NORTH COUNTRY HEALTH SERVICES INC: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- NORTH COUNTRY HEALTH SERVICES INC (EIN 22-2570334)
- Tax period
- 2010-10-01 to 2011-09-30
- Filed
- 2012-08-08
- IRS object ID
- 201212219349301361
- Schema version
- 2010v3.7
- 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-08-08T15:34:39-05:00 | Timestamp |
| Tax Period End Date | 2011-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BKD LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 910 E ST LOUIS 200/PO BOX 1190 | AddressLine1 |
| City | SPRINGFIELD | City |
| State | MO | State |
| ZIP Code | 658062523 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 222570334 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | NORTH COUNTRY HEALTH SERVICES INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | NORT | NameControl |
| Phone | 8027662201 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | ANDRE BISSONNETTE | Name |
| Title | VP OF FINANCE | Title |
| Date Signed | 2012-07-18 | DateSigned |
| Authorize Third Party | true | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Brian D Todd | Name |
| Phone | 4178658701 | Phone |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | DERBY GREEN | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | LISA BOHLMAN CLAUDIO FORT | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 1519917 | GrossReceipts |
| Group Return For Affiliates | false | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.NCHSI.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1984 | YearFormation |
| State Legal Domicile | VT | StateLegalDomicile |
| Activity Or Mission Description | NORTH COUNTRY HEALTH SERVICES IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF FACILITY RESIDENTS. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 15 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 11 | NbrIndependentVotingMembers |
| Total Nbr Employees | 46 | TotalNbrEmployees |
| Total Nbr Volunteers | 19 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 16485 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 20098 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 1381291 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 1408853 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 10975 | InvestmentIncomePriorYear |
| Investment Income Current Year | 16051 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 0 | OtherRevenuePriorYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 1408751 | TotalRevenuePriorYear |
| Total Revenue Current Year | 1445002 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 918124 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 971538 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 423947 | OtherExpensePriorYear |
| Other Expenses Current Year | 411194 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 1342071 | TotalExpensesPriorYear |
| Total Expenses Current Year | 1382732 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 66680 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 62270 | RevenuesLessExpensesCY |
| Total Assets BOY | 813303 | TotalAssetsBOY |
| Total Assets EOY | 846813 | TotalAssetsEOY |
| Total Liabilities BOY | 89535 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 72094 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 723768 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 774719 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | NORTH COUNTRY HEALTH SERVICES IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF FACILITY RESIDENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. | MissionDescription |
| Significant New Program Services | false | SignificantNewProgramServices |
| Significant Change | false | SignificantChange |
| Expense | 1168652 | Expense |
| Revenue | 1197525 | Revenue |
| Description | THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2011, THE ORGANIZATION HAD 7,132 MEDICAID PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 23611 | Expense |
| Revenue | 197239 | Revenue |
| Description | THE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 13749 | Expense |
| Revenue | 14089 | Revenue |
| Description | THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2011, THE ORGANIZATION HAD 119 MEDICARE PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 1206012 | TotalProgramServiceExpense |
| Described In501 C3 | true | DescribedIn501C3 |
| Schedule B Required | true | ScheduleBRequired |
| Political Activities | false | PoliticalActivities |
| Lobbying Activities | true | LobbyingActivities |
