2020-08-11T13:34:42-05:00 2019-09-30 010494526 Baker Newman & Noyes PO Box 507 Portland ME 04112 990 2018-10-01 030177161 Carlos G Otis Health Care Center CARL 8023657920 PO Box 216 Townshend VT 053530216 Stephen A Brown CFO 8023657920 2020-08-10 1 Lisa M Dickson P00068196 2078792100 2020-08-10 208.105.168.164 2020-08-10 11:22:49 ED P 4950B0318DE8D55CD0245DC492FF2601D954F5E9 9B798FEAEBCFA942D115C8A4F3C866B2F97A63F0 2018 2020-11-19 02:30:22Z Grace Cottage Hospital Kevin Meyer PO Box 216 Townshend VT 053530216 24392886 0 X www.gracecottage.org X 1949 VT Provision of health care services 9 8 250 98 0 0 1362167 1126798 22989229 23265422 -11688 -16616 0 0 24339708 24375604 0 0 0 0 15664670 16338008 0 0 268185 8173275 8445154 23837945 24783162 501763 -407558 15316029 16126241 5528786 6299659 9787243 9826582 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 22375709 0 23265422 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. 22375709 1 1 0 1 0 0 0 0 0 1 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 16 0 1 250 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 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 X Alexandra Clark Trustee (end 9/23/2019) 1.00 0.00 X 0 0 0 John Clark Trustee 1.00 1.00 X 0 0 0 John Nopper Trustee (end 11/2018) 1.00 0.00 X 0 0 0 Terry Pollio Trustee 1.00 0.00 X 0 0 0 Cheryl Sanctuary Trustee (end 5/2019) 1.00 0.00 X 0 0 0 Sheila Scheuerman Trustee 1.00 0.00 X 0 0 0 Timothy P Shafer MD Trustee/Family Physician 44.00 0.00 X 273526 0 27305 Allan Shirks Trustee 1.00 0.00 X 0 0 0 Stephan Morse President (end 11/2018) 1.00 0.00 X X 0 0 0 Kevin Meyer President (eff 11/2018) 1.00 0.00 X X 0 0 0 Martha Dale Vice President (eff 11/2018) 1.00 0.00 X X 0 0 0 Barry Emerson Treasurer 1.00 0.00 X X 0 0 0 Edward Druke Secretary 1.00 0.00 X X 0 0 0 Douglas DiVello CEO 40.00 1.00 X 275925 0 37404 Stephen A Brown CFO 45.25 0.00 X 225595 0 26304 Maurice Geurts MD Physician 58.08 0.00 X 345153 0 39332 Kenneth Rudd MD Physician 53.84 0.00 X 288071 0 36742 Kimona Alin MD Physician 40.03 0.00 X 260067 0 37283 Moss Linder DO Physician 40.42 0.00 X 259108 0 36019 Ewa Arnold MD Physician 38.15 0.00 X 229186 0 37940 Roger Allbee CEO(end 2/2018)/Trustee (end 1/2014) 0.00 0.00 X 36050 0 0 2192681 0 278329 26 1 1 0 Cerner Corporation PO Box 412702 Kansas City MO 64141 Hardware/Software Support 417334 Brook Field Service LLC PO Box 47 Northfield VT 05663 Generator Installation/Service 150426 Tafts Heating & Cooling 17 Eric Street Springfield VT 05156 HVAC Installation/Servic 150074 AMN Healthcare Inc 2735 Collection Ctr Dr Chicago IL 60693 Travel Nursing Services-RNs 103964 Virtual Radiologic Corporation 25983 Network Place Chicago IL 60673 Radiologist Services 101574 5 977268 143070 6460 1126798 Patient Service Revenue 621400 19200794 19200794 Pharmacy Revenue 446110 3686636 3686636 GCF Administration/Other 621400 293723 293723 Cafeteria Revenue 722514 75551 75551 8718 8718 23265422 666 666 17282 -17282 -17282 -17282 24375604 23265422 0 -16616 922769 315184 607585 11867794 10960895 717753 189146 218577 203061 11971 3545 2458337 2217417 203290 37630 870531 770861 86707 12963 17414 17414 70123 70123 634337 622169 12168 85317 177 85140 590333 436803 139633 13897 720164 628170 89221 2773 207231 201622 5609 134187 107743 18692 7752 4398 4398 155800 126442 29358 644180 644180 297216 252133 44604 479 Medical Supplies and La 3133596 3133596 Medicaid Tax 631409 631409 Provision for Bad Debt 571623 571623 Equipment Repair 365886 365886 181940 181940 24783162 22375709 2139268 268185 2107 178507 21279 20515 2083725 1917986 1715794 1847467 209789 221271 15724356 12541446 3364427 3182910 7918908 8757585 15316029 16126241 2764099 3178275 660000 515000 1783540 2606384 321147 0 5528786 6299659 X 6558441 6405496 477324 672186 2751478 2748900 9787243 9826582 15316029 16126241 X -407558 446897 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 3853 0 0 0 3853 0 Part II-B, Line 1: 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: $559 VAHHS, portion of dues available for lobbying: $3,294 3228802 192284 3421086 3319792 -90990 3228802 3040711 279081 3319792 2927438 113273 3040711 3073919 -146481 2927438 0.13180 0.80350 0.06470 0 1 1 30549 30549 7886137 6072315 1813822 7703019 6439896 1263123 104651 