2025-04-23T14:07:01-05:00 2023-06-30 450250958 Eide Bailly LLP 4585 Coleman St Ste 200 Bismarck ND 58503 990 2022-07-01 450222079 Jacobson Memorial Hospital Care Center JACO 7015842792 601 E St N Elgin ND 58533 Scott Brooks CEO 7015842792 2025-04-23 1 1 Lisa Chaffee CPA P00193453 7012551091 2025-04-21 2022 2025-03-06 01:10:19Z Scott Brooks 601 E St N Elgin ND 58533 11438282 0 X www.jacobsonhospital.org X 1949 ND To provide quality healthcare to advance the health of patients and communities we serve. 9 9 134 15 0 0 777869 206368 11547922 11222566 3231 1298 -5227 -669 12323795 11429563 0 0 0 0 6165812 6815166 0 0 0 6980896 6211695 13146708 13026861 -822913 -1597298 9238083 7380677 3908290 3648182 5329793 3732495 X To advance the health of patients and communities we serve through a culture of leadership, continuous improvement and accountability. Jacobson Memorial Hospital Care Center (JMHCC) understands the relationship that exists between body, mind and the human spirit. We believe that respect, integrity, quality, commitment and accountability are the foundation by which a healthcare provider should practice in accordance with respect of this relationship. 0 0 10583492 0 11222566 Jacobson Memorial Hospital Care Center (JMHCC) is a 25 bed non-profit made up of community members from the surrounding areas served by JMHCC. JMHCC's primary activity is to provide health care to Grant County. It provides acute care services, ER, swing bed, and clinical services. JMHCC also provides a wide range of outpatient services such as physical, speech and occupational therapy and cardiac rehab. JMHCC provides non-emergency services through clinics in the communities of Elgin, Glen Ullin, and Richardton, in addition to the emergency services it provides in Elgin. 10583492 1 0 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 46 0 1 134 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 0 X Stephanie LaBrie 7015847339 601 E St N Elgin ND 58533 Leslie Niederman Chairperson (partial year) 1.00 X X 0 0 0 Joel Klein Vice Chair (partial year) 1.00 X X 0 0 0 Ron Bartz Chairperson 1.00 X X 0 0 0 Julie Armijo Vice Chair 1.00 X X 0 0 0 Patrick Diehl Secretary 1.00 X X 0 0 0 Ann Hertz Director 1.00 X 0 0 0 Dennis Sabin Director 1.00 X 0 0 0 Dave Marion Director as of February 2023 1.00 X 0 0 0 Dennis Rivinius Director as of February 2023 1.00 X 0 0 0 Leona Zemliska Director as of February 2023 1.00 X 0 0 0 JoAnn Schatz Director (partial year) 1.00 X 0 0 0 Theo Stoller CEO/Administrator until June 2023 40.00 2.00 X 210382 0 26537 Scott Brooks CEO/Administrator as of Jan 2023 40.00 X 0 0 0 Micaela Meyer CFO 40.00 X 60998 0 5174 Carrie Gerving FNP/COO 32.00 X 135320 0 24762 Elizabeth Sundberg MD 32.00 X 263015 0 15619 April Berger NP 32.00 X 170882 0 26197 Rhonda Schmidt FNP 32.00 X 149381 0 17796 Jolene Engelhart FNP 24.00 X 118074 0 22374 1108052 0 138459 7 0 1 0 Homestead 821 Senior Ave Dickinson ND 58601 Locums 680051 Medical Solutions LLC 1010 N 102nd St STE 300 Omaha NE 68114 Locums 425815 National Medical Resources Inc 2792 E Broadway Ave Bismarck ND 58501 Locums 204527 ARL Inc PO Box 52 Elgin ND 58533 Provider 108550 Bogerosa Inc 4729 Amberglow Dr Bismarck ND 58503 PT Therapist 104069 5 206368 206368 Net Patient Revenue 621110 10798344 10798344 Other Revenue 900099 183909 183909 Management Revenue 900099 149536 149536 Pharmacy Revenue 456110 90777 90777 11222566 1298 1298 8050 8719 -669 -669 -669 11429563 11222566 0 629 X 420854 420854 24407 24407 5414531 4844929 569602 145001 115273 29728 587104 440594 146510 223269 160411 62858 150000 150000 3293683 2551104 742579 181383 134572 46811 2894 2894 241915 178026 63889 119753 108557 11196 740816 671553 69263 175319 83896 91423 Medical Supplies 662186 634678 27508 Other Expenses 334013 334013 Equipment Maintenance 17216 17216 292517 284263 8254 13026861 10583492 2443369 0 624621 630571 2391114 1575366 195984 201875 85513 93981 13450753 9722499 4321335 3728254 214516 231630 1405000 919000 9238083 7380677 1421636 1085984 84516 655 655 2401483 2411543 0 150000 3908290 3648182 X 5313187 3732495 16606 0 5329793 3732495 9238083 7380677 -1597298 0 X 0 1 X 1 1 1 X 0 0 0 0 0 0 0 0 1 1469 1469 0 Part II-B, Line 1: Jacobson Memorial Hospital is a member of the North Dakota Hospital Association. A portion of the dues paid are used for lobbying activities. 0 1 X 13294 13294 7557821 5231542 2326279 5000202 3996857 1003345 879436 494100 385336 3728254 Estimated Third Party Payor Settlement 919000 919000 Claims reserve 150000 150000 X 11104269 -334013 -334013 11438282 -8719 -8719 11429563 12701567 8719 8719 12692848 334013 334013 13026861 Part IV, Line 2b: The Hospital acts as custodian for the funds of the swing bed patients. These funds are included in cash and cash equivalents and accounts payable in the consolidated financial statements. Patient trust funds totaled $655 at June 30, 2023 and 2022. Part X, Line 2: JMHCC believes it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. JMHCC would recognize future accrued interest and penalties related to unrecognized tax liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Other Expenses included with Revenue in Financial Statement -334,013. Part XI, Line 4b - Other Adjustments: Rental Expenses -8,719. Part XII, Line 2d - Other Adjustments: Rental Expenses 8,719. Part XII, Line 4b - Other Adjustments: Other Expenses included with Revenue in Financial Statement 334,013. 