2020-08-13T08:41:33-05:00 2019-09-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-10-01 410724034 KITTSON MEMORIAL HOSPITAL KITT 2188433612 PO BOX 700 HALLOCK MN 56728 JENI SCHWENZFEIER CFO 2188433612 2020-08-12 1 RYAN ENGEBRETSON P01585625 6123764500 67.137.57.251 2020-08-12 10:07:03 CD P A5795B2AF6391D8EE41853777EBEE033D1D6DDEC 8DF0D5A1DBF8E44DE93554FEEDBEEE801640FE4C 2018 2020-11-06 18:47:13Z KITTSON MEMORIAL HEALTHCARE CENTER JENI SCHWENZFEIER 1010 S BIRCH AVE HALLOCK MN 56728 15299581 0 X WWW.KITTSONHC.ORG X 1919 MN KITTSON ENSURES THAT NORTHWESTERN MINNESOTA RESIDENTS HAVE ACCESS TO HEALTH SERVICES. 7 7 248 10 11940 -3232 131285 107535 15120138 14926821 1834 32241 53843 228374 15307100 15294971 6116 5450 0 0 9383804 9684849 0 0 3267 6151004 6676894 15540924 16367193 -233824 -1072222 8848483 7781932 4491135 4491473 4357348 3290459 X CARING FOR FRIENDS AND NEIGHBORS, KITTSON MEMORIAL HEALTHCARE CENTER PROVIDES AND COOPERATES WITH OTHERS TO ENSURE THAT RESIDENTS HAVE ACCESS TO SERVICES NECESSARY TO MAINTAIN THEIR HEALTH AND WELL-BEING. 0 0 12963916 5450 14995915 KITTSON MEMORIAL HEALTHCARE CENTER (KMHC) PROVIDES SERVICE TO EMERGENCY, ACUTE, AND CLINIC PATIENTS. ALL PATIENTS ARE TREATED IN AN EMERGENCY SETTING REGARDLESS OF ABILITY TO PAY OR FINANCIAL CLASS STATUS. KMHC HOME HEALTH PROVIDES MEDICAL AND PERSONAL ASSISTANCE TO THOSE PATIENTS WHO ARE HOME BOUND. THIS VALUED SERVICE PROVIDES AREA RESIDENTS WITH THE ASSISTANCE THEY NEED TO LIVE INDEPENDENTLY WHETHER IT BE HOUSEKEEPING SERVICES, MEDICATION DISPENSATION, OR DAILY DRESSING CHANGES. KMHC'S ASSISTED LIVING COMPLEX PROVIDES THOSE AREA RESIDENTS WITH OPTIONS TO ASSIST IN THEIR TRANSGRESSION FROM LIVING INDEPENDENTLY TO CONGREGATE DINING WITH OTHER ASSISTED LIVING RESIDENTS, MEDICATION DISPENSATION ASSISTANCE, AND ACCESS TO ACTIVITIES IN THE NURSING HOME. RESIDENTS ARE ALSO ABLE TO "COME AND GO" AS THEY PLEASE WITH ACCESS TO THEIR OWN TRANSPORTATION OR TRANSPORTATION MAY BE ARRANGED. 12963916 1 0 0 1 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 22 0 248 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X X JENI SCHWENZFEIER 2188433802 1010 SOUTH BIRCH AVENUE HALLOCK MN 56728 RICHARD MORTENSON PRESIDENT 1.00 X X 0 0 0 JANELLE CRAIGMILE VICE PRESIDENT 1.00 X X 1087 0 0 SANDY WILSON SECRETARY 1.00 X X 0 0 0 BOB JASZCZAK TREASURER 1.00 X X 0 0 0 CHARLIE BERNSTROM BOARD MEMBER (THROUGH DEC 2018) 1.00 X 0 0 0 HUGH HUNT BOARD MEMBER 1.00 X 0 0 0 DR ROLAND LARTER BOARD MEMBER 1.00 X 0 0 0 MARLENE PEARSON BOARD MEMBER (THROUGH DEC 2018) 1.00 X 0 0 0 JANA RILEY-KRAULIK BOARD MEMBER 1.00 X 0 0 0 ASHLEY RIVERA CEO (THROUGH FEB 2019) 40.00 X 225141 0 33542 EVERETT BUTLER INTERIM CEO 30.00 X 0 0 0 DEREK HOLT CFO (THROUGH JAN 2019) 40.00 X 51646 0 806 JENI SCHWENZFEIER CFO 40.00 X 0 0 0 JULIE JOHNSON NURSE PRACTITIONER 32.00 X 127267 0 48141 AMANDA PINNOCK NURSE PRACTITIONER 40.00 X 115209 0 37988 JAMES SURDY MEDICAL DOCTOR 40.00 X 335422 0 41866 KAREN WARNER PHYSICIAN ASSISTANT 40.00 X 143897 0 37079 999669 0 199422 5 0 1 0 DTN STAFFING 1200 COLLINS AVENUE MANDAN ND 58554 NH STAFFING 423712 ALTRU HEALTH SYSTEM PO BOX 13780 GRAND FORKS ND 58206 OUTREACH THERAPY 349698 WAPITI MEDICAL STAFFING 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 LOCUM STAFFING 230982 DIAGNOSTIC MEDICAL SYSTEM 26273 NETWORK PLACE CHICAGO IL 60673 CT, MAMMO, MRI, US 169433 AGILITI HEALTH INC PO BOX 851313 MINNEAPOLIS MN 55485 EQUIPMENT MAINT. 