29235 75416 3182910 Beneficial interest in net assets of GCF 8268337 Deposits with Trustee 56618 Meaningful use receivable 17000 Estimated Third Party Payor Settlements 415630 8757585 X 24822501 446897 446897 24375604 0 24375604 24783162 0 24783162 0 24783162 Part V, Line 4: OHCC uses its endowment funds to assist in the provision of health care. Part X, Line 2: OHCC and the Foundation are tax-exempt corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Internal Revenue Code. In addition, the Foundation qualifies for the charitable contribution deduction under Section 170(b)(1)(a) and had been classified as an organization that is not a private foundation under Section 509(a)(3). Management evaluated the Organization's tax positions and concluded the Organization has maintained its tax-exempt status, does not have any significant unrelated business income and had taken no uncertain tax positions that require adjustment to or disclosure in the accompanying consolidated financial statements. Part XI, Line 2d - Other Adjustments: Change in Beneficial Interest in Net Assets of GCF 446,897. 1 1 1 X 1 X 1 1 1 0 1 1 149759 149759 0.00600 3364674 1369184 1995490 0.08050 3514433 1369184 2145249 0.08650 455105 294291 160814 0.00650 7358 7358 0.00030 462463 294291 168172 0.00680 3976896 1663475 2313421 0.09330 1 384826 61405 11218167 11376244 -158077 X 1 1 1 1 Grace Cottage Hospital 185 Grafton Road Townshend VT 05353 www.gracecottage.org 894 X X X X Grace Cottage Hospital 1 0 0 1 X X X X X X X X X 17 1 1 0 1 X See Part V, Section C X See Part V, Section C X 1 18 1 See Part V, Section C 1 0 1 X 150.000000000000 350.000000000000 X X X X X 1 1 X X X 1 X See Part V, Section C X See Part V, Section C X See Part V, Section C X X X X X X 1 X 0 X X X 1 X 0 0 Grace Cottage Hospital Part V, Section B, Line 5: As required by Vermont statute and Treasury Regulation 501(r), Grace Cottage Hospital conducts a Community Health Needs Assessment (CHNA) every three years. Our most recent CHNA was done collaboratively in 2018 with Brattleboro Memorial Hospital (BMH) and the Brattleboro Retreat. These three healthcare organizations focused on involving as many stakeholders and community members as possible in the data collection process, which took place from October 2017 to May 2018. Secondary data was collected from multiple sources including: Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, Vermont Department of Health, Vermont Department of Labor, Vermont Department of Transportation, Vermont Foodbank, and Vermont Town and County Data Pages. The secondary data was benchmarked against state and national trends, where possible. Primary data was obtained through a consumer survey and a secondary survey of representatives of medically underserved populations. The consumer survey was distributed in both paper copy as well as online. In total, 1,257 surveys were collected for Windham County. The secondary survey was held to collect qualitative data on at-risk populations. The following medically underserved populations were represented in the focus group: - Elderly/Senior Population - HIV+ Individuals - Homeless Population - LGBTQ (Lesbian, Gay, Bisexual, Transgender and/or Questioning) Individuals - Racial and Ethnic Minority PopulationsThe three hospitals set up a steering committee made up of individuals from the State of Vermont Department of Health, Brattleboro Memorial Hospital, Grace Cottage Hospital, and The Brattleboro Retreat. Additionally, the participating organizations engaged a wide range of stakeholders through the surveys, including health care providers, human service organizations, and other nonprofit organizations. Grace Cottage identified the following as High Priority Significant Health Needs in our service area: Diabetes/Obesity/Weight Management, Mental Health Issues (Stress, Anxiety, Depression), Substance Abuse.The 2018 Community Health Needs Assessment was adopted by the Grace Cottage Board of Trustees on September 21, 2018 and the Implementation Plan was approved by the Board on January 18, 2019. An updated Implementation Plan for FY18 is available for public viewing at https://gracecottage.org/about-us/our-hospital/community-health-needs-assessment/. Grace Cottage Hospital Part V, Section