2019-08-08T00:56:28-05:00 2018-09-30 861065772 DELOITTE TAX LLP TWO JERICHO PLAZA JERICHO NY 11753 990 2017-10-01 042103554 SIGNATURE HEALTHCARE CORPORATION INC SIGN 5089417000 680 CENTRE STREET BROCKTON MA 02302 KIM HOLLON PRESIDENT/CEO 5089417000 2019-08-07 1 CHRISTINE KAWECKI P00743140 5169187000 183.83.70.163 2019-08-07 06:47:26 US P 9D77D5089F6CFDFA10E33FA204CA8B8BB51CC565 0E4C15207DC127BDB52450F77D4060F40C3F1AE4 2017 2019-02-21 02:37:17Z SIGNATURE HEALTHCARE KIM HOLLON 680 CENTRE STREET BROCKTON MA 02302 21130474 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. 20 16 0 130 0 0 2483350 2324859 654288 651231 66250 515302 -92792 -41276 3111096 3450116 0 0 0 0 0 0 72900 57614 658796 801901 843337 874801 900951 2236295 2549165 10504882 11297502 30509 0 10474373 11297502 X SEE SCHEDULE O 0 0 143504 651231 SOLICIT, RECEIVE, INVEST AND HOLD CONTRIBUTIONS RECEIVED FROM ANY AND ALL SOURCES FOR THE BENEFIT OF ITS NON-PROFIT AFFILIATE BROCKTON HOSPITAL, INC. 143504 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 1 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 20 16 1 0 0 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 JAMES LEARY CHAIRMAN 1.00 1.00 X X 0 0 0 JOSEPH DRIER III VICE CHAIRMAN 1.00 1.00 X X 0 0 0 KIM N HOLLON PRESIDENT/CEO 1.00 41.00 X X 0 697581 27891 TIMOTHY CRUZ TRUSTEE 1.00 1.00 X 0 0 0 MICHAEL L DERN MD TRUSTEE 1.00 41.00 X 0 506345 29758 DAVID DRINKWATER MD PHYSICIAN ELECT 1.00 41.00 X 0 534634 29334 DAVID F ENGELKEMEYER TRUSTEE (START 12/12/2017) 1.00 0.00 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 303199 10360 REV CHERYL HARRIS TRUSTEE 1.00 1.00 X 0 0 0 STEVEN LANE MD PRES MEDICAL STAFF (START 1/22/2018) 1.00 1.00 X 0 0 0 EUGENE MARROW TRUSTEE 1.00 1.00 X 0 0 0 CHERYL MCCALLION MD PRES MEDICAL STAFF (END 1/22/2018) 1.00 1.00 X 0 0 0 FRED NICCOLI CHAIRMAN BH FOUNDATION 1.00 1.00 X 0 0 0 DAVID M OFFUTT TRUSTEE (START 1/26/2017) 1.00 0.00 X 0 0 0 WALLACE PECKHAM III TRUSTEE 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 JAMES PAPADAKOS CFO/TREASURER 1.00 41.00 X 0 360753 24119 0 2402512 121462 0 0 1 0 0 324243 2000616 42038 2324859 RENT FROM AFFILIATES 900099 651231 651231 651231 65760 65760 109231 0 109231 109231 109231 17931289 17481747 449542 449542 449542 48104 324243 198611 -150507 -150507 3450116 651231 0 474026 X 57614 57614 82845 59648 23197 FUNDRAISING EXPENSES 601182 601182 TRANSPORTATION EXPENSES 47936 47936 ADMINSTRATIVE EXPENSES 33993 24475 9518 SCHOLARSHIP EXPENSES 18000 18000 59381 59381 900951 143504 98651 658796 21146 41025 1077185 1782234 3270221 3209414 4499806 1973547 2612393 2526259 3523937 3738570 10504882 11297502 9787 0 20722 30509 0 X 5936996 5997092 2942435 3680468 1594942 1619942 10474373 11297502 10504882 11297502 X 2549165 -45212 -515303 -1165521 X 0 1 X 1 0 X X 2 BROCKTON HOSPITAL INC 222472997 3 1 165616 0 SIGNATURE HEALTHCARE MEDICAL GROUP INC 043306782 10 0 234900 0 2 400516 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: THE 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: THE MEMBERSHIP COMPOSITION OF THE BOARD OF TRUSTEES (BOT) FOR SIGNATURE HEALTHCARE CORPORATION (SHC) AND ITS NON-PROFIT AFFILIATE BROCKTON HOSPITAL, INC. ARE THE SAME BUT DIFFERS FROM THE BOT OF IT'S NON-PROFIT AFFILIATE, SIGNATURE HEALTHCARE MEDICAL GROUP, INC. (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 BOARD OF DIRECTORS FOR SMG. SUBJECT TO THE RIGHTS OF SHC THE SMG BOARD OF DIRECTORS 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. 