2024-08-15T15:26:15-05:00 2023-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-10-01 020280367 ANDROSCOGGIN VALLEY HOSPITAL INC ANDR 6037522200 59 PAGE HILL ROAD BERLIN NH 03570 MATTHEW STREETER SYSTEM CFO 6037522200 2024-08-15 1 1 MICHAEL J PETERSON CPA P01833529 2187224705 2024-08-15 2022 2024-08-08 14:25:15Z MICHAEL PETERSON 59 PAGE HILL ROAD BERLIN NH 03570 96982192 0 X WWW.AVHNH.ORG X 1971 NH CRITICAL ACCESS HOSPITAL 12 10 410 51 0 0 2584058 793435 74261440 95188802 684763 -123612 85890 866489 77616151 96725114 692569 589892 0 0 40204428 36041754 0 0 0 34227643 50876217 75124640 87507863 2491511 9217251 74030462 77160767 37838892 32019828 36191570 45140939 DELIVERING THE BEST HEALTHCARE EXPERIENCE FOR EVERY PATIENT, EVERY DAY. 0 0 68813116 589892 95170869 ANDROSCOGGIN VALLEY HOSPITAL IS A CRITICAL ACCESS HOSPITAL. THE HOSPITAL PROVIDES A BROAD RANGE OF INPATIENT AND OUTPATIENT SERVICES TO MEET THE HEALTH NEEDS OF THE UPPER ANDROSCOGGIN VALLEY AND SURROUNDING COMMUNITIES. WITH A COMMITMENT TO THE HIGHEST QUALITY SURGICAL CARE - AVH IS LEADING THE WAY TO A HEALTHIER FUTURE FOR OUR HEALTH CARE COMMUNITY. OTHER COMMUNITY BENEFITS PROVIDED BY THE HOSPITAL INCLUDE THE PROVISION OF CARE TO THE UNDERINSURED; THE PROMOTION OF GOOD HEALTH FOR CHILDREN THROUGH PARTICIPATION IN THE HEALTHY KIDS PROGRAM; AND THE SPONSORSHIP OF NUMEROUS CLINICS AND PROGRAMS SUPPORTING GOOD HEALTH IN THE COMMUNITY. EDUCATIONAL PROGRAMS OFFERED BY AVH INCLUDE CHILDBIRTH CLASSES, BABYSITTING COURSE, WELLNESS FAIRS, LECTURE SERIES, CPR AND FIRST AID COURSES, NUTRITIONAL COUNSELING, AND A VARIETY OF SUPPORT GROUPS. 68813116 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 126 0 1 410 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 10 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 DONNA GOODRICH CHAIR 1.00 1.50 X X 0 0 0 JAY POULIN VICE CHAIR 1.00 0.50 X X 0 0 0 THOMAS MCCUE TREASURER 1.00 1.00 X X 0 0 0 MARTHA LAFLAMME SECRETARY 1.00 0.50 X X 0 0 0 JAVIER CARDENAS DIRECTOR 40.00 X 469471 0 37186 BRIANNE TEABOLDT MEDICAL STAFF PRESIDENT 1.00 X 0 0 0 LYNN BEEDE DIRECTOR 1.00 X 0 0 0 ALTA CHASE DIRECTOR 1.00 1.00 X 0 0 0 JESSICA FOSTER-HEBERT DIRECTOR/NCHHHA DIR. CLIN SERV 1.00 39.00 X 0 113558 22301 DANIEL VAN BUREN DIRECTOR 1.00 X 0 0 0 SARAH VERNEY FRECHETTE DIRECTOR 1.00 X 0 0 0 TYLER WHITE DIRECTOR 1.00 X 0 0 0 THOMAS MEE SYSTEM CEO 1.00 45.00 X 0 681354 28979 MICHAEL PETERSON PRESIDENT 40.00 2.00 X 406469 0 6555 MATTHEW STREETER SYSTEM CFO 1.00 45.00 X 0 300812 10917 KEITH SHUTE MD CHIEF MEDICAL OFFICER 39.50 0.50 X 501124 0 34023 MAHLON BRADLEY ORTHOPEDIC SURGEON 40.00 X 618141 0 10949 KRZYSZTOF PLOCIENNIK