2017-08-11T09:42:22-05:00 2016-09-30 BKD LLP 910 E ST LOUIS 200/PO BOX 1190 SPRINGFIELD MO 658062523 990 2015-10-01 222566964 NORTH COUNTRY HEALTH SYSTEMS INC % ANDRE BISSONNETTE NORT 8023343263 189 PROUTY DRIVE NEWPORT VT 05855 ANDRE BISSONNETTE CFO 2017-04-21 true Brian D Todd P00422601 4178658701 2015 2021-01-29 14:40:06Z ANDRE BISSONNETTE 189 PROUTY DRIVE NEWPORT VT 05855 195146 false X WWW.NCHSI.ORG X 1984 VT TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. 14 10 0 25 0 0 235448 174668 0 0 0 0 4248 -14009 239696 160659 44482 62000 0 0 0 0 0 0 0 31217 32863 75699 94863 163997 65796 1126927 1240039 9180 7778 1117747 1232261 TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. false false 74364 62000 TO ORGANIZE FUNDRAISING EFFORTS TO PROVIDE AFFILIATED ORGANIZATIONS WITH RESOURCES NEEDED TO CARRY OUT THEIR EXEMPT FUNCTIONS. 74364 true true false false false false false false false false false false false false false false false true false false false false false false true false false false true true false false false false false false false false false false false false false true true true false false true 1 0 true 0 false false false false false true true false false false false X 14 10 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 CLAUDIO FORT CEO 1.0 41.0 X X 0 369848 48092 KATHRYN AUSTIN CHAIR 1.0 11.0 X X 0 0 0 ALAN WING VICE CHAIR - BOARD 1.0 6.0 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 TRUSTEE 1.0 6.0 X 0 0 0 VERONIKA JEDLOVSZKY MD MED STAFF PRESIDENT 1.0 41.0 X X 0 468325 52975 FRANK KNOLL TRUSTEE 1.0 6.0 X 0 0 0 THOMAS MILNAMOW TRUSTEE 1.0 6.0 X 0 0 0 CHIRSTOPHER RICKMAN MD TRUSTEE/PHYSICIAN 1.0 41.0 X 0 342567 41264 LARRY SISSON MD MEDICAL STAFF VP BEG 10/2015 1.0 41.0 X 0 542515 44159 BILL STENGER TRUSTEE 1.0 6.0 X 0 0 0 BOB WILSON TRUSTEE 1.0 6.0 X 0 0 0 ANDRE BISSONNETTE CHIEF FINANCIAL OFFICER 1.0 41.0 X 0 209638 40550 RACHEL DISANTO MD TRUSTEE/MD STAFF PRES END 9/15 0.0 0.0 X 0 240833 41169 0 2173726 268209 0 true true false 0 83398 91270 174668 0 0 0 0 0 0 0 0 20478 83398 34487 -14009 -14009 0 0 0 160659 -14009 0 62000 62000 0 0 0 0 0 0 0 0 0 0 3026 3026 0 0 7827 7827 6096 6096 0 15595 12045 3550 0 0 0 0 0 0 0 0 0 0 MEDICAL SUPPLIES & DRUGS 319 319 94863 74364 20499 0 265581 0 279893 681086 50050 27000 0 0 0 0 0 0 0 0 0 0 500 500 0 530903 531453 0 0 0 0 0 0 0 0 1126927 1240039 6214 7778 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2966 0 9180 7778 X 283563 319885 834184 912376 0 0 1117747 1232261 1126927 1240039 65796 48718 X false true X true false X X 2 NORTH CO HOSP 030185556 3 true 0 0 NORTH CO HLTH 222570334 9 true 0 0 2 0 0 true false false false false false false false false false false false false false false true SCHEDULE A, PART I, LINE 11H, COLUMN (I) SUPPORTED ORGANIZATIONS: THE FULL NAMES OF THE SUPPORTED ORGANIZATIONS ARE: NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. NORTH COUNTRY HEALTH SERVICES, INC. