2023-10-31T17:03:11-05:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2022-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 KATIE WERNER CFO 7012658461 2023-10-31 1 KATIE WERNER 999009999 0 MACKENZIE MCNAUGHTON P02025805 6123764500 2023-10-31 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z LISA LETEXIER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 20826510 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. 10 10 193 14 0 0 3802058 871996 20811684 19750390 11280 12262 276599 191862 24901621 20826510 0 0 0 0 10516219 9489922 0 0 72390 10224439 9601271 20740658 19091193 4160963 1735317 19661768 20778796 2986789 2368500 16674979 18410296 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 16840311 0 19750390 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20 BED ACUTE CARE HOSPITAL, 40 BED NURSING HOME, A RURAL HEALTH CLINIC, AND 20 UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24 HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY AND PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. 16840311 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 34 0 193 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X KATIE WERNER 7012656281 301 MOUNTAIN ST E CAVALIER ND 58220 TOM VAUGHN PRESIDENT 0.80 0.00 X X 0 0 0 GEORGE WRIGHT VICE PRESIDENT 0.80 0.00 X X 0 0 0 DUANNE DERAAS SECRETARY/TREASURER 0.80 0.00 X X 0 0 0 TOM O'TOOLE DIRECTOR (THRU JUNE 22) 0.80 0.00 X 0 0 0 GORDON JOHNSON DIRECTOR 0.80 0.00 X 0 0 0 NICOLE SAFRANSKI DIRECTOR 0.80 0.00 X 0 0 0 KENNETH SCHWANDT DIRECTOR 0.80 0.00 X 0 0 0 DR KULVINDER SUMRA DIRECTOR 0.80 0.00 X 0 0 0 SUSAN THOMPSON MEDICAL STAFF PRESIDENT 40.00 0.00 X X 121347 0 0 DARIN OTTO DIRECTOR 0.80 0.00 X 0 0 0 GRETTA BEARD DIRECTOR 0.80 0.00 X 0 0 0 LARAE HORGAN DIRECTOR 0.80 0.00 X 0 0 0 LISA LETEXIER CEO 40.00 0.00 X 182335 0 15530 PATTI JOHNSON NURSING HOME ADMINISTRATOR 40.00 0.00 X 113374 0 27963 KATIE WERNER CFO 40.00 0.00 X 88054 0 38621 LAURA ERMER PHYSCIANS ASSISTANT 40.00 0.00 X 168038 0 8983 JENNA CARPENTER NURSE PRACTITIONER 40.00 0.00 X 158011 0 8581 KIM FORD NURSE PRACTITIONER 40.00 0.00 X 149368 0 11009 HEATHER SNELL NURSE PRACTITIONER 40.00 0.00 X 144197 0 18371 INDER KHOKHA SURGEON 16.00 0.00 X 148559 0 0 1273283 0 129058 10 0 1 0 TRIAD TRAVEL NURSING 3155 BLUESTEM DR 115 WEST FARGO ND 58078 NURSING AGENCY 650299 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 CONTRACT PHYSICIAN 622476 DAKOTA TRAVEL NURSING (DTN STAFFING) 1200 COLLINS AVE MANDAN ND 58554 NURSING AGENCY 488636 ALTRU HEALTH SYSTEMS PO BOX 13780 GRAND FORKS ND 582083780 EMR MANAGEMENT SERVICES 351325 DMS HEALTH TECHNOLOGIES PO BOX 670747 DALLAS TX 752670747 DIAGNOSTIC IMAGING SERVICES 304732 9 567921 304075 871996 NET PATIENT REVENUE 621110 18495445 18495445 340B REVENUE 456110 1115739 1115739 ANCILLARY REVENUES 621110 139206 139206 19750390 12262 12262 19479 0 19479 19479 19479 OTHER INCOME 900099 172383 172383 172383 20826510 19750390 0 204124 X 587224 587224 7282396 6466082 772151 44163 137986 121998 15163 825 931305 823400 102337 5568 551011 487168 60548 3295 5428 5428 68279 68279 1202 1202 4379024 4198674 176747 3603 50122 15455 33054 1613 133447 127916 5421 110 398299 323857 74442 30958 30958 669729 669729 123658 38130 81548 3980 MEDICAL SUPPLIES 2848027 2848027 EQUIPMENT RENTAL & REPA 263401 257602 5799 0 PROVISION FOR BAD DEBT 257886 257886 FOOD EXPENSE 219422 67659 144700 7063 152389 105770 44449 2170 19091193 16840311 2178492 72390 10340 10350 8159818 8504127 3333346 2950713 265686 318566 171886 142400 23787388 16537937 6190247 7249451 1530445 1603189 19661768 20778796 1549821 1647912 563817 24906 13310 13310 296674 259304 302599 267434 260568 155634 2986789 2368500 X 16674979 18410296 16674979 18410296 19661768 20778796 1735317 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1202 1202 0 PART II-B, LINE 1: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. 