2011-08-04T14:17:52-05:00 2010-09-30 BAKER NEWMAN & NOYES BOX 507 PORTLAND ME 04112 990 2009-10-01 030177161 CARLOS G OTIS HEALTH CARE CENTER INC CARL 8023657920 PO BOX 216 TOWNSHEND VT 053530216 STEPHEN A BROWN 8023657920 2011-08-03 2078792100 2009 2016-02-24 21:20:13Z MICHAEL L BRANT PO BOX 216 TOWNSHEND VT 053530216 20063901 0 X www.gracecottage.org X 1949 VT PROVISION OF HEALTH CARE SERVICES 11 8 209 88 0 0 666632 431034 18802764 19239545 1368 1262 325912 392060 19796676 20063901 50000 0 11332232 11966938 0 299578 8085688 8002170 19417920 20019108 378756 44793 12346222 12117111 5248661 4651223 7097561 7465888 The Otis Health Care Center promotes excellence in healthcare and well being, putting people first. It aims to be the standard for patient care. 0 0 17100055 50000 19631605 GRACE COTTAGE HOSPITAL IS A CRITICAL ACCESS HOSPITAL OFFERING 24-HOUR EMERGENCY SERVICES, INPATIENT ACUTE AND SKILLED CARE, 24 HOUR DIAGNOSTIC IMAGING SERVICES, A FULL-SERVICE LABORATORY, A PHARMACY, A VARIETY OF OUTPATIENT MEDICAL CARE SERVICES, INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY, AND A RURAL HEALTH CLINIC PROVIDING PRIMARY CARE AND PSYCHIATRIC SERVICES. 17100055 1 1 0 1 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 1 0 0 1 13 0 209 1 0 0 0 0 0 0 0 0 0 11 8 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X STEPHEN A BROWN 8023653601 185 GRAFTON ROAD TOWNSHEND VT 05353 EFFIE CHAMBERLIN 45.00 X X 91225 0 2569 DEBORAH BOYLE 1.00 X X 0 0 0 JANE ROBINSON 1.00 X X 0 0 0 KATHLEEN BALLANTINE 1.00 X X 0 0 0 ROGER ALLBEE 1.00 X 0 0 0 ROBERT W BACKUS MD 66.00 X 185860 0 21087 EDWARD ELLIOTT MD 1.00 X 0 0 0 GAIL ANN FISHER 1.00 X 0 0 0 STANLEY HOLT 1.00 X 0 0 0 KEVIN MEYER 1.00 X 0 0 0 JOHN NOPPER 1.00 X 0 0 0 DAVID PENNOCK ESQ 1.00 X 0 0 0 TIMOTHY P SHAFER MD 57.50 X 203959 0 26913 MICHAEL L BRANT 41.00 X 180121 0 16518 STEPHEN A BROWN 47.10 X 162060 0 25656 EVAN GINSBERG 45.00 X 176943 0 21898 MAURICE GEURTS MD 55.00 X 168487 0 25849 MOSS J LINDER MD 50.00 X 149861 0 22461 JAMES S HEAL 39.40 X 132263 0 26739 KATHLEEN STOVER 44.80 X 120831 0 18246 1571610 0 207936 14 0 1 0 CPSI PO BOX 850309 MOBILE AL 366850309 COMPUTER HARDWARE/SOFTWARE SUPPORT, BILL 179853 1 273062 33012 124960 431034 PATIENT SERVICE REVENU 900099 15572085 15572085 PHARMACY REVENUE 900099 3667460 3667460 19239545 1262 1262 GCF ADMINISTRATION & O 900099 300554 300554 MISCELLANEOUS REVENUE 900099 91506 91506 392060 20063901 19631605 0 1262 50000 50000 831610 433085 398525 8682215 7515914 956153 210148 145024 126912 13030 5082 1659108 1410229 201190 47689 648981 544659 89962 14360 17564 17564 77241 77241 352764 203412 149352 97969 97969 705800 558382 137135 10283 345196 96682 248514 375787 368704 7083 78262 47769 27349 3144 138344 100578 37766 613492 609471 4021 239493 55181 184312 PHARMACY & LAB EXP 3774048 3761498 12550 PROVISION FOR BAD DEBTS 493656 493656 MEDICAID TAX 438305 438305 DUES & SUBSCRIPTIONS 157300 106273 49238 1789 EQUIPMENT & MISC EXPENS 96949 81376 15573 20019108 17100055 2619475 299578 122986 255907 163823 135354 1670447 1491822 427791 28694 775488 852236 123019 156620 10445040 6548518 4052996 3896522 5009672 5299956 12346222 12117111 1392583 1307516 305834 1710000 1625000 1840244 1718707 5248661 4651223 X 4799301 5022863 106295 211191 2191965 2231834 7097561 7465888 12346222 12117111 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 6320 6320 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: CARLOS G. OTIS HEALTH CARE CENTER IS A MEMBER OF THE VERMONT ASSOCIATION OF HOSPITALS AND HEALTH SYSTEMS AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF CARLOS G. OTIS HEALTH CARE CENTER IN FURTHERANCE OF ITS EXEMPT PURPOSE. CARLOS G. OTIS HEALTH CARE CENTER DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITIES. AHA, PORTION OF DUES AVAILABLE FOR LOBBYING: $493 