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Carlos G Otis Health Care Center
Townshend, VT 05353
|Bed count||19||Medicare provider number||471300||Member of the Council of Teaching Hospitals||YES||Children's hospital||NO|
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)
(as % of total functional expenses)
Community Benefit Expenditures: 2021
All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Operating expenses $ 31,503,356 Total amount spent on community benefitsas % of operating expenses $ 3,566,92811.32 %
- Amount spent in the following IRS community benefit categories:
Financial Assistance at costas % of operating expenses $ 241,8460.77 % Medicaidas % of operating expenses $ 3,200,71210.16 % Costs of other means-tested government programsas % of operating expenses $ 00 % Health professions educationas % of operating expenses $ 00 % Subsidized health servicesas % of operating expenses $ 00 % Researchas % of operating expenses $ 00 % Community health improvement services and community benefit operations*
as % of operating expensesNote: these two community benefit categories are reported together on the Schedule H, part I, line 7e.
$ 116,0630.37 % Cash and in-kind contributions for community benefit*as % of operating expenses $ 8,3070.03 % Community building*
as % of operating expenses
$ 00 %
- * = CBI denoted preventative categories
- Community building activities details:
Did tax-exempt hospital report community building activities? Not available Number of activities or programs (optional) 0 Physical improvements and housing 0 Economic development 0 Community support 0 Environmental improvements 0 Leadership development and training for community members 0 Coalition building 0 Community health improvement advocacy 0 Workforce development 0 Other 0 Persons served (optional) 0 Physical improvements and housing 0 Economic development 0 Community support 0 Environmental improvements 0 Leadership development and training for community members 0 Coalition building 0 Community health improvement advocacy 0 Workforce development 0 Other 0 Community building expense
as % of operating expenses
$ 00 % Physical improvements and housingas % of community building expenses $ 0 Economic developmentas % of community building expenses $ 0 Community supportas % of community building expenses $ 0 Environmental improvementsas % of community building expenses $ 0 Leadership development and training for community membersas % of community building expenses $ 0 Coalition buildingas % of community building expenses $ 0 Community health improvement advocacyas % of community building expenses $ 0 Workforce developmentas % of community building expenses $ 0 Otheras % of community building expenses $ 0 Direct offsetting revenue $ 0 Physical improvements and housing $ 0 Economic development $ 0 Community support $ 0 Environmental improvements $ 0 Leadership development and training for community members $ 0 Coalition building $ 0 Community health improvement advocacy $ 0 Workforce development $ 0 Other $ 0
Other Useful Tax-exempt Hospital Information: 2021
In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.
Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt
as % of operating expenses
$ 518,6351.65 % Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program? NO
- Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2022 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.
Does the organization have a written financial assistance (charity care) policy? YES Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients? YES Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy
as % of operating expenses
$ 23,5964.55 %
- Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Reported to credit agency Not available
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
After enactment of the ACA, has the state in which this tax-exempt hospital is located expanded Medicaid? YES
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
If not, is the state's Medicaid threshold for working parents at or below 76% of the federal poverty guidelines? Not available
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.
Does the state in which the tax-exempt hospital is located have a mandatory community benefit reporting statute? YES
Community Health Needs Assessment Activities: 2021
The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.
Did the tax-exempt hospital report that they had conducted a CHNA? YES Did the CHNA define the community served by the tax-exempt hospital? YES Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital? YES Did the tax-exempt hospital make the CHNA widely available (i.e. post online)? YES Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA? YES
Supplemental Information: 2021
- Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4A (Expenses $ 28533693 including grants of $ 0) (Revenue $ 29588353) Grace Cottage Hospital is a critical access hospital offering 24-hour emergency services, inpatient acute and skilled care, 24-hour diagnostic imaging services, a full-service laboratory, a pharmacy, a variety of outpatient medical care services, including physical therapy, occupational therapy, and speech therapy, and a rural health clinic providing primary care and psychiatric services.
