PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (EIN 45-6013474)
- Tax period
- 2020-01-01 to 2020-12-31
- Filed
- 2021-11-15
- IRS object ID
- 202133199349331508
- Schema version
- 2020v4.1
- 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 H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2021-11-15T21:21:23-06:00 | ReturnTs |
| Tax Period End | 2020-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 410746749 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLIFTONLARSONALLEN LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 220 S 6TH STREET SUITE 300 | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55402 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 456013474 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEMBINA COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | PEMB | BusinessNameControlTxt |
| Phone | 7012658461 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | KATIE WERNER | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 7012658461 | PhoneNum |
| Signature | 2021-11-15 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | KATIE | PersonFirstNm |
| Person Last | WERNER | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | RYAN ENGEBRETSON | PreparerPersonNm |
| PTIN | P01585625 | PTIN |
| Phone | 6123764500 | PhoneNum |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | LISA LETEXIER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $21,037,274 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CAVALIERHOSPITAL.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1976 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 194 | TotalEmployeeCnt |
| Total Volunteers | 20 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $110,953 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,701,954 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $16,110,610 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $18,919,122 | CYProgramServiceRevenueAmt |
| PY Investment Income | $31,773 | PYInvestmentIncomeAmt |
| CY Investment Income | $23,557 | CYInvestmentIncomeAmt |
| PY Other Revenue | $2,579,271 | PYOtherRevenueAmt |
| CY Other Revenue | $392,641 | CYOtherRevenueAmt |
| PY Total Revenue | $18,832,607 | PYTotalRevenueAmt |
| CY Total Revenue | $21,037,274 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $8,256,485 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $8,670,860 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $65,120 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,009,691 | PYOtherExpensesAmt |
| CY Other Expenses | $9,161,543 | CYOtherExpensesAmt |
| PY Total Expenses | $17,266,176 | PYTotalExpensesAmt |
| CY Total Expenses | $17,832,403 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,566,431 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $3,204,871 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $11,552,882 | TotalAssetsBOYAmt |
| Total Assets EOY | $18,508,005 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $2,243,738 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $5,993,990 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $9,309,144 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $12,514,015 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $16,345,033 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $18,919,122 | RevenueAmt |
| Desc | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20 BED ACUTE CARE HOSPITAL, 40 BED NURSING HOME, A RURAL HEALTH CLINIC, AND 20 UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24 HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY. THE ASSOCIATION ALSO PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. | Desc |
| Total Program Service Expenses | $16,345,033 | 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 | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | 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 | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| 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 | Yes (1) | 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 | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 8 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 194 | 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 | 6 | 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 | 0 | 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 | 0 | 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 | KATIE WERNER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7012656281 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (14 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| TOM FORD | |||||||
| PRESIDENT | 5.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TOM VAUGHN | |||||||
| VICE PRESIDENT | 5.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| DUANNE DERAAS | |||||||