| Donor Advised Funds | false | DonorAdvisedFunds |
| Conservation Easements | false | ConservationEasements |
| Collections Of Art | false | CollectionsOfArt |
| Credit Counseling | true | CreditCounseling |
| Term Or Permanent Endowments | false | TermOrPermanentEndowments |
| Report Land Bldg Equip | true | ReportLandBldgEquip |
| Report Invest Oth Securities | false | ReportInvestOthSecurities |
| Report Prog Rel Invest | false | ReportProgRelInvest |
| Report Other Assets | false | ReportOtherAssets |
| Report Other Liabilities | true | ReportOtherLiabilities |
| Report Fin48 Footnote | false | ReportFin48Footnote |
| Independent Audit Financial Stmt | false | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | true | ConsolidatedAuditFinancialStmt |
| School | false | School |
| Foreign Office | false | ForeignOffice |
| Foreign Activities | false | ForeignActivities |
| More Than5000 K To Organizations | false | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | false | MoreThan5000KToIndividuals |
| Professional Fundraising | false | ProfessionalFundraising |
| Fundraising Activities | false | FundraisingActivities |
| Gaming | false | Gaming |
| Hospital | false | Hospital |
| Grants To Organizations | false | GrantsToOrganizations |
| Grants To Individuals | false | GrantsToIndividuals |
| Schedule J Required | true | ScheduleJRequired |
| Tax Exempt Bonds | false | TaxExemptBonds |
| Excess Benefit Transaction | false | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | false | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | false | LoanToOfficerOrDQP |
| Grant To Related Person | false | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | false | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | false | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | false | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | false | DeductibleNonCashContributions |
| Deductible Contributions Of Art | false | DeductibleContributionsOfArt |
| Terminated | false | Terminated |
| Partial Liquidation | false | PartialLiquidation |
| Disregarded Entity | false | DisregardedEntity |
| Related Entity | true | RelatedEntity |
| Related Org Controlled Entity | false | RelatedOrgControlledEntity |
| Transaction Related Entity | false | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | false | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | false | ActivitiesConductedPartnership |
| Schedule O Required | true | ScheduleORequired |
| Number Forms Transmitted With1096 | 8 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | true | ComplianceWithBackupWitholding |
| Number Of Employees | 46 | NumberOfEmployees |
| Employment Tax Returns Filed | true | EmploymentTaxReturnsFiled |
| Unrelated Business Income | false | UnrelatedBusinessIncome |
| Foreign Financial Account | false | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | false | ProhibitedTaxShelterTrans |
| Taxable Party Notification | false | TaxablePartyNotification |
| Non Deductible Contributions | false | NonDeductibleContributions |
| Quid Pro Quo Contributions | false | QuidProQuoContributions |
| Form8282 Property Disposed Of | false | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | false | FundsToPayPremiums |
| Premiums Paid | false | PremiumsPaid |
| Indoor Tanning Services | false | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 15 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 11 | NumberIndependentVotingMembers |
| Family Or Business Relationship | false | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | false | DelegationOfManagementDuties |
| Changes To Organizing Docs | false | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | false | MaterialDiversionOrMisuse |
| Members Or Stockholders | true | MembersOrStockholders |
| Election Of Board Members | true | ElectionOfBoardMembers |
| Decisions Subject To Approval | true | DecisionsSubjectToApproval |
| Minutes Of Governing Body | true | MinutesOfGoverningBody |
| Minutes Of Committees | true | MinutesOfCommittees |
| Officer Mailing Address | false | OfficerMailingAddress |
| Local Chapters | false | LocalChapters |
| Form990 Provided To Governing Body | true | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | true | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | true | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | true | RegularMonitoringEnforcement |
| Whistleblower Policy | true | WhistleblowerPolicy |
| Document Retention Policy | true | DocumentRetentionPolicy |
