2012-11-15T12:46:02-06:00 2011-12-31 010523282 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2011-01-01 010545327 Penobscot Valley Hospital PENO 2077943321 7 Transalpine Road Box 368 Lincoln ME 04457 David Shannon 2077943321 2012-11-15 1 Barbara J McGuan CPA P00219457 2077752387 2012-11-15 2011 2016-02-24 21:20:13Z David Shannon 7 Transalpine Road Box 368 Lincoln ME 04457 26571420 0 X www.pvhme.org X 1973 ME Critical Access Hospital 10 10 258 27 0 0 66084 100430 24221341 26211100 7314 72409 -3328 -3102 24291411 26380837 13330 14229 0 0 13197429 14172619 0 0 0 11028123 11663966 24238882 25850814 52529 530023 16252735 16723968 12160849 12132873 4091886 4591095 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 21744936 14229 26211100 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 2011, 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. 21744936 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 30 0 1 258 1 0 0 0 0 0 1 1 0 0 0 0 X 10 10 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 Frederick Woodman Jr 1.50 X X 0 0 0 Gilberte Mayo 1.50 X X 0 0 0 Lynn Sanderson 1.50 X 0 0 0 Carl Alessi MD 1.50 X 0 0 0 Hervey Clay 1.50 X 0 0 0 Phillip Dawson Jr 1.50 X 0 0 0 Victor Jipson 1.50 X X 0 0 0 Michael McFalls 1.50 X 0 0 0 Ed Woolley 1.50 X 0 0 0 Richard Wyman 1.50 X 0 0 0 David Shannon 50.00 X 203527 0 23919 Ann Marie Rush 50.00 X 129600 0 15229 David L Ettinger 40.00 X 262996 0 25470 David H Dumont 40.00 X 276236 0 14742 Samer Sbayi 40.00 X 332338 0 24808 Paul E Turnquist 40.00 X 252346 0 21795 Karen Mueller 40.00 X 130806 0 12637 1587849 0 138600 6 0 1 1 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ED Physician Services 1180508 Nurse Anesthesia of Maine LLC 141 North Main Street Suite 205 Brewer ME 04412 Nursing Services 585388 CompHealth PO Box 972651 Dallas TX 75397 Physician Services 485107 Unidine PO Box 60479 Charlotte NC 28260 Dietary Services 369707 Quorum Health Resources LLC 105 Continental Place Brentwood TN 37027 Hospital Management Svcs. 289348 15 17618 20755 62057 100430 Patient Service Revenu 621400 35479280 35479280 Meaningful Use Revenue 621400 406601 406601 Cafeteria & Other 722210 219349 109702 109647 Charity Care 621400 -1360647 -1360647 Contractual Allowances 621400 -8533483 -8533483 26211100 23242 23242 230400 787 177915 4105 52485 -3318 49167 49167 5461 17618 8563 -3102 -3102 26380837 26101453 0 178954 14229 14229 372275 372275 9338967 8631450 707517 62614 55877 6737 3742363 3405203 337160 656400 585776 70624 22317 22317 41100 41100 5120 5120 4730263 3804510 925753 30431 30431 1027043 76122 950921 1079034 1019146 59888 127618 80680 46938 322711 322711 995155 995155 259047 54386 204661 Medical Supplies 1855599 1855599 Provision for Bad Debts 1166803 1166803 Physician Events 1725 1725 25850814 21744936 4105878 0 2023867 3158145 714830 768291 2624508 2819117 452740 479893 137996 215373 16828153 10009994 7190458 6818159 550425 556665 -11824 6588 14604 13334 2555131 1888403 16252735 16723968 2701779 2838986 1104634 1024908 5244887 5060075 3109549 3208904 12160849 12132873 X 3892932 4361605 122405 152941 76549 76549 4091886 4591095 16252735 16723968 X 530023 -30814 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4034 4034 0 Explanation of Lobbying Activities: 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 ($3,428) and American Hospital Association ($606) were attributable to lobbying expenses. 28897 28897 7762560 4100923 3661637 433876 378650 55226 8027994 5079251 2948743 574826 451170 123656 6818159 Estimated Third-Party Payor Settlements 1871903 Deferred Compensation 16500 1888403 Estimated Third-Party Payor Settlements 3192404 Deferred Compensation 16500 3208904 Golf Tournament 15226 10558 4668 3852 1727 Fashion Show 7852 7060 792 2175 809 23078 17618 5460 3852 2175 2536 8563 -3103 1 1 1 X 1 X 275.000000000000 1 1 1 0 938677 938677 0.03800 5620801 5259266 361535 0.01460 11740358 12157302 -416944 0.00000 18299836 17416568 883268 0.05260 10577 1722 8855 0.00040 10625 10625 0.00040 21202 1722 19480 0.00080 18321038 17418290 902748 0.05340 1 804949 10509166 10509166 X 1 1 1 1 Penobscot Valley Hospital

7 Transalpine Road Lincoln ME 04457

