2020-11-18T08:43:13-06:00 2020-06-30 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2019-07-01 450308484 Tioga Medical Center TIOG 7016643305 PO Box 159 Tioga ND 58852 Randall K Pederson President & CEO 7016643305 2020-11-11 1 Lisa Chaffee CPA P00193453 7012551091 2020-11-11 63.157.195.138 2020-11-11 07:56:19 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 DEA5AAEEBA04E2AF66A8E14BCCBEC2FC2C377148 2019 2021-01-29 14:40:06Z Randall K Pederson PO Box 159 Tioga ND 58852 13737570 0 X www.tiogahealth.org X 1960 ND Health care and nursing care services 8 6 174 150 0 0 577538 870430 12268273 12723794 104057 24784 120115 101838 13069983 13720846 500 500 0 0 7536054 7761484 0 0 0 5479057 5541560 13015611 13303544 54372 417302 18169788 24421078 8167100 14001088 10002688 10419990 X The mission of Tioga Medical Center is to address the health care needs of the community through providing quality health care and promoting education and wellness. 0 0 6500447 7991743 Tioga Medical Center provides delivery of healthcare services over eastern Williams county, Burke County and western Mountrail county of the state of North Dakota.Requirements of the IRS community benefit standard for tax-exempt organizations are integral to Tioga Medical Center's larger charitable mission of improving health and quality of life. Specifically, an independent board including community leaders, business experts and consumer representatives governs Tioga Medical Center. The Board has a history of commitment to acting with the highest integrity. For example:-Policies on confidentiality of patient and corporate information are reviewed annually as a component of mandatory education, and a confidentiality statement is signed and/or reviewed annually by all employees and board members.-Board members and key employees review and sign a conflict of interest statement annually.-Tioga Medical Center's code of conduct is published in its employee handbook and included in general orientation of all new employees and volunteers.Tioga Medical Center also makes medical care accessible to the entire community it serves. Tioga Medical Center operates a 24 hour emergency room and provides emergency care regardless of ability to pay. Tioga Medical Center had 1804 emergency room visits during the past fiscal year. Tioga Medical Center provides clinical services needed to operate the emergency room.In addition, Tioga Medical Center provides non-emergency services to the community it serves. It makes these services accessible to the community through participation in government programs like Medicare and Medicaid and by offering assistance through the Tioga Medical Center's uncompensated care program.Tioga Medical Center's uncompensated care (charity care) program provides free services to patients who lack the resources to be fully responsible for the health care they receive. The uncompensated care program is designed to ensure the entire community served by Tioga Medical Center has access to needed healthcare services. The Tioga Medical Center administration oversees services delivered under the uncompensated care program, including assessing community needs, approving eligibility criteria and monitoring the effectiveness of the program in providing community access to medical care.Tioga Medical Center maintains records to identify and monitor the level of care provided under the uncompensated care program. These records include the amount of charges foregone for services and supplies furnished under its charity care program. Tioga Medical Center had costs for charity care for the year ended June 30, 2020 of approximately $22,000.Tioga Medical Center takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad needs of the community. It strives to identify the community needs beyond basic healthcare, and then respond to them, aiming to make a positive, life-enhancing difference in the community. For example, many employees and Board members of Tioga Medical Center are actively involved in volunteer organizations that serve to protect the community, such as the Tioga Fire & Ambulance Department. As a small community, it is vital for people to come to the aid, as volunteers, when people are in need of assistance. Tioga Medical Center allows its employees to leave the workplace to tend to the emergency needs of the community we serve.The Tioga Medical Center, located at Tioga, North Dakota, is a provider of integrated healthcare delivery services consisting of a 25 bed Medicare designated Critical Access Hospital (CAH). The Tioga Medical Center CAH is a Level V designated trauma center. Within the CAH, acute care services are provided, along with swing bed services. 2628595 2572852 Attached to the CAH is a 30 bed skilled nursing facility. This facility provides skilled and long term care services to its residents. 