2015-02-11T11:10:07-06:00 2014-09-30 020476956 TYLER SIMMS & STSAUVEUR CPAS PC 19 MORGAN DRIVE LEBANON NH 03766 990 2013-10-01 020276210 UPPER CONNECTICUT VALLEY HOSPITAL UPPE 6032374971 CORLISS LANE COLEBROOK NH 03576 JAMES TIBBETTS TREASURER 6032374971 2015-02-02 1 JAMES N GODFREY CPA P00913422 6036530044 2015-02-02 2013 2016-02-25 16:41:14Z GREG PLACY CORLISS LANE COLEBROOK NH 03576 17122554 0 X WWW.UCVH.ORG X 1969 NH TO PROVIDE HEALTH CARE SERVICES. 13 11 154 20 0 0 56697 97385 13921381 15055633 395132 630220 848125 42991 15221335 15826229 50000 50000 0 0 8215712 7943323 0 0 2118 6596387 6652023 14862099 14645346 359236 1180883 19408317 21230154 5700013 6232373 13708304 14997781 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. 0 0 11384723 50000 15055633 UPPER CONNECTICUT VALLEY HOSPITAL PROVIDED HOSPITAL CARE AND INPATIENT AND OUTPATIENT SERVICES ON A REGION-WIDE BASIS. THE NET CHARITY CARE PROVIDED BY THE HOSPITAL FOR THE YEAR-ENDED SEPTEMBER 30, 2014 WAS $515,372. 11384723 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 35 0 1 154 1 0 0 0 0 0 0 0 0 0 0 X 13 11 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X X THE ORGANIZATION 6032374971 UCVH CORLISS LANE COLEBROOK NH 03576 X E HARLAN CONNARY SECRETARY 1.00 X X 0 0 0 BRUCE BEAN DIRECTOR 1.00 X 0 0 0 ODETTE CRAWFORD VICE CHAIR 1.00 X X 0 0 0 JAMES TIBBETTS TREASURER 1.00 X X 0 0 0 GREG PLACY CHAIRMAN 1.00 X X 0 0 0 PALMER LEWIS DIRECTOR 1.00 X 0 0 0 PETER MORAN MD DIRECTOR 1.00 X 0 0 0 ERIC STOHL DIRECTOR 1.00 X 0 0 0 SALLY WENTZELL DIRECTOR 1.00 X 0 0 0 EDWARD LAVERTY PA-C MEDICAL STAFF REPRESENTATIVE 56.00 X 175511 0 22582 FREDERICK D BROCK DIRECTOR 1.00 X 0 0 0 PETER L GOSLINE STARTED MAY 2014 CHIEF ADMINISTRATIVE OFFICER 24.00 X X 0 0 0 NICOLE PAIER-MULLEN PHYSICIAN, CHIEF MEDICAL OFFICER 32.00 X 253220 0 16642 CHARLES WHITE - PART-YEAR CHIEF ADMINISTRATIVE OFFICER 40.00 X X 168816 0 5257 CELESTE PITTS CHIEF FINANCIAL OFFICER 16.00 X 55269 0 4384 THOMAS COCHRAN PHYSICIAN 16.00 X 115122 0 0 JOHN EPPOLIOTO PHYSICIAN 63.00 X 344808 0 20655 CHARANJIT VEDI PHYSICIAN 34.00 X 358545 0 7200 JOSEPH KIEMAN PHYSICIAN 31.00 X 215447 0 23759 ROBERT GOOCH PHARMACIST 41.00 X 158420 0 5489 1845158 0 105968 11 0 1 0 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL ROAD BERLIN NH 03570 REHAB SERVICES 716622 CPSI 6600 WALL STREET MOBILE AL 36695 BILLING OUTSOURCE 692318 DANIEL HEBERT INC 12 PLEASANT STREET COLEBROOK NH 03576 BUILDING UPGRADES 391483 AMN HEALTHCARE 12400 HIGH BLUFF DRIVE SAN DIEGO CA 92130 LOCUMS STAFFING 290962 DARTMOUTH HITCHCOCK CLINIC 1 MEDICAL CENTER DRIVE LEBANON NH 03756 PATHOLOGIST & RADIOLOGIST STAFFING 206778 5 60810 36575 97385 PATIENT SERVICE REVENU 900099 24112708 24112708 MISCELLANOUS REVENUE 900099 269704 269704 SCHOOL NURSING 624100 186513 186513 MEANINGFUL USE REVENUE 900099 133809 133809 MEDICAL RECORD TRANSMI 900099 1723 1723 -9648824 -9648824 15055633 157500 157500 1766166 2879 1296325 0 469841 2879 472720 472720 CAFETERIA 900099 42991 42991 42991 15826229 15055633 0 673211 50000 50000 200995 200995 6428029 5730596 697433 55658 48143 7515 858802 746171 112631 399839 345850 53989 68835 68835 66793 66793 26146 23662 2484 1153474 1103340 50134 251812 161972 89840 601118 490809 110309 126816 85989 40827 1090 1090 