Civic Intelligence

Lake Champlain Physician Services PC

990 • Fiscal year 2020 • EIN 27-3785445

Oct 01, 2019 to Sep 30, 2020 • Filed on Aug 10, 2021

75 Beekman StreetPlattsburgh, NY 12901

(518) 561-2000

Siviq Scores

Precomputed percentiles for this filing year versus similar nonprofits in the same peer cohort.

Liabilities / Assets

96th percentile

2.99x

Higher debt load relative to assets than 96% of similar nonprofits.

2020 filings • NTEE E • <$500k nonprofits • Source year 2020

Liabilities / Revenue

96th percentile

3.52x

Higher debt load relative to revenue than 96% of similar nonprofits.

2020 filings • NTEE E • <$500k nonprofits • Source year 2020

Net Margin

4th percentile

-451%

Higher net margin than 4% of similar nonprofits.

2020 filings • NTEE E • <$500k nonprofits • Source year 2020

Top Officer Pay

100th percentile

$756,434

Higher top officer pay than 100% of similar nonprofits.

Top officer pay equals 3080.6% of source-year revenue.

2020 filings • NTEE E60 • <$500k nonprofits • Source year 2020

Asset Growth

3rd percentile

-88%

Faster asset growth than 3% of similar nonprofits.

2020 filings • NTEE E • <$500k nonprofits • Annualized from 2019 to 2020

Revenue Growth

6th percentile

-98%

Faster revenue growth than 6% of similar nonprofits.

2020 filings • NTEE E • <$500k nonprofits • Annualized from 2019 to 2020

Assets

Down

$28,921

Down $211,161 (-88%) from 2019

Net Assets

Down

-$57,508

Down $110,840 (-208%) from 2019

Liabilities

Down

$86,429

Down $100,321 (-54%) from 2019

Revenue

Down

$24,555

Down $1,239,858 (-98%) from 2019

Expenses

Down

$135,395

Down $1,122,196 (-89%) from 2019

Net Income

Down

-$110,840

Down $117,662 (-1725%) from 2019

Historical Trend

Balance Sheet Trend

The highlighted filing sits inside the broader history for assets, liabilities, and net assets.

$2.0M$1.0M$0-$1.0M-$2.0MAssets 2011: $160,404Liabilities 2011: $323,116Net Assets 2011: -$162,7122011Assets 2012: $473,365Liabilities 2012: $748,478Net Assets 2012: -$275,1132012Assets 2013: $168,639Liabilities 2013: $1,266,224Net Assets 2013: -$1,097,5852013Assets 2014: $343,880Liabilities 2014: $648,164Net Assets 2014: -$304,2842014Assets 2017: $121,226Liabilities 2017: $0Net Assets 2017: $121,2262017Assets 2018: $310,445Liabilities 2018: $263,935Net Assets 2018: $46,5102018Assets 2019: $240,082Liabilities 2019: $186,750Net Assets 2019: $53,3322019Assets 2020: $28,921Liabilities 2020: $86,429Net Assets 2020: -$57,5082020Assets 2021: $248,126Liabilities 2021: $358,516Net Assets 2021: -$110,3902021Assets 2022: $90,276Liabilities 2022: $264,699Net Assets 2022: -$174,4232022Assets 2023: $90,284Liabilities 2023: $263,415Net Assets 2023: -$173,1312023Assets 2024: $20,000Liabilities 2024: $229,898Net Assets 2024: -$209,8982024

Highlighted filing

2020

Assets$28,921
Liabilities$86,429
Net Assets-$57,508

Operations Trend

Revenue, expenses, and net income across loaded years, with this filing highlighted.