1 5473 3354 3908 4919 1 X 160304 160304 10349493 6912772 3436721 1168399 613718 554681 11750755 9011447 2739308 358437 358437 7249451 DUE TO MEDICARE - PAYABLE 15712 ROU LEASE LIABILITY 139922 155634 X 20451897 0 20451897 374613 374613 20826510 18748321 0 18748321 342872 342872 19091193 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2022 AND 2021 TOTALED $13,310 AND $13,310 RESPECTIVELY. PART X, LINE 2: THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 12,262. RENTAL INCOME 19,479. BAD DEBT EXPENSE 257,886. CHARITY CARE 84,986. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 257,886. CHARITY CARE 84,986. 1 1 X 1 X 1 X 0 0 1 1 63401 63401 0.00330 2693479 3163701 0 0.00000 2756880 3163701 63401 0.00330 49035 49035 0.00260 5000 5000 0.00030 7363050 7026838 336212 0.01760 7417085 7026838 390247 0.02050 10173965 10190539 453648 0.02380 700 700 0.00000 700 700 0.00000 1 257886 19599 6626841 6671142 -44301 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 456013474 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 20 1 0 1 1 X SEE PART V, SECTION B, LINE 7D X X 1 20 1 SEE PART V, SECTION B, LINE 7D 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X X X X X X 1 0 X X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1. GATHERING FEEDBACK FROM THE COMMUNITY, RESIDENTS OF THE AREA WERE GIVEN THE OPPORTUNITY TO PARTICIPATE IN A SURVEY. SIXTY-EIGHT PCMH SERVICE AREA RESIDENTS COMPLETED THE SURVEY. 2. ADDITIONAL INFORMATION WAS COLLECTED THROUGH 11 KEY INFORMANT INTERVIEWS WITH COMMUNITY MEMBERS.THE INPUT FROM THE RESIDENTS, WHO PRIMARILY RESIDE IN PEMBINA COUNTY, REPRESENTED THE BROAD INTERESTS OF THE COMMUNITIES IN THE SERVICE AREA. TOGETHER WITH SECONDARY DATA GATHERED FROM A WIDE RANGE OF SOURCES, THE SURVEY PRESENTS A SNAPSHOT OF THE HEALTH NEEDS AND CONCERNS IN THE COMMUNITY. DUE TO THE COVID PANDEMIC INTERVIEWS WERE CONDUCTED VIRTUALLY. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THE ORGANIZATION'S COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT HTTPS://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: IN 2020, PCMHA DEVELOPED AN IMPLEMENTATION PLAN BASED ON THE RESULTS OF THE 2020 CHNA. THE TOP NEEDS IDENTIFIED IN THE CHNA PROCESS INCLUDED:- ALCOHOL USE AND ABUSE- YOUTH AND ADULTS- ATTRACTING AND RETAINING YOUNG FAMILIES- AVAILABILITY OF MENTAL HEALTH SERVICES- AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES- COST OF LONG-TERM/ NURSING HOME CARE- DEPRESSION/ ANXIETY- YOUTH AND ADULTS- DRUG USE AND ABUSE (INCLUDING PRESCRIPTION DRUG USE)- ADULTS- HAVING ENOUGH CHILD DAYCARE SERVICES- NOT ENOUGH AFFORDABLE HOUSINGTHE PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) BOARD OF DIRECTORS HAS DETERMINED THAT THE FOLLOWING HEALTH NEEDS IDENTIFIED IN THE CHNA SHOULD BE ADDRESSED THROUGH THE IMPLEMENTATION STRATEGY NOTED FOR EACH SUCH NEED:PRIORITY AREA: AVAILABILITY OF MENTAL HEALTH SERVICESGOAL: INCREASE ACCESSIBILITY TO BEHAVIORAL HEALTH SERVICESSTRATEGIES:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MENTAL HEALTH PROVIDER SERVICES AT CLINICARE AND SEEK ANY OPPORTUNITY TO EXPAND SERVICES.2. ENCOURAGE ATTENDANCE AND CONTINUE TO SUPPORT LOCAL LED SUPPORT GROUPS. SEEK OPPORTUNITIES TO EXPAND SUCH GROUPS.3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES. PRIORITY AREA: ALCOHOL USE AND ABUSE, DEPRESSION/ANXIETY- YOUTH AND ADULTGOAL: DECREASE THE USE OF ALCOHOL BY OUR YOUTH AND ADULTS AND PROVIDE ACCESS TO TREATMENT FOR DEPRESSION AND ANXIETY.STRATEGIES:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MENTAL HEALTH PROVIDER SERVICES AT CLINICARE AND SEEK ANY OPPORTUNITY TO EXPAND SERVICES.2. ENCOURAGE ATTENDANCE AND CONTINUE TO SUPPORT LOCAL LED SUPPORT GROUPS. SEEK OPPORTUNITIES TO EXPAND SUCH GROUPS.3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES. PRIORITY AREA: DRUG USE AND ABUSE (INCLUDING PRESCRIPTION DRUG USE) ADULTSGOAL: DECREASE THE USE AND MISUSE OF DRUGSPRIORITY AREA: AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES STRATEGIES:1. PROMOTE THE PCBHC SUPPORTED PROGRAMS AND ALL FAITH BASED ORGANIZATIONS.2. RESEARCH THE VIABILITY OF EXPANDING THE PALLIATIVE CARE GROUP TO INCLUDE A GRIEF SUPPORT PROGRAM.3. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALITY VIA TELEMEDICINE.4. SUPPORT YOUTH AND ADULT ALCOHOL FREE ACTIVITIES AND EDUCATION WITHIN OUR COMMUNITIES.5. CONTINUE TO PROVIDE SPACE FOR SUPPORT GROUPS TO MEET AT PCMH.STRATEGIES:1. PROMOTE THE DESTRUCTION OF LEFT OVER OR UNUSED MEDICATIONS WITH DETERA OR DROP OFF BOXES LOCATED THROUGHOUT THE COMMUNITIES.2. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALTY VIA TELEMEDICINE.3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES.4. COLLABORATE WITH HEALTH PROVIDERS TO BRING MAT (MEDICATION ASSISTED TREATMENT) TO PEMBINA COUNTY.GOAL: INCREASE ACCESS AND AWARENESS TO RESOURCES, SERVICES AND PROGRAMS TO ALLOW ELDERLY TO STAY IN THEIR HOMES LONGEROTHER NEEDS IDENTIFIED IN THE CHNA, BUT NOT ADDRESSED IN THIS IMPLEMENTATION PLAN:1. ATTRACTING AND RETAINING YOUNG FAMILIES - PCMHA CONTINUES TO BE AN ACTIVE PARTICIPANT IN COMMUNITY RECRUITMENT EFFORTS. SUPPORTING THE CAVLANDIC BIKE SHARE PROGRAM IN 2020 - PCMHA CONTINUES TO OFFER COMPETITIVE WAGES AND BENEFITS TO RECRUIT AND RETAIN FAMILIES. 2. COST OF LONG-TERM/NURSING HOME CARE - HOSPITAL SOCIAL WORK DESIGNEE IS AVAILABLE TO ASSIST INDIVIDUALS WHO LACK HEALTH INSURANCE THROUGH PROGRAMS OFFERED AND OUR FINANCIAL ASSISTANCE PROGRAM. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES OCCUR ON A REGULAR BASIS. ADMINISTRATION PROVIDES ONGOING FEEDBACK TO GOVERNMENT POLICY MAKERS AT THE STATE LEVEL REGARDING LONG TERM HEALTH CARE AND HEALTH INSURANCE COSTS.3. HAVING ENOUGH CHILD DAYCARE SERVICES - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE CHILD DAYCARE SERVICES WITHIN ITS SERVICE AREA.4. NOT ENOUGH AFFORDABLE HOUSING - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE AFFORDABLE HOUSING WITHIN ITS SERVICE AREA.STRATEGIES:1. CONTINUE TO WORK WITH THE PEMBINA COUNTY HEALTH COALITION TO PROVIDE AND DISTRIBUTE A RESOURCE GUIDE FOR PEMBINA COUNTY OF SERVICES OFFERED.2. PROMOTE THE QSP PROGRAM AND OTHER SERVICES OFFERED THROUGH PEMBINA COUNTY SOCIAL SERVICES.3. MEDICAL PROVIDERS WILL PROMOTE THE SENIOR MEAL PROGRAM.4. CONTINUE TO COLLABORATE WITH NDSU PEMBINA COUNTY EXTENSION OFFICE WITH THE DIABETES PREVENTION AND STEPPING ON PROGRAMS.5. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES AND HOUSING AUTHORITY. 3 1 - WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME 2 - CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC 3 - COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING PART I, LINE 3C: IN ADDITION TO LOOKING AT THE FEDERAL POVERTY GUIDELINES, OTHER FACTORS, SUCH AS THE PATIENT'S FINANCIAL STATUS AND/OR ABILITY TO PAY ARE CONSIDERED. PART I, LINE 7: THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, SKILLED NURSING FACILITY, AND EMERGENCY ROOM. PART II, COMMUNITY BUILDING ACTIVITIES: PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. PART III, LINE 2: IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: 7.6% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2020 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE THE ORGANIZATION ESTIMATES THAT 7.6% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 9 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFIT TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION.1. SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. 2. PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. A. THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. B. THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. C. THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. 3. ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME SHALL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $1.