2024-08-15T15:49:44-05:00 2023-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-10-01 020222242 WEEKS MEDICAL CENTER WEEK 6037884911 173 MIDDLE STREET LANCASTER NH 03584 MATTHEW STREETER SYSTEM CFO 6037884911 2024-08-15 1 0 MICHAEL J PETERSON CPA P01833529 2187224705 2024-08-15 2022 2024-08-08 14:25:15Z MICHAEL D LEE 173 MIDDLE STREET LANCASTER NH 03584 86960017 0 X WWW.WEEKSMEDICAL.ORG X 1948 NH TO PROVIDE HIGH QUALITY AND EFFICIENT HEALTH CARE SERVICES. 15 13 433 36 0 0 3695217 785141 71393106 84639662 575248 248804 509792 1237822 76173363 86911429 219365 318227 0 0 40147695 34175015 0 0 0 32895908 53611021 73262968 88104263 2910395 -1192834 76551082 71649472 26275393 22721834 50275689 48927638 WEEKS MEDICAL CENTER'S COMPASSIONATE STAFF IS COMMITTED TO PROVIDING HIGH QUALITY AND EFFICIENT HEALTH CARE SERVICES TO ENSURE THE WELL-BEING OF OUR PATIENTS, FAMILIES AND COMMUNITIES. 0 0 68462481 318227 84639662 HEALTH CARE SERVICES TO INDIVIDUALS IN THE SURROUNDING REGION ON AN INPATIENT & OUTPATIENT BASIS, WHICH INCLUDES HOSPITAL SERVICES AS WELL AS PHYSICIAN OFFICE SERVICES. 68462481 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 55 0 433 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 13 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X MATTHEW STREETER 6033265610 8 CLOVER LANE WHITEFIELD NH 03598 MARK MORGAN MD CMO 40.00 X 595264 0 14514 AMBER SCHMIDT MEDICAL STAFF PRESIDENT 40.00 X X 275066 0 40448 WILLIAM EVERLETH DIRECTOR 1.00 39.00 X 0 125375 8257 KEITH YOUNG CHAIR 1.00 1.00 X X 0 0 0 DENNIS COUTURE VICE CHAIR 1.00 X X 0 0 0 RUBY BERRYMAN TREASURER 1.00 X X 0 0 0 CHARLIE COTTON SECRETARY 1.00 X X 0 0 0 DENISE BRISSON DIRECTOR 1.00 X 0 0 0 SCOTT BURNS DIRECTOR 1.00 X 0 0 0 SARAH DESROCHERS DIRECTOR 1.00 2.00 X 0 0 0 ZEANNY EGEA DIRECTOR 1.00 X 0 0 0 STANLEY HOLZ DIRECTOR 1.00 X 0 0 0 SHARON KOPP DIRECTOR 1.00 X 0 0 0 FRANCES LADUKE DIRECTOR 1.00 X 0 0 0 EDWARD SAMSON III DIRECTOR 1.00 X 0 0 0 THOMAS MEE SYSTEM CEO 1.00 45.00 X 0 681354 28979 MICHAEL D LEE PRESIDENT/CEO 40.00 1.00 X 361347 0 5547 MATTHEW STREETER SYSTEM CFO 1.00 45.00 X 0 300812 10917 PROUSKEH B EBRAHIMPOUR PHYSICIAN 40.00 X 591081 0 25878 CHRISTOPHER LAURENT NP NURSE PRACTICIONER 40.00 X 495132 0 35271 ELISABETH MOORE PHYSICIAN 40.00 X 424748 0 48979 JOHN FORD PRIMARY CARE/FAMILY MEDICINE PRACT. 40.00 X 420791 0 16397 MAUDE OETKING PHYSICIAN 40.00 X 430082 0 23207 CELESTE PITTS FORMER CFO 24.00 16.00 X 175540 0 19714 3769051 1107541 278108 66 1 1 0 FASTAFF PO BOX 911452 DENVER CO 802911452 CONTRACT LABOR 1170956 NORTH COUNTRY HEALTHCARE 8 CLOVER LANE WHITEFIELD NH 03598 MANAGEMENT SERVICES 974140 MEDICAL SOLUTIONS PO BOX 670529 DALLAS TX 752670529 CONTRACT LABOR 801557 AMERICAN HEALTHCARE STAFFING ASSOCIATION PO BOX 850737 MINNEAPOLIS MN 554850737 CONTRACT LABOR 763162 ANDROSCOGGIN VALLEY HOSPITAL 59 PAGE HILL RD BERLIN NH 03570 MANAGEMENT