2021-12-20T14:48:01-06:00 2021-04-30 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2020-05-01 113686120 Coal Country Community Health Center COAL 7018737788 1312 Highway 49 N Beulah ND 585236038 Brian Williams CEO 7018737788 2021-12-16 1 Brian Williams 999009999 Lisa Chaffee CPA P00193453 7012551091 2021-12-16 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Brian Williams 1312 Highway 49 N Beulah ND 585236038 14965092 0 X www.coalcountryhealth.com X 2003 ND CCCHC provides and promotes quality health care to the medically underserved population in the North Dakota counties of Mercer, Dunn, and Oliver. 10 10 132 13 0 0 2925137 5431566 9966586 9467558 -3316 0 66860 65968 12955267 14965092 0 0 0 0 7529300 7977426 0 0 0 5293225 5040066 12822525 13017492 132742 1947600 15797286 16459479 6084310 4798903 9712976 11660576 X Working together as partners to enhance the lives of area residents by providing a neighborhood of patient centered healthcare services that promote wellness, prevention and care coordination. 0 0 10813144 9467558 Coal Country Community Health Center is part of a family of over 1,400 health centers nationally that provide care to more than 28 million people in the United States. Community health centers are local, non-profit health care providers serving low income and medically underserved communities. Also known as Federally-Qualified Health Centers (FQHCs), they are located in areas where care is needed, and improve access to care for millions of Americans. Their costs of care rank among the lowest, and their focus on prevention reduces the need for more expensive in-patient and specialty care, saving billions of dollars for taxpayers. (Continued on Schedule O)The focus of the care we provide can be summed up in one word - community. Coal Country is governed by a board of members from the communities we serve, and every decision they make has the best interest of the community in mind. Our medical staff and support staff are also your neighbors, helping us truly understand you and the health care issues that are important to you.The team of providers delivers primary care for the entire community. Funded by a federal grant, our sliding fee scale allows patients to pay according to their individual ability. This and other efforts ensure that no one in the community goes without proper health care services. That's what we're all about.Coal Country Community Health Center, with clinics in Beulah, Center, Hazen, and Killdeer, is a member of the PrimeCare Health Group. Furthermore, Coal Country remains a member of the other health care networks in the region.At Coal Country Community Health Center, our top priority is to provide complete health care services for the entire community.With a background in every area of medicine, our primary care physicians provide continuing and comprehensive care, from preventative care to diagnosis and treatment of health conditions.For more focused care, we bring in specialists to our clinic in Beulah,all the while continuing to oversee your total care.Our ongoing medical care of all levels includes the areas of::: Acute and chronic disease:: Adult care medicine:: Emergency medicine:: Geriatrics:: Mental health:: Medicated Assisted Therapy:: Obstetrics:: Occupational medicine:: Pediatrics:: Prenatal care:: Sports medicine:: Women's healthSpecialists from Bismarck regularly visit our clinics to provide treatment in the areas of::: Audiology:: Ear, nose and throat:: General surgery:: Mental health:: Obstetrics and Gynecology:: OrthopedicsCoronavirus response services continue to expand as the Health Center expanded lab services to include testing and read out of Covid testing, providing Covid vaccines at all four clinic locations, expanded case management and care coordination for Covid patients including Covid Take home kits and follow-up. Virtual care visits expanded through the use of Tytocare. In addition, a Behavioral Health (BH) Case Manager was added to manage all patients in addiction service which will assist with long term sobriety. A BH Integration Care Coordinator provides follow-up for all patients with BH conditions; such as, depression, anxiety, suicidal, and addiction to provide a warm hand off to BH services including referral management and crisis intervention. A licensed master social worker was added to the team to continue to expand mental health services at our clinic sites with scheduled appointments added to CCCHC's Center, ND clinic location. 