2022-08-22T16:31:19-05:00 2022-03-31 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2021-04-01 450226419 Good Samaritan Hospital Association GOOD 7017765261 800 South Main Avenue Rugby ND 583682118 Erik Christenson CEO 7017765261 2022-08-18 1 Erik Christenson 999009999 Lisa Chaffee CPA P00193453 7012551091 2022-08-18 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z Heart of America Medical Center Erik Christenson 800 South Main Avenue Rugby ND 583682118 34939098 0 X www.hamc.com X 1905 ND Provide quality medical care based on the needs and demographics of north central North Dakota. 9 8 387 70 0 0 2002421 7780704 26340969 26886234 119311 215310 57375 56850 28520076 34939098 133371 50000 0 0 18348949 17678310 0 68088 68088 8959755 9344911 27442075 27141309 1078001 7797789 19858204 21983981 10920632 5222779 8937572 16761202 X To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. 0 0 23384620 50000 26886234 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. 23384620 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 42 0 1 387 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Erik Christenson 7017765261 800 South Main Avenue Rugby ND 583682118 Will Griffin President 1.00 0.00 X X 0 0 0 Wayne Trottier Vice Chair 1.00 0.00 X X 0 0 0 Richard Anderson Trustee until 2/6/22 1.00 0.00 X 0 0 0 Annette Leier Trustee 1.00 0.00 X 0 0 0 Craig Zachmeier Trustee 1.00 0.00 X 0 0 0 Jason Lee Trustee until 10/26/21 1.00 0.00 X 0 0 0 Kolin Johnson Trustee 1.00 0.00 X 0 0 0 Deanna Marchus Trustee 1.00 1.00 X 0 0 0 Kim Bott Trustee 1.00 0.00 X 0 0 0 Michael Graner Trustee starting 4/14/21 1.00 0.00 X 0 0 0 Tanner Johnson Trustee starting 10/18/21 1.00 0.00 X 0 0 0 Erik Christenson Secretary - CEO 58.00 2.00 X 113683 0 32518 Melissa Shepard Treasurer - CFO 58.00 2.00 X 124808 0 14707 Dustin Hager CMO / COO 40.00 0.00 X 181864 0 33541 Cammy Kelsch FNP-C ER Provider 66.50 0.00 X 287954 0 33913 Ronald Skipper MD General Surgeon 40.00 0.00 X 329909 0 32413 Josalynne Hoff Rue MD Physician 40.00 0.00 X 241226 0 30840 Chelsey Wyatt CRNA 40.00 0.00 X 288858 0 31882 Steven Schoneberg MD Physician 40.00 0.00 X 252064 0 27411 1820366 0 237225 22 0 1 0 Wipfli 11 Scott Street Wausau WI 54402 Masterplan/Feasibility Study 150079 Rugby Electric 6260 26th Ave NE Rugby ND 58368 Electrical Services 125900 Mike Swanson Construction 6250 24th Ave NE Rugby ND 58368 Construction Services 115319 Eide Bailly LLP PO Box 2545 Fargo ND 581082545 Accounting Services 105082 4 288583 7475270 16851 7780704 Patient Service Revenue 621400 24707224 24707224 Pharmacy Revenue 446110 1266606 1266606 Daycare Services 812900 91961 91961 Cafeteria Revenue 722514 84434 84434 736009 736009 26886234 199694 199694 56850 0 56850 56850 56850 15616 0 15616 15616 15616 34939098 26886234 0 272160 50000 50000 504078 163837 340241 155404 155404 14155328 12514879 1640449 198224 173154 25070 1635408 1428051 207357 1029868 880527 149341 96333 96333 14196 14196 68088 68088 1718523 1408249 310274 33975 33975 373079 198601 174478 34296 34296 871868 742373 129495 63089 47101 15988 75370 51319 24051 106591 106591 1094326 988598 105728 235683 235683 Medical Supplies 3062144 3062144 Repairs & Maintenance 841909 841506 403 Food 398974 398974 Dues and Subscriptions 21353 1630 19723 303202 171682 131520 27141309 23384620 3688601 68088 8124678 7614046 2903676 3325728 203955 249502 88468 238223 18966347 11110327 6207661 7856020 1894 138603 117667 105277 2210205 2456582 19858204 21983981 2376036 2608100 3792331 755090 355781 217795 17403 18361 1484128 1148979 2857200 37753 474454 10920632 5222779 X 8112099 15905005 825473 856197 8937572 16761202 19858204 21983981 X 7797789 4762 21079 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 649 1 0 0 0 649 0 Part II-B, Line 1: 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. 