2021-05-11T11:55:20-05:00 2020-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2019-07-01 450306787 CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION CAVA 7012566177 909 SECOND STREET LANGDON ND 58249 JEFF STANLEY CEO 7012566177 2021-05-07 1 MICHAEL J PETERSON CPA P01833529 2187224705 2021-05-07 2019 2022-09-23 18:48:47Z JEFF STANLEY 909 SECOND STREET LANGDON ND 58249 11406495 0 X WWW.CAVALIERCOUNTYHOSPITAL.COM X 1969 ND RURAL HEALTHCARE FACILITY PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES. 7 7 111 8 0 0 677840 1143081 8036408 10002012 13841 15385 1115726 246017 9843815 11406495 0 0 0 0 4457589 4988021 0 0 0 4237174 4322122 8694763 9310143 1149052 2096352 11303103 17676887 2539945 6869805 8763158 10807082 STANDING PROUDLY ON THE TRADITIONS AND PERSEVERANCE OF OUR MANY HOSPITAL FOUNDERS, CCMH IS DEDICATED TO EXCEL AT PROVIDING HIGH QUALITY, COMPASSIONATE HEALTHCARE TO ALL THAT WE SERVE. 0 0 6474956 0 10002012 PROVIDE PATIENT HEALTHCARE SERVICES INCLUDING HOSPITAL AND CLINIC TO SURROUNDING COMMUNITY. THE ORGANIZATION PROVIDED APPROXIMATELY $64,000 OF CHARITY CARE DURING THE YEAR ENDED 06/30/2020. 6474956 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 8 0 111 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHRISTOPER CARTER CONTROLLER 7012566177 909 SECOND STREET LANGDON ND 58249 CHRISS WYATT FORMER CEO 40.00 X 264483 0 0 COURTNEY SHORT FNP 40.00 X 105496 0 5528 MARK HILL FNP 40.00 X 101133 0 6863 RICHARD FROMME CFO 40.00 X 105391 0 3 ANGELA KOBEL CFO (THRU AUGUST) 40.00 X 64210 0 28 JEFF STANLEY CEO 40.00 X 199050 0 3665 WILLIAM VAN NOY CFO 40.00 X 17453 0 0 CHARLES EMERSON CMO 40.00 X 283454 0 11792 DARLA RODER COO 40.00 X 103105 0 15157 JAMIE NIENHUIS CNO 40.00 X 87824 0 13479 DAWN ROPPEL PRESIDENT 1.00 X X 0 0 0 JAY DUBOIS VICE PRESIDENT 1.00 X X 0 0 0 SHAUNA SCHNEIDER TREASURER 1.00 X X 0 0 0 JERRY NOWATZKI SECRETARY 1.00 X X 0 0 0 DAROL HOFFMAN DIRECTOR (THRU NOVEMBER) 1.00 X 0 0 0 KATHRYN KOPF DIRECTOR 1.00 X 0 0 0 KAREN RING DIRECTOR 1.00 X 0 0 0 JANINE WITZEL DIRECTOR 1.00 X 0 0 0 1331599 0 56515 7 1 1 0 NATIONAL MEDICAL RESOURCES INC 2792 E BROADWAY AVE BISMARCK ND 58501 PROVIDER CONTRACT SERVICES 401343 NXC IMAGING 2118 4TH AVE S MINNEAPOLIS MN 554042642 IMAGING CONTRACT SERVICES 280213 JOHNSON CONTROLS INC DEPT CH 10320 PALATINE IL 600550320 EQUIP. MAINT. AND REPAIR SERVICES 196859 3 1101163 41918 1143081 NET PATIENT REVENUE 621400 8964864 8964864 340B PHARMACY REVENUE 621400 1037148 1037148 10002012 15385 15385 15212 0 15212 15212 15212 230805 230805 230805 11406495 10002012 0 261402 X 799216 198273 600943 3569127 2868960 700167 66955 46347 20608 249432 176614 72818 303291 198204 105087 53755 53755 215019 215019 963795 764508 199287 184287 13982 170305 183891 183891 138091 19463 118628 60115 37115 23000 92471 92471 612457 612457 74366 74366 MEDICAL SUPPLIES 923050 920554 2496 BAD DEBT EXPENSE 325306 325306 REPAIRS & MAINTENANCE 