2022-08-11T09:55:33-05:00 2021-09-30 010523282 Berry Dunn McNeil & Parker LLC 2211 Congress St Portland ME 04102 990 2020-10-01 020276210 Upper Connecticut Valley Hospital UPPE 6032374971 181 Corliss Lane Colebrook NH 03576 Matthew Streeter CFO 6032374971 2022-08-08 1 Matthew Streeter 999009999 Joseph R Byrne P01289281 2077752387 2022-08-08 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Scott Colby 181 Corliss Lane Colebrook NH 03576 29438202 0 X www.ucvh.org X 1969 NH Upper Connecticut Valley Hospital strives to improve the well-being of the rural communities it serves by promoting health and assuring access to quality care. 12 9 164 14 0 0 986188 3182506 19722921 22463460 335814 1680028 0 0 21044923 27325994 239204 95909 0 0 10851682 11685553 0 0 0 8349817 10384323 19440703 22165785 1604220 5160209 45365598 46987886 22602533 18179317 22763065 28808569 Upper Connecticut Valley Hospital strives to improve the well-being of the rural communities it serves by promoting health and assuring access to quality care. 0 0 17080248 95909 22463460 Upper Connecticut Valley Hospital provided hospital care and inpatient and outpatient services on a region-wide basis. The net charity care provided by the Hospital for the year-ended September 30, 2021 was $389,855. 17080248 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 4 0 1 164 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 1 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 Odette Crawford Chair 1.00 1.00 X X 0 0 0 Lynn Brewer Vice Chair 1.00 0.00 X X 1559 0 0 James Wells Treasurer 1.00 0.00 X X 0 0 0 Eric Stohl Secretary 1.00 1.00 X X 0 0 0 Avis Brosseau Director 1.00 0.00 X 0 0 0 Jeannine Burns Director 1.00 0.00 X 0 0 0 Fr Craig Cheney Director 1.00 0.00 X 0 0 0 Laura Mills Director 1.00 0.00 X 0 0 0 Morgan Wade Director 1.00 0.00 X 0 0 0 Sharon Ellingwood White Director 1.00 0.00 X 0 0 0 Edward Laverty PA-C Chief Medical Officer 40.00 0.00 X X 332450 0 39734 Robert Dawson President of Medical Staff 40.00 0.00 X 158609 0 0 Scott Cooper Past Director 1.00 0.00 X 0 0 0 Scott Colby President/CEO 40.00 0.00 X 243866 0 38712 Celeste Pitts Chief Financial Officer 16.00 25.00 X 73283 109924 16360 Thomas Cochran Physician 40.00 0.00 X 351338 0 35346 Stephen Kraunz Physician 40.00 0.00 X 261285 36670 10817 Arnold Albert DNP 40.00 0.00 X 198325 0 8436 Robert Gooch Pharmacist 40.00 0.00 X 168397 0 30746 Lindsay Lea CNO 40.00 0.00 X 133747 0 13863 1922859 146594 194014 11 0 1 1 Daniel Hebert Inc 12 Pleasant Street Colebrook NH 03598 Construction 3320401 Androscoggin Valley Hospital 59 Page Hill Road Berlin NH 03570 Medical Staff Services 1817121 North Country Healthcare Inc PO Box 240 Whitefield NH 03598 Administrative Services 679128 Weeks Medical Center 173 Middle Street Lancaster NH 03584 Medical Staff Services 674334 Medical Solutions LLC PO Box 850737 Minneapolis MN 554850737 Temporary Staffing 625467 10 3133892 48614 3182506 Patient Service Revenue 621400 30214605 30214605 Miscellanous Revenue 624100 299002 235005 63997 Contractual/Char. Adj. 621400 -8050147 -8050147 22463460 336988 336988 3444998 10250 2112208 0 1332790 10250 1343040 1343040 27325994 22399463 0 1744025 X 95909 95909 814930 532352 282578 8901391 7420917 1480474 127726 108604 19122 1283339 1078157 205182 558167 459607 98560 79827 79827 97845 97845 105775 105775 127103 127103 3489037 2012942 1476095 157341 43149 114192 522588 181830 340758 462172 349546 112626 111341 35148 76193 1455647 1455647 247508 247508 Supplies Expense 1724151 1598518 125633 Medicaid Enhancement Ta 1188439 1188439 Repairs and Maintenance 457604 435940 21664 Miscellanous 157945 83543 74402 22165785 17080248 5085537 0 X 1522637 1274943 11354331 7499598 1673 0 2252652 4305894 275071 329622 274720 324920 25101985 11787473 12267709 13314512 17061801 19386567 355004 551830 45365598 46987886 1677966 2662968 57856 148983 20866711 15367366 22602533 18179317 X 22469639 28479341 293426 329228 22763065 28808569 45365598 46987886 5160209 885295 0 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 4688 4688 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. 