B, Line 6a: The 2018 Community Health Needs Assessment was conducted with Brattleboro Memorial Hospital and The Brattleboro Retreat. Grace Cottage Hospital Part V, Section B, Line 11: Please see attached 2018 CHNA Implementation Plan for information on how the Hospital is addressing the significant needs identified in its most recently conducted CHNA. While a significant health need in our service area, Grace Cottage Hospital is not addressing dental issues as we do not provide dental services. The additional Level 2 Priorities identified in the 2018 CHNA -- Healthy Aging, Smoking/Tobacco Use, and Heart Disease -- are addressed with all patients on an on-going and personal basis. Grace Cottage Hospital Part V, Section B, Line 13b: Generally, Grace Cottage Hospital uses the Federal Poverty Guidelines to determine eligibility for financial assistance. However, applications may be reviewed on a case by case basis and at times financial assistance granted even if a patient is above the prescribed FPG level or qualifies only for a lesser reduction in fees if there is a prevailing circumstance that justifies additional financial support. Grace Cottage Hospital Part V, Section B, Line 20e: Grace Cottage Hospital (GCH) located in rural, mountainous Townshend, VT provides services to patients, whether a community member, second homeowner, or vacationer, through our Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation. Taking pride in the community we serve, we make every attempt possible to notify patients of The Reduced Fee Program and Formal Payment Plan options at GCH that will allow patients to receive care without undue hardship. The following are some of the steps currently in place, to notify patients of the available options: - All registration areas of the Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation Services have visible signs on display notifying patients of our Reduced Fee Program. - All registration staff upon verification of no insurance, limited insurance coverage with high patient responsibility portions, or communication from patient indicating difficulty with paying bill, will offer a Reduced Fee Application, Policy, and business card for our Resource Advocate, identifying the many services she provides to patients free of charge and her contact information. Staff will also offer to schedule an appointment for the patient with Resource Advocate for assistance in completing the Reduced Fee Application, troubleshooting issues with insurance, and/or applying for insurance coverage whether it is primary or secondary. - Patients receive at least 5 billing statements over the course of 120 day time frame (patients in a formal payment plan or whom have a billing issue arise may increase the number of statements to be received or increase the number of days to complete the 5 billing statement cycle). Every statement has a message that notifies them of the Reduced Fee Program and steps to take to get started. - Once a patient balance is past due (>30 days from date of first patient billing) Patient Accounts Specialists contact patients via phone in an attempt to alert patient to past due balance, offer a formal payment plan if balance unable to be paid in full. If/when patient indicates difficulty in paying their bill, Patient Accounts Specialists will notify patient of the Reduced Fee Program and offer to mail the application and policy to them. Patient Accounts Specialists note patients account with a briefing of the phone call. If a patient balance is aged >120 days from the date of the first billing statement and a potential to be sent to a third party collections agency the account is reviewed, if there is a note from patient accounts indicating a Reduced Fee application and policy have been mailed to the patient within the last 45 days a hold will be placed on transferring the balance to the third party collections agency. After 45-60 days if no Reduced Fee application or communication from the patient the balance will be transferred to the third party collections agency at that time. - All Reduced Fee applications are processed with required documentation to determine eligibility in accordance with our Sliding Fee Scale based on Federal Poverty Guidelines. If missing