GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2021-04-01 to 2022-03-31
- Filed
- 2022-08-22
- IRS object ID
- 202232349349300623
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule G
- Schedule H
- Schedule I
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-08-22T16:31:19-05:00 | ReturnTs |
| Tax Period End | 2022-03-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1730 Burnt Boat Loop Ste 100 | AddressLine1Txt |
| City | Bismarck | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 585030886 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-04-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOOD | BusinessNameControlTxt |
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Erik Christenson | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017765261 | PhoneNum |
| Signature | 2022-08-18 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | Erik | PersonFirstNm |
| Person Last | Christenson | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Lisa Chaffee CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012551091 | PhoneNum |
| Preparation | 2022-08-18 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Erik Christenson | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $34,939,098 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.hamc.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1905 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | Provide quality medical care based on the needs and demographics of north central North Dakota. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 387 | TotalEmployeeCnt |
| Total Volunteers | 70 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $2,002,421 | PYContributionsGrantsAmt |
| CY Contributions Grants | $7,780,704 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $26,340,969 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $26,886,234 | CYProgramServiceRevenueAmt |
| PY Investment Income | $119,311 | PYInvestmentIncomeAmt |
| CY Investment Income | $215,310 | CYInvestmentIncomeAmt |
| PY Other Revenue | $57,375 | PYOtherRevenueAmt |
| CY Other Revenue | $56,850 | CYOtherRevenueAmt |
| PY Total Revenue | $28,520,076 | PYTotalRevenueAmt |
| CY Total Revenue | $34,939,098 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $133,371 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $50,000 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $18,348,949 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $17,678,310 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $68,088 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $68,088 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $8,959,755 | PYOtherExpensesAmt |
| CY Other Expenses | $9,344,911 | CYOtherExpensesAmt |
| PY Total Expenses | $27,442,075 | PYTotalExpensesAmt |
| CY Total Expenses | $27,141,309 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,078,001 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $7,797,789 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $19,858,204 | TotalAssetsBOYAmt |
| Total Assets EOY | $21,983,981 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $10,920,632 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $5,222,779 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $8,937,572 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $16,761,202 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $23,384,620 | ExpenseAmt |
| Grant | $50,000 | GrantAmt |
| Revenue | $26,886,234 | RevenueAmt |
| Desc | Good Samaritan Hospital Association (GSHA) is a nonprofit health care organization, owned by 21 area churches representing all the local denominations of the Christian faith. The area churches at an annual meeting every year elect a board of trustees. This board is the legal governing body that is responsible for the Association. GSHA's primary focus is healthcare within and around the community of Rugby, ND. GSHA has 25 licensed acute/swing beds as a critical access hospital, 3 rural health clinics, along with a surgical clinic/pain clinic, 45 Medicare skilled nursing home beds (2 in layaway), 60 basic care beds, and 37 assisted living apartments. We also service the community through a robust hospital-based hospice program. GHSA was impacted by COVID in many ways such that many activities and volunteer work were cancelled due to infection control risks and CDC guidance. Additionally, we continued to see increased charity care due to patients being impacted with industries shutting down during COVID waves. COVID testing was provided to the community. And our infection control nurse was working with public health to improve the community's awareness. GSHA provides numerous community and social programs including, but not limited to the following: Charity Care - the estimated cost of providing charity care services was $164,000 during the year ended March 31, 2022 (calculated by multiplying the ratio of cost to gross charges for the Organization by the gross uncompensated charges associated with providing charity care to patients), reduced fee flu shot clinics, diabetic education program, chronic care management, public healthcare educational and informational notices, testing and information during health shows and community events, ambulance volunteers, provides EMT courses for ambulances, educational outreach for school system, provides senior citizen meals, free blood pressure checks, community education, physical therapy, provides meeting room for various organizations and churches, CPR training, wellness programs, affiliated with LPN/RN school program through consortium of facilities and colleges. Through CRH's CHNA process, we were able to determine the base needs of our community that we can work towards completing: more daycare, increased mental health services, and attracting and attaining young families. | Desc |
