2020-04-30T09:30:42-05:00 2019-06-30 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2018-07-01 450222079 Jacobson Memorial Hospital Care Center JACO 7015842792 601 E St N Elgin ND 58533 Theo Stoller CEO/Administrator 7015842792 2020-04-30 1 Lisa Chaffee CPA P00193453 7012551091 2020-04-30 96.2.60.209 2020-04-30 08:56:17 CD P 66CC91E6B7F11C4783FFFA5645E675327CB67316 DEA5AAEEBA04E2AF66A8E14BCCBEC2FC2C377148 2018 2020-09-22 18:59:49Z Theo Stoller 601 E St N Elgin ND 58533 9563856 0 X www.jacobsonhospital.org X 1949 ND To provide quality healthcare to advance the health of patients and communities we serve. 9 9 94 100 0 0 38755 257555 8633617 9293893 973 1808 3927 4516 8677272 9557772 0 0 0 0 3244108 3831758 0 0 0 5263267 5513727 8507375 9345485 169897 212287 5735433 6817217 2586304 3455845 3149129 3361372 X To advance the health of patients and communities we serve through a culture of leadership, continuous improvement and accountability. Jacobson Memorial Hospital Care Center (JMHCC) understands the relationship that exists between body, mind and the human spirit. We believe that respect, integrity, quality, commitment and accountability are the foundation by which a healthcare provider should practice in accordance with respect of this relationship. 0 0 8054445 9293893 Jacobson Memorial Hospital Care Center (JMHCC) is a 30 bed non-profit hospital organization in Elgin, North Dakota. The Board of Directors is made up of community members from the surrounding areas served by JMHCC. JMHCC's primary activity is to provide health care to Grant County. It provides acute care services, ER, swing bed, and clinical services. JMHCC also provides a wide range of outpatient services such as physical, speech and occupational therapy and cardiac rehab. JMHCC provides non-emergency services through clinics in the communities of Elgin and Glen Ullin, in addition to the emergency services it provides in Elgin. 8054445 1 1 0 1 0 0 0 0 1 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 20 0 1 94 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 0 1 1 0 0 X Scott Ostenson 7015847236 601 E St N Elgin ND 58533 Leslie Niederman Chairperson 1.00 X X 0 0 0 Joel Klein Vice Chair 1.00 X X 0 0 0 Julie Armijo - Director (until Nov)/Secretary (as of Nov) 1.00 X X 0 0 0 Marcia Koepplin - Secretary (until Nov)/Director (as of Nov) 1.00 X X 0 0 0 Ann Hertz Director 1.00 X 0 0 0 Marcy Haase Director 1.00 X 0 0 0 Ron Bartz Director 1.00 X 0 0 0 Patrick Diehl Director (as of Nov) 1.00 X 0 0 0 Dennis Sabin Director (as of Nov) 1.00 X 0 0 0 Claire Hauge Director (until Nov) 1.00 X 0 0 0 Kim Oien Director (until Nov) 1.00 X 0 0 0 Theo Stoller CEO/Administrator 40.00 X 183055 0 0 Scott Ostenson CFO 40.00 X 80716 0 5419 Lori Hill NP 32.00 X 115488 0 2316 Carrie Gerving NP 32.00 X 103114 0 18852 Carey Rivinius NP 32.00 X 138560 0 19594 620933 0 46181 3 0 1 1 Medical Solutions PO Box 310737 Des Moines IA 50331 Interim DON, Rad Supervisor 458478 ARL Inc 7205 68th Ave SW Elgin ND 58533 Medical Director 323820 Titan Nurse 2110 S 169th Plaza Omaha NE 68130 Travel Nurses 312397 Dakota Travel Nurse 1200 Collins Ave Mandan ND 58554 Travel Nurses 289312 CHI St Alexius 900 East Broadway Bismarck ND 58506 Management Services 231272 7 257555 257555 Net Patient Revenue 623000 8564074 8564074 340B Pharmacy Revenue 446110 597069 597069 Other Revenue 900099 132750 132750 9293893 1808 1808 10600 6084 4516 4516 4516 9557772 9293893 0 6324 X 270778 270778 87795 87795 2737356 2517178 220178 33540 29817 3723 476075 444577 31498 226214 204441 21773 66419 66419 3113021 2777378 335643 28321 28321 203122 117927 85195 23011 23011 216104 197934 18170 43852 33015 10837 21571 12273 9298 73512 66639 6873 542618 491885 50733 52258 52258 Medical Supplies 740983 740983 Bad Debt 183767 183767 Food 80678 80678 Dues and Subscriptions 65107 43076 22031 59383 25082 34301 9345485 8054445 1291040 0 1552439 1312240 1282479 1209547 109745 115152 48887 63543 10654664 7073084 2591987 3581580 149896 165155 0 370000 5735433 6817217 557464 899010 655 655 1743185 2556180 285000 0 2586304 3455845 X 3149129 3361372 3149129 3361372 5735433 6817217 212287 -44 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 706 0 0 0 706 0 Part II-B, Line 1: Jacobson Memorial Hospital is a member of the North Dakota Hospital Association. A portion of the dues paid are used for lobbying activities. 