2020-03-23T16:44:49-05:00 2019-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2018-07-01 410307617 Hendricks Community Hospital Assn & Retirement Home HEND 5072753134 PO Box 106 Hendricks MN 56136 Jeff Gollaher CEO 5072753134 2020-03-16 1 Kim Hunwardsen CPA P00484560 6122536500 2020-03-16 216.147.181.49 2020-03-16 11:34:28 CD P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC EFC25E59FA7409AE560978A003AFB9E955B778C6 2018 2020-09-23 17:36:50Z Jeff Gollaher PO Box 106 Hendricks MN 56136 13834478 0 X www.hendrickshosp.org X 1941 MN Provision of healthcare 9 9 205 75 0 0 96475 122318 13806010 13589977 326403 46676 68507 68744 14297395 13827715 27095 11335 0 0 8005963 7465563 0 0 0 6313852 6800251 14346910 14277149 -49515 -449434 17637117 20969153 2805245 6552550 14831872 14416603 X Hendricks Community Hospital Assn & Retirement Home strives to provide the highest quality health and residential care in a Christian environment. 0 0 13113339 11335 13608277 Hendricks Community Hospital, a 24-bed hospital, 48-bed long-term care facility, 16-unit senior rental housing facility, and home health agency promotes health of the community by providing a variety of health care services. The facility had 69 acute, 41 swing bed, 4 transitional bed and 33 long-term care facility admissions for the year ended June 30, 2019; 459 visits to the Emergency Room; and 89 surgical cases (including ambulatory).The hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as patient and resident service revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $15,000 for the year ended June 30, 2019. The estimated cost of providing these services was $11,000 for the year ended June 30, 2019 based on average ratio of cost to gross charges. 13113339 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 55 0 1 205 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 MN X Julie Hogie 5072753134 PO Box 106 Hendricks MN 56136 Allen Molascon President 3.00 X X 940 0 0 Mark VanEck Vice President 2.00 X X 620 0 0 John Engels Secretary 2.00 X X 600 0 0 Vince Robinson Treasurer 2.00 X X 850 0 0 Norris Patrick Director 2.00 X 760 0 0 James Ness Director 2.00 X 0 0 0 Miriam Iverson Director 2.00 X 0 0 0 Dean Nielsen Director 2.00 X 770 0 0 Julie Leibfried Director 2.00 X 0 0 0 Jeff Gollaher CEO 40.00 X 173362 0 20464 Julie Hogie Business Office Manager 40.00 X 67780 0 13790 Grant Eyjolfson Physician 40.00 X 335983 0 44261 Tabb McCluskey Physician 40.00 X 279112 0 47176 Tomasz Lis Physician 40.00 X 213522 0 47546 Kathryn Christensen Nurse Practitioner 40.00 X 120569 0 5912 1194868 0 179149 5 0 1 0 CURA Hospitality PO Box 743676 Atlanta GA 303763676 Contracted Dietary Services 580701 Wapiti Medical Group Lyfjaberg LLC 107 Flynn Dr Suite 600 Milbank SD 57252 Locum/ER pProviders 233782 Fusion Medical Staffing LLC PO Box 82674 Lincoln NE 685012674 Contracted Nursing Service 103865 3 9150 48634 64534 122318 Net patient & resident service re 622110 13512375 13512375 77602 77602 13589977 13719 13719 9060 0 9060 9060 9060 32957 0 32957 32957 32957 5015 9150 4431 584 584 43132 2332 40800 40800 AR Interest 900099 18300 18300 18300 13827715 13608277 0 97120 X 11335 11335 276487 276487 52229 52229 5573360 5381042 192318 149355 147810 1545 1003424 955324 48100 410708 381958 28750 68279 68279 2672778 2509508 163270 26379 26379 623808 594551 29257 17950 17950 344962 338730 6232 102658 102658 39992 38684 1308 90769 82909 7860 852310 802340 49970 192693 176006 16687 Repairs and Maintenance 735114 657427 77687 Medical Supplies 413200 413200 MN Care Tax 266471 266471 Bad Debt Expense 89652 89652 263236 67176 196060 14277149 13113339 1163810 0 1255403 3888874 1628866 2266238 50931 129594 276868 215722 62916 59906 26041803 13681230 12411874 12360573 1924268 2027818 25991 20428 17637117 20969153 1338871 1279423 26042 27542 490304 5155074 950028 90511 2805245 6552550 X 14831872 14416603 14831872 14416603 17637117 20969153 X -449434 16414 17751 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 266 266 0 Part II-B, Line 1: MN Hospital Association dues for FYE 2019 were $7,837 of which 3.4% is related to lobbying activities; total attributed to lobbying is $266.46. 