| Total Program Service Expenses | $23,384,620 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | Yes (1) | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | Yes (1) | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 42 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 387 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Erik Christenson | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (19 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Key EmployeeKeyEmployeeInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|---|
| Will Griffin | |||||||||
| President | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| Wayne Trottier | |||||||||
| Vice Chair | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | ||
| Richard Anderson | |||||||||
| Trustee until 2/6/22 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Annette Leier | |||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Craig Zachmeier | |||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Jason Lee | |||||||||
| Trustee until 10/26/21 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Kolin Johnson | |||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Deanna Marchus | |||||||||
| Trustee | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Kim Bott | |||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Michael Graner | |||||||||
| Trustee starting 4/14/21 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Tanner Johnson | |||||||||
| Trustee starting 10/18/21 | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |||
| Erik Christenson | |||||||||
| Secretary - CEO | 58.00 | 2.00 | Yes (X) | $113,683 | $0 | $32,518 | |||
| Melissa Shepard | |||||||||
| Treasurer - CFO | 58.00 | 2.00 | Yes (X) | $124,808 | $0 | $14,707 | |||
| Dustin Hager | |||||||||
| CMO / COO | 40.00 | 0.00 | $181,864 | $0 | $33,541 | Yes (X) | |||
| Cammy Kelsch FNP-C | |||||||||
| ER Provider | 66.50 | 0.00 | $287,954 | $0 | $33,913 | Yes (X) | |||
| Ronald Skipper MD | |||||||||
| General Surgeon | 40.00 | 0.00 | $329,909 | $0 | $32,413 | Yes (X) | |||
| Josalynne Hoff Rue MD | |||||||||
| Physician | 40.00 | 0.00 | $241,226 | $0 | $30,840 | Yes (X) | |||
| Chelsey Wyatt | |||||||||
| CRNA | 40.00 | 0.00 | $288,858 | $0 | $31,882 | Yes (X) | |||
| Steven Schoneberg MD | |||||||||
| Physician | 40.00 | 0.00 | $252,064 | $0 | $27,411 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,820,366 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $237,225 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 22 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Wipfli | |||||
| 11 Scott Street | Wausau | WI | 54402 | Masterplan/Feasibility Study | $150,079 |
| Rugby Electric | |||||
| 6260 26th Ave NE | Rugby | ND | 58368 | Electrical Services | $125,900 |
| Mike Swanson Construction | |||||
| 6250 24th Ave NE | Rugby | ND | 58368 | Construction Services | $115,319 |
| Eide Bailly LLP | |||||
| PO Box 2545 | Fargo | ND | 581082545 | Accounting Services | $105,082 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $288,583 | RelatedOrganizationsAmt |
| Government Grants | $7,475,270 | GovernmentGrantsAmt |
| All Other Contributions | $16,851 | AllOtherContributionsAmt |
| Total Contributions | $7,780,704 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient Service Revenue | 621400 | $24,707,224 | $24,707,224 |
| Pharmacy Revenue | 446110 | $1,266,606 | $1,266,606 |
| Daycare Services | 812900 | $91,961 | $91,961 |
| Cafeteria Revenue | 722514 | $84,434 | $84,434 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $736,009 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $736,009 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $26,886,234 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $199,694 | TotalRevenueColumnAmt |
| Exclusion | $199,694 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $56,850 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $56,850 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $56,850 | TotalRevenueColumnAmt |
| Exclusion | $56,850 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $15,616 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $15,616 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,616 | TotalRevenueColumnAmt |
| Exclusion | $15,616 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $34,939,098 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $26,886,234 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $272,160 | ExclusionAmt |
Grants To Domestic Orgs GrantsToDomesticOrgsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $50,000 | TotalAmt |
| Program Services | $50,000 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $504,078 | TotalAmt |
| Program Services | $163,837 | ProgramServicesAmt |
| Management And General | $340,241 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $155,404 | TotalAmt |
| Program Services | $155,404 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,155,328 | TotalAmt |
| Program Services | $12,514,879 | ProgramServicesAmt |
| Management And General | $1,640,449 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $198,224 | TotalAmt |
| Program Services | $173,154 | ProgramServicesAmt |
| Management And General | $25,070 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,635,408 | TotalAmt |
| Program Services | $1,428,051 | ProgramServicesAmt |
| Management And General | $207,357 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,029,868 | TotalAmt |
| Program Services | $880,527 | ProgramServicesAmt |
| Management And General | $149,341 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $96,333 | TotalAmt |
| Management And General | $96,333 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,196 | TotalAmt |
| Management And General | $14,196 | ManagementAndGeneralAmt |
Fees For Services Prof Fundraising FeesForServicesProfFundraising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $68,088 | TotalAmt |
| Fundraising | $68,088 | FundraisingAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,718,523 | TotalAmt |
| Program Services | $1,408,249 | ProgramServicesAmt |
| Management And General | $310,274 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $33,975 | TotalAmt |