| SECRETARY/TREASURER | 5.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| KENNETH SCHWANDT | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| NICOLE SAFRANSKI | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| DR KULVINDER SUMRA | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| TOM O'TOOLE | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| DARLENE WATSON | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| GEORGE WRIGHT | |||||||
| DIRECTOR | 5.00 | Yes (X) | $0 | $0 | $0 | ||
| LISA LETEXIER | |||||||
| CEO | 40.00 | Yes (X) | $160,385 | $0 | $10,559 | ||
| KATIE WERNER | |||||||
| CFO | 40.00 | Yes (X) | $67,183 | $0 | $31,791 | ||
| LAURA ERMER | |||||||
| PHYSCIANS ASSISTANT | 40.00 | $144,442 | $0 | $7,761 | Yes (X) | ||
| KIM FORD | |||||||
| NP | 40.00 | $132,418 | $0 | $10,492 | Yes (X) | ||
| JANAE HEUCHERT | |||||||
| PHARMACIST | 40.00 | $116,183 | $0 | $28,095 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $620,611 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $88,698 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 4 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| ALTRU HEALTH SYSTEMS | |||||
| PO BOX 1370 | GRAND FORKS | ND | 58208 | THERAPY SERVICES, PHYSICIAN SERVICES, IT | $601,928 |
| PARK RIVER CLINIC | |||||
| PO BOX 380 | CAVALIER | ND | 58220 | PHYSICIAN SERVICES | $557,139 |
| MAXON NURSING | |||||
| 313 5TH AVE NE | ROLLA | ND | 58367 | AGENCY NURSES | $330,054 |
| INDER V KHOKHA MD PC | |||||
| PO BOX 380 | CAVALIER | ND | 58220 | SURGEON SERVICES | $281,520 |
| DMS HEALTH TECHNOLOGIES | |||||
| PO BOX 670747 | DALLAS | TX | 75267 | MRI | $274,215 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 9 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $74,501 | RelatedOrganizationsAmt |
| Government Grants | $1,390,900 | GovernmentGrantsAmt |
| All Other Contributions | $236,553 | AllOtherContributionsAmt |
| Total Contributions | $1,701,954 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT REVENUE | 621110 | $16,478,399 | $16,478,399 |
| 340B REVENUE | 446110 | $2,350,700 | $2,350,700 |
| ANCILLARY REVENUES | 621110 | $90,023 | $90,023 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $18,919,122 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $23,557 | TotalRevenueColumnAmt |
| Exclusion | $23,557 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $54,245 | 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 | $54,245 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $54,245 | TotalRevenueColumnAmt |
| Exclusion | $54,245 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | OTHER INCOME | Desc |
| Business | 900099 | BusinessCd |
| Total Revenue Column | $338,396 | TotalRevenueColumnAmt |
| Exclusion | $338,396 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $338,396 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,037,274 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $18,919,122 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $416,198 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $269,919 | TotalAmt |
| Program Services | $243,183 | ProgramServicesAmt |
| Management And General | $25,565 | ManagementAndGeneralAmt |
| Fundraising | $1,171 | FundraisingAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,887,901 | TotalAmt |
| Program Services | $6,205,651 | ProgramServicesAmt |
| Management And General | $652,380 | ManagementAndGeneralAmt |
| Fundraising | $29,870 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $173,533 | TotalAmt |
| Program Services | $156,344 | ProgramServicesAmt |
| Management And General | $16,436 | ManagementAndGeneralAmt |
| Fundraising | $753 | FundraisingAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $844,512 | TotalAmt |
| Program Services | $760,863 | ProgramServicesAmt |
| Management And General | $79,987 | ManagementAndGeneralAmt |
| Fundraising | $3,662 | FundraisingAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $494,995 | TotalAmt |
| Program Services | $445,965 | ProgramServicesAmt |
| Management And General | $46,883 | ManagementAndGeneralAmt |
| Fundraising | $2,147 | FundraisingAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,641 | TotalAmt |
| Program Services | $2,380 | ProgramServicesAmt |
| Management And General | $250 | ManagementAndGeneralAmt |
| Fundraising | $11 | FundraisingAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,705 | TotalAmt |
| Program Services | $50,187 | ProgramServicesAmt |
| Management And General | $5,276 | ManagementAndGeneralAmt |
| Fundraising | $242 | FundraisingAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,466,901 | TotalAmt |
| Program Services | $4,024,453 | ProgramServicesAmt |
| Management And General | $423,077 | ManagementAndGeneralAmt |
