2016-11-15T13:23:34-06:00 2015-12-31 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2015-01-01 010545327 Penobscot Valley Hospital PENO 2077943321 7 Transalpine Road Box 368 Lincoln ME 04457 Gary Poquette CEO 2077943321 2016-11-15 1 Barbara J McGuan CPA P00219457 2077752387 2016-11-15 2015 2017-02-10 21:41:12Z Gary Poquette 7 Transalpine Road Box 368 Lincoln ME 04457 23220779 0 X www.pvhme.org X 1973 ME Critical Access Hospital 10 9 251 45 0 0 86814 66387 24973107 22789956 68618 53565 16692 31048 25145231 22940956 0 1500 0 0 14981895 13755322 0 0 0 11011866 10235758 25993761 23992580 -848530 -1051624 13378530 12545033 9998207 10267261 3380323 2277772 X Penobscot Valley Hospital exists to provide quality healthcare and to serve as an educational and referral resource that meets our customer's needs by providing appropriate services, providing health related information, and making arrangements for additional health services. PVH provides vital services to the community which are not accessible in any other way to many of our patients due to geographical or transportation issues. See Schedule H for additional details. 0 0 19812115 1500 22789956 Penobscot Valley Hospital is a 25 bed critical access hospital in Lincoln, ME. The Hospital provided a wide range of medical services to its patients in 2015, some of the largest being Emergency Room Services, Laboratory Services, Pharmacy Services, & Radiology Services. Please refer to Schedule H for a more comprehensive list of services provided. 19812115 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 25 0 1 251 1 0 0 0 0 0 1 1 0 0 0 0 X 10 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 ME X Ann Marie Rush 2077943321 7 Transalpine Road Box 368 Lincoln ME 04457 Richard Wyman Board Member 1.50 X 0 0 0 Phillip Dawson Jr Vice President 1.50 X X 0 0 0 Pam Hoxie Board Member 1.50 X 0 0 0 Michael McFalls Past Board Member 1.50 X 0 0 0 Hervey Clay Past Board Member 1.50 X 0 0 0 H Joseph Thibodeau DMD Board Member 1.50 X 0 0 0 Gilberte Mayo Treasurer 1.50 X X 0 0 0 Frederick Woodman Jr President 1.50 X X 0 0 0 Ed Woolley Board Member 1.50 X 0 0 0 Annette Haynes Board Member 1.50 X 0 0 0 Amanda Dunn Board Member 1.50 X 0 0 0 William Thornton Board Member 1.50 X 0 0 0 Ann Marie Rush CFO 50.00 X 170943 0 19465 Gary Poquette CEO 50.00 X 223169 0 24570 Michael Lescord ED Physician 40.00 X 513366 0 23421 Glenn Deyo Surgeon 40.00 X 385461 0 25959 David L Ettinger ED Physician 40.00 X 414332 0 26774 Paul Turnquist ED Physician 40.00 X 263880 0 18951 Barbar Junaidi Hospitalist 40.00 X 235286 0 33099 2206437 0 172239 13 0 1 1 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ER Physician Services 887587 Nurse Anesthesia of Maine LLC 141 North Main Street Suite 205 Brewer ME 04412 Nursing Services 649099 NEHE MRI LLC PO Box 6600 Newport Beach CA 92658 MRI Services 358884 Quorum Health Resources LLC 105 Continental Place Brentwood TN 37027 Hospital Management Svcs. 337921 Comprehensive Pharmacy Services LLC PO Box 638316 Cincinnati OH 452638316 Pharmacy 257086 10 21914 30795 13678 66387 Patient Revenue 621400 36313289 36313289 Cafeteria & Other 722210 337241 255379 81862 Meaningful Use Revenue 621400 16917 16917 Provision for Bad Debts 621400 -1559983 -1559983 Contractual/Char. Adj. 621400 -12317508 -12317508 22789956 32790 32790 290259 256199 13285 34060 -13285 20775 20775 9478 21914 10339 -861 -861 Earnings from Investment 900099 17524 17524 Earnings from Subsidiary 900099 14385 14385 31909 22940956 22708094 0 166475 X 1500 1500 438147 438147 11034955 10140805 894150 1553518 1498357 55161 728702 646564 82138 54017 43870 10147 56150 56150 6961 6961 4807054 3817639 989415 16692 16692 839522 387176 452346 665554 621780 43774 94442 68727 25715 258367 13188 245179 830793 830793 278538 27504 251034 Medical Supplies 1714212 1714212 Service Provider Tax 612242 612242 Physician Events 1214 1214 23992580 19812115 4180465 0 X 1711046 1388457 747883 744177 22681 0 2693406 2640830 44976 26365 746891 708900 210920 241624 19002008 13143218 6193249 5858790 833352 779228 36423 68332 18574 16097 119129 72233 13378530 12545033 2516841 1984535 786296 685519 5292284 4629070 1402786 2968137 9998207 10267261 X 3138413 2036636 165361 164587 76549 76549 3380323 2277772 13378530 12545033 -1051624 -50927 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5472 5472 0 Part II-B, Line 1: The Organization pays dues to the Maine Hospital Association and the American Hospital Association. A portion of dues paid to the Maine Hospital Association ($4866) and American Hospital Association ($606) were attributable to lobbying expenses. 