GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2018
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2018-04-01 to 2019-03-31
- Filed
- 2020-02-22
- IRS object ID
- 202020539349300702
- Schema version
- 2018v3.1
- 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 K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2020-02-22T07:59:50-06:00 | ReturnTs |
| Tax Period End | 2019-03-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1730 Burnt Boat Loop Ste 100 | AddressLine1Txt |
| City | Bismarck | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 585030886 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2018-04-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOOD | BusinessNameControlTxt |
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Jerry Jurena | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017765261 | PhoneNum |
| Signature | 2020-02-22 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Lisa Chaffee CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012551091 | PhoneNum |
| Preparation | 2020-02-14 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 63.157.104.106 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2020-02-22 | IPDt |
| IP Tm | 07:57:54 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 66CC91E6B7F11C4783FFFA5645E675327CB67316 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 4A22B0C6F89CA7817A18FDE072DED4220BFE3CF6 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2018 | TaxYr |
| Build TS | 2020-09-23 17:36:50Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Jerry Jurena | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $29,689,126 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.hamc.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1905 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | Provide quality medical care based on the needs and demographics of north central North Dakota. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 8 | VotingMembersIndependentCnt |
| Total Employee | 425 | TotalEmployeeCnt |
| Total Volunteers | 128 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $1,726,886 | PYContributionsGrantsAmt |
| CY Contributions Grants | $564,209 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $26,664,519 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $29,071,497 | CYProgramServiceRevenueAmt |
| PY Investment Income | $317,109 | PYInvestmentIncomeAmt |
| CY Investment Income | $1,927 | CYInvestmentIncomeAmt |
| PY Other Revenue | $540,908 | PYOtherRevenueAmt |
| CY Other Revenue | $51,493 | CYOtherRevenueAmt |
| PY Total Revenue | $29,249,422 | PYTotalRevenueAmt |
| CY Total Revenue | $29,689,126 | 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 | $19,287,308 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $15,710,880 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $10,438,000 | PYOtherExpensesAmt |
| CY Other Expenses | $12,717,767 | CYOtherExpensesAmt |
| PY Total Expenses | $29,725,308 | PYTotalExpensesAmt |
| CY Total Expenses | $28,428,647 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$475,886 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,260,479 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $10,891,477 | TotalAssetsBOYAmt |
| Total Assets EOY | $14,666,914 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $3,937,977 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,290,987 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $6,953,500 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $8,375,927 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $23,338,747 | ExpenseAmt |
| Revenue | $29,071,497 | RevenueAmt |
| Desc | Good Samaritan Hospital Association (GSHA) is a nonprofit health care organization, owned by over 30 area churches representing all the local denominations of the christian faith. The area churches at an annual meeting every fall elect a board of trustees. This board is the legal governing body that is responsible for the Association. GSHA's primary focus is healthcare within and around the community of Rugby, ND. GSHA has 25 licensed acute/swing beds as a critical access hospital, 3 rural health clinics, along with a surgical clinic, 54 medicare skilled nursing home beds, 68 basic care beds, and 37 assisted living apartments. We also service the community through a hospital based hospice. GSHA provides numerous community and social programs including, but not limited to the following: Charity Care - the estimated cost of providing charity care services was $45,000 during the year ended March 31, 2019 (calculated by multiplying the ratio of cost to gross charges for the Organization by the gross uncompensated charges associated with providing charity care to patients), reduced fee flu shot clinics, diabetic education program, public healthcare educational and informational notices, testing and information during health shows and community events, ambulance volunteers, provides EMT courses for ambulances, educational outreach for school system, provides senior citizen meals at minimal fee, free blood pressure checks, community education, physical therapy, provides meeting room for various organizations and churches, CPR training, wellness programs, sponsor LPN/RN school program through consortium of facilities and colleges. | Desc |