required documents, a written request is sent to the patient and application held while awaiting documents. All processed applications are filed, written notice of eligibility is mailed to the patient, eligibility is noted on patient's account and adjustments are made manually after insurance processing and prior to a billing statement being mailed to the patient, and all applications are documented on a yearly spreadsheet showing household members, date of application (eligibility begin date), expiration date, whether they are eligible, percentage they are eligible for, and comments for case by case applications that identifies parameters for this approval/denial i.e.: only one date of service. Schedule H, Part V, Section B, Line 7a, 7b and 10a: The Hospital's 2018 CHNA, 2018 CHNA Implementation Plan, and 2015 CHNA Implementation Plans are available on its website at: https://gracecottage.org/about-us/our-hospital/community-health-needs-assessment/The Hospital's 2018 CHNA is available at: https://3ohond29fxl43b8tjw115y91-wpengine.netdna-ssl.com/wp-content/uploads/2018-BMH-CHNA-report-FINAL.doc.pdf Schedule H, Part V, Section B, Line 16a-16c: The Hospital's Financial Assistance Policy is available on its website at: https://gracecottage.org/wp-content/uploads/2020/02/16.0050-REDUCED-FEE-FREE-CARE-POLICY-rev-2-2020.pdfThe Hospital's Financial Assistance Application is available on its website at:https://gracecottage.org/wp-content/uploads/2019/08/16.0050-REDUCED-FEE-FREE-CARE-APPLICATION.pdfThe Hospital's Plain Language Summary is available on its website at:http://gracecottage.org/patients-visitors/billing-and-insurance/free-or-reduced-fee-care/ 2 1 - Messenger Valley Pharmacy 170 Grafton Road Townshend VT 05353 Pharmacy 2 - Grace Cottage Family Health 185 Grafton Road Townshend VT 05353 Rural health clinic Part I, Line 3c: N/A Part I, Line 6a: N/A Part I, Line 7: The amounts reported for Charity Care and Means-Tested Government Programs were calculated using a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges. Part I, Line 7g: N/A 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 $ 571,623. Part II, Community Building Activities: See previous and subsequent narrative responses. Part III, Line 2: 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. Part III, Line 3: 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 Reduced Fee/Free Care Applications. The number of approved completed applications versus the number of incomplete applications was compared and a ratio applied to the Charity Care balance to estimate this number. It is felt 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 patients 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 believe it is primarily attributable to patients not wanting to share the income information. Part III, Line 4: Please see Footnote 1 on Page 8 of the attached financial statements for the footnote that addresses bad debt. 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: Grace Cottage Hospital does not pursue collections actions against patients for amounts qualified for financial assistance. If a patient is unable to pay a balance in full after reduced fees and financial assistance have been applied, the patient is required to setup an acceptable payment plan per the collections policy. Any patient making acceptable monthly payments on their balance will not be at risk for further collections actions and/or forfeiture of their reduced fee care or financial assistance. However, any balance remaining after that discount that goes unpaid as agreed upon will follow the collections actions outlined in the Hospital's collection policy. Failure to resolve the balance in full or any missed payments will result in forfeiture of reduced fees and/or financial assistance, and the patient's account will be placed with a collections agency for further action. Additionally, the patient will not be eligible for reduced fees or financial assistance until a substantial effort is put forth to rectify the outstanding balance. Part VI, Line 2: Grace Cottage Hospital is such a small hospital in a rural, relatively sparsely populated area that our community leaders, patients, and members of the public are quick to inform our administrators and our medical staff about how Grace Cottage serves the healthcare needs of the public. Grace Cottage's small size ensures that we can be responsive to community requests made via our website, e-mails to members of our staff, or informal face-to-face meetings with people in the communities we serve. 