$1.5M$1.0M$500K$0-$500K-$1.0MExpenses 2011: $570,7762011Expenses 2012: $685,3462012Revenue 2013: $330,255Expenses 2013: $861,473Net Income 2013: -$531,2182013Revenue 2014: $689,498Expenses 2014: $633,103Net Income 2014: $56,3952014Revenue 2017: $682,458Expenses 2017: $777,010Net Income 2017: -$94,5522017Revenue 2018: $861,953Expenses 2018: $936,669Net Income 2018: -$74,7162018Revenue 2019: $1,264,413Expenses 2019: $1,257,591Net Income 2019: $6,8222019Revenue 2020: $24,555Expenses 2020: $135,395Net Income 2020: -$110,8402020Revenue 2021: $235,741Expenses 2021: $288,623Net Income 2021: -$52,8822021Revenue 2022: $22,264Expenses 2022: $86,297Net Income 2022: -$64,0332022Revenue 2023: $2,550Expenses 2023: $1,258Net Income 2023: $1,2922023Revenue 2024: $444Expenses 2024: $37,211Net Income 2024: -$36,7672024

Highlighted filing

2020

Revenue$24,555
Expenses$135,395
Net Income-$110,840
Jump To
Filing Snapshot
Filing Period
Oct 1, 2019 to Sep 30, 2020
Signed
Aug 10, 2021
Return Version
2019v5.2
Gross Receipts
$24,555
Mission and Program Overview

Mission

Lake champlain physician services, p.c. Is a professional services company formed to further the charitable purposes of champlain valley physicians' hospital medical center through providing medical services to the community.

Balance Sheet Detail
LineBeginningEndChange
Assets
Cash and Non-Interest-Bearing Accounts$90,196$27,573▼ $62,623
Accounts Receivable$26,777$1,276▼ $25,501
Pd in Cap Srpls Land Bldg Eqp Fund$0$0→ $0
Cap Stk Tr Prin Current Funds$0$0→ $0
Rtn Earn Endowment Incm Other Fnds$53,332$-57,508▼ $110,840
Total Assets$240,082$28,921▼ $211,161
Other Assets Total$123,109$72▼ $123,037
Liabilities
Other Liabilities$186,750$86,429▼ $100,321
Total Liabilities$186,750$86,429▼ $100,321
Net Assets / Fund Balance
Total Net Assets Fund Balance$53,332$-57,508▼ $110,840
Total Liabilities and Net Assets / Fund Balance$240,082$28,921▼ $211,161
Compensation and Service Providers

Board Members and Trustees

NameTitle
Stephens MundyFormer President & CEO
Michelle LebeauPresident/COO
Wouter Jan Rietsema MdShareholder/member
Christopher HickeyVP of Finance
Revenue and Support

Revenue Composition

Contributions and Grants
$3,161
Program Service Revenue
$21,394
Investment Income
$0
Other Revenue
$0
All Other Contributions
$3,161
Change in Net Assets
$-110,840
Expenses and Functional Allocation

Major Expense Lines

Line ItemAmount
Other Expenses$135,395
Grants and Similar Amounts Paid$0
Professional Fundraising Fees$0
Salaries, Compensation, and Employee Benefits$0
Total Fundraising Expense$0

Functional Expense Allocation

Line ItemProgramManagementFundraisingTotal
All Other Expenses$8,865--$8,865
Travel$7,220--$7,220
Fees for Services Management$3,751--$3,751
Fees for Services Accounting$3,504--$3,504
Occupancy$3,354--$3,354
Other Expenses$2,068--$2,068
Insurance$1,101--$1,101
Total Functional Expenses$135,395$0$0$135,395
Fundraising, Events, and Gaming
Fundraising activities
No
Gaming activities
No
Professional fundraiser used
No

Fundraising and Gaming Totals

Line ItemAmount
Professional Fundraising Fees$0
Political and Lobbying Activity
Political campaign activity
No
Lobbying activity
No
Subject to proxy tax
No
Debt and Bond Financing

Other Reported Liabilities

LiabilityAmount
Due to Related Parties$86,429
Governance and Compliance

Governance Checklist

Compiled or reviewed by an accountant
No
Annual disclosure for covered persons
Yes
Audit committee
Yes
Business relationship with 35% controlled entity
No
Business relationship with family members
No
Business relationship with organization members
No
Material changes to governing documents
No
Compensation from other sources disclosed
No
CEO compensation reviewed
Yes
Other officer compensation reviewed
Yes
Conflict-of-interest policy
Yes
Audited financial statements prepared
Yes
Key decisions subject to board approval
No
Management duties delegated
No

Governance Explanations

Form 990, Part VI, Section A, Line 6

Wouter jan rietsema, md is the sole voting member of the organization.