SERVICES 620038 22 657177 127964 785141 PATIENT SERVICE REVENUE 621400 81565921 81565921 PHARMACY REVENUE 456110 1844861 1844861 1228880 1228880 84639662 296392 296392 561315 0 561315 561315 561315 1000 48588 0 -48588 1000 -47588 -47588 CAFETERIA REVENUE 722514 169522 169522 GAIN ON AFFILIATE ACTIVITY 621990 45147 45147 461838 461838 676507 86911429 84639662 0 1486626 X 318227 318227 1247672 880474 367198 24679390 22987520 1691870 448778 353019 95759 5908927 4656937 1251990 1890248 1489549 400699 60041 60041 10194 10194 7114 7114 10709599 10684451 25148 641887 4992 636895 218787 165674 53113 3384594 3384594 2285280 2248193 37087 147331 142822 4509 55345 50265 5080 412587 236615 175972 3979616 2571803 1407813 1087150 512427 574723 PHARMACEUTICAL EXPENSE 10054820 10054820 INTERCOMPANY ALLOCATION 6803608 3573361 3230247 ENHANCEMENT TAX 5668836 5668836 BAD DEBT EXPENSE 3578994 3578994 4505238 3952338 552900 88104263 68462481 19641782 0 1392559 168398 7124495 10636374 0 946771 9492049 8735189 9534913 9534913 1407868 1759746 1480157 1145301 68050966 44833786 23528598 23217180 21372093 13021535 1218350 2484065 76551082 71649472 4014808 8732601 336358 32561 5223590 4840504 3513796 3321280 13186841 5794888 26275393 22721834 X 49057380 47512984 1218309 1414654 50275689 48927638 76551082 71649472 X -1192834 1874877 -2030094 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 10194 10194 0 PART II-B, LINE 1: WEEKS MEDICAL CENTER IS A MEMBER OF THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION. A PORTION OF THE DUES PAID TO THESE ORGANIZATIONS IS AVAILABLE FOR LOBBYING EXPENDITURES ON BEHALF OF WMC AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. WMC DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITIES. 1030257 100161 1130418 1118195 -87938 1030257 1012784 105411 1118195 1038704 -25920 1012784 1040597 -1893 1038704 0.00000 0.80671 0.19330 0 0 532630 532630 20119341 12476849 7642492 46341646 32356937 13984709 1057349 1057349 23217180 AMOUNTS PAYABLE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 4599836 DUE TO RELATED PARTIES 1195052 5794888 PART V, LINE 4: WEEKS MEDICAL CENTER ENDOWMENT FUNDS WERE GIFTED WITH THE INTENT TO HELP DEFRAY THE COSTS OF INDIGENT CARE FOR ADULTS AND CHILDREN, AND GENERAL UPKEEP AND OPERATIONS OF THE HOSPITAL. THE INCOME GENERATED BY THE ENDOWMENT FUNDS ARE TO BE USED FOR HOSPITAL OPERATIONS AND SCHOLARSHIPS FOR MEDICAL EDUCATION FOR EMPLOYEES OF THE HOSPITAL. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 190787 190787 0.00230 14363750 7996516 6367234 0.07530 14554537 7996516 6558021 0.07760 25909874 14875899 11033975 0.13050 180473 180473 0.00210 26090347 14875899 11214448 0.13260 40644884 22872415 17772469 0.21020 1 1420426 0 19295016 19385125 -90109 X 1 1 1 1 WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 WWW.WEEKSMEDICAL.ORG 00015 X X X X WEEKS MEDICAL CENTER 1 0 0 1 X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X X 1 21 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 300.000000000000 300.000000000000 X X 1 1 X X X X 1 X HTTPS://WEEKSMEDICAL.