VAHHS, PORTION OF DUES AVAILABLE FOR LOBBYING: $5,827 2298260 104897 39869 0 2443026 2513056 24191 -75026 163961 2298260 0.07050 0.91360 0.01590 0 1 1 30549 30549 5732596 3391744 2340852 4470368 3093814 1376554 211527 62960 148567 3896522 DEFERRED FINANCING COSTS & BOND FEES, NET 48249 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 610476 BENEFICIAL INTEREST IN NET ASSETS OF GCF 4583262 BOND INTEREST RESERVE 57969 5299956 20063901 20019108 44793 323534 323534 368327 20063901 0 20063901 0 20063901 20019108 0 20019108 0 20019108 Part V, Line 4: Description of Intended Use of Endowment Funds: ASSIST IN THE PROVISION OF HEALTHCARE. Part XI, Line 8 - Other Adjustments: INCREASE IN BENEFICIAL INTEREST & UNRESTRICTED NET ASSETS OF GCF: 323534. 1 1 1 X 1 X 1 1 0 1 1 206855 206855 0.01030 2271347 1487228 784119 0.03920 2478202 1487228 990974 0.04950 129448 19646 109802 0.00550 71250 71250 0.00360 200698 19646 181052 0.00910 2678900 1506874 1172026 0.05860 50000 50000 0.00250 740 740 0.00000 50740 50740 0.00250 1 418941 29326 9002871 9012536 -9665 X 1 0 GRACE COTTAGE HOSPITAL

185 GRAFTON ROAD TOWNSHEND VT 05353

X X X X GRACE COTTAGE FAMILY HEALTH

185 GRAFTON ROAD TOWNSHEND VT 05353

RURAL HEALTH CLINIC MESSENGER VALLEY PHARMACY

170 GRAFTON ROAD TOWNSHEND VT 05353

PHARMACY Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: N/A (Bad Debt expense included on Form 990, Part IX, line 25, column (A), was not subtracted for purposes of calculating the percentage in this column). Part I, Line 7g: N/A Part III, Line 4: The cost of the Bad Debt expense reported on line 2 was calculated by applying the Ratio of Patient Care Cost-to-Charges (calculated on Worksheet 2) to the total Bad Debt expense. The amount of Bad Debt expense for accounts written off as bad debt is the account balance after all charity care discounts, contractual allowances, and insurance/patient payments have been applied. Any cash collected on accounts previously written off is included as an offset to bad debt expense.The amount of bad debt expense (at cost) attributable to patients eligible under our charity care policy reported on line 3 was estimated based on a review of accounts written off and identifying those that had charity care eligibility and/or Medicaid eligibility for dates of service in close proximity to the dates of service that were written off as bad debt. We feel that this estimate should actually be much higher because though we work hard to educate our patients regarding the charity care policy, including having a Resource Advocate to help them complete them if they require assistance, many of the applications we distribute to patients are not returned; knowing our patient population as we do, we feel it is primarily attributable to patients not wanting to share the income information. Footnote 1 to the Audited Consolidated Financial Statements of the hospital contains the following to address bad debt: 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 the allowance for doubtful accounts based on its assessment of individual accounts and historical experience. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the allowance for doubtful accounts and a credit to accounts receivable. Part III, Line 8: Medicare allowable costs reported in the Medicare Cost Report are reported in accordance with CMS Guidelines using the cost-to-charge ratio methodology. Part III, Line 9b: N/A Part V: All three of the facilities listed in Part V are required to be licensed/registered. Part VI, Line 2: The hospital conducts a community health needs assessment, as required by Vermont statute, every three years. The results of the 2007 survey showed a need for improved access to diagnostic imaging services (X-ray, CT scan, ultrasound and bone density testing) as well as improved access to wellness