MD PROVIDER 40.00 X 509769 0 37991 RICHARD KARDELL ED PHYSICIAN 40.00 X 472990 0 11862 STEPHEN KRAUNZ EMERGENCY MEDICINE PRACTITIONER 40.00 X 432825 0 2565 ARTHUR RUEDIGER EMERGENCY MEDICINE PRACTITIONER 40.00 X 398424 0 13123 3809213 1095724 216451 88 0 1 0 NORTH COUNTRY HEALTHCARE INC 8 CLOVER LAND WHITEFIELD NH 03598 MANAGEMENT SERVICES 1957736 AMERICAN HEALTHCARE STAFFING ASSOC 226 E SIXTEENTH ST SUITE A TRAVERSE CITY MI 49684 CONTRACT LABOR 1076119 WEEKS MEDICAL CENTER 173 MIDDLE ST LANCASTER NH 03598 CONTRACT LABOR/PURCHASED SERV 878568 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 PHYSICIAN CONTRACT LABOR 817938 NEW HAMPSHIRE IMAGING SERVICES INC 1 PILLSBURY ST SUITE 200 CONCORD NH 03301 MRI PURCHASED SERVICES 674172 23 38078 675917 79440 793435 NET PATIENT REVENUE 621400 94245421 94245421 340(B) PHARMACY REVENUE 456110 899496 899496 43885 25952 17933 95188802 105234 105234 116767 0 116767 116767 116767 8633 227328 10151 -227328 -1518 -228846 -228846 5600 38078 19599 -13999 -13999 CAFETERIA REVENUE 722514 401029 401029 362692 362692 763721 96725114 95170869 0 760810 X 589892 589892 1282798 887853 394945 26409647 25513997 895650 859201 706620 152581 5752102 4744668 1007434 1738006 1433444 304562 225805 225805 14557 14557 40391 40391 12212584 12166857 45727 18880 18880 128631 111516 17115 1102137 1102137 474485 441033 33452 81860 67830 14030 88318 76804 11514 3663974 3186312 477662 1316734 1316734 INTERCOMPANY ALLOCATION 10724040 3122989 7601051 MEDICAL SUPPLIES 8167471 8167471 MCD TAX 7056990 7056990 BAD DEBT EXPENSE 3085420 3085420 2473940 2091539 382401 87507863 68813116 18694747 0 4193 0 11969545 5604951 5942551 9744180 1005558 1026390 409563 846828 69784187 44955032 22280331 24829155 22146687 18330061 10272034 16779202 74030462 77160767 5443251 8986192 4317205 3322832 28078436 19710804 37838892 32019828 X 36191570 45140939 36191570 45140939 74030462 77160767 X 9217251 2276102 -518580 -2025404 X 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 14557 14557 0 PART II-B, LINE 1: THE HOSPITAL 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 THE HOSPITAL AND OTHER MEMBER ORGANIZATIONS IN FURTHERANCE OF THEIR EXEMPT PURPOSES. THE HOSPITAL DOES NOT DIRECTLY PERFORM ANY LOBBYING ACTIVITIES. 198192 198192 32638012 21750550 10887462 359449 359449 0 34429391 22845033 11584358 2159143 2159143 24829155 INVESTMENT IN AFFILIATE 10463 DEFERRED COMPENSATION 8918335 3RD PARTY REIMBURSEMENT RECEIVABLE 7604954 DUE FROM RELATED PARTIES 245450 16779202 DEFERRED COMPENSATION 8918335 AMOUNTS PAYABLE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 9350552 DUE TO RELATED PARTIES 1441917 19710804 GOLF