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION X HTTPS://WEEKSMEDICAL.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION X HTTPS://WEEKSMEDICAL.ORG/PATIENTS-VISITORS/FINANCIAL-INFORMATION X X X X X X 1 X 0 X X X X 1 X 0 0 WEEKS MEDICAL CENTER PART V, SECTION B, LINE 5: AN ELECTRONIC SURVEY WAS SENT TO A SELECT GROUP OF LOCAL EXPERTS THAT INCLUDED INFORMATION FROM WELL-RESPECTED SECONDARY SOURCES ON THE CURRENT STATE OF HEALTH CARE IN THE COMMUNITY. INDIVIDUALS AND AGENCIES INVOLVED IN PUBLIC HEALTH AND STATE & LOCAL HEALTH WERE INCLUDED AS WERE INDIVIDUALS FROM PRIORITY POPULATIONS, CHRONIC DISEASE GROUPS AND OTHER COMMUNITY MEMBERS. WEEKS MEDICAL CENTER PART V, SECTION B, LINE 6A: THE HOSPITAL'S CHNA WAS CONDUCTED ALONG WITH UPPER CONNECTICUT VALLEY HOSPITAL AND ANDROSCOGGIN VALLEY HOSPITAL. WEEKS MEDICAL CENTER PART V, SECTION B, LINE 6B: THE HOSPITAL'S CHNA WAS CONDUCTED ALONG WITH COOS COUNTY FAMILY HEALTH AND NORTH COUNTRY HOME HEALTH & HOSPICE AGENCY. THE FIRST IS A LOCAL FQHC. WEEKS MEDICAL CENTER PART V, SECTION B, LINE 7D: PART V, SECTION B, LINE 7A & 10A:HTTPS://WEEKSMEDICAL.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ WEEKS MEDICAL CENTER PART V, SECTION B, LINE 11: WEEKS MEDICAL CENTER TOOK THE FOLLOWING STEPS DURING FY 2023 TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENT CHNA, COMPLETED IN TAX YEAR 2021:- ADDITIONAL PROVIDERS ADDED TO EXISTING WMC BEHAVIORAL HEALTH PRACTICE- CONTINUANCE OF FINANCIAL ASSISTANCE- PA-C ADDED TO BERLIN AND COLEBROOK MARKET TO REPLACE PREVIOUS PA-C. (CHRONIS DISEASE MANAGEMENT HEART DISEASE)- WE HAVE CONDUCTED VIRTUAL LECTURES ON VARIOUS HEALTH-RELATED TOPICS, BASED ON PROVIDER AVAILABILITY. NOT NECESSARILY CHRONIC DISEASE EDUCATION. WE HAVE HAD A PRESENCE (AND WILL LATER THIS MONTH AND NEXT) AT LANCASTER FAIR TO CONDUCT BLOOD PRESSURE SCREENINGS, PROVIDE INFORMATION. COMMUNITY WELLNESS FAIR WAS SCHEDULED EARLIER THIS SUMMER, BUT POSTPONED DUE TO EXTREME HEAT.- UNDER ACCESS TO HEALTHCARE- WE ADDED A NEW POSITION: CLINICAL LIAISON, WHO IS A NURSE, SHE ROUNDS AT EACH HOSPITAL DAILY TO FACILITATE DISCHARGES TO HOME HEALTH, PALLIATIVE CARE AND HOSPICE.- UNDER CHRONIC DISEASE MANAGEMENT: WEEKS HIRED A PALLIATIVE APRN IN MARCH. PALLIATIVE CARE CAN HELP OUR COMMUNITY GREATLY BY ASSISTING PATIENTS WHO HAVE CHRONIC ILLNESSES ACHIEVE SYMPTOM CONTROL, COMPLETE ADVANCED DIRECTIVES AND STAY OUT OF THE HOSPITAL- ALZHEIMER'S AND DEMENTIA- NCHHHA STARTED AN ALZHEIMER'S AND DEMENTIA SUPPORT GROUP FOR CAREGIVERS WEEKS MEDICAL CENTER PART V, SECTION B, LINE 16J: BROCHURES AND FINANCIAL COUNSELOR INFORMATION ARE AVAILABLE IN LOBBIES AND HANDED OUT TO PATIENTS. ALSO, CONTACT