X X X X Penobscot Valley Hospital 1 1 1 200.000000000000 1 275.000000000000 1 X X 1 1 X X 1 0 1 X 0 0 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 $ 1166803. Part III, Line 4: Patient accounts receivable are stated at the amount management expects to collect from outstanding balances. Management provides for probable uncollectible amounts through a charge to earnings and a credit to a valuation allowance based on its assessment of the current status of individual accounts. Balances that are outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient accounts receivable. The amount of $ reported on Line 3 was estimated based on a review of patient records. 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. Penobscot Valley Hospital Part V, Section B, Line 13g: The FAP application is sent with all first time statements. A notice of the FAP is also posted in the FAQ section of the Organization's website. Notices are also posted at all entrances to the Hospital and at various locations within the building. Penobscot Valley Hospital Part V, Section B, Line 19d: The Hospital applied the determined discount to the gross charge amount for self pay patients. The Hospital applied the determined discount to the remaining balance after insurance payment, if applicable. Part VI, Line 2: In 2010, PVH joined three other healthcare organizations in performing a joint community needs assessment for all of our service areas in northern Penobscot County. This group retained professional help to do the research, community focus groups, surveys, data manipulation, and report writing. We looked to identify gaps in services for the entire area, and also to try and identify opportunities for collaboration in providing those services to our communities. In addition to this assessment, the three largest hospitals in the state conducted a state-wide needs assessment that was broken down by county and service area. This too has provided us with information to use in our hospital planning sessions. We continually ask our patients if there are things that we could do better, or if there are services that they need that are not currently being offered locally. If something is identified that we have the capability to do, then we try to meet the needs of our community. One example would be expanding the hours available for walk-in services at our laboratory and x-ray departments. This was done in response to feedback from a survey done by the staff. 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, logging companies, and paper mill 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 2008 was 40.7 years. Lincoln is located in a modest area of the State, where the median resident income in 2008 was $32,229. Maine's average income for that same time period was $46,581. Part VI, Line 5: Penobscot Valley Hospital in Lincoln, Maine provides a substantial range of free or low-cost services, care, and educational opportunities to the Lincoln Lakes Region in northern Maine. PVH is one of the largest employers in the area and provides careers for more than 225 people in a region in which people struggle to find full-time, good paying employment. PVH is also the only rural health center with emergency care in the region for many of our patients and clients. The nearest Critical Access Hospital is 30 minutes away, and the nearest full service hospital is more than 45 minutes away from PVH. Sustaining PVH's longevity not only means vital services remain nearby for our patients but also that the economic vitality of the region is better secured. During 2011, PVH partnered with many agencies to reach a broad range of people. Some of those agencies included Millinocket Regional Hospital, Health Access Network, the Town of Lincoln, the Lincoln Police Department, the Lincoln Fire Department, R.S.U. #67, Community Health and Counseling Services, Katahdin Shared Services, the Maine CDC, Colonial Acres Nursing Home, and Cummings Health Care Center. These partnerships allowed PVH to provide education, services, and informational materials to people in our region and help people learn to be and stay well.Blood DrivesPVH held two American Red Cross blood drives in 2011 - one in June and another in December, both at the Lincoln Knights of Columbus Hall. The blood drives resulted in over 100 units of blood being collected for those in need.Childbirth EducationSeveral times a year, PVH provides education at low or no cost to expectant mothers and families. These classes are typically held on the weekends and teach comfort during pregnancy, relaxation techniques, pain control, baby