2014-08-14T13:13:05-05:00 2013-09-30 010494526 BAKER NEWMAN & NOYES PO BOX 507 PORTLAND ME 04112 990 2012-10-01 030177161 Carlos G Otis Health Care Center CARL 8023657920 PO Box 216 Townshend VT 053530216 Stephen A Brown 8023657920 2014-08-08 1 Nicholas E Porto P01310283 2078792100 2012 2015-11-30 17:44:51Z Grace Cottage Hospital Deborah Boyle PO Box 216 Townshend VT 053530216 21050908 0 X www.gracecottage.org X 1949 VT Provision of health care services 11 10 218 110 0 0 811781 684536 22879619 20366174 -12989 198 323244 0 24001655 21050908 0 0 0 0 13340068 12674441 0 0 161778 8347554 8850682 21687622 21525123 2314033 -474215 17706645 14546744 7891445 4787260 9815200 9759484 The Otis Health Care Center promotes excellence in healthcare and well being, putting people first. It aims to be the standard for patient care. 0 0 19538079 20366174 Grace Cottage Hospital is a critical access hospital offering 24-hour emergency services, inpatient acute and skilled care, 24-hour diagnostic imaging services, a full-service laboratory, a pharmacy, a variety of outpatient medical care services, including physical therapy, occupational therapy, and speech therapy, and a rural health clinic providing primary care and psychiatric services. 19538079 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 18 0 1 218 1 0 0 0 0 0 0 0 0 0 0 X 11 10 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Stephen A Brown 8023653601 185 Grafton Road Townshend VT 05353 X Roger Allbee 1.00 1.00 X 0 0 0 Edward Elliott MD 1.00 0.00 X 0 0 0 Barry Emerson 1.00 0.00 X 0 0 0 Stanley Holt 1.00 0.00 X 0 0 0 John Nopper 1.00 0.00 X 0 0 0 Timothy P Shafer MD 50.00 0.00 X 259398 0 30643 Allan Shirks 1.00 0.00 X 0 0 0 Deborah Boyle 1.00 0.00 X X 0 0 0 Stephan Morse 1.00 0.00 X X 0 0 0 Kevin Meyer 1.00 0.00 X X 0 0 0 Gail Ann Fisher 1.00 0.00 X X 0 0 0 J Walter Corcoran 1.00 1.00 X X 0 0 0 Michael L Brant 41.10 1.00 X 178237 0 25603 Jeffrey G White LFACHE 20.80 1.00 X 0 0 0 Margaret S Cleary FACHE 20.80 1.00 X 0 0 0 Stephen A Brown 48.60 0.00 X 181841 0 28929 Maurice Geurts MD 50.00 0.00 X 273667 0 30681 Moss J Linder MD 44.00 0.00 X 185749 0 28212 Jeanne Fortier 44.30 0.00 X 137467 0 13449 Lynn Madsen MD 41.00 0.00 X 152741 0 8234 Richard Meyer MD 42.00 0.00 X 231448 0 28081 1600548 0 193832 18 0 1 0 Cerner Corporation PO Box 412702 Kansas City MO 64141 Computer hardware/software/support 957613 Brunelle & Son Construction 416 Tucker Reed Road East Dummerston VT 05346 Building Construction/renovation 275212 Brattleboro Retreat PO Box 803 Brattleboro VT 05302 Contracted Psychiatrist 217289 Mary Morgan (Lockwood Morgan LLC) 1515 Windham Hill Road West Townshend VT 05359 EMR Implementation Consultant 165180 CPSI PO Box 850309 Mobile AL 366850309 Computer hardware/software/support 128070 5 562475 54869 67192 684536 Patient Service Revenue 621400 15787196 15787196 Pharmacy Revenue 446110 3865321 3865321 GCF Administration/Other 621400 232651 232651 Disproportionate Share Funding 621400 216999 216999 Meaningful Use Revenue 621990 174461 174461 89546 89546 20366174 198 198 21050908 20366174 0 198 542507 290429 252078 9442347 8620274 715344 106729 169406 156191 11250 1965 1852861 1678500 153924 20437 667320 597197 62946 7177 22211 22211 85701 85701 508658 443367 65291 116847 15408 98657 2782 568104 401920 153427 12757 498910 428943 67552 2415 283752 271159 7543 5050 116582 105437 9006 2139 27131 27131 160363 126845 33518 1410562 1406541 4021 270261 229359 40575 327 Medical supplies & lab 3193955 3193955 Provision for bad debts 706937 706937 Medicaid tax 570735 570735 Equipment repair expens 266666 266666 43307 1085 42222 21525123 19538079 1825266 161778 59804 232224 38102 52679 2259928 2135385 7021 983595 1009449 103272 103585 14383527 9251334 6137949 5132193 36185 8116974 5845044 17706645 14546744 2398201 1667812 1425000 1310000 4068244 1674399 0 135049 7891445 4787260 X 7206493 7117438 254035 226364 2354672 2415682 9815200 9759484 17706645 14546744 X -474215 418499 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 5144 0 0 0 5144 0 Explanation of Lobbying Activities: Part II-B, Line 1: Carlos G. Otis Health Care Center is a member of the Vermont Association of Hospitals and Health Systems and the American Hospital Association. A portion of the dues paid to these organizations is available for lobbying expenditures on behalf of Carlos G. Otis Health Care Center in furtherance of its exempt purpose. Carlos G. Otis Health Care Center does not directly perform any lobbying activities. AHA, portion of dues available for lobbying: $523 VAHHS, portion of dues available for lobbying: $4,621 2608707 48373 15034 2642046 2636804 1267 99915 129279 2608707 2443026 186971 25839 19032 2636804 2298260 104897 39869 2443026 2513056 24191 -75026 163961 2298260 0.07120 0.91430 0.01450 0 1 1 30549 30549 6361991 4197814 2164177 7916415 5014077 2902338 74572 39443 35129 5132193 Beneficial interest in net assets of GCF 5524624 Deposits with Trustee 57955 Meaningful use receivable 174460 Other Receivables 88005 5845044 Estimated Third Party Payor Settlements 135049 135049 X 21469407 418499 418499 21050908 0 21050908 21525123 0 21525123 0 21525123 Description of Intended Use of Endowment Funds: Part V, Line 4: OHCC uses its endowmnent funds to assist in the provision of health care. Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: OHCC and the Foundation are tax-exempt corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Internal Revenue Code. In addition, the Foundation qualifies for the charitable contribution deduction under Section 170(b)(1)(a) and had been classified as an organization that is not a private foundation under Section 509(a)(2). Management evaluated the Organization's tax positions and concluded the Organization has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements. With few exceptions, the Organization is no longer subject to income tax examination by the U.S. federal or state tax authorities for years before 2010. Part XI, Line 2d - Other Adjustments: Increase in Beneficial Interest in Net Assets of GCF 418,499. 1 1 1 X 1 X 1 1 0 1 1 254858 254858 0.01220 3218680 1423685 1794995 0.08620 3473538 1423685 2049853 0.09840 82232 17063 65169 0.00310 66085 66085 0.00320 148317 17063 131254 0.00630 3621855 1440748 2181107 0.10470 1 600180 119416 9501264 8755628 745636 X 1 0 1 1 Grace Cottage Hospital

185 Grafton Road Townshend VT 05353

X X X X Grace Cottage Hospital 1 1 X X X X X X X X X 12 1 1 1 X X X 1 0 1 1 100.000000000000 1 200.000000000000 1 X 1 1 X X 0 0 1 X 0 1 2 Messenger Valley Pharmacy

170 Grafton Road Townshend VT 05353

Pharmacy Grace Cottage Family Health

185 Grafton Road Townshend VT 05353

Rural health clinic Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: The amounts reported for Charity Care and Means-Tested Government Programs were calculated using a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. Part I, Line 7g: N/A Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 706937. Part II: See previous footnotes. Part III, Line 4: The cost of the bad debt expense reported on line 2 was calculated by applying the ratio of patient care cost-to-charges (calculated on Worksheet 2) to the total bad debt expense. The amount of bad debt expense for accounts written off as bad debt is the account balance after all charity care discounts, contractual allowances, and insurance/patient payments have been applied. Any cash collected on accounts previously written off is included as an offset to bad debt expense.The amount of bad debt expense (at cost) attributable to patients eligible under our charity care policy reported on line 3 was estimated based on a review of reduced fee/free care applications. The number of approved completed applications versus the number of incomplete applications was compared and a ratio applied to the charity care balance to estimate this number. It is felt that this estimate should actually be much higher because, though we work hard to educate our patients regarding the charity care policy, including having a resource advocate to help patients complete them if they require assistance, many of the applications we distribute to patients are not returned. Knowing our patient population as we do, we feel it is primarily attributable to patients not wanting to share the income information. Footnote I to the audited consolidated financial statements of the Hospital contains the following to address bad debt: Accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to the allowance for doubtful accounts based on its assessment of individual accounts and historical experience. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the allowance for doubtful accounts and a credit to accounts receivable. Part III, Line 8: Medicare allowable costs reported in the Medicare Cost Report are reported in accordance with CMS Guidelines using the cost-to-charge ratio methodology. Part III, Line 9b: N/A Grace Cottage Hospital Part V, Section B, Line 3: As required by Vermont statute, Grace Cottage Hospital conducts a Community Health Needs Assessment (CNHA) every three years. Our most recent CHNA was done collaboratively in 2012 with Brattleboro Memorial Hospital (BMH) and the Brattleboro Retreat. These three healthcare organizations focused on involving as many stakeholders and community members as possible in the data collection. The three hospitals set up a steering committee made up of individuals from the State of Vermont Department of Health, Brattleboro Memorial Hospital, Grace Cottage Hospital, The Brattleboro Retreat, United Way of Windham County, Agency of Human Services, Visiting Nurse Association & Hospice of VT & NH, Valley Cares, West River Valley Assisted Living, and Senior Solutions. Additionally, the participating organizations engaged a wide range of stakeholders through the surveys and focus groups, including health care providers, human service organizations, youth development organizations, schools and other nonprofit organizations. Grace Cottage Hospital continues to collaborate with BMH and the Brattleboro Retreat to improve community awareness of existing health and wellness programs and services to Windham County residents, which was one of the needs identified in the Community Health Needs Assessment. The three organizations publish a comprehensive Health and Wellness Calendar, distributed county-wide, twice annually, which includes listings of all health and wellness events and classes that are available for the public. In addition, the Wellness in Windham website (www.wellnessinwindham.org) is maintained by the three organizations with updated, current information on classes, programs, and services. Grace Cottage Hospital has been addressing two additional needs identified in the assessment:-Diabetes awareness, management and education. Through the Vermont Blueprint for Health initiative, Grace Cottage's Community Health Team, made up of skilled health professionals, works with diabetes patients, one-on-one, to help with disease management. -Transportation needs for the rural area in which we serve. During FY13, Grace Cottage Hospital was an active participant in the Brattleboro Business Transportation Roundtable group, working with United Way of Windham County, Windham Regional Commission, Connecticut River Transit, Go Vermont and Vital Communities to identify transportation issues in the West River Valley and in Brattleboro, and to work towards finding solutions to these issues. Grace Cottage Hospital Part V, Section B, Line 4: The Community Health Needs Assessment 2012 was conducted with Brattleboro Memorial Hospital and The Brattleboro Retreat. Grace Cottage Hospital Part V, Section B, Line 5c: The results of the 2012 survey are available to the public on the Hospital's website, www.gracecottage.org, and are also available upon request from the hospital facility. Grace Cottage Hospital Part V, Section B, Line 6i: The information in the 2012 Community Health Needs Assessment was part of the discussion during Grace Cottage Hospital's strategic planning process throughout FY13. Grace Cottage Hospital Part V, Section B, Line 20d: The Hospital charged standard facility rates as billed to all patient and insurers. Patients were eligible to apply for financial assistance based on policy. Grace Cottage Hospital Part V, Section B, Line 22: As stated on line 19d, all charges billed were standard facility charges. Part VI, Line 2: Grace Cottage Hospital is such a small hospital in a rural, relatively sparsely populated area that our community leaders, patients, and members of the public are quick to inform our administrators and our medical staff about how Grace Cottage serves the healthcare needs of the public. Grace Cottage's small size ensures that we can be responsive to community requests made via our website, e-mails to members of our staff, or informal face-to-face meetings with people in the communities we serve. Part VI, Line 3: Although we are Vermont's smallest Critical Access Hospital, Grace Cottage Hospital believes that quality health care should be available to all; and that we all have a responsibility to help others in need regardless of their ability to pay. Posters and brochures detailing the availability of help with billing, public programs, and charity care are displayed in high traffic areas throughout the Hospital, rural health clinic and pharmacy, as well as listed on the Hospital's website. The staff reaches out to patients in a variety of ways to ensure that they are aware that help is available. During FY13, the Hospital employed a Resource Advocate to help uninsured and underinsured patients locate and procure services for which they may qualify. The Resource Advocate's services were free of charge for community members between the ages of 18-64 years (those 65 and older were encouraged to contact Senior Solutions, formerly Southeastern Vermont Council on Aging, located on the Hospital premises during