2017-02-15T08:53:14-06:00 2016-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2015-10-01 020276210 Upper Connecticut Valley Hospital UPPE 6032374971 Corliss Lane Colebrook NH 03576 Scott Colby President 6032374971 2017-02-10 1 Barbara J McGuan CPA P00219457 2077752387 2017-02-10 2015 2021-01-29 14:40:06Z Scott Colby Corliss Lane Colebrook NH 03576 19014132 0 X www.ucvh.org X 1969 NH To provide high quality and efficient health care services 12 10 147 32 0 0 160264 548486 15616811 15707982 358185 397493 44750 0 16180010 16653961 12500 0 0 0 8181244 7869615 0 32933 37255 7442599 8106798 15636343 16009346 543667 644615 23313655 24768458 8151482 8446861 15162173 16321597 X Upper Connecticut Valley Hospital strives to improve the well-being of the rural communities it serves by promoting health and assuring access to quality care. 1 0 12950965 15707982 Upper Connecticut Valley Hospital provided hospital care and impatient and outpatient services on a region-wide basis. The net charity care provided by the Hospital for the year-ended September 30, 2016 was $487,621. 12950965 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 22 0 1 147 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Celeste Pitts 6032374971 Corliss Lane Colebrook NH 03576 Greg E Placy Chairman 1.00 0.00 X X 0 0 0 Odette Crawford Vice Chair 1.00 0.00 X X 0 0 0 James Tibbetts Treasurer 1.00 0.00 X X 0 0 0 E Harlan Connary Secretary 1.00 0.00 X X 0 0 0 Bruce Bean Director 1.00 0.00 X 0 0 0 Frederick D Brock Director 1.00 0.00 X 0 0 0 Palmer Lewis Director 1.00 0.00 X 0 0 0 Peter Moran MD Director 1.00 0.00 X 0 0 0 Eric Stohl Director 1.00 0.00 X 0 0 0 Robert Rose MD Physician, Chief Medical Officer 62.00 0.00 X X 443642 0 4350 James Wells Director 1.00 0.00 X 0 0 0 Avis Brosseau Director 1.00 0.00 X 0 0 0 Sally S Wentzell Past Director 1.00 0.00 X 0 0 0 Edward Laverty PA-C Past Chief of Staff 59.00 0.00 X 198550 0 12496 Scott Colby President 40.00 0.00 X 0 0 0 Peter L Gosline Past Chief Administrative Officer 24.00 0.00 X 0 0 0 Celeste Pitts Chief Financial Officer 16.00 24.00 X 55123 82685 10750 Kimberlee Daley Patient Experience Officer 42.00 0.00 X 114550 0 8190 Thomas Cochran ER Medical Director 32.00 0.00 X 225649 0 4815 Robert Gooch Director of Pharmacy 42.00 0.00 X 156413 0 7174 Joseph Kiernan General Surgeon 32.00 0.00 X 271615 0 9090 Thomas Marallo Director of Lab 49.00 0.00 X 115161 0 7968 Charanjit Veeramalla Hospitalist 34.00 0.00 X 377634 0 18351 1958337 82685 83184 8 0 1 0 Androscoggin Valley Hospital 59 Page Hill Road Berlin NH 03570 Lab, Rehab & Office Staff Svcs. 1059602 CPSI PO Box 850309 Mobile AL 36685 Billing Services/Software Support 718559 Northern NH Healthcare Management LLC 59 Page Hill Road Berlin NH 03570 Management Services 345171 Vista Staffing Solutions 275 East 200 South Salt Lake City UT 84111 Locum Physician Staffing 153206 4 25400 523086 548486 Patient Service Revenue 621400 29609774 29609774 Miscellanous Revenue 624100 307398 264715 42683 Meaningful Use Revenue 621400 146237 146237 Provision for Bad debts 621400 -846974 -846974 Contractual/Char. Adj. 621400 -13508453 -13508453 15707982 240245 240245 2517419 2355054 5117 162365 -5117 157248 157248 16653961 15665299 0 440176 841201 659038 182163 5343730 4735330 608400 57329 52865 4464 1241285 1090385 150900 386070 337270 48800 338035 338035 59414 59414 53800 53800 32933 32933 78975 78975 2830503 2168013 662490 6933 6933 98332 98332 284253 284253 269973 269973 114732 60669 54063 1153 1153 690972 690972 159846 159846 Supplies Expense 1658754 1625398 33356 Medicaid Enhancement Ta 747004 747004 Miscellanous 714119 512895 196902 4322 16009346 12950965 3021126 37255 X 189100 131461 2790585 6808927 439500 2546607 1872163 296832 291351 268316 125873 12462589 8085893 4233781 4376696 10834794 10185655 473161 1680479 536832 23313655 24768458 2485739 1929583 356417 402641 750405 521081 4558921 5593556 8151482 8446861 X 14791324 15583933 197779 564594 173070 173070 15162173 16321597 23313655 24768458 644615 514809 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3683 3683 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. 