NORTH COUNTRY HEALTH SERVICES INC: Form 990, tax year 2015

View the entire original 990 at ProPublica ↗

Organization
NORTH COUNTRY HEALTH SERVICES INC (EIN 22-2570334)
Tax period
2015-10-01 to 2016-09-30
Filed
2017-08-11
IRS object ID
201702239349300720
Schema version
2015v3.0
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2017-08-11T09:42:22-05:00ReturnTs
Tax Period End2016-09-30TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1BKD LLPBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line1910 E ST LOUIS 200/PO BOX 1190AddressLine1Txt
CitySPRINGFIELDCityNm
State AbbreviationMOStateAbbreviationCd
ZIP658062523ZIPCd
FieldValueIRS element (for citing)
Return Type990ReturnTypeCd
Tax Period Begin2015-10-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN222570334EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1NORTH COUNTRY HEALTH SERVICES INCBusinessNameLine1Txt
FieldValueIRS element (for citing)
In Care Of% ANDRE BISSONNETTEInCareOfNm
Business Name ControlNORTBusinessNameControlTxt
Phone8027662201PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line1189 PROUTY DRIVEAddressLine1Txt
CityNEWPORTCityNm
State AbbreviationVTStateAbbreviationCd
ZIP05855ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonANDRE BISSONNETTEPersonNm
Person TitleCFOPersonTitleTxt
Signature2017-04-24SignatureDt
Discuss With Paid PreparerYes (true)DiscussWithPaidPreparerInd

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonBrian D ToddPreparerPersonNm
PTINP00422601PTIN
Phone4178658701PhoneNum
FieldValueIRS element (for citing)
Tax2015TaxYr
Build TS2021-01-29 14:40:06ZBuildTS

Form 990 IRS990

Doing Business As Name DoingBusinessAsName

FieldValueIRS element (for citing)
Business Name Line1DERBY GREENBusinessNameLine1Txt
FieldValueIRS element (for citing)
Principal OfficerLISA BOHLMAN AND CLAUDIO FORTPrincipalOfficerNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line1189 PROUTY DRIVEAddressLine1Txt
CityNEWPORTCityNm
State AbbreviationVTStateAbbreviationCd
ZIP05855ZIPCd
FieldValueIRS element (for citing)
Gross Receipts$1,754,414GrossReceiptsAmt
Group Return For AffiliatesfalseGroupReturnForAffiliatesInd
Organization501c3Yes (X)Organization501c3Ind
Website AddressWWW.NCHSI.ORGWebsiteAddressTxt
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Formation1984FormationYr
Legal Domicile StateVTLegalDomicileStateCd
Activity Or MissionNORTH COUNTRY HEALTH SERVICES IS A NOT- FOR-PROFIT CORPORATION THAT PROVIDES HEALTH CARE SERVICES TO NURSING FACILITY PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION.ActivityOrMissionDesc
Voting Members Governing Body14VotingMembersGoverningBodyCnt
Voting Members Independent10VotingMembersIndependentCnt
Total Employee58TotalEmployeeCnt
Total Volunteers22TotalVolunteersCnt
Total Gross UBI$0TotalGrossUBIAmt
Net Unrelated Bus Txbl Incm$0NetUnrelatedBusTxblIncmAmt
PY Contributions Grants$4,568PYContributionsGrantsAmt
CY Contributions Grants$161CYContributionsGrantsAmt
PY Program Service Revenue$1,628,422PYProgramServiceRevenueAmt
CY Program Service Revenue$1,697,280CYProgramServiceRevenueAmt
PY Investment Income$17,453PYInvestmentIncomeAmt
CY Investment Income$2,683CYInvestmentIncomeAmt
PY Other Revenue$0PYOtherRevenueAmt
CY Other Revenue$0CYOtherRevenueAmt
PY Total Revenue$1,650,443PYTotalRevenueAmt
CY Total Revenue$1,700,124CYTotalRevenueAmt
PY Grants And Similar Paid$0PYGrantsAndSimilarPaidAmt
CY Grants And Similar Paid$0CYGrantsAndSimilarPaidAmt
PY Benefits Paid To Members$0PYBenefitsPaidToMembersAmt
CY Benefits Paid To Members$0CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid$1,119,751PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid$1,228,196CYSalariesCompEmpBnftPaidAmt
PY Total Prof Fndrsng Expns$0PYTotalProfFndrsngExpnsAmt
CY Total Prof Fndrsng Expns$0CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense$0CYTotalFundraisingExpenseAmt
PY Other Expenses$543,415PYOtherExpensesAmt
CY Other Expenses$636,200CYOtherExpensesAmt
PY Total Expenses$1,663,166PYTotalExpensesAmt
CY Total Expenses$1,864,396CYTotalExpensesAmt
PY Revenues Less Expenses-$12,723PYRevenuesLessExpensesAmt
CY Revenues Less Expenses-$164,272CYRevenuesLessExpensesAmt
Total Assets BOY$1,286,636TotalAssetsBOYAmt
Total Assets EOY$1,214,026TotalAssetsEOYAmt
Total Liabilities BOY$458,956TotalLiabilitiesBOYAmt
Total Liabilities EOY$525,560TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY$827,680NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY$688,466NetAssetsOrFundBalancesEOYAmt
Info In Schedule O Part IIIYes (X)InfoInScheduleOPartIIIInd
MissionNORTH COUNTRY HEALTH SERVICES IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF FACILITY RESIDENTS.MissionDesc
Significant New Program SrvcfalseSignificantNewProgramSrvcInd
Significant ChangefalseSignificantChangeInd
Expense$1,598,708ExpenseAmt
Revenue$1,459,661RevenueAmt
DescTHE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2016, THE ORGANIZATION HAD 7,167 MEDICAID PATIENT DAYS. SCHEDULE O FOR ADDITIONAL INFORMATION.Desc

Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp

FieldValueIRS element (for citing)
Expense$5,984ExpenseAmt
Revenue$220,646RevenueAmt
DescTHE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION.Desc

Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp

FieldValueIRS element (for citing)
Expense$18,590ExpenseAmt
Revenue$16,973RevenueAmt
DescTHE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2016, THE ORGANIZATION HAD 107 MEDICARE PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION.Desc
FieldValueIRS element (for citing)
Total Program Service Expenses$1,623,282TotalProgramServiceExpensesAmt
Described In Section501c3Yes (true)DescribedInSection501c3Ind
Schedule B RequiredfalseScheduleBRequiredInd
Political Campaign ActyfalsePoliticalCampaignActyInd
Lobbying ActivitiesYes (true)LobbyingActivitiesInd
Subject To Proxy TaxfalseSubjectToProxyTaxInd
Donor Advised FundfalseDonorAdvisedFundInd
Conservation EasementsfalseConservationEasementsInd
Collections Of ArtfalseCollectionsOfArtInd
Credit CounselingYes (true)CreditCounselingInd
Temp Or Permanent EndowmentsfalseTempOrPermanentEndowmentsInd
Report Land Building EquipmentYes (true)ReportLandBuildingEquipmentInd
Report Investments Other SecfalseReportInvestmentsOtherSecInd
Report Program Related InvstfalseReportProgramRelatedInvstInd
Report Other AssetsfalseReportOtherAssetsInd
Report Other LiabilitiesYes (true)ReportOtherLiabilitiesInd
Include FIN48 FootnotefalseIncludeFIN48FootnoteInd
Independent Audit Fincl StmtfalseIndependentAuditFinclStmtInd
Consolidated Audit Fincl StmtYes (true)ConsolidatedAuditFinclStmtInd
School OperatingfalseSchoolOperatingInd
Foreign OfficefalseForeignOfficeInd
Foreign ActivitiesfalseForeignActivitiesInd
More Than5000 K To OrgfalseMoreThan5000KToOrgInd
More Than5000 K To IndividualsfalseMoreThan5000KToIndividualsInd
Professional FundraisingfalseProfessionalFundraisingInd
Fundraising ActivitiesfalseFundraisingActivitiesInd
Gaming ActivitiesfalseGamingActivitiesInd
Operate HospitalfalseOperateHospitalInd
Grants To OrganizationsfalseGrantsToOrganizationsInd
Grants To IndividualsfalseGrantsToIndividualsInd
Schedule J RequiredYes (true)ScheduleJRequiredInd
Tax Exempt BondsfalseTaxExemptBondsInd
Engaged In Excess Benefit TransfalseEngagedInExcessBenefitTransInd
PY Excess Benefit TransfalsePYExcessBenefitTransInd
Loan OutstandingfalseLoanOutstandingInd
Grant To Related PersonfalseGrantToRelatedPersonInd
Business Rln With Org MemfalseBusinessRlnWithOrgMemInd
Business Rln With Fam MemfalseBusinessRlnWithFamMemInd
Business Rln With Officer EntfalseBusinessRlnWithOfficerEntInd
Deductible Non Cash ContrifalseDeductibleNonCashContriInd
Deductible Art ContributionfalseDeductibleArtContributionInd
Terminate OperationsfalseTerminateOperationsInd
Partial LiquidationfalsePartialLiquidationInd
Disregarded EntityfalseDisregardedEntityInd
Related EntityYes (true)RelatedEntityInd
Related Organization Ctrl EntfalseRelatedOrganizationCtrlEntInd
Trnsfr Exmpt Non Chrtbl Rltd OrgfalseTrnsfrExmptNonChrtblRltdOrgInd
Activities Conducted PrtshpfalseActivitiesConductedPrtshpInd
Schedule O RequiredYes (true)ScheduleORequiredInd
IRP Document6IRPDocumentCnt
IRP Document W2 G0IRPDocumentW2GCnt
Backup Wthld ComplianceYes (true)BackupWthldComplianceInd
Employee58EmployeeCnt
Employment Tax Returns FiledYes (true)EmploymentTaxReturnsFiledInd
Unrelated Bus Incm Over LimitfalseUnrelatedBusIncmOverLimitInd
Foreign Financial AccountfalseForeignFinancialAccountInd
Prohibited Tax Shelter TransfalseProhibitedTaxShelterTransInd
Taxable Party NotificationfalseTaxablePartyNotificationInd
Nondeductible ContributionsfalseNondeductibleContributionsInd
Quid Pro Quo ContributionsfalseQuidProQuoContributionsInd
Form8282 Property Disposed OffalseForm8282PropertyDisposedOfInd
Rcv Fnds To Pay Prsnl Bnft CntrctfalseRcvFndsToPayPrsnlBnftCntrctInd
Pay Premiums Prsnl Bnft CntrctfalsePayPremiumsPrsnlBnftCntrctInd
Indoor Tanning ServicesfalseIndoorTanningServicesInd
Info In Schedule O Part VIYes (X)InfoInScheduleOPartVIInd
Governing Body Voting Members14GoverningBodyVotingMembersCnt
Independent Voting Member10IndependentVotingMemberCnt
Family Or Business RlnfalseFamilyOrBusinessRlnInd
Delegation Of Mgmt DutiesfalseDelegationOfMgmtDutiesInd
Change To Org DocumentsfalseChangeToOrgDocumentsInd
Material Diversion Or MisusefalseMaterialDiversionOrMisuseInd
Members Or StockholdersYes (true)MembersOrStockholdersInd
Election Of Board MembersYes (true)ElectionOfBoardMembersInd
Decisions Subject To ApprovaYes (true)DecisionsSubjectToApprovaInd
Minutes Of Governing BodyYes (true)MinutesOfGoverningBodyInd
Minutes Of CommitteesYes (true)MinutesOfCommitteesInd
Officer Mailing AddressfalseOfficerMailingAddressInd
Local ChaptersfalseLocalChaptersInd
Form990 Provided To Gvrn BodyYes (true)Form990ProvidedToGvrnBodyInd
Conflict Of Interest PolicyYes (true)ConflictOfInterestPolicyInd
Annual Disclosure Covered PrsnYes (true)AnnualDisclosureCoveredPrsnInd
Regular Monitoring EnfrcYes (true)RegularMonitoringEnfrcInd
Whistleblower PolicyYes (true)WhistleblowerPolicyInd
Document Retention PolicyYes (true)DocumentRetentionPolicyInd
Compensation Process CEOfalseCompensationProcessCEOInd
Compensation Process OtherfalseCompensationProcessOtherInd
Investment In Joint VenturefalseInvestmentInJointVentureInd
Upon RequestYes (X)UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