196013 96360 99653 DUES & SUBSCRIPTIONS 107909 11148 96761 191597 93194 98403 9310143 6474956 2835187 0 230701 110166 3453510 9963738 788939 858962 10773 134895 184903 106208 62107 12945026 8799291 4174373 4145735 2403704 2351276 11303103 17676887 757660 623113 0 4730626 1187482 1019878 190230 126531 121300 47497 283273 322160 2539945 6869805 X 6207454 8455806 2555704 2351276 8763158 10807082 11303103 17676887 X 2096352 -52428 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 458 458 0 PART II-B, LINE 1: THE NORTH DAKOTA HOSPITAL ASSOCIATION HAS DETERMINED THAT 8.7% OF CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION'S ANNUAL MEMBERSHIP DUES PAID ARE TREATED AS LOBBYING EXPENSES. 13167 13167 7874010 5082777 2791233 4453914 3716514 737400 603935 603935 4145735 BENEFICIAL INTEREST IN ASSETS HELD BY FOUNDATION 2351276 F 2351276 OTHER LONG-TERM DEBT 143298 DUE TO THIRD PARTIES 178862 322160 11081189 0 11081189 325306 325306 11406495 8984837 0 8984837 325306 325306 9310143 PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 325,306. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 325,306. 1 1 X 1 X 1 X 1 1 0 0 64218 64218 0.00690 4288334 8696861 0 0.00000 4352552 8696861 64218 0.00690 2943250 287938 2655312 0.28520 2943250 287938 2655312 0.28520 7295802 8984799 2719530 0.29210 0 325306 65061 4986437 4982434 4003 X 1 1 1 1 CAVALIER COUNTY MEMORIAL HOSPITAL 909 2ND STREET LANGDON ND 58249 WWW.CAVALIERCOUNTYHOSPITAL.COM 5029 X X X X CAVALIER COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 18 1 0 1 1 X SEE SUPPLEMENTARY INFO X 1 18 1 SEE SUPPLEMENTARY INFO 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X 1 X SEE SUPPLEMENTARY INFO X SEE SUPPLEMENTARY INFO X SEE SUPPLEMENTARY INFO X X X X X X 1 X 0 X X X X X 1 X 0 0 PART V, LINE 7A: WWW.CAVALIERCOUNTYHOSPITAL.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT PART V, LINE 10: WWW.CAVALIERCOUNTYHOSPITAL.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT PART V, LINE 16A, FAP WEBSITE: HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE PART V, LINE 16B, FAP APPLICATION WEBSITE: HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE PART V, LINE 5: THE HOSPITAL'S CHNA INCLUDED COMMUNITY INPUT THROUGH SURVEYS, A COMMUNITY GROUP, AND ONE-ON-ONE INTERVIEWS. THE PROCESS WAS OVERSEEN BY A COMMITTEE CONSISTING OF LEADERS FROM CAVALIER COUNTY MEMORIAL HOSPITAL, CAVALIER COUNTY HEALTH DISTRICT, AND A COMMUNITY REPRESENTATIVE. THE HOSPITAL DISTRIBUTED A BROAD COMMUNITY SURVEY TO THE COMMUNITY MEMBERS. 