2011-11-15T08:41:51-06:00 2010-12-31 Berry Dunn McNeil & Parker LLC PO Box 1100 Portland ME 041041100 990 2010-01-01 010545327 Penobscot Valley Hospital PENO 2077943321 7 Transalpine Road Box 368 Lincoln ME 04457 David Shannon 2077943321 2011-11-14 1 Barbara J McGuan CPA 2077752387 2011-11-14 2010 2016-03-07 17:11:31Z David Shannon 7 Transalpine Road Box 368 Lincoln ME 04457 24562607 0 X www.pvhme.org X 1973 ME Critical Access Hospital 10 10 265 26 0 0 174466 66084 23527277 24221341 -10504 7314 -2957 -3328 23688282 24291411 4000 13330 0 0 12244151 13197429 0 0 0 11354578 11028123 23602729 24238882 85553 52529 15058533 16252735 11063249 12160849 3995284 4091886 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 20170730 13330 24221341 Penobscot Valley Hospital is a critical access hospital in Lincoln, ME. The Hospital provided a wide range of medical services to its patients in 2010, including but not limited to the following:1. Dietary Services - 94 patients served2. Adult & Pediatric Services - 1,021 patients served3. Intensive Care Services - 11 patients served4. Nursery Services - 87 patients served5. Operating Room Services - 817 patients served6. Recovery Room Services - 193 patients served7. Delivery & Labor Room Services - 54 patients served8. Anesthesiology Services - 861 patients served9. Radiology Services - 9,955 patients served10. Laboratory Services - 21,894 patients served11. Therapy Services - 6,528 patients served12. Pharmacy Services - 13,980 patients served13. Clinic Services - 4,065 patients served14. Emergency Room Services - 8,901 patients served15. Ambulance Services - 1,107 patients served 20170730 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 31 0 265 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 X 0 0 0 Carl Alessi MD 1.50 X 3846 0 0 Hervey Clay 1.50 X 0 0 0 Phillip Dawson Jr 1.50 X 0 0 0 Victor Jipson 1.50 X 0 0 0 Michael McFalls 1.50 X 0 0 0 Cathy Severance 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 191260 0 48771 Ann Marie Rush 50.00 X 121400 0 30982 Manoucher Afshari 40.00 X 258639 0 16958 David L Ettinger 40.00 X 259890 0 24159 Samer Sbayi 40.00 X 271547 0 22897 David H Dumont 40.00 X 265637 0 14157 Gerald S Laird 40.00 X 147387 0 11351 1519606 0 169275 7 0 1 1 Emcare Inc 7032 Collection Center Drive Chicago IL 60693 ER Physician Services 1305558 NEHE-MRI LLC PO Box 6600 Newport Beach CA 92658 Nuclear Medicine Svcs. 320614 Unidine Corporation PO Box 60479 Charlotte NC 282600479 Dietary Services 302188 Quorum Health Resources LLC 105 Continental Place Brentwood TN 37027 Hospital Management Svcs. 242248 Nurse Anesthesia of Maine LLC 141 North Main Street Brewer ME 04412 Nursing Services 230269 8 11568 9112 45404 66084 Patient Service Revenu 621400 33096214 33096214 Cafeteria Income 722210 107582 107582 Other Revenue 621400 99706 99706 Charity Care 621400 -1028591 -1028591 Contractual Allowances 621400 -8053570 -8053570 24221341 16065 16065 252013 4690 252452 13002 -439 -8312 -8751 -8751 2414 11568 5742 -3328 -3328 24291411 24113759 0 111568 13330 13330 396259 3846 392413 9472778 8751416 721362 59983 53647 6336 2625493 2388606 236887 642916 575006 67910 37125 37125 42470 42470 70000 70000 3184170 2402262 781908 36695 36695 4337145 3308280 1028865 776808 699147 77661 94844 63295 31549 331290 331290 1008864 1008864 260927 56351 204576 Provision for Bad Debts 846680 846680 Physician Events 1105 1105 24238882 20170730 4068152 0 1746456 2023867 749131 714830 2292512 2624508 407602 452740 192842 137996 16435868 9245410 7735269 7190458 473171 538601 15874 14604 1445676 2555131 15058533 16252735 2760979 2701779 1184361 1104634 5480275 5244887 1637634 3109549 11063249 12160849 X 3816818 3892932 101917 122405 76549 76549 3995284 4091886 15058533 16252735 X 52529 44073 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 1 75882 0 1 4111 79993 0 Explanation of Other Lobbying Activities: Part II-B, Line 1i: The organization pays dues to the Maine Hospital Association and the American Hospital Association. A portion of dues paid to the Maine Hospital Association ($3,530) and American Hospital Association ($581) were attributable to lobbying expenses. 28897 28897 7759072 3747982 4011090 433876 350672 83204 7665695 4754264 2911431 548328 392492 155836 7190458 Estimated Third-Party Payor Settlements 2555131 2555131 Estimated Third-Party Payor Settlements 3109549 3109549 1 1 1 X 1 X 275.000000000000 1 1 1 0 726417 726417 0.03110 5818641 5743964 74677 0.00320 10321737 9700228 621509 0.02660 16866795 15444192 1422603 0.06090 13205 3485 9720 0.00040 1500 1500 0.00010 7800 7800 0.00030 22505 3485 19020 0.00080 16889300 15447677 1441623 0.06170 1 597925 9604252 9604252 X 1 0 1 1 Penobscot Valley Hospital

7 Transalpine Road Lincoln ME 04457