FieldValueIRS element (for citing)
PersonANDRE BISSONNETTEPersonNm
Phone8023347331PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line1189 PROUTY DRIVEAddressLine1Txt
CityNEWPORTCityNm
State AbbreviationVTStateAbbreviationCd
ZIP05855ZIPCd
FieldValueIRS element (for citing)
Info In Schedule O Part VIIYes (X)InfoInScheduleOPartVIIInd

Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)

TitleTitleTxtAverage Hours Per WeekAverageHoursPerWeekRtAverage Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRtIndividual Trustee Or DirectorIndividualTrusteeOrDirectorIndOfficerOfficerIndReportable Comp From OrgReportableCompFromOrgAmtReportable Comp From Rltd OrgReportableCompFromRltdOrgAmtOther CompensationOtherCompensationAmtFormer Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd
CLAUDIO FORT
CEO1.041.0Yes (X)Yes (X)$0$369,848$48,092
KATHRYN AUSTIN
CHAIR1.011.0Yes (X)Yes (X)$0$0$0
ALAN WING
VICE CHAIR - BOARD1.06.0Yes (X)Yes (X)$0$0$0
GARY GILLESPIE
VICE CHAIR FINANCE1.06.0Yes (X)Yes (X)$0$0$0
MELISSA PETTERSSON
SECRETARY/CLERK1.06.0Yes (X)Yes (X)$0$0$0
RICHARD BARAW
TRUSTEE1.06.0Yes (X)$0$0$0
MARK BEAMS
TRUSTEE1.06.0Yes (X)$0$0$0
VERONIKA JEDLOVSZKY MD
MED STAFF PRESIDENT1.041.0Yes (X)Yes (X)$0$468,325$52,975
CHRISTOPHER RICKMAN MD
TRUSTEE/PHYSICIAN1.041.0Yes (X)$0$342,567$41,264
LARRY SISSON MD
MEDICAL STAFF VP BEG 10/20151.041.0Yes (X)Yes (X)$0$542,515$44,159
BILL STENGER
TRUSTEE1.06.0Yes (X)$0$0$0
BOB WILSON
TRUSTEE1.06.0Yes (X)$0$0$0
FRANK KNOLL
TRUSTEE1.06.0Yes (X)$0$0$0
THOMAS MILNAMOW
TRUSTEE1.06.0Yes (X)$0$0$0
ANDRE BISSONNETTE
CHIEF FINANCIAL OFFICER1.041.0Yes (X)$0$209,638$40,550
RACHEL DISANTO MD
TRUSTEE/MD STAFF PRES END 9/150.00.0$0$240,833$41,169Yes (X)
FieldValueIRS element (for citing)
Total Reportable Comp From Org$0TotalReportableCompFromOrgAmt
Tot Reportable Comp Rltd Org$2,173,726TotReportableCompRltdOrgAmt
Total Other Compensation$268,209TotalOtherCompensationAmt
Indiv Rcvd Greater Than100 K0IndivRcvdGreaterThan100KCnt
Former Ofcr Employees ListedYes (true)FormerOfcrEmployeesListedInd
Total Comp Greater Than150 KYes (true)TotalCompGreaterThan150KInd
Compensation From Other SrcsfalseCompensationFromOtherSrcsInd
Cntrct Rcvd Greater Than100 K0CntrctRcvdGreaterThan100KCnt
All Other Contributions$161AllOtherContributionsAmt
Total Contributions$161TotalContributionsAmt