| Management And General | $33,975 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $373,079 | TotalAmt |
| Program Services | $198,601 | ProgramServicesAmt |
| Management And General | $174,478 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $34,296 | TotalAmt |
| Management And General | $34,296 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $871,868 | TotalAmt |
| Program Services | $742,373 | ProgramServicesAmt |
| Management And General | $129,495 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $63,089 | TotalAmt |
| Program Services | $47,101 | ProgramServicesAmt |
| Management And General | $15,988 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $75,370 | TotalAmt |
| Program Services | $51,319 | ProgramServicesAmt |
| Management And General | $24,051 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $106,591 | TotalAmt |
| Program Services | $106,591 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,094,326 | TotalAmt |
| Program Services | $988,598 | ProgramServicesAmt |
| Management And General | $105,728 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $235,683 | TotalAmt |
| Management And General | $235,683 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $3,062,144 | $3,062,144 | |
| Repairs & Maintenance | $841,909 | $841,506 | $403 |
| Food | $398,974 | $398,974 | |
| Dues and Subscriptions | $21,353 | $1,630 | $19,723 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $303,202 | TotalAmt |
| Program Services | $171,682 | ProgramServicesAmt |
| Management And General | $131,520 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $27,141,309 | TotalAmt |
| Program Services | $23,384,620 | ProgramServicesAmt |
| Management And General | $3,688,601 | ManagementAndGeneralAmt |
| Fundraising | $68,088 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,124,678 | BOYAmt |
| EOY | $7,614,046 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,903,676 | BOYAmt |
| EOY | $3,325,728 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $203,955 | BOYAmt |
| EOY | $249,502 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $88,468 | BOYAmt |
| EOY | $238,223 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $18,966,347 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $11,110,327 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,207,661 | BOYAmt |
| EOY | $7,856,020 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,894 | BOYAmt |
| EOY | $138,603 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $117,667 | BOYAmt |
| EOY | $105,277 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,210,205 | BOYAmt |
| EOY | $2,456,582 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,858,204 | BOYAmt |
| EOY | $21,983,981 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,376,036 | BOYAmt |
| EOY | $2,608,100 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,792,331 | BOYAmt |
| EOY | $755,090 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $355,781 | BOYAmt |
| EOY | $217,795 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,403 | BOYAmt |
| EOY | $18,361 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,484,128 | BOYAmt |
| EOY | $1,148,979 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,857,200 | BOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $37,753 | BOYAmt |
| EOY | $474,454 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,920,632 | BOYAmt |
| EOY | $5,222,779 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,112,099 | BOYAmt |
| EOY | $15,905,005 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $825,473 | BOYAmt |
| EOY | $856,197 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,937,572 | BOYAmt |
| EOY | $16,761,202 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $19,858,204 | BOYAmt |
| EOY | $21,983,981 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $7,797,789 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $4,762 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $21,079 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | Yes (1) | GrantsOtherOrganizationsInd |
| Grants Other Organizations | $649 | GrantsOtherOrganizationsAmt |
| Direct Contact Legislators | Yes (1) | DirectContactLegislatorsInd |
| Direct Contact Legislators | $0 | DirectContactLegislatorsAmt |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | 0 | OtherActivitiesInd |
| Total Lobbying Expenditures | $649 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part II-B, Line 1: | FormAndLineReferenceDesc |
| Explanation | Good Samaritan Hospital Association is a member of several organizations that take part in lobbying. These organizations include the North Dakota Hospital Association, the National Rural Health, and the North Dakota Long Term Care Association. A portion of the dues paid to the various organizations is for lobbying costs. These various organizations advocate on behalf of their members by supporting legislation that is in their collective interests. These organizations work to ensure that laws and regulations provide a reasonable and equitable environment in which health care facilities can provide affordable, high quality care. In addition, during the year, the organization visited with Senator Hoeven and his staff when they came to visit the employees and aged facilities. They came to hear and see what the organization was experiencing in healthcare and the impact to the regional area should we not build a new healthcare facility. The senate team provided valuable feedback about the impact of building new versus remodeling and the additional strain to the city infrastructure and what an empty building would mean for main street. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $79,414 | BeginningBalanceAmt |
| Additions During Year | $23,863 | AdditionsDuringYearAmt |
| Distributions During Year | $40,629 | DistributionsDuringYearAmt |
| Ending Balance | $62,648 | EndingBalanceAmt |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $137,447 | OtherCostOrOtherBasisAmt |