programs (osteoporosis prevention and exercise classes being the most needed) by the rapidly aging population/patients in rural, southern Vermont. Grace Cottage Hospital used this information for strategic planning purposes, and in December 2009 the hospital opened a new Community Wellness Center on hospital grounds to house the expanded number of health and wellness classes. The Community Wellness Center is used heavily by a wide array of individuals of varying ages. Many of these classes address the health needs of the elderly population in this rural, medically underserved area with the purpose of preventing falls, broken bones and decreasing the incidence of institutionalization of this vulnerable population. Part VI, Line 3: Although we are Vermont's smallest Critical Access Hospital, Grace Cottage Hospital believes that quality health care should be available to all; and that we all have a responsibility to help others in need regardless of their ability to pay. Posters and brochures detailing the availability of help with billing, public programs and charity care are posted in high traffic areas throughout the hospital, rural health clinic and pharmacy, as well as listed on the Hospital's website. The staff reaches out to patients in a variety of ways to ensure that they are aware that help is available. The hospital employs a Resource Advocate to help uninsured and underinsured patients locate and procure services for which they may qualify. The resource advocate's services are free of charge for community members between the ages of 18-64 years (those 65 and older are encouraged to contact the Vermont Council on Aging, located on the hospital premises). The hospital's resource advocate has helped many people with a wide variety of resource issues, helping to fill out necessary forms and making connections for patients with other federal, state and local resources. This employee is an expert in filling out reduced fee applications, finding sources for reduced-cost or free prescription medications, and locating other avenues of support. Part VI, Line 4: Grace Cottage Hospital plays a vital role in this rural, mountainous community. Its federal designation as a Critical Access Hospital recognizes its importance in providing health care to an otherwise medically underserved community. The hospital's Emergency Department is especially vital to members of the community, who would otherwise have to travel many miles on winding mountainous highways to reach emergency medical care at another hospital. Grace Cottage Hospital is located in Windham County, in southeastern Vermont. According to the U.S. Census Bureau, Windham County has an estimated total of 44,513 residents. Grace Cottage Hospital's patient base is approximately 26,000 residents, mostly from 21 surrounding towns. The median household income of Windham County, Vermont, is $46,912, below the national average of $50,221 (U.S. Census Bureau "Quick Facts," updated 6-3-11). Income statistics for the total population served by Grace Cottage Hospital are not available because Grace Cottage only requires income information from patients requesting reduced fees or free care. Part VI, Line 5: Grace Cottage Hospital plays a pivotal role in Disaster Preparedness in this rural, mountainous area of Windham County, Vermont. The hospital works collaboratively with the local town Volunteer Fire & First Responder Rescue Departments; the regional ambulance service, Rescue Inc., which is housed (free of charge) within the hospital and is designated as the only patient transport ambulance service for the area by the State of Vermont; with the Windham County Regional Commission; the Citizens Emergency Response Team and the Radio Amateur Civil Emergency Service; the Vermont Association of Hospitals and Health Systems; as