2462081 1873307 The Medical Center also operates three clinics located in Tioga, Ray, and Powers Lake. These clinics are Medicare and Medicaid designated provider-based rural health clinics. Within the clinics, they employ one Family Medicine Physician, one Physician Assistants and two Family Nurse Practitioners. These practitioners provide physician related services at these clinics, as well as to the CAH and SNF. 284558 500 285892 Finally, attached to the Nursing home is a 22 unit independent living unit. The organization also has a Foundation that distributes scholarships. 284558 500 285892 11875681 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 20 0 1 174 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X Ryan Mickelsen 7016643305 PO Box 159 Tioga ND 58852 Dr Robert Rotering Physician 40.00 X 381168 0 15562 Jeffrey Moberg Jr Physician Assistant 40.00 X 359396 0 16409 Nancy Carlson Nurse Practitioner 40.00 X 220699 0 7796 Randall K Pederson President/CEO 40.00 X 203912 0 14255 Dr Ronald Burinsky Former Physician 40.00 X 184193 0 3772 Ryan Mickelsen VP/CFO/COO 40.00 X 156912 0 12672 Lorena Stout Nurse Practitioner 40.00 X 131906 0 5029 James Booth Chairman 1.00 X X 0 0 0 Brodie Odegaard Vice Chairman 0.50 X X 0 0 0 Brandon Hauge- Dir Jul-Mar Secretary/Treasurer (Apr-Jun) 0.50 X X 0 0 0 Arlene Grubb Secretary/Treasurer (Jul-Mar) 0.50 X X 0 0 0 Scott Sundhagen Director (Jul-Dec) 0.50 X 0 0 0 Lee Olson Director 0.50 X 0 0 0 Carolyn Eide Director 0.50 X 0 0 0 Seth Wisthoff Director 0.50 X 0 0 0 Jeremy Becker Director (starting Oct 2019) 0.50 X 0 0 0 Nathan Germundson Director (starting May 2020) 0.50 X 0 0 0 1638186 0 75495 7 1 1 0 Titan Nurse Staffing LLC 2110 S 169th Plaza Suite 100 Omaha NE 68130 Contracted Nursing Services 288461 Avant PO Box 744554 Atlanta GA 30374 Contracted Nursing Services 205034 Prairie Travelers Inc 130 3rd St S Glascow MT 59230 Contracted Nursing Services 186791 DMS Imaging PO Box 670747 Dallas TX 75267 Imaging Services 161249 4 301783 568647 870430 Patient & Resident Revenue 621110 12205810 12205810 340B Pharmacy 446110 323915 323915 Other Revenue 900099 194069 194069 12723794 10602 10602 51872 51872 66690 16724 49966 49966 49966 14182 0 14182 14182 14182 13720846 12723794 0 126622 500 500 395273 395273 232792 232792 5965565 5824374 141191 66951 66951 659398 624033 35365 441505 407218 34287 15834 15834 73754 73754 1289589 1289589 15727 15727 1251273 648173 603100 237633 220968 16665 9467 4045 5422 50223 40017 10206 139811 139811 948316 908398 39918 87244 87244 Medical Supplies 1316048 1316048 Avera E-Emergency 63144 63144 43497 2376 41121 13303544 11875681 1427863 0 2192372 8400355 1864314 2288710 71450 60948 84695 80938 23990662 12529039 12226243 11461623 1707714 1933504 23000 195000 18169788 24421078 950071 938308 13745 5300 7203284 8104830 0 4952650 8167100 14001088 X 9987688 10409490 15000 10500 10002688 10419990 18169788 24421078 417302 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1842 0 0 0 1842 0 Part II-B, Line 1: Tioga Medical Center is a member of the American Hospital Association (AHA), the North Dakota Hospital Association (NDHA), and the North Dakota Long Term Care Association (NDLTCA). A portion of the membership dues for these organizations are used for lobbying. 0 1 X 14053 14053 739067 16180227 6894226 10025068 6366806 5247370 1119436 690509 387443 303066 11461623 CMS Advanced Payments 1344567 Refundable Advance 3608083 4952650 X 13720846 0 13720846 0 13720846 13303544 0 13303544 0 13303544 Part IV, Line 2b: The Organization holds funds under an agency relationship for the residents of the nursing facility. Part X, Line 2: The Medical Center 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 financial statements. The Medical Center 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. 1 1 X 1 X 110.000000000000 1 X 0 0 0 22000 22000 0.00170 1361064 1246078 114986 0.00860 1383064 1246078 136986 0.01030 35105 35105 0.00260 126136 126136 0.00950 3269215 2820969 448246 0.03370 9140 9140 0.00070 3439596 2820969 618627 0.04650 4822660 4067047 755613 0.05680 1 590773 38400 3202822 3210474 -7652 X 1 1 1 1 Tioga Medical Center Hospital 810 Welo Street Tioga ND 58852 www.tiogahealth.org 5048P X X X X 3 provider based rural health clinics Tioga Medical Center Hospital 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X www.tiogahealth.org X 1 18 1 www.tiogahealth.org 0 1 X 110.000000000000 200.000000000000 1 1 X X X X 1 X www.tiogahealth.org X www.tiogahealth.org X www.tiogahealth.org X X X X X X 1 X 0 X X X X 1 X 0 0 Tioga Medical Center Hospital Part V, Section B, Line 5: Tioga Medical Center distributed health needs surveys to patients at the hospital and clinic. Surveys were distributed at the senior citizens center. Public meetings were advertised in the local paper inviting all