COPLEY HOSPITAL INC: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
COPLEY HOSPITAL INC (EIN 03-0179423)
Tax period
2012-10-01 to 2013-09-30
Filed
2014-02-14
IRS object ID
201440459349301859
Schema version
2012v2.1
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2014-02-14T13:31:29-06:00Timestamp
Tax Period End Date2013-09-30TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN010523282EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1Berry Dunn McNeil & Parker LLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line1PO Box 1100AddressLine1
CityPortlandCity
StateMEState
ZIP Code041041100ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-10-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN030179423EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1Copley Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlCOPLNameControl
Phone8028884231Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line1528 Washington HighwayAddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameMelvyn PatashnickName
TitleCEOTitle
Phone8028884231Phone
Date Signed2014-02-12DateSigned
Authorize Third Party1AuthorizeThirdParty

Preparer Preparer

FieldValueIRS element (for citing)
NameBarbara J McGuan CPAName
PTINP00219457PTIN
Phone2077752387Phone
Date Prepared2014-02-12DatePrepared
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2015-11-30 17:44:51ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Name Of Principal Officer PersonMelvyn PatashnickNameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line1528 Washington HighwayAddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode
FieldValueIRS element (for citing)
Gross Receipts56398512GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501c3XOrganization501c3
Web Sitecopleyvt.orgWebSite
Type Of Organization CorporationXTypeOfOrganizationCorporation
Year Formation1934YearFormation
State Legal DomicileVTStateLegalDomicile
Activity Or Mission DescriptionCritical Access HospitalActivityOrMissionDescription
Nbr Voting Members Governing Body15NbrVotingMembersGoverningBody
Nbr Independent Voting Members13NbrIndependentVotingMembers
Total Nbr Employees496TotalNbrEmployees
Total Nbr Volunteers130TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year2121510ContributionsGrantsPriorYear
Contributions Grants Current Year988405ContributionsGrantsCurrentYear
Program Service Revenue Prior Year52191066ProgramServiceRevenuePriorYear
Program Service Revenue CY55316779ProgramServiceRevenueCY
Investment Income Prior Year203982InvestmentIncomePriorYear
Investment Income Current Year62580InvestmentIncomeCurrentYear
Other Revenue Prior Year39605OtherRevenuePriorYear
Other Revenue Current Year29082OtherRevenueCurrentYear
Total Revenue Prior Year54556163TotalRevenuePriorYear
Total Revenue Current Year56396846TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year309326GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY57500GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year0BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY0BenefitsPaidToMembersCY
Salaries Etc Prior Year29339448SalariesEtcPriorYear
Salaries Etc Current Year30268921SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year22604696OtherExpensePriorYear
Other Expenses Current Year23249608OtherExpensesCurrentYear
Total Expenses Prior Year52253470TotalExpensesPriorYear
Total Expenses Current Year53576029TotalExpensesCurrentYear
Revenues Less Expenses Prior Year2302693RevenuesLessExpensesPriorYear
Revenues Less Expenses CY2820817RevenuesLessExpensesCY
Total Assets BOY37487979TotalAssetsBOY
Total Assets EOY40042628TotalAssetsEOY
Total Liabilities BOY11330820TotalLiabilitiesBOY
Total Liabilities EOY11394630TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY26157159NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY28647998NetAssetsOrFundBalancesEOY
Info In Schedule O Part IIIXInfoInScheduleOPartIII
Mission DescriptionTo oversee and coordinate the provision of services, to provide leadership in implementing the vision promoting wellness and to assure clear access to services regardless of ability to pay.MissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense48632944Expense
Grants57500Grants
Revenue55316779Revenue
DescriptionCopley Hospital provides quality medical healthcare regardless of race, creed, sex, national origin, handicap, age or ability to pay. Although reimbursement is critical to the hospital, it is recognized that not all individuals possess the ability to purchase essential medical services. Further, our mission is to serve the community with respect to providing healthcare services and healthcare education in keeping with the hospital's commitment to serve all members of its community. The Hospital offers free care and or subsidized care, care provided to persons covered by governmental programs at below cost, and health activities and programs to support the community and are considered where the need and/or individual's inability to pay coexists. These activities include a variety of services in the form of seminars, workshops, clinics, and screenings at minimal or no charge.Description
Total Program Service Expense48632944TotalProgramServiceExpense
Described In501 C31DescribedIn501C3
Schedule B Required1ScheduleBRequired
Political Activities0PoliticalActivities
Lobbying Activities1LobbyingActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip1ReportLandBldgEquip
Report Invest Oth Securities1ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities1ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt1ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital1Hospital
Financial Stmt Attached1FinancialStmtAttached
Grants To Organizations1GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required1ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Excess Benefit Transaction0ExcessBenefitTransaction
Prior Excess Benefit Transaction0PriorExcessBenefitTransaction
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp1OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions1DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity1RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Transfers To Exempt Non Chrtbl Org0TransfersToExemptNonChrtblOrg
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With1096110NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Compliance With Backup Witholding1ComplianceWithBackupWitholding
Number Of Employees496NumberOfEmployees
Employment Tax Returns Filed1EmploymentTaxReturnsFiled
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Funds To Pay Premiums0FundsToPayPremiums
Premiums Paid0PremiumsPaid
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members15NbrVotingGoverningBodyMembers
Number Independent Voting Members13NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs1ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders1MembersOrStockholders
Election Of Board Members1ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body0Form990ProvidedToGoverningBody
Conflict Of Interest Policy1ConflictOfInterestPolicy
Annual Disclosure Covered Persons1AnnualDisclosureCoveredPersons
Regular Monitoring Enforcement1RegularMonitoringEnforcement
Whistleblower Policy1WhistleblowerPolicy
Document Retention Policy1DocumentRetentionPolicy
Compensation Process CEO1CompensationProcessCEO
Compensation Process Other1CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1Kevin DorainBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number8028884231TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1528 Washington HighwayAddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode

Form990 Part VII Section A Form990PartVIISectionA (22 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekAverage Hours Per Week RelatedAverageHoursPerWeekRelatedIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficerHighest Compensated EmployeeHighestCompensatedEmployee
Michael Alexander
Trustee1.900.10X000
Willa Farrell
Trustee1.900.10X000
Elaine Nichols
Treasurer1.900.10X000X
Melvyn Patashnick
President and CEO38.002.00X321948032080X
Nancy Putnam
Vice Chair1.900.10X000X
Elizabeth Rouse
Trustee1.900.10X000
Jan Roy
Trustee1.900.10X000
Brian Smale MD
Past Trustee1.900.10X23220900
John Steel
Past Vice Chair/Current Trustee1.900.10X000X
Dana Wildes
Chair1.900.10X000X
David Yacovone
Trustee1.900.10X000
Sharon Green
Secretary1.900.10X000X
Patrick Keith
Trustee/Med. Staff Pres.1.900.10X3085000
Richard Westman
Trustee1.900.10X000
Henry Binder MD
Trustee1.900.10X000
Walter Frame
Trustee1.900.10X000
Rassoul Rangaviz
CFO38.002.00173861024684X
Bryan Huber MD
Physician40.000.00590296048270X
Eric Mullins MD
Physician40.000.00534731041710X
Brian Aros MD
Physician40.000.00539935029128X
Christopher Rohan MD
Physician40.000.00339516029516X
Adam Kunin MD
Physician40.000.00279874033010X
FieldValueIRS element (for citing)
Total Reportable Comp From Org3043220TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation238398TotalOtherCompensation
Number Individuals GT100 K29NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K1TotalCompGT150K
Compensation From Other Sources1CompensationFromOtherSources

Contractor Compensation ContractorCompensation (5 entries)

Address Line1AddressOfContractor/AddressUS/AddressLine1CityAddressOfContractor/AddressUS/CityStateAddressOfContractor/AddressUS/StateZIP CodeAddressOfContractor/AddressUS/ZIPCodeDescription Of ServicesDescriptionOfServicesCompensationCompensation
HP Cummings Construction Co
PO Box 269WoodsvilleNH037850269General Contractor710836
Fletcher Allen Health Care
PO Box 1902BurlingtonVT054021902Medical Services438324
Apogee Medical Management Inc
2525 E Camelback Road Suite 1100PhoenixAZ85016Hospitalist Services385110
CPSG Inc
PO Box 749MorrisvilleVT05661Grant & Physician Services301374
Bay View Funding Inc
PO Box 881774San FranciscoCA941881774Contract Labor299225
FieldValueIRS element (for citing)
Number Of Contractors GT100 K23NumberOfContractorsGT100K
Related Organizations798405RelatedOrganizations
All Other Contributions190000AllOtherContributions
Noncash Contributions190000NoncashContributions
Total Contributions988405TotalContributions

Program Service Revenue ProgramServiceRevenue (5 entries)

DescriptionDescriptionBusiness CodeBusinessCodeTotal Revenue ColumnTotalRevenueColumnRelated Or Exempt Function IncomeRelatedOrExemptFunctionIncomeExclusionExclusionAmount
Gross Patient Revenue6214009034134190341341
Miscellaneous Revenue6214001157133$1,157,133
Cafeteria Revenue900099297223$297,223
Provision for Bad Debt621400-2130224-2130224
Contractual/Char. Adj.621400-34348694-34348694
FieldValueIRS element (for citing)
Total Program Service Revenue55316779TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column61024TotalRevenueColumn
Exclusion$61,024ExclusionAmount

Gross Rents GrossRents

FieldValueIRS element (for citing)
Real29082Real

Less Rental Expenses LessRentalExpenses

FieldValueIRS element (for citing)
Real0Real

Rental Income Or Loss RentalIncomeOrLoss

FieldValueIRS element (for citing)
Real29082Real

Net Rental Income Or Loss NetRentalIncomeOrLoss

FieldValueIRS element (for citing)
Total Revenue Column29082TotalRevenueColumn
Exclusion$29,082ExclusionAmount

Gross Amount Sales Assets GrossAmountSalesAssets

FieldValueIRS element (for citing)
Other3222Other

Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses

FieldValueIRS element (for citing)
Other1666Other

Gain Or Loss GainOrLoss

FieldValueIRS element (for citing)
Other1556Other

Net Gain Or Loss Investments NetGainOrLossInvestments

FieldValueIRS element (for citing)
Total Revenue Column1556TotalRevenueColumn
Exclusion$1,556ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column56396846TotalRevenueColumn
Related Or Exempt Function Income53862423RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$1,546,018ExclusionAmount
FieldValueIRS element (for citing)
Info In Schedule O Part IXXInfoInScheduleOPartIX

Grants To Domestic Orgs GrantsToDomesticOrgs

FieldValueIRS element (for citing)
Total57500Total
Program Services57500ProgramServices

Comp Current Officers Directors CompCurrentOfficersDirectors

FieldValueIRS element (for citing)
Total815632Total
Program Services263059ProgramServices
Management And General552573ManagementAndGeneral

Other Salaries And Wages OtherSalariesAndWages

FieldValueIRS element (for citing)
Total24053422Total
Program Services22236259ProgramServices
Management And General1817163ManagementAndGeneral

Pension Plan Contributions PensionPlanContributions

FieldValueIRS element (for citing)
Total574483Total
Program Services535607ProgramServices
Management And General38876ManagementAndGeneral

Other Employee Benefits OtherEmployeeBenefits

FieldValueIRS element (for citing)
Total3221617Total
Program Services2954249ProgramServices
Management And General267368ManagementAndGeneral

Payroll Taxes PayrollTaxes

FieldValueIRS element (for citing)
Total1603767Total
Program Services1452664ProgramServices
Management And General151103ManagementAndGeneral

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total151037Total
Program Services3296ProgramServices
Management And General147741ManagementAndGeneral

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total47331Total
Management And General47331ManagementAndGeneral

Fees For Services Lobbying FeesForServicesLobbying

FieldValueIRS element (for citing)
Total48475Total
Management And General48475ManagementAndGeneral

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total6470670Total
Program Services5866511ProgramServices
Management And General604159ManagementAndGeneral

Advertising Advertising

FieldValueIRS element (for citing)
Total175952Total
Management And General175952ManagementAndGeneral