TOURNAMENT 43678 38078 5600 700 1898 7400 2000 7601 43678 38078 5600 700 1898 7400 2000 7601 19599 -13999 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 426201 426201 0.00500 12519881 10427220 2092661 0.02480 12946082 10427220 2518862 0.02980 6955070 8070608 0 0.00000 6955070 8070608 0 0.00000 19901152 18497828 2518862 0.02980 0 1358777 24156746 24308154 -151408 X 1 0 1 1 ANDROSCOGGIN VALLEY HOSPITAL INC 59 PAGE HILL ROAD BERLIN NH 03570 WWW.AVHNH.ORG 00050 X X X X ANDROSCOGGIN VALLEY HOSPITAL INC 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 X 1 1 X X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 ANDROSCOGGIN VALLEY HOSPITAL, INC. 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. ANDROSCOGGIN VALLEY HOSPITAL, INC. PART V, SECTION B, LINE 6A: THE HOSPITAL'S CHNA WAS CONDUCTED ALONG WITH WEEKS MEDICAL CENTER AND UPPER CONNECTICUT VALLEY HOSPITAL. ANDROSCOGGIN VALLEY HOSPITAL, INC. 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. ANDROSCOGGIN VALLEY HOSPITAL, INC. PART V, SECTION B, LINE 7D: SECTION B, LINE 7A:HTTPS://AVHNH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/SECTION B, LINE 10A:HTTPS://AVHNH.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/ ANDROSCOGGIN VALLEY HOSPITAL, INC. PART V, SECTION B, LINE 11: ANDROSCOGGIN VALLEY HOSPITAL, INC. TOOK THE FOLLOWING STEPS DURING FY 2023 TO ADDRESS THE SIGNIFICANT NEEDS IDENTIFIED IN ITS MOST RECENT CHNA, COMPLETED IN TAX YEAR 2021:- 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. 4 1 - AVH SURGICAL ASSOCIATES 7 PAGE HILL RD BERLIN NH 03570 PHYSICIAN PRACTICE OFFICE 2 - ANDROSCOGGIN VALLEY HOSPITAL 133 PLEASANT ST BERLIN NH 03570 OUTREACH CLINIC/LAB SERVICES 3 - ANDROSCOGGIN VALLEY HOSPITAL 2 BROADWAY AVE GORHAM NH 03581 OUTREACH CLINIC/LAB SERVICES 4 - SACO RIVER MEDICAL GROUP 15 US ROUTE 302 GLEN NH 03838 SLEEP AND CARDIOLOGY 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: THE COSTS OF SUBSIDIZED HEALTH SERVICES ARE RELATED TO THE EMERGENCY SERVICES UNIT. 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 $ 3,085,420. PART III, LINE 2: THE HOSPITAL USES A COST-TO-CHARGE RATIO. THE COST-TO-CHARGE RATIO WASU 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 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: IF KNOWN TO QUALIFY FOR CHARITY OR FINANCIAL ASSISTANCE, PATIENTS ARE GIVEN THE ASSISTANCE NEEDED. PART VI, LINE 2: EVERY 3 YEARS, ANDROSCOGGIN VALLEY HOSPITAL 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: ANDROSCOGGIN VALLEY HOSPITAL OFFERS MANY FINANCIAL ASSISTANCE AND REFERRAL PROGRAMS TO ENSURE THAT COST WILL NOT BE A BARRIER TO PATIENTS GETTING THE HEALTHCARE SERVICES THEY