2019-08-12T16:55:26-05:00 2018-09-30 BKD LLP 910 E ST LOUIS 200/PO BOX 1190 SPRINGFIELD MO 658062523 990 2017-10-01 222570334 NORTH COUNTRY HEALTH SERVICES INC % ANDRE BISSONNETTE NORT 8027662201 189 PROUTY DRIVE NEWPORT VT 05855 ANDRE BISSONNETTE CFO 2019-08-15 true Brian D Todd P00422601 4178658701 167.68.126.162 43032920192245000037 2019-08-12 P A07EE01C807EDE64C0F4BB6FE60B819990AE8C34 AE6E5E46D41BC60DF08B4BEE75B34EFCBA1C7A6F 2017 2019-02-21 02:37:17Z DERBY GREEN DONALD LYNCH AND BRIAN NALL 189 PROUTY DRIVE NEWPORT VT 05855 1858457 false X WWW.NCHSI.ORG X 1984 VT NORTH COUNTRY HEALTH SERVICES IS A NOT-FOR-PROFIT CORPORATION THAT PROVIDES HEALTH CARE SERVICES TO NURSING FACILITY PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 15 11 64 14 0 0 502 984 1723403 1802979 17904 22838 0 0 1741809 1826801 0 0 0 0 1378934 1563874 0 0 0 481640 459040 1860574 2022914 -118765 -196113 1187883 1205963 599126 798216 588757 407747 X NORTH COUNTRY HEALTH SERVICES IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF FACILITY RESIDENTS. false false 1371801 1546951 THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2018, THE ORGANIZATION HAD 7,027 MEDICAID PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 207366 228186 THE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 15951 24459 THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2018, THE ORGANIZATION HAD 111 MEDICARE PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 1595118 true false false true false false false false true false true false false false true false false true false false false false false false false false false false false true false false false false false false false false false false false false false true false false false true 9 0 true 64 true false false false false false false false false false false X 15 11 false false false false true true true true true false false true true true true true true false false false X ANDRE BISSONNETTE 8023347331 189 PROUTY DRIVE NEWPORT VT 05855 X THOMAS MILNAMOW TRUSTEE 1.0 6.0 X 0 0 0 CLAUDIO FORT CEO 1.0 41.0 X X 0 340587 43837 KATHRYN AUSTIN CHAIR 1.0 11.0 X X 0 0 0 GARY GILLESPIE VICE CHAIR FINANCE 1.0 6.0 X X 0 0 0 MELISSA PETTERSSON SECRETARY/CLERK 1.0 6.0 X X 0 0 0 RICHARD BARAW TRUSTEE 1.0 6.0 X 0 0 0 MARK BEAMS VICE CHAIR - BOARD 1.0 6.0 X X 0 0 0 FRANK KNOLL TRUSTEE 1.0 6.0 X 0 0 0 CHRISTOPHER RICKMAN MD TRUSTEE/PHYSICIAN 1.0 41.0 X 0 369495 36885 HEIDI BROWN TRUSTEE 1.0 6.0 X 0 0 0 JANET OSBORNE TRUSTEE 1.0 6.0 X 0 0 0 MARIA FATIGATI MD MEDICAL STAFF PRES BEG 10/17 1.0 41.0 X X 0 275229 38901 BOB WILSON TRUSTEE 1.0 6.0 X 0 0 0 JIM BIERNAT TRUSTEE BEG 10/17 1.0 5.0 X 0 0 0 UMAR MALIK MD MEDICAL STAFF VP BEG 10/17 1.0 41.0 X X 0 346724 36747 ANDRE BISSONNETTE CHIEF FINANCIAL OFFICER 1.0 41.0 X 0 205858 38801 0 1537893 195171 0 false true false 0 984 984 NET PATIENT SERVICE REVENUE 624100 1778204 1778204 OTHER REVENUE 900099 24775 24775 1802979 7887 7887 0 0 0 0 0 46607 0 28273 3383 18334 -3383 14951 14951 0 0 0 0 0 0 0 0 0 0 1826801 1802979 22838 0 0 0 0 0 0 1050073 820756 229317 26368 20610 5758 400743 313228 87515 86690 67758 18932 1000 1000 0 20942 20942 0 0 6228 6228 58879 43012 15867 0 86476 69029 17447 8945 7140 1805 0 39873 31829 8044 