Grace Cottage Hospital Part V, Section B, Line 5: As required by Vermont statute and Treasury Regulation 501(r), Grace Cottage Hospital conducts a Community Health Needs Assessment (CHNA) every three years. Our most recent CHNA was done collaboratively in 2021 with Brattleboro Memorial Hospital (BMH) and the Brattleboro Retreat. These three healthcare organizations focused on involving as many stakeholders and community members as possible in the data collection process, which took place from January to June 2021. Secondary data was collected from multiple sources including: U.S. Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, U.S. Census, National Institute of Health, Feeding America, Vermont Department of Health, Vermont Department of Labor, Vermont Department of Education, Vermont Department of Transportation, Vermont Foodbank, Vermont Town and County Data Pages, and the Windham Regional Commission. The secondary data was benchmarked against state and national trends, where possible. Primary data was obtained through a consumer survey and a secondary survey of representatives of medically underserved populations. The consumer survey was distributed in both paper copy as well as online. In total, 2,194 surveys were collected for Windham County. The secondary survey was held to collect qualitative data on at-risk populations. The following medically underserved populations were represented in the secondary survey: - Elderly/Senior Population - HIV+ Individuals - Homeless Population - Refugees & Migrants - LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning Individuals) - Racial and Ethnic Minority Populations - Terminally ill individuals - Low-income individualsThe three hospitals set up a steering committee made up of individuals from the State of Vermont Department of Health, Brattleboro Memorial Hospital, Grace Cottage Hospital, and The Brattleboro Retreat. Additionally, the participating organizations engaged a wide range of stakeholders through the surveys, including health care providers, human service organizations, and other nonprofit organizations. Grace Cottage identified the following as High Priority Significant Health Needs in our service area: Mental Health Issues (Anxiety, Depression, Social Isolation, Stress), Substance Abuse, and Nutritional Fitness/Diabetes.The 2022 (tax year 2021) Community Health Needs Assessment was adopted by the Grace Cottage Board of Trustees on July 16, 2021, and the Implementation Plan was approved by the Board on November 19, 2021. An updated Implementation Plan is available for public viewing at:https://gracecottage.org/about-us/our-hospital/community-health-needs-assessment/
Grace Cottage Hospital Part V, Section B, Line 6a: The 2021 Community Health Needs Assessment was conducted with Brattleboro Memorial Hospital and The Brattleboro Retreat.
Grace Cottage Hospital Part V, Section B, Line 11: Please refer to the 2021 CHNA Implementation Plan for information on how the Hospital is addressing the significant needs identified in its most recently conducted CHNA. Additionally, the 2022 Annual Update to the Implementation Plan may be found on our website at:https://gracecottage.org/wp-content/uploads/2023/03/CHNA-Update-2022.pdfWhile a significant health need in our service area, Grace Cottage Hospital is not addressing dental issues as we do not provide dental services. The Level 2 & 3 Priorities identified in the 2021 CHNA - Healthy Aging, High Blood Pressure, Cancer (especially colon cancer), Arthritis, Basic Needs, and Physical Fitness - are addressed with all patients on an on-going and personal basis.
Grace Cottage Hospital Part V, Section B, Line 13b: Generally, Grace Cottage Hospital uses the Federal Poverty Guidelines to determine eligibility for financial assistance. However, applications may be reviewed on a case-by-case basis and at times financial assistance granted even if a patient is above the prescribed FPG level or qualifies only for a lesser reduction in fees if there is a prevailing circumstance that justifies additional financial support.