Form 990, Part VI, Section A, Line 7A

According to the shareholders agreement, dr. Rietsema, the sole shareholder and director of lake champlain physician services, p.c., is required to vote all of his shares to elect, or remove, as directors those individuals designated by the board of directors of the medical center.

Form 990, Part VI, Section B, Line 11B

Lake champlain physician services, p.c. Provides an electronic copy of form 990 to each board member prior to the form being filed.

Form 990, Part VI, Section B, Line 12C

Lake champlain physician services, p.c. Has a written conflict of interest policy as a part of its governing documents. The policy is applicable to members of the governing body, officers and key employees. The organization requires that members having a conflict of interest in a transaction recuse themselves of voting on the matter. Proposed and ongoing transactions are reviewed by appropriate groups of indiviuals (committees and/or levels of review) to ensure the best interest of the hospital. The organization solicits from each member of the governing body, officers, and key employees an annual signed statement certifying compliance with the organization's conflict of interest policy and self-disclosure of certain interest for each annual period.

Form 990, Part VI, Section B, Line 15

Lake champlain physician services, p.c. Has a formal process that is used to determine the compensation of the ceo on an annual basis. This process includes a compensation committee of the board of trustees, engaging an independent consultant, performance of a compensation survey or study, review of other organization's 990 forms, and approval by the board of compensation committee. A written employment agreement is established setting forth the compensation and benefits of the ceo. Lake champlain physician services, p.c. Pays non-fixed earnings based on the success in meeting performance criteria that are prospectively agreed upon as goals for the ceo. Part b: the same formal process noted in 15(a) above is used to determine the base compensation of other officers. Non-fixed earnings of other officers are based on the success in meeting performance criteria and comparative market data. In addition to the tools and processes identified in schedule j, part i, champlain valley physicians hospital receives guidance regarding its president's compensation from the compensation committee of the board of trustees of the university of vermont health network, which is the sole member of the hospital. That network compensation committee utilizes the following methods to establish that guidance: -compensation committee -independent compensation consultant -compensation survey or study -approval by the board or compensation committee

Form 990, Part VI, Section C, Line 19

Lake champlain physician services, p.c. Makes its governing documents, conflicts of interest policy, and financial statements available to the public upon request. Parties desiring copies of such documents must present themselves at the administrative offices of lake champlain physician services, p.c. Or by sending a request in writing to the administrative offices. The organization has instructions posted on its website for those seeking copies of documents.

Filing and Contact Details

Filer

Filer Name
Lake Champlain Physician Services Pc
EIN
27-3785445
Phone
5185612000
Address
75 BEEKMAN STREET, PLATTSBURGH, NY 12901

Signing Officer

Name
Christopher Hickey
Title
Vice President of Finance
Phone
5185612000
Signed
2021-08-10
Discuss with paid preparer
Yes

Organization Details

Principal Officer
Wouter Rietsema
Formed
2010
Legal Domicile
Ny
Voting Board Members
1
Independent Board Members
1
Employees
0
Volunteers
0

Preparer

Firm
Fust Charles Chambers Llp
Address
5784 WIDEWATERS PARKWAY, SYRACUSE, NY 13214
Preparer
Thomas J Giufre
Phone
3154463600
Supplemental Narrative

Additional Explanations

FORM 990, PART XII, LINE 2C:

The process has not changed from the prior year.

Financial Statement Notes

PART X, LINE 2:

The system consists of not-for-profit corporations under section 501(c)(3) of the internal revenue code (the code) and are exempt from federal income taxes on related income pursuant to section 501(a) of the code. As of september 30, 2020, the system did not have any unrecognized tax benefits or any related accrued interest or penalties. The tax years open to examination by federal and state taxing authorities are 2017 through 2020.