263522 20177 3042 280657 191998 80000 3175 11651 263522 170203 20000 14929 13134 191998 161056 18320 9173 170203 129746 31310 161056 0.00000 0.61670 0.38330 0 0 9700 9700 3962786 2407522 1555264 8123284 5539838 2583446 366819 138533 228286 4376696 Due to Third Party Payers 5593556 5593556 17085473 514809 514809 16570664 78975 4322 83297 16653961 15926049 0 15926049 78975 4322 83297 16009346 Part XI, Line 4b - Other Adjustments: Fundraising Expenses 4,322. Part XII, Line 4b - Other Adjustments: Fundraising Expenses 4,322. X X 1 Robert P Pettegrew 117 Middle Road Hancock NH 03449 Feasibility Study and Fundraising 0 457750 32933 424817 457750 32933 424817 NH 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 565916 78295 487621 0.03050 3032528 1702928 1329600 0.08310 3598444 1781223 1817221 0.11360 447679 22027 425652 0.02660 110053 110053 0.00690 4216672 2982636 1234036 0.07710 4774404 3004663 1769741 0.11060 8372848 4785886 3586962 0.22420 58903 58903 0.00370 3251 3251 0.00020 62154 62154 0.00390 1 500295 8066763 8148245 -81482 X 1 1 1 1 Upper Connecticut Valley Hospital Corliss Lane Colebrook NH 03576 www.ucvh.org 000592 X X X X Upper Connecticut Valley Hospital 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X www.ucvh.org X 1 15 1 www.ucvh.org 0 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X www.ucvh.org X www.ucvh.org X www.ucvh.org X X X X X 1 X 0 X X X 1 X 0 0 Upper Connecticut Valley Hospital Part V, Section B, Line 5: Input from the community was solicited through a survey, which was available both electronically (through Survey Monkey) and via paper copy. Paper copies were distributed to various community locations. Electronic surveys were available via the UCVH and North Country Healthcare websites plus other community partner websites. 203 Surveys were completed. In addition, 89 Community leaders were also surveyed electronically. This group represented area business & economic development leaders, community board members of health & human service organizations, municipal government and human services providers. Upper Connecticut Valley Hospital Part V, Section B, Line 6a: The Hospital's CHNA was conducted along with Weeks Medical Center, Littleton Regional Hospital, and Androscoggin Valley Hospital. Upper Connecticut Valley Hospital Part V, Section B, Line 11: Significant Needs Identified and Being Addressed:1. Substance Misuse, Alcohol Abuse & Mental health problems: 24/7 Emergency medical care available. Naloxone (Narcan) treatment for overdose is an available option. Policy being developed for sharing Narcan kits with 3rd party friends and families. Indian Stream Health Center, the local FQHC, employs several Behavioral Health Providers through their Primary Care offices located on the same campus as the hospital. In addition, there are other Community based services available. Alcohol Anonymous is given space in the hospital for regular weekly meetings. North Country Healthcare is currently in discussion with the State to determine feasibility of creating a more in-depth hospitalization/outpatient type program for the entire region and is collaborating with the NH Region 7 activities that are targeting behavioral health concerns for the entire state.2. Obesity/Overweight: UCVH employs a registered dietician and diabetes educator who is available to provide consults and diabetes prevention classes. Meeting space for Weight Watchers and healthy and affordable meal choices for the public/visitors are also available. 3. Smoking and Tobacco Use: Ongoing smoking cessation classes available to the public. In addition, UCVH is a smoke/tobacco free campus.Significant Needs not being addressed and why:The needs identified that UCVH is not able to address center around the County's lack of jobs. Low Income/Poverty and Unemployment/Lack of Jobs were two such items. Cost of healthy foods was also mentioned. These are not within the scope of our mission; however we will continue to work with local resources in our role as a responsible corporate citizen to improve our economy where we can. There are currently several economic development groups active in the area and some new businesses are considering moving in.Other needs we are currently unable to meet revolve around lack of dental insurance, cost of prescription drugs, and access to health insurance. While UCVH cannot fix these issues, we continue to work with our patients to enroll them with Medicaid Expansion products or the Insurance Exchanges. This has resulted in a significant drop in our uninsured population. UCVH continues to offer free care for eligible patients through our UCV Free Care program. Part I, Line 7: The Hospital uses a cost-to-charge ratio. The cost-to-charge ratio was derived from the Form 990 Schedule H worksheet 2, Ratio of patient care cost-to-charges Part I, lines 7E-I. The Hospital determines cost by combining direct expenses identified by its accounting system with an estimated overhead allocation. Part I, Line 7g: Specialty Care Providers & Emergency Department Part II, Community Building Activities: The community building activities undertaken by UCVH consist of supporting local government and other health care providers, coordination of disaster drills, emergency preparedness, and support of other local organizations within the community. In addition, in an effort to provide the necessary health care services for the population within a reasonable driving distance, UCVH has entered into a collaboration with the other two Coos county