| Book Value | $137,447 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,724,039 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,939,304 | DepreciationAmt |
| Book Value | $2,784,735 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,329,375 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,171,023 | DepreciationAmt |
| Book Value | $3,158,352 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,775,486 | OtherCostOrOtherBasisAmt |
| Book Value | $1,775,486 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $7,856,020 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (3 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| Beneficial Interest in Assets Held by Others | $1,486,584 |
| Third Party Settlements | $519,998 |
| Insurance Receivable | $450,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $2,456,582 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| Special Assessments Payable | $24,454 |
| Insurance Payable | $450,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $474,454 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $34,874,310 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $4,762 | NetUnrealizedGainsInvstAmt |
| Other Revenue | -$45,687 | OtherRevenueAmt |
| Revenue Not Reported | -$40,925 | RevenueNotReportedAmt |
| Revenue Subtotal | $34,915,235 | RevenueSubtotalAmt |
| Other Revenues Not Included | $23,863 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $23,863 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $34,939,098 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $27,050,680 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $27,050,680 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $90,629 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $90,629 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $27,141,309 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 1b: | The auxiliary is operated by volunteers. The funds are maintained by this organization as segregated funds for activities and the gift shop. The auxiliary determines where these funds are utilized. |
| Part IV, Line 2b: | The Organization acts as custodian for the funds of the nursing facility residents and Haaland Estates residents. |
| Part X, Line 2: | The Organization believes that 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. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Under the 501r regulations associated with being a 501(c)(3) entity, the Association is required to complete a Community Health Needs Assessment (CHNA) every three years. The Association was required to complete their CHNA by March 31, 2019. As the Association failed to complete this as required it is subject to a penalty of $50,000 for untimely completion. The Association recorded a penalty and has since completed the CHNA and paid the penalty. |
| Part XI, Line 2d - Other Adjustments: | Change in interest in net assets of Foundation 4,313. Grants given out included in revenue on financial statements -50,000. |
| Part XI, Line 4b - Other Adjustments: | Auxillary Revenue 23,863. |
| Part XII, Line 4b - Other Adjustments: | Auxillary Expenses 40,629. Grants given out included in revenue on financial statements 50,000. |
Schedule G IRS990ScheduleG
| Field | Value | IRS element (for citing) |
|---|---|---|
| Mail Solicitations | Yes (X) | MailSolicitationsInd |
| Email Solicitations | Yes (X) | EmailSolicitationsInd |
| Phone Solicitations | Yes (X) | PhoneSolicitationsInd |
| In Person Solicitations | Yes (X) | InPersonSolicitationsInd |
| Solicitation Of Non Govt Grants | Yes (X) | SolicitationOfNonGovtGrantsInd |
| Solicitation Of Govt Grants | Yes (X) | SolicitationOfGovtGrantsInd |
| Agrmt Prof Fundraising Acty | Yes (1) | AgrmtProfFundraisingActyInd |
Fundraiser Activity Info FundraiserActivityInfoGrp
Organization Business Name OrganizationBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Catholic Development Group LLC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1020 1st Ave N | AddressLine1Txt |
| City | Fargo | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58102 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activity | Campaign director for new building project | ActivityTxt |
| Fundraiser Control Of Funds | 0 | FundraiserControlOfFundsInd |
| Gross Receipts | $0 | GrossReceiptsAmt |
| Retained By Contractor | $68,088 | RetainedByContractorAmt |
| Net To Organization | $0 | NetToOrganizationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Retained By Contractors | $68,088 | TotalRetainedByContractorsAmt |
| Licensed States | ND | LicensedStatesCd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Schedule G, part I, line 2b, column (iv) | FormAndLineReferenceDesc |
| Explanation | The organization paid money to Catholic Development Group LLC in order to raise funds towards building of a new hospital building. The related Foundation is the recipient of the funds being raised and so no gross receipts are reported in schedule G, part I, line 2b, column (iv). The Foundation's mission is to support the mission of Good Samaritan Hospital Association. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $164,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $164,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00600 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,617,086 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,541,839 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $75,247 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00280 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,781,086 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,541,839 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $239,247 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00880 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $897 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $897 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,705,550 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,166,748 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,538,802 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09350 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,706,447 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,166,748 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,539,699 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09350 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $9,487,533 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $6,708,587 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,778,946 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10230 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $513,044 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $128,261 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,099,263 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,036,711 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $62,552 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.hamc.com | WebsiteAddressTxt |
| State License | 5046 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 21 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | https://www.hamc.com/CHNA/ | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | See Part V, Page 8 | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 21 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | https://www.hamc.com/CHNA/ | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | https://www.hamc.com/patientinfo/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | https://www.hamc.com/uploads/4/CommunityCareApplication2112020.pdf | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | https://www.hamc.com/uploads/3/plainlang.pdf | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Heart of America Medical Center | Part V, Section B, Line 5: Our initial task force involved public health, city government, local school, pastoral and HAMC representation. Our community meetings involved those areas along with agricultural, business owners, first responders, and social services representation from our service area. We collaborated with Lake Region District Health Unit for conducting our CHNA. The representative from our local office attended task force meetings, distributed surveys to patients, was involved in press releases and participated in community meetings. Surveys were available online as well as paper in several locations. Throughout the process, task force and community meetings were held intermittently from September 2021 through January 2022. CRH conducted community interviews for informational purposes. |
| Heart of America Medical Center | Part V, Section B, Line 6b: Lake Region District Health Unit & UND Center for Rural Health |
| Heart of America Medical Center | Part V, Section B, Line 11: During the current fiscal year, the organization completed a new CHNA. The latest CHNA completed identified the following needs in our Community:-Attaining and Retaining Young Families: The organization plans to address this need by recruiting to the organization and introducing the families to the culture of Rugby and the surrounding areas. Focusing on what the community and surrounding areas have to offer in our rural communities such as hiking, fishing, county fair, and a great school district.-Availability of mental health services: The organization plans to address this need by informing the patients and public that mental health services are available through their provider in the clinic. -Not enough healthcare staff in general: HAMC is working to recruit more staff back to healthcare through advertising, job fairs, and working with the schools. -Having enough daycare services: HR is working on an analysis to determine if the organization has capacity to take in community children into the daycare. In addition, during the fiscal year, the organization also took steps to address the needs from the prior CHNA. Some of the needs identified in the prior CHNA were similar to those identified in the most recent CHNA.Needs identified in our prior CHNA included:-Attaining and Retaining Young Families-Availability of resources to help the elderly stay in their homes-Depression/Anxiety Youth-Cost of Health Care InsuranceIn the current year, the facility took the following actions to address these needs as follows from the prior completed CHNA:Attracting and Retaining Young Families: As the largest employer in our service area, we realize the important part we play in impacting this need. We restructured our benefits and increased the employer contribution to make benefits more affordable and attractive to new employees. We adjusted wages based on salary surveys to be competitive in the market and will review annually salary and benefits to remain competitive. In addition, we have increased our marketing of services offered and career opportunities available. Daycare is available to employees as a fringe benefit. We designed an education reimbursement program for staff development and growth. Availability of resources to help the elderly stay in their homes: We have added home visits in several areas such as PT and RT and recently started offering telehealth visits in our clinics. If a needed service is not offered at HAMC at this time but is available in our service area, we communicate that to our patients. We also research the viability of adding that service in the future.Cost of Health Care Insurance: Although we may not be able to affect our entire service area's cost of health insurance, as the largest employer, reducing our employees' health insurance costs will have a significant impact in itself. We were able to join the NDHA Health Trust and save the staff with a reduction in health benefit expenses and avoided an increase that was proposed by Sanford had we not switched.The organization may not address the following needs identified as extensively due to limited resources and the need to allocate significant resources to the priority needs identified above, however the following actions have been taken:Depression/Anxiety in Youth: We were unable to successfully recruit a mental health provider due to the high demand for this specialty. We are working with a telehealth provider and made the staff aware of the benefit offered from our carrier. Talks have been ongoing to share these services with our school, county social services and the county prison but no movement at this time due to limited available mental health providers. |