| Fundraising | $19,371 | FundraisingAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $34,513 | TotalAmt |
| Program Services | $31,094 | ProgramServicesAmt |
| Management And General | $3,269 | ManagementAndGeneralAmt |
| Fundraising | $150 | FundraisingAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $147,740 | TotalAmt |
| Program Services | $133,106 | ProgramServicesAmt |
| Management And General | $13,993 | ManagementAndGeneralAmt |
| Fundraising | $641 | FundraisingAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $366,776 | TotalAmt |
| Program Services | $330,446 | ProgramServicesAmt |
| Management And General | $34,739 | ManagementAndGeneralAmt |
| Fundraising | $1,591 | FundraisingAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $42,001 | TotalAmt |
| Program Services | $37,841 | ProgramServicesAmt |
| Management And General | $3,978 | ManagementAndGeneralAmt |
| Fundraising | $182 | FundraisingAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $696,863 | TotalAmt |
| Program Services | $627,838 | ProgramServicesAmt |
| Management And General | $66,003 | ManagementAndGeneralAmt |
| Fundraising | $3,022 | FundraisingAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $95,896 | TotalAmt |
| Program Services | $86,397 | ProgramServicesAmt |
| Management And General | $9,083 | ManagementAndGeneralAmt |
| Fundraising | $416 | FundraisingAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt | FundraisingFundraisingAmt |
|---|---|---|---|---|
| MEDICAL SUPPLIES | $2,457,801 | $2,457,801 | ||
| PROVISION FOR BAD DEBT | $358,321 | $358,321 | ||
| EQUIPMENT RENTAL & REPA | $230,050 | $207,263 | $21,789 | $998 |
| FOOD EXPENSE | $162,912 | $146,776 | $15,430 | $706 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,423 | TotalAmt |
| Program Services | $39,124 | ProgramServicesAmt |
| Management And General | $4,112 | ManagementAndGeneralAmt |
| Fundraising | $187 | FundraisingAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $17,832,403 | TotalAmt |
| Program Services | $16,345,033 | ProgramServicesAmt |
| Management And General | $1,422,250 | ManagementAndGeneralAmt |
| Fundraising | $65,120 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $4,872 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,887,217 | BOYAmt |
| EOY | $9,368,514 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,271,349 | BOYAmt |
| EOY | $2,188,004 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $284,474 | BOYAmt |
| EOY | $224,168 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $47,442 | BOYAmt |
| EOY | $199,108 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $19,697,004 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $15,194,135 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,303,442 | BOYAmt |
| EOY | $4,502,869 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,603,212 | BOYAmt |
| EOY | $1,599,459 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $155,746 | BOYAmt |
| EOY | $421,011 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,552,882 | BOYAmt |
| EOY | $18,508,005 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,243,181 | BOYAmt |
| EOY | $5,177,783 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,310 | BOYAmt |
| EOY | $13,310 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $617,360 | BOYAmt |
| EOY | $461,713 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $369,887 | BOYAmt |
| EOY | $341,184 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,243,738 | BOYAmt |
| EOY | $5,993,990 | 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 | $9,309,144 | BOYAmt |
| EOY | $12,514,015 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,309,144 | BOYAmt |
| EOY | $12,514,015 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,552,882 | BOYAmt |
| EOY | $18,508,005 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $3,204,871 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | 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) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | 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 | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $539 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $539 | 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 | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $6,002 | BeginningBalanceAmt |
| Additions During Year | $1,705 | AdditionsDuringYearAmt |
| Distributions During Year | $3,168 | DistributionsDuringYearAmt |
| Ending Balance | $4,539 | 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 | $160,304 | OtherCostOrOtherBasisAmt |
| Book Value | $160,304 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,543,136 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,378,885 | DepreciationAmt |
