Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
SOUTHWESTERN VERMONT HEALTH CARE CORPORATION
Employer identification number
03-0179435
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2011.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2010.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2010.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2011
Schedule A (Form 990 or 990-EZ) 2011
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2011
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
SOUTHWESTERN VERMONT HEALTH CARE CORPORATION
Employer identification number
03-0179435
Identifier
Return Reference
Explanation
ORGANIZATION'S MISSION
FORM 990, PART III, LINE 1
THE PURPOSE OF THE ORGANIZATION IS ALSO TO PROMOTE AND SUPPORT THE DEVELOPMENT AND MAINTENANCE OF A HIGHLY EFFICIENT, PATIENT-FOCUSED, INTEGRATED HEALTHCARE DELIVERY SYSTEM.
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART VI, SECTION A, LINE 4
AT SVHC, STAFF WORKING DIRECTLY WITH PATIENTS IDENTIFY A PATIENT'S NEED AND FILL OUT A RESTRICTED GIFT CHECK REQUEST FORM TO PAY FOR SOMETHING THAT THE STAFF MEMBER BELIEVES THE PATIENT IS UNABLE TO PAY FOR HIMSELF. NEED IS DETERMINED BY THE STAFF MEMBER'S CONVERSATIONS WITH THE PATIENT AS WELL AS OBSERVATION AND KNOWLEDGE OF THE PATIENT'S LIVING CONDITIONS AND SITUATION. THE CHECK REQUEST IS APPROVED AND SIGNED BY THE STAFF MEMBER'S SUPERVISOR AND SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT. IN THE CANCER CENTER, STAFF MEMBERS ARE ENCOURAGED TO REPORT ANY PATIENT NEED THEY IDENTIFY TO THE CANCER CENTER DIRECTOR, NURSE MANAGER, PHYSICIAN, OR SOCIAL SERVICES. IF THE PATIENT'S NEED IS FOR AN "EMOTIONAL BOOST", SUCH AS A MASSAGE OR OTHER SUCH SERVICE, THE PATIENT IS ELIGIBLE BY VIRTUE OF HIS/HER CANCER DIAGNOSIS. IF THE PATIENT'S NEED IS FOR FINANCIAL ASSISTANCE WITH RENT, UTILITIES, PRESCRIPTIONS, ETC., HE/SHE IS REFERRED TO SOCIAL SERVICES. SOCIAL SERVICES DETERMINES FINANCIAL NEED BY TALKING WITH THE PATIENT TO FIND OUT THEIR CURRENT SITUATION. SOCIAL SERVICES LOOKS FOR OTHER FINANCIAL RESOURCES IN THE COMMUNITY WITH WHICH TO HELP THE PATIENT AND CONSIDERS THE HEALTH SYSTEM'S PATIENT RESOURCE FUNDS. ASSISTANCE IS GENERALLY CONSIDERED TO BE A ONE-TIME, EMERGENCY STOP-GAP AID, AND NOT SOMETHING THAT WILL BE ONGOING. ONCE NEED HAS BEEN DETERMINED, THE NURSE MANAGER, THE CHIEF RADIATION THERAPIST OR SOCIAL SERVICES COMPLETES THE RESTRICTED GIFT CHECK REQUEST FORM AND OBTAINS APPROVAL FROM THE DIRECTOR OF THE CANCER CENTER. THE CHECK REQUEST FORM IS THEN SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT. THE SVMC PATIENT RESOURCE FUND IS MAINLY USED BY SOCIAL SERVICES TO HELP NON-CANCER PATIENTS WITH THE SAME SORTS OF NEEDS THAT THE OTHER TWO FUNDS ARE USED FOR. CHECK REQUESTS TO ACCESS THIS FUND WOULD BE FILLED OUT BY A SOCIAL SERVICES STAFF MEMBER, APPROVED BY THE HEAD OF SOCIAL SERVICES AND SENT TO THE VP OF DEVELOPMENT FOR HER APPROVAL AND PROCESSING FOR PAYMENT.
FORM 990 REVIEW PROCESS
FORM 990, PART VI, SECTION B, LINE 11B
THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. THE DRAFT 990 IS THEN REVIEWED BY MANAGEMENT AND ACCOUNTING. AFTER ALL SUGGESTED CHANGES FROM MANAGEMENT ARE MADE, THE UPDATED DRAFT FORM 990 IS THEN PRESENTED TO THE FINANCE COMMITTEE. AFTER ANY FINAL CHANGES ARE MADE, THE FORM 990 IS PRESENTED TO THE FULL BOARD OF DIRECTORS BEFORE FILING WITH THE IRS.