| Total Program Service Expenses | $23,338,747 | 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 |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | 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 | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| 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 With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| 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 | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | Yes (1) | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 75 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 425 | 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 | 8 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | 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 | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | 0 | 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 | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | Yes (1) | InvestmentInJointVentureInd |
| Written Policy Or Procedure | Yes (1) | WrittenPolicyOrProcedureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jerry Jurena | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (19 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| Kris Thiel | ||||||||
| President | 2.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Jason Lee | ||||||||
| Vice Chair | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Andrew Shae | ||||||||
| President (April-June) | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Bonita Lindseth | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Patricia Heggen | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Richard Anderson | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Annette Leier | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Arland Geiszler | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| William Griffin | ||||||||
| Trustee | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Tanner Johnson | ||||||||
| Trustee, GSHS Foundation rep. | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Christine Bubach | ||||||||
| Trustee (April-October) | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Patrick Branco | ||||||||
| Secretary - CEO | 40.00 | 1.00 | Yes (X) | $238,635 | $0 | $14,658 | ||
| Richard Baland | ||||||||
| Treasurer - Interim CFO | 40.00 | 4.00 | Yes (X) | $0 | $0 | $0 | ||
| Lee Holter | ||||||||
| Treasurer - CFO | 40.00 | 4.00 | Yes (X) | $97,866 | $0 | $13,263 | ||
| Cammy Kelsch FNP-C | ||||||||
| Emergency Room provider | 40.00 | 0.00 | $272,128 | $0 | $18,897 | Yes (X) | ||
| Ronald Skipper MD | ||||||||
| General Surgeon | 40.00 | 0.00 | $309,485 | $0 | $24,154 | Yes (X) | ||
| Rylan Brantl | ||||||||
| ER Physician | 72.00 | 0.00 | $631,532 | $0 | $10,923 | Yes (X) | ||
| Chelsey Wyatt | ||||||||
| CRNA | 40.00 | 0.00 | $222,343 | $0 | $23,830 | Yes (X) | ||
| Steven Schoneberg MD | ||||||||
| Family Practice Physician | 40.00 | 0.00 | $216,814 | $0 | $17,137 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,988,803 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $122,862 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 13 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp
Contractor Name ContractorName
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | BE Smith | BusinessNameLine1Txt |
Contractor Address ContractorAddress
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | Dept 200 PO Box 219241 | AddressLine1Txt |
| City | Kansas City | CityNm |
| State Abbreviation | MO | StateAbbreviationCd |
| ZIP | 641219241 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Services | Interim CFO Services | ServicesDesc |
| Compensation | $177,729 | CompensationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 1 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $160,322 | RelatedOrganizationsAmt |
| Government Grants | $226,802 | GovernmentGrantsAmt |
| All Other Contributions | $177,085 | AllOtherContributionsAmt |
| Total Contributions | $564,209 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient Service Revenue | 621400 | $25,976,076 | $25,976,076 |
| Pharmacy Revenue | 900099 | $1,591,204 | $1,591,204 |
| Daycare Services | 900099 | $199,414 | $199,414 |
| Cafeteria Revenue | 900099 | $105,924 | $105,924 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,198,879 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $1,198,879 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $29,071,497 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,927 | TotalRevenueColumnAmt |
| Exclusion | $1,927 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $51,493 | 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 | $51,493 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $51,493 | TotalRevenueColumnAmt |
| Exclusion | $51,493 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $29,689,126 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $29,071,497 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $53,420 | 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 | $389,873 | TotalAmt |
| Management And General | $389,873 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $40,592 | TotalAmt |
| Program Services | $40,592 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,083,389 | TotalAmt |
| Program Services | $11,365,777 | ProgramServicesAmt |
| Management And General | $1,717,612 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $63,924 | TotalAmt |
| Program Services | $55,461 | ProgramServicesAmt |
| Management And General | $8,463 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,236,180 | TotalAmt |
| Program Services | $1,064,398 | ProgramServicesAmt |
| Management And General | $171,782 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $896,922 | TotalAmt |
| Program Services | $767,461 | ProgramServicesAmt |
| Management And General | $129,461 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $223,162 | TotalAmt |
| Management And General | $223,162 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $152,287 | TotalAmt |
| Management And General | $152,287 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,104,937 | TotalAmt |
| Program Services | $2,678,509 | ProgramServicesAmt |