INFORMATION FOR FINANCIAL COUNSELORS IS PROVIDED ON BILLS AND LETTERS THAT GO OUT. 4 1 - LANCASTER PHYSICIANS OFFICES 170 MIDDLE ST LANCASTER NH 03584 PHYSICIAN OFFICE FOR PRIMARY CARE 2 - WHITEFIELD PHYSICIANS OFFICES 8 CLOVER LANE WHITEFIELD NH 03598 PHYSICIAN OFFICE FOR PRIMARY CARE 3 - NORTH STRATFORD PHYSICIANS OFFICES 43 MAIN ST NORTH STRATFORD NH 03590 PHYSICIAN OFFICE FOR PRIMARY CARE 4 - GROVETON PHYSICIANS OFFICES 12 CHURCH ST GROVETON NH 03582 PHYSICIAN OFFICE FOR PRIMARY CARE PART I, LINE 7: THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES PART I, LINES 7E-I. THE HOSPITAL DETERMINES COST BY COMBINING DIRECT EXPENSES IDENTIFIED BY ITS ACCOUNTING SYSTEM WITH AN ESTIMATED OVERHEAD ALLOCATION. PART I, LINE 7G: THE COSTS OF SUBSIDIZED HEALTH SERVICES ARE RELATED TO THE EMERGENCY DEPARTMENT AND FOUR RURAL HEALTH CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,578,994. PART III, LINE 2: THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WAS DERIVED FROM THE FORM 990 SCHEDULE H WORKSHEET 2, RATIO OF PATIENT CARE COST-TO-CHARGES. THE CCR WAS THEN APPLIED TO BAD DEBT EXPENSE AT CHARGE VALUE IN ORDER TO ARRIVE AT THE ESTIMATED EXPENSE REPORTED. PART III, LINE 4: PLEASE SEE PAGES 9-13 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: THE HOSPITAL IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND, AS SUCH, A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN BASED ON THE IRS 990 INSTRUCTIONS INCLUDES ONLY A PORTION OF THE TOTAL MEDICARE REVENUE OF THE HOSPITAL. THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: ALL PATIENTS OF WEEKS MEDICAL CENTER WHO HAVE NO INSURANCE ARE NOTIFIED OF THE WEEKS HEALTH ACCESS FINANCIAL ASSISTANCE POLICY AND ENCOURAGED TO MAKE AN APPOINTMENT WITH ONE OF OUR FINANCIAL COUNSELORS OR SOCIAL WORKERS. THIS INFORMATION IS GIVEN OUT, ALONG WITH FINANCIAL ASSISTANCE APPLICATIONS, AT THE TIME OF APPOINTMENT AND IS ALSO AVAILABLE ON OUR WEBSITE AND IS REITERATED WITH OUR MONTHLY STATEMENTS SENT TO THE PATIENT. IT IS IMPOSSIBLE FOR OUR ORGANIZATION TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNTIL AN APPLICATION IS FILED - WE DO NOT ACCESS CREDIT REPORTS BUT RELY ON THE PATIENT SUPPLYING US WITH THE NECESSARY FINANCIAL INFORMATION. AT THAT TIME OF APPLICATION, IF A PATIENT IS DETERMINED TO BE ELIGIBLE, THEY ARE PROVIDED WITH FINANCIAL ASSISTANCE. PART VI, LINE 2: EVERY 3 YEARS, WEEKS MEDICAL CENTER PARTICIPATES IN A COMMUNITY NEEDS ASSESSMENT WITH THREE OTHER MEMBERS OF THE COMMUNITY'S HEALTH CARE SYSTEM. USING INFORMATION FROM THAT ASSESSMENT ALLOWS THE HOSPITAL TO PROVIDE HEALTHCARE SERVICES TO THE NORTH COUNTRY COMMUNITY ON AN ONGOING BASIS. PART VI, LINE 3: THE STAFF IS TRAINED TO DISCUSS THE HOSPITAL'S CHARITY CARE POLICY WITH PATIENTS, THE POLICY IS AVAILABLE THROUGHOUT THE HOSPITAL IN THE BROCHURE AND IT IS AVAILABLE ON THE HOSPITAL'S WEBSITE. WMC