2016-08-02T07:00:28-05:00 2015-12-31 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2015-01-01 010409788 COMMUNITY CLINICAL SERVICESINC COMM 2077778546 CAMPUS AVE PO BOX 7291 LEWISTON ME 042407291 JOAN CHURCHILL EXECUTIVE DIRECTOR/CFO 2077778546 2016-07-26 E DREW CHENEY P00182972 8002447444 2016-07-26 2015 2016-12-15 16:53:06Z JOAN CHURCHILL 57 BIRCH ST SUITE 201 LEWISTON ME 042407291 15001742 0 X WWW.STMARYSMAINE.COM X 1984 ME PRIMARY AND SPECIALTY HEALTHCARE TO ALL RESIDENTS. 12 8 159 0 0 0 2934214 2155660 9881443 12837168 -35728 8914 0 0 12779929 15001742 0 0 0 0 10205677 11940016 0 0 0 2534161 3038246 12739838 14978262 40091 23480 2043712 2927466 1531776 1864687 511936 1062779 X 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 7027032 5985037 BEHAVIORAL MEDICINE: PSYCHIATRIC CARE FOR CHILDREN AND ADULTS. 2015 VISITS - 44,997 3496389 3139937 FAMILY PRACTICE: MEDICAL CARE FOR INFANTS, CHILDREN, AND ADULTS. 2015 VISITS - 19,799 1407237 1934582 OUTPATIENT COUNSELING: COUNSELING SERVICES FOR CHILDREN AND ADULTS. 2015 VISITS - 17,291 866424 1162823 DENTAL CLINIC - DENTAL CARE FOR CHILDREN AND ADULTS - 2015 VISITS 7,437 753589 614789 SCHOOL BASED HEALTH CARE - NURSING AND COUNSELING SERVICES OFFERED TO THE LOCAL AREA SCHOOL SYSTEM - 2015 VISIT 5,738 1620013 1777612 13550671 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 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 1 159 1 0 0 0 0 0 0 0 0 0 0 X 12 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 ME X X CAROLYN KASABIAN 2077778546 96 CAMPUS AVENUE PO BOX 7291 LEWISTON ME 042407291 ABDIFATAH AHMED DIRECTOR 3.00 X 0 0 0 BARBARA RANKINS DIRECTOR 2.00 X 0 0 0 BOB ROWE THRU JUNE 2015 CHAIR 4.00 X X 0 0 0 CAROLE MOREAU DIRECTOR 2.00 X 0 0 0 CAROLYN KASABIAN TREASURER 2.00 38.00 X X 0 274848 23417 ELIZABETH KEENE DIRECTOR 2.00 38.00 X 0 123213 8217 ELMUATZ ABDELRAHIM DIRECTOR 2.00 X 0 0 0 LEO MYLES THRU 12015 DIRECTOR 2.00 38.00 X 0 365796 22464 MELISSA DUNN VICE CHAIR 2.00 X X 0 0 0 RENE DUMONT DIRECTOR 2.00 38.00 X 0 204676 25374 ROBERT GAGNON DIRECTOR 2.00 X 0 0 0 SALLY BELISLE CHAIR 2.00 X X 0 0 0 SUSAN KEILER SECRETARY 2.00 38.00 X X 0 276777 21316 ZAMZAM MOHAMUD DIRECTOR 2.00 X 0 0 0 JOAN CHURCHILL CFO/CEO 40.00 X 89410 0 4486 MICHAEL KELLEY PHYSICIAN 40.00 X 486963 0 21147 SCOTT TREWORGY PHYSICIAN 40.00 X 411513 0 22352 KEVIN KAVOOKJIAN PHYSICIAN 40.00 X 379406 0 21064 THADDEUS SHATTUCK PHYSICIAN 40.00 X 312521 0 21397 ABHAY SINGH PHYSICIAN 40.00 X 277132 0 20236 1956945 1245310 211470 28 0 1 0 ST MARY'S REGIONAL MEDICAL CENTER PO BOX 7291 CAMPUS AVE LEWISTON ME 042430291 PURCHASED SERVICES 997986 BARTON ASSOCIATES INC PO BOX 417844 BOSTON MA 022417844 PEDIATRIC LOCUM 196585 ST MARY'S HEALTH SYSTEM PO BOX 7291 CAMPUS AVE LEWISTON ME 042430291 PURCHASED SERVICES 138672 3 1904962 226621 24077 2155660 NET PATIENT SERVICES REVENUE 621110 11414778 11414778 OTHER PROGRAM SERVICES REVENUE 621110 