well as the Vermont Department of Health. Staff participates in onsite training for disaster preparedness as well as offsite training with other hospitals. In FY2010 H1N1 influenza pandemic preparedness included vaccination clinics for staff, the general public, and some area schools; as well as participation in a state-wide table top drill conducted by the Vermont Department of Health.Expenditures reported in Part II include costs associated with Grace Cottage Hospital collaborating in FY2010 with the Windham County Solid Waste Management District, in a region-wide "Drug Collection Day" to provide members of the community with an environmentally safe method to dispose of outdated, unused, unneeded, prescription and non-prescription medications; as well as an operating subsidy that was given to a local non-profit Assisted Living housing facility providing services to vulnerable low income seniors within the hospital's service area. Part VI, Line 6: Grace Cottage Hospital is a Critical Access Hospital located in rural, mountainous Townshend, Vermont. The hospital is served by a Board of Trustees consisting of local citizens active in community businesses and organizations. Only one of the eleven trustees, a physician, is a hospital employee. All trustees reside in the hospital's service area and bring a wealth of community input to the hospital's strategic planning process. The hospital extends medical staff privileges to all qualified physicians in the community.Despite its small size, Grace Cottage Hospital is committed to giving back to the community to the greatest extent possible. Area non-profit organizations providing health-related and emergency preparedness-related services to the community are provided with meeting and training space at the hospital. In response to the last Community Health Needs Assessment, the hospital has worked collaboratively with local schools and organizations to promote healthy, fun activities and provides opportunities that make the most of staying as healthy as possible. In 2010 Grace Cottage Hospital partnered with over 40 local agencies in planning and producing an interactive and educational Community Health Fair which was attended by more than 400 people. Grace Cottage also assisted in coordinating two community blood drives in conjunction with the American Red Cross.Grace Cottage Hospital applies all surplus funds towards improving its ability to provide quality patient care and being an integral part of assuring the health and well being of the community we serve. Part VI, Line 7: N/A VT 0 VALLEY CARES INC PO BOX 341 TOWNSHEND VT 05353 201980713 501(C)(3) 50000 OPERATING SUBSIDY FOR ELDERLY HOUSING/ASSISTED LIVING PROJECT 1 0 X X X 0 0 0 0 0 0 0 1 0 ROBERT W BACKUS MD 179129 0 0 0 6731 0 5576 0 15511 0 206947 0 0 0 TIMOTHY P SHAFER MD 200000 0 0 0 3959 0 6119 0 20794 0 230872 0 0 0 MICHAEL L BRANT 167015 0 10000 0 3106 0 1007 0 15511 0 196639 0 0 0 STEPHEN A BROWN 159101 0 0 0 2959 0 4862 0 20794 0 187716 0 0 0 EVAN GINSBERG 174230 0 0 0 2713 0 0 0 21898 0 198841 0 0 0 MAURICE GEURTS MD 165096 0 0 0 3391 0 5055 0 20794 0 194336 0 0 0 MOSS J LINDER MD 146064 0 0 0 3797 0 1667 0 20794 0 172322 0 0 0 JAMES S HEAL 129797 0 0 0 2466 0 3778 0 22961 0 159002 0 0 0 Part I, Line 7 THE HOSPITAL CEO, MICHAEL L. BRANT, WAS ISSUED A DISCRETIONARY $10,000 BONUS BASED ON HIS EXCEPTIONAL PERFORMANCE. THE ISSUANCE OF THIS BONUS WAS REVIEWED AND APPROVED BY THE HOSPTIAL BOARD OF TRUSTEES AS PART OF THE REGULAR PERFORMANCE EVALUATION PROCESS. EDWARD ELLIOTT MD TRUSTEE WHO IS ALSO PRESIDENT OF WINDHAM RADIOLOGY ASSOCIATES, INC. 11550 WINDHAM RADIOLOGY ASSOCIATES, INC. WAS REIMBURSED A TOTAL OF $11,550 IN THE FISCAL YEAR ENDED 9/30/10 FOR THE AMOUNTS THEY PAID ON OHCC'S BEHALF TO VIRTUAL RADIOLOGIC CORPORATION. 