FY13). The Hospital's Resource Advocate helped many people with a wide variety of resource issues, helping to fill out necessary forms and making connections for patients with other federal, state and local resources. This employee was an expert in filling out reduced fee applications, finding sources for reduced-cost or free prescription medications, and locating other avenues of support. Part VI, Line 4: Grace Cottage Hospital plays a vital role in healthcare for this rural, mountainous community. Its federal designation as a critical access hospital recognizes its importance in providing health care to an otherwise medically underserved community. The Hospital's emergency department is especially vital to members of the community, who would otherwise have to travel many miles on winding, mountainous highways to reach emergency medical care at another hospital. Grace Cottage Hospital is located in Windham County, in southeastern Vermont. According to the U.S. Census Bureau, Windham County has an estimated total of 44,857 residents. Grace Cottage Hospital's patient base is approximately 26,000 residents, mostly from 21 surrounding towns. The median household income of Windham County, Vermont, is $51,113 (U.S. Census Bureau "Quick Facts," updated 4-1-12). Income statistics for the total population served by Grace Cottage Hospital are not available because Grace Cottage only requires income information from patients requesting reduced fees or free care. Part VI, Line 5: Grace Cottage Hospital is a Critical Access Hospital located in rural, mountainous Townshend, Vermont. The Hospital is served by a board of trustees consisting of local citizens active in community businesses and organizations. Only one of the eleven trustees, a physician, is a hospital employee. All trustees reside in the Hospital's service area and bring a wealth of community input to the Hospital's strategic planning process. The Hospital extends medical staff privileges to all qualified physicians in the community.Grace Cottage Hospital applies any surplus funds towards improving its ability to provide quality patient care and being an integral part of assuring the health and well-being of the communities we serve. Despite its small size, Grace Cottage Hospital is committed to giving back to the community to the greatest extent possible. Area non-profit organizations providing health-related and emergency preparedness-related services to the community are provided with meeting and training space at the Hospital. In response to the last Community Health Needs Assessment, the Hospital has worked collaboratively with local schools and organizations to promote healthy, fun activities and provides opportunities that make the most of staying as healthy as possible. Community Wellness: In 2013, 664 people attended activities in the Community Wellness Center at Grace Cottage Hospital, with a total of 4,568 wellness visits. In 2013, wellness activities included: dance meditation, strong bones exercise classes, meditation circle, weight control programs, yoga, and zumba. Tobacco cessation classes at Grace Cottage Hospital were held under the auspices of Vermont's Blueprint for Health program.For the second consecutive year, Grace Cottage Hospital employees collaborated with Brattleboro Memorial Hospital and The Brattleboro Retreat to organize and implement a Community Health Festival. Over 50 area non-profit organizations and more than 400 members of the community attended the Health Festival on September 21, 2013. In addition, Brattleboro Memorial Hospital, The Brattleboro Retreat, and Grace Cottage Hospital collaborate on a Wellness in Windham website and Health Education calendar. Grace Cottage employees also assisted in coordinating a community blood drive in Newfane, Vermont, in conjunction with the American Red Cross.Grace Cottage Hospital plays a pivotal role in Emergency/Disaster Preparedness in this rural, mountainous area of Windham County, Vermont. The Hospital works collaboratively with:-the local town volunteer fire and first responder rescue departments; the regional ambulance service, Rescue Inc.; Windham County Regional Commission the Local Emergency Planning Committee covering the towns that Grace Cottage serves; The local Citizens Emergency Response Team (CERT); The local Radio Amateur Civil Emergency Service (RACES) West River Radio Club meets and stores equipment at Grace Cottage Hospital; -Vermont Association of Hospitals and Health Systems; -Vermont Department of Health. Grace Cottage Hospital houses the local non-profit transport ambulance service, Rescue Inc., free of charge, on the hospital grounds, providing