care, and much more. For those families delivering at PVH, they are showered with gifts from the PVH Auxiliary, enjoy the baby's first birthday cake made special by our Food Services Staff, and receive books through the Raising Readers program.Disaster PreparednessPVH participates in a regional disaster preparedness committee with several other agencies including doctors' groups, other hospitals, local police and fire departments, schools, and other organizations. The goal of these monthly meetings is to prepare for pandemic flu, natural disasters, or other incidents that could affect our communities as well as to find ways to work together to share resources and protect the community. Economic ImpactPVH is one of the largest employers in the Lincoln Lakes Region. By employing more than 240 people in the community, PVH is a critical leader in creating and maintaining jobs and livelihoods in the region.EducationEach week, the PVH staff places articles and ads in the local paper, the Lincoln News, the PVH website, PVH Facebook page, and other nearby publications covering topics that are helpful to the general public. These include topics such as hand hygiene, disease prevention, and nutritional advice. The hospital also produces a variety of brochures and educational materials covering a wide range of health-related topics which are handed out to the public. Our ED staff and Emergency Medical Technicians taught a parenting group the Heimlich maneuver, car seat safety, and helmet safety, as well as proper hand washing and first aid to a Cub Scout den. Our Quality Improvement department conducted two lectures to the University of Maine nursing students on quality and service issues. The Pharmacist offered a medication safety session to the Golden Key Senior Center in Lincoln.Educational ToursStudents from local schools throughout the region, as well as Boy and Girl Scout troops, were given tours of PVH during 2011. Also, students from Northern Penobscot Technical School (Region III) and several colleges visited the hospital on tours, learning about nuclear medicine, nursing, becoming Certified Nursing Assistants, and pursuing other careers in healthcare. Every 15-Minutes ParticipantPVH is a major contributor to the Mattanawcook Academy Every 15 Minutes mock accident. On Thursday, April 28, two students from Mattanawcook Academy were transported to PVH as part of a mock accident set up at the high school. Students were treated for "injuries" as part of the drill to teach students the harsh realities of drunk and distracted driving. "Every 15 Minutes" is a national program designed to remind us about all of the dangers associated with driving while impaired or texting. The event was a true community-wide effort including students, parents, educators, school personnel, law enforcement, legal representatives, medical professionals, media, and many local businesses. All juniors and seniors at Mattanawcook Academy play a role in the event, whether they are part of the accident or bystanders at the scene. The two-day event is filled with harsh realities and consequences. Some students lose lives and some lose freedoms in this mock drill, but all of the students see the impact they have on the community when they choose to drive while impaired or text while driving. Falls RisksPVH is also providing education on fall risks and measures that can be taken at home to decrease a patient's risk of falls and injury. The hospital provides patients with a handout that teaches ways to make their home safe and other tips to avoid falls. There is an active Falls Team who works on projects to make the hospital and our community a safer place. Food Cupboard SupportThroughout the year, staff and visitors to the PVH Cafeteria place change in a special container by the checkout counter. Periodically, this change is removed and donated to the Lincoln Area Food Cupboard, which supplies food, clothing, and other necessities to people in need. In 2011, PVH collected $500 for the Lincoln Area Food Cupboard. InfluenzaOur clinicians and support staff held multiple influenza vaccination clinics in our immediate community as well as for the schools and the public. Internships/Job ShadowingThe hospital works closely with students from the Greater Bangor area. PVH has hosted many job shadow opportunities from local high school and college students. Beal