NEED. IF PAYMENT OF HEALTHCARE EXPENSES COULD CREATE A FINANCIAL HARDSHIP, HOSPITAL STAFF WILL WORK WITH PATIENTS TO APPLY FOR FINANCIAL ASSISTANCE. INFORMATION REGARDING FINANCIAL ASSISTANCE POLICIES IS AVAILABLE AT THE HOSPITAL'S ENTRANCES AND PATIENT REGISTRATION AND ON THE HOSPITAL'S WEBSITE. AS PART OF THE FINANCIAL COUNSELING APPLICATION PROCESS, THE HOSPITAL WILL ASSESS ELIGIBILITY FOR HEALTH INSURANCE COVERAGE THROUGH FEDERAL OR STATE PROGRAMS SUCH AS NEW HAMPSHIRE MEDICAID AND ASSIST IN THE APPLICATION PROCESS. PART VI, LINE 4: THE GEOGRAPHIC AREA SERVED BY ANDROSCOGGIN VALLEY HOSPITAL IS THE BERLIN SERVICE AREA. THE BERLIN SERVICE AREA IS COMPOSED OF THE CITY OF BERLIN, AND THE TOWNS OF GORHAM, SHELBURNE, MILAN, RANDOLPH, DUMMER, ERROL AND STARK. THESE COMMUNITIES ARE WITHIN THE BOUNDARIES OF COOS COUNTY, WHICH IS BORDERED BY THE STATE OF MAINE TO THE EAST, THE STATE OF VERMONT TO THE WEST AND QUEBEC, CANADA TO THE NORTH. THE CITY OF BERLIN DEFINES MUCH OF THE REGION AS THE LARGEST COMMUNITY IN THE COUNTY WITH A POPULATION OF 10,025. THE TOTAL POPULATION OF THE BERLIN SERVICE AREA IS 16,121. THE CHANGING ECONOMIC LANDSCAPE AND THE CLOSING OF PAPER AND PULP MILLS OVER THE LAST DECADE IN THE COOS COUNTY HAVE SIGNIFICANTLY IMPACTED THE AREA'S UNEMPLOYMENT RATE AND POPULATION COMPARED TO THOSE EXPERIENCED BY THE OVERALL STATE OF NEW HAMPSHIRE. PART VI, LINE 5: ANDROSCOGGIN VALLEY HOSPITAL IS THE LEADING PROVIDER OF HEALTHCARE TO THOUSANDS OF FAMILIES IN THE SMALL-TOWN COMMUNITIES OF NEW HAMPSHIRE'S NORTH COUNTRY. AS A CRITICAL ACCESS HOSPITAL, AVH OFFERS 24/7 EMERGENCY CARE, IN-HOUSE TREATMENT OF MOST MEDICAL ISSUES, AND AN ARRANGEMENT FOR TREATMENT OF ALL OTHER PROBLEMS WITH THE NEAREST TERTIARY-CARE FACILITY. OVER THE PAST DECADE, AVH HAS INVESTED SIGNIFICANTLY IN EXPANDING AND IMPROVING OUR FACILITIES AND SERVICES, AND ENHANCING OUR TEAM OF DEDICATED, HIGHLY TRAINED DOCTORS, NURSES AND OTHER STAFF. THE RESULT IS A HOSPITAL THAT MORE EFFECTIVELY CONTRIBUTES TO THE HEALTH OF OUR COMMUNITIES THAN EVER BEFORE. OUR NEW LOCATION IN NORTH CONWAY, NH OFFERS COMFORTABLE AND PRIVATE TREATMENT ROOMS FOR PAIN PROCEDURES AS WELL AS SOME ELECTIVE TREATMENTS. RECENT RENOVATIONS HAVE TAKEN PLACE TO UPDATE THE OBSTETRICS AND GYNECOLOGY SPACE OFFERING AN IMPROVED PATIENT EXPERIENCE THROUGH OPEN RECEPTION AND MORE NATURAL FLOW FOR PATIENTS AS WELL AS CLOSER PROXIMITY TO THE INPATIENT WOMEN'S SERVICES AREA. AT THE END OF THE DAY, OUR TOP PRIORITY IS TO ENSURE THE HIGHEST LEVEL OF QUALITY HEALTHCARE TO THOSE THAT WE ARE SO FORTUNATE TO SERVE. IN AN EFFORT TO CONTINUE TO PROVIDE A HIGH QUALITY OF HEALTHCARE FOR ALL