| Book Value | $2,164,251 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $727,438 | OtherCostOrOtherBasisAmt |
| Depreciation | $541,604 | DepreciationAmt |
| Book Value | $185,834 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $10,233,618 | OtherCostOrOtherBasisAmt |
| Depreciation | $8,273,646 | DepreciationAmt |
| Book Value | $1,959,972 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $32,508 | OtherCostOrOtherBasisAmt |
| Book Value | $32,508 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $4,502,869 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $19,135,750 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $19,135,750 | RevenueSubtotalAmt |
| Other Revenues Not Included | $1,901,524 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $1,901,524 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $21,037,274 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $17,474,082 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $17,474,082 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $358,321 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $358,321 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $17,832,403 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART IV, LINE 1B: | A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. |
| PART IV, LINE 2B: | THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2020 AND 2019 TOTALED $13,310 AND $13,310 RESPECTIVELY. |
| PART X, LINE 2: | THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | INVESTMENT INCOME 23,557. RENTAL INCOME 54,245. GRANTS AND CONTRIBUTIONS FOR LONG-LIVED ASSETS 74,501. BAD DEBT EXPENSE 358,321. DEBT FORGIVENESS 1,390,900. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 358,321. |
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 |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | 0 | FinancialAssistanceBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $43,291 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $43,291 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00240 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,943,216 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,000,656 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,986,507 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,000,656 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $43,291 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00240 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $52,006 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $52,006 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00290 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $2,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,238,087 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,740,651 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $497,436 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02790 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,292,093 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,740,651 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $551,442 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03090 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $8,278,600 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $7,741,307 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $594,733 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03330 | TotalExpensePct |
Coalition Building CoalitionBuildingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $700 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $700 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $700 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $700 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $358,321 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $54,504 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,057,342 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,093,458 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$36,116 | 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 | PEMBINA COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.CAVALIERHOSPITAL.COM | WebsiteAddressTxt |
| State License | 5009 | StateLicenseNum |
| Subordinate Hospital EIN | 456013474 | SubordinateHospitalEIN |