| Heart of America Medical Center | Part V, Section B, Line 15e: As part of the application the patient will provide name demographic information, occupation, employer, spouse demographic and employment information, dependent information and insurance information.As part of the application patient may provide paystubs, or itemized income and expenses, or verification from welfare agencies, verification from unemployment or workers compensation, or income tax returns as supporting documentation. |
| Part V, Line 7b: | Other Website:https://ruralhealth.und.edu/projects/community-health-needs-assessment/reports |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 7 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (7 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - Heart of America Nursing Facility | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Long-term Skilled Care Nursing Facility |
| 2 - Haaland Estates Basic Care | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Basic Care Nursing Facility |
| 3 - Haaland Estates Assisted Living | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Assisted Living Facility |
| 4 - Heart of America Johnson Clinic | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Rural Health Clinic |
| 5 - Heart of America Johnson Clinic | ||||
| 215 Main St SE | Dunseith | ND | 58329 | Rural Health Clinic |
| 6 - Heart of America Johnson Clinic | ||||
| 301 Roosevelt Ave | Maddock | ND | 58348 | Rural Health Clinic |
| 7 - Heart of America Hospice | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Hospice care |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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. Community Health Improvement Services, line 7e, reflects actual expenses recorded to the general ledger. Medicaid, line 7b, and Subsidized health services, line 7g, were calculated based on information from the Cost Report. |
| Part III, Line 2: | The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concession based on its historical collection experience with this class of patients. |
| Part III, Line 3: | The Organization estimated the implicit price concessions attributable to patients who likely would qualify for financial assistance by applying the percentage of financial assistance applications sent out but not received back or not completed. |
| Part III, Line 4: | The footnote to the Organization's financial statements related to implicit price concessions can be found on page 13-14 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. |
| Part III, Line 9b: | Our accounts are worked effectively and thoroughly with self-pay statements printed monthly once insurances have met their obligations. The goal is to obtain payment in full, establish acceptable payment arrangements, and look at other appropriate agencies or low income programs, or offer the charity care program if needed. In the collection process, the bill guarantor is reminded they may qualify for our charity care program and are given information on how to apply. Our third party collection company also offers charity care during collection calls. The statements explain who to call for a charity care application. Our charity program is income based and patients have 120 days to submit a financial assistance application, and uses 200% of the Federal poverty guidelines. If they qualify, the bill is written off 100% to charity care. Once approved they qualify for assistance for 6 months before and 6 months after of the approval date. After 120 days in collections, the account is written to bad debt. At least 30 days before we take extraordinary collection action we send notification. Up to 240 days we accept application and stop collection actions and reverse the collection effort. |
| Part VI, Line 2: | Heart of America Medical Center and its associated facilities serves a smaller community where providers know their patients. GSHA board members live in the communities we serve. We expect board members to bring back concerns of their communities so we can prioritize the needs. We also receive valuable community feedback from the HAMC Auxiliary Board and dozens of volunteers who contribute thousands of hours to the hospital and our long-term care and basic care facilities. |
| Part VI, Line 3: | Good Samaritan Hospital Association, doing business as Heart of America Medical Center, provides medical care regardless of patients' ability to pay. We provide information on federal, state and local payment assistance programs prior to the rendering of services or, in emergency situations, as soon as is appropriate. HAMC Community (Charity) Care is available for inpatient and outpatient hospital services, clinic services and swing bed care. Social work staff provide patients with this information. Patients can also find Community Care information on our website and it's also included with information on our Prompt Payment Discount program. Staff members processing self-pay bills encourage patients to apply for Community Care and our third-party collection company encourages patients to apply for Community Care if they are experiencing financial hardships. |