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 displayed 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. During fiscal year 2019, the Hospital continued to employ a Patient Resource Advocate to help uninsured and underinsured patients locate and procure services for which they may qualify. The Patient Resource Advocate's services are free of charge for community members (those 65 and older were also encouraged to contact Senior Solutions, formerly Southeastern Vermont Council on Aging). The Hospital's Patient Resource Advocate helps 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 healthcare for 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 43,714 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 $50,917 (U.S. Census Bureau "Quick Facts," updated 2016). 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 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 twelve trustees, a physician, is a hospital employee. All trustees reside or work 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.Grace Cottage Hospital applies any 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 communities we serve. For example, in view of the fact that Mental Health was identified as a High Priority Significant Need in our Community Health Needs Assessment, Grace Cottage continues to employ both a full-time psychiatric nurse practitioner and a full-time licensed clinical social worker. Both professionals are embedded in the family health practice, where they are key players in the healthcare team. Despite its small size, Grace Cottage Hospital is committed to giving back to the community to the greatest extent possible. Thanks to the Vermont Blueprint for Health, Grace Cottage's Community Health Team has been able to provide free consultations, open to everyone in the community served by Grace Cottage. Members of the Community Health Team, including a care coordinator and an outreach coordinator (both registered nurses), two health coaches, a diabetes educator (also a registered nurse), and a behavioral health specialist work with patients one-on-one, conduct support groups, and also attend area senior lunches and provide screenings at area organizations (such as Neighborhood Connections).In addition, the Community Health Team interacts with another Vermont Blueprint for Health program, SASH (Support and Services at Home), and provides, in collaboration with SASH, ongoing support groups and workshops. Grace Cottage Hospital is a very active partner in numerous community collaborations and programs, including (but not limited to): - West River Valley Thrives: supporting and promoting healthy lifestyle choices, with an emphasis on the prevention of alcohol, tobacco, and other drug use by young people. - Townshend Community Hope and Action: promoting a healthy, connected community through area events. - West River Valley Food Group/Vermont Food Bank: organizing the procurement and distribution of food to those in need. A Veggie Van Go truck from the Vermont Food Bank comes to Grace Cottage once a month for free food distribution of fresh produce and other healthy food items. No proof of eligibility is required. On average, 50-60 individuals take the free food home to their families. - Windham County Consortium on Substance Use (COSU) is a multi-agency collaboration which focuses efforts and education/awareness within communities to address the devastating impacts of heroin, fentanyl and other substances on Windham County. Highlights include: collaborative prevention, harm reduction, treatment and recovery efforts. These efforts are bolstered by a three-year, $1 million federal Health Resources & Services Administration (HRSA) grant as well as a VT Department of Health Community Action grant through the Centers for Disease Control & Prevention, both awarded to COSU and its fiscal agent, Health Care & Rehabilitation Services of Southeastern Vermont, Inc. (HCRS), starting on September 1st, 