an ambulance garage and two rooms for use by rescue personnel. Rescue Inc. is based in Brattleboro, VT, 18 miles away; the branch that is located at Grace Cottage 24 hours a day, 365 days a year, is known as Rescue Inc. Division Two. Grace Cottage Hospital staff participates in onsite training for disaster preparedness as well as offsite training with other hospitals. Part VI, Line 6: N/A Reports Filed With States Part VI, Line 7 VT X X 0 0 0 0 0 0 0 1 0 Timothy P Shafer MD 201035 0 55125 0 3238 0 7169 0 23474 0 290041 0 0 0 Michael L Brant 159231 0 0 0 19006 0 4569 0 21034 0 203840 0 0 0 Stephen A Brown 168294 0 0 0 13547 0 5455 0 23474 0 210770 0 0 0 Maurice Geurts MD 222327 0 48862 0 2478 0 7207 0 23474 0 304348 0 0 0 Moss J Linder MD 157111 0 25895 0 2743 0 4738 0 23474 0 213961 0 0 0 Jeanne Fortier 129359 0 0 0 8108 0 3569 0 9880 0 150916 0 0 0 Lynn Madsen MD 132923 0 18000 0 1818 0 0 0 8234 0 160975 0 0 0 Richard Meyer MD 229270 0 0 0 2178 0 4607 0 23474 0 259529 0 0 0 Part I, Line 7 Physician contracts provide the opportunity to receive additional payments for productivity above minimum thresholds. For the period reported, four physicians listed in Part VII were under such a contract: Dr. Maurice Geurts, Dr. Moss Linder, Dr. Lynn Madsen, and Dr. Timothy Shafer, who received incentive compensation payments of $48,862, $25,895, 18,000 and $55,125, respectively. Margaret S Cleary & Jeffrey G White Interim CEOs 190323 The Organization paid Helms & Company, Inc. a healthcare consulting and management company, for their two interim CEOs, Margaret S. Cleary, FACHE and Jeffrey G. White, LFACHE, who served the Hospital from December 2012 throughout the remaining portion of the fiscal year. Total fiscal year 2013 amount paid to Helms & Company, Inc. for providing CEO services was $190,323. 0 Form 990, Part VI, Section A, line 3 The Organization paid Helms & Company, Inc., a healthcare consulting and management company, for their two interim CEOs, Margaret S. Cleary, FACHE and Jeffrey G. White, LFACHE, who served the Hospital from December 2012 throughout the remaining portion of the fiscal year. Total fiscal year 2013 amount paid to Helms & Company, Inc. for providing CEO services was $190,323. Form 990, Part VI, Section B, line 11 A draft of the Form 990 is initially reviewed in detail by Carlos G. Otis Health Care Center's key finance employees. Thereafter, the final draft is provided to the full Board for review prior to filing with the IRS. Form 990, Part VI, Section B, line 12c A copy of the conflict of interest policy is distributed annually to the Board of Trustees and each trustee signs to confirm that they have thoroughly read, understand, and agree to comply with the conflict of interest policy. Form 990, Part VI, Section B, line 15 CEO's Compensation: The CEO's compensation and benefits are reviewed, adjusted and voted on by the full board annually. The Board used external market compensation data to determine the CEO's initial compensation when hired and annually uses such data to compare OHCC's CEO compensation with that of other hospital executives in the Northeast region. The CEO is excused from Board discussion and voting on issues surrounding CEO compensation and benefits. Compensation of other hospital employees: The CEO reviews the salaries of employees annually and determines compensation based on performance and salary ranges, using regional salary range data for comparison. Form 990, Part VI, Section C, line 19 Upon request, Carlos G. Otis Health Care Center, Inc. makes its governing documents, conflict of interest policy, and financial statements available to the public. Reportable compensation for services as employee Form 990, Part VII, Section A, Column D The compensation reported for Dr. Timothy Shafer was for his services as a full-time physician. He was not compensated for his services as members of OHCC's Board of Trustees. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Increase in Beneficial Interest in Net Assets of GCF 418,499. Audit Review Process Form 990, Part XI, Line 2c: The Finance and Audit Committee oversees the audit process for the Carlos G. Otis Health Care Center, Inc. and Grace Cottage Foundation, Inc. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit for both fiscal years. Grace Cottage Foundation Inc PO Box 1 Townshend VT 05353 030343282 Solicit contributions for the funding of health care services by OHCC VT 501(c)(3) Line 11a, I Carlos G Otis Health Care Center 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 Grace Cottage Foundation Inc Q 232651 Actual per books Grace Cottage Foundation Inc C 562475 Actual per books