1 79414 23863 40629 62648 1 X 137447 137447 8724039 5939304 2784735 8329375 5171023 3158352 1775486 1775486 7856020 Beneficial Interest in Assets Held by Others 1486584 Third Party Settlements 519998 Insurance Receivable 450000 2456582 Special Assessments Payable 24454 Insurance Payable 450000 474454 X 34874310 4762 -45687 -40925 34915235 23863 23863 34939098 27050680 0 27050680 90629 90629 27141309 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. X X X X X X 1 Catholic Development Group LLC 1020 1st Ave N Fargo ND 58102 Campaign director for new building project 0 0 68088 0 68088 ND Schedule G, part I, line 2b, column (iv) 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. 1 1 X 1 X 1 X 1 1 1 0 0 164000 164000 0.00600 3617086 3541839 75247 0.00280 3781086 3541839 239247 0.00880 897 897 0.00000 5705550 3166748 2538802 0.09350 5706447 3166748 2539699 0.09350 9487533 6708587 2778946 0.10230 1 513044 128261 6099263 6036711 62552 X 1 1 1 1 Heart of America Medical Center 800 S Main Ave Rugby ND 583682118 www.hamc.com 5046 X X X X Heart of America Medical Center 1 0 0 1 X X X X X X X X X 21 1 0 1 1 X https://www.hamc.com/CHNA/ X See Part V, Page 8 X 1 21 1 https://www.hamc.com/CHNA/ 0 1 X 200.000000000000 300.000000000000 1 1 X X X 1 X https://www.hamc.com/patientinfo/ X https://www.hamc.com/uploads/4/CommunityCareApplication2112020.pdf X https://www.hamc.com/uploads/3/plainlang.pdf X X X X X 1 X 0 X X X X 1 X 0 0 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 7 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 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. 1 Good Samaritan Health Services Foundation 800 S Main Avenue Rugby ND 58368 363513553 501(c)(3) 50000 0 To support build 2024 capital campaign 1 0 Part I, Line 2: 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. X X X X 0 0 0 0 0 0 0 0 0 Ronald Skipper MD General Surgeon 327244 0 2665 0 0 0 4973 0 27808 0 362690 0 0 0 Cammy Kelsch FNP-C ER Provider 286704 0 1250 0 0 0 4424 0 29870 0 322248 0 0 0 Chelsey Wyatt CRNA 286481 0 2377 0 0 0 4007 0 28256 0 321121 0 0 0 Steven Schoneberg MD Physician 249863 0 2201 0 0 0 3798 0 23982 0 279844 0 0 0 Josalynne Hoff Rue MD Physician 239059 0 2167 0 0 0 3733 0 27488 0 272447 0 0 0 Dustin Hager CMO / COO 180127 0 1737 0 0 0 2851 0 31065 0 215780 0 0 0 A City of Rugby North Dakota Health Care Facility 456002152 000000000 2013-09-19 1215000 Improvements to hospital and clinic 0 0 0 A 997205 1215000 15000 1200000 2013 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 1 0 1 0 0 0 1 A 1 Julie Baustad Family member of board member Richard Anderson 13730 Compensation 0 Sarah Christenson Family member of CEO 64850 Compensation 0 Lauren McClintock Family member of CEO 38830 Compensation 0 Carlie Johnson Family member of board member Tanner Johnson 37994 Compensation 0 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. Good Samaritan Health Services Foundation 800 South Main Ave Rugby ND 58368 363513553 Fundraising for Good Samaritan Hospital Association ND 501(c)(3) Line 7 Good Samaritan Hospital Association 1 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 Good Samaritan Health Services Foundation C 288583 Accrual Good Samaritan Health Services Foundation B 50000 Accrual