hospitals to provide necessary specialty services for the UCVH service area. Part III, Line 2: The Hospital uses a cost-to-charge ratio. The cost-to-charge ratio was derived from the Form 990 Schedule H worksheet 2, Ratio of patient care cost-to-charges. The CCR was then applied to bad debt expense at charge value in order to arrive at the estimated expense reported. Part III, Line 4: Patient accounts receivable are carried at the amount management expects to collect from outstanding balances.Patient receivables are periodically evaluated for collectability based on credit history and current financial condition. Provisions for losses on receivables are determined on the basis of loss experience, known and inherent risks, estimated value of collateral and current economic conditions. The Hospital uses the allowance method to account for uncollectible accounts receivable.In evaluating the collectability of accounts receivable, the Hospital analyzes past results and identifies trends for each major payer source of revenue for the purpose of estimating the appropriate amounts of the allowance for doubtful accounts and the provision for bad debts. Data in each major payer source are regularly reviewed to evaluate the adequacy of the allowance for doubtful accounts. Specifically, for receivables relating to services provided to patients having third-party coverage, an allowance for doubtful accounts and a corresponding provision for bad debts are established at varying levels based on the age of the receivables and the payer source. For receivables relating to self-pay patients, a provision for bad debts is made in the period services are rendered based on experience indicating the inability or unwillingness of patients to pay amounts for which they are financially responsible. Actual write-offs are charged against the allowance for doubtful accounts. Part III, Line 8: Allowable costs come from the filed cost report as UCVH operates at a loss from Medicare. The shortfall could be treated as community benefit as there are no other funds available to subsidize the loss. UCVH uses CCR to determine cost revenue received is net patient revenue. Part III, Line 9b: If known to qualify for charity of financial assistance, patients are given the assistance needed. Part VI, Line 2: In 2016, North Country Healthcare partnered with the North Country Health Consortium based in Littleton, NH to complete a Community health needs assessment (CHNA) for the four affiliated hospitals. Once the CHNA was completed, a strategic planning committee of the four hospitals met to determine which community needs were to be addressed by the hospitals and which specific initiatives would be put into place to meet these needs. The initiatives will become part of the overall 2017-2019 Strategic Plan. The CHNA and the implementation plan are available on the UCVH website. Part VI, Line 3: UCVH has a full time patient financial counselor who is responsible for working with patients and any who may be billed for their care to determine their eligibility, on a case by case basis. For any government programs, such as Medicaid or the UCVH fiancial assistance program all staff at UCVH, particularly registration staff who will be the first ones to notice if a patient does not have insurance, are trained to refer the patient to the financial counselor. In addition, brochures are available, as is contact information on the website. Part VI, Line 4: UCVH is the smallest critical assess hospital in New Hampshire that serves the largest geographic service area (over 850 square miles) including communities in the states of New Hampshire, Vermont, and Maine. According to the New Hampshire state health profile, our residents are the most fragile of all citizens in New Hampshire as it relates to health outcomes and economic conditions. UCVH is dependent of public funding and disproportionate share funding to subsidize the care provided to the patients we serve Part VI, Line 7, Reports Filed With States NH X X X 0 0 0 0 0 0 0 0 0 Robert Rose MD Physician, Chief Medical Officer 440594 0 0 0 3048 0 0 0 4350 0 447992 0 0 0 Edward Laverty PA-C Past Chief of Staff 198332 0 0 0 218 0 3277 0 9219 0 211046 0 0 0 Thomas Cochran ER Medical Director 225559 0 0 0 90 0 0 0 4815 0 230464 0 0 0 Robert Gooch Director of Pharmacy 155835 0 0 0 578 0 3241 0 3933 0 163587 0 0 0 Joseph Kiernan General Surgeon 270594 0 0 0 1021 0 5396 0 3694 0 280705 0 0 0 Charanjit Veeramalla Hospitalist 377394 0 0 0 240 0 5300 0 13051 0 395985 0 0 0 Shari Parker Family member of Board Director Eric Stohl 70579 Employment 0 Form 990, Part III, line 2 Mobile MRI services began in March, 2016 through a contract with NH Imaging Services. MRI is on site 1 day/week Form 990, Part VI, Section A, line 3 Northern New Hampshire Healthcare Management, LLC