| 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 | PEMBINA COUNTY MEMORIAL HOSPITAL | 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 | 20 | 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 | SEE PART V, SECTION B, LINE 7D | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 20 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | SEE PART V, SECTION B, LINE 7D | 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 | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| 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 |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML | 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 Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| 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 (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1) A SURVEY OF AREA RESIDENTS, INCLUDING HEALTH CARE PROFESSIONALS WHO UTILIZE SERVICES PROVIDED BY AND/OR WORK AT PEMBINA COUNTY MEMORIAL HOSPITAL, WEDGEWOOD MANOR, CLINICARE, AND PEMBINA COUNTY PUBLIC HEALTH.2) COMMUNITY LEADERS REPRESENTING THE BROADER INTERESTS OF THE COMMUNITY TOOK PART IN ONE-ON-ONE KEY INFORMANT INTERVIEWS;3) THE COMMUNITY GROUP, COMPRISED OF COMMUNITY LEADERS AND AREA RESIDENTS, WAS CONVENED TO DISCUSS AREA HEALTH NEEDS AND INFORM THE ASSESMENT PROCESS; AND4) A WIDE RANGE OF SECONDARY SOURCES OF DATA WERE EXAMINED, PROVIDING INFORMATION OF A MULTITUDE OF MEASURES INCLUDING DEMOGRAPHICS; HEALTH CONDITIONS, INDICATORS, AND OUTCOMES; RATES OF PREVENTIVE MEASURES; RATES OF DISEASE; AND AT-RISK BEHAVIOR. |
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. |
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 7D: THE ORGANIZATION'S COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT HTTPS://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML. |
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: IN 2020, PCMHA DEVELOPED AN IMPLEMENTATION PLAN BASED ON THE RESULTS OF THE 2020 CHNA. THE TOP NEEDS IDENTIFIED AND STRATEGIES DEVELOPED IN THE CHNA PROCESS INCLUDED:AVAILABILITY OF MENTAL HEALTH SERVICES - 1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MENTAL HEALTH PROVIDER SERVICES AT CLINICARE AND SEEK ANY OPPORTUNITY TO EXPAND SERVICES. 2. ENCOURAGE ATTENDANCE AND CONTINUE TO SUPPORT LOCAL LED SUPPORT GROUPS. SEEK OPPORTUNITIES TO EXPAND SUCH GROUPS. 3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES. ALCOHOL USE AND ABUSE, DEPRESSION/ANXIETY (YOUTH AND ADULT) - 1. PROMOTE THE PCBHC SUPPORTED PROGRAMS AND ALL FAITH BASED ORGANIZATIONS. 2. RESEARCH THE VIABILITY OF EXPANDING THE PALLIATIVE CARE GROUP TO INCLUDE A GRIEF SUPPORT PROGRAM. 3. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALITY VIA TELEMEDICINE. 4. SUPPORT YOUTH AND ADULT ALCOHOL FREE ACTIVITIES AND EDUCATION WITHIN OUR COMMUNITIES. 5. CONTINUE TO PROVIDE SPACE FOR SUPPORT GROUPS TO MEET AT PCMH.DRUG USE AND ABUSE (INCLUDING PRESCRIPTION DRUG USE) ADULTS - 1. PROMOTE THE DESTRUCTION OF LEFT OVER OR UNUSED MEDICATIONS WITH DETERA OR DROP OFF BOXES LOCATED THROUGHOUT THE COMMUNITIES. 2. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALTY VIA TELEMEDICINE. 3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES. 4. COLLABORATE WITH HEALTH PROVIDERS TO BRING MAT (MEDICATION ASSISTED TREATMENT) TO PEMBINA COUNTY.AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES - 1. CONTINUE TO WORK WITH THE PEMBINA COUNTY HEALTH COALITION TO PROVIDE AND DISTRIBUTE A RESOURCE GUIDE FOR PEMBINA COUNTY OF SERVICES OFFERED. 2. PROMOTE THE QSP PROGRAM AND OTHER SERVICES OFFERED THROUGH PEMBINA COUNTY SOCIAL SERVICES. 3. MEDICAL PROVIDERS WILL PROMOTE THE SENIOR MEAL PROGRAM. 4. CONTINUE TO COLLABORATE WITH NDSU PEMBINA COUNTY EXTENSION OFFICE WITH THE DIABETES PREVENTION AND STEPPING ON PROGRAMS. 5. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES AND HOUSING AUTHORITY.OTHER NEEDS IDENTIFIED IN THE CHNA, BUT NOT ADDRESSED IN THIS IMPLEMENTATION PLAN DUE TO LIMITED RESOURCES ARE:1. ATTRACTING AND RETAINING YOUNG FAMILIES - PCMHA CONTINUES TO BE AN ACTIVE PARTICIPANT IN COMMUNITY RECRUITMENT EFFORTS. PCMHA IS ALSO SUPPORTING THE CAVLANDIC BIKE SHARE PROGRAM IN 2020. PCMHA CONTINUES TO OFFER COMPETITIVE WAGES AND BENEFITS TO RECRUIT AND RETAIN FAMILIES2. COST OF LONG-TERM/ NURSING HOME CARE - HOSPITAL SOCIAL WORK DESIGNEE IS AVAILABLE TO ASSIST INDIVIDUALS WHO LACK HEALTH INSURANCE THROUGH PROGRAMS OFFERED AND OUR FINANCIAL ASSISTANCE PROGRAM. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES OCCUR ON A REGULAR BASIS. ADMINISTRATION PROVIDES ONGOING FEEDBACK TO GOVERNMENT POLICY MAKERS AT THE STATE LEVEL REGARDING LONG TERM HEALTH CARE AND HEALTH INSURANCE COSTS3. HAVING ENOUGH CHILD DAYCARE SERVICES - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE CHILD DAYCARE SERVICES WITHIN ITS SERVICE AREA.4. NOT ENOUGH AFFORDABLE HOUSING - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE AFFORDABLE HOUSING WITHIN ITS SERVICE AREA. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - WEDGEWOOD MANOR | ||||
| 804 MAIN STREET WEST | CAVALIER | ND | 58220 | SKILLED NURSING HOME |
| 2 - CLINICARE | ||||
| 301 MOUNTAIN STREET EAST | CAVALIER | ND | 58220 | RURAL HEALTH CLINIC |
| 3 - COUNTRY ESTATES | ||||
| 107 BJORNSON DRIVE | CAVALIER | ND | 58220 | CONGREGATE HOUSING |
