2012-03-13T10:56:20-05:00 2011-09-30 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2010-10-01 030179423 Copley Hospital Inc COPL 8028884231 528 Washington Highway Morrisville VT 05661 Melvyn Patashnick 8028884231 2012-03-06 1 Barbara J McGuan CPA 2077752387 2012-03-05 2010 2016-02-24 21:20:13Z Melvyn Patashnick 528 Washington Highway Morrisville VT 05661 50134497 0 X www.copleyhealthsystems.org X 1934 VT Critical Access Hospital 16 13 530 112 0 0 211733 1479616 45564271 48281768 45023 301547 104609 69691 45925636 50132622 191667 412292 0 0 25305047 26806788 0 0 0 19202427 20335254 44699141 47554334 1226495 2578288 32180471 33665149 11636406 10421163 20544065 23243986 X To 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. 0 0 43058251 412292 48281768 Copley 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. 43058251 1 1 0 1 0 0 0 0 0 0 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 93 0 1 530 1 0 0 0 0 0 0 0 0 0 0 X 16 13 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Kevin Dorain 8028884231 528 Washington Highway Morrisville VT 05661 Michael Alexander 2.00 X 0 0 0 Bryce Breton 2.00 X 0 0 0 Brian Coles 2.00 X 0 0 0 Willa Farrell 2.00 X 0 0 0 Elaine Nichols 2.00 X 0 0 0 Nancy Putnam 2.00 X 0 0 0 Elizabeth Rouse 2.00 X X 0 0 0 Jan Roy 2.00 X 0 0 0 Judy Shanley 2.00 X 0 0 0 Brian Smale MD 2.00 X 312231 0 0 John Steel 2.00 X X 0 0 0 Anne Vitaletti-Coughlin MD 2.00 X X 0 0 0 Dana Wildes 2.00 X X 0 0 0 Mark Woodward 2.00 X 0 0 0 David Yacovone 2.00 X 0 0 0 Melvyn Patashnick 40.00 X X 259084 0 31415 Sharon Green 2.00 X 0 0 0 Patrick Keith 2.00 X 5913 0 0 Rassoul Rangaviz 40.00 X 164599 0 29542 Bryan Huber MD 40.00 X 668234 0 39092 Eric Mullins MD 40.00 X 527528 0 37423 John Kaeding MD 40.00 X 276544 0 33980 Neil Nigro MD 40.00 X 240661 0 34336 Mirjam McCormack 40.00 X 299470 0 38947 2754264 0 244735 24 0 1 1 HP Cummings Construction Co PO Box 269 Woodsville NH 037850269 Building Contractor 1093565 Apogee Medical Equipment 2525 E Camelback Road Suite 1100 Phoenix AZ 85016 Hospitalist Services 421822 Fletcher Allen Health Care PO Box 1902 Burlington VT 054021902 Medical Services 409019 CPSG Inc PO Box 749 Morrisville VT 05561 Medical Services 408485 Weatherby Locums Inc PO Box 972633 Dallas TX 753972633 Physician Services 320002 18 1479366 250 1479616 Net Patient Revenue 621400 49173073 49173073 Cafeteria Revenue 900099 282629 282629 Miscellaneous Revenue 621400 273589 273589 Management Fees 900099 118000 118000 Provision for Bad Debt 621400 -1565523 -1565523 48281768 92665 92665 69691 69691 69691 69691 210757 1875 208882 208882 208882 50132622 47607550 0 1045456 412292 412292 802784 318144 484640 21103638 19448101 1655537 568455 528135 40320 2874664 2637500 237164 1457247 1316499 140748 73731 73731 44303 44303 5870535 5245568 624967 158522 158522 7798893 7286911 511982 1580953 1251306 329647 60043 35643 24400 72086 72086 1806447 1683749 122698 525300 477876 47424 Provider Tax Expense 2344441 2344441 47554334 43058251 4496083 0 2425 2375 9850724 10004309 3453598 3757799 1686877 1757339 975034 1174467 32442806 20622600 11629463 11820206 3782207 3903840 62121 0 738022 1244814 32180471 33665149 5600873 4479424 503 3775000 3393972 2260030 2547767 11636406 10421163 X 16756858 19340146 91431 110214 3695776 3793626 20544065 23243986 32180471 33665149 X 2578288 121633 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 18434 18434 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. 158876 158876 16154089 9149806 7004283 15465777 11099025 4366752 664064 373769 290295 11820206 Beneficial Interest in Net Assets of Copley Health Systems, Inc. 3903840 F 3903840 Deferred Compensation 747767 Estimated Third Party Payor Settlements 1800000 2547767 50132622 47554334 2578288 121633 121633 2699921 50254255 121633 121633 50132622 0 50132622 47554334 0 47554334 0 47554334 Part XI, Line 8 - Other Adjustments: Change in beneficial interest in net assets of Copley Health Systems, Inc. 121,633. Part XII, Line 2d - Other Adjustments: Change in beneficial interest in net assets of Copley Health Systems, Inc. 121,633. 1 1 1 X 225.000000000000 1 X 1 1 0 1 1 2976 602790 0 602790 0.01270 10328842 6193110 4135732 0.08700 2976 10931632 6193110 4738522 0.09970 6127 198887 65875 133012 0.00280 2930659 2074148 856511 0.01800 413803 413803 0.00870 6127 3543349 2140023 1403326 0.02950 9103 14474981 8333133 6141848 0.12920 0 862088 0 12107896 12234337 -126441 X 1 1 1 1 Copley Hospital Inc

528 Washington Highway Morrisville VT 05661