28897 28897 8066186 5164265 2901921 433876 433876 0 10002995 7163366 2839629 470054 381711 88343 5858790 Estimated Third-Party Payor Settlements 2895904 Deferred Compensation 72233 2968137 Golf Tournament 21973 18455 3518 3567 2785 Murder Mystery 9419 3459 5960 504 1101 1800 582 31392 21914 9478 4071 1101 1800 3367 10339 -861 1 1 1 X 1 X 225.000000000000 1 1 1 0 1 1 905802 905802 0.03780 4363385 3276392 1086993 0.04530 10881972 10920683 -38711 0.00000 16151159 14197075 1954084 0.08310 22868 465 22403 0.00090 22868 465 22403 0.00090 16174027 14197540 1976487 0.08400 1 1025954 9118700 9118700 X 1 1 1 1 Penobscot Valley Hospital 7 Transalpine Road Lincoln ME 04457 www.pvhme.org 38340 X X X X Penobscot Valley Hospital 1 0 0 1 X X X X X X X X X 13 1 0 0 1 X www.pvhme.org/About-Us/Newsletters-Publications.aspx X 1 13 1 www.pvhme.org/About-Us/Newsletters-Publications.aspx 1 0 1 X 150.000000000000 225.000000000000 X 1 1 X X X 1 X www.pvhme.org/billing.aspx X www.pvhme.org/billing.aspx X www.pvhme.org/resources/billing.aspx X X X X X X 1 X 0 X X X X 1 X 0 0 Penobscot Valley Hospital Part V, Section B, Line 5: Local Expert Advisors included the Community Health Educator and Nutritian Education Coordinator from Partnership for Healthy Northern Penobscot, the owner of Select Designs, the Manager of Clinical Operations from Community Health & Counseling Services, CEO and Penquis District Public Health Liaison of the PV Hospital, Director of Community Services from Eastern Area Agency on Aging, the school nurse from the local school district SAU31, clinician from Clinical Consultation & Counseling PA, FNP and CEO from Health Access Network, and Town Manager of Lincoln.When the analysis was complete, the information and summary conclusions were put before a local group of experts, who were asked to agree or disagree with the summary conclusions. They were free to augment potential conclusions with additional statements of need, and new needs did emerge from this exchange. Consultation with local experts occurred again via an internet-based survey during the period beginning October 4, 2013, and ending October 10, 2013.With the prior steps identifying potential community needs, the local experts participated in a structured communication technique called a Delphi method, originally developed as a systematic, interactive forecasting method that relies on a panel of experts. Experts answer questionnaires in a series of rounds. We contemplated and implemented one round as referenced during the above dates. After each round, we provided an anonymous summary of the experts' forecasts from the previous round, as well as reasons provided for their judgments. The process encouraged experts to revise their earlier answers in light of the replies of other members of their panel. Typically, this process decreases the range of answers and moves the expert opinions toward a consensus "correct" answer. The process stops when we identify the most pressing, highest priority, community needs. In the PVH process, each local expert allocated 100 points among all identified needs, having the opportunity to introduce needs previously unidentified and challenge conclusions developed from the data analysis. A rank order of priorities emerged, with some needs receiving none or virtually no support, and other needs receiving identical point allocations. Penobscot Valley Hospital Part V, Section B, Line 11: Please see the Hospital's Community Health Needs Assessment & Implementation Strategy located at the following web address:www.pvhme.org/About-Us/Newsletters-Publications.aspx Penobscot Valley Hospital Part V, Section B, Line 13h: State Regulation Penobscot Valley Hospital Part V, Section B, Line 16i: The FAP application is sent with all first time statements. A notice of the FAP and a copy of the FAP application is also posted in the Billing Help section of the Organization's website. Notices are also posted at all entrances to the Hospital and at various locations within the building. Part II, Community Building Activities: Many families rely on us for a comprehensive range of services. Without access to these services including primary and preventative care, chronic diseases may go untreated. Often this results in poor health with high emergent or inpatient costs. At PVH, we strive to be our Community's first choice in healthcare, known for a culture of compassion, quality, and safety; to be an excellent community partner, working together every day to improve health and well-being of those we serve. Throughout 2015, we partnered with many other organizations to reach people within our communities to educate, train and inform, including: Colonial Healthcare, Cummings Nursing Home, Eastern Maine Community College, Golden Key Senior Center, Health Access Network, Husson