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1390799Total
Program Services1126332ProgramServices
Management And General264467ManagementAndGeneral

Occupancy Occupancy

FieldValueIRS element (for citing)
Total1673972Total
Program Services1331711ProgramServices
Management And General342261ManagementAndGeneral

Travel Travel

FieldValueIRS element (for citing)
Total33265Total
Program Services18879ProgramServices
Management And General14386ManagementAndGeneral

Interest Interest

FieldValueIRS element (for citing)
Total52540Total
Program Services52540ProgramServices

Depreciation Depletion DepreciationDepletion

FieldValueIRS element (for citing)
Total2074254Total
Program Services1822917ProgramServices
Management And General251337ManagementAndGeneral

Insurance Insurance

FieldValueIRS element (for citing)
Total614218Total
Program Services562123ProgramServices
Management And General52095ManagementAndGeneral

Other Expenses OtherExpenses (4 entries)

DescriptionDescriptionTotalTotalProgram ServicesProgramServicesManagement And GeneralManagementAndGeneral
Medical Supplies7138347710093437413
Service Provider Tax30586743058674
Dues & Subscriptions18818570074118111
Education13188911961512274

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total53576029Total
Program Services48632944ProgramServices
Management And General4943085ManagementAndGeneral
Fundraising0Fundraising

Cash Non Interest Bearing CashNonInterestBearing

FieldValueIRS element (for citing)
BOY2375BOY
EOY2475EOY

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY11763866BOY
EOY11224298EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY4152112BOY
EOY4363081EOY

Inventories For Sale Or Use InventoriesForSaleOrUse

FieldValueIRS element (for citing)
BOY2404734BOY
EOY2622936EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
BOY1202645BOY
EOY1195433EOY
FieldValueIRS element (for citing)
Land Buildings Equipment Basis37662723LandBuildingsEquipmentBasis
Land Bldg Equipment Accum Deprec22451587LandBldgEquipmentAccumDeprec

Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet

FieldValueIRS element (for citing)
BOY12471282BOY
EOY15211136EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
BOY4514320BOY
EOY4184342EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY976645BOY
EOY1238927EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY37487979BOY
EOY40042628EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
BOY5125883BOY
EOY4984875EOY

Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp

FieldValueIRS element (for citing)
BOY3181254BOY
EOY2995720EOY

Other Liabilities OtherLiabilities

FieldValueIRS element (for citing)
BOY3023683BOY
EOY3414035EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY11330820BOY
EOY11394630EOY
FieldValueIRS element (for citing)
Follow SFAS117XFollowSFAS117

Unrestricted Net Assets UnrestrictedNetAssets

FieldValueIRS element (for citing)
BOY21642839BOY
EOY24463656EOY

Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY608577BOY
EOY189304EOY

Permanently Restricted Net Assets PermanentlyRestrictedNetAssets

FieldValueIRS element (for citing)
BOY3905743BOY
EOY3995038EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY26157159BOY
EOY28647998EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY37487979BOY
EOY40042628EOY
FieldValueIRS element (for citing)
Info In Schedule O Part XIXInfoInScheduleOPartXI
Reconcilation Revenue Expenses2820817ReconcilationRevenueExpenses
Reconcilation Other Changes-329978ReconcilationOtherChanges
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement BothXFinancialStatementBoth
FieldValueIRS element (for citing)
Audit Committee1AuditCommittee
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Hospital170b1 AiiiXHospital170b1Aiii

Schedule B IRS990ScheduleB

Contributor Info ContributorInfo

FieldValueIRS element (for citing)
Contributor NumberRESTRICTEDContributorNumber

Contributor Name Business ContributorNameBusiness

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor Address US ContributorAddressUS

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Aggregate ContributionsRESTRICTEDAggregateContributions

Schedule C IRS990ScheduleC

FieldValueIRS element (for citing)
Volunteers0Volunteers
Paid Staff Or Management0PaidStaffOrManagement
Media Advertisements0MediaAdvertisements
Mailings Members0MailingsMembers
Publications Or Broadcast0PublicationsOrBroadcast
Grants Other Organizations0GrantsOtherOrganizations
Direct Contact Legislators1DirectContactLegislators
Direct Contact Legislators$32,023DirectContactLegislatorsAmount
Rallies Demonstrations0RalliesDemonstrations
Other Activities1OtherActivities
Other Activities$16,452OtherActivitiesAmount
Total Lobbying Expenditures IIB48475TotalLobbyingExpendituresIIB
Not Described In501c30NotDescribedIn501c3

Form990 Schedule C Part IV Form990ScheduleCPartIV

FieldValueIRS element (for citing)
IdentifierExplanation of Lobbying Activities:Identifier
Return ReferencePart II-B, Line 1:ReturnReference
ExplanationThe Organization pays dues to various organizations, a portion (16,452) of which is attributable to lobbying expenses. The Hospital also engaged a law firm for 32,023 for lobbying services.Explanation

Schedule D IRS990ScheduleD

Land Land

FieldValueIRS element (for citing)
Other Cost Or Other Basis352422OtherCostOrOtherBasis
Book Value352422BookValue

Buildings Buildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis18759837OtherCostOrOtherBasis
Depreciation10151758Depreciation
Book Value8608079BookValue

Equipment Equipment

FieldValueIRS element (for citing)
Other Cost Or Other Basis17437222OtherCostOrOtherBasis
Depreciation11909924Depreciation
Book Value5527298BookValue

Other Land Buildings OtherLandBuildings

FieldValueIRS element (for citing)
Other Cost Or Other Basis1113242OtherCostOrOtherBasis
Depreciation389905Depreciation
Book Value723337BookValue
FieldValueIRS element (for citing)
Total Of Book Value Land Buildings15211136TotalOfBookValueLandBuildings

Other Securities OtherSecurities

FieldValueIRS element (for citing)
DescriptionBeneficial Interest in Net Assets of Copley Health Systems, Inc.Description
Book Value4184342BookValue
Method Of ValuationFMethodOfValuation
FieldValueIRS element (for citing)
Total Of Book Value Securities4184342TotalOfBookValueSecurities

Other Liabilities OtherLiabilities (2 entries)

