2019-06-25T07:59:10-05:00 2018-09-30 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2017-10-01 020276210 Upper Connecticut Valley Hospital UPPE 6032374971 Corliss Lane Colebrook NH 03576 Celeste Pitts CFO 6032374971 2019-06-24 1 Barbara J McGuan CPA P00219457 2077752387 2019-06-24 69.49.157.66 2019-06-24 15:52:12 ED P 8137B2580CE35FA01CCDEB6EA4E8E3B48DE58F96 BCE379EC6B2F882893C3F02DE0A5A3D951B1B2ED 2017 2019-02-21 02:37:17Z Scott Colby Corliss Lane Colebrook NH 03576 25324624 0 X www.ucvh.org X 1969 NH To provide high quality and efficient health care services 12 9 155 26 0 0 690228 455556 16690820 17409225 605279 760903 0 0 17986327 18625684 172014 139331 0 0 7630571 8209906 46750 0 0 9015121 9130688 16864456 17479925 1121871 1145759 26594382 29801477 8651686 10469202 17942696 19332275 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 13920991 139331 17409225 Upper Connecticut Valley Hospital provided hospital care and impatient and outpatient services on a region-wide basis. The net charity care provided by the Hospital for the year-ended September 30, 2017 was $299,600. 13920991 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 12 0 1 155 1 0 0 0 0 0 0 0 0 0 0 X 12 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X Celeste Pitts 6032374971 Corliss Lane Colebrook NH 03576 Scott Colby President 40.00 0.00 X X 219159 0 36637 Greg E Placy Chairman 1.00 1.00 X X 0 0 0 Odette Crawford Vice Chair 1.00 0.00 X X 0 0 0 Palmer Lewis Treasurer 1.00 0.00 X X 0 0 0 E Harlan Connary Secretary 1.00 0.00 X X 0 0 0 Edward Laverty PA-C Chief Medical Officer 58.00 0.00 X 229805 0 9148 Lynn Brewer Director, Pharmacist 1.00 0.00 X 4480 0 0 Avis Brosseau Director 1.00 0.00 X 0 0 0 Eric Stohl Director 1.00 0.00 X 0 0 0 Ann Morgan Wade Director 1.00 0.00 X 0 0 0 James Wells Director 1.00 0.00 X 0 0 0 Sally Wentzell Director 1.00 0.00 X 0 0 0 Peter Moran MD Past Director 1.00 0.00 X 0 0 0 Robert Rose MD Past Chief Medical Officer 40.00 0.00 X X 87091 0 0 Celeste Pitts Chief Financial Officer 16.00 24.00 X 65678 98517 12580 Albert Arnold ER Physician 45.00 0.00 X 205358 0 4387 Thomas Cochran ER Physician 38.00 0.00 X 269847 0 40969 Robert Gooch Pharmacist 40.00 0.00 X 190372 0 28551 Joseph Kiernan Surgeon 36.00 0.00 X 109630 0 3285 Heidi Root ER Physician 18.00 0.00 X 122904 0 0 1504324 98517 135557 6 0 1 0 Hebert Daniel Inc 12 Pleasant Street Colebrook NH 03576 General Contractor, Building Renovations 1957947 AHSA LLC PO Box 945 Traverse City MI 49685 Staffing Agency 688979 Catholic Medical Center 195 McGregor Street 3rd Floor Manchester NH 03102 Physician & Physician Assisstant Staffin 374386 Vista Staffing Solutions File 50834 Los Angeles CA 900740834 Physician & Physician Assisstant Staffin 224893 Weeks Medical Center PO Box 240 Whitefield NH 03598 Management & Physician Staff 152415 7 20600 434956 5088 455556 Patient Service Revenue 621400 30596617 30596617 Miscellanous Revenue 624100 249362 205450 43912 Meaningful Use Revenue 621400 74658 74658 Provision for Bad debts 621400 -755526 -755526 Contractual/Char. Adj. 621400 -12755886 -12755886 17409225 340374 340374 7118167 1302 6554658 144282 563509 -142980 420529 420529 18625684 17365313 0 804815 X 139331 139331 586320 330524 255796 5965479 5001756 963723 93212 76558 16654 1141157 960413 180744 423738 346697 77041 78008 78008 45663 45663 60000 60000 102240 102240 3462162 2769212 692950 80398 80398 75755 75755 341274 341274 276184 276184 116851 61044 55807 1868 1868 901247 901247 230308 230308 Supplies Expense 1555166 1508463 46703 Miscellanous 932874 677004 255870 Medicaid Enhancement Ta 870690 870690 17479925 13920991 3558934 0 X 339039 660049 6906770 4113247 180410 308099 2229104 1917872 306228 342333 263289 267574 16718572 9224245 6725720 7494327 9305497 14371334 338325 326642 26594382 29801477 1751296 1771499 241195 146954 284782 0 6374413 8550749 8651686 10469202 X 17707557 18806252 62069 352953 173070 173070 17942696 19332275 26594382 29801477 1145759 243820 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 5710 5710 0 Part II-B, Line 1: The Organization pays dues to various organizations, a portion of which is attributable to lobbying expenses. In addition, North Country Healthcare has contracted with a local firm to lobby on our behalf at the State Level. 