University, Katahdin Shared Services, Katahdin Valley Community College, Lincoln Economic Development Committee, Lincoln Lakes Region Chamber of Commerce, LifeFlight, Lincoln Police & Fire Departments, Maine Breast & Cervical Health Program, Maine Centers for Disease Control and Prevention, Maine Department of Transportation, Mayo Regional Hospital, Millinocket Regional Hospital, New England Organ Bank, Northern Penobscot Tech Region III, Quorum Health Resources, Raising Readers Program, Red Cross, RSU #67, SAD #30, SAD #31, PVH Auxiliary, PVH Cancer Support Group, Save-A-Life Substance Abuse Task Force, SPRINT for Life, the University of Maine, University of New England, University of Vermont, WomenHeart, Yale University, and more. By employing over 200 people in the community, PVH is a leader in creating good paying jobs and attributing to a positive economy in the region. With the "ripple effect" (jobs the hospital helped create and dollars spent in the area), the U.S. Department of Commerce's Bureau of Economic Analysis determined the multiplier for employment in Maine to be 2.1174, meaning for every employed person in a hospital in Maine, there is another 1.1174 jobs created in supporting industries. Penobscot Valley Hospital supports 478 jobs.PVH does not turn away people who need vital care, regardless of their ability to pay. Each person we treat receives the same high-quality care with utmost compassion from our staff. Our hospital is providing more Free Care, which includes charity care and bad debts, than ever before.Other direct impacts that PVH provided to the communities that we serve:Education/Scholarships:1. Auxiliary provided scholarships to non-traditional students pursuing a degree in healthcare.2. Cancer Support Group meetings twice a month for survivors and caregivers. 3. Promoted National Donor Month in May to commemorate those who have given the gift of life and to raise awareness about registering as an organ donor.4. Published educational articles monthly in the Lincoln News on topics such as hand hygiene, disease prevention, and nutritional advice.5. General Surgeon did a presentation on cancer, and our Registered Dietitian demonstrated holiday recipes at the Golden Key Senior Center. 6. Staff created educational displays in our lobby which have included health and nutrition pieces created by students at Hichborn Middle School to promote healthy choices among our staff and community. 7. In February, WomenHeart hosted a display to educate staff and community members about heart disease in women. 8. PVH offered educational tours where students learn age-specific healthcare information like proper hand hygiene, x-ray processing, laboratory testing, and facility tours.9. Our Falls Team provided education on falls risks and measures that can be taken at home to decrease a patient's risk of falls and injury. 10. Laboratory staff made weekly visits to four area nursing homes to collect specimens from residents.11. Participated in the March Lincoln Expo with surgical equipment to entertain the crowd. We also provided information from our imaging department on breast cancer prevention, preventative care with Penobscot Valley Primary Care, Rehab fitness testing, swing beds, hand hygiene, free Audiology screenings, and free diabetes screenings.12. PVH is a clinical site for Northern Penobscot Tech Region III and several colleges and universities. During 2015, PVH had approximately 37 students conducting clinical rotations here for certifications with Medical Assistant, Certified Nursing Assistant and Phlebotomy. Husson University sent students to the PVH pharmacy and nursing departments for their rotations. PVH has also worked with the University of Maine School of Nursing and Kennebec Valley Community College Radiology Program. PVH provided emergency medicine training of family medicine residents from Eastern Maine Medical Center. We serve as a rotation site for physician assistants and medical students from University of New England, University of Vermont, and Yale University. Time spent with the students varies from a couple of hours to the entire semester of hands-on education. The demand for students to utilize PVH as a clinical site has increased over the last several years. 13. Professionals at PVH often visit local schools to share information on health-related topics with young people. These range from our infection prevention officer teaching students the importance of good hand washing to staff teaching children about their career field. 