33 OUT OF 82 SURVEYS WERE COMPLETED AND RETURNED. THE CHNA REPORT CONTAINS VARIOUS DEMOGRAPHIC INFORMATION OF THE SURVEY PARTICIPANTS. IN ADDITION, A COMMUNITY GROUP CONSISTING OF SEVEN COMMUNITY MEMBERS MET ON MULTIPLE OCCASIONS TO PROVIDE INPUT. FINALLY, ONE-ON-ONE INTERVIEWS WERE HELD WITH FIVE KEY COMMUNITY MEMBERS TO OBTAIN THEIR INPUT. PART V, LINE 6B: CAVALIER COUNTY MEMORIAL HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT WITH CAVALIER COUNTY HEALTH DEPARTMENT. PART V, LINE 11: CAVALIER COUNTY MEMORIAL HOSPITAL, IN PARTNERSHIP WITH CAVALIER COUNTY HEALTH DEPARTMENT, CONDUCTED A CHNA OF THE AREAS IN WHICH WE SERVE THE INTENTION WAS TO DISCOVER THE WANTS, NEEDS AND DESIRES OF OUR POPULATION AS IT RELATES TO HEALTH CARE RELATED ISSUES. THIS PROJECT WAS ENTERED INTO WITH THE UNDERSTANDING THAT MANY SOCIAL FACTORS AFFECT THE OVERALL HEALTH OF THE COMMUNITY. FOR THIS REASON, A VARIETY OF QUESTIONS WERE ASKED TO GAIN A FULL UNDERSTANDING OF COMMUNITIES' VALUES AS IT RELATES TO THEIR HEALTH CARE DECISIONS. TO ENTICE INDIVIDUALS TO PARTICIPATE. CCMH USED ITS PERSONAL FUNDS TO PURCHASE PRIZES, FOR A RANDOM DRAWING FROM ALL THAT PARTICIPATED WHILE THERE WERE MANY MORE AREAS OF OPPORTUNITY, CCMH BELIEVES THAT IT WILL TAKE A COMMUNITY EFFORT TO ACCOMPLISH MANY OF THESE GOALS, AND WANT TO PARTNER WITH THE COMMUNITY ON ANY INITIATIVE THAT INDIVIDUALS OR OTHER ORGANIZATIONS WOULD LIKE TO FOCUS ATTENTION. THREE AREAS OF CONCERN WERE IDENTIFIED: ABILITY TO RETAIN PRIMARY CARE PROVIDERS, DEPRESSION/ANXIETY AND ALCOHOL USE AND ABUSE. CCMH HAS BEGUN A FOCUS ON IMPROVING PROVIDER AVAILABILITY, EDUCATION AND RECRUITING NEW PROVIDERS IN WAYS THAT HAVE NOT BEEN DONE PREVIOUSLY, SUCH AS ADDING SERVICES (COLONOSCOPY) AND TELEHEALTH SERVICES. CCMH IS ALSO DEDICATED TO IMPROVING THE LIVES OF THE COMMUNITY THROUGH OVERALL WELLNESS. WE HAVE CREATED A MENTAL HEALTH TASK FORCE WHICH MEETS MONTHLY (LESS OFTEN WITH COVID) WHICH PROVIDES COUNSELING SERVICES WEEKLY TO AREA SCHOOLS, DISCUSS' VAPING WITH STUDENT ATHLETES, PROVIDES DRUG DEACTIVATION BAGS, PERSONAL STORIES OF ADDITION, TOBACCO CESSATION TRAINING AND PROMOTIONAL CAMPAIGNS. WE HAVE IMPLEMENTED DEPRESSION SCREENING QUESTIONS AND AVAILABILITY FOR ASSISTANCE. WE HAVE PROMOTED SERVICES TO HELP WITH DEPRESSION AND ALCOHOL USE AND ABUSE. PART OF THIS IS MAKING THE PUBLIC AWARE OF THE SERVICES OFFERED AND ENCOURAGING THEM TO UTILIZE LOCAL FACILITIES. THROUGHOUT THE 2020 FISCAL YEAR, JULY 2019-JUNE 2020, CCMH CONTINUED OFFERING A SERIES OF CHARITY EVENTS THAT ENCOURAGE AN ACTIVE LIFE-STYLE UNTIL COVID RESULTED IN THE CANCELLATION OF EVENTS. CCMH HOPES TO IMPACT CHANGE WITHIN THE COMMUNITY THAT IT SERVES AND PROMOTE INCREASED SERVICES AND AVAILABILITY AS COVID REDUCES. PART V, LINE 13H: PATIENTS WHO HAVE DIED AND HAVE NO ESTATE ARE DEEMED BY CCMH TO HAVE NO INCOME FOR THE PURPOSE OF DETERMINING CHARITY CARE ELIGIBILITY. PART V, LINE 20E: ALL PATIENTS RECEIVE LETTERS AFTER NONPAYMENT THAT INCLUDE A PLAIN LANGUAGE SUMMARY OF OUR FINANCIAL ASSISTANCE PLAN. 2 1 - CAVALIER COUNTY MEMORIAL HOSPITAL CLINIC 909 2ND STREET LANGDON ND 58249 OUTPATIENT PHYSICIAN CLINIC - RURAL HEALTH CLINIC 2 - WALHALLA CLINIC 301 5TH STREET WALHALLA ND 58282 OUTPATIENT PHYSICIAN CLINIC PART I, LINE 3C: THE HOSPITAL USES THE FEDERAL POVERTY GUIDELINES ("FPG") AS