| Management And General | $1,426,428 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,383 | TotalAmt |
| Management And General | $26,383 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $333,919 | TotalAmt |
| Program Services | $170,403 | ProgramServicesAmt |
| Management And General | $163,516 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,564 | TotalAmt |
| Management And General | $8,564 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,146,519 | TotalAmt |
| Program Services | $1,034,109 | ProgramServicesAmt |
| Management And General | $112,410 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $122,125 | TotalAmt |
| Program Services | $79,139 | ProgramServicesAmt |
| Management And General | $42,986 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $144,631 | TotalAmt |
| Program Services | $70,441 | ProgramServicesAmt |
| Management And General | $74,190 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $60,132 | TotalAmt |
| Program Services | $60,132 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $866,698 | TotalAmt |
| Program Services | $866,698 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $210,658 | TotalAmt |
| Management And General | $210,658 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| Medical Supplies | $2,037,287 | $2,037,287 |
| Provision for Bad Debt | $1,903,821 | $1,903,821 |
| Repairs & Maintenance | $650,247 | $650,247 |
| Food | $382,872 | $382,872 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $343,525 | TotalAmt |
| Program Services | $111,400 | ProgramServicesAmt |
| Management And General | $232,125 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,428,647 | TotalAmt |
| Program Services | $23,338,747 | ProgramServicesAmt |
| Management And General | $5,089,900 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $602,590 | BOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $36,184 | BOYAmt |
| EOY | $2,151,600 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,474,073 | BOYAmt |
| EOY | $3,741,934 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $192,412 | BOYAmt |
| EOY | $219,950 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $25,779 | BOYAmt |
| EOY | $76,715 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $26,735,909 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $21,564,355 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,644,593 | BOYAmt |
| EOY | $5,171,554 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $1,892 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $67,361 | BOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $64,143 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,848,485 | BOYAmt |
| EOY | $3,239,126 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,891,477 | BOYAmt |
| EOY | $14,666,914 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,672,820 | BOYAmt |
| EOY | $2,431,783 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $734,000 | BOYAmt |
| EOY | $613,420 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $20,064 | BOYAmt |
| EOY | $19,603 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $426,429 | BOYAmt |
| EOY | $780,105 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $76,000 | BOYAmt |
| EOY | $28,377 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,008,664 | BOYAmt |
| EOY | $2,417,699 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,937,977 | BOYAmt |
| EOY | $6,290,987 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,345,985 | BOYAmt |
| EOY | $7,315,834 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $607,515 | BOYAmt |
| EOY | $1,060,093 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,953,500 | BOYAmt |
| EOY | $8,375,927 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,891,477 | BOYAmt |
| EOY | $14,666,914 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,260,479 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $161,948 | 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) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | 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 | Yes (1) | GrantsOtherOrganizationsInd |
| Grants Other Organizations | $2,951 | GrantsOtherOrganizationsAmt |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | 0 | OtherActivitiesInd |
| Total Lobbying Expenditures | $2,951 | 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 | Good Samaritan Hospital Association is a member of several organizations that take part in lobbying. These organizations include the North Dakota Hospital Association, the National Rural Health, and the North Dakota Long Term Care Association. A portion of the dues paid to the various organizations is for lobbying costs. These various organizations advocate on behalf of their members by supporting legislation that is in their collective interests. These organizations work to ensure that laws and regulations provide a reasonable and equitable environment in which health care facilities can provide affordable, high quality care. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $68,291 | BeginningBalanceAmt |
| Additions During Year | $36,241 | AdditionsDuringYearAmt |
| Distributions During Year | $41,424 | DistributionsDuringYearAmt |
| Ending Balance | $63,108 | 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 | $137,447 | OtherCostOrOtherBasisAmt |
| Book Value | $137,447 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $12,053,643 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,934,866 | DepreciationAmt |
| Book Value | $2,118,777 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $14,531,292 | OtherCostOrOtherBasisAmt |
| Depreciation | $11,629,489 | DepreciationAmt |
| Book Value | $2,901,803 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,527 | OtherCostOrOtherBasisAmt |