X X X X Copley Hospital Inc 1 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 I, Line 7g: All costs reported on Part I, Line 7g are attributable to a physician clinic. 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 8: The Organization used a cost report model as the costing methodology to determine the amount of allowable Medicare costs. 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 VI, Line 2: Copley Hospital is part of an Integrated Health Systems (I.H.S.) team in our community. Together we are working to address community healthcare. Reaching out to the community to achieve meaningful public participation is integral to Copley's mission and to inform the I.H.S. Copley completed a Community Healthcare Needs Assessment in 2011 and will update the document 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 Workplace Wellness program and through aggregate data from our I.H.S. team with the Copley Service Area Blueprint for Health initiative. - We survey community members, community leaders, including health and community service providers, school administrators and others who have knowledge of and serve to meet population-based health needs. We review data of Vermonters' health, health practices and behavioral risks published by Vermont Department of Health, BISHCA, Blueprint and Federal Centers for Disesase Control. We have formed a community based advisory committee to develop an implementation plan to address identified community health needs. - We also host an annual Community Forum that is open to the public to discuss community health needs. - 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 Integrated Health Team of the Copley Area Blueprint for Health Initiative, Lamoille Home Health and Hospice, The Manor (long term residential care), Lamoille Community Connections, Behavioral Health and Wellness, Lamoille Prevention Campaign (substance abuse), the Morrisville district office of the Vermont Department of Health, United Way, Lamoille Valley Fit and Healthy 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 Vermont Department of Banking, Insurance, Securities and Health Care Administration. 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. 1 Copley Professional Services Group Inc 530 Washington Highway No 12 Morrisville VT 05661 043358048 501(c)(3) 412292 Support obstetrics and gynecology services to residents of Lamoille County. 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The Organization obtains financial information from the grantee to determine the amount of funds to be granted. X X X X X X 0 0 0 1 0 0 0 0 0 Brian Smale MD 312231 0 0 0 0 0 0 0 0 0 312231 0 0 0 Melvyn Patashnick 223903 0 0 0 35181 0 9695 0 21720 0 290499 0 0 0 Rassoul Rangaviz 157957 0 0 0 6642 0 6448 0 23094 0 194141 0 0 0 Bryan Huber MD 478280 0 172644 0 17310 0 9800 0 29292 0 707326 0 0 0 Eric Mullins MD 472129 0 30440 0 24959 0 9800 0 27623 0 564951 0 0 0 John Kaeding MD 258405 0 0 0 18139 0 9800 0 24180 0 310524 0 0 0 Neil Nigro MD 240424 0 0 0 237 0 9264 0 25072 0 274997 0 0 0 Mirjam McCormack 299208 0 0 0 262 0 9800 0 29147 0 338417 0 0 0 Part I, Line 5 Bryan Huber, a highest compensated employee, received a bonus of $172,644. Eric Mullins, a highest compensated employee, received a bonus of $30,440. Each of the individuals were paid an incentive bonus based upon the gross revenue they 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. Supplemental Information Part III Form 990, Part VII, Line 5: Dr. Brian Smale, a 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 $312,231 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. Green Mountain General Surgery An Entity more than 35% owned by Brian Smale, Trustee of the Organization 312231 Independent Contractor Arrangement 0 Form 990, Part VI, Section A, line 6 Copley 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 7a Copley 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, the President of the Medical Staff of Copley Hospital, Inc., and the President of Copley Hospital Auxiliary, Inc., all as voting members. All Trustees must be members of the Corporation. Form 990, Part VI, Section B, line 11 The 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 12c The 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 15 The 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 19 The 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Change in beneficial interest in net assets of Copley Health Systems, Inc. 121,633. Total to Form 990, Part XI, Line 5: 121,633. Oversight of Audit Form 990, Part XI, Line 2c: The audit process has not changed from prior year. Form 990, Part I, Lines 8-18: Prior year numbers have been restated to present revenue net of contractual allowances and charity care. Bad debt expense has also been netted against revenue in accordance with the new Accounting Pronouncement ASC 954. Lamoille Area Housing Corporation Copley Terrace Project 528 Washington Highway Morrisville VT 05661 030270255 Subsidized Elderly Housing VT 501(c)(3) Line 9 Copley Health Systems Inc 0 Copley Health Systems Inc 528 Washington Highway Morrisville VT 05661 030301457 Support of Copley Hospital VT 501(c)(3) Line 11b, II N/A 0 Health Center Building Inc 528 Washington Highway Morrisville VT 05661 030220357 Office Building Rental VT Copley Health Systems Inc C 0 0 1 1 0 0 0 0 0 1 1 0 0 1 0 1 0 0 Health Center Building K 29500 FMV Health Center Building J 49884 FMV