THE PRIMARY BASIS FOR THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL ALSO USES THE PATIENT'S ADJUSTED GROSS INCOME FIGURE FROM THEIR INCOME TAX RETURN AND CHECK IT WITH THE FPG. THE HOSPITAL DOES NOT USE AN ASSET TEST. THE HOSPITAL REQUIRES APPLICANTS TO SUBMIT A MEDICAID DENIAL, THE PRIOR YEAR'S TAX FILING, AND 3 MONTHS OF INCOME VERIFICATION AS PART OF THE FINANCIAL ASSISTANCE APPLICATION PROCESS. PART I, LINE 7: COST TO CHARGE RATIO WAS DERIVED USING WORKSHEET 2 FROM THE IRS TO CALCULATED THE AMOUNTS INCLUDED IN SCHEDULE H, PART I, LINE 7A & 7B COMMUNITY HEALTH IMPROVEMENTS SERVICES & COMMUNITY BENEFIT OPERATIONS (LINE 7E) AND HEALTH PROFESSIONAL EDUCATION ARE REPORTED AT COST. PART III, LINE 2: BAD DEBT EXPENSE IS CALCULATED UTILIZING DIRECT BAD DEBT COSTS FROM NONPAYMENT AFTER CONTRACTUAL DISCOUNTS AND PAYMENTS HAVE BEEN RECEIVED. THE STANDARD FORMULA FOR ACCOUNTS RECEIVABLE HAS BEEN UTILIZED FOR ANY OUTSTANDING ACCOUNTS AFTER CONTRACTUAL DISCOUNTS WERE TAKEN. PART III, LINE 3: DUE TO THE FACT THAT THE FINANCIAL ASSISTANCE PROGRAM WAS NOT CONSISTENTLY FOLLOWED AND SOME PATIENTS WERE LIKELY NOT ADEQUATELY INFORMED, WE BELIEVE APPROXIMATELY 20% OF BAD DEBT WOULD HAVE QUALIFIED. PART III, LINE 4: FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: IF A PATIENT QUALIFIES FOR CHARITY CARE, A PERCENTAGE OF THEIR BILL IS WRITTEN OFF DEPENDING ON THEIR INCOME LEVEL. THE BALANCE THAT REMAINS IS SUBJECT TO OUR COLLECTION POLICY. IF A PAYMENT HAS NOT BEEN MADE FOR 2 MONTHS, A 1ST LETTER IS SENT STATING THAT THEY HAVE A MONTH TO MAKE A PAYMENT. IF A PAYMENT HAS NOT BEEN MADE AFTER THAT MONTH, A 2ND LETTER IS SENT OUT STATING THEY HAVE ANOTHER MONTH TO MAKE A PAYMENT. IF A PAYMENT HAS STILL NOT BEEN MADE, THEN THEY GET TURNED OVER TO OUR COLLECTION AGENCY. PART VI, LINE 2: CAVALIER COUNTY MEMORIAL HOSPITAL HAS BEGUN A FAMILY AND PATIENT ADVISORY COUNCIL SO THAT MEMBERS OF THE COMMUNITY CAN MEET WITH LEADERS TO DISCUSS OPTIONS FOR GROWTH AND HEALTH CARE CONCERNS. CCMH HAS ALSO BEGUN THE PROCESS OF ENGAGING IN AN ACCOUNTABLE CARE ORGANIZATION TO IMPROVE UPON ITS MISSION AND VISION BY HELPING MANAGE OUR POPULATIONS HEALTH ON AN ONGOING BASIS RATHER THAN THE ACUTE EPISODES ALONE. PART VI, LINE 3: WE HAVE OUR FAP ADVERTISED ON OUR WEBSITE. WE HAVE CONSPICUOUS SIGNS POSTED AT ALL ADMITTING AREAS REGARDING OUR FAP. ANY PATIENT THAT MAY BE ELIGIBLE IS OFFERED OUR APPLICATION/POLICY AT TIME OF ADMISSION. OUR FAP IS ADVERTISED WITH THE COMMUNITY CALENDAR IN THE LOCAL NEWSPAPER. WE HAVE A PATIENT INFORMATION HANDBOOK, WHICH DESCRIBES THE GOVERNMENT PROGRAMS SUCH AS MEDICARE AND MEDICAID. IT ALSO MENTIONS THAT WE OFFER CHARITY CARE AND TO CONTACT THE BUSINESS OFFICE MANAGER OR THE SOCIAL WORKER IF INTERESTED IN THIS PROGRAM. PART VI, LINE 4: CAVALIER COUNTY MEMORIAL HOSPITAL'S COMMUNITY SERVICE AREA POPULATION IS APPROXIMATELY 3,700 RESIDENTS AND IS LOCATED 17 MILES SOUTH OF