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IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/PersonNm0WOUTER JAN RIETSEMA MD
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/PersonNm1CHRISTOPHER HICKEY
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/PersonNm2MICHELLE LEBEAU
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/PersonNm3STEPHENS MUNDY
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/TitleTxt0SHAREHOLDER/MEMBER
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/TitleTxt1VP OF FINANCE
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/TitleTxt2PRESIDENT/COO
IRS990ScheduleJ/RltdOrgOfficerTrstKeyEmplGrp/TitleTxt3FORMER PRESIDENT & CEO
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IRS990ScheduleJ/SupplementalInformationDetail/ExplanationTxt0TRAVEL FOR COMPANIONS: TOTAL TRAVEL COSTS FOR COMPANION OF THE CEO OF LESS THAN $1,000 IS ALLOWED TO BE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVES THIS BENEFIT.
IRS990ScheduleJ/SupplementalInformationDetail/ExplanationTxt1TRAVEL FOR COMPANIONS: TOTAL TRAVEL COSTS FOR COMPANION OF THE CEO OF LESS THAN $1,000 IS ALLOWED TO BE INCURRED AND REIMBURSED BY CVPH MEDICAL CENTER. NO OTHER BOARD MEMBER, OFFICER, DIRECTOR, OR KEY EMPLOYEE RECEIVES THIS BENEFIT.
IRS990ScheduleJ/SupplementalInformationDetail/ExplanationTxt2IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
IRS990ScheduleJ/SupplementalInformationDetail/ExplanationTxt3STEPHENS MUNDY, PRESIDENT & CFO OF CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER, SEPARATED FROM SERVICE ON JULY 1, 2018. IN ACCORDANCE WITH THE SEPARATION AGREEMENT, HE IS ENTITLED TO 18 MONTHS CONTINUATION OF SALARY AND CONTINUATION OF CERTAIN BENEFITS. IN 2019 HE RECEIVED PAYMENTS IN LIEU OF BENEFIT CONTINUATION PLUS SALARY CONTINUATION PAYMENTS TOTALLING $734,021. A DISTRIBUTION TO WOUTER RIETSEMA IN THE AMOUNT OF $18,831 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MR. RIETSEMA'S TAXABLE COMPENSATION. A DISTRIBUTION TO MICHELLE LEBEAU IN THE AMOUNT OF $95,039 WAS MADE FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE AMOUNT WAS INCLUDED IN MS. LEBEAU'S TAXABLE COMPENSATION.
IRS990ScheduleJ/SupplementalInformationDetail/ExplanationTxt4DURING 2020, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL MEDICAL CENTER CONTINUED A COMPENSATION INCENTIVE PLAN FOR MANAGEMENT OF THE ORGANIZATION. THE PLAN SETS FORTH NUMEROUS OBJECTIVES AND GOALS (16) TO BE MET IN ORDER TO EARN AN INCENTIVE AWARD. EACH OF THE GOALS ARE AIMED AT IMPROVING THE EXPANSE OF CVPH'S SERVICE OFFERINGS, QUALITY OF SERVICE AND OPERATION, AND MEETING COMMUNITY NEEDS. ONLY ONE OF THE 16 OBJECTIVES INCLUDED IN THE 2020 PLAN IS KEYED TO NET MARGIN OF THE ORGANIZATION. THIS MEASURE IS INTENDED TO MEET THE OVERALL GOAL OF MAINTAINING THE FINANCIAL HEALTH OF THE ORGANIZATION. OTHER GOALS IN THE PLAN ARE TO IMPROVE PATIENT & EMPLOYEE SATISFACTION.
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IRS990ScheduleJ/SupplementalInformationDetail/FormAndLineReferenceDesc2PART I, LINE 3
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IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt0WOUTER JAN RIETSEMA, MD IS THE SOLE VOTING MEMBER OF THE ORGANIZATION.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt1ACCORDING TO THE SHAREHOLDERS AGREEMENT, DR. RIETSEMA, THE SOLE SHAREHOLDER AND DIRECTOR OF LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C., IS REQUIRED TO VOTE ALL OF HIS SHARES TO ELECT, OR REMOVE, AS DIRECTORS THOSE INDIVIDUALS DESIGNATED BY THE BOARD OF DIRECTORS OF THE MEDICAL CENTER.