PATIENTS IN THE NORTH COUNTRY, THE HOSPITALS OF COOS & GRAFTON COUNTY CAME TOGETHER TO EXPLORE COLLABORATION. WE, THE BOARDS AND SENIOR MANAGEMENT OF ANDROSCOGGIN VALLEY HOSPITAL, UPPER CONNECTICUT VALLEY HOSPITAL, AND WEEKS MEDICAL CENTER REALIZE THAT SIGNIFICANT NATIONAL, STATE AND LOCAL ECONOMIC PRESSURES ARE JEOPARDIZING LOCAL ACCESS, QUALITY AND SUSTAINABILITY. WE HAVE THEREFORE FORMED NORTH COUNTRY HEALTHCARE (NCHC) WITH THE STATED OBJECTIVE OF WORKING COLLABORATIVELY TO BETTER SERVE THE HEALTHCARE NEEDSOF NORTH COUNTRY PATIENTS. THIS COLLABORATIVE EFFORT WILL WORK TO:1. ENSURE ACCESS TO QUALITY CARE WITHIN THE COMMUNITIES IN WHICH OUR PATIENTS LIVE2. PROVIDE LOCAL AND HIGH QUALITY CARE WITH POSITIVE OUTCOMES TO OUR PATIENTS IN THE NORTH COUNTRY3. CONTROL THE COST OF CARE THROUGH INNOVATIVE PROGRAMS AND THE USE OF SHARED RESOURCESNATIONAL HEALTHCARE REFORM DEMANDS LOWER COSTS AND HIGHER QUALITY FROM ALL HOSPITALS, REQUIRING COLLABORATION IN PATIENT CARE ACROSS ALL PROVIDERS: FROM PRIMARY CARE TO SPECIALIST, FROM AMBULANCE TO HOSPITAL, FROM HOSPITAL TO REHABILITATION TO HOME CARE, FROM LOCAL HOSPITAL TO TERTIARY (SPECIALTYHOSPITAL) CARE. THEREFORE, ANDROSCOGGIN VALLEY HOSPITAL, UPPER CONNECTICUT VALLEY HOSPITAL, AND WEEKS MEDICAL CENTER HAVE FORMED THIS JOINT VENTURE TO IDENTIFY AND IMPLEMENT SUSTAINABLE OPPORTUNITIES FOR OUR FUTURE. THE NCHC AND ITS MEMBER HOSPITALS ARE PREPARED TO MANAGE COSTS AND COORDINATE CARE IN A WAY THAT IS FINANCIALLY SUSTAINABLE, WHILE CONTINUING TO PROVIDE LOCAL ACCESS TO QUALITY CARE THROUGHOUT THE COUNTY AND BEYOND. THE HOSPITALS OF THE NORTH COUNTRY MUST WORK TOGETHER AS CRITICAL PARTS OF OUR ECONOMY AND COMMUNITY. 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 COOS COUNTY FAMILY HEALTH SERVICES 133 PLEASANT STREET BERLIN NH 03570 020350051 501(C)(3) 395833 0 COMMUNITY BENEFIT FOUNDATION FOR HEALTHY COMMUNITIES 125 AIRPORT RD CONCORD NH 03570 020275078 501(C)(3) 194059 0 GOVERNOR'S COMMISSION ON ALCOHOL & OTHER DRUGS TO SUPPORT SUBSTANCE ABUSE PR 2 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. THE HOSPITAL HAS ENTERED INTO AN AGREEMENT WITH COOS COUNTY FAMILY HEALTH SERVICES (CCFHS) WHEREBY THE HOSPITAL WILL PROVIDE FUNDING IN THE FORM OF A COMMUNITY BENEFIT GRANT. THE TERMS OF THE AGREEMENT REQUIRE THAT THE HOSPITAL PROVIDE CCFHS WITH THE AGREED-UPON COMMUNITY BENEFIT GRANT ON JULY 1 OF THE GRANT YEAR. THE AMOUNT OF THE COMMUNITY BENEFIT GRANT TO BE AWARDED IS DETERMINED ON AN ANNUAL BASIS IN ACCORDANCE WITH THE TERMS OF THE AGREEMENT. 