1 1 X 1 X 1 X 1 1 0 0 2000 2000 0.00020 714019 306060 407959 0.03130 716019 306060 409959 0.03150 716019 306060 409959 0.03150 1 255988 35838 6357272 6425115 -67843 X 1 1 1 1 Jacobson Memorial Hospital Care Center 601 E St N Elgin ND 58553 www.jacobsonhospital.org 5014 X X X X Jacobson Memorial Hospital Care Center 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X See Part V, Section C X 1 22 1 www.jacobsonhospital.org/About-Us.html 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X 1 X http://www.jacobsonhospital.org/Patients-Visitors.html X http://www.jacobsonhospital.org/Patients-Visitors.html X http://www.jacobsonhospital.org/Patients-Visitors.html X X X X X 1 X 0 X X X X 1 X 0 1 Jacobson Memorial Hospital Care Center Part V, Section B, Line 5: JMHCC had two open to the public meetings where a representative, Bridget Winkler, with Western Plains Public Health participated at both meetings. Western Plains welcomes 'all ages, all beliefs, all colors, all cultures, all genders, all orientations, all religions, all sizes, all people' (https://www.westernplainsph.org). These meetings were advertised via local mediums as being open to any one who would like to attend. Jacobson Memorial Hospital Care Center Part V, Section B, Line 6b: The CHNA was conducted with Western Plains (formerly Custer Health). Jacobson Memorial Hospital Care Center Part V, Section B, Line 11: JMHCC conducted a CHNA during 2022. Needs identified are listed below:- Availability of home health- Ability to recruit and retain primary care providers and nurses- Attracting and retaining young families- Alcohol use and abuse for all agesDuring the fiscal year, the organization has done the following to address the above mentioned needs identified in the most recently conducted CHNA:-JMHCC has started a visiting nurse program.-JMHCC has hired 1 midlevel provider in FY2023. For recruiting, in addition to competitive salaries, we offer sign-on bonuses. For retention, we offer student loan reimbursement and a competitive benefits package.-JMHCC has above average income levels for staff to attract young families to the area. We also offer sign-on bonuses and student loan reimbursement and a competitive benefits package.-JMHCC created and hired for the position of patient financial advocate which will educate patients about Medicaid and long-term care planning.-JMHCC provides home health care via visiting nurse who can provide care in the patient's home.-JMHCC continues to work with agencies to recruit providers and nurses including the potential recruitment of foreign staff.-Recruitment campaign materials have been developed and posted.-JMHCC will continues to conduct employee engagement, such as the monthly employee newsletter, employee of the month recognition and in-house activities such as door decorating, board-sponsored lunches and other activities.-JMHCC has and continues to provide competitive salaries and benefits, incentives such as sign-on bonuses and student loan repayment, and a strong work/life balance.-JMHCC is the largest employer of the area.-JMHCC communicates need through community and civic organizations.The organization will not address the need related to alcohol use and abuse for all ages. There is a local AA program provided through the church, Prairie recovery, located in a nearby town, and our facility has limited resources. Jacobson Memorial Hospital Care Center Part V, Section B, Line 13h: Family size is also a factor in determining amounts charged to patients under the financial assistance policy. Jacobson Memorial Hospital Care Center Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency andother medically necessary care. FAP-eligible patients without insurance may be charged gross charges on elective procedures. Schedule H, Part V, line 7a http://www.jacobsonhospital.org/About-Us.html 3 1 - Elgin Community Clinic 603 E St N Elgin ND 58553 Rural Health Clinic 2 - Glen Ullin Family Medical Clinic 602 E Ash Ave Glen Ullin ND 58631 Rural Health Clinic 3 - Richardton Clinic 215 3rd Ave W Richardton ND 58652 Rural Health Clinic Part I, Line 3c: The organization does offer free care under their charity care policy for people at 100% of the federal poverty guidelines, and they offer discounted care starting at 200% of the Federal Poverty Guidelines. Family size and residency are also a factor in determining discounted care. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. The cost for Medicaid, line 7b was determined using the Cost Report. Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with this class of patients. Part III, Line 3: Approximately 14% of the individuals in Grant county are below the Federal Poverty Guidelines and so we estimate that approximately 14% of the total implicit price concessions is attributable to patients eligible for charity care. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 12-13 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs were obtained from the Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.If there is a Medicare shortfall, then all of the shortfall should be treated as a community benefit. The Organization treats individuals regardless of the ability to pay. Providing Medicare services promotes access to healthcare services which are vitally needed by our community.Hospital services reimbursed on a fee schedule are not included in the Medicare calculation per the 990 instructions. Had this been reported the Hospital would have had a greater loss from Medicare services of $62,420.Medicare fee schedule revenue: $31,224Medicare estimated costs of care relating to payments (93,664)Net (Shortage) $(62,420) Part III, Line 9b: Jacobson Memorial Hospital Care Center (JMHCC) has established a collections policy and procedure to facilitate effective and efficient collections for self-pay balances. When a patient submits an application for charity care, collection proceedings are stopped until a decision is made. If an application is determined to be incomplete, a letter is sent letting the patient know additional information is required. If we still do not receive the additional information in 30 days, the patient is sent a letter stating that their application for charity care has been declined and that collection proceedings could start again if payments are not made. When a complete application is received the finance committee meets, which includes the CEO, CFO, and two board members, and they determine if the patient qualifies for charity care and for how much of a discount. If it is determined that a patient is eligible for charity care they receive a letter stating so with a percentage that they qualified for and amount due. It is communicated that they are still expected to make payments. If a patient is sent to collections and later fills out a charity care application and is found to be eligible for a discount, we would pull the account back from collections and set up a payment plan with the patient. Part VI, Line 2: JMHCC obtains information about the needs of the community through a strategic planning committee made up of representatives from the service area including members of the board of directors, medical staff, hospital administration, hospital staff and community members. These individuals provide the hospital with insight on the issues facing the members of the community. Part VI, Line 3: Jacobson Memorial Hospital Care Center communicates information about the Charity Care Program to its patients and those living within its primary service area, identifies potential applicants and assists the patients that qualify for discounted services with the application process. Jacobson Memorial Hospital Care Center informs the general public within its primary service area of the availability of Charity Care through the following: includes the Charity Care policy in the Patient/Resident Payment Policy provided to all patients at the point of service or admission; posts the policy on community bulletin boards within the Jacobson Memorial Hospital Care Center facilities; posts the policy and information on the Jacobson Memorial Hospital Care Center website; releases general information at least annually in the legal newspaper located within Jacobson Memorial Hospital Care Center's primary service area; and other as deemed appropriate by the Administrator. Part VI, Line 4: According to the data collected while preparing the Community Health Needs Assessment in the Spring of 2022, approximately 30.6% of the population of Grant County is over the age of 65. The median household income in Grant county is significantly lower than for the rest of North Dakota - $56,750 compared to $75,949. Grant County had a population of 2,323 while the city of Elgin had a population of 525. There are no other hospitals that serve the community. In fact, the next nearest hospital is roughly 80 miles away. Part VI, Line 5: Jacobson Memorial Hospital Care Center (JMHCC) has a Board of Directors made up of volunteers and members of the community. JMHCC does extend medical staff privileges to all qualified physicians serving in the community. Net increases in net assets are invested back into facilities and equipment in order to provide better patient care. In addition to our charity care policy, JMHCC provides many other services to meet the needs of those in Grant County which include:-provide office space so that we can continue to offer mental health services to the community on an outpatient basis.-participate in a number of community events every year including annual discounted lab services during hospital week.