X X X X Penobscot Valley Hospital 1 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 $ 846680. 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 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 6: 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 2010, 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 Area Partnership, Katahdin Shared Services, the Maine CDC, the Wellness Council of Maine, Colonial Acres Nursing Home, Cummings Health Care Center, the City of Bangor Public Health Department, the Penobscot County local Emergency Planning Committee, the Northeastern Maine Regional Resources Center, and River Coalition of Old Town. 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 2010 - one in June and another in December, both at the Lincoln Knights of Columbus Hall. The blood drives resulted in more than 110 units of blood being collected for those in need.Charity CareAs more and more Mainers are going without insurance, PVH is providing more "Free Care." The hospital does not turn away people who need vital care, regardless of whether they have insurance or if they are able to pay out of pocket. Consequently, during 2010, PVH gave away more than $1,028,591 in free care for patients 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. Diabetes Education SeminarsThroughout the year, PVH offered several free, diabetes seminars focusing on how to manage diabetes and increasing physical activity. These are offered periodically, based on interest. PVH has the only local Diabetes Education program recognized for quality by the American Diabetes Association. The hospital's diabetes education classes are based on a sliding scale for those who are unable to pay. The program also helped form and organize a diabetes support group which now meets monthly on its own. 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 225 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, and other nearby publications covering topics that are helpful to the general public. These include topics such as infection control, 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. Also during 2010, staff in the Quality Improvement department taught two sessions on quality improvement to nursing students at the University of Maine in Orono.Educational ToursStudents from local elementary, middle, and high schools throughout the region were given tours of PVH during 2010. 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. The hospital also gave tours for several groups of foreign students attending Lee Academy to help lessen their fears of being treated at an American hospital. 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 to bring home and the following sessions have been provided:1. May 2010 - Physical Therapy provided a two-hour exercise class with fall prevention exercises at an Eastern Area Agency sponsored community event to reduce the risk of falls2. October 2010 - Physical Therapy offered free standardized balance assessments to the public at a Rehabilitation & Wellness open house providing recommendations for safetyFood 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 2010, PVH collected $500 for the Lincoln Area Food Cupboard. In addition to offering financial support, staff at PVH helped the food cupboard to perform a safety audit, provided employee training to ensure the program met state guidelines, built shelving and storage racks to organize stock and ensure proper food rotation, and performed monthly follow-up inspections to ensure compliance. InfluenzaOur clinicians and support staff held multiple vaccination clinics in our immediate community as well as for the schools and the public. One clinic was held at the Lincoln Police & Fire Department to help immunize our public safety officers who may not have the chance to leave work for their vaccinations. Internships/Job ShadowingTwo college seniors interested in Case Management had the opportunity to learn about the position during an internship; the students booked over 800 hours of combined experience during their time at the hospital. Students from Region III Vocational School also had the opportunity to job shadow nurses and certified nursing assistants throughout the year. 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 advanced directives, Cardio-Pulmonary, green folders, LifeLine, medication charts, nutrition, recruitment, and safety advances at the hospital.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. Nutritional EducationIn 2010, PVH offered a variety of nutritional, educational opportunities through seminars and small group speaking engagements. These sessions were performed through our nutritional expert 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. In 2010, the group offered a smoking cessation open house to coincide with National Smoke-Out Day in November. Penobscot Valley Primary Care also provided a support group to help teenagers quit smoking. 