4502193 25000 190715 4717908 4090994 411199 4502193 3763490 1539 325965 0 0 0 4090994 4017169 82461 -288537 0 47603 0 3763490 3742703 82000 192466 0 0 0 4017169 0.00000 0.74000 0.26000 1 1 1 1069674 1069674 3042193 1589807 1452386 387939 383740 4199 2526259 BOARD-DESIGNATED INVESTMENTS 197960 F DONOR-RESTRICTED INVESTMENTS 3540610 F 3738570 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 1 SUNNY STICH CONSULTING 8 MARSHALL AVENUE NATICK MA 01760 GRANT WRITING SERVICES 0 0 34535 -34535 BLACKBAUD SYSTEMS INC 2000 DANIEL ISLAND DRIVE CHARLESTON SC 29492 ANALYSIS OF CONTRIBUTORS 0 0 17579 -17579 CRESCENDO INTERACTIVE INC 110 CAMINO RUIZ CAMARIELO CA 93012 PLANNED GROUP SERVICES 0 0 5500 -5500 57614 -57614 MA RING OF CHAMPIONS 55534 42277 13257 675 14406 450 18951 CANCER WALK 203967 193602 10365 20061 0 107764 1 112846 88364 24482 8674 15500 12130 372347 324243 48104 29410 29906 450 138845 198611 -150507 X X X X X 0 1 0 0 0 0 0 0 0 KIM N HOLLON PRESIDENT/CEO 0 604714 0 71066 0 21801 0 0 0 27891 0 725472 0 0 MICHAEL L DERN MD TRUSTEE 0 500945 0 0 0 5400 0 424 0 29334 0 536103 0 0 DAVID DRINKWATER MD PHYSICIAN ELECT 0 531341 0 0 0 3293 0 0 0 29334 0 563968 0 0 ROBERT S GREENBERG MD TRUSTEE 0 297799 0 0 0 5400 0 196 0 10164 0 313559 0 0 JAMES PAPADAKOS CFO/TREASURER 0 342475 0 0 0 18278 0 0 0 24119 0 384872 0 0 PART I, LINE 4B DURING THE YEAR ENDED 12/31/2017 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 196 40288 OTHER X GIFT CARDS 13 1750 OTHER 0 0 1 0 PART I, COLUMN (B): THE ORGANIZATION IS REPORTING BASED ON THE NUMBER OF ITEMS RECEIVED. 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, CHERYL MCCALLION, FRED NICCOLI, ROBERT S. GREENBERG, M.D., DAVID DRINKWATER, M.D., KIM N. HOLLON, MICHAEL L. DERN, M.D., JAMES PAPADAKOS, DAVID ENGELKEMEYER, DAVID OFFUTT, AND STEVEN LANE HAVE A BUSINESS RELATIONSHIP WITH EACH OTHER AS THEY ARE ALSO TRUSTEES OF BROCKTON HOSPITAL, INC. 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. 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: $59,381 FORM 990, PART XI, LINE 9: TRANSFERS (TO) FROM AFFILIATES -69,285. INVESTMENT INCOME 174,038. NET ASSETS RELEASED FROM RESTRICTIONS -1,270,274. 110 LIBERTY STREET REALTY COMPANY LLC 680 CENTRE ST BROCKTON MA 02302 320048951 REALTY COMPANY MA 0 0 SIGNATURE HEALTHCARE CORPORATION BROCKTON HOSPITAL INC 680 CENTRE ST BROCKTON MA 02302 222472997 HOSPITAL MA 501(C)(3) 3 SIGNATURE HEALTHCARE CORPORATION 1 SIGNATURE HEALTHCARE MEDICAL GROUP INC 680 CENTRE ST BROCKTON MA 02302 043306782 PHYSICIAN PRACTICES MA 501(C)(3) 10 SIGNATURE HEALTHCARE CORPORATION 1 BRIDGEWATER GODDARD PARK MEDICAL ASSOCIATES 680 CENTRE ST BROCKTON MA 02302 042530255 PHYSICIAN PRACTICE MA SIGNATURE HEALTHCARE CORPORATION C 1.00000 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1 1 1 1 BROCKTON HOSPITAL INC J 420000 FMV BROCKTON HOSPITAL INC M -687914 FMV BROCKTON HOSPITAL INC P -11099 FMV BROCKTON HOSPITAL INC R 506313 FMV BROCKTON HOSPITAL INC S -362147 FMV BROCKTON HOSPITAL INC Q -30769 FMV SIGNATURE HEALTHCARE MEDICAL GROUP INC J 234900 FMV