| Book Value | $13,527 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $5,171,554 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (2 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| Beneficial Interest in Assets Held by Others | $1,269,263 |
| Related Party Receivable | $1,969,863 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $3,239,126 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (3 entries)
| DescDesc | AmtAmt |
|---|---|
| Estimated Third-Party Payor Settlements | $333,800 |
| Related Party Payable | $2,013,789 |
| Special Assessments Payable | $70,110 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $2,417,699 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $27,935,263 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$1,717,622 | OtherRevenueAmt |
| Revenue Not Reported | -$1,717,622 | RevenueNotReportedAmt |
| Revenue Subtotal | $29,652,885 | RevenueSubtotalAmt |
| Other Revenues Not Included | $36,241 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $36,241 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $29,689,126 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $26,512,836 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $26,512,836 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $1,915,811 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $1,915,811 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $28,428,647 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 1b: | The Heart of America Medical Center Auxiliary operates under the EIN of the Hospital. |
| Part IV, Line 2b: | The Organization acts as custodian for the funds of the nursing facility residents and Haaland Estates residents. Damage Deposits are also held. At March 31, 2019, resident trust funds, security deposits, and damage deposits were $19,603. |
| Part X, Line 2: | The Association is organized as North Dakota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Association is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the entities are subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. Management has determined that the Association is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Under the 501r regulations associated with being a 501(c)(3) entity, the Association is required to complete a Community Health Needs Assessment (CHNA) every three years. The Association was required to complete their CHNA by March 31, 2019. As the Association failed to complete this as required it is subject to a penalty of $50,000 for untimely completion. The Association is currently in process of completing their CHNA and has recorded a penalty at the year ended March 31, 2019. This penalty is included in accounts payable and operating expenses in the consolidated financial statements. |
| Part XI, Line 2d - Other Adjustments: | Bad debt expense included in revenues for financial statements -1,874,387. Change in interest in net assets of Foundation 156,765. |
| Part XI, Line 4b - Other Adjustments: | Auxiliary Revenues 36,241. |
| Part XII, Line 4b - Other Adjustments: | Bad debt expense included in revenues for financial statements 1,874,387. Auxiliary expenses 41,424. |
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 |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent300 | Yes (X) | Percent300Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $45,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $45,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00170 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $45,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $45,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00170 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 4 | ActivitiesOrProgramsCnt |
| Persons Served | 11906 | PersonsServedCnt |
| Total Community Benefit Expns | $8,573 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $8,573 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,602,403 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,582,535 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,019,868 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07620 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 4 | ActivitiesOrProgramsCnt |
| Persons Served | 11906 | PersonsServedCnt |
| Total Community Benefit Expns | $5,610,976 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,582,535 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,028,441 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07650 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 5 | ActivitiesOrProgramsCnt |
| Persons Served | 11906 | PersonsServedCnt |
| Total Community Benefit Expns | $5,655,976 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,582,535 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,073,441 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07820 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,903,821 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $67,200 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $5,771,573 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $5,816,177 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$44,604 | 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 | Heart of America Medical Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.hamc.com | WebsiteAddressTxt |
| State License | 5046 | StateLicenseNum |
| 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 | Heart of America Medical Center | 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 | 0 | CHNAConductedInd |
| Organization Incur Excise Tax | Yes (1) | OrganizationIncurExciseTaxInd |
| Form4720 Filed | Yes (1) | Form4720FiledInd |