14. At the end of each school year, PVH awards scholarships to three graduating seniors from Lee Academy, Mattanawcook Academy and Penobscot Valley High School. Each recipient is selected by the schools and must be pursuing a healthcare-related degree. They are awarded $500 each with the hospital giving a total of $1,500 annually. Community Contributions:Penobscot Valley Hospital volunteers, staff and providers are committed to providing quality healthcare services to the people in our community. In 2015, staff and volunteers provided:1. Free educational programs to seniors at the Golden Key Senior Center.2. Holiday gifts for area nursing home residents.3. Teddy Bear Clinic to make children comfortable with the hospital and equipment.4. Kids Activity Packs for children visiting the ED.5. Books for pediatric patients at well child checkups through Raising Readers.6. Free screenings on diabetes, pre-diabetes, hearing, and strength at the Lincoln Expo.7. Vaccinations through the Maine Impact Program. 8. ImPact head injury prevention program provided to area athletes.9. Scholarships for college students obtaining healthcare degrees.10. Artwork projects with the students in the Mattanawcook Academy Community Integration Progam.11. Hosted two Red Cross Blood Drives.12. School Supply Drive through Penquis Cap.13. Substance Abuse prevention education.14. Run/Walk for Wellness for obesity prevention.15. Community Service provider meetings for networking.16. Free meeting space for area non-profits.17. Leadership to the Lincoln Economic Development Community & Lincoln Lakes Region Chamber of Commerce. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. In evaluating the collectibility of accounts receivable, the Hospital analyzes past results and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payor sources in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a provision for bad debts in the period of service based on past experience, which indicates that many patients are unable or unwilling to pay amounts for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated or eligible) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged against the allowance for doubtful accounts. Part III, Line 8: The Organization uses its Medicare Cost Report to obtain the amounts reported above. Part III, Line 9b: The Hospital would not initiate collection efforts against a patient that qualified for a sliding fee scale unless that patient failed to meet their obligation under payment arrangement agreed to by both parties. After it was determined that the patient did not qualify for a readjustment to their payment terms, the Hospital would follow normal notification practices dictated by our collection policy until the account eventually ended up in collections. Part VI, Line 2: The Organization took a comprehensive approach to assess community health needs. Several independent data analyses were performed based on secondary source data, augmented with local survey data, and any data inconsistency or discrepancies are resolved from the combined opinions formed from local experts. PVH relies on secondary source data, and most secondary sources use the county as the smallest unit of analysis. We asked our local expert area residents to note if they perceived the problems or needs identified by secondary sources to exist in their portion of the county. Most data used in the analysis is available from public internet sources. Critical data needed to address specific regulations or developed by the individuals cooperating with us in this study is displayed in the report of the appendix. Part VI, Line 3: Notices regarding PVH's charity care policy are posted around the hospital. We also have information in each patient room, and our employees know to refer patients to the registration or billing offices of the hospital if they have questions. Part VI, Line 4: Lincoln is a rural community of approximately 5,700 people located in north central Maine. Our service area consists of many small towns that use Lincoln as a hub. The hospital, school system, and logging companies, are the major employers in town. Life and industry primarily revolve around the woods of central Maine. It is an area rich with history for making paper. Maine is one of the oldest states in the nation according to the latest US Census report, and Lincoln reflects that demographic. The median resident age in 2013 was 43.3 years. Lincoln is located in a modest area of the State, where the median resident income in 2013 was $44,649. Maine's average income for that same time period was $46,288. Part VI, Line 7, Reports Filed With States ME X X X X 0 0 0 0 0 0 0 0 0 Ann Marie Rush CFO 167343 0 0 0 3600 0 0 0 19465 0 190408 0 0 0 Gary Poquette CEO 205909 0 10000 0 7260 0 0 0 24570 0 247739 0 0 0 Michael Lescord ED Physician 513366 0 0 0 0 0 0 0 23421 0 536787 0 0 0 Glenn Deyo Surgeon 385461 0 0 0 0 