0 1 X 13294 13294 6100174 3797259 2302915 3805544 2939838 865706 735652 335987 399665 3581580 Estimated Third Party Payor Settlement 370000 370000 X 9380045 -44 -183767 -183811 9563856 -6084 -6084 9557772 9167802 6084 6084 9161718 183767 183767 9345485 Part IV, Line 2b: The Hospital acts as custodian for the funds of the swing bed patients. These funds are included in cash and cash equivalents and accounts payable in the consolidated financial statements. Patient trust funds totaled $655 at June 30, 2019 and 2018. Part X, Line 2: Jacobson Memorial Hospital Care Center (JMHCC) is organized as a North Dakota nonprofit organization and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). JMHCC is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, JMHCC is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. JMHCC has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. JMHCC believes it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. JMHCC would recognize future accrued interest and penalties related to unrecognized tax liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts included in Revenue in the Financial Statements -183,767. Part XI, Line 4b - Other Adjustments: Rental Expenses -6,084. Part XII, Line 2d - Other Adjustments: Rental Expenses 6,084. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts included in Revenue in the Financial Statements 183,767. 1 1 X 1 X 1 X 0 1 0 0 12000 12000 0.00130 504901 320842 184059 0.02010 516901 320842 196059 0.02140 1249528 1185633 63895 0.00700 1249528 1185633 63895 0.00700 1766429 1506475 259954 0.02840 0 183767 25727 3728260 3757793 -29533 X 1 1 1 1 Jacobson Memorial Hospital Care Center 601 E St N Elgin ND 58553 www.jacobsonhospital.org 5014 X X X X Jacobson Memorial Hospital Care Center 1 0 0 1 X X X X X X X X X 16 1 0 0 1 X See Part V, Section C X 1 16 1 www.jacobsonhospital.org/About-Us.html 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X 1 X www.jacobsonhospital.org/Patients-Visitors.html X www.jacobsonhospital.org/Patients-Visitors.html X www.jacobsonhospital.org/Patients-Visitors.html X X X X X 1 X 0 X X X 1 X 0 1 Jacobson Memorial Hospital Care Center Part V, Section B, Line 5: To gather feedback from the community, residents of the county and local health care professionals were given the chance to participate in a survey. Approximately 100 community members and health care professionals took the survey. Additional information was collected through a Community Group comprised of community members and through key informant interviews with community leaders. Fifteen residents participated as a Community Group member, key informant interviewee, or both. Jacobson Memorial Hospital Care Center Part V, Section B, Line 11: JMHCC conducted a CHNA during 2016. Needs identified in the CHNA are listed below along with how they are currently being addressed:Access to Exercise and wellness activities: JMHCC is actively working with the school to open a fitness center that would be available to the public. We also hold a 5k every year while also helping sponsor and promote other area 5k's and other walks. We offer health fairs targeting preventative care issues. Youth alcohol use and abuse: Jacobson Memorial Hospital does not intend to address this need directly, but has plans to work with Custer Health and the local Sherriff to get education out to the community. Attracting and retaining young families: Jacobson Memorial Hospital does not intend to address this need directly, but will continue to recruit as best we can for open positions. We recently conducted an economic impact study to show how JMHCC supports the community, and we continue to offer above average pay and benefits to employees to entice them to stay. Availability of specialists: We continue to work with larger health systems to bring in specialists for our patients needs. During FY 2019, we were able to have a cardiologist come once a month to see patients in Elgin. Jacobson Memorial Hospital Care Center Part V, Section B, Line 13h: Family size is also a factor in determining amounts charged to patients under the financial assistance policy. Jacobson Memorial Hospital Care Center Part V, Section B, Line 16j: An ad is in the local newspaper once per year. Jacobson Memorial Hospital Care Center Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. FAP-eligible patients without insurance may be charged gross charges on elective procedures. Part V, Section B, Line 7a: http://www.jacobsonhospital.org/About-Us.html 2 1 - Elgin Community Clinic 603 E St N Elgin ND 58553 Rural Health Clinic 2 - Glen Ullin Family Medical Clinic 602 E Ash Ave Glen Ullin ND 58631 Rural Health Clinic Part I, Line 3c: The organization does offer free care under their charity care policy for people at 100% of the federal poverty guidelines, and they offer discounted care starting at 200% of the Federal Poverty Guidelines. Family size is also a factor in determining discounted care. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overallcost-to-charge ratio addressing all patient segments. The cost for Medicaid, line 7b, and subsidized health services, line 7g, were determined using the Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator is $183,767. Part III, Line 2: Bad debt expense is reported as charges shown on the financial statements. Part III, Line 3: Approximately 14% of the individuals in Grant county are below the Federal Poverty Guidelines and so we estimate that approximately 14% of the total bad debt expense is attributable to patients eligible for charity care. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs were obtained from the 2018 Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.Even though Medicare was at a loss, the hospital still provided services to these patients. The elderly are an underserved population who experience issues with access to healthcare services. It is a community benefit to be able to treat them at the local hospital. Part III, Line 9b: Jacobson Memorial Hospital Care Center (JMHCC) has established a collections policy and procedure to facilitate effective and efficient collections for self-pay balances. When a patient submits an application for charity care, collection proceedings are stopped until a decision is made. If an application is determined to be incomplete, a letter is sent letting the patient know additional information is required. If we still do not receive the additional information in 30 days, the patient is sent a letter stating that their application for charity care has been declined and that collection proceedings could start again if payments are not made. When a complete application is received the finance committee meets, which includes the CEO, CFO, and two board members, and they determine if the patient qualifies for charity care and for how much of a discount. If it is determined that a patient is eligible for charity care they receive a letter stating so with a percentage that they qualified for and amount due. It is communicated that they are still expected to make payments. If a patient is sent to collections and later fills out a charity care application and is found to be eligible for a discount, we would pull the account back from collections and set up a payment plan with the patient. Part VI, Line 2: JMHCC obtained information about the needs of the community through a strategic planning committee made up of representatives from the service area including members of the board of directors, medical staff, hospital administration, hospital staff and community members. These individuals provide the hospital with insight on the issues facing the members of the community. JMHCC completed a community health needs assessment in the spring of 2017. The assessment was completed by the Center for Rural Health. Part VI, Line 3: Jacobson Memorial Hospital Care Center communicates information about the Charity Care Program to its patients and those living within its primary service area, identifies potential applicants and assists the patients that qualify for discounted services with the applicant process. Jacobson Memorial Hospital Care Center informs the general public within its primary service area of the availability of Charity Care through the following: includes the Charity Care policy in the Patient/Resident Payment Policy provided to all patients at the point of service or admission; posts the policy on community bulletin boards within the Jacobson Memorial Hospital Care Center facilities; posts the policy and information on the Jacobson Memorial Hospital Care Center website; releases general information at least annually in the legal newspaper located within Jacobson Memorial Hospital Care Center's primary service area; and other as deemed appropriate by the Administrator. Part VI, Line 4: According to data collected while preparing the Community Health Needs Assessment in the spring of 2017, approximately 27% of the population of Grant County is over age 65. The median household income in Grant County is significantly lower than for the rest of North Dakota - $31,852 compared to $46,050. Grant County had a population of 2,388 while the city of Elgin had a population of 642. There are no other hospitals that serve the community. In fact the next nearest hospital is roughly 80 miles away. Part VI, Line 5: Jacobson Memorial Hospital Care Center (JMHCC) has a Board of Directors made up of volunteers and members of the community. JMHCC does extend medical staff privileges to all qualified physicians serving in the community. Net increases in net assets are invested back into facilities and equipment in order to provide better patient care. In addition to our charity care policy, JMHCC provides many other services to meet the needs of those in Grant County which include:-provide office space so that we can continue to offer mental health services to the community on an outpatient basis.-participate in a number of community events every year including annual discounted lab services during hospital week.-participate in a Scrubs Camp sponsored by the Center for Rural Health and many other local health care organizations such as the New Leipzig ambulance and the local pharmacy, vision and dental practices.