2468 1970 498 0 0 13396 10693 2703 0 47395 37833 9562 8315 6637 1678 MEDICAID TAXES 113149 113149 MEDICAL SUPPLIES & DRUGS 44282 44282 BAD DEBT 5212 5212 LICENSES, DUES, SUBSCRIPTIONS 2480 1980 500 2022914 1595118 427796 0 600 183030 29075 176 0 0 143058 143951 0 0 0 0 0 0 100 100 23535 16419 1516879 1033915 515167 482964 476348 379323 0 0 0 0 0 0 0 0 1187883 1205963 76052 62283 0 0 0 0 0 0 599 176 0 0 342090 326392 0 0 180385 409365 599126 798216 X 588757 407747 0 0 0 0 588757 407747 1187883 1205963 -196113 15103 X false true X true false X 727 4568 161 502 984 6942 1585465 1628422 1697280 1723403 1802979 8437549 0 0 0 1586192 1632990 1697441 1723905 1803963 8444491 0 0 0 8444491 6470 6860 6727 6875 7887 34819 0 6470 6860 6727 6875 7887 34819 0 0 1592662 1639850 1704168 1730780 1811850 8479310 0.99589 0.99589 0.00411 0.00411 X false false false false false false false false true false SCHEDULE C, PART II-B, LINE 1(I) OTHER LOBBYING ACTIVITIES: THE ORGANIZATION PAYS DUES TO THE VERMONT HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING PURPOSES. false true X 30000 30000 1124549 782953 341596 311692 217800 93892 50638 33162 17476 482964 0 DUE TO AFFILIATE 409365 409365 1813185 -13616 -13616 1826801 1826801 2009298 2009298 13616 13616 2022914 SCHEDULE D, PART IV, LINE 2B TRUST, ESCROW, AND CUSTODIAL ACCOUNTS: THE ORGANIZATION MAINTAINS A "RESIDENT PERSONAL FUNDS PAYABLE" ACCOUNT. THIS ACCOUNT HOLDS PERSONAL FUNDS OF RESIDENTS IN AN INTEREST BEARING ACCOUNT AT A LOCAL BANK. IN ORDER TO ISSUE CHECKS FROM THE ACCOUNT, TWO SIGNATURES ARE REQUIRED. SCHEDULE D, PART X, LINE 2 UNCERTAIN TAX POSITIONS: MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. SCHEDULE D, PART XI, LINE 2D AMOUNTS INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12: $ (7,228) INVESTMENT MANAGEMENT FEES (1,176) EXPENSES PAID OUT OF GRANT FUNDS (5,212) BAD DEBT -------- $(13,616) SCHEDULE D, PART XII, LINE 4B AMOUNTS INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1: $ 7,228 INVESTMENT MANAGEMENT FEES 1,176 EXPENSES PAID OUT OF GRANT FUNDS 5,212 BAD DEBT -------- $ 13,616 false false false false false false false false false CLAUDIO FORT CEO 0 304423 0 36164 0 0 0 10698 0 33139 0 384424 0 0 CHRISTOPHER RICKMAN MD TRUSTEE/PHYSICIAN 0 322409 0 12744 0 34342 0 14465 0 22420 0 406380 0 0 MARIA FATIGATI MD MEDICAL STAFF PRES BEG 10/17 0 233774 0 20865 0 20590 0 8513 0 30388 0 314130 0 0 ANDRE BISSONNETTE CHIEF FINANCIAL OFFICER 0 184648 0 18318 0 2892 0 9934 0 28867 0 244659 0 0 UMAR MALIK MD MEDICAL STAFF VP BEG 10/17 0 315332 0 18151 0 13241 0 6139 0 30608 0 383471 0 0 SCHEDULE J, PART I, LINE 3 COMPENSATION DETERMINATION: NORTH COUNTRY HOSPITAL, A RELATED ORGANIZATION, USES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD IN DETERMINING THE COMPENSATION OF THE CEO. FORM 990, PART I, LINE 1 ORGANIZATION'S MISSION: NORTH COUNTRY HEALTH SERVICES, INC., IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF OUR FACILITY RESIDENTS. THE CENTRAL PURPOSE OF THE CORPORATION IS TO SUPPORT AND OVERSEE THE OPERATION OF DERBY GREEN. DERBY GREEN IS A TWENTY-THREE BED FACILITY CERTIFIED BY MEDICARE/MEDICAID. NORTH COUNTRY HEALTH SERVICES, INC., HAS A FURTHER COMMITMENT TO ASSIST COMMUNITY MEMBERS IN THE