0 0 0 25959 0 411420 0 0 0 David L Ettinger ED Physician 396332 0 0 0 18000 0 0 0 26774 0 441106 0 0 0 Paul Turnquist ED Physician 263880 0 0 0 0 0 0 0 18951 0 282831 0 0 0 Barbar Junaidi Hospitalist 235286 0 0 0 0 0 0 0 33099 0 268385 0 0 0 Part VII Section B Line 5 Gary Poquette, CEO, and Ann Marie Rush, CFO, are compensated by Quorum Health Resources, an unrelated organization, for services rendered to the Organization. The amounts listed below are not included in the total reported on Form 990, Part VII, Section B for Quorum Health Resources, LLC. A breakdown of their 2015 compensation is as follows: Gary Poquette, CEO: Salary: $215,909 Benefits: $24,570 Automobile Allowance: $7,260 Ann Marie Rush, CFO: Salary: $167,343 Benefits: $19,465 Automobile Allowance: $3,600 A Maine Health and Higher Educational Facilities Authority Revenue Bonds 010314384 560427EU4 2012-06-28 1117769 To refinance Series 2002A bond 0 0 1 A 432250 1117769 132031 24765 960973 2012 0 1 1 1 A 0 0 0 0 0 0 0 A 0 0 1 0 0 0 0 0 0 A 0 Glenn Deyo Employee of the Organization Sign-On Loan X 118054 26365 0 1 1 26365 Debbie Rancourt Family member of Frederick Woodman, Jr., Board President 78401 Employment 0 Form 990, Part VI, Section B, line 11 Once Form 990 is prepared by the certified public accounting firm, a draft copy is e-mailed to the controller. The controller will then review the Form, and also compare it with the previous year's 990. Once the controller is satisfied with the draft copy, it is forwarded to the CFO. The CFO will then review the document. Any questions she has will either be answered by the controller or the accounting firm. Once the CFO approves the draft 990, a copy is provided to the board of directors for their review. Once the board has approved the draft, the accounting firm is notified and the final version is prepared for filing. Form 990, Part VI, Section B, line 12c It is the expectation of Penobscot Valley Hospital that our board of directors, medical staff, regular and contracted employees, and our volunteers avoid activities that may involve, or appear to involve, a conflict of interest. This is a standard of conduct communicated through Administrative Policy 109 "Code of Ethics," our code of conduct and ethics, and our medical by-laws. These documents are drafted and signed off by the president of the board of directors, the chief executive officer, chief of medical staff and the compliance officer as appropriate. Every individual employed by, or otherwise representing the Hospital, is responsible for complying with this standard. It is the responsibility of the compliance officer and the chief executive officer to ensure that this standard is communicated, maintained and enforced within the Organization. Administrative Policy 127 "Compliance Reporting" outlines the expectation for reporting non-compliance, the mechanisms in place to do so, and the investigative process. Such mechanisms include a 24-hour confidential reporting hotline. Education on Penobscot Valley Hospital's code of conduct and ethics is provided during orientation or at the beginning of the business relationship. Reinforcement of this education is provided annually and upon any business contract renewal. Form 990, Part VI, Section B, line 15 CEO & CFO - Quorum Health Resources, an unrelated organization, does an extensive national compensation analysis. Ranges are presented to the finance/personnel committee of the board by QHR, and the wage is set. Other officer's wages are set using a state-wide wage survey conducted annually by the Maine Society for Healthcare Human Resources Administration. Wages are set by evaluating the position in conjunction with the job description listed in the survey. Form 990, Part VI, Section C, line 19 The Organization does not make its governing documents, conflict of interest policy, and financial statements available to the public. Form 990, Part IX, line 11g Physician Fees: Program service expenses 1,916,439. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,916,439. Purchased Services: Program service expenses 1,901,200. Management and general expenses 989,415. Fundraising expenses 0. Total expenses 2,890,615. Form 990, Part X, Line 10: Land, Buildings, and Equipment Section 1.263(a)-3(n) Election: Penobscot Valley Hospital 7 Transalpine Road, Box 368 Lincoln, ME 04457 EIN 01-0545327 Penobscot Valley Hospital is electing to capitalize repair and maintenance costs under Regulation Section 1.263(a)-3(n). Alpine Health Services Inc PO Box 460 West Enfield ME 04493 222533280 Support to provide health services in underserved areas of Maine. ME 501(c)(3) Line 9 Penobscot Valley Hospital 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0