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 165672 40751 40751 124921 35738 35738 160659 129350 34487 34487 94863 94863 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: $ 40,751 NET ASSETS RELEASED FROM RESTRICTIONS SCHEDULE D, PART XI, LINE 4B AMOUNTS INCLUDED ON FORM 990, PART VIII, LINE 12, BUT NOT ON LINE 1: $ 70,225 TEMPORARILY RESTRICTED CONTRIBUTIONS (34,487) SPECIAL EVENT EXPENSES --------- $ 35,738 SCHEDULE D, PART XII, LINE 2D AMOUNTS INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART IX, LINE 25: $ 34,487 SPECIAL EVENT EXPENSES MOONLIGHT BALL 75979 62251 13728 14279 7250 3404 GOLF CLASSIC 27897 21147 6750 3746 2860 2160 788 0 103876 83398 20478 3746 2860 16439 7250 4192 34487 -14009 true SCHOLARSHIPS 42 25000 PATIENT ASSISTANCE 489 37000 SCHEDULE I, PART I, LINE 2 MONITORING USE OF FUNDS: NORTH COUNTRY HEALTH SYSTEMS IS THE PARENT ORGANIZATION OF NORTH COUNTRY HOSPITAL & HEALTH CENTER AND SHARES CONSOLIDATED FINANCIALS WITH THE HOSPITAL; THEREFORE, THE ORGANIZATION HAS ACCESS TO THE HOSPITAL FINANCIALS AND IS ABLE TO MONITOR THE USE OF THE FUNDS. SCHOLARSHIP RECIPIENTS MUST COMPLETE AN APPLICATION SHOWING THAT THEY ARE A RESIDENT OF THE NORTH COUNTRY HOSPITAL SERVICE AREA INTENDING TO PURSUE A CAREER INVOLVING PATIENT CARE, PRESENTLY TRAINING FOR A HEALTH CARE CAREER INVOLVING PATIENT CARE, OR ALREADY PROVIDING PATIENT CARE IN THE HEALTH CARE FIELD AND INTERESTED IN CONTINUING THEIR EDUCATION IN THAT FIELD. THE SCHOLARSHIP AWARDS ARE BASED ON ACHIEVEMENT, APTITUDE, SCHOLASTICS, MOTIVATION, AND NEED. THE SCHOLARSHIP CHECKS ARE MADE PAYABLE DIRECTLY TO THE SCHOOL CHOSEN BY THE STUDENT. SUBSEQUENT AWARDS ARE AVAILABLE AFTER THE FIRST YEAR, AND RECIPIENT ARE EVALUATED EACH YEAR THROUGH A TRANSCRIPT REVIEW. PATIENT ASSISTANCE IS GIVEN TO SPECIFIC PATIENTS BASED ON IDENTIFIED NEEDS THROUGHOUT THE YEAR. THIS YEAR, AWARDS WERE GIVEN FOR THE PURCHASE OF PRESCRIPTIONS, MEDICAL BILLS, GAS CARDS, WRAPS THERAPY, MEDICAL SUPPLIES, PROTEIN BARS, AND OTHER BILLS THROUGH MANY DEPARTMENTS, INCLUDING ONCOLOGY, DIALYSIS, AND RESPIRATORY. false false false false false false false false false CLAUDIO FORT CEO 0 296336 0 73512 0 0 0 15446 0 32646 0 417940 0 0 VERONIKA JEDLOVSZKY MD MED STAFF PRESIDENT 0 448158 0 18878 0 1289 0 19226 0 33749 0 521300 0 0 CHIRSTOPHER RICKMAN MD TRUSTEE/PHYSICIAN 0 312303 0 21560 0 8704 0 17515 0 23749 0 383831 0 0 LARRY SISSON MD MEDICAL STAFF VP BEG 10/2015 0 516554 0 0 0 25961 0 19793 0 24366 0 586674 0 0 RACHEL DISANTO MD TRUSTEE/MD STAFF PRES END 9/15 0 240833 0 0 0 0 0 8921 0 32248 0 282002 0 0 ANDRE BISSONNETTE CHIEF FINANCIAL OFFICER 0 175466 0 32111 0 2061 0 9098 0 31452 0 250188 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 VI, SECTION A, LINE 6, 7A & 7B MEMBERS/STOCKHOLDERS/OTHER PERSONS: THE MEMBERSHIP OF THE CORPORATION SHALL CONSIST OF ALL PERSONS REFERRED TO IN THE ARTICLES OF ASSOCIATION AS