10813144 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 25 0 1 132 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Victoria Oberlander 7018737788 1312 Hwy 49 N Beulah ND 585236038 Aaron Garman MD Physician 40.00 X 334492 0 41333 Darrold Bertsch CEO (May-Dec) 40.00 X 275772 0 32709 Jacinta-Jon Klindworth MD Physician 40.00 X 279009 0 43596 Michelle Placke Physician 40.00 X 259845 0 48145 Orlan Jackson DO Physician 40.00 X 186420 0 27627 Rodney Zimmerman Physician 40.00 X 165886 0 27939 Dovie Borth CFO 40.00 X 108817 0 4820 Brian Williams CEO (Jan-April) 40.00 X 34523 0 5014 Dr DJ Erickson Chair 1.00 X X 0 0 0 Keith Johnson Vice Chair 1.00 X X 0 0 0 Arlene Helling Secretary/Treasurer 1.00 X X 0 0 0 Fred Stern Director 1.00 X 0 0 0 Sienna Sailer Director 1.00 X 0 0 0 Jody Doe Director 1.00 X 0 0 0 Anna Mae Batke Director 1.00 X 0 0 0 Kathy Kelsch Director 1.00 X 0 0 0 Travis Jordan Director (through Nov) 1.00 X 0 0 0 Heidi Moore Director 1.00 X 0 0 0 1644764 0 231183 13 0 1 0 Beulah Drug 147 W Main Beulah ND 58523 Contract Pharmacy Dispensing Fees 890641 Sakakawea Medical Center 510 8th Avenue NE Hazen ND 58545 Shared Staff & Rent 232091 Altru Health System PO Box 6002 Grand Forks ND 58206 Software Subscription & Support 168784 Hazen Drug 30 Main Street Hazen ND 58545 Contract Pharmacy Dispensing Fees 145314 4 5329620 101946 5431566 Patient Service Revenue 621110 5913557 5913557 Pharmacy Revenue 621110 2826865 2826865 Other Program Revenue 621110 727136 727136 9467558 65968 0 65968 65968 65968 14965092 9467558 0 65968 X 370723 370723 6099682 5721530 378152 315663 176150 139513 751091 679866 71225 440267 317832 122435 5019 5019 73046 73046 1694362 1374059 320303 38670 38670 419923 339749 80174 619118 490839 128279 33303 28011 5292 14515 4277 10238 43166 43166 792285 662420 129865 51927 6000 45927 Medical Supplies 887666 887666 Dues and Subscriptions 41055 6729 34326 Licenses 40678 39837 841 285333 35013 250320 13017492 10813144 2204348 0 5971602 7194237 1194446 927306 45420 44580 100319 139060 10643233 2688750 8377699 7954483 107800 199813 15797286 16459479 1212930 1124440 126465 297539 3489197 3376924 1185600 0 70118 0 6084310 4798903 X 9712976 11660576 9712976 11660576 15797286 16459479 1947600 0 X 0 1 X 1 1 1 X 2696142 2606233 2524057 2925137 5431566 16183135 2696142 2606233 2524057 2925137 5431566 16183135 16183135 30248 66860 65968 163076 16346211 49228650 0.99000 0.99250 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8950546 1870843 7079703 33173 16221 16952 1492378 695348 797030 167136 106338 60798 7954483 X 14965092 0 14965092 0 14965092 13017492 0 13017492 0 13017492 Part X, Line 2: The Health Center 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 financial statements. The Health Center 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. X X X 0 0 0 0 0 1 0 0 0 Aaron Garman MD Physician 278600 0 54650 0 1242 0 11746 0 29764 0 376002 0 0 0 Darrold Bertsch CEO (May-Dec) 268750 0 0 0 7022 0 10800 0 21909 0 308481 0 0 0 Jacinta-Jon Klindworth MD Physician 218384 0 59520 0 1105 0 11177 0 33028 0 323214 0 0 0 Michelle Placke Physician 213334 0 45695 0 816 0 10676 0 38456 0 308977 0 0 0 Orlan Jackson DO Physician 176248 0 6314 0 3858 0 7302 0 20324 0 214046 0 0 0 Rodney Zimmerman Physician 148266 0 13904 0 3716 0 5280 0 22659 0 193825 0 0 0 Part I, Line 6 An annual management team incentive program was started in FY2014 with the first annual payment occurring in August 2014 for fiscal year ending 04/30/2014. This program was continued for FY2021. The incentive payment is based on a combination of ten clinical and financial performance measures relating to the patient population and the health center. The ten measures are: 1. Diabetes Control > National Average 2. Blood Pressure Control > National Average 3. Cholesterol Treatment > National Average 4. Adult Weight Screening & Follow-up > National Average 5. Childhood Immunizations > National Average 6. Days in AR < 55 7. Days Cash on Hand > 90 8. Net Profit Margin > 5% 9. Long Term Debt to Equity < .50 10. Medical Cost Per Medical Patient < National Average Of the 10 measures, only net profit margin could