| Excise Report Form4720 For All | $50,000 | ExciseReportForm4720ForAllAmt |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 300.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| 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 |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | https://www.hamc.com/uploads/4/CommunityCareNoticeandApplication9262019.pdf | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | https://www.hamc.com/uploads/4/CommunityCareNoticeandApplication9262019.pdf | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | https://www.hamc.com/uploads/3/plainlang.pdf | 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 Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| 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 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 7 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (7 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - Heart of America Nursing Facility | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Skilled and Long Term Care Facility |
| 2 - Haaland Estates Basic Care | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Basic Care Nursing Facility |
| 4 - Haaland Estates Assisted Living | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Assisted Living Facility |
| 5 - Heart of America Hospice | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Hospice care |
| 6 - Heart of America Johnson Clinic | ||||
| 880 S Main Ave | Rugby | ND | 58368 | Rural Health Clinic |
| 7 - Heart of America Johnson Clinic | ||||
| 215 Main St SE | Dunseith | ND | 58329 | Rural Health Clinic |
| 8 - Heart of America Johnson Clinic | ||||
| 301 Roosevelt Ave | Maddock | ND | 58348 | Rural Health Clinic |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 7: | Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Community Health Improvement Services, line 7e, reflects actual expenses recorded to the general ledger. Subsidized health services, line 7g, was calculated based on information from the Cost Report. |
| Part I, Ln 7 Col(f): | The amount of bad debt expense removed from the denominator is $1,903,821. |
| Part III, Line 2: | Bad debt expense is reported at charges as recorded by the organization. All discounts and payments on a patient's account are accounted for prior to determining bad debt expense. |
| Part III, Line 3: | The Organization estimated the amount of bad debt attributable to patients who likely would qualify for financial assistance by applying the percentage of financial assistance applications sent out but not received back or not completed. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on pages 9 and 10 of the attached audited financial statements. |
| Part III, Line 8: | Good Samaritan Hospital Association is a critical access hospital and is reporting a Medicare shortfall for 2018 due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit.Medicare allowable costs were obtained from the Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. |
| Part III, Line 9b: | Our accounts are worked effectively and thoroughly with self-pay statements printed monthly once insurers have met their obligations. The goal is to obtain payment in full, establish acceptable payment arrangements, look at other appropriate agencies or low-income programs, or offer the charity care program if needed. In the collection process, the bill guarantor is reminded they may qualify for our charity care program and are given information on how to apply. Our third-party collection company also offers charity care during collection calls. The statements explain who to call for a charity care application. Our charity program is income based and patients have 120 days to submit a financial assistance application before collection actions begin. At least 30 days before we take extraordinary collection action we send notification to the patient. Once approved they are eligible for financial assistance for services six months in the past and six months in the future from the approval date. For up to 240 days the patient can submit a financial assistance application. If collection actions have begun, they will be suspended until a determination of financial assistance has been made. After 120 days in collections, the account is written off to bad debt. |
| Schedule H, Part V, Line 3: | Good Samaritan Hospital Association (Heart of America) did not properly complete its Community Health Needs Assessment (CHNA) during the time period as required under IRC Section 501(r)(3). Under the rules, Heart of America was required to complete a CHNA report and have it approved by an authorized body of the organization and made publicly available by March 31st, 2019 and adopt and approve an implementation strategy related to the CHNA by August 15, 2019. Upon discovery the CHNA had not been timely completed, a process was put in place to complete the assessment which will be completed by March 31, 2020.The failure was caused by turnover in the CFO position, the individual responsible for the completion of the process. The CFO position had been held by three different individuals during the three year time period since the prior report had been completed. The failure was discovered in August of 2019 and work began at that time to complete the process.The CHNA process will be completed for the tax year ended March 31, 2020 and the report and implementation strategy will be made available to the public as required. During the timeframe when the error occurred, the CHNA reports for 2012 and 2015 have still been made available on the website. The responsibility for the completion of the CHNA process has been moved to a committee within the hospital and procedures have been put in place to ensure the required timelines will be met in the future. |
