2011-02-11T13:32:56-06:00 2010-09-30 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2009-10-01 030179423 Copley Hospital Inc COPL 8028884231 528 Washington Highway Morrisville VT 05661 Melvyn Patashnick 8028884231 2011-02-10 1 Barbara J McGuan CPA 2077752387 2011-02-10 2009 2016-02-24 21:20:13Z Melvyn Patashnick 528 Washington Highway Morrisville VT 05661 72939153 0 X www.copleyhealthsystems.org X 1934 VT Critical Access Hospital 17 13 481 100 0 0 364491 211733 67162450 72483009 214453 45023 95672 104609 67837066 72844374 191667 0 24402905 25305047 0 0 42972088 46121165 67374993 71617879 462073 1226495 31112324 32180471 11902906 11636406 19209418 20544065 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 67626250 191667 72483009 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. 67626250 1 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 1 104 0 481 1 0 0 0 0 0 0 0 0 0 17 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 Joel Silverstein MD 2.00 X 17938 0 0 Brian Smale MD 2.00 X 0 0 0 John Steel 2.00 X X 0 0 0 Anne Vitaletti-Coughlin 2.00 X X 12000 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 251101 0 27964 Rassoul Rangaviz 40.00 X 159507 0 24547 Bryan Huber MD 40.00 X 462537 0 39839 SG Neale MD 40.00 X 432740 0 46946 Eric Mullins MD 40.00 X 450762 0 37695 John Kaeding MD 40.00 X 274121 0 29278 Neil Nigro MD 40.00 X 239454 0 37119 2300160 0 243388 23 0 1 1 HP Cummings Construction Co PO Box 269 Woodsville NH 03785 Building Contractor 890225 CPSG Inc 530 Washington Highway Suite 12 Morrisville VT 05561 Medical Services 433450 Fletcher Allen Health Care PO Box 1902 Burlington VT 054021902 Medical Services 399709 Bay View Funding PO Box 881774 San Francisco CA 94188 Contracted Labor 343811 Central VT Anesthesia PO Box 297 Waitsfield VT 05673 Medical Services 262460 18 211125 608 13428 211733 Outpatient Services 621400 53742851 53742851 Inpatient Services 621400 17668780 17668780 Skilled Nursing 621400 489417 489417 Cafeteria Revenue 900099 278734 278734 Miscellaneous Revenue 621400 189227 189227 114000 114000 72483009 126204 126204 104609 104609 104609 104609 13598 94779 -81181 -81181 -81181 72844374 71901048 0 731593 191667 191667 493057 29938 463119 20027869 18482268 1545601 535720 497894 37826 2855491 2616222 239269 1392910 1259592 133318 57163 57163 47368 47368 6161034 5631329 529705 152039 152039 6847996 6420072 427924 1414229 1127927 286302 83651 57892 25759 60907 60907 1715603 1715603 615175 568939 46236 Contractual Allowances 24582109 24582109 Provider Tax Expense 2047262 2047262 Provision for Bad Debts 1621408 1621408 Charity Care 715221 715221 71617879 67626250 3991629 0 310277 2425 10543874 9850724 3037948 3453598 1711478 1686877 743792 975034 30775566 19146103 10459119 11629463 3674055 3782207 65307 62121 566474 738022 31112324 32180471 6801081 5600873 503 3865000 3775000 1236825 2260030 11902906 11636406 X 15530363 16756858 71020 91431 3608035 3695776 19209418 20544065 31112324 32180471 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 19718 19718 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: A small percentage of dues paid to VAHHS include lobbying expenses. 158876 158876 15394815 8666387 6728428 14501015 10098790 4402225 720860 380926 339934 11629463 Beneficial Interest in Net Assets of Copley Health Systems, Inc. 3782207 F 3782207 Deferred Compensation 680722 Estimated Third Party Payor Settlements 1579308 2260030 72844374 71617879 1226495 108152 108152 1334647 47655196 108152 108152 47547044 25297330 25297330 72844374 46320549 0 46320549 25297330 25297330 71617879 Part XI, Line 8 - Other Adjustments: Change in beneficial interest in net assets of Copley Health Systems, Inc.: 108152. Part XII, Line 2d - Other Adjustments: Change in beneficial interest in net assets of Copley Health Systems, Inc.: 108152. Part XII, Line 4b - Other Adjustments: Contractual Allowances: 24582109. Charity Care: 715221. Part XIII, Line 4b - Other Adjustments: Contractual Allowances: 24582109. Charity Care: 715221. 1 1 1 X 225.000000000000 1 X 1 1 0 1 1 2273 414015 0 414015 0.00580 9643852 5837607 3806245 0.05310 2273 10057867 5837607 4220260 0.05890 6210 196037 63421 132616 0.00190 9 1705 1705 0.00000 3238202 2097839 1140363 0.01590 191990 191990 0.00270 6219 3627934 2161260 1466674 0.02050 8492 13685801 7998867 5686934 0.07940 0 938571 0 10791537 10931674 -140137 X 1 1 Copley Hospital Inc

528 Washington Highway Morrisville VT 05661