potentially be considered as compensation contingent on net earnings. Only the measures met for the current fiscal year are included in the calculation of the incentive payment. Each measure met receives a rating of 1%. A maximum incentive of 10% is allowed. The incentive payment calculation is based on the individual team member's base salary/wages as of the end of the current fiscal year. For FY2020 paid in September 2020, Dovie Borth received a management team incentive payment of $6,645.60. The other five participants in the program do not meet the criteria for Part VII and are not listed in Part VII. Schedule J, Part II: Darrold Bertsch & Brian Williams are employees of Coal Country Community Health Center (CCCHC) and also provide services to Sakakawea Medical Center (SMC). The compensation reported in Part VII, and Part II of the Schedule J, reflects total compensation Darrold and Brian received from CCCHC for their services to both SMC and CCCHC. 49% of their compensation is reimbursed by SMC as a shared services agreement. Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of at least five (5) voting members, including the Chair, Vice Chair, Secretary, Treasurer, and one (1) at-large member. The Executive Director of the Corporation shall serve without voting powers. The Executive Committee shall have the power to transact all business of the Corporation during the interim between meetings of the Board of Directors, provided that any action so taken shall not conflict with the policies and express wishes of the Board of Directors, and that it shall refer all matters of major importance to the full Board of Directors, including any amendments to the Articles and Bylaws. Form 990, Part VI, Section B, line 11b The full copy of the Form 990 is provided to the board via email. The Form 990 is reviewed and approved by the board and signed by the CEO after approval. Form 990, Part VI, Section B, line 12c The conflict of interest and compensation disclosure statements are completed annually. All board members and officers of CCCHC are covered by the policy. The annual conflict of interest and compensation disclosure statements obtained from board members and officers of CCCHC are reviewed by the CEO and Administration staff of CCCHC. It is at this review that the determination is made as to whether a conflict exists. Actual conflicts of interest identified are brought before the Board Executive Committee or the entire Board, depending on the situation and circumstances. Board members and officers of CCCHC are required to recuse themselves from voting on issues where it has been determined that a conflict of interest does exist. If the conflict of interest is pervasive, the Board Executive Committee or the entire Board will determine if further actions are needed. In all situations, the Board will document the restrictions imposed or acted upon. Form 990, Part VI, Section B, line 15a To determine compensation, the organization uses the following salary surveys for both the CEO and CFO as well as other positions within the organization: National Community Health Center Association (NACHC), Community Healthcare Association of the Mountain Plain States (CHAMPS), Medical Group Management Association (MGMA), and state of ND. The board of directors determines the salary of the CEO. CEO Salary adjustments are documented on a payroll notification form, signed by the board chair and forwarded to the accounting department for entry into the accounting/payroll system. Compensation for the CFO is reviewed and approved by the CEO. The board of directors approves an annual budget to provide guidance for expenditures which includes personnel salaries. In addition, annual salary adjustments are presented to the board for approval through the budgetary process. Personnel salary adjustments are documented on a payroll notification form signed by the CEO or Human Resources and forwarded to the accounting department for entry into the accounting/payroll system. The process for determining compensation is undertaken annually before the new fiscal year in May begins. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Other Medical Service Fees: Program service expenses 1,374,059. Management and general expenses 320,303. Fundraising expenses 0. Total expenses 1,694,362.