DescriptionDescriptionAmountAmount
Deferred Compensation$1,214,035
Estimated Third Party Payor Settlements$2,200,000
FieldValueIRS element (for citing)
Total Of Amounts3414035TotalOfAmounts
Tot Revenue Etc Audited Fincl Stmt56066868TotRevenueEtcAuditedFinclStmt
Other Revenues-329978OtherRevenues
Revenue Not Rptd F990-329978RevenueNotRptdF990
Revenue Subtotal56396846RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form99056396846TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt53576029TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal53576029ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form99053576029TotalExpensesPerForm990

Form990 Schedule D Part XIII Form990ScheduleDPartXIII

FieldValueIRS element (for citing)
IdentifierPart XI, Line 2d - Other Adjustments:Identifier
ExplanationChange in Beneficial Interest in Net Assets of Copley Health Systems, Inc. -329,978.Explanation

Schedule H IRS990ScheduleH

FieldValueIRS element (for citing)
Charity Care Policy1CharityCarePolicy
Written Policy1WrittenPolicy
FPG Reference Free Care1FPGReferenceFreeCare

Other Percentage OtherPercentage

FieldValueIRS element (for citing)
OtherXOther
Free Other Percentage250.000000000000FreeOtherPercentage
FieldValueIRS element (for citing)
FPG Reference Discounted Care1FPGReferenceDiscountedCare
Pcent400XPcent400
Free Disc Care Medically Indigent1FreeDiscCareMedicallyIndigent
Amounts Budgeted For Charity Care1AmountsBudgetedForCharityCare
Expenses Exceeded Budget0ExpensesExceededBudget
Annual Community Benefit Report1AnnualCommunityBenefitReport
Report Publically Available1ReportPublicallyAvailable

Charity Care At Cost CharityCareAtCost

FieldValueIRS element (for citing)
Total Community Benefit Expense603698TotalCommunityBenefitExpense
Direct Offsetting Revenue0DirectOffsettingRevenue
Net Community Benefit Expense603698NetCommunityBenefitExpense
Percent Of Total Expense0.01130PercentOfTotalExpense

Unreimbursed Medicaid UnreimbursedMedicaid

FieldValueIRS element (for citing)
Total Community Benefit Expense11580241TotalCommunityBenefitExpense
Direct Offsetting Revenue6640051DirectOffsettingRevenue
Net Community Benefit Expense4940190NetCommunityBenefitExpense
Percent Of Total Expense0.09220PercentOfTotalExpense

Total Charity Care TotalCharityCare

FieldValueIRS element (for citing)
Total Community Benefit Expense12183939TotalCommunityBenefitExpense
Direct Offsetting Revenue6640051DirectOffsettingRevenue
Net Community Benefit Expense5543888NetCommunityBenefitExpense
Percent Of Total Expense0.10350PercentOfTotalExpense

Community Health Services CommunityHealthServices

FieldValueIRS element (for citing)
Total Community Benefit Expense195920TotalCommunityBenefitExpense
Direct Offsetting Revenue53238DirectOffsettingRevenue
Net Community Benefit Expense142682NetCommunityBenefitExpense
Percent Of Total Expense0.00270PercentOfTotalExpense

Cash And In Kind Contributions CashAndInKindContributions

FieldValueIRS element (for citing)
Total Community Benefit Expense57500TotalCommunityBenefitExpense
Net Community Benefit Expense57500NetCommunityBenefitExpense
Percent Of Total Expense0.00110PercentOfTotalExpense

Total Other Benefits TotalOtherBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense253420TotalCommunityBenefitExpense
Direct Offsetting Revenue53238DirectOffsettingRevenue
Net Community Benefit Expense200182NetCommunityBenefitExpense
Percent Of Total Expense0.00380PercentOfTotalExpense

Total Community Benefits TotalCommunityBenefits

FieldValueIRS element (for citing)
Total Community Benefit Expense12437359TotalCommunityBenefitExpense
Direct Offsetting Revenue6693289DirectOffsettingRevenue
Net Community Benefit Expense5744070NetCommunityBenefitExpense
Percent Of Total Expense0.10730PercentOfTotalExpense
FieldValueIRS element (for citing)
Bad Debt Expense Reported0BadDebtExpenseReported
Bad Debt Expense$1,150,702BadDebtExpenseAmount
Written Debt Collection Policy1WrittenDebtCollectionPolicy
Provision For Charity Care1ProvisionForCharityCare
Number Of Hospital Facilities1NumberOfHospitalFacilities

Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA

FieldValueIRS element (for citing)
Facility Number1FacilityNumber

Name Name

FieldValueIRS element (for citing)
Business Name Line1Copley Hospital IncBusinessNameLine1

Address Address

FieldValueIRS element (for citing)
Address Line1528 Washington HighwayAddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode
FieldValueIRS element (for citing)
Licensed HospitalXLicensedHospital
General Medical And SurgicalXGeneralMedicalAndSurgical
Critical Access HospitalXCriticalAccessHospital
Er24 HoursXEr24Hours

Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB

Hospital Facility Name HospitalFacilityName

FieldValueIRS element (for citing)
Business Name Line1Copley Hospital IncBusinessNameLine1
FieldValueIRS element (for citing)
Hospital Facility Number1HospitalFacilityNumber
CHNA Conducted1CHNAConducted
Community DefinitionXCommunityDefinition
Community DemographicsXCommunityDemographics
Existing ResourcesXExistingResources
How Data ObtainedXHowDataObtained
Community Health NeedsXCommunityHealthNeeds
Other Health IssuesXOtherHealthIssues
Identifying ProcessXIdentifyingProcess
Consulting ProcessXConsultingProcess
Information GapsXInformationGaps
Needs Assessment Conducted12NeedsAssessmentConducted
Take Into Account1TakeIntoAccount
Other Facilities0OtherFacilities
CHNA Widely Available1CHNAWidelyAvailable
Own WebsiteXOwnWebsite
On RequestXOnRequest
Other MethodXOtherMethod
Adopt Implement StrategyXAdoptImplementStrategy
Execute Implement StrategyXExecuteImplementStrategy
Develop Community PlanXDevelopCommunityPlan
Participate Community PlanXParticipateCommunityPlan
Prioritize Health NeedsXPrioritizeHealthNeeds
Prioritize ServicesXPrioritizeServices
All Needs Addressed0AllNeedsAddressed
Organization Incur Excise Tax0OrganizationIncurExciseTax
Eligibility Criteria Explained1EligibilityCriteriaExplained
Uses FPG Free1UsesFPGFree
FPG Free Percent250.000000000000FPGFreePercent
Uses FPG Discounted1UsesFPGDiscounted
FPG Discount Percent400.000000000000FPGDiscountPercent
Explains Basis1ExplainsBasis
Income LevelXIncomeLevel
Explains Application Method1ExplainsApplicationMethod
Includes Publicity Measures1IncludesPublicityMeasures
Posted On WebsiteXPostedOnWebsite
Attached To InvoicesXAttachedToInvoices
Posted In Emergency RoomXPostedInEmergencyRoom
Posted In Admission OfficeXPostedInAdmissionOffice
Provided On AdmissionXProvidedOnAdmission
Available On RequestXAvailableOnRequest
Actions On Nonpayment1ActionsOnNonpayment
Collection Activities0CollectionActivities
Notify Upon AdmissionXNotifyUponAdmission
Notified All PatientsXNotifiedAllPatients
Documented DeterminationXDocumentedDetermination
Nondiscrim Emergency Care Policy1NondiscrimEmergencyCarePolicy
Used Other MethodXUsedOtherMethod
Amounts Generally Billed0AmountsGenerallyBilled
Gross Charges1GrossCharges

Form990 Schedule H Part VI Form990ScheduleHPartVI (11 entries)