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: 1. REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD. 2. REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD. 3. CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. PART VI, LINE 3: NOTICES OF THE FAP ARE POSTED IN ALL WAITING AREAS, REGISTRATION AREAS, AND UPON DISCHARGE. PART VI, LINE 4: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS COMPRISED OF A 20-BED CRITICAL ACCESS HOSPITAL, 40-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND RURAL HEALTH CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2020 SHOWED A POPULATION OF 6,844 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $60,910. THE PER CAPITA INCOME FOR THE COUNTY WAS $35,096. 8.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) SERVES THE NORTHEASTERN CORNER OF NORTH DAKOTA AND NORTHWESTERN PART OF MINNESOTA. IT IS OUR MISSION TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE FOR THOSE WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVE. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PCMHA SUPPORTS AND PARTICIPATES IN INITIATIVES TO HELP MANAGE CHRONIC CONDITIONS SUCH AS DIABETES, PROVIDING HEALTH EDUCATION, AND PROMOTING THE IMPORTANCE OF ADDRESSING MENTAL AND BEHAVIORAL HEALTH NEEDS. IN REPSONSE TO COVID-19, PCMHA DIRECTED RESOURCES TO SUPPORT AND PROVIDE EDUCATION TO PATIENTS AND RESIDENTS AND THEIR FAMILIES TO HELP NAVIGATE THIS UNPRECEDENTED SITUATION. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. X X 0 0 0 0 0 0 0 0 0 LISA LETEXIER CEO 182335 0 0 0 0 0 7454 0 8076 0 197865 0 0 0 LAURA ERMER PHYSCIANS ASSISTANT 168038 0 0 0 0 0 6737 0 2246 0 177021 0 0 0 JENNA CARPENTER NURSE PRACTITIONER 158011 0 0 0 0 0 6336 0 2245 0 166592 0 0 0 HEATHER SNELL NURSE PRACTITIONER 144197 0 0 0 0 0 5950 0 12421 0 162568 0 0 0 KIM FORD NURSE PRACTITIONER 149368 0 0 0 0 0 0 0 11009 0 160377 0 0 0 PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 622477 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE CONSISTS OF THE PRESIDENT, VICE PRESIDENT, AND SECRETARY/TREASURER. THIS COMMITTEE SHALL HAVE THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OF DIRECTORS: A) MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE, ALL SUCH ACTIONS SHALL BE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. B) MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE ADMINISTRATOR/CHIEF EXECUTIVE OFFICER (CEO). C) REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY CHANGES TO THESE BYLAWS. D) EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. E) PERFORM SUCH OTHER DUTIES AND RESPONSIBILITIES AS MAY BE ASSIGNED BY THE BOARD OF DIRECTORS TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. FORM 990, PART VI, SECTION A, LINE 6 ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. THE CORPORATION SHALL ALWAYS MEET THE IRS COMMUNITY BOARD REQUIREMENTS FOR EXEMPTION FROM INCOME TAXATION - THE COMMUNITY BOARD IS ONE IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY. NO EMPLOYEE OF THE CORPORATION, EXCEPT FOR MEMBERS MAINTAINING ACTIVE MEDICAL STAFF PRIVILEGES OF THE CORPORATION, SHALL BE ELIGIBLE FOR MEMBERSHIP ON THE BOARD BECAUSE OF THE PERCEIVED CONFLICT OF INTEREST. A MAJORITY OF THE BOARD SHALL CONSIST OF INDEPENDENT DIRECTORS. ONE (1) MEMBER OF THE BOARD SHALL BE AN EX-OFFICIO MEMBER APPOINTED BY ALTRU HEALTH SYSTEM FOR THE TERMS OF THE ALTRU/PCMHA AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7A ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. FORM 990, PART VI, SECTION B, LINE 11B A COMPLETE COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS VIA EMAIL FOR THEIR REVIEW PRIOR TO MEETING APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT RAISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTORS. COMPARATIVE DATA IS GATHERED FROM THE ND HOSPITAL ASSOCIATION'S WAGE SURVEYS. A BLUE FORM IS GIVEN TO HR INDICATING ANY SALARY DECISIONS. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON NORTH DAKOTA HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2022. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 4,198,674. MANAGEMENT AND GENERAL EXPENSES 176,747. FUNDRAISING EXPENSES 3,603. TOTAL EXPENSES 4,379,024.