| Compensation Process CEO | false | CompensationProcessCEO |
| Compensation Process Other | false | CompensationProcessOther |
| Investment In Joint Venture | false | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | ANDRE BISSONNETTE | NamePerson |
| Telephone Number | 8023347331 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 189 PROUTY DRIVE | AddressLine1 |
| City | NEWPORT | City |
| State | VT | State |
| ZIP Code | 05855 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (18 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| CLAUDIO D FORT | ||||||
| CEO | 1.0 | X | X | 0 | 251462 | 29342 |
| KATHRYN AUSTIN | ||||||
| CHAIR | 1.0 | X | X | 0 | 0 | 0 |
| SCOTT PERRY | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| SUSAN PENHARLOW | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| MELISSA PETTERSSON | ||||||
| SECRETARY/CLERK | 1.0 | X | X | 0 | 0 | 0 |
| RICHARD BARAW | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| ALAN WING | ||||||
| VICE CHAIR - BOARD | 1.0 | X | X | 0 | 0 | 0 |
| BILL STENGER | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| BONNIE NASH | ||||||
| VICE CHAIR - FINANCE | 1.0 | X | X | 0 | 0 | 0 |
| JEANE KADMIRI | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| DAVE LAFORCE | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| THOMAS MOSELEY MD | ||||||
| MEDICAL STAFF PRES THRU 1/11 | 1.0 | X | 0 | 0 | 0 | |
| BOB WILSON | ||||||
| TRUSTEE | 1.0 | X | 0 | 0 | 0 | |
| CHRISTOPHER RICKMAN MD | ||||||
| PHYSICIAN/TRUSTEE | 1.0 | X | 0 | 225297 | 40361 | |
| MARC BOUCHARD MD | ||||||
| MEDICAL STAFF VP BEG 1/11 | 1.0 | X | 0 | 288508 | 44120 | |
| PETER STUART MD | ||||||
| MEDICAL STAFF PRES BEG 1/11 | 1.0 | X | 0 | 324800 | 41643 | |
| ANDRE BISSONNETTE | ||||||
| VP OF FINANCE | 1.0 | X | 0 | 133566 | 28118 | |
| LISA BOHLMAN | ||||||
| ADMINISTRATOR | 40.0 | X | 76920 | 0 | 25131 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 76920 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1223633 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 208715 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | false | FormersListed |
| Total Comp GT150 K | true | TotalCompGT150K |
| Compensation From Other Sources | false | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Government Grants | 20098 | GovernmentGrants |
| Total Contributions | 20098 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| PATIENT REVENUE | 623000 | 1406140 | 1406140 |
| OTHER | 623000 | 2713 | 2713 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 1408853 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 7125 | TotalRevenueColumn |
| Exclusion | $7,125 | ExclusionAmount |
Income From Invest Bond Proceeds IncomeFromInvestBondProceeds
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Royalties Revenue RoyaltiesRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 83841 | Securities |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 74915 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 8926 | Securities |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 8926 | TotalRevenueColumn |
| Exclusion | $8,926 | ExclusionAmount |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Net Income From Gaming NetIncomeFromGaming
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
Net Income Or Loss NetIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 0 | TotalRevenueColumn |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 0 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1445002 | TotalRevenueColumn |
| Related Or Exempt Function Income | 1408853 | RelatedOrExemptFunctionIncome |
| Exclusion | $16,051 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Foreign Grants ForeignGrants
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Benefits To Members BenefitsToMembers
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 102051 | Total |
| Management And General | 102051 | ManagementAndGeneral |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 685294 | Total |
| Program Services | 662102 | ProgramServices |
| Management And General | 23192 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 22351 | Total |
| Program Services | 21595 | ProgramServices |
| Management And General | 756 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 100430 | Total |
| Program Services | 97031 | ProgramServices |
| Management And General | 3399 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 61412 | Total |
| Program Services | 53346 | ProgramServices |