ExplanationExplanationIdentifierIdentifier
Part I, Line 7: A cost accounting system was used to calculate the amounts reported in the table. The cost accounting system addresses all patient segments. A cost-to-charge ratio was used. The ratio was derived from Worksheet 2.
Part III, Line 4: Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating collectibility of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provisions for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services 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 example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant 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 (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts.The Organization utilized a cost to charge ratio as the costing methodology used to determine the amount of bad debt expense at cost.
Part III, Line 9b: Financial Assistance is available to guarantors who meet the eligibility requirements. Income level, household size, residency status, etc, determine eligibility. Federal Poverty Level guidelines are utilized to determine the amount of assistance a household may be eligible for. For the patient's convenience, all statements have an abbreviated version of the Financial Assistance Application on the back. Copley personnel also help patients review and apply for appropriate state-sponsored programs.
Part V, Section B, Line 3: In March 2011, Copley Hospital engaged Toby Knox and Associates, LLC (TKA) to conduct a formal Community Healthcare Needs Assessment. The assessment process invited feedback from community stakeholders as well as reviewing relevant data and publications published by government and non-profit agencies from within the Copley community and statewide. A survey tool designed to ascertain the most pressing health and wellness needs in the Copley community was distributed by mail and email to 153 individual stakeholders representing the broad interests of the community served by Copley Hospital, including:School NursesStaff or local non-profit organizationsVermont Health Department staffAuxiliary BoardCopley Foundation CommitteeCopley Health System TrusteesTown Health OfficersCopley Medical StaffA second survey was administered at the 2011 town meetings in the towns of Morristown, Cambridge, Hyde Park, Wolcott, Waterville and Stowe. In September 2011, Copley created a multidisciplinary advisory committee, called the Community Assessment Steering Committee (CASC), consisting of the hospital's community health team, community leaders and members of the Extended Community Health Team of the Copley Service Area Blueprint for Health Program. This team includes representatives from:Lamoille Home Health & HospiceBlueprint Community Health Team LeaderBlueprint Program Area FacilitatorBehavioral Health & Wellness (CHSLV)Copley Hospital Patient & Family Services, Wellness Center and VP of Community RelationsVermont Department of Health, including Field Services Director, Public Health Specialist, and Substance Abuse Prevention ConsultantLamoille Family CenterLamoille Community Food ShareThe Manor (Long Term Care)Lamoille Regional Chamber of CommerceDepartment of Vermont Health AccessCentral Vermont Council on AgingNorthern Counties Health CareBlue Cross Blue Shield of VTLamoille County Mental HealthIn February 2012, an updated survey tool was created based on the CASC's recommendations. It was distributed by mail and email and also administered in person to clients of:Hardwick Food ShareJohnson Food ShareLamoille Community Food ShareCentral Vermont Community Action Council Central Vermont Adult Basic EducationHardwick Area Health CenterMorrisville Family HealthcareStowe Family PracticeLeadership LamoilleCopley Hospital staff conducted a secondary data review in Spring 2012 based on benchmarking guidelines suggested by the Vermont Department of Health and CASC. Data sources reviewed included:Center for Rural Studies, UVMVermont Department of Labor Economic Demographic Profile 2011U.S Bureau of Labor StatisticsU.S Census Bureau 2000 and 2010American Community Survey 2005-2009Vermont Department of Health: Health and Healthcare Trends in Vermont 2010Vermont Department of Health: Physician Survey 2010Vermont Department of Health: Behavioral Risk Factor Surveillance System (BRFSS) 2010VPQHC: Vermont Health Care Quality Report 2010Vermont Office of Health Access: Study of the Uninsured and Underinsured 2011AHEC: The Primary Care Workforce 2011 SnapshotVermont Department of Health: 2009 Dentist Survey Statistical ReportCenters for Disease Control and Prevention, Nat'l Center for Health StatisticsKaiser Family Foundation: www.statehealthfacts.org 2010 dataVermont Agency of Human Services Department of Disabilities, Aging & Independence: State of Vermont 2006-2014 Shaping the Future of Long Term Care and Independent LivingVermont Housing Finance AgencyVoices for Vermont Kids, 2007-2009Copley Hospital Quality Reports2011 Hospital Report Card, www.copleyvt.org2012 County Health Ranking from the University of Wisconsin Population Health InstituteNational Center for Health Statistics, Centers for Disease Control: Vital Statistics Reporting System, Community Health Status Report 20092012 County Health Rankings, Dartmouth Atlas of HealthVermont AHEC Search Handbook 2012Vermont Department of Health, Health Status of Vermonters, Appendix, 2008EPA Air Quality DatabaseVermont Department of Health, Health Disparities/Health Status Report 2008Copley Hospital, Inc.
Part V, Section B, Line 5c: A copy of Copley Hospital's 2012 Community Healthcare Needs Assessment is available on the hospital's website, www.copleyvt.org/Aboutus. The public was invited to learn more about our assessment and implementation plan at a Community Forum held in September, 2013.Copley Hospital, Inc.
Part V, Section B, Line 7: The Hospital adopted an implementation strategy to address the top three needs of the community, as recommended by the CASC. Other needs are being addressed by the hospital without being specifically addressed in the implementation strategy. The Hospital is not treating Obesity and Nutrition as a separate priority as obesity is included in our Blueprint integrated health system goal of "improving residents' self management of chronic conditions." Our Healthier Living Workshops, the Workforce Wellness Program and the Pediatric Outreach Programs currently underway all address obesity. Copley Hospital does provide a health recipe in each edition of the Copley Courier, the hospital's newsletter distributed through community newspapers (circulation ~25,000 quarterly). In addition, healthy living tips are shared quarterly with the HOPE Health Newsletter, distributed to Copley's 475 employees, and 400 friends of Copley; it is also available in the hospital's common areas. In addition, a Copley Hospital employee serves on the Lamoille Fit and Health Council and Copley Hospital has advocated to town officials for the adoption of a Town Wellness Plan crafted by the Fit and Healthy Council. The Town Wellness Plan encourages community development and zoning policies that encourage pedestrian and bicycling infrastructure, mixed-use development that provides opportunities for people to be physically active as part of their daily routine, and access to safe, well-maintained parks and recreation facilities. Mental Health and Substance Abuse are being addressed separately, because of the work being done in the community by Lamoille County Mental Health (the Vermont Department of Mental Health Designated Agency), CHSLV's Behavioral Health and Wellness and independent practitioners and Copley Hospital. Work is being done to improve access to behavioral health resources for all residents. Copley Hospital is contributing to this by having our Diabetes Educator and Registered Dietitian screen all Wellness Center referrals for depression and refer to a behavioral health professional as needed. We also have a program in place in our Emergency Department to refer patients without a primary care physician to a Care Coordinator for assistance in securing a primary care physician. Our Emergency Department works closely with Lamoille County Mental Health emergency response staff. We helped this organization establish A.S.A.P. public inebriate program, which provides a safe environment to sober-up followed by next day assessment and counseling.Although not part of the CASC discussion, Copley Hospital is also instrumental in assisting the state of Vermont in opening and operating the 8-bed Green Mountain Psychiatric Care Center (GMPCC) in Morrisville. The GMPCC was built due to the destruction of the Vermont State Hospital during Hurricane Irene, leaving the state in dire straits in trying to meet the need of in-patient psychiatric care. The Center opened in 2013, with the hospital providing key services including pharmacy, medical management, linen, environmental services, and food services.Copley Hospital, Inc.
Part V, Section B, Line 20d: Financial assistance applications must be completed to determine eligibility for assistance and therefore applicability of the limitation on charges under 501(r)(5). If not eligible, discount is granted for prompt payment similar to the average negotiated commercial discount rate for prompt payment of a clean claim.Copley Hospital, Inc.
Part V, Section B, Line 22: If patients do not pay promptly, then the discount on gross charges is waived, as it would be under contractual arrangements with commercial insurers if they did not pay promptly.Copley Hospital, Inc.
Part VI, Line 2: Copley Hospital is part of an Extended Community Health Team in our community. Together we are working to address community healthcare needs. Reaching out to the community to achieve meaningful public participation is integral to Copley's mission and to inform the Extended Community Health Team. Copley completed a Community Healthcare Needs Assessment in 2012.For our assessments, Copley gathers and analyzes information about the greater Lamoille Valley community and its healthcare needs through various means including: analyzing and responding to health trends in our patients, through aggregate data from our Quality and Wellness initiatives and the Copley Service Area Blueprint for Health Program. We also review relevant data published by the Vermont Department of Health, Green Mountain Care Board, Vermont Department of Health's Blueprint for Health Program, and Federal Centers for Disease Control. Our community based advisory committee informs a Board of Trustee-approved implementation plan. The Hospital reports out on the implementation plan to the Extended Community Health Team and Board of Trustees annually. The Hospital is governed by a volunteer board of trustees made up of local citizens representing a cross section of the community served. We maintain involvement in a number of community groups within our service area. Copley continues to work collaboratively with other organizations to identify and address community health needs. Our collaborations include but are not limited to the Extended Community Health Team of the Copley Area Blueprint for Health Initiative (primary care practices) Lamoille Home Health and Hospice, The Manor (long term residential care), Lamoille County Mental Health, CHSLV Behavioral Health & Wellness, Lamoille Prevention Campaign (substance abuse), the Morrisville district office of the Vermont Department of Health, United Way, Lamoille Valley Fit & Health Council, Lamoille Valley Tobacco Task Force, and Leadership Lamoille through the Chamber of Commerce.
Part VI, Line 3: Information about Copley's Charitable Care policy, which includes helping patients apply for assistance under federal, state or local government programs, is posted by each registration desk (Main Lobby and Emergency Department). It is also available, along with the application form, online on the Hospital's website in addition to the "Hospital Report Card" website of the Green Mountain Care Board. Details are also included in the Patient Guide for inpatients, families and visitors.Copley's Charitable Care program is also promoted in our philanthropy efforts as many donors give to the program. All care providers may refer patients to the Hospital's Patient Financial Services counselors or to Patient and Family Services to connect them to assistance.
Part VI, Line 4: Copley Health Systems (CHS) is an essential health care resource in the rural greater Lamoille County area of Vermont. Our services include a 25-bed Critical Access community hospital, low-income elderly housing and an independent living facility. Copley Hospital's services include 24 hour/7 days a week emergency services, women's and children's services, general surgery, primary care including laboratory services and diagnostic imaging; and an excellent orthopaedic service given our proximity to major ski areas. Our patients are largely the elderly and low-income families in a rural area. Nearly a third are below 200% of poverty level. We serve all patients, regardless of ability to pay. Chronic health conditions impact many adults in our area. We are working to increase access to healthcare and work with members of our community to improve their self management of chronic conditions such as diabetes, high blood pressure, high cholesterol, asthma and obesity. We are also helping people quit tobacco. Copley provides services for residents whose next nearest hospital may be an hour away in good weather.