1029640 1029640 MEDICAL DIRECTOR REVENUE 621110 392750 392750 12837168 8914 8914 15001742 12837168 0 8914 10530636 10293318 237318 51558 50747 811 734704 708484 26220 623118 613317 9801 20491 20491 19138 19138 277575 272813 4762 115473 112241 3232 46550 45776 774 138629 78503 60126 PURCHASED SERVICES 1034875 59591 975284 OUTSIDE LABOR 844709 819707 25002 MINOR EQUIPMENT 160687 160687 COMPUTER SERVICE 147401 147364 37 232718 188123 44595 14978262 13550671 1427591 0 263228 810895 813604 1199714 6291 1610 88579 82475 738035 457934 162990 280101 709020 552671 2043712 2927466 1393558 1820980 138218 43707 1531776 1864687 X 459721 1035951 52215 26828 511936 1062779 2043712 2927466 X 23480 -3745 531108 X 0 1 X 1 0 X 310464 3143641 2324833 2894589 2155660 10829187 8963848 8996437 10366097 9881443 12837168 51044993 9274312 12140078 12690930 12776032 14992828 61874180 0 0 0 61874180 -1 44 1082 4968 8914 15007 -1 44 1082 4968 8914 15007 9274311 12140122 12692012 12781000 15001742 61889187 0.99980 0.99990 0.00020 0.00010 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. 52215 19735 45122 26828 56576 40092 44452 52215 1601 55000 25 56576 14101 2500 15000 1601 11845 12865 10609 14101 0.00000 0.00000 1.00000 0 0 41590 13183 28407 5200 5200 0 691245 439551 251694 280101 DUE TO RESTRICTED FUNDS 26828 BOARD DESIGNATED FUNDS 433788 DUE FROM SMHS 459730 DUE TO SMRMC -336264 DUE TO RESIDENCES -31411 552671 DUE TO THIRD PARTY PAYORS 43707 43707 X 13073300 -3745 -3745 13077045 1924697 1924697 15001742 14978262 0 14978262 0 14978262 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, 2015. CCS'S TAX YEARS FROM 2012 THROUGH 2015 ARE OPEN AND SUBJECT TO EXAMINATION. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS-RESTRICTED 1,535. COMMUNITY SUPPORT GRANT 1,904,962. GRANT DONATION-RESTRICTED 18,200. X X 0 0 0 0 0 0 0 1 0 CAROLYN KASABIAN TREASURER 0 274848 0 0 0 0 0 2624 0 20793 0 298265 0 0 LEO MYLES THRU 12015 DIRECTOR 0 365796 0 0 0 0 0 2614 0 19850 0 388260 0 0 RENE DUMONT DIRECTOR 0 204676 0 0 0 0 0 2154 0 23220 0 230050 0 0 SUSAN KEILER SECRETARY 0 276777 0 0 0 0 0 2634 0 18682 0 298093 0 0 MICHAEL KELLEY PHYSICIAN 369612 0 117351 0 0 0 2637 0 18510 0 508110 0 0 0 SCOTT TREWORGY PHYSICIAN 323361 0 88152 0 0 0 2524 0 19828 0 433865 0 0 0 KEVIN KAVOOKJIAN PHYSICIAN 315865 0 63541 0 0 0 2622 0 18442 0 400470 0 0 0 THADDEUS SHATTUCK PHYSICIAN 231514 0 81007 0 0 0 1843 0 19554 0 333918 0 0 0 ABHAY SINGH PHYSICIAN 150307 0 126825 0 0 0 2263 0 17973 0 297368 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 11 FORM 990 IS PROVIDED TO THE BOARD MEMBERS AND REVIEWED AT THE JULY 2016 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 -45,122. INTERCOMPANY TRANSFERS 576,230. 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 ST MARY'S D'YOUVILLE PAVILLION 102 CAMPUS AVE LEWISTON ME 04240 010211558 NURSING HOME FACILITY 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