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. |
| PART I, LINE 7G: | SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, SKILLED NURSING FACILITY, AND EMERGENCY ROOM. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. |
| PART III, LINE 2: | IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. |
| PART III, LINE 3: | 8.8% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2019 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE, THE ORGANIZATION ESTIMATES THAT 8.8% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. |
| PART III, LINE 4: | SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 9 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. |
| PART III, LINE 8: | ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFIT TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. |
| PART III, LINE 9B: | IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION.1. SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. 2. PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. A. THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. B. THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. C. THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. 3. ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME SHALL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $1.00, IT WILL NOT BE REFUNDED. |
| PART VI, LINE 2: | 1. REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD. 2. REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD. 3. CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. |
| PART VI, LINE 3: | NOTICES OF THE FAP ARE POSTED IN ALL WAITING AREAS, REGISTRATION AREAS, AND UPON DISCHARGE. |
| PART VI, LINE 4: | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 40-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2020 SHOWED A POPULATION OF 6,844 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $64,549. THE PER CAPITA INCOME FOR THE COUNTY WAS $36,251. 8.8% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. |
| PART VI, LINE 5: | OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 (2 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| LISA LETEXIER | ||||||||||||||
| CEO | $149,095 | $0 | $1,000 | $0 | $10,290 | $0 | $6,528 | $0 | $4,031 | $0 | $170,944 | $0 | $0 | $0 |
| LAURA ERMER | ||||||||||||||
| PHYSCIANS ASSISTANT | $143,442 | $0 | $1,000 | $0 | $0 | $0 | $5,801 | $0 | $1,960 | $0 | $152,203 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 3 | FormAndLineReferenceDesc |
| Explanation | COMPARATIVE DATA IS GATHERED FROM THE ND HOSPITAL ASSOCIATION'S WAGE SURVEYS, AND THE BOARD OF DIRECTORS ANNUALLY REVIEWS THE CEO'S COMPENSATION. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (3 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| PARK RIVER CLINIC | |||
| PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER | $557,139 | PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES | 0 |
| KIM FORD | |||
| DAUGHTER-IN-LAW OF TOM FORD, A BOARD MEMBER | $132,418 | EMPLOYEE COMPENSATION | 0 |
| RITA VAUGHN | |||
| WIFE OF TOM VAUGHN, A BOARD MEMBER | $3,612 | EMPLOYEE COMPENSATION | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 1 | THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. |
| FORM 990, PART VI, SECTION A, LINE 6 | ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. |
| FORM 990, PART VI, SECTION A, LINE 7A | ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. IN ADDITION, ONE BOARD MEMBER SHALL BE APPOINTED BY ALTRU HEALTH SYSTEM. |
| FORM 990, PART VI, SECTION B, LINE 11B | FULL BOARD REVIEWS THE DRAFT OF THE 990 PRIOR TO FILING OF THE FINAL REPORT WITH THE IRS. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT RAISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. THE BOARD MINUTES CONTAINS AN ACKNOLWEDGEMENT OF THE CONFLICT-OF-INTEREST FORMS. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. |
| FORM 990, PART VI, SECTION B, LINE 15A | THE CEO'S COMPENSATION IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTOR'S. COMPARATIVE DATA IS GATHERED FROM THE ND HOSPITAL ASSOCIATION'S WAGE SURVEYS. A BLUE FORM IS GIVEN TO HR INDICATING ANY SALARY DECISIONS. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON NORTH DAKOTA HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2020. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | OTHER FEES: PROGRAM SERVICE EXPENSES 4,024,453. MANAGEMENT AND GENERAL EXPENSES 423,077. FUNDRAISING EXPENSES 19,371. TOTAL EXPENSES 4,466,901. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 300052569 | EIN |
| Primary Activities | FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12A, I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | 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 | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
Comments