| Part VI, Line 2: | Heart of America Medical Center and its associated facilities serve a smaller community where providers know their patients. GSHA board members live in the communities we serve. We expect board members to share community health concerns during the board discussions so we can prioritize the needs. We also receive valuable community feedback from the HAMC Auxiliary Board and dozens of volunteers who contribute thousands of hours to the hospital and our long-term care and basic care facilities. |
| Part VI, Line 3: | Good Samaritan Hospital Association, doing business as Heart of America Medical Center, provides medical care regardless of patients' ability to pay. We provide information on federal, state and local payment assistance programs prior to the rendering of services or, in emergency situations, as soon as is appropriate. HAMC Community (Charity) Care is available for inpatient and outpatient hospital services, clinic services and swing bed care. Social work staff provide patients with this information. Patients can also find Community Care information on our website and it's also included with information on our Prompt Payment Discount program. Staff members processing self-pay bills encourage patients to apply for Community Care and our third-party collection company encourages patients to apply for Community Care if they are experiencing financial hardships. |
| Part VI, Line 4: | Heart of America Medical Center is a Critical Access Hospital located in Rugby, N.D. Heart of America Johnson Clinics are located in Rugby, Dunseith, and Maddock, N.D., serving people within a 50-mile radius of Rugby. The closest tertiary facility is 65 miles to the west. Our primary service area is Pierce County and portions of Benson, McHenry, Rolette and Bottineau counties. According to the 2010 U.S. Census the population in Pierce County was 4,357 of which the vast majority were Caucasian (3.9 percent were Native American) and 27.2 percent were age 62 or older. Major employers in Rugby are the hospital, Rugby Manufacturing and the public schools. |
| Part VI, Line 5: | Good Samaritan Hospital Association is sponsored by 14 member churches located throughout our service area. The GSHA board of directors reside in our primary service area, are engaged in various occupations and activities and are elected by GSHA member churches. Through Heart of America Johnson Clinics, Heart of America Medical Center has a presence in Rugby, Dunseith and Maddock, N.D., providing our patients with health care services close to home. We make specialty services in ophthalmology, podiatry, audiology and mental health available to our patients through partnerships with specialty clinics and providers. We offer state-of-the-art cancer treatment in our chemotherapy suite and recently added life-saving 3D mammography equipment to our radiology department. Heart of America Hospice provides personalized, holistic end-of-life care and services for local hospice patients and their families in a 60-mile radius of Rugby. Without GSHA, there would be no hospital, no emergency room, no rural health clinics, no surgical clinic, no skilled nursing care facility, no basic case facility, no assisted living facility, and no wellness/fitness center in our service area. We operate most of these programs at a loss, but we continue to offer them to serve the needs of the people who live here. For those providers that apply to HAMC, they have privileges in our community once approved by the board of directors as presented by the medical staff. If there are surplus funds, they are used to improve the facility for patient care and upgrade medical equipment. |
| Part VI, Line 6: | GSHA is not part of an affiliated healthcare system, however, as a Critical Access Hospital we provide and promote high-quality care for our patients via rural health network agreements with Trinity Medical Center in Minot and MedCenter One in Bismarck, N.D. These agreements enhance our patients' continuity of care by identifying and forming processes that facilitate patient referrals and easy transfer between facilities and enhance communication between providers. GSHA piggy-backs on Altru's EPIC system and is an Accountable Care Organization. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| 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 (6 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Patrick Branco | ||||||||||||||
| Secretary - CEO | $237,372 | $0 | $0 | $0 | $1,263 | $0 | $0 | $0 | $16,292 | $0 | $254,927 | $0 | $0 | $0 |
| Cammy Kelsch FNP-C | ||||||||||||||
| Emergency Room provider | $271,933 | $0 | $0 | $0 | $195 | $0 | $0 | $0 | $20,554 | $0 | $292,682 | $0 | $0 | $0 |
| Ronald Skipper MD | ||||||||||||||
| General Surgeon | $307,925 | $0 | $0 | $0 | $1,560 | $0 | $0 | $0 | $26,451 | $0 | $335,936 | $0 | $0 | $0 |
| Rylan Brantl | ||||||||||||||
| ER Physician | $631,152 | $0 | $0 | $0 | $380 | $0 | $0 | $0 | $14,834 | $0 | $646,366 | $0 | $0 | $0 |
| Chelsey Wyatt | ||||||||||||||
| CRNA | $222,180 | $0 | $0 | $0 | $163 | $0 | $0 | $0 | $24,084 | $0 | $246,427 | $0 | $0 | $0 |
| Steven Schoneberg MD | ||||||||||||||
| Family Practice Physician | $215,538 | $0 | $0 | $0 | $1,276 | $0 | $0 | $0 | $18,591 | $0 | $235,405 | $0 | $0 | $0 |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | City of Rugby North Dakota Health Care Facility | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 456002152 | BondIssuerEIN |
| CUSIP | 000000000 | CUSIPNum |
| Bond Issued | 2013-09-19 | BondIssuedDt |
| Issue Price | $1,215,000 | IssuePriceAmt |
| Purpose | Improvements to hospital and clinic | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $601,580 | RetiredAmt |
| Total Proceeds | $1,215,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $15,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $1,200,000 | CapitalExpendituresAmt |