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. 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 infection control officer teaching kids about proper hand-washing to our laparoscopic surgeon explaining surgical procedures to kids on their level. Normally, kids 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 gathering 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. S.P.R.I.N.T. 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 coalition's recent projects include prescription drug take back events, technical assistance for worksite wellness programs, and childcare provider trainings on a range of health topics. All services are provided to the community free of charge.S.P.R.I.N.T. for Life1. 5K Run/Walk for Wellness: Nearly 80 participants raced in the 5K organized by S.P.R.I.N.T. during the Lincoln Homecoming celebration. The walk raises awareness of the importance of living a healthy lifestyle.2. Facilitated Training for Childcare Providers: Approximately 15 area childcare providers received over 45 hours of training from S.P.R.I.N.T. on health topics such as childhood obesity, secondhand smoke, personal health, physical activity and nutrition. 3. Head Starts: S.P.R.I.N.T. for Life offers free trainings for parents of young people through the Head Start programs in the region. During 2010, these sessions focused on nutrition and exercise. 4. Maine Youth Action Conference: The S.P.R.I.N.T. for Life program sponsored four children to a statewide meeting in Augusta on youth issues and helped the group explore how to address substance abuse and other challenges facing young people today. The program also included team building and leadership training for teens. 5. Newsletters: Distributed a monthly health newsletter to area worksites, healthcare providers, and community members. 6. Partnering with Other Agencies: S.P.R.I.N.T. 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. Prescription Drug Take-Back Events: Sponsored a drug take-back event in September along with the Lincoln Police Department.8. Recognizing Substance Abuse: In 2010, S.P.R.I.N.T. for Life 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: Nearly 40 local retailers sent participants to this five hour 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 S.P.R.I.N.T. to offer smoking cessation programs to their patients. Also offered four scholarships for healthcare/behavioral health providers to attend Basic Skills Tobacco Intervention Training and one scholarship to attend Intensive Tobacco Intervention Training. Provided portable "Thank You for Not Smoking" signs for the Town of Lincoln to use during the Homecoming Festival. Purchased "no tobacco" signage for two childcare centers and one municipal beach.11. Wellness in the Workplace: S.P.R.I.N.T. for Life worked with five area worksites to help them develop employee wellness strategies through technical assistance and/or mini grants. Vital ServicesPVH provides vital services to the community, of which most are paid for through individuals, insurance companies, MaineCare and Medicare. In 2010, the hospital handled or performed:1. 39,159 patient visits 2. 8,144 visits to the emergency room3. 858 operating room cases4. 96 newborns5. 1,386 ambulance runs6. 2,930 EKGs7. 26,766 respiratory therapy treatments8. 77,976 lab tests 9. 12,369 physical therapy modalities10. 3,639 speech therapy treatments11. 2,969 occupational therapy treatments12. 449 cases involving nuclear medicine 13. 1,379 mammograms14. 1,930 CT scans15. 182 bone density tests16. 700 MRIs 1 Alpine Health Services PO Box 460 West Enfield ME 04493 222533280 501(c)(3) 13330 To fund operations 1 0 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 184000 0 0 0 7260 0 0 0 48771 0 240031 0 0 0 Ann Marie Rush 117800 0 0 0 3600 0 0 0 30982 0 152382 0 0 0 Manoucher Afshari 218639 0 40000 0 0 0 0 0 16958 0 275597 0 0 0 David L Ettinger 259890 0 0 0 0 0 3675 0 20484 0 284049 0 0 0 Samer Sbayi 271547 0 0 0 0 0 0 0 22897 0 294444 0 0 0 David H Dumont 265637 0 0 0 0 0 3675 0 10482 0 279794 0 0 0 Gerald S Laird 147387 0 0 0 0 0 0 0 11351 0 158738 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 2010 compensation is as follows: Dave Shannon, CEO: Salary: $184,000 Benefits: $48,771 Automobile Allowance: $7,260 Ann Marie Rush: Salary: $117,800 Benefits: $30,982 Automobile Allowance: $3,600 Form 990, Part I, Lines 8-18: Prior year numbers have been restated to present revenue net of contractual and charity care adjustments. 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 gains on investments: 33,325. Share in Earnings of Subsidiary 10,748. Total to Form 990, Part XI, Line 5: 44,073. 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