555846 555846 110010 110010 PURCHASED SERVICES 2361541 1403038 958503 MEDICAID ENHANCEMENT TA 620583 620583 REPAIRS AND MAINTENANCE 226262 221599 4663 RECRUITMENT 226070 225906 164 255627 191802 61707 2118 14645346 11384723 3258505 2118 331548 303517 3401509 3498816 2012004 2137100 295772 267879 226509 210553 11745629 7295714 4173078 4449915 7480449 8293695 358769 271581 1128679 1797098 19408317 21230154 1806337 2274599 173973 417675 1244193 977598 2475510 2562501 5700013 6232373 X 13185384 14542320 449850 362391 73070 93070 13708304 14997781 19408317 21230154 1180883 108594 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 3685 3685 0 PART II-B, LINE 1: UPPER CONNECTICUT VALLEY HOSPITAL IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THIS ORGANIZATION IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF UCVH AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. UPPER CONNECTICUT VALLEY HOSPITAL DOES NOT DIRECLTY PERFORM ANY LOBBYING ACTIVITIES. 170203 20000 14929 13134 191998 161056 18320 9173 170203 129746 31310 161056 127616 2130 129746 112258 15358 127616 0.48470 0.51530 0 0 9700 9700 4101374 2251682 1849692 231555 126862 104693 7344353 4917170 2427183 58647 58647 4449915 OTHER RECEIVABLES 1562057 DEPOSITS & OTHER 38782 RECEIVABLE FROM NORTHERN NH HEALTHCARE COLLABORATIVE 171259 RECEIVABLE FROM NORTHERN NH HEALTHCARE MANAGEMENT 25000 1797098 DUE TO THIRD PARTY PAYERS 2562501 2562501 15932705 108594 108594 15824111 2118 2118 15826229 14643228 0 14643228 2118 2118 14645346 PART V, LINE 4: THE INVESTMENTS ARE TO BE HELD IN PERPETUITY. THE INCOME FROM THE INVESTMENTS IS EXPENDABLE TO SUPPORT THE HOSPITAL'S HEALTH CARE SERVICES. PART XI, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 2,118. PART XII, LINE 4B - OTHER ADJUSTMENTS: FUNDRAISING EXPENSE 2,118. 1 1 1 X 1 X 1 1 0 1 1 522813 241658 281155 0.01920 2031302 2004899 26403 0.00180 2554115 2246557 307558 0.02100 3791229 2291136 1500093 0.10240 108184 108184 0.00740 712503 337677 374826 0.02560 50213 50213 0.00340 4662129 2628813 2033316 0.13880 7216244 4875370 2340874 0.15980 1347 1347 0.00010 1996 1996 0.00010 0 2194 2194 0.00010 53789 53789 0.00370 5167 5167 0.00040 64493 64493 0.00440 1 677118 21667 7510139 7585999 -75860 X 1 1 1 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC LLC OF 3 COOS COUNTY HOSPITALS 1 1 UPPER CONNECTICUT VALLEY HOSPITAL 181 CORLISS LANE COLEBROOK NH 03576 X X X X UPPER CONNECTICUT VALLEY HOSPITAL 1 1 X X X X X X X X X 13 1 0 1 X WWW.UCVH.ORG X 1 0 1 1 125.000000000000 1 300.000000000000 1 X X X X X X X X 1 1 X X X 1 0 X X X 1 X 0 0 PART I, LINE 7: PART I, LINES 7A-C; 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, LET NO WOMAN BE OVERLOOKED 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 4: PATIENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTIBILITY OF ACCOUNTS RECEIVABLE, THE HOSPITAL ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICE PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, INCLUDING BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND CO-PAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR ONLY PART OF THE BILL, THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE HOSPITAL HAS ESTIMATED ITS COST OF BAD DEBT USING COST-TO-CHARGE METHODOLOGY IN ACCRODANCE WITH WORKSHEET 2 OF THE FORM 990 SCHEDULE H INSTRUCTIONS. 