MONITORING COMPLIANCE WITH CONFLICT ON INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12C
OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES ARE REQUIRED TO ANNUALLY DISCLOSE INTERESTS WHICH COULD RESULT IN CONFLICTS. THE COMPLIANCE OFFICER MAINTAINS RECORDS ON THE COMPLETION OF THE CONFLICT OF INTEREST FORMS, ANY POTENTIAL CONFLICTS ARE DISCUSSED AT THE AUDIT AND COMPLIANCE MEETING AND THEN RECOMMENDATIONS ARE BROUGHT BEFORE THE FULL BOARD FOR A VOTE. IN THE CASE OF A POTENTIAL CONFLICT OF INTEREST, THE BOARD MEMBER ABSTAINS FROM ALL DISCUSSION AND CONSIDERATION OF THE ITEM THAT PRESENTS THE POTENTIAL CONFLICT.
COMPENSATION REVIEW
FORM 990, PART VI, SECTION B, LINES 15A & 15B
ALL COMPENSATION IS PAID BY SOUTHWESTERN VERMONT MEDICAL CENTER, A RELATED ORGANIZATION. THE BOARD ENGAGES AN OUTSIDE CONSULTING FIRM TO REVIEW COMPARABLE CEO SALARY DATA AND USES NATIONAL PROFESSIONAL ORGANIZATION SURVEY DATA IN THE DETERMINATION OF THE CEO'S SALARY AND BENEFITS. IN ADDITION, THE BOARD ENGAGES AN OUTSIDE CONSULTING FIRM AND ALSO USES NATIONAL PROFESSIONAL ORGANIZATION SURVEY DATA TO REVIEW THE WAGE DATA OF OTHER OFFICERS AND KEY EMPLOYEES. PROCESS BEGINS WITH A REQUEST TO OUR COMPENSATION CONSULTANT MIKE MACIEKOWICH OF ASTRON SOLUTIONS TO PERFORM A MARKET ANALYSIS OF THE CEO POSITION. THIS REPORT IS USED AS THE BASES FOR STRUCTURING COMPENSATION FOR THE CEO DURING THE NEXT CONTRACT PERIOD. USING THE RESULTS OF THE MARKET ANALYSIS WITH INPUT FROM OUR CEO, THE COMPENSATION OFFER FOR THE NEXT CONTRACT PERIOD IS DEVELOPED AND INCORPORATED INTO THE CONTRACT. THE COMPENSATION IS THEN DISCUSSED BY THE GOVERNANCE COMMITTEE OF THE BOARD WITH MIKE MACIEKOWICH IN ATTENDANCE OR ON THE PHONE. IF MIKE MACIEKOWICH IS IN AGREEMENT HE WILL PROVIDE A WRITTEN LETTER CONFIRMING HIS AGREEMENT.
DOCUMENT DISCLOSURE
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
BOARD MEMBER COMPENSATION
FORM 990, PART VII, SECTION A
ERIC SEYFERTH, MD IS AN EMPLOYED PHYSICIAN OF SOUTHWESTERN VERMONT MEDICAL CENTER ("SVMC"), A RELATED ORGANIZATION. WILLIAM TOCK, MD IS ALSO AN EMPLOYED PHYSICIAN OF SVMC, AS WELL AS THE PRESIDENT OF THE MEDICAL STAFF. WILLIAM SARCHINO, MD, REPLACED WILLIAM TOCK AS PRESIDENT OF THE MEDICAL STAFF IN MARCH OF 2012 AND RECEIVED COMPENSATION DURING THE FISCAL YEAR, BUT WAS NOT COMPENSATED DURING THE CALENDAR YEAR. NO TRUSTEE RECEIVES COMPENSATION FOR THEIR SERVICES AS A TRUSTEE OF THE BOARD.
HOURS WORKED FOR RELATED ORGANIZATIONS
FORM 990, PART VII, SECTION A, COLUMN B
ALL TRUSTEES SERVED AN AVERAGE OF 1 HOUR PER WEEK ON THE BOARD OF SOUTHWESTERN VERMONT MEDICAL CENTER ("SVMC") AND MT. ANTHONY HOUSING CORPORATION ("MAHC"), BOTH RELATED ORGANIZATIONS. OFFICER THOMAS DEE SERVED ON THE BOARD OF SOUTHWESTERN VERMONT HEALTH CARE AUXILIARY ("SVHCA"), A RELATED ORGANIZATION, FOR AN AVERAGE OF .20 HOURS PER WEEK. OFFICERS THOMAS DEE, MARK DONOVAN, AND STEPHEN D MAJETICH WORKED AN AVERAGE OF 40 HOURS PER WEEK BETWEEN SVHC, SVMC, AND MAHC AS CHIEF EXECUTIVE OFFICER, CHIEF MEDICAL OFFICER, AND CHIEF FINANCIAL OFFICER, RESPECTIVELY.
OTHER CHANGES IN NET ASSETS
FORM 990, PART XI, LINE 5
$ 4,986,074 NET TRANSFER FROM AFFILIATES ( 24,512) DEFINED BENEFIT PENSION COSTS 143,744 CHANGE IN BENEFICIAL INTEREST IN TRUST ( 41,609) RECOVERY OF PRIOR YEAR PLEDGES 5,420,160 NET UNREALIZED GAIN ON INVESTMENTS -------------- $ 10,483,857 NET ADJUSTMENT
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.