263236 35802 0 299038 240915 24066 1745 263236 232266 13836 5187 240915 233884 3524 5142 232266 280657 22414 69187 233884 0.00000 0.57880 0.42120 0 0 9700 9700 11268443 3354947 7913496 13551107 8309747 5241360 272735 122779 149956 13314512 Estimated Third-Party Payor Settlements 10678789 Medicare Accelerated Payments 2559365 Deferred U.S. Department of Health and Human Services Stimulus Revenue 2129212 15367366 28084186 885295 885295 27198891 127103 127103 27325994 22038682 0 22038682 127103 127103 22165785 Part V, Line 4: The Organization's endowments are used for staff education, nursing projects and indigent care. 1 1 1 X 300.000000000000 1 X 1 1 1 0 1 1 623818 236456 387362 0.01750 623818 236456 387362 0.01750 7 368304 15639 352665 0.01590 319802 319802 0.01440 5623366 908592 4714774 0.21270 3 199803 199803 0.00900 10 6511275 924231 5587044 0.25200 10 7135093 1160687 5974406 0.26950 2663 2663 0.00010 16681 16681 0.00080 4583 4583 0.00020 862 862 0.00000 24789 24789 0.00110 1 624386 9322116 8954412 367704 X 1 1 1 1 Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook NH 03576 www.ucvh.org 00592 X X X X Upper Connecticut Valley Hospital 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X https://www.ucvh.org/community-benefits-report/ X 1 18 1 https://www.ucvh.org/community-benefits-report/ 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X https://www.ucvh.org/patients-visitors/financial-information/ X https://www.ucvh.org/patients-visitors/financial-information/ X https://www.ucvh.org/patients-visitors/financial-information/ X X X X X 1 X 0 X X X X 1 X 0 0 Upper Connecticut Valley Hospital 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. Upper Connecticut Valley Hospital Part V, Section B, Line 6a: The Hospital's CHNA was conducted along with Weeks Medical Center, Littleton Regional Hospital, Androscoggin Valley Hospital. Upper Connecticut Valley Hospital Part V, Section B, Line 6b: The Hospital's CHNA was conducted along with Ammonoosuc Community Health Services, Coos County Family Health, and North Country Home Health & Hospice Agency. The first two are local FQHC's. Upper Connecticut Valley Hospital Part V, Section B, Line 11: Significant Needs Identified and Being Addressed:1. Drug/Substance Abuse: This was identified in the last CHNA. UCVH has partnered with both Dartmouth-Hitchcock and Northern Human Services to provide Tele-psych services through the Emergency Department. Education on the use of Narcan is given during complimentary CPR/BLS/First Aid Community trainings. Education regarding Substance Abuse & Alcohol abuse is given through the Emergency Department. Mental Health inpatient accommodations are available for patients awaiting placement in State or Private Institutions. A Pain Management program has been instituted to offer an alternative to opioid use. This program includes a behavioral health counseling component.2. Mental Health: See above response.3. Obesity/Overweight: Nutritionist available for dietary counseling with Inpatients. Medical Nutrition Counseling and Diabetes Self-Management program are available to members of the community. Prescription Food Program developed in 2019. Community health wellness fairs/activities that provide nutrition information to the public, glucose screenings, cholesterol screenings and Bike Blender for healthy smoothies. UCVH works in partnership with the UNH Cooperative Extension, SAU#7, and the Farm School Beacon Project, providing cooking nutrition classes to low income community members, and focusing on the improvement of health of our area school's children and their families.4. Accessibility (Transportation, Disability, Access to Care, etc.): UCVH partners with Weeks Medical Center and Androscoggin Valley Hospital to bring many Specialists to Colebrook for accessibility within our community. Patient would need to drive an hour or more for an office visit otherwise. In addition, Case Management staff work with patients for transportation and UCVH staff offer Rehabilitation services to our local schools and nursing home. Cardiac Rehab is available at the hospital for those who qualify which makes this valuable program more accessible to those who need it most. UCVH is working with Weeks Medical Center to bring substance abuse counseling to the Colebrook area over the next year and is researching further Telemedicine opportunities, such as Rheumatology.5. Alcohol Abuse: See response #1. 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: Specialty Care Providers & Emergency Department Part II, Community Building Activities: The community building activities undertaken by UCVH consist of supporting local government and other health care providers, coordination of disaster drills, emergency preparedness, and support of other local organizations within the community. In addition, in an effort to provide the necessary health care services for the population within a reasonable driving distance, UCVH has entered into a collaboration with the other two Coos county hospitals to provide necessary primary care, behavioral health, and specialty services for the UCVH service area. 