-participate in a Scrubs Camp sponsored by the Center for Rural Health and many other local health care organizations such as the New Leipzig ambulance and the local pharmacy, vision and dental practices.-operate a 24 hour emergency department that is available to anyone regardless of the ability to pay.-offer volunteer opportunities for capable area residents to come in and give our long term care residents and our swing-bed patients some activities to participate in. X X 0 0 0 0 0 0 0 0 0 Elizabeth Sundberg MD 263015 0 0 0 0 0 9150 0 6476 0 278641 0 0 0 Theo Stoller CEO/Administrator until June 2023 210382 0 0 0 0 0 7131 0 19418 0 236931 0 0 0 April Berger NP 170882 0 0 0 0 0 6790 0 19418 0 197090 0 0 0 Rhonda Schmidt FNP 149381 0 0 0 0 0 4858 0 12949 0 167188 0 0 0 Carrie Gerving FNP/COO 135320 0 0 0 0 0 5355 0 19418 0 160093 0 0 0 Crystal Stoller Family member of Officer Theo Stoller 24407 Compensation as PRN 0 Form 990, Part VI, Section A, line 1a The Executive Committee shall consist of the Board Chairperson, Vice Chairperson, and the Secretary. The Executive Committee shall have power to transact all regular business of the hospital during the period between the meetings of the governing board, subject to any prior limitations imposed by the governing board and with the understanding that all matters of major importance will be referred to the governing board. It shall be the further duty of the Executive Committee to examine the monthly financial reports. Minutes of the Executive Committee meetings shall be submitted to the Board, and its actions shall be subject to approval or disapproval at the next regular board meeting. The board president only votes if there is a tie. Form 990, Part VI, Section A, line 6 There is one class of members. Each member pays a one-time fee of $10 for membership. Form 990, Part VI, Section A, line 7a Each member receives one vote to elect a director to the Hospital Board. Elections take place at the scheduled annual meeting which is held during the last quarter in the calendar year. Form 990, Part VI, Section A, line 7b The by-laws of the corporation may be amended by affirmative vote of a two-thirds (2/3) majority of the members present at the annual meeting or any special meeting of the corporation, provided, that a notice of such proposed amendments shall have been published in the notice calling the meeting, or, the by-laws may be amended by a vote of three-fourths (3/4) of the Board of Directors members. Form 990, Part VI, Section B, line 11b The CEO and CFO reviewed the Form 990 prior to submission and copies were provided to the board prior to filing. The board also reviews the Form 990 at the next scheduled board meeting. Form 990, Part VI, Section B, line 12c Yearly, Officers, Directors and key employees are given the Organization's Conflict of Interest Policy and a Conflict of Interest Acknowledgement Statement in which they must sign. It is the duty of an interested person to disclose the existence of a potential conflict of interest. If any individual discloses a possible conflict, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon by the remaining board or committee members to determine if in fact a conflict of interest exists. If it is found that a conflict exists the conflicted individual is asked to leave the meeting. The remaining board or committee members shall exercise due diligence in determining whether JMHCC can obtain with reasonable efforts a more advantageous transaction or arrangement from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably possible under circumstances not producing a conflict of interest, the Governing Board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in JMHCC's best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the transaction or arrangement. In this fiscal year each affected person signed the policy with no conflicts noted. Form 990, Part VI, Section B, line 15 The compensation of the Hospital Administrator is reviewed and approved by the independent Board of Directors. The Hospital obtains salary surveys from the Long Term Care Association and the North Dakota Hospital Association in deliberating the compensation amount. The compensation determination is presented and approved at a board meeting each year. Compensation for the CFO is reviewed with salary surveys from the NDHA. The CEO does an annual evaluation of the CFO's performance. The CFO falls under the policy for merit based evaluation and raises are based on this. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Part IX, line 11g Contracted Services: Program service expenses 2,551,104. Management and general expenses 742,579. Fundraising expenses 0. Total expenses 3,293,683. Jacobson Memorial Hospital Foundation PO Box 367 Elgin ND 58533 208145158 To support Jacobson Memorial Hospital ND 501(c)(3) Line 7 Jacobson Memorial Hospital Care Center 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0