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Records Maintained1RecordsMaintained

Recipient Table RecipientTable

Recipient Name Business RecipientNameBusiness

FieldValueIRS element (for citing)
Business Name Line1Copley Professional Services Group IncBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1530 Washington Highway No 12AddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode
FieldValueIRS element (for citing)
EIN Of Recipient043358048EINOfRecipient
IRC Section501(c)(3)IRCSection
Amount Of Cash Grant57500AmountOfCashGrant
Purpose Of GrantSupport obstetrics and gynecology services to residents of Lamoille County.PurposeOfGrant
FieldValueIRS element (for citing)
Total Nbr Of501 C3 And Govt Grants1TotalNbrOf501C3AndGovtGrants
Total Nbr Of Other Organizations0TotalNbrOfOtherOrganizations

Form990 Schedule I Part IV Form990ScheduleIPartIV

FieldValueIRS element (for citing)
IdentifierProcedure for Monitoring Grants in the U.S.:Identifier
Return ReferencePart I, Line 2:ReturnReference
ExplanationSchedule I, Part I, Line 2: The Organization obtains financial information from the grantee to determine the amount of funds to be granted.Explanation

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Compensation CommitteeXCompensationCommittee
Independent ConsultantXIndependentConsultant
Form990 Of Other OrganizationsXForm990OfOtherOrganizations
Written Employment ContractXWrittenEmploymentContract
Compensation SurveyXCompensationSurvey
Board Or Committee ApprovalXBoardOrCommitteeApproval
Severance Payment0SeverancePayment
Supplemental Nonqual Retire Plan0SupplementalNonqualRetirePlan
Equity Based Comp Arrangement0EquityBasedCompArrangement
Comp Based On Revenue Of Filing Org1CompBasedOnRevenueOfFilingOrg
Comp Based On Revenue Related Orgs0CompBasedOnRevenueRelatedOrgs
Comp Based Net Earnings Filing Org0CompBasedNetEarningsFilingOrg
Comp Based Net Earnings Relate Orgs0CompBasedNetEarningsRelateOrgs
Any Non Fixed Payments0AnyNonFixedPayments
Initial Contract Exception0InitialContractException

Form990 Schedule J Part II Form990ScheduleJPartII (8 entries)

TitleTitleBase Compensation Filing OrgBaseCompensationFilingOrgComp Based On Related OrgsCompBasedOnRelatedOrgsBonus Filing OrgBonusFilingOrgBonus Related OrgsBonusRelatedOrgsOther Compensation Filing OrgOtherCompensationFilingOrgOther Compensation Related OrgsOtherCompensationRelatedOrgsDeferred Comp Filing OrgDeferredCompFilingOrgDeferred Comp Related OrgsDeferredCompRelatedOrgsNontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgNontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgsTotal Compensation Filing OrgTotalCompensationFilingOrgTotal Compensation Related OrgsTotalCompensationRelatedOrgsComp Report Prior990 Filing OrgCompReportPrior990FilingOrgComp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs
Melvyn Patashnick
President and CEO286411000355370100000220800354028000
Brian Smale MD
Past Trustee232209000000000232209000
Rassoul Rangaviz
CFO1666270007234068370178470198545000
Bryan Huber MD
Physician5034790515000353170100000382700638566000
Eric Mullins MD
Physician512680000220510100000317100576441000
Brian Aros MD
Physician46702100072914000291280569063000
Christopher Rohan MD
Physician32251600017000000295160369032000
Adam Kunin MD
Physician25477600025098000330100312884000

Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
Part I, Line 5Bryan Huber, a highest compensated employee, received a bonus of $51,500. A portion of the bonus ($37,500) was based upon the gross revenue he produced individually for the Hospital. The bonus is triggered when the individual produces a certain level of revenue. The bonus is 20% of the excess revenue produced over that level. There is a cap on the amount of bonus the indivdual can receive.
Part IIIForm 990, Part VII, Line 5: Dr. Brian Smale, a past member of the board of trustees is an owner of Green Mountain General Surgery. Copley Hospital paid Green Mountain General Surgery for surgical services that Dr. Smale provided through his Organization to the Hospital. Copley Hospital paid Green Mountain General Surgery $232,209 for these services. Dr. Smale's compensation for services rendered specifically to the Hospital was not available as Green Mountain General Surgery is an unrelated organization.Supplemental Information

Schedule L IRS990ScheduleL

Form990 Schedule L Part IV Form990ScheduleLPartIV

Name Of Interested Person NameOfInterestedPerson

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1Green Mountain General SurgeryBusinessNameLine1
FieldValueIRS element (for citing)
RelationshipAn Entity more than 35% owned by Brian Smale, Past Trustee of the BoardRelationship
Amount Of Transaction232209AmountOfTransaction
Description Of TransactionIndependent Contractor ArrangementDescriptionOfTransaction
Sharing Of Revenues0SharingOfRevenues

Schedule M IRS990ScheduleM

Real Estate Residential RealEstateResidential

FieldValueIRS element (for citing)
Non Cash CheckboxXNonCashCheckbox
Number Of Contributions1NumberOfContributions
Noncash Contribs Rptd F990190000NoncashContribsRptdF990
Method Of Determining RevenuesFair Market ValueMethodOfDeterminingRevenues
FieldValueIRS element (for citing)
Number Of8283 Received1NumberOf8283Received
Any Property That Must Be Held0AnyPropertyThatMustBeHeld
Review Process Unusual NC Gifts1ReviewProcessUnusualNCGifts
Third Parties Used0ThirdPartiesUsed

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (9 entries)