THE CANADIAN BORDER AND 60 MILES WEST OF THE MINNESOTA BORDER. THE COMMUNITY DEMOGRAPHICS ARE A MIX OF EVENLY PROPORTIONED GENDER WITH AN AVERAGE AGE OF 50 YEARS. PART VI, LINE 5: CAVALIER COUNTY MEMORIAL HOSPITAL (CCMH) CONSISTENTLY PROMOTES GOOD HEALTH THROUGHOUT OUR COMMUNITY WITH PLACEMENT OF MEDICAL EDUCATION ARTICLES IN OUR LOCAL NEWSPAPER. CCMH ALSO PROVIDES THE FOLLOWING SERVICES FREE OF CHARGE TO THE LOCAL SCHOOLS, EDUCATIONAL OPPORTUNITIES SUCH AS JOB SHADOWING, USE OF HOSPITAL FACILITIES FOR HEALTH CAREERS CLASS, AND THE USE OF OUR MEDICAL PROFESSIONALS TO SPEAK TO THEIR STUDENTS. CCMH ANNUALLY PROVIDES APPROXIMATELY $37,500 OF CHARITY CARE TO OUR COMMUNITY AND VARIOUS OTHER BENEFICIAL HEALTH RELATED SERVICES FOR MINIMAL PROFIT RETURNS AND/OR BREAK EVEN COST TO CHARGE RATES. SURPLUS REVENUES ARE REINVESTED BACK INTO THE FACILITY FOR PLANT UPGRADES AND NEW EQUIPMENT. CCMH PROVIDES TWO CLINICS TO THE COMMUNITY THAT PROVIDE FREE SERVICES DURING 3 DIFFERENT MONTHS THROUGHOUT THE YEAR. MEN'S HEALTH - JUNE, WOMEN'S HEALTH - OCTOBER, & CHILDREN'S HEALTH - MAY. FREE SCREENINGS AND DISCOUNTED DIAGNOSTIC CARE ARE PROVIDED TO THE COMMUNITY IN BOTH CLINICS. PART VI, LINE 7, REPORTS FILED WITH STATES ND X X 1 0 0 0 0 0 0 0 0 CHRISS WYATT FORMER CEO 0 0 0 0 264483 0 0 0 0 0 264483 0 0 0 JEFF STANLEY CEO 186550 0 12500 0 0 0 0 0 3665 0 202715 0 0 0 CHARLES EMERSON CMO 248092 0 35362 0 0 0 0 0 11792 0 295246 0 0 0 PART I, LINE 4A CHRIS WYATT LEFT CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION IN MAY 2018. CHRIS RECEIVED A DEFERRED COMPENSATION PAYOUT OF 264,483 DURING 2019. A CITY OF LANGDON NORTH DAKOTA 456002108 515679AL2 2010-03-25 2500000 HOSPITAL RENOVATION PROJECT 0 0 0 A 1445000 2500000 50000 2450000 2012 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF LANGDON, NORTH DAKOTA DATE THE REBATE COMPUTATION WAS PERFORMED: 02/28/2020 PART IV, LINE 2C: THE REBATE COMPUTATION WAS PERFORMED 03/30/2015. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 IS FIRST REVIEWED BY THE CONTROLLER AND MANAGEMENT TEAM. THE FINANCE COMMITTEE WILL LOOK AT THE RETURN FOLLOWING THE CFO. FINALLY, THE BOARD OF DIRECTORS WILL RECEIVE AN ELECTRONIC COPY OF THE FORM 990 PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS, OFFICERS, AND TRUSTEES OF THE ORGANIZATION ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. POTENTIAL OR POSSIBLE CONFLICTS OF INTEREST ARE REVIEWED AT THE BOARD LEVEL AND A DETERMINATION IS MADE. RESTRICTIONS AND/OR ADJUSTMENTS ARE DETERMINED AND THEN IMPLEMENTED PER BOARD DIRECTION. RESTRICTIONS AND/OR ADJUSTMENTS ARE DOCUMENTED WITHING THE BOARD MINUTES. IF ANY VARIANCES OF THE CONFLICT IN QUESTION ARE DISCOVERED THE BOARD WILL MAKE A DETERMINATION ON ACTION TO BE TAKEN. ANY POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY MEMBER OF THE BOARD OF DIRECTORS SHALL BE DISCLOSED IN WRITING TO THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL DISCLOSURE AND ALSO WHEN THE INTEREST INVOLVED A SPECIFIC ISSUE OR TRANSACTION BEFORE THE BOARD. IF A CONFLICT ARISES AFTER A MEMBER HAS COMPLETED THE DISCLOSURE, THE MEMBER SHOULD COMPLETE AN EMENDED DISCLOSURE INCLUDING THE NEW CONFLICT. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THE ENTIRE BOARD OF DIRECTORS VOTES ON APPROVAL OR DISAPPROVAL OF THE TRANSACTION. THE MEMBER INVOLVED IN THE TRANSACTION REFRAINS FROM VOTING OR OTHERWISE ATTEMPTING TO EXERT ANY INFLUENCE ON THE OTHER MEMBERS THAT WILL AFFECT THEIR DECISION ON THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15 THE PROCEDURE THAT CCMH UTILIZES TO DETERMINE ITS CEO'S COMPENSATION IS AS FOLLOWS. UPON EXPIRATION OF CEO'S CONTRACT, THE CCMH BOARD OF DIRECTORS (BOD) CALLS FOR AN EXECUTIVE SESSION TO DISCUSS THE CEO'S CONTINUED/DISCONTINUED EMPLOYMENT. UPON APPROVAL TO CONTINUE THE CEO'S EMPLOYMENT, THE BOD PRESENTS AND REVIEWS THE CURRENT NORTH DAKOTA PREVAILING WAGE DATA COMMENSURATE WITH CEO JOB DESCRIPTION. ONCE AN APPROPRIATE COMPENSATION FIGURE HAS BEEN NEGOTIATED AND ACCEPTED BY THE CEO, THE BOD PASSES A MOTION TO RATIFY THE COMPENSATION AGREEMENT BETWEEN THE BOD AND CEO. FINALLY, REQUIRED DELIVERABLES AND OTHER MEASURABLE INDICATORS ARE MEMORIALIZED IN A FORMAL AGREEMENT OR CONTRACT WITH THE CEO. THE PROCEDURES UTILIZED BY CCMH TO SET WAGES FOR SUBORDINATE OFFICERS AND ALL OTHER EMPLOYEES IS DETERMINED BY THE CEO WHO IS EMPOWERED BY THE BOD TO DO SO. THE CEO REVIEWED THE CURRENT NORTH DAKOTA JOB SERVICE EDITION AND NORTH DAKOTA HEALTHCARE ASSOCIATION WAGES/SALARY ADJUSTMENTS OF SUBORDINATE OFFICERS AND EMPLOYEES IS SUPPLIED TO THE BOARD UPON REQUEST. FINALLY, THE APPROPRIATE COMPENSATION AND OTHER DELIVERABLES ARE MEMORIALIZED IN A FORMAL OFFER LETTER EXTENDED TO THE EMPLOYEE. FORM 990, PART VI, SECTION C, LINE 19 CAVALIER COUNTY MEMORIAL HOSPITAL MAKES THEIR GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ALSO PRESENTED ANNUALLY AT THE PUBLIC MEMBERS' MEETING. FORM 990, PART IX, LINE 11G PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 162,961. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 162,961. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 56,604. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 56,604. LAB SERVICES: PROGRAM SERVICE EXPENSES 35,564. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 35,564. CONSULTATION SERVICES: PROGRAM SERVICE EXPENSES 246,241. MANAGEMENT AND GENERAL EXPENSES 123,311. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 369,552. OTHER SERVICES: PROGRAM SERVICE EXPENSES 263,138. MANAGEMENT AND GENERAL EXPENSES 75,976. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 339,114. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -52,428. CAVALIER COUNTY MEMORIAL HOSPITAL FOUNDATION 909 2ND STREET LANGDON ND 58249 363617578 TO SUPPORT THE HOSPITAL ND 501(C)(3) LINE 12A, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0