2019. - Community Wellness: In 2019, there were a total of 3,739 wellness program visits. Wellness activities included strong bones exercise classes, Tai Chi for fall prevention, living alone support group, Alzheimer's Caregiver support group, mental illness family support group, men's support groups, and yoga.In addition, 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. Heavily promoted activities include a 5K in the spring, a 19.6-mile bike ride in the summer, and a Poker Walk in the fall, among others. Grace Cottage Hospital plays a pivotal role in Emergency/Disaster Preparedness in this rural, mountainous area of Windham County, Vermont. The Hospital works collaboratively with: - the local town volunteer fire and first responder rescue departments; - the regional ambulance service, Rescue Inc.; - Windham County Regional Commission - the Local Emergency Planning Committee covering the towns that Grace Cottage serves; - the local Citizens Emergency Response Team (CERT); - the local Radio Amateur Civil Emergency Service (RACES) - West River Radio Club meets and stores equipment at Grace Cottage Hospital; - Vermont Association of Hospitals and Health Systems; - Vermont Department of Health. Grace Cottage Hospital staff participate in onsite training for disaster preparedness as well as offsite training with other hospitals. Part VI, Line 6: N/A Part VI, Line 7, Reports Filed With States VT X X 0 0 0 0 0 0 0 1 0 Timothy P Shafer MD Trustee/Family Physician 268843 0 1827 0 2856 0 7358 0 19947 0 300831 0 0 0 Douglas DiVello CEO 232986 0 27500 0 15439 0 0 0 37404 0 313329 0 0 0 Stephen A Brown CFO 206250 0 0 0 19345 0 6865 0 19439 0 251899 0 0 0 Maurice Geurts MD Physician 343057 0 0 0 2096 0 8250 0 31082 0 384485 0 0 0 Kenneth Rudd MD Physician 286425 0 0 0 1646 0 8250 0 28492 0 324813 0 0 0 Kimona Alin MD Physician 258271 0 0 0 1796 0 6201 0 31082 0 297350 0 0 0 Moss Linder DO Physician 248357 0 8390 0 2361 0 4937 0 31082 0 295127 0 0 0 Ewa Arnold MD Physician 203163 0 14227 0 11796 0 6858 0 31082 0 267126 0 0 0 Roger Allbee CEO(end 2/2018)/Trustee (end 1/2014) 36050 0 0 0 0 0 0 0 0 0 36050 0 0 0 Part I, Line 7 Physician contracts provide the opportunity to receive additional payments for productivity above minimum thresholds. For the period reported, five physicians listed in Part VII were under such a contract: Dr. Ewa Arnold, Dr. Jesper Brickley, Dr. Maurice Geurts, Dr. Moss Linder, and Dr. Timothy Shafer. Of these, three received an incentive compensation payment: Dr. Ewa Arnold $14,227; Dr. Moss Linder $8,390; and Dr. Timothy Shafer $1,827. The CEO's contract provides an opportunity to earn annual incentive compensation of up to a maximum of 15% of annual base salary upon attainment of mutually agreed upon goals. This incentive compensation opportunity may be modified from time to time, at the discretion of the Board of Directors. For the period reported, Douglas DiVello received a payment of $27,500. Schedule J, Part II: Roger Allbee, former CEO of Otis Health Care Center, was a part-time employee. In February 2018, Mr. Allbee left the organization. He received total reportable compensation for calendar year 2018 of $36,050. This compensation was solely for his services as the CEO. He was a trustee until January 2014 and his calendar year 2018 CEO compensation exceeded the $10,000 threshold for reporting payments to former directors during the filing period. Form 990, Part VI, Section B, line 11b 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, and financial statements available to the public. Form 990, Part VII, Section A: The compensation reported for Dr. Timothy Shafer was for his services as a full-time physician. He was not compensated for his services as members of OHCC's Board of Trustees. Form 990, Part XI, line 9: Change in Beneficial Interest in Net Assets of GCF 446,897. Form 990, Part XI, Line 2c: 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. 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) Line 12a, I Carlos G Otis Health Care Center 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 1 0 1 0 0 Grace Cottage Foundation Inc Q 293723 Actual per books Grace Cottage Foundation Inc C 977268 Actual per books Grace Cottage Foundation Inc E 5864314 Actual per books