1 98310 49881 67632 80559 1 X 91512 91512 15407602 8160899 7246703 10466472 5520331 4946141 76217 76217 12360573 Estimated third-party payor settlements 90511 90511 X 13750197 -36363 -36363 13786560 41155 41155 13827715 14181880 0 14181880 95269 95269 14277149 Part IV, Line 1b: The assets of Hendricks Hospital Auxiliary are held by Hendricks Community Hospital Association. The Auxiliary uses the EIN of the Hospital, therefore the activity is reported on Form 990 of the Hospital. The ending balance for the Auxiliary was $79,088. In addition, the Hospital holds funds on behalf of its residents. The amount held at the end of the year for residents was $1,471. Part IV, Line 2b: The organization holds security deposits. Part X, Line 2: The Association is organized as a Minnesota not-for-profit 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 Association is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Association has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Association believes it has appropriate support for any tax positions taken affecting its annual filing requirements, and, as such, does not have any uncertain tax positions that are material to the financial statements. The Association 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. Part XI, Line 2d - Other Adjustments: Bad debt expense reported in revenue on financial statements -89,652. Auxiliary contributions to Hospital not reported on Form 990 53,289. Part XI, Line 4b - Other Adjustments: Auxiliary revenue not included in financial statements 43,487. Auxiliary Thrift shop expenses reported in revenue on Form 990 -2,332. Part XII, Line 4b - Other Adjustments: Auxiliary expenses not included in financial statements 1,914. Bad debt expense reported in revenue on financial statements 89,652. Resident fund expenses not included in financial statements 3,703. Hospice Tour of Tables 8372 5400 2972 2181 296 Hospice Golf Tournament 5793 3750 2043 531 1423 14165 9150 5015 2712 1719 4431 584 1 1 X 1 X 1 X 125.000000000000 1 1 0 1 1 11000 11000 0.00080 3154154 2502543 651611 0.04590 3165154 2502543 662611 0.04670 11216 11216 0.00080 73953 73953 0.00520 4903713 2396910 2506803 0.17670 11335 11335 0.00080 5000217 2396910 2603307 0.18350 8165371 4899453 3265918 0.23020 0 89652 44826 3255096 3230287 24809 X 1 1 1 1 Hendricks Community Hospital Association 503 East Lincoln Hendricks MN 56136 www.hendrickshosp.org 00340 X X X X 2 provider based RHCs Hendricks Community Hospital Association 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X www.hendrickshosp.org X 1 18 1 www.hendrickshosp.org 0 1 X 100.000000000000 125.000000000000 X X X X 1 1 X X X 1 X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X X X X X X 1 X 0 X X X 1 X 0 0 Hendricks Community Hospital Association Part V, Section B, Line 5: A community survey was distributed to all households in the HCHA service area & on-line completion was offered. A focus group meeting was held in March, 2019. Approximately 2,900 surveys were distributed with 284 returned for a rate of just under 10%. A total of 10 individuals participated in the focus group. Additional interviews were conducted for some community leaders that were unable to attend the focus group. Hendricks Community Hospital Association Part V, Section B, Line 11: Based on the Community Health Needs Assessment completed in June, 2019, the hospital governing board and facility leadership team identified the following as priority community health needs:1) Communication and Education - including awareness of services; health and wellness2) Mental HealthBoth of these needs are being addressed with an Implementation Strategy Action Plan developed in June, 2019 to be implemented during 2019-2021.The projected impact of communication and education is to increase understanding of services offered thru HCHA, and the goal established would be to expand outreach and education efforts in the community to positively impact the health and wellbeing of residents. A task force has been established to implement these efforts during the implementation period stated above.The projected impact of behavioral and mental health access is to increase awareness of resources available for those in need of mental health services, with a goal of providing a platform for members of the community to better understand mental health services and to participate in activities which improve mental health. A committee has also been established to implement these efforts during the implementation period stated above. Hendricks Community Hospital Association Part V, Section B, Line 13h: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Hendricks Community Hospital Association Part V, Section B, Line 16j: Summaries of the financial assistance policy are posted in the hospital/clinic facilities, as well as waiting rooms and admission area. Billing statements to potentially eligible clients also include summary and contact information for obtaining the appropriate application. 2 1 - Hendricks Nursing Home 503 E Lincoln St Hendricks MN 56136 Long term care 2 - Lincoln Lane Villa 500 E Lincoln St Hendricks MN 56136 Senior Housing Part I, Line 3c: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Part I, Line 7: Charity care is based on an overall cost to charge ratio addressing all patient segments. Community health improvement services, health professions education, and cash and in-kind contributions for community benefit expenses are based on actual expenses recorded to the general ledger. Subsidized health services are reported according to costs allocated to the relevant cost centers on the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $89,652. Part III, Line 2: Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces the bad debt expense in the current year. Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: Bad debt expense is determined based on a patient's payment history as well as current known financial status. Such expense is determined by a patient's non-payment status and non-probability of payment. Because of the nature of these accounts, it is found that at least 50% of these accounts would fall into the charity care status. Part III, Line 4: The footnote to the organization's financial statements that describes bad debt expense is located on page 7 of the attached financial statements. Part III, Line 8: The Hospital provides services to Medicare patients because access to healthcare and patient's health is important to the Hospital. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: Patients are classified in the poverty level utilizing the Federal poverty guidelines as also referenced in our facility collection policy. The guidelines are referenced when a patient fails to complete payment of his/her account in a timely manner. Prior to being turned over to a collection agency, a patient is offered 120 days to complete a charity care application, thereby allowing staff time to deterime the income level of the patient and their qualification as a poverty level individual. If they so chose to not complete an application, their account will be referred to a collection agency. The hospital allows an additional 120 days for a patient to apply for financial assistance. If the patient is determined to be eligible for financial assistance, collection activities will cease. Part VI, Line 2: We are consistently addressing the additional services needs as voiced though the physicians who serve our clientele, as well as the clientele themselves.The recently completed community health needs assessment and implementation strategy has been established and is available on our website www.hendrickshosp.org Part VI, Line 3: Patient's insurance information is obtained upon admission, and those patients not having current third party coverage are informed of the ability to apply for medical assistance funding or visit with our business office staff and social service staff regarding alternative payments and the charity care options. In addition, the patient statements provide information related to contacting our business office personnel to complete alternative payment arrangements, i.e. charity care, Medicaid or planned payment schedule. Patients are offered an option of setting an appointment to meet with staff to complete such arrangements. These procedures are also detailed in our financial assistance/charity care policy. Part VI, Line 4: Hendricks Community Hospital serves a primarily rural population within a 30-mile radius of the community of Hendricks. The facility is located in Lincoln County, Minnesota, which is slated as one of the highest elderly population counties in the State. The average medican income for the county is $49,438 with the highest portion of the population being over 65 years of age. However, because of the high elderly population, many of those constituents are insured through federal government programs and do not necessarily relate to increased Medicaid levels. There is one other acute care facility in the county approximately 30 miles away. Our facility is also located within one mile of the South Dakota border, and a good margin of population served is located in that state. During the fiscal year ending 6/30/19, it was noted approximately 22% of our patients were insured through Medical Assistance programs, and approximately 11% were un-insured. Part VI, Line 5: The nine members of the association's Board of Directors represent varying communities within the 30-mile service area. The board members provide valuable input of the health care needs of the area served.Medical staff privileges are extended to qualified physicians within the service area as well as outlying areas to provide the optimum level of care for our constituents. These privileges are granted to several specialty physicians to eliminate the need for additional travel for our patients.The Association continually allocates funds to the improvement of the facilities and equipment utilized to provide the optimum service to our patients. Surplus funds are also provided to enhance community services with donations to service organizations who offer additional health-enhancing services to the residents of the area. The rural health clinics in the Hendricks community and neighboring Ivanhoe community provide for improved community access. Particularily in the Ivanhoe community it has proved beneficial to be able to offer services in their primary dwelling location.Emergency room services are available 