Program Service Revenue ProgramServiceRevenueGrp (2 entries)

DescDescBusinessBusinessCdTotal Revenue ColumnTotalRevenueColumnAmtRelated Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt
NET PATIENT SERVICE REVENUE624100$1,697,187$1,697,187
OTHER REVENUE900099$93$93
FieldValueIRS element (for citing)
Total Program Service Revenue$1,697,280TotalProgramServiceRevenueAmt

Investment Income InvestmentIncomeGrp

FieldValueIRS element (for citing)
Total Revenue Column$6,727TotalRevenueColumnAmt
Exclusion$6,727ExclusionAmt

Incm From Invest Bond Proceeds IncmFromInvestBondProceedsGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt

Royalties Revenue RoyaltiesRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt

Rental Income Or Loss RentalIncomeOrLossGrp

FieldValueIRS element (for citing)
Real$0RealAmt
Personal$0PersonalAmt

Net Rental Income Or Loss NetRentalIncomeOrLossGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt

Gross Amount Sales Assets GrossAmountSalesAssetsGrp

FieldValueIRS element (for citing)
Securities$50,246SecuritiesAmt

Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp

FieldValueIRS element (for citing)
Securities$54,290SecuritiesAmt

Gain Or Loss GainOrLossGrp

FieldValueIRS element (for citing)
Securities-$4,044SecuritiesAmt

Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp

FieldValueIRS element (for citing)
Total Revenue Column-$4,044TotalRevenueColumnAmt
Exclusion-$4,044ExclusionAmt

Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt

Net Income From Gaming NetIncomeFromGamingGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt

Net Income Or Loss NetIncomeOrLossGrp

FieldValueIRS element (for citing)
Total Revenue Column$0TotalRevenueColumnAmt
FieldValueIRS element (for citing)
Other Revenue Total$0OtherRevenueTotalAmt

Total Revenue TotalRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$1,700,124TotalRevenueColumnAmt
Related Or Exempt Func Income$1,697,280RelatedOrExemptFuncIncomeAmt
Exclusion$2,683ExclusionAmt
FieldValueIRS element (for citing)
Info In Schedule O Part IXYes (X)InfoInScheduleOPartIXInd

Grants To Domestic Orgs GrantsToDomesticOrgsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Grants To Domestic Individuals GrantsToDomesticIndividualsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Foreign Grants ForeignGrantsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Benefits To Members BenefitsToMembersGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Comp Disqual Persons CompDisqualPersonsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Other Salaries And Wages OtherSalariesAndWagesGrp

FieldValueIRS element (for citing)
Total$831,865TotalAmt
Program Services$709,178ProgramServicesAmt
Management And General$122,687ManagementAndGeneralAmt

Pension Plan Contributions PensionPlanContributionsGrp

FieldValueIRS element (for citing)
Total$28,072TotalAmt
Program Services$23,932ProgramServicesAmt
Management And General$4,140ManagementAndGeneralAmt

Other Employee Benefits OtherEmployeeBenefitsGrp

FieldValueIRS element (for citing)
Total$297,073TotalAmt
Program Services$253,259ProgramServicesAmt
Management And General$43,814ManagementAndGeneralAmt

Payroll Taxes PayrollTaxesGrp

FieldValueIRS element (for citing)
Total$71,186TotalAmt
Program Services$60,687ProgramServicesAmt
Management And General$10,499ManagementAndGeneralAmt

Fees For Services Management FeesForServicesManagementGrp

FieldValueIRS element (for citing)
Total$1,000TotalAmt
Management And General$1,000ManagementAndGeneralAmt

Fees For Services Legal FeesForServicesLegalGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Fees For Services Accounting FeesForServicesAccountingGrp

FieldValueIRS element (for citing)
Total$23,466TotalAmt
Management And General$23,466ManagementAndGeneralAmt

Fees For Services Lobbying FeesForServicesLobbyingGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Fees For Services Prof Fundraising FeesForServicesProfFundraising

FieldValueIRS element (for citing)
Total$0TotalAmt

Fees For Srvc Invst Mgmnt Fees FeesForSrvcInvstMgmntFeesGrp

FieldValueIRS element (for citing)
Total$5,198TotalAmt
Management And General$5,198ManagementAndGeneralAmt

Fees For Services Other FeesForServicesOtherGrp

FieldValueIRS element (for citing)
Total$243,286TotalAmt
Program Services$227,917ProgramServicesAmt
Management And General$15,369ManagementAndGeneralAmt