provides management services to Upper Connecticut Valley Hospital. Northern New Hampshire Healthcare Management, LLC provided a Chief Administrative Officer (Peter Gosline) to UCVH from October 2015 through August 2016. Mr. Gosline was paid $193,500 during calendar year 2015 for services rendered to UCVH by Northern New Hampshire Healthcare Management, LLC. Form 990, Part VI, Section A, line 4 On June 30, 2015, Weeks Medical Center, Upper Connecticut Valley Hospital Association, Androscoggin Valley Hospital and Littleton Hospital Association, Inc. (collectively, the "Hospitals") entered into an Affiliation Agreement (the "Affiliation Agreement"), pursuant to which the Hospitals agreed to affiliate under a single common parent upon the closing of the agreement. The Affiliation Agreement resulted in the formation of North Country Healthcare, Inc. ("NCH"), a 501(c)(3) charitable organization. Effective April 1, 2016, the closing of the Affiliation Agreement occurred and NCH became the sole member of each of the Hospitals. In accordance with the Affiliation Agreement, each Hospital's charter and bylaws were amended to effect the establishment of NCH as the sole member and to create a shared governance structure between the Board of Directors of NCH and the Boards of each Hospital. Each Hospital continues to maintain its own Board of Directors (Corporation Board) that is distinct from the NCH Board of Directors. However, the Bylaws of NCH and each Hospital identify certain "Major matters" (divided into organizational and operational matters) that require initiation and/or authorization by a majority of the NCH Board. Members of the Hospital Boards are nominated exclusively by the Hospitals. However, the election of any such director must be approved by both the Hospital Board and the NCH Board. Some examples of other organizational "Major matters" requiring the initiation and/or approval of the NCH Board include amendments to by-laws, election of officers, dissolution of a Hospital, merger decisions and hiring/termination of Hospital Presidents. Examples of operational "Major matters" requiring the initiation and/or approval of the NCH Board include approval of annual capital and operating budgets, adoption of compensation and benefit programs, approval of information technology systems, financial systems and auditors, plus approval of any major changes to clinical services offered. The Chief Executive Officer position at each of the Hospitals has been changed to a President position. As with Board members, each Hospital President must be nominated at the Hospital level and then approved by both the Hospital Board and the NCH Board. This position reports to both the applicable Hospital Board and the Chief Executive Officer of NCH. The Chief Financial Officer of each of the Hospitals will remain an appointed position by the President, but this individual will also report to the President/Chief Financial Officer of NCH. Form 990, Part VI, Section A, line 6 Effective April 1, 2016, North Country Healthcare (NCH) became the Sole Member of Upper Connecticut Valley Hospital. Form 990, Part VI, Section A, line 7a See narrative provided for Form 990, Part VI, line 4. Form 990, Part VI, Section A, line 7b See narrative provided for Form 990, Part VI, line 4. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by CFO & President of the Hospital. After their review is complete, the Form is shared with the Board Finance Committee prior to filing. Form 990, Part VI, Section B, line 12c Directors, Officers, Highly Compensated Employees are all required to review and sign the Conflict of Interest Document. Form 990, Part VI, Section B, line 15 The hospital CAO's compensation and benefit package is reviewed periodically by community board members who govern the non-profit organization as unpaid, independent volunteers. The periodic review includes comparability data, and the deliberation and decision making is substantiated by written minutes. Form 990, Part VI, Section C, line 18 UVCH makes its 990 available upon request. Form 990, Part VI, Section C, line 19 Available upon request. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Upper Connecticut Valley Hospital Corliss Lane Colebrook, NH 03576 EIN: 02-0276210 Upper Connecticut Valley Hospital is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 812225283 Healthcare Management NH 501(c)(3) Line 11a, I 0 Androscoggin Valley Hospital Inc 59 Page Hill Road Berlin NH 03570 020280367 Critical Access Hospital NH 501(c)(3) Line 3 0 Weeks Medical Center 173 Middle Street Lancaster NH 03584 020222242 Critical Access Hospital NH 501(c)(3) Line 3 0 Littleton Hospital Association 600 St Johnsbury Road Littleton NH 03561 020222152 Critical Access Hospital NH 501(c)(3) Line 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0