College and Northern Penobscot Tech (Region III) had students complete their clinical rotations for Medial Assistant, Certified Nursing Assistant and Phlebotomy at the hospital. Husson University sent students to the PVH Pharmacy for their rotations. The hospital conducts "mock interviews" with Region III students in their Skills Lab to help prepare them for the workforce.PVH also partnered with the University of Maine Business School students in the American Marketing Association to conduct a community awareness and perception study. The students gained valuable, real-life education skills through survey implementation, data collection, analysis, and business presentation. Laboratory ServicesMedical Laboratory Technologists in the PVH Laboratory make weekly visits to four area nursing homes to collect specimens from residents. The technologists have also provided free educational sessions to nursing home staff members on specimen collection. Lincoln ExpoIn April, staff at PVH volunteered their time to teach the community about services offered at PVH. Attendees at the Lincoln Expo had the opportunity to learn about imaging and radiology services, how to properly use an AED device, volunteering through the Auxiliary, rehabilitation services, meaningful use in healthcare, and the new patient beds.Meeting Space for Non-ProfitsPVH offers conference room space to local non-profit organizations. This space is offered when it does not interfere with hospital business, at no cost to the organizations.Nursing Home PresentsEach year, the PVH staff collects presents for local nursing home residents. These gifts are given to local residents of nursing and boarding homes, who may not have received holiday gifts otherwise. The staff and residents truly look forward to each holiday season. At least three dozen presents are generally distributed in time for the holidays. Nutritional EducationPVH offered a variety of nutritional, educational opportunities through seminars and small group speaking engagements. These sessions were performed through our registered dietitian and our nursing staff. Primary Care Penobscot Valley Primary Care is located in the hospital's Medical Arts Building and provides walk-in care on Wednesdays and Thursdays.Public CPR, First Aid, and Babysitting ClassesPVH staff makes several classes available to the community throughout the year at low or no cost to teenagers and adults. Reports Filed With States Part VI, Line 7 ME Continuation of Schedule H, Part VI, Line 5 Form 990, Schedule H, Part VI, Line 5: School VisitsProfessionals at PVH often visit local schools to share information on health-related topics with young people. These range from our laboratory technicians teaching kids about their career field to our laparoscopic surgeon explaining surgical procedures to kids on their level. Normally, students are given something to help retain the material, such as coloring books, posters, informational materials for parents, or small promotional items such as hand sanitizer or bandage containers.Social Work NetworkingEach month, PVH hosts a networking luncheon for social workers and others who do similar work in the community. PVH provides education for them and facilitates discussions about social work-related issues. These luncheons are offered at no cost to the participants.PVH also supports a grant-funded community health coalition in collaboration with Millinocket Regional Hospital and the River Coalition in Old Town. SPRINT for Life is part of a statewide system of public health organizations that bring people and resources together to improve the health of Maine residents. Some of the coalitions recent projects include prescription drug take back events, community education, and childcare provider trainings on a range of health-related topics. All services are provided to the community free of charge.SPRINT for Life1. 5K Run/Walk for Wellness: Nearly 90 participants raced in the 5K organized by SPRINT during the Lincoln Homecoming celebration. The walk raises awareness of the importance of living a healthy lifestyle.2. Facilitated Training for Childcare Providers:Approximately 20 area childcare providers received over 60 hours of training from SPRINT on health topics such as childhood obesity, secondhand smoke, personal health, physical activity and nutrition. 