MAINTENANCE AND IMPROVEMENT OF THEIR OWN HEALTH. DERBY GREEN WILL OFFER OTHER PROGRAMS THAT WILL BE BENEFICIAL TO THE COMMUNITY AND IN THE BEST INTERESTS OF DERBY GREEN. IN RECOGNITION OF THE BURDEN THAT THE COSTS OF HEALTH CARE PLACES ON THE COMMUNITY, NORTH COUNTRY HEALTH SERVICES, INC., WILL PROVIDE QUALITY HEALTH CARE WHILE EVERY EFFORT WILL BE MADE TO CONTAIN COSTS. FORM 990, PART III, LINES 4A-4C PROGRAM SERVICES: THE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. DERBY GREEN PROVIDES A FULL RANGE OF HEALTH CARE SERVICES AND IS COMMITTED TO PROVIDING EXCELLENT HEALTHCARE IN A KIND AND CARING ENVIRONMENT. DERBY GREEN IS A PROGRESSIVE NURSING FACILITY WITH CARING STAFF WHO WILL STRIVE TO MEET THE INDIVIDUAL NEEDS OF EACH RESIDENT. SERVICES PROVIDED INCLUDE: -24-HOUR NURSING CARE AND ON-CALL PHYSICIAN, -LAUNDRY, SOCIAL, PODIATRY, AND BEAUTICIAN SERVICES, -PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY IN ADDITION, RECREATIONAL, RELIGIOUS, AND SOCIAL EVENTS ARE AVAILABLE TO ALL RESIDENTS. INDIVIDUAL AND GROUP ACTIVITIES SUCH AS BINGO, CHURCH SERVICES, MOVIES, SEASONAL PARTIES, AND MUSICAL ENTERTAINMENT ARE ROUTINELY OFFERED. REALITY ORIENTATION AND STIMULATION IS DIRECTED THROUGH THE LIFE ENHANCEMENT PROGRAM. SPECIAL OUTINGS MAY INCLUDE PICNICS IN THE PARK, BARBEQUES, AND SCENIC RIDES IN THE WHEELCHAIR LIFT EQUIPPED VAN. IN-ROOM CABLE AND PHONE SERVICE IN AVAILABLE. FORM 990, PART VI, SECTION A, LINE 6, 7A, & 7B MEMBERS OF THE ORGANIZATION: THE SOLE MEMBER OF THE CORPORATION SHALL BE NORTH COUNTRY HEALTH SYSTEMS, INC., A VERMONT NOT-FOR-PROFIT CORPORATION, ACTING THROUGH ITS BOARD OF TRUSTEES AND HEREINAFTER REFERRED TO AS THE MEMBER WHEN ACTING IN ITS CAPACITY AS SUCH. THE MEMBER SHALL HAVE THE EXCLUSIVE RIGHT TO ENJOY AND EXERCISE ALL RIGHTS AND POWERS CONFERRED ON MEMBERS OF NON-PROFIT CORPORATIONS UNDER THE LAWS OF THE STATE OF VERMONT. THE MEMBER SHALL HAVE SUCH OTHER POWERS AS ARE SPECIFIED IN THE ARTICLES OF ASSOCIATION AND IN THE BY-LAWS, INCLUDING, WITHOUT LIMITATION, THE POWER TO ELECT AND REMOVE TRUSTEES AND TO AMEND AND RESTATE THE ARTICLES OF ASSOCIATION. THE AUTHORITY OF THE BOARD OF TRUSTEES TO EXERCISE THE POWERS LISTED IN THE BYLAWS IS CONDITIONED ON THE PRIOR APPROVAL OF THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11B REVIEW OF THE FORM 990: THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S MANAGEMENT AND FINANCE TEAM IN DETAIL. AFTER IT HAS BEEN REVIEWED, IT IS THEN PROVIDED TO THE FULL BOARD. FORM 990, PART VI, SECTION B, LINE 12C MONITORING COMPLIANCE WITH CONFLICT OF INTEREST POLICY: IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE BOARD, COMMITTEE, OR OTHER INDIVIDUALS WHO, ON BEHALF OF THE CORPORATION, ARE CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. IN THE EVENT THAT A TRUSTEE, OFFICER, COMMITTEE MEMBER OR MEMBER OF THE CORPORATION'S LEADERSHIP GROUP BECOMES CONCERNED THAT ANOTHER INTERESTED PERSON HAS AN UNDISCLOSED FINANCIAL INTEREST OR IS EXERTING INAPPROPRIATE INFLUENCE RELATED TO A FINANCIAL INTEREST, THIS CONCERN SHOULD BE RAISED WITH THE CHAIR OF THE APPROPRIATE BOARD OR COMMITTEE OR, IF INVOLVING THE LEADERSHIP GROUP, AN APPROPRIATE CORPORATE OFFICER. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD OR COMMITTEE MEMBERS. IT SHALL BE THE RESPONSIBILITY OF THE CHAIR OF THE BOARD OR COMMITTEE TO INSTRUCT AN INTERESTED PERSON ON THE RESTRICTIONS ON HIS OR HER PARTICIPATION PURSUANT TO THIS POLICY IN ANY FURTHER CONSIDERATION OF THE SUBJECT MATTER OF THE CONFLICT OF INTEREST AND TO ENFORCE THESE RESTRICTIONS. AWARENESS/COMPLIANCE WITH POLICY EACH INTERESTED PERSON SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT, IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. EACH INTERESTED PERSON SHALL DISCLOSE ON AN ANNUAL SURVEY FORM POTENTIAL CONFLICTS OF INTEREST AND FINANCIAL INTERESTS RELEVANT TO THIS POLICY. EACH INTERESTED PERSON SHALL ALSO PROVIDE ON AN ANNUAL SURVEY FORM A LIST OF IMMEDIATE FAMILY MEMBERS, INCLUDING SPOUSE, CHILDREN, GRANDCHILDREN, PARENTS, SIBLINGS AND ANY OTHER PERSON WHO LIVES IN HIS/HER HOUSEHOLD, IN ORDER THAT THE CORPORATION MAY HAVE A RECORD OF ALL INDIVIDUALS WHO MAY BE CONSIDERED DISQUALIFIED PERSONS UNDER INTERNAL REVENUE SERVICE REGULATIONS FOR THE PURPOSE OF ENSURING COMPLIANCE WITH TAX EXEMPT STATUS REQUIREMENTS FOR CHARITABLE ORGANIZATIONS. PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT INVOLVES THE CONFLICT OF INTEREST. THE CHAIR OF THE BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, INCLUDING A CONSIDERATION OF INDEPENDENT COMPARABILITY DATA, VALUATIONS OR APPRAISALS, THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE (OR QUORUM) OF ALL OF THE DISINTERESTED TRUSTEES OR COMMITTEE MEMBERS (REGARDLESS OF THE NUMBER PRESENT AT A MEETING): (I) WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST AND FOR ITS OWN BENEFIT, (II) WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, AND (III) WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATIONS. FORM 990, PART VI, SECTION B, LINE 15A COMPENSATION REVIEW: THE BOARD OF NORTH COUNTRY HOSPITAL & HEALTH CENTER, A RELATED ORGANIZATION, ANNUALLY REVIEWS THE CEO AND SENIOR TEAM SALARIES USING COMPARABILITY DATA. THE REVIEW PROCESS IS DOCUMENTED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENT DISCLOSURE: THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO BE VIEWED BY THE PUBLIC UPON AN APPOINTMENT WITH THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER OR ASSISTANT. FORM 990, PART VII, SECTION A COMPENSATION OF BOARD OF DIRECTORS: NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS SHARE A BOARD OF DIRECTORS. NO BOARD MEMBERS RECEIVE COMPENSATION FOR THEIR DUTIES AS DIRECTORS. CLAUDIO FORT, CEO, AND ANDRE BISSONNETTE, CHIEF FINANCIAL OFFICER, EACH WORK APPROXIMATELY 40 HOURS PER WEEK BETWEEN NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS. THEY ARE COMPENSATED FOR THEIR DUTIES IN THAT CAPACITY. CHRISTOPHER RICKMAN, MARIA FATIGATI AND UMAR MALIK ARE COMPENSATED AS EMPLOYEES OF NORTH COUNTRY HOSPITAL. THEY DO NOT RECEIVE ANY COMPENSATION FOR THEIR DUTIES AS BOARD OF DIRECTORS MEMBERS. NORTH COUNTRY HOSPITAL & HEALTH CENTER 189 PROUTY DRIVE NEWPORT VT 05855 030185556 HOSPITAL VT 501(C)(3) 3 NCHS false NORTH COUNTRY HEALTH SYSTEMS 189 PROUTY DRIVE NEWPORT VT 05855 222566964 PARENT/FUNDRS VT 501(C)(3) 12B II NA false false false false false false false false false false false false false true true true true false false false