| Management And General | 8066 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1000 | Total |
| Management And General | 1000 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1180 | Total |
| Management And General | 1180 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 18943 | Total |
| Management And General | 18943 | ManagementAndGeneral |
Fees For Services Lobbying FeesForServicesLobbying
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Prof Fundraising FeesForServicesProfFundraising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4112 | Total |
| Management And General | 4112 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 72144 | Total |
| Program Services | 71045 | ProgramServices |
| Management And General | 1099 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 96802 | Total |
| Program Services | 92139 | ProgramServices |
| Management And General | 4663 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5040 | Total |
| Program Services | 5040 | ProgramServices |
Royalties Royalties
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 39830 | Total |
| Program Services | 39830 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4517 | Total |
| Program Services | 2026 | ProgramServices |
| Management And General | 2491 | ManagementAndGeneral |
Travel Entrtnmnt Public Officials TravelEntrtnmntPublicOfficials
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 544 | Total |
| Program Services | 500 | ProgramServices |
| Management And General | 44 | ManagementAndGeneral |
Payments To Affiliates PaymentsToAffiliates
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 0 | Total |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 39503 | Total |
| Program Services | 36304 | ProgramServices |
| Management And General | 3199 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7273 | Total |
| Program Services | 7273 | ProgramServices |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| MEDICAID TAXES | 94286 | 94286 | |
| DUES & SUBSCRIPTIONS | 2979 | 563 | 2416 |
| RECRUITING & RETENTION | 2015 | 2015 | |
| MEDICAL SUPPLIES & DRUGS | 20917 | 20917 | |
| MISCELLANEOUS | 109 | 109 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1382732 | Total |
| Program Services | 1206012 | ProgramServices |
| Management And General | 176720 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1100 | BOY |
| EOY | 1100 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 275408 | BOY |
| EOY | 241608 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 96535 | BOY |
| EOY | 115537 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 100 | BOY |
| EOY | 100 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 19284 | BOY |
| EOY | 21329 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 1024698 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 783741 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 198298 | BOY |
| EOY | 240957 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 222578 | BOY |
| EOY | 226182 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 813303 | BOY |
| EOY | 846813 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 43224 | BOY |
| EOY | 51012 | EOY |
Escrow Account Liability EscrowAccountLiability
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1455 | BOY |
| EOY | 1076 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 44856 | BOY |
| EOY | 20006 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 89535 | BOY |
| EOY | 72094 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 723768 | BOY |
| EOY | 774719 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 723768 | BOY |
| EOY | 774719 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 813303 | BOY |
| EOY | 846813 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 62270 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | -11319 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | false | AccountantCompileOrReview |
| FS Audited | true | FSAudited |
| Audit Committee | true | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | false | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Publicly Supported Org509a2 | X | PubliclySupportedOrg509a2 |
Gifts Grants Contrib Received509 GiftsGrantsContribReceived509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus2 Years | 16853 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 16485 | CurrentTaxYearMinus1Year |
| Current Tax Year | 20098 | CurrentTaxYear |
| Total | 53436 | Total |