| Part VI, Line 4: | Heart of America Medical Center is a 25 bed Critical Access Hospital Designated Level V trauma center, Chemotherapy/infusion suite, surgical suite, pharmacy, lab, and radiology (including MRI on site). Outpatient services include wellness center, sports medicine, pain clinic, and diabetes education. Also, located in Rugby, N.D is the LTC nursing home and the separate campus at Haaland Estates which includes 60 basic care beds with a memory care unit and a 37-bed assisted living apartment building. Heart of America Johnson Clinics are in Rugby, Dunseith, and Maddock, N.D., serving people within a 50-mile radius of Rugby. The closest tertiary facility is 65 miles to the west. Our primary service area is Pierce County and portions of Benson, McHenry, Rolette, Wells, Towner, Sheridan, and Bottineau counties. According to the Fiscal Year 2022 CHNA, HAMC is providing crucial medical services to more than 13,000 people in their service area. Roughly 300 employees make HAMC the largest employer in the region. HAMC has a significant economic impact on the region with the annual payroll utilized in the region which also leads to additional jobs and income for the region as they interact with other sectors of the local economy. The population in Pierce County is 3,945, of which the majority have insurance via employers 71%, 13% Medicare, 12% self-insured, 6% Indian Health Services (IHS), 4% Medicaid, 3% Veterans Choice, 3% No insurance, 6% Other. Major employers in Rugby and Pierce County are the HAMC, Rugby Manufacturing, and the public schools. |
| Part VI, Line 5: | Good Samaritan Hospital Association is sponsored by 14 member churches located throughout our service area. The GSHA board of directors reside in our primary service area, are engaged in various occupations and activities and are elected by GSHA member churches. Through Heart of America Johnson Clinics, Heart of America Medical Center has a presence Rugby, Dunseith and Maddock, N.D., providing our patients with health care services close to home. We make specialty services in ophthalmology, podiatry, audiology and mental health available to our patients through partnerships with specialty clinics and providers. We offer state-of-the-art cancer treatment in our chemotherapy suite and recently added life-saving 3D mammography equipment to our radiology department. Heart of America Hospice provides personalized, holistic end-of-life care and services for local hospice patients and their families in a 60-mile radius of Rugby. Without GSHA, there will be no hospital, no emergency room, no rural health clinics, no surgical clinic, no skilled nursing care facility, no basic case facility, no assisted living facility, no wellness/fitness center in our service area. We operate most of these programs at a loss, but we continue to offer them to serve the needs of the people who live here. For those providers that apply to HAMC they have privileges in our community once approved by board of directors as presented by the medical staff.Surplus funds, if available, are used to improve the facility for patient care and upgrade the medical equipment. |
| Part VI, Line 6: | GSHA is not part of an affiliated healthcare system, however, as a Critical Access Hospital we provide and promote high-quality care for our patients via rural health network agreements with Trinity Medical Center in Minot and MedCenter One in Bismarck, N.D. These agreements enhance our patients' continuity of care by identifying and forming processes that facilitate patient referrals and easy transfer between facilities and enhance communication between providers. GSHA piggy-backs on Altru's Epic system and is an Accountable Care Organization. |
Schedule I IRS990ScheduleI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Grant Records Maintained | Yes (1) | GrantRecordsMaintainedInd |
Recipient Table RecipientTable
Recipient Business Name RecipientBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58368 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Recipient EIN | 363513553 | RecipientEIN |
| IRC Section | 501(c)(3) | IRCSectionDesc |
| Cash Grant | $50,000 | CashGrantAmt |
| Non Cash Assistance | $0 | NonCashAssistanceAmt |
| Purpose Of Grant | To support build 2024 capital campaign | PurposeOfGrantTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total501c3 Org | 1 | Total501c3OrgCnt |
| Total Other Org | 0 | TotalOtherOrgCnt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 2: | FormAndLineReferenceDesc |
| Explanation | The Hospital gave the Foundation an allocation to be used to grow the capital campaign funds for the Build 2024 project. The proceeds were given to support the new building project for the updated Healthcare Campus. The Board approved the transfer to the Foundation per CEO contract agreement. | ExplanationTxt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Ronald Skipper MD | ||||||||||||||
| General Surgeon | $327,244 | $0 | $2,665 | $0 | $0 | $0 | $4,973 | $0 | $27,808 | $0 | $362,690 | $0 | $0 | $0 |
| Cammy Kelsch FNP-C | ||||||||||||||
| ER Provider | $286,704 | $0 | $1,250 | $0 | $0 | $0 | $4,424 | $0 | $29,870 | $0 | $322,248 | $0 | $0 | $0 |
| Chelsey Wyatt | ||||||||||||||
| CRNA | $286,481 | $0 | $2,377 | $0 | $0 | $0 | $4,007 | $0 | $28,256 | $0 | $321,121 | $0 | $0 | $0 |
| Steven Schoneberg MD | ||||||||||||||
| Physician | $249,863 | $0 | $2,201 | $0 | $0 | $0 | $3,798 | $0 | $23,982 | $0 | $279,844 | $0 | $0 | $0 |
| Josalynne Hoff Rue MD | ||||||||||||||
| Physician | $239,059 | $0 | $2,167 | $0 | $0 | $0 | $3,733 | $0 | $27,488 | $0 | $272,447 | $0 | $0 | $0 |
| Dustin Hager | ||||||||||||||
| CMO / COO | $180,127 | $0 | $1,737 | $0 | $0 | $0 | $2,851 | $0 | $31,065 | $0 | $215,780 | $0 | $0 | $0 |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | City of Rugby North Dakota Health Care Facility | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 456002152 | BondIssuerEIN |
| CUSIP | 000000000 | CUSIPNum |
| Bond Issued | 2013-09-19 | BondIssuedDt |
| Issue Price | $1,215,000 | IssuePriceAmt |
| Purpose | Improvements to hospital and clinic | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $997,205 | RetiredAmt |
| Total Proceeds | $1,215,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $15,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $1,200,000 | CapitalExpendituresAmt |