233884 3524 5142 232266 280657 22414 69187 233884 263522 20177 3042 280657 191998 80000 3175 11651 263522 170203 20000 14929 13134 191998 0.00000 0.74510 0.25490 0 0 9700 9700 6472425 2585496 3886929 9494931 6540302 2954629 741516 98447 643069 7494327 Due to Third Party Payers 8550749 8550749 18767264 243820 243820 18523444 102240 102240 18625684 17377685 0 17377685 102240 102240 17479925 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 474197 70465 403732 0.02310 2473872 1838393 635479 0.03640 2948069 1908858 1039211 0.05950 4685875 3242849 1443026 0.08260 120442 120442 0.00690 548107 58273 489834 0.02800 140580 140580 0.00800 5495004 3301122 2193882 0.12550 8443073 5209980 3233093 0.18500 1979 1979 0.00010 3939 3939 0.00020 2375 2375 0.00010 8293 8293 0.00040 1 441049 8506423 8592346 -85923 X 1 1 1 1 Upper Connecticut Valley Hospital Corliss Lane Colebrook NH 03576 www.ucvh.org 000592 X X X X Upper Connecticut Valley Hospital 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X www.ucvh.org X 1 15 1 www.ucvh.org 0 1 X 300.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X www.ucvh.org X www.ucvh.org X www.ucvh.org X X X X X 1 X 0 X X X 1 X 0 0 Upper Connecticut Valley Hospital Part V, Section B, Line 5: Input from the community was solicited through a survey, which was available both electronically (through Survey Monkey) and via paper copy. Paper copies were distributed to various community locations. Electronic surveys were available via the UCVH and North Country Healthcare websites plus other community partner websites. 203 Surveys were completed. In addition, 89 Community leaders were also surveyed electronically. This group represented area business & economic development leaders, community board members of health & human service organizations, municipal government and human services providers. Upper Connecticut Valley Hospital Part V, Section B, Line 6a: The Hospital's CHNA was conducted along with Weeks Medical Center, Littleton Regional Hospital, and Androscoggin Valley Hospital. Upper Connecticut Valley Hospital Part V, Section B, Line 11: Significant Needs Identified and Being Addressed:1. Substance Misuse, Alcohol Abuse & Mental health problems: 24/7 Emergency medical care available. Naloxone (Narcan) treatment for overdose is an available option. Policy being developed for sharing Narcan kits with 3rd party friends and families. Indian Stream Health Center, the local FQHC, employs several Behavioral Health Providers through their Primary Care offices located on the same campus as the hospital. In addition, there are other Community based services available. Alcohol Anonymous is given space in the hospital for regular weekly meetings. North Country Healthcare affiliates were recently awarded a Hub & Spoke grant through the Department of Health & Human Services to bring Medication Assisted Therapy and Substance Abuse counseling to a wider region in Coos & Grafton Counties. These programs are through our affiliated hospitals, all working together. The program has already been active and successful at Weeks Medical Center and is being rolled out to Androscoggin Valley Hospital. Once those other two locations are up and running, the plan is to extend the service area up to Colebrook through UCVH.2. Obesity/Overweight: UCVH employs a registered dietician and diabetes educator who is available to provide consults and diabetes prevention classes. Meeting space for Weight Watchers and healthy and affordable meal choices for the public/visitors are also available. 3. Smoking and Tobacco Use: Ongoing smoking cessation classes available to the public. In addition, UCVH is a smoke/tobacco free campus.Significant Needs not being addressed and why:The needs identified that UCVH is not able to address center around the County's lack of jobs. Low Income/Poverty and Unemployment/Lack of Jobs were two such items. Cost of healthy foods was also mentioned. While originally this was not within the scope of UCVH's mission, we have recently started working with the NH Food Bank to implement a prescription food program that would allow patients who would have health benefits receive a prescription from their Primary Care Provider to receive nutritious fruits, vegetables, and protein sources. The food will be housed at UCVH. These are not within the scope of our mission; however we will continue to work with local resources in our role as a responsible corporate citizen to improve our economy where we can. There are currently several economic development groups active in the area and some new businesses are considering moving in.Other needs we are currently unable to meet revolve around lack of dental insurance, cost of prescription drugs, and access to health insurance. While UCVH cannot fix these issues, we continue to work with our patients to enroll them with Medicaid Expansion products or the Insurance Exchanges. This has resulted in a significant drop in our uninsured population. UCVH continues to offer free care for eligible patients through our UCV Free Care program. 