Grace Cottage Hospital Part V, Section B, Line 20e: Grace Cottage Hospital (GCH) located in rural, mountainous Townshend, VT provides services to patients, whether a community member, second homeowner, or vacationer, through our Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation. Taking pride in the community we serve, we make every attempt possible to notify patients of the Reduced Fee Program and Formal Payment Plan options at GCH that will allow patients to receive care without undue hardship. The following are some of the steps currently in place, to notify patients of the available options:- All registration areas of the Critical Access Hospital, Rural Health Clinic, and Outpatient Rehabilitation Services have visible signs on display notifying patients of our Reduced Fee Program.- All registration staff upon verification of no insurance, limited insurance coverage with high patient responsibility portions, or communication from patient indicating difficulty with paying bill, will offer a Reduced Fee Application, Policy, and business card for our Resource Advocate, identifying the many services she provides to patients free of charge and her contact information. Staff will also offer to schedule an appointment for the patient with Resource Advocate for assistance in completing the Reduced Fee Application, troubleshooting issues with insurance, and/or applying for insurance coverage whether it is primary or secondary.- Patients receive at least 5 billing statements over the course of 120-day time frame (patients in a formal payment plan or whom have a billing issue arise may increase the number of statements to be received or increase the number of days to complete the 5 billing statement cycle). Every statement has a message that notifies them of the Reduced Fee Program and steps to take to get started.- Once a patient balance is past due (>30 days from date of first patient billing) Patient Accounts Specialists contact patients via phone in an attempt to alert patient to past due balance, offer a formal payment plan if balance unable to be paid in full. If/when patient indicates difficulty in paying their bill, Patient Accounts Specialists will notify patient of the Reduced Fee Program and offer to mail the application and policy to them. Patient Accounts Specialists note patients account with a briefing of the phone call. If a patient balance is aged >120 days from the date of the first billing statement and a potential to be sent to a third- party collections agency the account is reviewed, if there is a note from patient accounts indicating a Reduced Fee application and policy have been mailed to the patient within the last 45 days a hold will be placed on transferring the balance to the third-party collections agency. After 45-60 days if no Reduced Fee application or communication from the patient the balance will be transferred to the third-party collections agency at that time.- All Reduced Fee applications are processed with required documentation to determine eligibility in accordance with our Sliding Fee Scale based on Federal Poverty Guidelines. If missing required documents, a written request is sent to the patient and application held while awaiting documents. All processed applications are filed, written notice of eligibility is mailed to the patient, eligibility is noted on patient's account and adjustments are made manually after insurance processing and prior to a billing statement being mailed to the patient, and all applications are documented on a yearly spreadsheet showing household members, date of application (eligibility begin date), expiration date, whether they are eligible, percentage they are eligible for, and comments for case by case applications that identifies parameters for this approval/denial i.e.: only one date of service.
Schedule H, Part V, Section B, Line 7a, 7b and 10a: The Hospital's 2021 (tax year 2020) CHNA is available at: https://gracecottage.org/pdf/2021-CHNA-Report-9-10-21.pdfAdditionally, the 2022 Updates to the Hospital's Needs Assessment is available at:https://gracecottage.org/wp-content/uploads/2023/03/CHNA-Update-2022.pdfThe Hospital's 2021 CHNA Implementation Plan is available at: https://gracecottage.org/wp-content/uploads/2022/06/2021-CHNA-Implementation-Plan-Final-11-19-21.pdfThe Hospital's 2020 Annual Update to the Implementation Plan is available at: https://gracecottage.org/wp-content/uploads/2021/09/GCH-CHNA-Report-for-2020_final.pdf
Schedule H, Part V, Section B, Line 16a-16c: The Hospital's Financial Assistance Policy is available on its website at: https://gracecottage.org/wp-content/uploads/2021/01/16.0050-REDUCED-FEE-FREE-CARE-POLICY-rev-1-2021.pdfThe Hospital's Financial Assistance Application is available on its website at: https://gracecottage.org/wp-content/uploads/2019/08/16.0050-REDUCED-FEE-FREE-CARE-APPLICATION.pdfThe Hospital's Plain Language Summary is available on its website at: https://gracecottage.org/wp-content/uploads/2022/02/16.0050-REDUCED-FEE-FREE-CARE-PLAIN-LANGUAGE-SUMMARY-updated-2-21-22.pdf
Part I, Line 3c: N/A
Part I, Line 6a: N/A
Part I, Line 7: The amounts reported for Charity Care and Means-Tested Government Programs were calculated using a cost-to-charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges.
Part I, Line 7g: N/A
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 $ 777,211.
Part II, Community Building Activities: See previous and subsequent narrative responses.
Part III, Line 2: The cost of the bad debt expense reported on line 2 was calculated by applying the ratio of patient care cost-to-charges (calculated on Worksheet 2) to the total bad debt expense. The amount of bad debt expense for accounts written off as bad debt is the account balance after all charity care discounts, contractual allowances, and insurance/patient payments have been applied. Any cash collected on accounts previously written off is included as an offset to bad debt expense.
Part III, Line 3: The amount of bad debt expense (at cost) attributable to patients eligible under our charity care policy reported on line 3 was estimated based on a review of Reduced Fee/Free Care Applications. The number of approved completed applications versus the number of incomplete applications was compared and a ratio applied to the Charity Care balance to estimate this number. It is felt that this estimate should actually be much higher because, though we work hard to educate our patients regarding the charity care policy, including having a Resource Advocate to help patients complete them if they require assistance, many of the applications we distribute to patients are not returned. Knowing our patient population as we do, we believe it is primarily attributable to patients not wanting to share the income information.
