2017-11-07T08:31:29-06:00 2016-12-31 990 2016-01-01 010409788 COMMUNITY CLINICAL SERVICESINC COMM 2077778546 CAMPUS AVE PO BOX 7291 LEWISTON ME 042407291 JOAN CHURCHILL EXECUTIVE DIRECTOR/CFO 2077778546 2017-11-07 155.212.6.161 2017-11-07 09:31:16 ES P 7EA5F91826FDEC39AFBB39687538FEB01BFA2691 E1A65C102B06E5C9ADAF8DC78101520DB9B2CC9D 2016 2018-03-14 21:41:22Z JOAN CHURCHILL 57 BIRCH ST SUITE 201 LEWISTON ME 042407291 15811752 0 X WWW.COMMUNITYCLINICALSERVICES.COM X 1984 ME PRIMARY AND SPECIALTY HEALTHCARE TO ALL RESIDENTS. 16 11 173 0 0 0 2155660 2241901 12837168 13558506 8914 11345 0 0 15001742 15811752 0 0 0 0 11940016 12372589 0 0 0 3038246 3306446 14978262 15679035 23480 132717 2927466 2830166 1864687 1634344 1062779 1195822 COMMUNITY CLINICAL SERVICES, INC. IS A NOT-FOR-PROFIT, FEDERALLY QUALIFIED HEALTH CENTER, WHICH PROVIDES PRIMARY AND SPECIALTY HEALTHCARE SERVICES TO RESIDENTS IN THE SURROUNDING COMMUNITY REGARDLESS OF THE ABILITY TO PAY. 0 0 7172281 5711804 BEHAVIORAL MEDICINE: PSYCHIATRIC CARE FOR CHILDREN AND ADULTS. 2016 VISITS - 39,599 3765353 3453439 FAMILY PRACTICE: MEDICAL CARE FOR INFANTS, CHILDREN, AND ADULTS. 2016 VISITS - 19,589 1282456 1988042 OUTPATIENT COUNSELING: COUNSELING SERVICES FOR CHILDREN AND ADULTS. 2016 VISITS - 16,681 2627055 2405221 2627055 2405221 14847145 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 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 0 0 0 1 0 0 173 1 0 0 0 0 0 0 0 0 X 16 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 ME X X MICHAEL HENDRIX 2077778546 96 CAMPUS AVENUE PO BOX 7291 LEWISTON ME 042407291 ABDIFATAH AHMED DIRECTOR 3.00 X 0 0 0 BARBARA RANKINS TERMED 62016 DIRECTOR 2.00 X 0 0 0 BRADELY EDWARDS DIRECTOR 2.00 X 0 0 0 CAROLE MOREAU SECRETARY 2.00 X X 0 0 0 ELIZABETH KEENE DIRECTOR 2.00 38.00 X 0 126247 9667 ELMUATZ ABDELRAHIM DIRECTOR 2.00 X 0 0 0 FOWSIA MUSSE DIRECTOR 2.00 X 0 0 0 MELISSA DUNN CHAIR 2.00 X X 0 0 0 RENE DUMONT DIRECTOR 2.00 38.00 X 0 209279 28515 ROBERT GAGNON VICE CHAIR 2.00 X X 0 0 0 SALLY BELISLE DIRECTOR 2.00 X X 0 0 0 SUSAN KEILER TERM 32106 SECRETARY 2.00 38.00 X X 0 0 0 ZAMZAM MOHAMUD TERM 62016 DIRECTOR 2.00 X 0 0 0 LAURA PETERSON DIRECTOR 2.00 X 0 0 0 PAIGE HAGERSTROM DIRECTOR 2.00 38.00 X 0 121894 7653 CAROLYN KASABIAN TREASURER 2.00 38.00 X 0 262122 12429 JOAN CHURCHILL CFO/CEO 40.00 X 89300 0 8619 SYED FAHD PHYSICIAN 40.00 X 356695 0 23403 KEVIN KAVOOKJIAN PHYSICIAN 40.00 X 399935 0 25779 MICHAEL KELLEY PHYSICIAN 40.00 X 489312 0 23290 THADDEUS SHATTUCK PHYSICIAN 40.00 X 471109 0 25185 SCOTT TREWORGY PHYSICIAN 40.00 X 419967 0 22199 2226318 719542 186739 34 0 1 0 ST MARY'S REGIONAL MEDICAL CENTER PO BOX 7291 CAMPUS AVE LEWISTON ME 042430291 PURCHASED SERVICES 1267896 BARTON