X X X X 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 I, Line 7f: Amount of bad debt expense included on Form 990, Part IX, Line 25 subtracted for purposes of calculating percentage: $1,621,408. Part III, Line 4: Accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to operations and a credit to a valuation allowance based on its assessment of individual accounts and historical adjustments. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable.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. Part VI, Line 2: Reaching out to the community to achieve meaningful public participation is integral to Copley's success and mission of meeting the healthcare needs of the community. 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 and through aggregate data from our Workplace Wellness program. - Meeting with community leaders including town and state officials, health and community service providers, EMS providers, police and fire officials, school administrators and others who have knowledge of the community's health needs. Includes review of data of Vermonters' health, health practices and behavioral risks published by Vermont Department of Health, VITL, BISHCA and Federal Centers for Disease Control. -Hosting an annual Community Forum, an annual meeting and informal community needs assessment surveys in the community-Governance by a volunteer board of trustees comprised of local citizensrepresenting a cross section of the community served. -Copley Hospital maintains a strong level of involvement in the majority of community groups within our service area-Copley Hospital works collaboratively with other organizations to identify and meet community health needs. Our collaborations include but are not limited to: Blueprint for Health Community Activation and Support Work group, Friends of Lamoille Youth led by the United Way; 4-H; Lamoille Family Health Coalition with the Vermont Department of Health, Lamoille Valley Fit & Healthy Council, Lamoille Valley TobaccoTask 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; according to data from the Vermont Department of Health: 21% are obese; 30% have high cholesterol; 25% have asthma; 19% smoke; 18.5% binge drink. Copley provides services for residents whose next nearest hospital, in most cases, is an hour away in good weather. 1 Copley Professional Services Group Inc 530 Washington Highway No 12 Morrisville VT 05661 043358048 501(c)(3) 191667 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 Melvyn Patashnick 225715 0 0 0 25386 0 8747 0 19217 0 279065 0 0 0 Rassoul Rangaviz 159231 0 0 0 276 0 6125 0 18422 0 184054 0 0 0 Bryan Huber MD 398005 0 47491 0 17041 0 9800 0 30039 0 502376 0 0 0 SG Neale MD 403914 0 11004 0 17822 0 9800 0 37146 0 479686 0 0 0 Eric Mullins MD 429998 0 20428 0 336 0 9800 0 27895 0 488457 0 0 0 John Kaeding MD 256037 0 0 0 18084 0 9800 0 19478 0 303399 0 0 0 Neil Nigro MD 239226 0 0 0 228 0 9352 0 27767 0 276573 0 0 0 Part I, Line 5 Bryan Huber, a highest compensated employee, received a bonus of $47,491. Eric Mullins, a highest compensated employee, received a bonus of $20,428. Glen Neale, a highly compensated employee, received a bonus of $11,004. 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 $209,148 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. Brian Smale MD Trustee of the Organization 209148 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 A subcommittee of both the finance and governance committees review 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 compliance officer reviews the completed conflict of interest statements and assesses the potential for conflicts of interest for each individual. Those individuals who receive a risk rating of moderate or above are retained on the monitoring list for five years. The CEO is informed of any individuals who receive such a rating. The compliance officer makes recommendations to the CEO and board chair as to actions to address any conflicts of interest. The Organization also annually asks trustees, foundation committee members, purchasing agents, senior directors, and employed physicians to complete a conflict of interest disclosure statement. Conflicts are then compiled in the conflict matrix and reviewed by the ethics committee. The conflict matrix is available for review by the public at both the annual meeting and by request. Form 990, Part VI, Section B, line 15 The CEO's pay is determined through the use of the Millbrook Associates compensation data for Hospital CEOs. Senior leadership and other highly compensated individuals have their pay ranges determined through market data from Astron Solutions. The compensation for the CEO is then approved by the board of trustees. 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 at the annual meeting 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 XI, Line 2c: Oversight of Audit The audit process has not changed from prior year. 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 Copley Health Systems Inc 528 Washington Highway Morrisville VT 05661 030301457 Support of Copley Hospital VT 501(c)(3) Line 11b, II N/A 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 28500 Health Center Building J 57859