3. Head Start: SPRINT for Life offers free trainings for parents of young people through the Head Start programs in the region. During 2011, these sessions focused on healthy homes.4. Improving the Early Childhood Environment: Provided two $500 mini grants to childcare centers in the area for the purchase of play equipment and shade structures to enhance opportunities for physical activity and reduce sun exposure in the childcare setting.5. Newsletters: Distributed a monthly health newsletter to area worksites, healthcare providers, and community members.6. Partnering with Other Agencies: SPRINT for Life works with many local agencies to increase the reach of the community benefit, including Community Health and Counseling Services, Rape Response Services, Health Access Network, the Lincoln Police and Fire Departments, the Lincoln Recreation Department, Penquis Cap, Spruce Run, the River Coalition, Bangor Public Health, the Maine CDC, and Millinocket Regional Hospital,along with many others.7. Providing Opportunities to Dispose of Unwanted Medications: Sponsored two drug takeback events in 2011 in partnership with the Lincoln Police Department and Maine Drug Enforcement Agency. In addition to the events, SPRINT purchased a drug drop box for the Lincoln Public Safety Building so that community members can dispose of medications on an ongoing basis.8. Recognizing Substance Abuse: In 2011, SPRINT offered seminars for teachers on how to recognize the signs of substance abuse and what steps can be taken when substance abuse is suspected.9. Sponsored Responsible Beverage Server/Seller Training: Fifteen sellers and/or servers attended a five hour training session. These sessions train people who sell or serve alcoholic beverages specific ways to improve public health and safety.10. Tobacco Cessation: Provided tobacco quit packs to three area healthcare providers who partnered with SPRINT to offer smoking cessation programs to their patients.11. Tobacco Prevention: Purchased 25 new tobacco free signs for area playgrounds, playing fields, schools, community organizations and businesses.Vital ServicesPVH provides vital services to the community, of which most are paid for through individuals, insurance companies, MaineCare and Medicare. In 2011, the hospital handled or performed:1. 39,116 patient visits2. 8,378 visits to the emergency room3. 838 operating room cases4. 77 newborns5. 1,655 ambulance runs6. 3,459 EKGs7. 30,302 respiratory therapy treatments8. 83,235 lab tests9. 12,631 physical therapy modalities10. 2,871 speech therapy treatments11. 3,190 occupational therapy treatments12. 452 cases involving nuclear medicine13. 1,428 mammograms14. 1,693 CT scans15. 168 bone density tests16. 796 MRIs17. 2,149 ultrasounds18. 342 vascular exams19. 5,762 X-rays 1 Alpine Health Services PO Box 460 West Enfield ME 04493 222533280 501(c)(3) 14229 To fund operations 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Once a month the controller for Alpine prepares a spreadsheet listing cash on hand, expenses for the month, and balance needed. If Alpine is short on cash for that month the spreadsheet is printed and attached to a Check Request for the hospital for the amount that is needed to fund Alpine's expenses for that month. X X X X 0 0 0 0 0 0 0 0 0 David Shannon 196267 0 0 0 7260 0 0 0 23919 0 227446 0 0 0 David L Ettinger 262996 0 0 0 0 0 3675 0 21795 0 288466 0 0 0 David H Dumont 259736 0 0 0 16500 0 3675 0 11067 0 290978 0 0 0 Samer Sbayi 332338 0 0 0 0 0 600 0 24208 0 357146 0 0 0 Paul E Turnquist 252346 0 0 0 0 0 0 0 21795 0 274141 0 0 0 Supplemental Information Part III Dave Shannon, CEO & 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 2011 compensation is as follows: Dave Shannon, CEO: Salary: $196,267 Benefits: $23,919 Automobile Allowance: $7,260 Ann Marie Rush: Salary: $126,000 Benefits: $15,229 Automobile Allowance: $3,600 Amy Woodman Family member of Frederick Woodman, Jr., Board President 40290 Employment 0 Debbie Rancourt Family member of Frederick Woodman, Jr., Board President 74743 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 Dix Consulting. 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -43,495. Share in Earnings of Subsidiary 12,681. Total to Form 990, Part XI, Line 5: -30,814. Oversight of Audit Form 990, Part XI, Line 2c: The audit process has not changed from the prior year. 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0