Gross Receipts From Admissions GrossReceiptsFromAdmissions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1292325 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1306076 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1352992 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1381291 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1408853 | CurrentTaxYear |
| Total | 6741537 | Total |
Total509 Total509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1292325 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1306076 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1369845 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1397776 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1428951 | CurrentTaxYear |
| Total | 6794973 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Total509 | 6794973 | PublicSupportTotal509 |
Gross Investment Income509 GrossInvestmentIncome509
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 14384 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 4410 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7701 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 6547 | CurrentTaxYearMinus1Year |
| Current Tax Year | 7125 | CurrentTaxYear |
| Total | 40167 | Total |
Investment Income And UBTI InvestmentIncomeAndUBTI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 14384 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 4410 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 7701 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 6547 | CurrentTaxYearMinus1Year |
| Current Tax Year | 7125 | CurrentTaxYear |
| Total | 40167 | Total |
Total Support Total TotalSupportTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Current Tax Year Minus4 Years | 1306709 | CurrentTaxYearMinus4Years |
| Current Tax Year Minus3 Years | 1310486 | CurrentTaxYearMinus3Years |
| Current Tax Year Minus2 Years | 1377546 | CurrentTaxYearMinus2Years |
| Current Tax Year Minus1 Year | 1404323 | CurrentTaxYearMinus1Year |
| Current Tax Year | 1436076 | CurrentTaxYear |
| Total | 6835140 | Total |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Public Support Percentage509 | 0.99412 | PublicSupportPercentage509 |
| Prior Year Support Percentage | 0.99184 | PriorYearSupportPercentage |
| Investment Income Percentage | 0.00588 | InvestmentIncomePercentage |
| Prior Yr Invest Income Percentage | 0.00816 | PriorYrInvestIncomePercentage |
| Thirty Three Percnt Tests CY509 | X | ThirtyThreePercntTestsCY509 |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Grassroots Lobbying | TotalGrassrootsLobbying | |
| Total Direct Lobbying | TotalDirectLobbying | |
| Total Lobbying Expenditures | TotalLobbyingExpenditures | |
| Other Exempt Purpose Expenditures | OtherExemptPurposeExpenditures | |
| Total Exempt Purpose Expenditures | TotalExemptPurposeExpenditures | |
| Lobbying Nontaxable | LobbyingNontaxableAmount | |
| Grassroots Nontaxable | GrassrootsNontaxableAmount | |
| Tot Lobbying Grassroot Minus Non Tx | TotLobbyingGrassrootMinusNonTx | |
| Tot Lobby Expend Mns Lobbying Nontx | TotLobbyExpendMnsLobbyingNontx | |
| Volunteers | false | Volunteers |
| Paid Staff Or Management | false | PaidStaffOrManagement |
| Media Advertisements | false | MediaAdvertisements |
| Mailings Members | false | MailingsMembers |
| Publications Or Broadcast | false | PublicationsOrBroadcast |
| Grants Other Organizations | false | GrantsOtherOrganizations |
| Direct Contact Legislators | false | DirectContactLegislators |
| Rallies Demonstrations | false | RalliesDemonstrations |
| Other Activities | true | OtherActivities |
| Not Described In501c3 | false | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | OTHER LOBBYING ACTIVITIES | Identifier |
| Return Reference | SCHEDULE C, PART II-B, LINE 1(I) | ReturnReference |
| Explanation | THE ORGANIZATION PAYS DUES TO THE VERMONT HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING PURPOSES. | Explanation |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Art Public Exhibition Amts | ArtPublicExhibitionAmts | |
| Held Works Of Art Amts | HeldWorksOfArtAmts | |
| Agent Trustee Etc | false | AgentTrusteeEtc |
| Included On FS | true | IncludedOnFS |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 30000 | OtherCostOrOtherBasis |
| Book Value | 30000 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Buildings | Buildings |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 612843 | OtherCostOrOtherBasis |
| Depreciation | 518050 | Depreciation |
| Book Value | 94793 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 353294 | OtherCostOrOtherBasis |