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 OR FINANCIAL ASSISTANCE, PATIENTS ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: UCVH, WITH COLLABORATION FROM INDIAN STREAM HEALTH CENTER (A FEDERALLY QUALIFIED HEALTH CENTER), COMPLETED ITS LAST COMMUNITY HEALTH NEEDS ASSESSMENT IN 2013. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS CONDUCTED USING FOCUS GROUPS TO SOLICIT FEEDBACK FROM KEY STAKEHOLDERS, AND TO ANALYZE TRENDS IN REGARD TO POPULATION, HEALTH AND RISK FACTORS FOR THE COOS COUNTY. THE INFORMATION GATHERED IS THEN USED AS PART UCVH'S STRATEGIC PLANNING PROCESS. THE COMMUNITY HEALTH NEEDS ASSESSMENT IS AVAILABLE ON THE ORGANIZATION'S 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 FINANCIAL 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 ACCESS 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 0 INDIAN STREAM HEALTH CENTER INC 2 CORLISS LN RR2 BOX 25 COLEBROOK NH 03576 200999212 501(C)3 50000 FMV MEDICAL SERVICESMEDICAL SERVICES X 0 1 X X X 0 0 0 0 0 0 0 0 0 EDWARD LAVERTY PA-C MEDICAL STAFF REPRESENTATIVE 175457 0 54 0 0 0 3277 0 19305 0 198093 0 0 0 NICOLE PAIER-MULLEN PHYSICIAN, CHIEF MEDICAL OFFICER 252166 0 1054 0 0 0 0 0 16642 0 269862 0 0 0 CHARLES WHITE - PART-YEAR CHIEF ADMINISTRATIVE OFFICER 143774 0 25042 0 0 0 0 0 5257 0 174073 0 0 0 JOHN EPPOLIOTO PHYSICIAN 334454 0 10354 0 0 0 0 0 20655 0 365463 0 0 0 CHARANJIT VEDI PHYSICIAN 358491 0 54 0 0 0 7200 0 0 0 365745 0 0 0 JOSEPH KIEMAN PHYSICIAN 215393 0 54 0 0 0 0 0 23759 0 239206 0 0 0 ROBERT GOOCH PHARMACIST 158366 0 54 0 0 0 3241 0 2248 0 163909 0 0 0 PART I, LINE 1A THE HOSPITAL PAYS THE RENT FOR AN APARTMENT FOR THE USE OF A PHYSICIAN. FORM 990, PART VI, SECTION A, LINE 3 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT, LLC PROVIDES MANAGEMENT SERVICES TO THE HOSPITAL. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS PROVIDED TO THE FINANCE COMMITTEE FOR REVIEW AND APPROVAL BEFORE IT IS FILED. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS, AMD KEY EMPLOYEES ARE REQUIRED TO SIGN A 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 ORGANZATION 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 AND ON THE GUIDESTAR WEBSITE FORM 990, PART VI, SECTION C, LINE 19 AVAILABLE UPON REQUEST FORM 990, PART VII CELESTE PITTS IS THE CFO FOR UCVH AND FOR WEEKS MEDICAL CENTER, TWO FIFTHS OF HER TIME IS SPENT AT UCVH. SHE RECEIVES A FORM W-2 FROM WEEKS MEDICAL CENTER. WEEKS MEDICAL CENTER IS PAID FOR HER TIME BY NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC, WHICH IS PAID BY UCVH. AN ALLOCATION OF HER CALENDAR-YEAR WAGES AND BENEFITS ARE INCLUDED ON PART VII. HER FISCAL-YEAR WAGES AND BENEFITS ARE NOT SHOWN SEPARATELY ON PART IX, LINE 5, BUT ARE INCLUDED IN THE PAYMENT TO NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC. NORTHERN NEW HAMPSHIRE HEALTHCARE COLLABORATIVE INC 462459559 HEALTHCARE NH 501(C)(3) LINE 9 0 NORTHERN NEW HAMPSHIRE HEALTHCARE MANAGEMENT LLC 455617105 MANAGEMENT SERVICES NH RELATED 0 1 0.33330 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 NORTHERN NH HEALTHCARE COLLABORATIVE INC D 171259 NORTHERN NH HEALTHCARE MANAGEMENT LLC D 25000 NORTHERN NH HEALTHCARE MANAGEMENT LLC L 360218