2011-08-15T10:29:51-04:00 2010-09-30 BKD LLP 910 E ST LOUIS 200/PO BOX 1190 SPRINGFIELD MO 658062523 990 2009-10-01 222570334 NORTH COUNTRY HEALTH SERVICES INC D/B/A DERBY GREEN NORT 8027662201 189 PROUTY DRIVE NEWPORT VT 05855 ANDRE BISSONNETTE 2011-07-15 true Brian D Todd 4178658701 2009 2016-02-24 21:20:13Z DERBY GREEN LISA BOHLMAN CLAUDIO FORT 189 PROUTY DRIVE NEWPORT VT 05855 1476650 false X WWW.NCHSI.ORG X 1984 VT NORTH COUNTRY HEALTH SERVICES IS A PRIVATE, NOT-FOR-PROFIT CORPORATION COMMITTED TO THE IMPROVEMENT AND ATTAINMENT OF THE HEALTH OF FACILITY RESIDENTS. 16 11 37 34 0 0 16853 16485 1352992 1381291 -29498 10975 0 0 1340347 1408751 0 0 0 0 911620 918124 0 0 0 403995 423947 1315615 1342071 24732 66680 785340 813303 136237 89535 649103 723768 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. false false 935874 1091220 THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2010, THE ORGANIZATION HAD 6,671 MEDICAID PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 225083 262445 THE ORGANIZATION PROVIDES OTHER SERVICES TO ALL PATIENTS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 23693 27626 THE ORGANIZATION PROVIDED SKILLED NURSING HEALTH CARE FOR RESIDENTS OF A CERTIFIED INTERMEDIATE CARE FACILITY. FOR FISCAL YEAR 2010, THE ORGANIZATION HAD 131 MEDICARE PATIENT DAYS. SEE SCHEDULE O FOR ADDITIONAL INFORMATION. 1184650 true true false true false false false true false true false true false false false false false false false false false false false true false false false false false false false false false false false false false true false false false true 6 0 true 37 true false false false false false false false false false 16 11 false false false false true true true true true false false true true true true true true true false X ANDRE BISSONNETTE 8023347331 189 PROUTY DRIVE NEWPORT VT 05855 CLAUDIO D FORT 1.0 X X 0 268702 29885 DAVID BOUFFARD 1.0 X X 0 0 0 KATHRYN AUSTIN 1.0 X X 0 0 0 SCOTT PERRY 1.0 X 0 0 0 SUSAN PENHARLOW 1.0 X 0 0 0 MELISSA PETTERSSON 1.0 X X 0 0 0 RICHARD BARAW 1.0 X 0 0 0 ALAN WING 1.0 X X 0 0 0 BILL STENGER 1.0 X 0 0 0 BONNIE NASH 1.0 X X 0 0 0 JEANE KADMIRI 1.0 X 0 0 0 DAVE LAFORCE 1.0 X 0 0 0 THOMAS MOSELEY MD 1.0 X 0 15031 0 BOB WILSON 1.0 X 0 0 0 CHRISTOPHER RICKMAN MD 1.0 X 0 218038 31245 MARC BOUCHARD MD 1.0 X 0 274155 40961 PETER STUART MD 1.0 X 0 282912 17749 ANDRE BISSONNETTE 1.0 X 0 181791 27453 LISA BOHLMAN 40.0 X 75413 0 5319 75413 1240629 152612 0 false true false 0 16485 16485 PATIENT REVENUE 623000 1380447 1380447 OTHER 623000 844 844 1381291 6547 6547 0 0 72327 66658 1241 5669 -1241 4428 4428 0 0 0 0 1408751 1381291 10975 0 0 0 0 80732 80732 0 654352 635180 19172 22723 19778 2945 102815 94119 8696 57502 50049 7453 1000 1000 1000 1000 16975 16975 0 0 3678 3678 70956 70795 161 0 116339 111263 5076 746 746 0 25733 25733 13937 9587 4350 0 0 1266 1167 99 0 46116 42523 3593 8308 8308 DUES AND SUBSCRIPTIONS 3109 618 2491 RECRUITING & RETENTION 2555 2555 MEDICAID TAXES 91141 91141 MEDICAL SUPPLIES & DRUGS 21088 21088 1342071 1184650 157421 0 1100 1100 267117 275408 80180 96535 100 100 20375 19284 942536 744238 211032 198298 205436 222578 785340 813303 69530 43224 1324 1455 65383 44856 136237 89535 X 649103 723768 649103 723768 785340 813303 X false true true X false X 16853 16485 33338 1154716 1292325 1306076 1352992 1381291 6487400 1154716 1292325 1306076 1369845 1397776 6520738 6520738 20578 14384 4410 7701 6547 53620 20578 14384 4410 7701 6547 53620 1175294 1306709 1310486 1377546 1404323 6574358 0.99184 0.99203 0.00816 0.00797 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true false OTHER LOBBYING ACTIVITIES SCHEDULE C, PART II-B, LINE 1(I) THE ORGANIZATION PAYS DUES TO THE VERMONT HOSPITAL ASSOCIATION. A PORTION OF THESE DUES ARE ATTRIBUTABLE TO LOBBYING PURPOSES. false true 30000 30000 0 603026 493712 109314 280949 226405 54544 28561 24121 4440 198298 0 DUE TO AFFILIATES 44856 44856 1408751 1342071 66680 7985 7985 74665 1399317 7985 -17419 -9434 1408751 1408751 1324652 1324652 17419 17419 1342071 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. FIN 48 DISCLOSURE 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 RECONCILING ITEMS SCHEDULE D, PART XII, LINE 2D AND 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. $ 13,741 EXPENSES PAID OUT OF GRANT FUNDS 3,678 INVESTMENT FEES -------- $ 17,419 false false false false false false false false false CLAUDIO D FORT 0 211444 0 32594 0 24664 0 5982 0 23903 0 298587 ANDRE BISSONNETTE 0 103585 0 50366 0 27840 0 3675 0 23778 0 209244 CHRISTOPHER RICKMAN MD 0 217641 0 0 0 397 0 13175 0 18070 0 249283 MARC BOUCHARD MD 0 273578 0 0 0 577 0 17150 0 23811 0 315116 PETER STUART MD 0 282078 0 0 0 834 0 14673 0 3076 0 300661 COMPENSATION DETERMINATION SCHEDULE J, PART I, LINE 3 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. 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 11A 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 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. NORTH COUNTRY HOSPITAL & HEALTH CENTER 189 PROUTY DRIVE NEWPORT VT 05855 030185556 HOSPITAL VT 501(C)(3) 3 NORTH COUNTRY HEALTH SYSTEMS 189 PROUTY DRIVE NEWPORT VT 05855 222566964 PARENT/FUNDRS VT 501(C)(3) 11B II MEDICAL ARTS BUILDING 189 PROUTY DRIVE NEWPORT VT 05855 030275720 TITLE HOLDING VT 501(C)(2) false false false false false false false false false false false true true true true false false false