| Depreciation | 240436 | Depreciation |
| Book Value | 112858 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 28561 | OtherCostOrOtherBasis |
| Depreciation | 25255 | Depreciation |
| Book Value | 3306 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 240957 | TotalOfBookValueLandBuildings |
| Federal Income Tax Liability | 0 | FederalIncomeTaxLiability |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | DUE TO AFFILIATES | Description |
| Amount | $20,006 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 20006 | TotalOfAmounts |
| Total Revenue | 1445002 | TotalRevenue |
| Total Expenses | 1382732 | TotalExpenses |
| Excess Or Deficit For Year | 62270 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | -11319 | NetUnrealizedGLOnInvestments |
| Total Adjustments | -11319 | TotalAdjustments |
| Excess Or Deficit Per FS | 50951 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 1425834 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | -11319 | NetUnrealizedGainsInvestments |
| Other Revenues | -7849 | OtherRevenues |
| Revenue Not Rptd F990 | -19168 | RevenueNotRptdF990 |
| Revenue Subtotal | 1445002 | RevenueSubtotal |
| Total Revenue Per Form990 | 1445002 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 1374883 | TotExpensesEtcAuditedFinclStmt |
| Expenses Subtotal | 1374883 | ExpensesSubtotal |
| Other Expenses Not Included | 7849 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 7849 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 1382732 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| TRUST, ESCROW, AND CUSTODIAL ACCOUNTS | SCHEDULE D, PART IV, LINE 2B | THE ORGANIZATION MAINTAINS A "RESIDENT PERSONAL FUNDS PAYABLE" ACCOUNT. THIS ACCOUNT HOLDS PERSONAL FUNDS OF RESIDENTS IN AN INTEREST BEARING ACCOUNT AT A LOCAL BANK. IN ORDER TO ISSUE CHECKS FROM THE ACCOUNT, TWO SIGNATURES ARE REQUIRED. |
| UNCERTAIN TAX POSITIONS | SCHEDULE D, PART X, LINE 2 | MANAGEMENT HAS EVALUATED THEIR INCOME TAX POSITIONS UNDER THE GUIDANCE INCLUDED IN ASC 740. BASED ON THEIR REVIEW, MANAGEMENT HAS NOT IDENTIFIED ANY MATERIAL UNCERTAIN TAX POSITIONS TO BE RECORDED OR DISCLOSED IN THE FINANCIAL STATEMENTS. |
| OTHER REVENUE INCLUDED ON LINE 1, BUT NOT ON FORM 990, PART VIII, LINE 12 | SCHEDULE D, PART XII, LINE 2D | THE FOLLOWING EXPENSES WERE INCLUDED WITH REVENUES ON THE AUDIT REPORT; HOWEVER, WERE MOVED TO BE PROPERLY INCLUDED WITH EXPENSES ON THE AUDIT REPORT. $( 3,737) EXPENSES PAID OUT OF GRANT FUNDS ( 4,112) INVESTMENT FEES -------- $( 7,849) |
| OTHER EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, BUT NOT ON LINE 1 | SCHEDULE D, PART XIII, LINE 4B | THE FOLLOWING EXPENSES WERE INCLUDED WITH REVENUES ON THE AUDIT REPORT; HOWEVER, WERE MOVED TO BE PROPERLY INCLUDED WITH EXPENSES ON THE AUDIT REPORT. $ 3,737 EXPENSES PAID OUT OF GRANT FUNDS 4,112 INVESTMENT FEES -------- $ 7,849 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | false | SeverancePayment |
| Supplemental Nonqual Retire Plan | false | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | false | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | false | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | false | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | false | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | false | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | false | AnyNonFixedPayments |
| Initial Contract Exception | false | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (5 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CLAUDIO D FORT | |||||||||||||
| 0 | 247812 | 0 | 200 | 0 | 3450 | 0 | 6125 | 0 | 23217 | 0 | 280804 | 0 | 0 |
| ANDRE BISSONNETTE | |||||||||||||
| 0 | 128421 | 0 | 3212 | 0 | 1933 | 0 | 4901 | 0 | 23217 | 0 | 161684 | 0 | 0 |
| CHRISTOPHER RICKMAN MD | |||||||||||||
| 0 | 202949 | 0 | 20314 | 0 | 2034 | 0 | 13391 | 0 | 26970 | 0 | 265658 | 0 | 0 |
| MARC BOUCHARD MD | |||||||||||||
| 0 | 279062 | 0 | 7302 | 0 | 2144 | 0 | 17150 | 0 | 26970 | 0 | 332628 | 0 | 0 |
| PETER STUART MD | |||||||||||||
| 0 | 273116 | 0 | 33221 | 0 | 18463 | 0 | 14673 | 0 | 26970 | 0 | 366443 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | COMPENSATION DETERMINATION | Identifier |
| Return Reference | SCHEDULE J, PART I, LINE 3 | ReturnReference |