-operate a 24 hour emergency department that is available to anyone regardless of the ability to pay.-offer volunteer opportunities for capable area residents to come in and give our long term care residents and our swing-bed patients some activities to participate in. X X 0 0 0 0 0 0 0 0 0 Theo Stoller CEO/Administrator 183055 0 0 0 0 0 0 0 0 0 183055 0 0 0 Carey Rivinius NP 138560 0 0 0 0 0 2815 0 16805 0 158180 0 0 0 Form 990, Schedule J, Part I, Line 3: Jacobson Memorial Hospital Care Center does not pay compensation to Theo Stoller, Administrator, directly. He is compensated by an unrelated organization, CHI St. Alexius Health. The Jacobson Memorial Hospital Board of Directors uses the processes described in Part I, Question 3 to determine appropriate compensation for Theo. Any increase in compensation is communicated to CHI St. Alexius Health. CHI St. Alexius Health sends Jacobson Memorial a monthly bill for his wages earned at Jacobson Memorial. Crystal Stoller Family member of Officer Theo Stoller 87795 Compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of the Board Chairperson, Vice Chairperson, and the Secretary. The Executive Committee shall have power to transact all regular business of the hospital during the period between the meetings of the governing board, subject to any prior limitations imposed by the governing board and with the understanding that all matters of major importance will be referred to the governing board. It shall be the further duty of the Executive Committee to examine the monthly financial reports. Minutes of the Executive Committee meetings shall be submitted to the Board, and its actions shall be subject to approval or disapproval at the next regular board meeting. The board president only votes if there is a tie. Form 990, Part VI, Section A, line 6 There is one class of members. Each member pays a one-time fee of $10 for membership. Form 990, Part VI, Section A, line 7a Each member receives one vote to elect a director to the Hospital Board. Elections take place at the scheduled annual meeting which is held during the last quarter in the calendar year. Form 990, Part VI, Section A, line 7b The by-laws of the corporation may be amended by affirmative vote of a two-thirds (2/3) majority of the members present at the annual meeting or any special meeting of the corporation, provided, that a notice of such proposed amendments shall have been published in the notice calling the meeting, or, the by-laws may be amended by a vote of three-fourths (3/4) of the Board of Directors members. Form 990, Part VI, Section B, line 11b Upon receipt of the draft Form 990, the Organization will provide a copy to the Executive Committee to approve to meet the filing deadline, followed by a copy to each board member to review at the next regular board meeting. Form 990, Part VI, Section B, line 12c Yearly, Officers, Directors and key employees are given the Organization's Conflict of Interest Policy and a Conflict of Interest Acknowledgement Statement in which they must sign. It is the duty of an interested person to disclose the existence of a potential conflict of interest. If any individual discloses a possible conflict, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon by the remaining board or committee members to determine if in fact a conflict of interest exists. If it is found that a conflict exists the conflicted individual is asked to leave the meeting. The remaining board or committee members shall exercise due diligence in determining whether JMHCC can obtain with reasonable efforts a more advantageous transaction or arrangement from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably possible under circumstances not producing a conflict of interest, the Governing Board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in JMHCC's best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the transaction or arrangement. In this fiscal year each affected person signed the policy with no conflicts noted. Form 990, Part VI, Section B, line 15a The compensation of the Hospital Administrator is reviewed and approved by the independent Board of Directors. The Hospital obtains salary surveys from the Long Term Care Association and the North Dakota Hospital Association in deliberating the compensation amount. The compensation determination is presented and approved at a board meeting each year. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Part IX, line 11g Contracted Services: Program service expenses 2,777,378. Management and general expenses 335,643. Fundraising expenses 0. Total expenses 3,113,021. Jacobson Memorial Hospital Foundation PO Box 367 Elgin ND 58533 208145158 To support Jacobson Memorial Hospital ND 501(c)(3) Line 7 Jacobson Memorial Hospital Care Center 1 0 0 1 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0