0 1 0 0 0 0 0 0 0 THOMAS MEE SYSTEM CEO 0 537600 0 131095 0 12659 0 1891 0 27088 0 710333 0 0 MAHLON BRADLEY ORTHOPEDIC SURGEON 562871 0 24400 0 30870 0 0 0 10949 0 629090 0 0 0 KRZYSZTOF PLOCIENNIK MD PROVIDER 489074 0 15050 0 5645 0 0 0 37991 0 547760 0 0 0 KEITH SHUTE MD CHIEF MEDICAL OFFICER 408751 0 54975 0 37398 0 0 0 34023 0 535147 0 0 0 JAVIER CARDENAS DIRECTOR 441524 0 50 0 27897 0 0 0 37186 0 506657 0 0 0 RICHARD KARDELL ED PHYSICIAN 430658 0 15050 0 27282 0 0 0 11862 0 484852 0 0 0 STEPHEN KRAUNZ EMERGENCY MEDICINE PRACTITIONER 412225 0 100 0 20500 0 0 0 2565 0 435390 0 0 0 MICHAEL PETERSON PRESIDENT 305165 0 77489 0 23815 0 0 0 6555 0 413024 0 0 0 ARTHUR RUEDIGER EMERGENCY MEDICINE PRACTITIONER 381665 0 50 0 16709 0 0 0 13123 0 411547 0 0 0 MATTHEW STREETER SYSTEM CFO 0 276715 0 23655 0 442 0 2631 0 8286 0 311729 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. A 2012 NEW HAMPSHIRE HEALTH AND EDUCATION FACILITIES AUTHORITY REVENUE BONDS 020279866 2012-03-29 14500000 REFINANCING EXISTING BONDS, TERMINATE INTEREST RATE SWAP CONTRACT 0 0 0 A 11177167 14500000 125386 14374614 2012 1 0 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 1 A 0 MYSTIC VALLEY UROLOGY LLC ENTITY CONTROLLED MORE THAN 35% BY JERRY RITTENHOUSE, FORMER DIRECTOR 643508 INDEPENDENT 0 PART IV, COLUMN B SUPPLEMENTAL INFORMATION: JERRY RITTENHOUSE WAS A DIRECTOR THROUGH 12/2021 FORM 990, PART VI, SECTION A, LINE 6 EFFECTIVE APRIL 1, 2016, NORTH COUNTRY HEALTHCARE (NCH) BECAME THE SOLE MEMBER OF ANDROSCOGGIN VALLEY HOSPITAL. 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 PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 5,587,789. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,587,789. CONTRACT LABOR: PROGRAM SERVICE EXPENSES 3,510,076. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,510,076. OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 3,068,992. MANAGEMENT AND GENERAL EXPENSES 45,727. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,114,719. FORM 990, PART XI, LINE 9: TRANSFER OF EQUITY TO NORTH COUNTRY HEALTHCARE, INC. -2,025,404. FORM 990, PART XII, LINE 2C: THERE WERE NO CHANGES MADE FROM PRIOR YEAR. WEEKS MEDICAL CENTER 173 MIDDLE STREET LANCASTER NH 03584 020222242 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 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 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 NORTHCARE INC 59 PAGE HILL ROAD BERLIN NH 03570 521596952 SUPPORTING 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 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 LANCASTER PATIENT CARE CENTER 173 MIDDLE STREET LANCASTER NH 03584 832130386 SUPPORTING ORGANIZATION NH 501(C)(3) LINE 12A, I WEEKS MEDICAL CENTER 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1