0 LAURA D BRANT SPOUSE OF CEO 91391 MS. BRANT IS THE SPOUSE OF MICHAEL L. BRANT, WHO IS OHCC'S CEO AND LISTED IN PART VII. MS. BRANT IS COMPENSATED AS AN EMPLOYEE OF OHCC (AS THE DIRECTOR OF DIAGNOSTIC IMAGING). THE W-2 COMPENSATION PAID IS IN ACCORDANCE WITH OHCC'S STANDARD EMPLOYMENT PRACTICES AND POLICIES. 0 Form 990, Part VI, Section A, line 2 DEBORAH BOYLE IS MARRIED TO KATHLEEN BALLANTINE'S BROTHER. Form 990, Part VI, Section B, line 11 A DRAFT OF THE FORM 990 IS INITIALLY REVIEWED IN DETAIL BY CARLOS G. OTIS HEALTH CARE CENTER'S KEY FINANCE EMPLOYEES. THEREAFTER, THE FINAL DRAFT IS PROVIDED TO THE FULL BOARD FOR REVIEW PRIOR TO FILING WITH THE IRS. Form 990, Part VI, Section B, line 12c A COPY OF THE CONFLICT OF INTEREST POLICY IS DISTRIBUTED ANNUALLY TO THE BOARD OF TRUSTEES AND EACH TRUSTEE SIGNS TO CONFIRM THAT THEY HAVE THOROUGHLY READ, UNDERSTAND AND AGREE TO COMPLY WITH THE CONFLICT OF INTEREST POLICY. Form 990, Part VI, Section B, line 15 CEO's Compensation: The CEO's compensation and benefits are reviewed, adjusted and voted on by the full board annually. The Board used external market compensation data to determine the CEO's initial compensation when hired and annually uses such data to compare OHCC's CEO compensation with that of other hospital executives in the Northeast region. The CEO is excused from Board discussion and voting on issues surrounding CEO compensation and benefits. Compensation of other hospital employees: The CEO reviews the salaries of employees annually and determines compensation based on performance and salary ranges, using regional salary range data for comparison. Form 990, Part VI, Section C, line 19 UPON REQUEST, CARLOS G. OTIS HEALTH CARE CENTER, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART XI, LINE 2C AUDIT REVIEW PROCESS THE FINANCE AND AUDIT COMMITTEE OVERSEES THE AUDIT PROCESS FOR THE CARLOS G. OTIS HEALTH CARE CENTER, INC. AND GRACE COTTAGE FOUNDATION, INC. THE AUDIT PROCESS FOR THE FINANCIAL STATEMENTS DID NOT CHANGE FROM THE PRIOR YEAR. INDEPENDENT ACCOUNTANTS PERFORMED THE AUDIT FOR BOTH FISCAL YEARS. PART IV, LINE 28C BUSINESS TRANSACTIONS Otis Health Care Center maintains operating and investment accounts and has loan accounts with People's United Bank. Transactions in the fiscal year were in excess of $5,000. An exact figure cannot be stated due to daily account activity and balance changes. Deborah Boyle is a Board Trustee employed by People's United Bank as a commercial loan officer. Otis Health Care Center utilized the bank prior to Mrs. Boyle joining the Board. Otis Health Care Center utilized The Richards Group as an agent for purchasing all insurance during the fiscal year. Kathleen Ballantine is a Board Trustee employed by The Richards Group. Otis Health Care Center utilized the services of The Richards Group prior to Mrs. Ballantine joining the Board. All of the above transactions were at arm's length and for fair value. Neither trustee has any direct involvement with Otis Health Care Center's transactions at either organization. In addition, the circumstances of the transactions do not meet the Schedule L, Part IV filing requirements. FORM 990, PART VII, SECTION A, COLUMN D REPORTABLE COMPENSATION FOR SERVICES AS EMPLOYEES THE 2009 COMPENSATION REPORTED FOR EFFIE CHAMBERLIN, DR. ROBERT BACKUS, AND DR. TIMOTHY SHAFER WAS FOR THEIR SERVICES AS THE FULL-TIME DIRECTOR OF QUALITY, FULL-TIME PHYSICIAN, AND FULL-TIME PHYSICIAN RESPECTIVELY. THEY WERE NOT COMPENSATED FOR THEIR SERVICES AS MEMBERS OF OHCC'S BOARD OF TRUSTEES. GRACE COTTAGE FOUNDATION INC PO BOX 1 TOWNSHEND VT 05353 030343282 SOLICIT CONTRIBUTIONS FOR THE FUNDING OF HEALTH CARE SERVICES BY OHCC VT 501(C)(3) 509(A)(3) TYPE I 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 GRACE COTTAGE FOUNDATION INC P 300554 GRACE COTTAGE FOUNDATION INC C 273062