community members to participate. Special invitations were sent to members of the Community Ambulance Service and local business owner, the Chief of Police, The Elementary School Principal, Powers Lake Ambulance Service Squad Leaders, Ray Ambulance Squad Leaders, License Counselor, and representative of Faith. Tioga Medical Center Hospital Part V, Section B, Line 6b: Tioga Medical Center's CHNA was conducted in collaboration with the Upper Missouri Public Health District. Tioga Medical Center Hospital Part V, Section B, Line 11: A Community Health Needs Assessment was conducted during FY 19 with the assistance of the University of North Dakota and the community of Tioga and surrounding service area. Needs identified through this process are as follows: Attracting and retaining young families, Depression/Anxiety among the youth, Having enough child daycare services, and not enough affordable housing. Childcare services and affordable housing are not being addressed by Tioga Medical Center due to inadequate resources and because these needs do not pertain to the services provided by Tioga Medical Center.In the current year the facility has taken the following actions to address attracting and retaining young families and Depression/anxiety among the youth:-Participating through the Tioga Chamber of Commerce in developing a brochure for families outlaying the positive qualities of Tioga. -Participating in a community wide re-branding/leadership process initiated by the Tioga Economic Development Corporation. -Provided education events at the Tioga High School, Ray High School, and Powers Lake High School on the effects of depression and anxiety, bullying, effects of drug and alcohol during years of development, as well as risk factors of teen pregnancy. Tioga Medical Center Hospital Part V, Section B, Line 16j: If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them.A charity care application is sent with patient statements after 90 days. 1 1 - Tioga Medical Center Long Term Care 810 Welo Street Tioga ND 58852 Skilled Nursing Facility 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, and Health professionals education, line 7f, reflects actual expenses recorded to the general ledger. Medicaid, line 7b, and subsidized health services, line 7g, were calculated based on information from the Cost Report. Cash and in kind contributions, line 7i, was calculated based on wages paid to staff providing EMS services. Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concession based on its historical collection experience with this class of patients. Part III, Line 3: The estimated amount of the organization's implicit price concessions attributable to patients eligible under the organization's charity care policy was calculated by applying the estimated percentage of the service area below the poverty guideline (6.5%) to the amount of implicit price concessions. This estimate is due to a lack of information received from patients who may otherwise be eligible for the Organization's financial assistance policy, however, because of missing information they are otherwise classified as implicit price concessions. Part III, Line 4: The footnote to the Organization's financial statements can be found on pages 16 and 17 of the attached audited financial statements. Part III, Line 8: Medicare allowable cost is based on 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.All of the Medicare shortfall should be treated as a community benefit. The Organization treats individuals regardless of the ability to pay. Most of the Medicare shortfall comes from the nursing home. The elderly are an underserved population who experience issues with access to healthcare services. It is a community benefit to be able to treat them at the local nursing home. Part III, Line 9b: The billing and collection policy applies to all patients. Every effort is made to determine if a patient may be eligible for charity care. No collection actions are taken if a patient is in the process of applying for charity care or has been accepted for charity care. Any personal portion due would follow normal collection procedures. Part VI, Line 2: In addition to a Community Health Needs Assessment, a formal needs assessment has been conducted where providers are able to bring identified needs to administration. The identified needs are reviewed by the physicians/providers as well. The request is analyzed to see if it can be cost-justified; then, the request is brought to the Board of Directors for approval. Dexa Scan, Diabetes Education, an OR remodel, eEmergency, the purchase of an ablasion machine, and the purchase of a diagnostic ultrasound have all been added in the past five years through this process. Part VI, Line 3: If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them. Part VI, Line 