| Substantial Completion | 2013 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | 0 | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | Yes (1) | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | Yes (1) | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (4 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| Julie Baustad | |||
| Family member of board member Richard Anderson | $13,730 | Compensation | 0 |
| Sarah Christenson | |||
| Family member of CEO | $64,850 | Compensation | 0 |
| Lauren McClintock | |||
| Family member of CEO | $38,830 | Compensation | 0 |
| Carlie Johnson | |||
| Family member of board member Tanner Johnson | $37,994 | Compensation | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1a | The Executive Committee consists of all the Board of Trustees residing in the Rugby community plus the Chairman of the Board of Trustees. The Executive Committee shall have the power to transact all regular business of the hospital during the interim between meetings of the Board of Trustees and it shall refer to all matters of major importance to the Board. |
| Form 990, Part VI, Section A, line 6 | Membership in the corporation shall consist of such Lutheran congregations which are now members of this Association and such other congregations as shall from time to time apply for membership herein. The Congregational members of the Organization shall be represented by the following 4 specific designations: -4 From Rugby/Balta/Orrin -1 From Towner/Willow City -1 from Rolette/Wolford/Dunseith -1 from Leeds/Maddock The Board of Trustees shall also have at least one physician representative and, in its discretion, two members at large Trustees, one of whom shall have a background in legal or insurance and another who shall have a background in finance both of whom shall reside in the geographical region served by the Association. The physician representative shall be a non-voting representative appointed by the Board of Trustees. |
| Form 990, Part VI, Section A, line 7a | Each member church has up to three voting delegates at the annual meeting where the board of directors is elected to serve on the board. |
| Form 990, Part VI, Section A, line 7b | Amendments to the Articles of Incorporation must be voted on by a two-thirds majority vote of the members. Amendments to Bylaws must be voted on by a two-thirds majority vote of the Board of Trustees. |
| Form 990, Part VI, Section B, line 11b | A draft of the 990 will be made available to the GSHA board of trustees at a board meeting. Any questions will be addressed and corrections made as needed before the 990 is filed. |
| Form 990, Part VI, Section B, line 12c | Covered Persons: All employees, managers, medical staff, executive leadership, board members, volunteers, contractors, and others engaged in the work place. A conflict of Interest Statement must be signed by each board member and shall be dated no later than December 31st of each year. Determination of conflict: All employees and board members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Conflict review: Actual or potential board member conflicts of interest must be disclosed to the Corporate Compliance Committee (CCC). The CCC will handle reports or concerns of situations that may give rise to a conflict of interest with the assistance of legal counsel. The CCC will issue its decision to the Covered Persons in writing and will document and file its decision. Restrictions on those with a conflict: In self-dealing transactions the board member shall not participate in the board decision-making and shall make full disclosure of their interests. If the fairness of the transaction is questioned, the burden of establishing fairness falls upon the trustee involved and the board member must seek guidance and approval from the CCC prior to pursuing any business or personal activity that may constitute a conflict of interest. |
| Form 990, Part VI, Section B, line 15 | Comparative data is reviewed and incorporated into the review process such as looking at state wage survey data. For the CEO, each board member completes their own evaluation form. The human resource committee reviews the responses and makes a recommendation to the full board. The full board decides on any changes to CEO compensation. The review is done annually at time of anniversary date of contract. The board typically does not approve wages for other positions. The CEO approves the CFO wages. Comparative data is used throughout the facility and incorporated into the annual review of employee wages done by the department head or supervisor. Wages are compared to the NDHA annual salary survey report at the time of their annual review. |
| Form 990, Part VI, Section C, line 19 | These documents are available upon request. Financial statements are available for viewing by the public at all board meetings. |
| Form 990, Part VI, Line 16b: | The Organization is a 49% owner in a retail pharmacy located in the clinic building. The pharmacy bylaws requires an annual board meeting including representatives of the Hospital. The meeting evaluates the joint venture arrangement and assures the facility is not violating its tax exempt status. |
| Form 990, Part XI, line 9: | Change in interest in net assets of Foundation 4,313. Change in interest in net assets of Auxillary 16,766. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58368 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | Fundraising for Good Samaritan Hospital Association | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | Yes (1) | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | Yes (1) | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | Yes (1) | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (2 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| Good Samaritan Health Services Foundation | ||
| C | $288,583 | Accrual |
| Good Samaritan Health Services Foundation | ||
| B | $50,000 | Accrual |
Comments