ALSO EMPLOYS A FULL-TIME FINANCIAL COUNSELOR AND OTHER CASE MANAGEMENT STAFF TO ASSIST PATIENTS WITH THE FINANCIAL ASSISTANCE PROCESS. PART VI, LINE 4: WEEKS MEDICAL CENTER'S GENERAL GEOGRAPHIC CATCHMENT AREA CONSISTS OF NINE TOWNS, WHICH SUPPLY ALMOST 90% OF ITS PATIENTS. TOWNS INCLUDE LANCASTER, GROVETON, DALTON, WHITEFIELD, NORTH STRATFORD, JEFFERSON AND STARK, IN NEW HAMPSHIRE; AND LUNENBURG, GUILDHALL AND GILMAN, IN VERMONT. TOGETHER, THESE TOWNS HAVE A POPULATION OF APPROXIMATELY 13,000 AND COVER APPROXIMATELY 375 SQUARE MILES IN BOTH VERMONT AND NEW HAMPSHIRE. IN 2021, WEEKS OPENED A NEW PHYSICIAN OFFICE IN LITTLETON, NH. THE TOWN HAS A POPULATION OF APPROXIMATELY 4,500. WEEKS MEDICAL CENTER IS DEFINED BY THE GEOGRAPHIC COMMUNITIES THAT SURROUND ITS FACILITIES AND BY THE INDIVIDUALS AND GROUPS WHO BENEFIT FROM THE HEALTH AND WELLNESS SERVICES PROVIDED BY ITS VARIOUS HEALTH RELATED INSTITUTIONS. THE DEFINITION WAS DEVELOPED BY THE BOARD OF TRUSTEES, ITS COMMITTEES, ADMINISTRATIVE AND PROFESSIONAL STAFF IN THE PRACTICAL APPLICATION OF THE SERVICES PROVIDED BY THE INSTITUTIONS AND THE IDENTIFIED NEEDS OF THE COMMUNITIES SERVED. PART VI, LINE 5: WMC PLAYS AN INTEGRAL ROLE IN THE EMERGENCY PREPAREDNESS PLANS OF OUR COMMUNITY. IN ADDITION TO BEING AVAILABLE IN AN EMERGENCY FROM A CLINICAL STANDPOINT, WE ARE A LARGE PART OF THE COMMUNITY WIDE PLANNING TEAM, TAKING THE LEAD IN THE PLANNING OF TRAINING & DRILLS AND BRINGING THE VARIOUS COMPONENTS TOGETHER, BASED ON STATE-WIDE STANDARDS. PART VI, LINE 6: THE HOSPITAL IS AFFILIATED WITH OTHER ENTITIES UNDER THE NORTH COUNTRY HEALTHCARE WHICH OVERSEES THREE CRITICAL ACCESS HOSPITALS AND ONE HOME HEALTH AND HOSPICE AGENCY IN NORTHERN NEW HAMPSHIRE. PART VI, LINE 7, REPORTS FILED WITH STATES NH 1 FOUNDATION FOR HEALTHY COMMUNITIES 125 AIRPORT ROAD CONCORD NH 03301 020275078 501(C)(3) 103958 0 SUBSTANCE ABUSE PREVENTION, TREATMENT & RECOVERY 1 0 PART I, LINE 2: THE HOSPITAL WAS MANDATED BY THE STATE OF NH TO CONTRIBUTE FUNDS TO THE ALCOHOL AND DRUG PREVENTION TREATMENT FUND IN ORDER TO CONTINUE THE MEDICAID EXPANSION PROGRAM. THESE FUNDS GO TOWARDS VARIOUS PROGRAMS SURROUNDING RECOVERY, TREATMENT AND PREVENTION FOR SUBSTANCE MISUSE IN NEW HAMPSHIRE. 0 1 0 0 0 0 0 1 0 THOMAS MEE SYSTEM CEO 0 537600 0 131095 0 12659 0 1891 0 27088 0 710333 0 0 PROUSKEH B EBRAHIMPOUR PHYSICIAN 590292 0 0 0 789 0 0 0 25878 0 616959 0 0 0 MARK MORGAN MD CMO 545205 0 49270 0 789 0 1426 0 13088 0 609778 0 0 0 CHRISTOPHER LAURENT NP NURSE PRACTICIONER 488450 0 0 0 6682 0 13500 0 21771 0 530403 0 0 0 ELISABETH MOORE PHYSICIAN 363889 0 60333 0 526 0 8830 0 40149 0 473727 0 0 0 MAUDE OETKING PHYSICIAN 426609 0 0 0 3473 0 11605 0 11602 0 453289 0 0 0 JOHN FORD PRIMARY CARE/FAMILY MEDICINE PRACT. 