Part III, Line 4: Footnote 1 of the Organization's audited financial statements detail the Organization's significant accounting policies, including the Organization's treatment of accounts receivable and uncollectible amounts.
Part III, Line 8: Medicare allowable costs reported in the Medicare Cost Report are reported in accordance with CMS Guidelines using the cost-to-charge ratio methodology. As a Critical Access Hospital (CAH), the Organization is eligible for reimbursement of up to 101% of allowable Medicare costs and services. However, in previous years, the Organization was subject to a 2% Medicare Sequestration, which resulted in a Medicare Shortfall reported on its Form 990, Schedule H, Part III, Section B. The 2% Medicare Sequestration was temporarily suspended in May, 2020 as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, and reinstated in 2022. For its year ending September 30, 2022, the Hospital was able to claim the full 101% Medicare revenue rate for the first six months, 100% for the next three months, and only 99% for the last three months.
Part III, Line 9b: Grace Cottage Hospital does not pursue collections actions against patients for amounts qualified for financial assistance. If a patient is unable to pay a balance in full after reduced fees and financial assistance have been applied, the patient is required to setup an acceptable payment plan per the collections policy. Any patient making acceptable monthly payments on their balance will not be at risk for further collections actions and/or forfeiture of their reduced fee care or financial assistance. However, any balance remaining after that discount that goes unpaid as agreed upon will follow the collections actions outlined in the Hospital's collection policy. Failure to resolve the balance in full or any missed payments will result in forfeiture of reduced fees and/or financial assistance, and the patient's account will be placed with a collections agency for further action. Additionally, the patient will not be eligible for reduced fees or financial assistance until a substantial effort is put forth to rectify the outstanding balance.
Part VI, Line 2: Grace Cottage Hospital is such a small hospital in a rural, relatively sparsely populated area that our community leaders, patients, and members of the public are quick to inform our administrators and our medical staff about how Grace Cottage serves the healthcare needs of the public. Grace Cottage's small size ensures that we can be responsive to community requests made via our website, our monthly e-newsletter from the CEO to 2700+ community members, e-mails to members of our staff, or informal face-to-face meetings with people in the communities we serve.
Part VI, Line 3: Although we are Vermont's smallest Critical Access Hospital, Grace Cottage Hospital believes that quality health care should be available to all; and that we all have a responsibility to help others in need regardless of their ability to pay. Posters and brochures detailing the availability of help with billing, public programs, and charity care are displayed in high traffic areas throughout the Hospital, rural health clinic and pharmacy, as well as listed on the Hospital's website. The staff reaches out to patients in a variety of ways to ensure that they are aware that help is available. During fiscal year 2022, the Hospital continued to employ a Patient Resource Advocate to help uninsured and underinsured patients locate and procure services for which they may qualify. The Patient Resource Advocate's services are free of charge for community members (those 65 and older were also encouraged to contact Senior Solutions, formerly Southeastern Vermont Council on Aging). The Hospital's Patient Resource Advocate helps many people with a wide variety of resource issues, helping to fill out necessary forms and making connections for patients with other federal, state and local resources. This employee is an expert in filling out reduced fee applications, finding sources for reduced-cost or free prescription medications, and locating other avenues of support.
Part VI, Line 6: N/A
Part VI, Line 7, Reports Filed With States VT
Part VI, Line 4: "Grace Cottage Hospital plays a vital role in healthcare for this rural, mountainous community. Its federal designation as a critical access hospital recognizes its importance in providing health care to an otherwise medically underserved community. The Hospital's emergency department is especially vital to members of the community, who would otherwise have to travel many miles on winding, mountainous highways to reach emergency medical care at another hospital. Grace Cottage Hospital is located in Windham County, in southeastern Vermont. According to the U.S. Census Bureau, Windham County has an estimated total of 43,714 residents. Grace Cottage Hospital's patient base is approximately 26,000 residents, mostly from 21 surrounding towns. The median household income of Windham County, Vermont, is $50,917 (U.S. Census Bureau ""Quick Facts,"" updated 2016). Income statistics for the total population served by Grace Cottage Hospital are not available because Grace Cottage only requires income information from patients requesting reduced fees or free care."