Advertising AdvertisingGrp

FieldValueIRS element (for citing)
Total$1,625TotalAmt
Program Services$1,625ProgramServicesAmt

Office Expenses OfficeExpensesGrp

FieldValueIRS element (for citing)
Total$101,721TotalAmt
Program Services$97,886ProgramServicesAmt
Management And General$3,835ManagementAndGeneralAmt

Information Technology InformationTechnologyGrp

FieldValueIRS element (for citing)
Total$6,746TotalAmt
Program Services$6,746ProgramServicesAmt

Royalties RoyaltiesGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Occupancy OccupancyGrp

FieldValueIRS element (for citing)
Total$41,440TotalAmt
Program Services$41,440ProgramServicesAmt

Travel TravelGrp

FieldValueIRS element (for citing)
Total$5,285TotalAmt
Program Services$2,079ProgramServicesAmt
Management And General$3,206ManagementAndGeneralAmt

Pymt Travel Entrtnmnt Pub Ofcl PymtTravelEntrtnmntPubOfclGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Conferences Meetings ConferencesMeetingsGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Interest InterestGrp

FieldValueIRS element (for citing)
Total$14,641TotalAmt
Program Services$13,400ProgramServicesAmt
Management And General$1,241ManagementAndGeneralAmt

Payments To Affiliates PaymentsToAffiliatesGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Depreciation Depletion DepreciationDepletionGrp

FieldValueIRS element (for citing)
Total$46,438TotalAmt
Program Services$42,502ProgramServicesAmt
Management And General$3,936ManagementAndGeneralAmt

Insurance InsuranceGrp

FieldValueIRS element (for citing)
Total$6,397TotalAmt
Program Services$6,397ProgramServicesAmt

Other Expenses OtherExpensesGrp (4 entries)

DescDescTotalTotalAmtProgram ServicesProgramServicesAmtManagement And GeneralManagementAndGeneralAmt
MEDICAID TAXES$113,149$113,149
MEDICAL SUPPLIES & DRUGS$22,859$22,859
LICENSES, DUES, SUBSCRIPTIONS$2,882$226$2,656
MISCELLANEOUS EXPENSE$67$67

Total Functional Expenses TotalFunctionalExpensesGrp

FieldValueIRS element (for citing)
Total$1,864,396TotalAmt
Program Services$1,623,282ProgramServicesAmt
Management And General$241,114ManagementAndGeneralAmt
Fundraising$0FundraisingAmt

Cash Non Interest Bearing CashNonInterestBearingGrp

FieldValueIRS element (for citing)
BOY$1,100BOYAmt
EOY$600EOYAmt

Savings And Temp Cash Invst SavingsAndTempCashInvstGrp

FieldValueIRS element (for citing)
BOY$268,341BOYAmt
EOY$175,785EOYAmt

Pledges And Grants Receivable PledgesAndGrantsReceivableGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Accounts Receivable AccountsReceivableGrp

FieldValueIRS element (for citing)
BOY$131,656BOYAmt
EOY$176,829EOYAmt

Receivables From Officers Etc ReceivablesFromOfficersEtcGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Rcvbl From Disqualified Prsn RcvblFromDisqualifiedPrsnGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Inventories For Sale Or Use InventoriesForSaleOrUseGrp

FieldValueIRS element (for citing)
BOY$100BOYAmt
EOY$100EOYAmt

Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp

FieldValueIRS element (for citing)
BOY$23,315BOYAmt
EOY$24,273EOYAmt
FieldValueIRS element (for citing)
Land Bldg Equip Cost Or Other Bss$1,480,552LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec$947,962LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

FieldValueIRS element (for citing)
BOY$574,192BOYAmt
EOY$532,590EOYAmt

Investments Pub Traded Sec InvestmentsPubTradedSecGrp

FieldValueIRS element (for citing)
BOY$287,932BOYAmt
EOY$303,849EOYAmt

Investments Other Securities InvestmentsOtherSecuritiesGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Investments Program Related InvestmentsProgramRelatedGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Intangible Assets IntangibleAssetsGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Other Assets Total OtherAssetsTotalGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Total Assets TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$1,286,636BOYAmt
EOY$1,214,026EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

FieldValueIRS element (for citing)
BOY$71,799BOYAmt
EOY$101,643EOYAmt

Grants Payable GrantsPayableGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Deferred Revenue DeferredRevenueGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Escrow Account Liability EscrowAccountLiabilityGrp

FieldValueIRS element (for citing)
BOY$2,005BOYAmt
EOY$892EOYAmt

Loans From Officers Directors LoansFromOfficersDirectorsGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp

FieldValueIRS element (for citing)
BOY$371,627BOYAmt
EOY$357,174EOYAmt

Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Other Liabilities OtherLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$13,525BOYAmt
EOY$65,851EOYAmt

Total Liabilities TotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$458,956BOYAmt
EOY$525,560EOYAmt
FieldValueIRS element (for citing)
Organization Follows SFAS117Yes (X)OrganizationFollowsSFAS117Ind