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt2LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PROVIDES AN ELECTRONIC COPY OF FORM 990 TO EACH BOARD MEMBER PRIOR TO THE FORM BEING FILED.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt3LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. HAS A WRITTEN CONFLICT OF INTEREST POLICY AS A PART OF ITS GOVERNING DOCUMENTS. THE POLICY IS APPLICABLE TO MEMBERS OF THE GOVERNING BODY, OFFICERS AND KEY EMPLOYEES. THE ORGANIZATION REQUIRES THAT MEMBERS HAVING A CONFLICT OF INTEREST IN A TRANSACTION RECUSE THEMSELVES OF VOTING ON THE MATTER. PROPOSED AND ONGOING TRANSACTIONS ARE REVIEWED BY APPROPRIATE GROUPS OF INDIVIUALS (COMMITTEES AND/OR LEVELS OF REVIEW) TO ENSURE THE BEST INTEREST OF THE HOSPITAL. THE ORGANIZATION SOLICITS FROM EACH MEMBER OF THE GOVERNING BODY, OFFICERS, AND KEY EMPLOYEES AN ANNUAL SIGNED STATEMENT CERTIFYING COMPLIANCE WITH THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND SELF-DISCLOSURE OF CERTAIN INTEREST FOR EACH ANNUAL PERIOD.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt4LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. HAS A FORMAL PROCESS THAT IS USED TO DETERMINE THE COMPENSATION OF THE CEO ON AN ANNUAL BASIS. THIS PROCESS INCLUDES A COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, ENGAGING AN INDEPENDENT CONSULTANT, PERFORMANCE OF A COMPENSATION SURVEY OR STUDY, REVIEW OF OTHER ORGANIZATION'S 990 FORMS, AND APPROVAL BY THE BOARD OF COMPENSATION COMMITTEE. A WRITTEN EMPLOYMENT AGREEMENT IS ESTABLISHED SETTING FORTH THE COMPENSATION AND BENEFITS OF THE CEO. LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. PAYS NON-FIXED EARNINGS BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA THAT ARE PROSPECTIVELY AGREED UPON AS GOALS FOR THE CEO. PART B: THE SAME FORMAL PROCESS NOTED IN 15(A) ABOVE IS USED TO DETERMINE THE BASE COMPENSATION OF OTHER OFFICERS. NON-FIXED EARNINGS OF OTHER OFFICERS ARE BASED ON THE SUCCESS IN MEETING PERFORMANCE CRITERIA AND COMPARATIVE MARKET DATA. IN ADDITION TO THE TOOLS AND PROCESSES IDENTIFIED IN SCHEDULE J, PART I, CHAMPLAIN VALLEY PHYSICIANS HOSPITAL RECEIVES GUIDANCE REGARDING ITS PRESIDENT'S COMPENSATION FROM THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES OF THE UNIVERSITY OF VERMONT HEALTH NETWORK, WHICH IS THE SOLE MEMBER OF THE HOSPITAL. THAT NETWORK COMPENSATION COMMITTEE UTILIZES THE FOLLOWING METHODS TO ESTABLISH THAT GUIDANCE: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt5LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. MAKES ITS GOVERNING DOCUMENTS, CONFLICTS OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. PARTIES DESIRING COPIES OF SUCH DOCUMENTS MUST PRESENT THEMSELVES AT THE ADMINISTRATIVE OFFICES OF LAKE CHAMPLAIN PHYSICIAN SERVICES, P.C. OR BY SENDING A REQUEST IN WRITING TO THE ADMINISTRATIVE OFFICES. THE ORGANIZATION HAS INSTRUCTIONS POSTED ON ITS WEBSITE FOR THOSE SEEKING COPIES OF DOCUMENTS.
IRS990ScheduleO/SupplementalInformationDetail/ExplanationTxt6THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc0FORM 990, PART VI, SECTION A, LINE 6
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc1FORM 990, PART VI, SECTION A, LINE 7A
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc2FORM 990, PART VI, SECTION B, LINE 11B
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IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc5FORM 990, PART VI, SECTION C, LINE 19
IRS990ScheduleO/SupplementalInformationDetail/FormAndLineReferenceDesc6FORM 990, PART XII, LINE 2C:
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IRS990ScheduleR/IdRelatedOrgTxblCorpTrGrp/DirectControllingEntityName/BusinessNameLine1Txt2UVMHN VENTURES
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