4: The hospital's primary service area consists of residents in Williams County, with some residents of Mountrail/Burke Counties. The primary industries in this area are agriculture, oil, and tourism. Williams County had an estimated population of 37,589 as of July 2019 according to census.gov. An estimated 9.2% of the population was 65 or older in 2019, and 6.5% were estimated below the poverty level in 2019. Part VI, Line 5: Tioga Medical Center furthers its exempt purpose by promoting the health of the community through:* Medical staff privileges are extended to all community providers* Surplus funds are reinvested into equipment and facility upgrade* The next closest hospital is 30 miles away from the organization - sole provider in the immediate area* Provide emergency care regardless of a patient's ability to pay* Employees serve on a voluntary ambulance and fire department and the organization allows the employees to serve those duties without punching out* Therapy departments talk to coaches about sports injuries and educate coaches on caring for injuries* Educate senior citizen groups on medical awareness topics* Diabetes education services are provided to patients of Tioga Medical Center at no cost to the patient.*Collaboration with Williston State College to educate nurses*Collaboration with The University of North Dakota to educate providers in rural medicine*Collaboration with The University of North Dakota and The University of Mary to educate occupational and physical therapists. X X 1 1 X X X 0 0 0 0 0 0 0 0 0 Dr Robert Rotering Physician 356532 0 10416 0 14220 0 8024 0 7538 0 396730 0 0 0 Jeffrey Moberg Jr Physician Assistant 358980 0 416 0 0 0 8271 0 8138 0 375805 0 0 0 Nancy Carlson Nurse Practitioner 220366 0 333 0 0 0 0 0 7796 0 228495 0 0 0 Randall K Pederson President/CEO 199992 0 3920 0 0 0 6118 0 8138 0 218168 0 0 0 Dr Ronald Burinsky Former Physician 184193 0 0 0 0 0 0 0 3772 0 187965 0 0 0 Ryan Mickelsen VP/CFO/COO 153896 0 3016 0 0 0 4534 0 8138 0 169584 0 0 0 Part I, Line 1a The spending account is for a continuing medical education allowance. The doctors have an allowance of $4,000 per year for their continuing education. The board provides direction on the CME allowance. Review of the allowance is completed during each recruitment phase. An estimate is determined by the board based on a reasonable estimate provided by the recruiters. Total expenditures per person are reviewed and examined on an industry standard basis. These numbers are reevaluated each time a new doctor is recruited. Dr. Rotering lives in a Tioga Medical Center apartment. The organization did include this as a taxable benefit income on his W-2. Craig Odegaard Family of board member Brodie Odegaard 52078 Craig receives compensation as a maintenance employee. 0 Lori Olson Family of President & CEO Randall Pederson 75347 Lori receives compensation as a registered nurse. 0 Anna Nordloef Family of board member Seth Wisthoff 45657 Anna receives compensation as a registered nurse. 0 Marissa Olson Family of President & CEO Randall Pederson 59710 Marissa receives compensation as an RHIT Medical Records Director. 0 Form 990, Part VI, Section A, line 1 Board Chair does not vote. Form 990, Part VI, Section A, line 6 An individual interested in becoming a member must complete an application and submit to the Board of Directors for approval. There is only one class. Form 990, Part VI, Section A, line 7a An annual meeting is held in March of each year in which the members may elect board members if applicable. The members also vote on approval of the audited financial statements. Form 990, Part VI, Section A, line 8b The Physician Interview Committee does not take minutes as the committee meets only for physician interviews. This committee reports their recommendation to the full Board of Directors. Form 990, Part VI, Section B, line 11b A copy of the return is given to each board member and discussed at a regular monthly meeting. The board must approve the form before it is signed by the facility's representative. Form 990, Part VI, Section B, line 12c The policy covers all board members and officers. The Administration will determine if a conflict exists. In the event of a conflict, said board members abstain from related motions/votes but may still participate in discussions. Form 990, Part VI, Section B, line 15 Annual salary survey results from the North Dakota Hospital Association are reviewed. Related organization's 990 compensation information is also reviewed. The compensation of the President/CEO and Vice President/CFO and relevant employees is examined by the Board of Directors and adjusted annually if deemed necessary. This process is documented in the board minutes. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are available to the public upon request.