| Substantial Completion | 2013 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | 0 | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Schedule K, Part IV, line 2 | FormAndLineReferenceDesc |
| Explanation | The arbitrage calcuation is in process and will be completed in February of 2020. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Julie Baustad | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Family member of board member Richard Anderson | RelationshipDescriptionTxt |
| Transaction | $40,592 | TransactionAmt |
| Transaction | Compensation | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 3 | B.E. Smith provided interim CFO services by Richard Baland. During calendar year 2018, Richard Baland's wages were $152,960 and expense reimbursements for travel were $24,769.16. |
| Form 990, Part VI, Section A, line 6 | Membership in the corporation shall consist of such Lutheran congregations which are now members of this Association and such other congregations as shall from time to time apply for membership herein. The Congregational members of the Organization shall be represented by the following 10 specified designations: 1 from Willow City 1 from Leeds 1 from Maddock 1 from Towner 1 from Dunseith 1 from Balta/Orrin 1 from Rolette/Wolford 3 from Rugby The Board shall also have one physician representative and in its discretion one member-at-large who shall reside in the geographical region served by the Association. The physician representative shall be a non-voting representative appointed by the Board of Trustees. |
| Form 990, Part VI, Section A, line 7a | Each member church has up to two voting delegates at the annual meeting where the board of directors is elected to serve on the board. |
| Form 990, Part VI, Section A, line 7b | Amendments to Bylaws and the Articles of Incorporation must be voted on by a two-thirds majority vote of the members. |
| Form 990, Part VI, Section A, line 8b | There are no committees with authority to act on behalf of the governing body. |
| Form 990, Part VI, Section B, line 11b | A draft of the 990 will be made available to the GSHA board of trustees at a board meeting. Any questions will be addressed and corrections made as needed before the 990 is filed. |
| Form 990, Part VI, Section B, line 12c | Covered Persons: All employees, managers, medical staff, executive leadership, board members, volunteers, contractors, and others engaged in the work place. A conflict of Interest Statement must be signed by each board member and shall be dated no later than December 31st of each year. Determination of conflict: All employees and board members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Conflict review: Actual or potential board member conflicts of interest must be disclosed to the Corporate Compliance Committee (CCC). The CCC will handle reports or concerns of situations that may give rise to a conflict of interest with the assistance of legal counsel. The CCC will issue its decision to the Covered Persons in writing and will document and file its decision. Restrictions on those with a conflict: In self-dealing transactions the board member shall not participate in the board decision-making and shall make full disclosure of their interests. If the fairness of the transaction is questioned, the burden of establishing fairness falls upon the trustee involved and the board member must seek guidance and approval from the CCC prior to pursuing any business or personal activity that may constitute a conflict of interest. |
| Form 990, Part VI, Section B, line 15 | Comparative data is reviewed and incorporated into the review process such as looking at state wage survey data. For the CEO, each board member completes their own evaluation form. The human resource committee reviews the responses and makes a recommendation to the full board. The full board decides on any changes to CEO compensation. The review is done annually at time of anniversary date of contract. The board typically does not approve wages for other positions. The CEO approves the CFO wages. Comparative data is used throughout the facility and incorporated into the annual review of employee wages done by the department head or supervisor. Wages are compared to the NDHA annual salary survey report at the time of their annual review. |
| Form 990, Part VI, Section C, line 19 | These documents are available upon request. Financial statements are available for viewing by the public at all board meetings. |
| Form 990, Part VI, Line 16b: | The Organization is a 49% owner in a retail pharmacy located in the clinic building. The pharmacy bylaws requires an annual board meeting including representatives of the Hospital. The meeting evaluates the joint venture arrangement and assures the facility is not violating its tax exempt status. |
| Form 990, Part IX, line 11g | Contracted Services: Program service expenses 1,740,827. Management and general expenses 1,037,386. Fundraising expenses 0. Total expenses 2,778,213. Other Fees: Program service expenses 937,682. Management and general expenses 389,042. Fundraising expenses 0. Total expenses 1,326,724. |
| Form 990, Part XI, line 9: | Change in interest in net assets of Foundation 156,765. Auxiliary Net Assets 5,183. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58368 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | Fundraising for Good Samaritan Hospital Association | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | 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 | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionTypeTxt |
| Involved | $160,322 | InvolvedAmt |
| Method Of Amount Determination | Accrual | MethodOfAmountDeterminationTxt |
Comments