Part VI, Line 5: Grace Cottage Hospital is a Critical Access Hospital located in rural, mountainous Townshend, Vermont. The Hospital is served by a Board of Trustees consisting of local citizens active in community businesses and organizations. Only one of the twelve trustees, a physician, is a hospital employee. All trustees reside or work in the Hospital's service area and bring a wealth of community input to the Hospital's strategic planning process. The Hospital extends medical staff privileges to all qualified physicians in the community.Grace Cottage Hospital applies any surplus funds towards improving its ability to provide quality patient care and being an integral part of assuring the health and well-being of the communities we serve. For example, in view of the fact that Mental Health was identified as a High Priority Significant Need in our Community Health Needs Assessment, Grace Cottage continues to employ both a full-time psychiatric nurse practitioner and a full-time licensed clinical social worker. Both professionals are embedded in the family health practice, where they are key players in the healthcare team. Despite its small size, Grace Cottage Hospital is committed to giving back to the community to the greatest extent possible. Grace Cottage's Community Health Team has been able to provide free consultations, open to everyone in the community served by Grace Cottage. Members of the Community Health Team include a Diabetes Educator and an RN Care Coordinator. Grace Cottage Hospital is a very active partner in numerous community collaborations and programs, including (but not limited to): - West River Valley Thrives: supporting and promoting healthy lifestyle choices, with an emphasis on the prevention of alcohol, tobacco, and other drug use by young people. - Townshend Community Hope and Action: promoting a healthy, connected community through area events and education. - West River Valley Food Group/Vermont Food Bank: organizing the procurement and distribution of food to those in need. A Veggie Van Go truck hosted by Grace Cottage comes from the Vermont Food Bank to Newfane once a month for free food distribution of fresh produce and other healthy food items. No proof of eligibility is required. On average, 200 individuals take the free food home to their families. - Windham County Consortium on Substance Use (COSU) is a multi-agency collaboration which focuses efforts and education/awareness within communities to address the devastating impacts of heroin, fentanyl and other substances on Windham County. Highlights include: collaborative prevention, harm reduction, treatment and recovery efforts. These efforts are bolstered by a three-year, $1 million federal Health Resources & Services Administration (HRSA) grant as well as a VT Department of Health Community Action grant through the Centers for Disease Control & Prevention, both awarded to COSU and its fiscal agent, Health Care & Rehabilitation Services of Southeastern Vermont, Inc. (HCRS), starting on September 1st, 2019. COSU ended its collaboration at the completion of the grant cycle in August of 2022. Some of the agencies chose to carry on this important work, and have formed a new consortium called Community Substance Use Response (COSU); Grace Cottage is a collaborating partner with this consortium. -Accountable Communities for Health: a network of partners that support measurable improvement in meeting the needs of families and individuals in our community. Focus is developing systems to improve community health and well-being; supporting appropriate use of resources; and improving access to community services. - Community Wellness: Beginning in March, 2020, Wellness activities were suspended due to the COVID-19 pandemic, and were not resumed until May 2022. Current programs offered include: strong bones exercise classes, beginner Tai Chi, and advanced Tai Chi. In addition, area non-profit organizations providing health-related and emergency preparedness-related services to the community are provided with meeting and training space at the Hospital. In response to the last Community Health Needs Assessment, the Hospital has worked collaboratively with local schools and organizations to promote healthy, fun activities and provides opportunities that make the most of staying as healthy as possible. Heavily promoted activities included a 5K in the spring and a 17-mile bike ride in the summer. Grace Cottage Hospital plays a pivotal role in Emergency/Disaster Preparedness in this rural, mountainous area of Windham County, Vermont. The Hospital works collaboratively with: - the local town volunteer fire and first responder rescue departments; - the regional ambulance service, Rescue Inc.; - Windham County Regional Commission - the Local Emergency Planning Committee covering the towns that Grace Cottage serves; - the local Citizens Emergency Response Team (CERT); - the local Radio Amateur Civil Emergency Service (RACES) - West River Radio Club meets and stores equipment at Grace Cottage Hospital; - Vermont Association of Hospitals and Health Systems; - Vermont Department of Health.Grace Cottage Hospital staff participate in onsite training for disaster preparedness as well as offsite training with other hospitals.