Unrestricted Net Assets UnrestrictedNetAssetsGrp

FieldValueIRS element (for citing)
BOY$827,680BOYAmt
EOY$688,466EOYAmt

Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp

FieldValueIRS element (for citing)
BOY$0BOYAmt
EOY$0EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$827,680BOYAmt
EOY$688,466EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,286,636BOYAmt
EOY$1,214,026EOYAmt
FieldValueIRS element (for citing)
Reconcilation Revenue Expnss-$164,272ReconcilationRevenueExpnssAmt
Net Unrlzd Gains Losses Invst$25,058NetUnrlzdGainsLossesInvstAmt
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Accountant Compile Or ReviewfalseAccountantCompileOrReviewInd
FS AuditedYes (true)FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

FieldValueIRS element (for citing)
Consolidated Basis Fincl StmtYes (X)ConsolidatedBasisFinclStmtInd
FieldValueIRS element (for citing)
Audit CommitteeYes (true)AuditCommitteeInd
Federal Grant Audit RequiredfalseFederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Publicly Supported Org509a2Yes (X)PubliclySupportedOrg509a2Ind

Gifts Grants Contris Rcvd509 GiftsGrantsContrisRcvd509Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$10,115CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$15,736CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$727CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$4,568CurrentTaxYearMinus1YearAmt
Current Tax Year$161CurrentTaxYearAmt
Total$31,307TotalAmt

Gross Receipts Admissions GrossReceiptsAdmissionsGrp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$1,500,636CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$1,480,023CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$1,585,465CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$1,628,422CurrentTaxYearMinus1YearAmt
Current Tax Year$1,697,280CurrentTaxYearAmt
Total$7,891,826TotalAmt

Gross Receipts Non Unrlt Bus GrossReceiptsNonUnrltBusGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Tax Rev Levied Orgnztnl Bnft509 TaxRevLeviedOrgnztnlBnft509Grp

FieldValueIRS element (for citing)
Total$0TotalAmt

Govt Furn Srvc Fclts Vl509 GovtFurnSrvcFcltsVl509Grp

FieldValueIRS element (for citing)
Total$0TotalAmt

Total509 Total509Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$1,510,751CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$1,495,759CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$1,586,192CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$1,632,990CurrentTaxYearMinus1YearAmt
Current Tax Year$1,697,441CurrentTaxYearAmt
Total$7,923,133TotalAmt

Amounts Rcvd Dsqlfy Person AmountsRcvdDsqlfyPersonGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Substantial Contributors Amt SubstantialContributorsAmtGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Subst And Dsqlfy Prsns Tot SubstAndDsqlfyPrsnsTotGrp

FieldValueIRS element (for citing)
Total$0TotalAmt
FieldValueIRS element (for citing)
Public Support Total509$7,923,133PublicSupportTotal509Amt

Gross Investment Income509 GrossInvestmentIncome509Grp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$6,522CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$6,434CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$6,470CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$6,860CurrentTaxYearMinus1YearAmt
Current Tax Year$6,727CurrentTaxYearAmt
Total$33,013TotalAmt

Post1975 UBTI Post1975UBTIGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Investment Income And UBTI InvestmentIncomeAndUBTIGrp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$6,522CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$6,434CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$6,470CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$6,860CurrentTaxYearMinus1YearAmt
Current Tax Year$6,727CurrentTaxYearAmt
Total$33,013TotalAmt

Net Income From Other UBI NetIncomeFromOtherUBIGrp

FieldValueIRS element (for citing)
Total$0TotalAmt

Other Income509 OtherIncome509Grp

FieldValueIRS element (for citing)
Total$0TotalAmt

Total Support Calendar Year TotalSupportCalendarYearGrp

FieldValueIRS element (for citing)
Current Tax Year Minus4 Years$1,517,273CurrentTaxYearMinus4YearsAmt
Current Tax Year Minus3 Years$1,502,193CurrentTaxYearMinus3YearsAmt
Current Tax Year Minus2 Years$1,592,662CurrentTaxYearMinus2YearsAmt
Current Tax Year Minus1 Year$1,639,850CurrentTaxYearMinus1YearAmt
Current Tax Year$1,704,168CurrentTaxYearAmt
Total$7,956,146TotalAmt
FieldValueIRS element (for citing)
Public Support CY5090.99585PublicSupportCY509Pct
Public Support PY5090.99570PublicSupportPY509Pct
Investment Income CY0.00415InvestmentIncomeCYPct
Investment Income PY0.00430InvestmentIncomePYPct
Thirty Thr Pct Suprt Tests CY509Yes (X)ThirtyThrPctSuprtTestsCY509Ind