ASSOCIATES INC PO BOX 417844 BOSTON MA 022417844 PEDIATRIC LOCUM 193586 2 1903004 212694 126203 2241901 NET PATIENT SERVICES REVENUE 621110 11621395 11621395 OTHER PROGRAM SERVICES REVENUE 621110 1368061 1368061 MEDICAL DIRECTOR REVENUE 621110 569050 569050 13558506 11345 11345 15811752 13558506 0 11345 11011606 10819783 191823 56316 55432 884 650778 418450 232328 653889 643427 10462 2816 2816 17700 17700 304699 300549 4150 126862 125549 1313 58215 21295 36920 187537 92624 94913 PURCHASED SERVICES 1379297 1179625 199672 OUTSIDE LABOR 793554 793453 101 MINOR EQUIPMENT 105048 105048 0 SUPPLIES 97865 67646 30219 232853 224264 8589 15679035 14847145 831890 0 810895 631544 1199714 1239692 1610 82475 29988 746861 516149 280101 230712 552671 698230 2927466 2830166 1820980 1588938 43707 45406 1864687 1634344 X 1035951 1044413 26828 151409 1062779 1195822 2927466 2830166 X 132717 -248 574 X 0 1 X 1 0 X 3143641 2324833 2894589 2155660 2241901 12760624 8996437 10366097 9881443 12837168 13558506 55639651 12140078 12690930 12776032 14992828 15800407 68400275 0 0 0 68400275 44 1082 4968 8914 11345 26353 44 1082 4968 8914 11345 26353 12140122 12692012 12781000 15001742 15811752 68426628 0.99960 0.99980 0.00040 0.00020 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 125 125 0 PART II-B, LINE 1: COMMUNITY CLINCAL SERVICES IS A MEMBER OF THE MAINE PRIMARY CARE ASSOCIATION AND A PORTION OF THE DUES PAID IN THE AMOUNT OF $125.00 IS USED FOR LOBBYING. 26828 126205 1624 151409 52215 19735 45122 26828 56576 40092 44452 52215 1601 55000 25 56576 14101 2500 15000 1601 1.00000 0 0 47090 15219 31871 5200 5200 0 694571 495730 198841 230712 DUE TO RESTRICTED FUNDS 151409 BOARD DESIGNATED FUNDS 535633 DUE FROM SMHS 2472187 DUE TO SMRMC -2308232 DUE TO RESIDENCES -152767 698230 DUE TO THIRD PARTY PAYORS 45406 45406 X 13782545 2086 -462 1624 13780921 2030831 2030831 15811752 15679035 0 15679035 0 15679035 PART X, LINE 2: CCS IS CONSIDERED A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS 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. CCS HAS EVALUATED THE POSITIONS TAKEN ON ITS FILED TAX RETURNS. CCS HAS CONCLUDED NO UNCERTAIN INCOME TAX POSITIONS EXIST AT DECEMBER 31, 2016. CCS'S TAX YEARS FROM 2013 THROUGH 2016 ARE OPEN AND SUBJECT TO EXAMINATION. PART XI, LINE 2D - OTHER ADJUSTMENTS: TRANSFERS TO AFFILIATES -462. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS-RESTRICTED 614. COMMUNITY SUPPORT GRANT 1,903,004. GRANT DONATION-RESTRICTED 125,589. NET ASSETS RELEASED FOR PPE 1,624. X X 0 0 0 0 0 0 0 1 0 RENE DUMONT DIRECTOR 0 185279 0 0 0 24000 0 2117 0 26398 0 237794 0 0 CAROLYN KASABIAN TREASURER 0 238482 0 0 0 23640 0 2627 0 9802 0 274551 0 0 SYED FAHD PHYSICIAN 181995 0 156700 0 18000 0 2507 0 20896 0 380098 0 0 0 KEVIN KAVOOKJIAN PHYSICIAN 298110 0 83825 0 18000 0 2553 0 23226 0 425714 0 0 0 MICHAEL KELLEY PHYSICIAN 404652 0 72550 0 12110 0 2610 0 20680 0 512602 0 0 0 THADDEUS SHATTUCK PHYSICIAN 221010 0 232099 0 18000 0 1823 0 23362 0 496294 0 0 0 SCOTT TREWORGY PHYSICIAN 300786 0 95181 0 24000 0 2620 0 19579 0 442166 0 0 0 PART I, LINE 7 IN CONJUNCTION WITH COVENANT HEALTH THE ORGANIZATION MAINTAINS AN INCENTIVE COMPENSATION PLAN FOR EXECUTIVES THAT IS ADMINISTERED BY COVENANT HEALTH'S COMPENSATION COMMITTEE. THE PLAN PROVIDES EXECUTIVES WITH THE OPPORTUNITY TO EARN REASONABLE INCENTIVE COMPENSATION BASED ON THE PERFORMANCE OF THE INDIVIDUAL EXECUTIVE, AS MEASURED AGAINST GOALS THAT ARE SET AT THE BEGINNING OF THE YEAR. FORM 990, PART VI, SECTION A, LINE 6 ST. MARY'S HEALTH SYSTEM (SMHS) IS THE SOLE CORPORATE MEMBER WITH LIMITED RESERVE POWER. FORM 990, PART VI, SECTION A, LINE 7A THE ORGANIZATION HAS MEMBERS THAT CAN ELECT OTHER MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL OF THE MEMBERS IS REQUIRED FOR THE DISOLUTION OR MERGER OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 IS PROVIDED TO THE BOARD MEMBERS AND REVIEWED AT THE OCTOBER 2017 MEETING. FORM 990, PART VI, SECTION B, LINE 12C THIS PROCESS IS THE RESPONSIBILITY OF ORGANIZATIONAL INTEGRITY OFFICER. A FORM IS USUALLY SUBMITTED TO ALL BOARD MEMBERS, BOARD COMMITTEE MEMBERS, AND CERTAIN EMPLOYEES IN KEY POSITIONS ANNUALLY TO BE COMPLETED. REMINDERS ARE USUALLY SENT TO MAKE CERTAIN ALL CONFLICT OF INTEREST FORMS ARE RETURNED. FORM 990, PART VI, SECTION B, LINE 15 AN EXTERNAL COMPENSATION FIRM DOES A COMPENSATION SURVEY FOR THE EXECUTIVE DIRECTOR POSITION AND THE COMPENSATION PACKAGE IS REVIEWED BY THE BOARD. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION PROVIDES FORM 1023 AND FORM 990 TO THE PUBLIC WHEN REQUESTED. THE ORGANIZATION DOES NOT CURRENTLY PROVIDE ACCESS TO GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS. FORM 990, PART XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTION 1,624. INTERCOMPANY TRANSFERS -1,050. ST MARY'S HEALTH SYSTEMS POBOX 7291 CAMPUS AVE LEWISTON ME 042437291 222504349 PARENT COMPANY ME 501(C)3 11A COVENANT HEALTH INC 0 ST MARY'S REGIONAL MEDICAL CENTER POBOX 7291 CAMPUS AVE LEWISTON ME 042430291 010211551 HOSPITAL ME 501(C)3 3 ST MARY'S HEALTH SYSTEM 0 ST MARY'S RESIDENCES POBOX 7291 CAMPUS AVE LEWISTON ME 042437291 222504356 LOW-INCOME HOUSING ME 501(C)3 9 ST MARY'S HEALTH SYSTEM 0 COVENANT HEALTH INC 100 AMES POND DRIVE TEWKSBURY MA 01876 222484505 HEALTHCARE MANAGEMENT AND RESOURCE ADMINISTRATION MA 501(C)3 9 0 CAMPUS HOLDING PO BOX 7291 LEWISTON ME 04240 010406049 HOLDING COMPANY ME N/A C 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 1