTS) FOR REVIEW BY THE COMPENSATION COMMITTEE. THE MINUTES OF THE COMPENSATION COMMITTEE REFLECT THE DELIBERATIONS AND DECISIONS OF THE COMMITTEE. THIS SECTION IS ANSWERED NO DUE TO THE FACT THAT THE CEO AND OTHER OFFICERS' COMPENSATION IS PAID DIRECTLY BY BROCKTON HOSPITAL. FORM 990, PART VI, SECTION C, LINE 18 FORM 990 IS AVAILABLE FOR PUBLIC INSPECTION ON THE MASSACHUSETTS ATTORNEY GENERAL'S WEBSITE LOCATED AT WWW.MASS.GOV AND UPON REQUEST. FORM 990, PART VI, SECTION C, LINE 19 THE ARTICLES OF ORGANIZATION ARE OPEN TO THE PUBLIC ON THE MASSACHUSETTS SECRETARY OF STATE'S WEBSITE AND THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE AVAILABLE ON THE MASSACHUSETTS ATTORNEY GENERAL'S WEBSITE. PART IX, LINE 24E: ALL OTHER EXPENSES MISCELLANEOUS: $52,178 FORM 990, PART XI, LINE 9: TRANSFERS TO FROM AFFILIATES 270,148. INVESTMENT INCOME 157,583. NET ASSETS RELEASED FROM RESTRICTION -1,320,917. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE STREET BROCKTON MA 02302 320048951 REALTY COMPANY MA 0 0 SIGNATURE HEALTHCARE CORPORATION BROCKTON HOSPITAL INC 680 CENTRE STREET BROCKTON MA 02302 222472997 HOSPITAL MA 501(C)(3) 3 SIGNATURE HEALTHCARE CORPORATION 1 SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE STREET BROCKTON MA 02302 043306782 PHYSICIAN PRACTICES MA 501(C)(3) 10 SIGNATURE HEALTHCARE CORPORATION 1 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE STREET BROCKTON MA 02302 042530255 PHYSICIAN PRACTICE MA SIGNATURE HEALTHCARE CORPORATION C 1.00000 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 1 1 1 1 BROCKTON HOSPITAL INC I 7643 FMV BROCKTON HOSPITAL INC M 647174 FMV BROCKTON HOSPITAL INC P 1490 FMV BROCKTON HOSPITAL INC R 554172 FMV BROCKTON HOSPITAL INC S 413619 FMV BROCKTON HOSPITAL INC Q 4081 FMV SIGNATURE HEALTHCARE MEDICAL GROUP INC J 234900 FMV