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 8-12 and pages 16-18 of the attached audited financial statements. Part III, Line 8: Allowable costs come from the filed cost report. Over the past years, due to Sequester, UCVH has operated at a loss from Medicare. Sequester was discontinued during the Public Health Emergency and therefore in Fiscal 2021 there was no loss from Medicare. Normally this shortfall was treated as a community benefit as there are no other funds available to subsidize the loss. Part III, Line 9b: If known to qualify for charity or financial assistance, patients are given the assistance needed. Part VI, Line 2: In 2019, North Country Health Care engaged Quorum Health Resources to facilitate on our behalf the preparation of a Community Health Needs Assessment (CHNA) for the four affiliated hospitals, our Home Health Division and two community health centers. The CHNA was completed in September, 2019. An implementation plan was developed by Senior Leadership at the individual affiliates, and was then combined to develop the NCH Implementation plan. This plan was approved by the UCVH Board of Directors at the December, 2019 meeting. The CHNA and Implementation Plan are available on the UCVH website. Part VI, Line 3: UCVH has a patient financial counselor who is responsible for working with patients and any who may be billed for their care to determine their eligibility, on a case by case basis. For any government programs, such as Medicaid or the UCVH financial assistance program all staff at UCVH, particularly registration staff who will be the first ones to notice if a patient does not have insurance, are trained to refer the patient to the financial counselor. In addition, brochures are available, as is contact information on the website. Part VI, Line 4: UCVH is the smallest critical access hospital in New Hampshire that serves the largest geographic service area (over 850 square miles) including communities in the states of New Hampshire, Vermont, and Maine. According to the New Hampshire state health profile, our residents are the most fragile of all citizens in New Hampshire as it relates to health outcomes and economic conditions. UCVH is dependent on public funding and disproportionate share funding to subsidize the care provided to the patients we serve. Part VI, Line 7, Reports Filed With States NH 1 Foundation for Healthy Communities 125 Airport Road Concord NH 033017300 020275078 501(c)(3) 85909 Substance Abuse prevention, treatment & recovery North Country Healthcare Inc 8 Clover Lane Whitefield NH 03598 812225283 501(c)(3) 10000 Contribution for Mobile Medical Unit 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. Additionally, each of the Hospitals affiliated with North Country Healthcare elected to participate in an initiative with the Bowler-Bartlett Foundation to purchase a mobile medical unit to be made available for use throughout New Hampshire. 0 0 0 0 0 0 0 1 0 Thomas Cochran Physician 350978 0 0 0 360 0 7798 0 27548 0 386684 0 0 0 Edward Laverty PA-C Chief Medical Officer 330022 0 0 0 2428 0 7272 0 32462 0 372184 0 0 0 Stephen Kraunz Physician 261285 36670 0 0 0 0 0 0 10817 0 272102 36670 0 0 Scott Colby President/CEO 229955 0 0 0 13911 0 5727 0 32985 0 282578 0 0 0 Arnold Albert DNP 191018 0 0 0 7307 0 5461 0 2975 0 206761 0 0 0 Celeste Pitts Chief Financial Officer 70677 106015 0 0 2606 3909 1883 2825 4661 6991 79827 119740 0 0 Robert Gooch Pharmacist 162702 0 3414 0 2281 0 5261 0 25485 0 199143 0 0 0 Robert Dawson President of Medical Staff 158609 0 0 0 0 0 0 0 0 0 158609 0 0 0 Part I, Line 7 The President, Scott Colby, has an annual bonus clause in his contract. The amount is discretionary and determined by the Board of Directors, based on overall performance of the organization for that year. The other individuals received a purely discretionary bonus per the President based on recognition of additional responsibilities and special projects performed. Form 990, Part VII, Line 5: Dr. Robert Dawson, President of Medical Staff, is employed and compensated by Catholic Medical Center, an unrelated organization, for services rendered to the filing organization. During calendar year 2020, Upper Connecticut Valley Hospital paid CMC $158,609 for services rendered by Dr. Dawson. The Hospital is not aware of nor privvy to Dr. Dawson's compensation package from CMC, and thus pursuant to Form 990 instructions is reporting the $158,609 paid to CMC on Form 990, Part VII, Section A, column D. Schedule J, 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 - Independent compensation consultant - Form 990 of other organizations - Written employment contract - Compensation survey or study - Approval by the board or compensation committee Shari Parker Family member of Board Secretary Eric Stohl 120921 EmploymentWages: $89,351Benefits: $31,570 0 Form 990, Part VI, Section A, line 4 During FY21, the Hospital amended its bylaws and the following significant changes were made: 1. The President of the Hospital is no longer able to call a special meeting of the Board. 