| Explanation | NORTH COUNTRY HOSPITAL, A RELATED ORGANIZATION, USES AN INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD IN DETERMINING THE COMPENSATION OF THE CEO. | Explanation |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| ORGANIZATION'S MISSION | FORM 990, PART III, LINE 1 | NORTH COUNTRY HEALTH SERVICES, INC., IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF OUR FACILITY RESIDENTS. THE CENTRAL PURPOSE OF THE CORPORATION IS TO SUPPORT AND OVERSEE THE OPERATION OF DERBY GREEN. DERBY GREEN IS A TWENTY-THREE BED FACILITY CERTIFIED BY MEDICARE/MEDICAID. NORTH COUNTRY HEALTH SERVICES, INC., HAS A FURTHER COMMITMENT TO ASSIST COMMUNITY MEMBERS IN THE MAINTENANCE AND IMPROVEMENT OF THEIR OWN HEALTH. DERBY GREEN WILL OFFER OTHER PROGRAMS THAT WILL BE BENEFICIAL TO THE COMMUNITY AND IN THE BEST INTERESTS OF DERBY GREEN. IN RECOGNITION OF THE BURDEN THAT THE COSTS OF HEALTH CARE PLACES ON THE COMMUNITY, NORTH COUNTRY HEALTH SERVICES, INC., WILL PROVIDE QUALITY HEALTH CARE WHILE EVERY EFFORT WILL BE MADE TO CONTAIN COSTS. |
| PROGRAM SERVICES | FORM 990, PART III, LINE 4 | THE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. DERBY GREEN PROVIDES A FULL RANGE OF HEALTH CARE SERVICES AND IS COMMITTED TO PROVIDING EXCELLENT HEALTHCARE IN A KIND AND CARING ENVIRONMENT. DERBY GREEN IS A PROGRESSIVE NURSING FACILITY WITH CARING STAFF WHO WILL STRIVE TO MEET THE INDIVIDUAL NEEDS OF EACH RESIDENT. SERVICES PROVIDED INCLUDE: - 24-HOUR NURSING CARE AND ON-CALL PHYSICIAN, - LAUNDRY, SOCIAL, PODIATRY, AND BEAUTICIAN SERVICES, - PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY IN ADDITION, RECREATIONAL, RELIGIOUS, AND SOCIAL EVENTS ARE AVAILABLE TO ALL RESIDENTS. INDIVIDUAL AND GROUP ACTIVITIES SUCH AS BINGO, CHURCH SERVICES, MOVIES, SEASONAL PARTIES, AND MUSICAL ENTERTAINMENT ARE ROUTINELY OFFERED. REALITY ORIENTATION AND STIMULATION IS DIRECTED THROUGH THE LIFE ENHANCEMENT PROGRAM. SPECIAL OUTINGS MAY INCLUDE PICNICS IN THE PARK, BARBEQUES, AND SCENIC RIDES IN THE WHEELCHAIR LIFT EQUIPPED VAN. IN-ROOM CABLE AND PHONE SERVICE IS AVAILABLE. |
| MEMBERS OF THE ORGANIZATION | FORM 990, PART VI, SECTION A, LINES 6, 7A, & 7B | THE SOLE MEMBER OF THE CORPORATION SHALL BE NORTH COUNTRY HEALTH SYSTEMS, INC., A VERMONT NOT-FOR-PROFIT CORPORATION, ACTING THROUGH ITS BOARD OF TRUSTEES AND HEREINAFTER REFERRED TO AS THE "MEMBER" WHEN ACTING IN ITS CAPACITY AS SUCH. THE MEMBER SHALL HAVE THE EXCLUSIVE RIGHT TO ENJOY AND EXERCISE ALL RIGHTS AND POWERS CONFERRED ON MEMBERS OF NON-PROFIT CORPORATIONS UNDER THE LAWS OF THE STATE OF VERMONT. THE MEMBER SHALL HAVE SUCH OTHER POWERS AS ARE SPECIFIED IN THE ARTICLES OF ASSOCIATION AND IN THE BY-LAWS, INCLUDING, WITHOUT LIMITATION, THE POWER TO ELECT AND REMOVE TRUSTEES AND TO AMEND AND RESTATE THE ARTICLES OF ASSOCIATION. THE AUTHORITY OF THE BOARD OF TRUSTEES TO EXERCISE THE POWERS LISTED IN THE BYLAWS IS CONDITIONED ON THE PRIOR APPROVAL OF THE MEMBER. |
| REVIEW OF THE FORM 990 | FORM 990, PART VI, SECTION B, LINE 11B | THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE FORM 990 IS REVIEWED BY THE ORGANIZATION'S MANAGEMENT AND FINANCE TEAM IN DETAIL. AFTER IT HAS BEEN REVIEWED, IT IS THEN PROVIDED TO THE FULL BOARD. |
| CONFLICT OF INTEREST POLICY | FORM 990, PART VI, SECTION B, LINE 12C | IN CONNECTION WITH ANY ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF HIS OR HER FINANCIAL INTEREST AND MUST BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE BOARD, COMMITTEE, OR OTHER INDIVIDUALS WHO, ON BEHALF OF THE CORPORATION, ARE CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. IN THE EVENT THAT A TRUSTEE, OFFICER, COMMITTEE MEMBER OR MEMBER OF THE CORPORATION'S LEADERSHIP GROUP BECOMES CONCERNED THAT ANOTHER INTERESTED PERSON HAS AN UNDISCLOSED FINANCIAL INTEREST OR IS EXERTING INAPPROPRIATE INFLUENCE RELATED TO A FINANCIAL INTEREST, THIS CONCERN SHOULD BE RAISED WITH THE CHAIR OF THE APPROPRIATE BOARD OR COMMITTEE OR, IF INVOLVING THE LEADERSHIP GROUP, AN APPROPRIATE CORPORATE OFFICER. AFTER DISCLOSURE OF THE FINANCIAL INTEREST AND ALL MATERIAL FACTS, AND AFTER ANY DISCUSSION WITH THE INTERESTED PERSON, HE/SHE SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE DETERMINATION OF A CONFLICT OF INTEREST IS DISCUSSED AND VOTED UPON BY THE REMAINING BOARD OR COMMITTEE MEMBERS. IT SHALL BE THE RESPONSIBILITY OF THE CHAIR OF THE BOARD OR COMMITTEE TO INSTRUCT AN INTERESTED PERSON ON THE RESTRICTIONS ON HIS OR HER PARTICIPATION PURSUANT TO THIS POLICY IN ANY FURTHER CONSIDERATION OF THE SUBJECT MATTER OF THE CONFLICT OF INTEREST AND TO ENFORCE THESE RESTRICTIONS. AWARENESS/COMPLIANCE WITH POLICY EACH INTERESTED PERSON SHALL ANNUALLY SIGN A STATEMENT WHICH AFFIRMS THAT SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE CORPORATION IS A CHARITABLE ORGANIZATION AND