2020-02-22T07:59:50-06:00 2019-03-31 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2018-04-01 450226419 Good Samaritan Hospital Association GOOD 7017765261 800 South Main Avenue Rugby ND 583682118 Jerry Jurena CEO 7017765261 2020-02-22 1 Lisa Chaffee CPA P00193453 7012551091 2020-02-14 63.157.104.106 2020-02-22 07:57:54 CS P 66CC91E6B7F11C4783FFFA5645E675327CB67316 4A22B0C6F89CA7817A18FDE072DED4220BFE3CF6 2018 2020-09-23 17:36:50Z Heart of America Medical Center Jerry Jurena 800 South Main Avenue Rugby ND 583682118 29689126 0 X www.hamc.com X 1905 ND Provide quality medical care based on the needs and demographics of north central North Dakota. 9 8 425 128 0 0 1726886 564209 26664519 29071497 317109 1927 540908 51493 29249422 29689126 0 0 0 0 19287308 15710880 0 0 0 10438000 12717767 29725308 28428647 -475886 1260479 10891477 14666914 3937977 6290987 6953500 8375927 X To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. 0 0 23338747 29071497 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. 23338747 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 75 0 1 425 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 X Jerry Jurena 7017765261 800 South Main Avenue Rugby ND 583682118 Kris Thiel President 2.00 0.00 X X 0 0 0 Jason Lee Vice Chair 1.00 0.00 X X 0 0 0 Andrew Shae President (April-June) 1.00 0.00 X X 0 0 0 Bonita Lindseth Trustee 1.00 0.00 X 0 0 0 Patricia Heggen Trustee 1.00 0.00 X 0 0 0 Richard Anderson Trustee 1.00 0.00 X 0 0 0 Annette Leier Trustee 1.00 0.00 X 0 0 0 Arland Geiszler Trustee 1.00 0.00 X 0 0 0 William Griffin Trustee 1.00 0.00 X 0 0 0 Tanner Johnson Trustee, GSHS Foundation rep. 1.00 1.00 X 0 0 0 Christine Bubach Trustee (April-October) 1.00 0.00 X 0 0 0 Patrick Branco Secretary - CEO 40.00 1.00 X 238635 0 14658 Richard Baland Treasurer - Interim CFO 40.00 4.00 X 0 0 0 Lee Holter Treasurer - CFO 40.00 4.00 X 97866 0 13263 Cammy Kelsch FNP-C Emergency Room provider 40.00 0.00 X 272128 0 18897 Ronald Skipper MD General Surgeon 40.00 0.00 X 309485 0 24154 Rylan Brantl ER Physician 72.00 0.00 X 631532 0 10923 Chelsey Wyatt CRNA 40.00 0.00 X 222343 0 23830 Steven Schoneberg MD Family Practice Physician 40.00 0.00 X 216814 0 17137 1988803 0 122862 13 0 1 0 BE Smith Dept 200 PO Box 219241 Kansas City MO 641219241 Interim CFO Services 177729 1 160322 226802 177085 564209 Patient Service Revenue 621400 25976076 25976076 Pharmacy Revenue 900099 1591204 1591204 Daycare Services 900099 199414 199414 Cafeteria Revenue 900099 105924 105924 1198879 1198879 29071497 1927 1927 51493 0 51493 51493 51493 29689126 29071497 0 53420 X 389873 389873 40592 40592 13083389 11365777 1717612 63924 55461 8463 1236180 1064398 171782 896922 767461 129461 223162 223162 152287 152287 4104937 2678509 1426428 26383 26383 333919 170403 163516 8564 8564 1146519 1034109 112410 122125 79139 42986 144631 70441 74190 60132 60132 866698 866698 210658 210658 Medical Supplies 2037287 2037287 Provision for Bad Debt 1903821 1903821 Repairs & Maintenance 650247 650247 Food 382872 382872 343525 111400 232125 28428647 23338747 5089900 0 602590 36184 2151600 2474073 3741934 192412 219950 25779 76715 26735909 21564355 5644593 5171554 1892 67361 64143 1848485 3239126 10891477 14666914 1672820 2431783 734000 613420 20064 19603 426429 780105 76000 28377 1008664 2417699 3937977 6290987 X 6345985 7315834 607515 1060093 6953500 8375927 10891477 14666914 X 1260479 161948 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 2951 0 0 0 2951 0 Part II-B, Line 1: 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. 1 68291 36241 41424 63108 1 X 137447 137447 12053643 9934866 2118777 14531292 11629489 2901803 13527 13527 5171554 Beneficial Interest in Assets Held by Others 1269263 Related Party Receivable 1969863 3239126 Estimated Third-Party Payor Settlements 333800 Related Party Payable 2013789 Special Assessments Payable 70110 2417699 X 27935263 -1717622 -1717622 29652885 36241 36241 29689126 26512836 0 26512836 1915811 1915811 28428647 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. 1 1 X 1 X 1 X 1 1 0 0 1 45000 45000 0.00170 1 45000 45000 0.00170 4 11906 8573 8573 0.00030 5602403 3582535 2019868 0.07620 4 11906 5610976 3582535 2028441 0.07650 5 11906 5655976 3582535 2073441 0.07820 0 1903821 67200 5771573 5816177 -44604 X 1 1 1 1 Heart of America Medical Center 800 S Main Ave Rugby ND 583682118 www.hamc.com 5046 X X X X Heart of America Medical Center 1 0 0 0 1 1 50000 1 X 200.000000000000 300.000000000000 1 1 X X X 1 X https://www.hamc.com/uploads/4/CommunityCareNoticeandApplication9262019.pdf X https://www.hamc.com/uploads/4/CommunityCareNoticeandApplication9262019.pdf X https://www.hamc.com/uploads/3/plainlang.pdf X X X X X 1 X 0 X X X X 1 X 0 0 7 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 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. X X X X 0 0 0 0 0 0 0 0 0 Patrick Branco Secretary - CEO 237372 0 0 0 1263 0 0 0 16292 0 254927 0 0 0 Cammy Kelsch FNP-C Emergency Room provider 271933 0 0 0 195 0 0 0 20554 0 292682 0 0 0 Ronald Skipper MD General Surgeon 307925 0 0 0 1560 0 0 0 26451 0 335936 0 0 0 Rylan Brantl ER Physician 631152 0 0 0 380 0 0 0 14834 0 646366 0 0 0 Chelsey Wyatt CRNA 222180 0 0 0 163 0 0 0 24084 0 246427 0 0 0 Steven Schoneberg MD Family Practice Physician 215538 0 0 0 1276 0 0 0 18591 0 235405 0 0 0 A City of Rugby North Dakota Health Care Facility 456002152 000000000 2013-09-19 1215000 Improvements to hospital and clinic 0 0 0 A 601580 1215000 15000 1200000 2013 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 A 1 Schedule K, Part IV, line 2 The arbitrage calcuation is in process and will be completed in February of 2020. Julie Baustad Family member of board member Richard Anderson 40592 Compensation 0 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. Good Samaritan Health Services Foundation 800 South Main Ave Rugby ND 58368 363513553 Fundraising for Good Samaritan Hospital Association ND 501(c)(3) Line 7 Good Samaritan Hospital Association 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 1 Good Samaritan Health Services Foundation C 160322 Accrual