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Total Grassroots LobbyingTotalGrassrootsLobbyingGrp
Total Direct LobbyingTotalDirectLobbyingGrp
Total Lobbying ExpendTotalLobbyingExpendGrp
Other Exempt Purpose ExpendOtherExemptPurposeExpendGrp
Total Exempt Purpose ExpendTotalExemptPurposeExpendGrp
Lobbying Nontaxable AmountLobbyingNontaxableAmountGrp
Grassroots NontaxableGrassrootsNontaxableGrp
Tot Lbbyng Grassroot Mns Non TxTotLbbyngGrassrootMnsNonTxGrp
Tot Lbby Expend Mns Lbbyng Non TxTotLbbyExpendMnsLbbyngNonTxGrp
VolunteersfalseVolunteersInd
Paid Staff Or ManagementfalsePaidStaffOrManagementInd
Media AdvertisementsfalseMediaAdvertisementsInd
Mailings MembersfalseMailingsMembersInd
Publications Or BroadcastfalsePublicationsOrBroadcastInd
Grants Other OrganizationsfalseGrantsOtherOrganizationsInd
Direct Contact LegislatorsfalseDirectContactLegislatorsInd
Rallies DemonstrationsfalseRalliesDemonstrationsInd
Other ActivitiesYes (true)OtherActivitiesInd
Not Described Section501c3falseNotDescribedSection501c3Ind

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE C, PART II-B, LINE 1(I)FormAndLineReferenceDesc
ExplanationOTHER LOBBYING ACTIVITIES: THE ORGANIZATION PAYS DUES TO THE VERMONT HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING PURPOSES.ExplanationTxt

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Art Public Exhibition AmountsArtPublicExhibitionAmountsGrp
Held Works ArtHeldWorksArtGrp
Agent Trustee EtcfalseAgentTrusteeEtcInd
Incl Escrow Custodial Acct LiabYes (true)InclEscrowCustodialAcctLiabInd
Explanation ProvidedYes (X)ExplanationProvidedInd
CY Minus3 Yr Endwmt FundCYMinus3YrEndwmtFundGrp
CY Minus4 Yr Endwmt FundCYMinus4YrEndwmtFundGrp

Land LandGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$30,000OtherCostOrOtherBasisAmt
Book Value$30,000BookValueAmt

Buildings BuildingsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$0OtherCostOrOtherBasisAmt
Depreciation$0DepreciationAmt
Book Value$0BookValueAmt

Leasehold Improvements LeaseholdImprovementsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$1,115,656OtherCostOrOtherBasisAmt
Depreciation$711,931DepreciationAmt
Book Value$403,725BookValueAmt

Equipment EquipmentGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$284,258OtherCostOrOtherBasisAmt
Depreciation$202,967DepreciationAmt
Book Value$81,291BookValueAmt

Other Land Buildings OtherLandBuildingsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$50,638OtherCostOrOtherBasisAmt
Depreciation$33,064DepreciationAmt
Book Value$17,574BookValueAmt
FieldValueIRS element (for citing)
Total Book Value Land Buildings$532,590TotalBookValueLandBuildingsAmt
Federal Income Tax Liability$0FederalIncomeTaxLiabilityAmt

Other Liabilities Org OtherLiabilitiesOrgGrp

FieldValueIRS element (for citing)
DescDUE TO AFFILIATEDesc
Amt$65,851Amt
FieldValueIRS element (for citing)
Total Liability$65,851TotalLiabilityAmt
Total Rev Etc Audited Fincl Stmt$1,694,676TotalRevEtcAuditedFinclStmtAmt
Other Revenue-$5,448OtherRevenueAmt
Revenue Not Reported-$5,448RevenueNotReportedAmt
Revenue Subtotal$1,700,124RevenueSubtotalAmt
Total Revenue Per Form990$1,700,124TotalRevenuePerForm990Amt
Tot Expns Etc Audited Fincl Stmt$1,858,948TotExpnsEtcAuditedFinclStmtAmt
Expenses Subtotal$1,858,948ExpensesSubtotalAmt
Other Expenses Not Included$5,448OtherExpensesNotIncludedAmt
Expenses Not Rpt Fincl Stmt$5,448ExpensesNotRptFinclStmtAmt
Total Expenses Per Form990$1,864,396TotalExpensesPerForm990Amt

Supplemental Information Detail SupplementalInformationDetail (4 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
SCHEDULE D, PART IV, LINE 2BTRUST, 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 2UNCERTAIN 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 2DAMOUNTS INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12: $ (5,198) INVESTMENT MANAGEMENT FEES (250) EXPENSES PAID OUT OF GRANT FUNDS --------- $ (5,448)
SCHEDULE D, PART XII, LINE 4BAMOUNTS INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1: $ 5,198 INVESTMENT MANAGEMENT FEES 250 EXPENSES PAID OUT OF GRANT FUNDS -------- $ 5,448

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance PaymentfalseSeverancePaymentInd
Supplemental Nonqual Rtr PlanfalseSupplementalNonqualRtrPlanInd
Equity Based Comp ArrngmfalseEquityBasedCompArrngmInd
Comp Based On Revenue Of Flng OrgfalseCompBasedOnRevenueOfFlngOrgInd
Comp Bsd On Rev Related OrgsfalseCompBsdOnRevRelatedOrgsInd
Comp Bsd Net Earns Flng OrgfalseCompBsdNetEarnsFlngOrgInd
Comp Bsd Net Earns Rltd OrgsfalseCompBsdNetEarnsRltdOrgsInd
Any Non Fixed PaymentsfalseAnyNonFixedPaymentsInd
Initial Contract ExceptionfalseInitialContractExceptionInd

Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)

TitleTitleTxtBase Compensation Filing OrgBaseCompensationFilingOrgAmtCompensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmtBonus Filing OrganizationBonusFilingOrganizationAmountBonus Related OrganizationsBonusRelatedOrganizationsAmtOther Compensation Filing OrgOtherCompensationFilingOrgAmtOther Compensation Rltd OrgsOtherCompensationRltdOrgsAmtDeferred Compensation Flng OrgDeferredCompensationFlngOrgAmtDeferred Comp Rltd OrgsDeferredCompRltdOrgsAmtNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmtNontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmtTotal Compensation Filing OrgTotalCompensationFilingOrgAmtTotal Compensation Rltd OrgsTotalCompensationRltdOrgsAmtComp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmtComp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt
CLAUDIO FORT
CEO$0$296,336$0$73,512$0$0$0$15,446$0$32,646$0$417,940$0$0
VERONIKA JEDLOVSZKY MD
MED STAFF PRESIDENT$0$448,158$0$18,878$0$1,289$0$19,226$0$33,749$0$521,300$0$0
CHRISTOPHER RICKMAN MD
TRUSTEE/PHYSICIAN$0$312,303$0$21,560$0$8,704$0$17,515$0$23,749$0$383,831$0$0
LARRY SISSON MD
MEDICAL STAFF VP BEG 10/2015$0$516,554$0$0$0$25,961$0$19,793$0$24,366$0$586,674$0$0
RACHEL DISANTO MD
TRUSTEE/MD STAFF PRES END 9/15$0$240,833$0$0$0$0$0$8,921$0$32,248$0$282,002$0$0
ANDRE BISSONNETTE
CHIEF FINANCIAL OFFICER$0$175,466$0$32,111$0$2,061$0$9,098$0$31,452$0$250,188$0$0

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferenceSCHEDULE J, PART I, LINE 3FormAndLineReferenceDesc
ExplanationCOMPENSATION 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.ExplanationTxt

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (9 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
FORM 990, PART I, LINE 1ORGANIZATION'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-4CPROGRAM 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 IS AVAILABLE.
FORM 990, PART VI, SECTION A, LINE 6, 7A, & 7BMEMBERS 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 11BREVIEW 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 12CMONITORING 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 15ACOMPENSATION 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 19DOCUMENT 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 ACOMPENSATION 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, VERONIKA JEDLOVSZKY AND LARRY SISSON ARE COMPENSATED AS EMPLOYEES OF NORTH COUNTRY HOSPITAL. THEY DO NOT RECEIVE ANY COMPENSATION FOR THEIR DUTIES AS BOARD OF DIRECTORS MEMBERS.
FORM 990 PART IX, LINE 11GOTHER FEES FOR SERVICES: $ 221,359 CONTRACT SERVICES 2,921 SPEECH THERAPY 8,393 PHYSICAL THERAPY 4,374 OCCUPATIONAL THERAPY 6,239 OTHER FEES --------- $ 243,286

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (2 entries)

Address Line1USAddress/AddressLine1TxtCityUSAddress/CityNmState AbbreviationUSAddress/StateAbbreviationCdZIPUSAddress/ZIPCdEINEINPrimary ActivitiesPrimaryActivitiesTxtLegal Domicile StateLegalDomicileStateCdExempt Code SectionExemptCodeSectionTxtPublic Charity StatusPublicCharityStatusTxtBusiness Name Line1DirectControllingEntityName/BusinessNameLine1TxtControlled OrganizationControlledOrganizationInd
NORTH COUNTRY HOSPITAL & HEALTH CENTER
189 PROUTY DRIVENEWPORTVT05855030185556HOSPITALVT501(C)(3)3NCHSfalse
NORTH COUNTRY HEALTH SYSTEMS
189 PROUTY DRIVENEWPORTVT05855222566964PARENT/FUNDRSVT501(C)(3)11B IINAfalse
FieldValueIRS element (for citing)
Receipt Of Int Annts Rnts RyltsfalseReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth OrgfalseGiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth OrgfalseGiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other OrgfalseLoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth OrgfalseLoansOrGuaranteesFromOthOrgInd
Div Related OrganizationfalseDivRelatedOrganizationInd
Asset Sale To Other OrgfalseAssetSaleToOtherOrgInd
Asset Purchase From Other OrgfalseAssetPurchaseFromOtherOrgInd
Asset ExchangefalseAssetExchangeInd
Rental Of Facilities To Oth OrgfalseRentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth OrgfalseRentalOfFcltsFromOthOrgInd
Perform Of Services For Oth OrgfalsePerformOfServicesForOthOrgInd
Perform Of Services By Other OrgYes (true)PerformOfServicesByOtherOrgInd
Sharing Of FacilitiesYes (true)SharingOfFacilitiesInd
Paid Employees SharingYes (true)PaidEmployeesSharingInd
Reimbursement Paid To Other OrgYes (true)ReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other OrgfalseReimbursementPaidByOtherOrgInd
Transfer To Other OrgfalseTransferToOtherOrgInd
Transfer From Other OrgfalseTransferFromOtherOrgInd

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