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 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: Patient accounts receivable are carried at the amount management expects to collect from outstanding balances.Patient receivables are periodically evaluated for collectibility based on credit history and current financial condition. Provisions for losses on receivables are determined on the basis of loss experience, known and inherent risks, estimated value of collateral and current economic conditions. The Hospital uses the allowance method to account for uncollectible accounts receivable. In evaluating the collectibility of accounts receivable, the Hospital analyzes past results and identifies trends for each major payor source of revenue for the purpose of estimating the appropriate amounts of the allowance for doubtful accounts and the provision for bad debts. Data in each major payor source are regularly reviewed to evaluate the adequacy of the allowance for doubtful accounts. Specifically, for receivables relating to services provided to patients having third-party coverage, an allowance for doubtful accounts and a corresponding provision for bad debts are established at varying levels based on the age of the receivables and the payor source. For receivables relating to self-pay patients, a provision for bad debts is made in the period services are rendered based on experience indicating the inability or unwillingness of patients to pay amounts for which they are financially responsible. Actual write-offs after management has used reasonable collection efforts are charged against the allowance for doubtful accounts. Part III, Line 8: Allowable costs come from the filed cost report as UCVH operates at a loss from Medicare. The shortfall could be treated as community benefit as there are no other funds available to subsidize the loss. UCVH uses CCR to determine cost revenue received is net patient revenue. Part III, Line 9b: If known to qualify for charity or financial assistance, patients are given the assistance needed. Part VI, Line 2: In 2016, North Country Healthcare partnered with the North Country Health Consortium based in Littleton, NH to complete a Community health needs assessment (CHNA) for the four affiliated hospitals. Once the CHNA was completed, a strategic planning committee of the four hospitals met to determine which community needs were to be addressed by the hospitals and which specific initiatives would be put into place to meet these needs. The initiatives will become part of the overall 2017-2019 Strategic Plan. The CHNA and the 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 assess 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 of 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 0 Foundation for Healthy Communities 125 Airport Road Concord NH 03301 020275078 501(c)(3) 139331 Funding Medicaid Expansion 1 0 X X X 0 0 0 0 0 0 0 0 0 Scott Colby President 219159 0 0 0 0 0 1339 0 35298 0 255796 0 0 0 Edward Laverty PA-C Chief Medical Officer 229805 0 0 0 0 0 4414 0 4734 0 238953 0 0 0 Celeste Pitts Chief Financial Officer 52483 78724 3595 5393 9600 14400 2000 3000 3032 4548 70710 106065 0 0 Albert Arnold ER Physician 205358 0 0 0 0 0 4387 0 0 0 209745 0 0 0 Thomas Cochran ER Physician 269847 0 0 0 0 0 5801 0 35168 0 310816 0 0 0 Robert Gooch Pharmacist 190372 0 0 0 0 0 3801 0 24750 0 218923 0 0 0 Shari Parker Family member of Board Director Eric Stohl 77939 Employment 0 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 Board 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. 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 2,769,212. Management and general expenses 692,950. Fundraising expenses 0. Total expenses 3,462,162. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Upper Connecticut Valley Hospital 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 N/A 0 Weeks Medical Center 173 Middle Street Lancaster NH 03584 020222242 Critical Access Hospital NH 501(c)(3) Line 3 N/A 0 Littleton Hospital Association 600 St Johnsbury Road Littleton NH 03561 020222152 Critical Access Hospital NH 501(c)(3) Line 3 N/A 0 North Country Home Health & Hospice Agency Inc 536 Cottage Street Littleton NH 03561 020300637 Home Health Agency NH 501(c)(3) Line 10 N/A 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0