THAT, IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION, IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ONE OR MORE OF ITS TAX-EXEMPT PURPOSES. EACH INTERESTED PERSON SHALL DISCLOSE ON AN ANNUAL SURVEY FORM POTENTIAL CONFLICTS OF INTEREST AND FINANCIAL INTERESTS RELEVANT TO THIS POLICY. EACH INTERESTED PERSON SHALL ALSO PROVIDE ON AN ANNUAL SURVEY FORM A LIST OF IMMEDIATE FAMILY MEMBERS, INCLUDING SPOUSE, CHILDREN, GRANDCHILDREN, PARENTS, SIBLINGS AND ANY OTHER PERSON WHO LIVES IN HIS/HER HOUSEHOLD, IN ORDER THAT THE CORPORATION MAY HAVE A RECORD OF ALL INDIVIDUALS WHO MAY BE CONSIDERED DISQUALIFIED PERSONS UNDER INTERNAL REVENUE SERVICE REGULATIONS FOR THE PURPOSE OF ENSURING COMPLIANCE WITH TAX EXEMPT STATUS REQUIREMENTS FOR CHARITABLE ORGANIZATIONS. PROCEDURES FOR ADDRESSING THE CONFLICT OF INTEREST AN INTERESTED PERSON MAY MAKE A PRESENTATION AT THE BOARD OR COMMITTEE MEETING, BUT AFTER SUCH PRESENTATION, HE/SHE SHALL LEAVE THE MEETING DURING THE DISCUSSION OF, AND THE VOTE ON, THE TRANSACTION OR ARRANGEMENT THAT INVOLVES THE CONFLICT OF INTEREST. THE CHAIR OF THE BOARD OR COMMITTEE SHALL, IF APPROPRIATE, APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION OR ARRANGEMENT. AFTER EXERCISING DUE DILIGENCE, INCLUDING A CONSIDERATION OF INDEPENDENT COMPARABILITY DATA, VALUATIONS OR APPRAISALS, THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORT FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE (OR QUORUM) OF ALL OF THE DISINTERESTED TRUSTEES OR COMMITTEE MEMBERS (REGARDLESS OF THE NUMBER PRESENT AT A MEETING): (I) WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST AND FOR ITS OWN BENEFIT, (II) WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION, AND (III) WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGEMENT IN CONFORMITY WITH SUCH DETERMINATIONS. |
| COMPENSATION REVIEW | FORM 990, PART VI, SECTION B, LINE 15A | THE BOARD OF NORTH COUNTRY HOSPITAL & HEALTH CENTER, A RELATED ORGANIZATION, ANNUALLY REVIEWS THE CEO AND SENIOR TEAM SALARIES USING COMPARABILITY DATA. THE REVIEW PROCESS IS DOCUMENTED IN THE BOARD MINUTES. |
| DOCUMENT DISCLOSURE | FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO BE VIEWED BY THE PUBLIC UPON AN APPOINTMENT WITH THE ORGANIZATION'S CHIEF EXECUTIVE OFFICER OR ASSISTANT. |
| BOARD OF DIRECTORS | FORM 990, PART VII, SECTION A | NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS SHARE A BOARD OF DIRECTORS. CLAUDIO FORT, CEO, AND ANDRE BISSONNETTE, VP OF FINANCE, EACH WORK APPROXIMATELY 40 HOURS PER WEEK BETWEEN NORTH COUNTRY HOSPITAL AND HEALTH CENTER, NORTH COUNTRY HEALTH SERVICES, AND NORTH COUNTRY HEALTH SYSTEMS. CHRISTOPHER RICKMAN, MARC BOUCHARD, AND PETER STUART ARE COMPENSATED AS EMPLOYEES OF NORTH COUNTRY HOSPITAL. THEY DO NOT RECEIVE ANY COMPENSATION FOR THEIR DUTIES AS BOARD OF DIRECTORS MEMBERS. OTHER CHANGES IN NET ASSETS FORM 990, PART XI, LINE 5 UNREALIZED LOSS ON INVESTMENT $(11,319) |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (2 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 |
|---|---|---|---|---|---|---|---|---|---|
| NORTH COUNTRY HOSPITAL & HEALTH CENTER | |||||||||
| 189 PROUTY DRIVE | NEWPORT | VT | 05855 | 030185556 | HOSPITAL | VT | 501(C)(3) | 3 | NA |
| NORTH COUNTRY HEALTH SYSTEMS | |||||||||
| 189 PROUTY DRIVE | NEWPORT | VT | 05855 | 222566964 | PARENT/FUNDRS | VT | 501(C)(3) | 11B II | NA |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | false | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | false | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | false | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | false | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | false | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | false | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | false | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | false | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | false | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | false | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | false | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | true | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | true | SharingOfFacilities |
| Sharing Of Paid Employees | true | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | true | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | false | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | false | OtherTransferToOtherOrg |
| Other Transfer From Other Org | false | OtherTransferFromOtherOrg |
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