THE INITIAL MEMBERS OF THE CORPORATION, ALL PERSONS WHO SHALL THEREAFTER BE ELECTED MEMBERS IN CONFORMITY WITH THE BYLAWS, DEPARTMENT DIRECTORS AND ALL APPOINTEES OF THE ACTIVE MEDICAL STAFF OF NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. THE MEMBERS SHALL BE REFERRED TO AS NORTH COUNTRY MEMBERS. AS LISTED IN THE ARTICLES OF ASSOCIATION, THE SOLE MEMBER OF THE CORPORATION IS NORTH COUNTRY HOSPITAL AND HEALTH CENTER, INC. NORTH COUNTRY MEMBERS SHALL BE ELECTED AT THE ANNUAL MEETING BY A MAJORITY VOTE OF THE EXISTING NORTH COUNTRY MEMBERS PRESENT AND VOTING AT SAID MEETING. THE CORPORATION SHALL CONDUCT AN ANNUAL ENROLLMENT OF MEMBERS BUT PERSONS MAY BE ADMITTED TO MEMBERSHIP AT ANY TIME. THE OFFICER OR AGENT HAVING CHARGE OF THE BOOKS OF THE CORPORATION SHALL MAKE A COMPLETE RECORD OF THE MEMBERS ENTITLED TO VOTE AT EACH MEETING OF MEMBERS THEREOF, ARRANGED IN ALPHABETICAL ORDER. THE MEMBER LIST MUST BE AVAILABLE FOR INSPECTION BY ANY MEMBER, BEGINNING TWO (2) BUSINESS DAYS AFTER NOTICE OF THE MEETING IS GIVEN FOR WHICH THE LIST WAS PREPARED AND CONTINUING THROUGH THE MEETING DATE. THE LIST SHALL BE AVAILABLE AT THE PRINCIPLE OFFICE OF NORTH COUNTRY HOSPITAL. A MEMBER, HIS AGENT OR ATTORNEY IS ENTITLED, ON WRITTEN DEMAND, TO INSPECT AND TO COPY THE LIST DURING REGULAR BUSINESS HOURS AT HIS OR HER EXPENSE, DURING THE PERIOD IT IS AVAILABLE FOR INSPECTION. THE MEMBER LIST SHALL BE MAINTAINED IN WRITTEN FORM OR IN ANOTHER FORM CAPABLE OF CONVERSION TO WRITTEN FORM WITHIN A REASONABLE TIME. AT EACH ANNUAL MEETING, THE NORTH COUNTRY MEMBERS SHALL FIX, WITHIN THE LIMITS SPECIFIED ABOVE, THE SIZE OF THE BOARD OF TRUSTEES FOR THE ENSUING YEAR AND SHALL ELECT THE NUMBER OF TRUSTEES NECESSARY TO COMPLETE THE SIZE SO FIXED; PROVIDED, HOWEVER, THAT THE SIZE OF THE BOARD OF TRUSTEES MAY BE DECREASED ONLY TO ELIMINATE VACANCIES EXISTING BY REASONS OF THE DEATH, RESIGNATION, REMOVAL OR NATURAL EXPIRATION OF THE TERM OF ONE OR MORE TRUSTEES. THE BYLAWS MAY BE ALTERED, AMENDED OR REPEALED BY NORTH COUNTRY MEMBERS AT ANY REGULAR OR SPECIAL MEETING, PROVIDED THE NOTICE OF SUCH MEETING SHALL HAVE CONTAINED A COPY OF THE PROPOSED ALTERATION, AMENDMENT OR REPEAL AND PROVIDED A QUORUM IS PRESENT, SUBJECT TO RATIFICATION BY THE NORTH COUNTRY BOARD. 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 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, LINES 15A & 15B 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 VIEW ON-SITE OR BY WRITTEN REQUEST. FORM 990, PART VII, SECTION A 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. NORTH COUNTRY HOSPITAL & HEALTH CENTER 189 PROUTY DRIVE NEWPORT VT 05855 030185556 HOSPITAL VT 501(C)(3) 3 NCHS true NORTH COUNTRY HLTH SRVCS DBA DERBY GREEN 189 PROUTY DRIVE NEWPORT VT 05855 222570334 SKILLED NRSG VT 501(C)(3) 9 NCHS true false true false false false false false false false false false true false true true true false false false