2. Regarding a quorum - language was amended to reflect the following: "After a quorum has been established at a meeting of the Corporation Board, the subsequent withdrawal of directors from the meeting so as to reduce the number of directors present to fewer than the number required for a quorum shall not affect the validity of any action taken by the Corporation Board at the meeting or any adjournment thereof to the extent a quorum was present at the time such action was taken." 3. Regarding Committees of the Board - language was amended to reflect that other committees of the Board shall be established only in conjunction with the System Parent. 4. Regarding the Executive Committee - language was amended to include the Hospital President on the Committee. Form 990, Part VI, Section A, line 6 As the Parent Organization, North Country Healthcare (NCH) is the Sole Member of Upper Connecticut Valley Hospital. Form 990, Part VI, Section A, line 7a Members of the Hospital Boards are nominated exclusively by the Hospital, however the election of any such Director must be approved by the Hospital Board and the NCH Board. Form 990, Part VI, Section A, line 7b The Bylaws of NCH and each Hospital identify certain "Major Matters" (divided into organizational and operational matters) that require initiation and/or authorization by a majority of the NCH Board. Examples of organizational "Major Matters" include amendments to Bylaws, election of officers, dissolution of a Hospital, merger decisions and hiring/termination of Hospital Presidents. Examples of operational "Major Matters" include approval of annual capital and operating budgets, adoption of compensation and benefit programs, approval of information technology systems, financial systems and auditors, plus approval of any major changes to clinical services offered. Form 990, Part VI, Section B, line 11b The Form 990 is reviewed by CFO & President of the Hospital. After their review is complete, the Form is shared with the entire Board and Finance Committee prior to filing. Form 990, Part VI, Section B, line 12c Directors, Officers, Highly Compensated Employees are all required to review and sign the Conflict of Interest Document. Annual conflict of interest documents were distributed electronically this year through Corporate Compliance and a copy was shared with BerryDunn. Form 990, Part VI, Section B, line 15 The hospital President compensation and benefit package is reviewed periodically by community board members who govern the non-profit organization as unpaid, independent volunteers. The periodic review includes comparability data, and the deliberation and decision making is substantiated by written minutes. Form 990, Part VI, Section C, line 18 UVCH makes its 990 available upon request. Form 990, Part VI, Section C, line 19 Available upon request. Form 990, Part IX, line 11g Other Fees: Program service expenses 31,859. Management and general expenses 494,992. Fundraising expenses 0. Total expenses 526,851. Contract Labor: Program service expenses 1,981,083. Management and general expenses 981,103. Fundraising expenses 0. Total expenses 2,962,186. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Upper Connecticut Valley Hospital 181 Corliss Lane Colebrook, NH 03576 EIN: 02-0276210 Upper Connecticut Valley Hospital is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). 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 0 Weeks Medical Center 173 Middle Street Lancaster NH 03584 020222242 Critical Access Hospital NH 501(c)(3) Line 3 North Country Healthcare Inc 0 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 0 Northcare Inc 59 Page Hill Road Berlin NH 03570 521596952 Supporting Services NH 501(c)(3) Line 12b, II Androscoggin Valley Hospital Inc 0 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 0 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 0 Lancaster Patient Care Center 173 Middle Street Lancaster NH 03584 832130386 Supporting Organization NH 501(c)(3) Line 12a, I Weeks Medical Center 0 0 0 0 1 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0