24/7, and are offered regardless of payment source or ability to pay.The facility also participates in the Minnesota SAGE and South Dakota All Women County programs which offer women yearly physical exams, including mammograms and pap smears at no cost to the patient.Facility staff is involved in community economic planning groups as well as community service organizations.Many area residents are involved as volunteers within our organization and participate on a daily basis enhancing the lives of the residents and patients in our facility. X X X 0 0 0 0 0 0 0 0 0 Jeff Gollaher CEO 173362 0 0 0 0 0 7085 0 13379 0 193826 0 0 0 Grant Eyjolfson Physician 335983 0 0 0 0 0 11000 0 33261 0 380244 0 0 0 Tabb McCluskey Physician 279112 0 0 0 0 0 11000 0 36176 0 326288 0 0 0 Tomasz Lis Physician 213522 0 0 0 0 0 9271 0 38275 0 261068 0 0 0 Grant Eyjolfson Employee Physician Recruitment X 50000 50000 0 1 1 Kathryn Christensen Employee Nurse Practioner Recruitment X 45000 29594 0 1 1 Tomasz Lis Employee Physician Recruitment X 50000 50000 0 1 1 129594 Katie Wendinger Family member of board member Dean Nielsen 39532 Employee Compensation 0 Betty Johnson Family member of board member Dean Nielsen 12697 Employee Compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee is composed of the President, Vice-President, Secretary and Treasurer of the governing board. Responsibilities include: A. General management and control of the affairs of the corporation. In addition to formal meetings, the committee has informal conferences about corporation activities. B. Shall have the power to transact all regular business of the hospital during the interim between the meetings of the Board of Directors provided any action taken shall not conflict with the policies and expressed wishes of the Board of Directors, and that it shall refer all matters of major importance to the Board of Directors. C. It shall cause to be prepared and submit to the Board of Directors at its last meeting before the end of the fiscal year, a budget showing the expected receipts and income and expense for the ensuing year. It shall be the further duty of the Executive Committee to examine the monthly financial reports and to require an explanation from the Administrator for any material variation from the budget. D. The Executive Committee shall evaluate in April annually or as deemed necessary, the Chief Executive Officer's performance and recommend his/her remuneration to the full Board of Directors. This committee shall meet as necessary. Form 990, Part VI, Section A, line 6 There is one class of membership. Membership is open to any natural person who is of legal voting age and a voting resident within the organization's primary service area. Form 990, Part VI, Section A, line 7a Each member receives one vote. Form 990, Part VI, Section B, line 11b The return is reviewed by the Business Office Manager and CEO, then by the Board of Directors before it is filed. Form 990, Part VI, Section B, line 12c The policy covers all officers, directors, and key employees. A conflict of interest form is signed upon orientation to the Board of Directors. The form is reviewed by the CEO and any potential conflicts are reviewed with the Board of Directors. If a conflict exists, the person with the conflict is restricted from voting on related matters. Conflict of interest forms are completed annually by board of directors and key employees. These are reviewed by the HR director, and compliance report submitted to the governing board. Form 990, Part VI, Section B, line 15a The Executive Committee reviews the CEO's compensation annually and compares to similar positions at other hospitals of similar size and geographic location. The Board of Directors reviews and approves the recommendations of the Executive Committee. The officers of the board receive a stipend for attending meetings. The fee structure is based on meetings attended. This compensation process is determined by board members and the fee schedule is discussed by the board annually. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Contracted services: Program service expenses 988,148. Management and general expenses 0. Fundraising expenses 0. Total expenses 988,148. Medical fees: Program service expenses 520,358. Management and general expenses 0. Fundraising expenses 0. Total expenses 520,358. Purchased services: Program service expenses 922,296. Management and general expenses 163,270. Fundraising expenses 0. Total expenses 1,085,566. Collection fees: Program service expenses 4,753. Management and general expenses 0. Fundraising expenses 0. Total expenses 4,753. Recruitment: Program service expenses 73,953. Management and general expenses 0. Fundraising expenses 0. Total expenses 73,953. Form 990, Part XI, line 9: Change in net assets for Hendricks Hospital Auxiliary 14,048. Change in net assets for resident funds 3,703.