Return ReferenceReturnReferenceExplanationExplanationIdentifierIdentifier
Form 990, Part VI, Section A, line 4The Organization's bylaws were amended in January of 2013. With the exception of the CEO, the Organization now requires all compensation and evaluation committee members to be independent directors. Individuals who have applied for employment or contractor status within the previous three years shall be excluded.
Form 990, Part VI, Section A, line 6Copley Hospital, Inc. is a member organization whose sole corporate member is Copley Health Systems, Inc. Copley Health Systems, Inc. and the Hospital share the same board of trustees.
Form 990, Part VI, Section A, line 7aCopley Hospital, Inc. shares the same board as Copley Health Systems, Inc. Each year, the members of Copley Health Systems, Inc. will hold an annual meeting. The purposes of the annual meeting shall include the election of members to the Corporation, the election of Trustees to the Corporation's Board of Trustees, the election of the community member at large of the governance and bylaws committee, and the transaction of such other business as may properly come before the membership. The Board shall consist of up to twenty-one elected members, the Chief Executive Officer of the Corporation and the President of the Medical Staff of Copley Hospital, Inc., all as voting members. All Trustees must be members of the Corporation.
Form 990, Part VI, Section B, line 11The finance committee reviews the Form 990 prior to submission. A complete copy of the form is made available to all members of the governing body through the finance office.
Form 990, Part VI, Section B, line 12cThe Governance Committee reviews the statements and surveys completed by interested persons and maintains a list of individuals who may be considered disqualified persons under IRS regulations. The Governance Committee reports the results of its reviews annually to the Board. The internal Compliance Committee of the Corporation reviews any potential conflict of interest which involves an interested person who is not a trustee or officer of the Corporation. The internal Compliance Committee reports the results of its reviews annually to the Board.
Form 990, Part VI, Section B, line 15The CEO's pay is determined through the use of an outside compensation firm. Senior leadership and other highly compensated individuals have their pay ranges determined through market data from Astron Solutions. The compensation for the CEO is approved by the Board.
Form 990, Part VI, Section C, line 19The governing documents are made available upon request. The conflict of interest policy and Matrix are available upon request. The financial statements are summarized in an annual report that is available to the public. The Hospital also submits both their budget and actual financial information to the State of Vermont's Department of Banking, Insurance, Securities & Health Care Administration.
Form 990, Part IX, line 11gOther Fees: Program service expenses 1,768,806. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,768,806. Contract Labor: Program service expenses 1,427,882. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,427,882. Purchased Services: Program service expenses 2,669,823. Management and general expenses 604,159. Fundraising expenses 0. Total expenses 3,273,982.Other Fees
Form 990, Part XI, line 9:Change in Beneficial Interest in Net Assets of Copley Health Systems, Inc. -329,978.Changes in Net Assets or Fund Balances:

Schedule R IRS990ScheduleR

Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)

Address Line1AddressUS/AddressLine1CityAddressUS/CityStateAddressUS/StateZIP CodeAddressUS/ZIPCodeEINEINPrimary ActivitiesPrimaryActivitiesLegal Domicile StateLegalDomicileStateExempt Code SectionExemptCodeSectionPublic Charity StatusPublicCharityStatusBusiness Name Line1DirectControllingEntityName/BusinessNameLine1Controlled OrgControlledOrgDirect Controlling Entity NADirectControllingEntityNA
Lamoille Area Housing Corporation Copley Terrace Project
528 Washington HighwayMorrisvilleVT05661030270255Subsidized Elderly HousingVT501(c)(3)Line 9Copley Health Systems Inc0
Copley Health Systems Inc
528 Washington HighwayMorrisvilleVT05661030301457Support of Copley HospitalVT501(c)(3)Line 11b, II0N/A

Form990 Schedule R Part IV Form990ScheduleRPartIV

Name Of Related Org NameOfRelatedOrg

FieldValueIRS element (for citing)
Business Name Line1Health Center Building IncBusinessNameLine1

Address US AddressUS

FieldValueIRS element (for citing)
Address Line1528 Washington HighwayAddressLine1
CityMorrisvilleCity
StateVTState
ZIP Code05661ZIPCode
FieldValueIRS element (for citing)
EIN030220357EIN
Primary ActivityOffice Building RentalPrimaryActivity
Legal Domicile StateVTLegalDomicileState

Direct Controlling Entity Name DirectControllingEntityName

FieldValueIRS element (for citing)
Business Name Line1Copley Health Systems IncBusinessNameLine1
FieldValueIRS element (for citing)
Type Of EntityCTypeOfEntity
Controlled Org0ControlledOrg
FieldValueIRS element (for citing)
Receipt Of Int Ann Rents Royalties0ReceiptOfIntAnnRentsRoyalties
Gift Grant Or Cap Contr To Other Org0GiftGrantOrCapContrToOtherOrg
Gift Grant Or Cap Contr Fr Other Org1GiftGrantOrCapContrFrOtherOrg
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrg
Loans Or Guarantees From Other Org0LoansOrGuaranteesFromOtherOrg
Dividends Related Organization0DividendsRelatedOrganization
Sale Of Assets To Other Org0SaleOfAssetsToOtherOrg
Purchase Of Assets From Other Org0PurchaseOfAssetsFromOtherOrg
Exchange Of Assets0ExchangeOfAssets
Rental Of Facilities To Other Orgs0RentalOfFacilitiesToOtherOrgs
Rental Of Facilities Fr Other Orgs1RentalOfFacilitiesFrOtherOrgs
Perform Of Services For Other Orgs1PerformOfServicesForOtherOrgs
Perform Of Services By Other Orgs0PerformOfServicesByOtherOrgs
Sharing Of Facilities0SharingOfFacilities
Sharing Of Paid Employees1SharingOfPaidEmployees
Reimbursement Paid To Other Org0ReimbursementPaidToOtherOrg
Reimbursement Paid By Other Org1ReimbursementPaidByOtherOrg
Other Transfer To Other Org0OtherTransferToOtherOrg
Other Transfer From Other Org0OtherTransferFromOtherOrg

Transactions Related Orgs Table TransactionsRelatedOrgsTable (2 entries)

Transaction TypeTransactionTypeAmount InvolvedAmountInvolvedMethod Of Amt DeterminationMethodOfAmtDetermination
Health Center Building
K112275FMV
Copley Health Systems Inc
C798405FMV

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