411903 0 0 0 8888 0 11538 0 4859 0 437188 0 0 0 MICHAEL D LEE PRESIDENT/CEO 287983 0 67471 0 5893 0 336 0 5211 0 366894 0 0 0 AMBER SCHMIDT MEDICAL STAFF PRESIDENT 274541 0 0 0 525 0 2836 0 37612 0 315514 0 0 0 MATTHEW STREETER SYSTEM CFO 0 276715 0 23655 0 442 0 2631 0 8286 0 311729 0 0 CELESTE PITTS FORMER CFO 142945 0 32595 0 0 0 5399 0 14315 0 195254 0 0 0 PART I, LINE 3 NORTH COUNTRY HEALTHCARE, A RELATED ORGANIZATION, USES THE FOLLOWING METHODS TO ESTABLISH COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL OF THE FILING ORGANIZATION: - COMPENSATION COMMITTEE - FORM 990 OF OTHER ORGANIZATIONS - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THOMAS MEE, SYSTEM CEO, PARTICIPATED IN A 457(F) PLAN ADMINISTERED BY NORTH COUNTRY HEALTHCARE, A RELATED ORGANIZATION. THERE WERE NO CONTRIBUTIONS OR DISTRIBUTIONS IN 2022. PART I, LINE 7 PART OF THE COMPENSATION PROGRAM OVERSEEN BY THE COMPENSATION COMMITTEE AND APPROVED BY THE CORPORATION BOARD AND AFFILIATE BOARDS INCLUDES VARIABLE INCENTIVE COMPENSATION FOR EXECUTIVES. THIS VARIABLE COMPENSATION IS A WITHHOLD OF TOTAL COMPENSATION AND EARNED BACK BY EXECUTIVES BASED ON STRATEGIC GOAL PERFORMANCE. A BUSINESS FINANCE AUTHORITY OF THE STATE OF NH 521304598 2010-09-01 10000000 REFINANCE EXISTING DEBT AND FINANCE THE HOSPITAL'S CONTRUCTION PROJECT 0 0 0 A 5250000 10000000 112960 3044490 6842550 2011 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 1 0 0 0 1 A 0 SCHEDULE K, PART IV, ARBITRAGE, LINE 2C: (A) ISSUER NAME: BUSINESS FINANCE AUTHORITY OF THE STATE OF NH DATE THE REBATE COMPUTATION WAS PERFORMED: 09/02/2022 FORM 990, PART VI, SECTION A, LINE 6 EFFECTIVE APRIL 1, 2016, NORTH COUNTRY HEALTHCARE (NCH) BECAME THE SOLE MEMBER OF WEEKS MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OF THE CORPORATION BOARD SHALL BE NOMINATED BY ACTION OF AN AFFILIATE BOARD, OR BY THE CORPORATION BOARD, AS THE CASE MAY BE, IN ACCORDANCE WITH THE NOMINATION POWERS INDICATED IN THE CORPORATION'S BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE CORPORATION BYLAWS INCLUDE MAJOR MATTERS WHICH INCLUDE SPECIFIC DUTIES AND RESPONSIBILITIES WHICH ARE SHARED BY THE CORPORATION BOARD AND THE AFFILIATE BOARDS. THESE MAJOR MATTERS ARE FURTHER DISTINGUISHED BETWEEN MAJOR ORGANIZATIONAL MATTERS AND MAJOR OPERATIONAL MATTERS. IN BOTH CASES, THE BYLAWS CONTAIN THE PROVISIONS FOR THE APPROVAL OF THESE MATTERS INCLUDING WHETHER THEY ARE APPROVED BY A MAJORITY VOTE OR SUPER MAJORITY VOTE OF ALL BOARDS. IN ALL CASES, THE MAJOR MATTERS REQUIRE APPROVAL BY THE CORPORATION BOARD AND THE AFFILIATE BOARDS. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WILL BE SHARED ELECTRONICALLY WITH THE ENTIRE NCH BOARD AND FINANCE COMMITTEE BEFORE FILING, WITH ADEQUATE TIME FOR QUESTIONS TO BE ASKED. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST PROCESS: - CONFLICT OF INTEREST DISCLOSURE COMPLETED VIA BOARDPAQ (ELECTRONIC MEANS). - RESULTS COMPILED INTO CONFLICT MATRIX WHICH IS REVIEWED AND APPROVED BY THE BOARD. - CONFLICTS THAT MEET THE PECUNIARY BENEFIT CRITERIA ARE IDENTIFIED, SHARED WITH THE BOARD AND APPROVED. - DISCLOSURE NOTICES ARE PLACED IN LOCAL PAPERS. - THE NH DIVISION OF CHARITABLE TRUSTS IS NOTIFIED OF THE PECUNIARY BENEFIT AND COPIES OF THE PUBLIC NOTICES ARE ATTACHED. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE IS A SUBCOMMITTEE OF THE FINANCE COMMITTEE OF THE CORPORATION BOARD. THIS COMMITTEE OVERSEES THE EXECUTIVE COMPENSATION POLICY AND PRACTICES OF THE ORGANIZATION INCLUDING THE CEO, THE AFFILIATE PRESIDENTS, AND THE CEO CABINET WHICH INCLUDES KEY EXECUTIVE POSITIONS FOR THE ORGANIZATION. THE COMPENSATION COMMITTEE ENGAGES WITH AN OUTSIDE CONSULTANT TO DETERMINE COMPENSATION BENCHMARKS AND BEST PRACTICES WHICH GUIDE THE COMPENSATION PROCESSES FOR THESE EXECUTIVE POSITIONS. THE COMPARISON BENCHMARK DATA AND GUIDANCE ARE REVIEWED BY THE COMMITTEE AND RECOMMENDATIONS ARE MADE TO THE CORPORATION BOARD AND AFFILIATE BOARDS. THIS IS DONE ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION HAS IMPLEMENTED ALL POLICIES AND THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 5,474,041. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,474,041. MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 2,509,530. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,509,530. OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 2,700,880. MANAGEMENT AND GENERAL EXPENSES 25,148. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,726,028. FORM 990, PART XI, LINE 9: INTERCOMPANY EQUITY TRANSFER -2,030,094. LANCASTER PATIENT CARE CENTER 173 MIDDLE STREET LANCASTER NH 03584 832130386 SUPPORTING ORGANIZATION NH 501(C)(3) LINE 12A, I WEEKS MEDICAL CENTER 1 GREAT NORTHWOODS COMMUNITY FOUNDATION 59 PAGE HILL ROAD BERLIN NH 03570 020452547 HEALTHCARE SERVICES NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 ANDROSCOGGIN VALLEY HOSPITAL FOUNDATION 59 PAGE HILL ROAD BERLIN NH 03570 223035216 MANAGEMENT AND FINANCIAL SUPPORT NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 NORTHCARE INC 59 PAGE HILL ROAD BERLIN NH 03570 521596952 SUPPORTING SERVICES NH 501(C)(3) LINE 12B, II ANDROSCOGGIN VALLEY HOSPITAL INC 1 NORTH COUNTRY HOME HEALTH & HOSPICE AGENCY INC 536 COTTAGE STREET LITTLETON NH 03561 020300637 HOME HEALTH AGENCY NH 501(C)(3) LINE 10 NORTH COUNTRY HEALTHCARE INC 1 UPPER CONNECTICUT VALLEY HOSPITAL 181 CORLISS LANE COLEBROOK NH 03576 020276210 CRITICAL ACCESS HOSPITAL NH 501(C)(3) LINE 3 NORTH COUNTRY HEALTHCARE INC 1 NORTH COUNTRY HEALTHCARE INC 8 CLOVER LANE WHITEFIELD NH 03598 812225283 HEALTHCARE MANAGEMENT NH 501(C)(3) LINE 12A, I N/A 0 ANDROSCOGGIN VALLEY HOSPITAL INC 59 PAGE HILL ROAD BERLIN NH 03570 020280367 CRITICAL ACCESS HOSPITAL NH 501(C)(3) LINE 3 NORTH COUNTRY HEALTHCARE INC 1 0 0 0 1 0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 LANCASTER PATIENT CARE CENTER K 179000 CASH