146445 6 15287 92248 107535 PATIENT & RESIDENT SERVICE REVENU 622110 14868394 14868394 CENTRAL MN DIAGNOSTIC 900099 58427 58427 14926821 32241 32241 8394 0 8394 8394 8394 5799 15287 4610 1189 1189 100 0 100 100 PHARMACY 446110 69094 69094 HOME HEALTH 621610 65311 65311 MISCELLANEOUS 900099 42090 42090 42196 11940 30256 218691 15294971 14995915 11940 179581 X 5450 5450 187300 37460 149840 7857623 6610806 1246817 129982 119920 10062 960658 743437 217221 549286 467470 81816 189291 189291 210098 210098 2360605 2074318 286287 99698 27164 72534 791365 598797 192568 288913 47564 241349 319417 73312 246105 74546 48087 26459 54937 41840 13097 131921 34129 97792 617809 617809 86221 86221 MEDICAL SUPPLIES 683905 683905 BAD DEBT EXPENSE 419786 419786 FOOD 259712 244000 15712 OTHER EXPENSES 88670 68662 16741 3267 16367193 12963916 3400010 3267 711 711 2019814 1172305 1504979 1468544 12241 0 194337 377728 135919 38630 16023031 12871813 3508256 3151218 1246226 1035273 32667 226000 504856 8848483 7781932 1583964 1775701 34376 6706 7211 2724954 2538694 175511 135491 0 0 4491135 4491473 X 4306801 3238745 547 1714 50000 50000 4357348 3290459 8848483 7781932 -1072222 5333 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 6041 6041 0 PART II-B, LINE 1: THE ORGANIZATION PAYS DUES TO THE MINNESOTA HOSPITAL ASSOCIATION, A PORTION OF WHICH IS SPENT ON LOBBYING ON BEHALF OF ITS MEMBERS. 1 6946 6477 6178 7245 1 X 50547 1167 51714 0 50000 547 50547 0.96690 0.03310 0 0 12985 12985 8739539 7132789 1606750 461150 323593 137557 6809357 5415431 1393926 3151218 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 504856 504856 X 14879795 -419786 -419786 15299581 -4610 -4610 15294971 15952017 4610 4610 15947407 419786 419786 16367193 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE CENTER HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF THE NURSING FACILITY. PART X, LINE 2: THE CENTER IS ORGANIZED AS A MINNESOTA 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 CENTER UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THESE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES, AS DEFINED BY ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA. THE CENTER BELIEVES THAT IT IS COMPLIANT WITH ALL IRS TAX REGULATIONS AND AS OF SEPTEMBER 30, 2019 AND 2018 HAS NOT RECORDED LIABILITIES FOR INCOME TAXES. THE CENTER WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES IN INCOME TAX EXPENSE IF INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -419,786. PART XI, LINE 4B - OTHER ADJUSTMENTS: GOLF TOURNAMENT EXPENSE -4,610. PART XII, LINE 2D - OTHER ADJUSTMENTS: GOLF TOURNAMENT EXPENSE 4,610. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 419,786. GOLF TOURNAMENT 21086 15287 5799 640 1099 1740 1131 21086 15287 5799 640 1099 1740 1131 4610 1189 1 1 X 1 X 1 X 1 1 0 1 1 525 525 0.00000 910042 567363 342679 0.02090 910567 567363 343204 0.02090 10277223 8503943 1773280 0.10830 10277223 8503943 1773280 0.10830 11187790 9071306 2116484 0.12920 0 419786 2463436 3179612 -716176 X 1 1 1 1 KITTSON MEMORIAL HEALTHCARE CENTER 1010 SOUTH BIRCH AVENUE HALLOCK MN 56728 WWW.KMHC.NET 371450 X X X X KITTSON MEMORIAL HEALTHCARE CENTER 1 0 0 1 X X X X X X X X 18 1 0 0 1 X WWW.KITTSONHC.ORG/COMMUNITY-NEEDS X 1 18 1 WWW.KITTSONHC.ORG/COMMUNITY-NEEDS 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X X 1 X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X X X X X 1 X 0 X X 1 X 0 0 KITTSON MEMORIAL HEALTHCARE CENTER PART V, SECTION B, LINE 5: IN THE 2018 ASSESSMENT, COMPLETED BY SEPTEMBER 2019, WE REVIEWED OUR ASSESSMENT AND IMPLEMENTATION PLAN FROM 2016 AND REVIEWED THE CURRENT DATA FOR HEALTH TRENDS FOR OUR COUNTY. WE ALSO DID A SELECTED MAILING OF "QUALITY OF LIFE" SURVEYS TO A TARGETED AUDIENCE THROUGHOUT THE COUNTY. THE TARGET LIST OF INDIVIDUALS INCLUDED VARIOUS CITY LEADERS, SENIOR CENTERS, SCHOOL PERSONNEL, PUBLIC HEALTH AND HOME HEALTH STAFF, HEALTHCARE PROVIDERS, HOSPITAL BOARD MEMBERS, COUNTY EMPLOYEES, SOCIAL SERVICES STAFF, BUSINESS OWNERS, AND YOUNG FAMILIES IN OUR COUNTY. WE REQUESTED THEIR OPINIONS ON IMPORTANT SERVICES THAT THEY WOULD LIKE TO SEE ADDED TO OUR FACILITY OR MAINTAINED BY OUR FACILITY. KITTSON MEMORIAL HEALTHCARE CENTER PART V, SECTION B, LINE 11: KITTSON HEALTHCARE IS A 15-BED CRITICAL ACCESS HOSPITAL LOCATED IN THE FAR NORTHWEST CORNER OF MINNESOTA. THECOUNTY BORDERS CANADA AND NORTH DAKOTA. THE COMMUNITY OF KITTSON COUNTY STRONGLY DESIRES THE MAINTENANCE OF THIS FACILITY WITH THEIR EXPRESSED DESIRE FOR THE CONTINUATION OF THE EMERGENCY ROOM, CLINICAL SERVICES, ACUTE CARE AND PHARMACY SERVICES. IN AUGUST 2019, KITTSON HEALTHCARE OPENED A PHARMACY NEXT TO THE MEDICAL CLINIC AND WILL CONTINUE TO OFFER PHARMACY SERVICES TO THE RESIDENTS OF THIS SERVICE AREA UPON THE RETIREMENT OF OUR LONE PHARMACIST IN THE COUNTY AFTER NEARLY 60 YEARS OF SERVICE.THE CITY OF HALLOCK LOST ITS LONE DENTIST IN 2017 AND WHILE DENTAL SERVICES HAVE NOT BEEN SECURED FOR THE CITY OF HALLOCK, THERE CONTINUES TO BE DENTAL SERVICES PROVIDED BY TWO DENTISTS IN KARLSTAD, MINNESOTA, 30 MILES FROM HALLOCK AND LOCATED IN THE SOUTHEAST CORNER OF KITTSON COUNTY.IN PROMOTING HEALTHY BEHAVIORS AND LIFESTYLES, TWO OF OUR PUBLIC HEALTH NURSES HAVE BEEN TRAINED IN THE CDC'S EVIDENCE-BASED CURRICULUM, "I CAN PREVENT DIABETES". THE FIRST YEAR LONG COURSE IS JUST BEING COMPLETED. THESE CLASSES WILL CONTINUE TO BE OFFERED TO AREA CITIZENS.WE WILL CONTINUE TO EDUCATE AND ADDRESS SMOKING AND TOBACCO USE IN OUR AREA AS WELL AS DISSEMINATE AND EDUCATE OUR PATIENTS ON HEART DISEASE AND CANCER.IN THE 2016 MINNESOTA STUDENT SURVEY, WHEN THE STUDENTS WERE ASKED ABOUT THEIR SEAT BELT USE, 60% OF 11TH GRADE STUDENTS SAID THEY USED THEIR SEATBELTS ALWAYS, WHILE 32% OF 9TH GRADE STUDENTS SAID THEY USED THEIR SEATBELTS ALWAYS. THIS IS A MARKED IMPROVEMENT FROM THE 2010 MINNESOTA STUDENT SURVEY FOR KITTSON COUNTY, 28% OF 12 AND 9TH GRADE STUDENTS SAID THAT THEY WORE THEY ALWAYS WORE A SEATBELT.THE NEWLY ADOPTED CHNA IDENTIFIED THE FOLLOWING ISSUES: TRANSPORTATION AND ACCESS TO HEALTHCARE SERVICES MENTAL HEALTH SERVICES VAPING/TOBACCO USE OBESITY CONTINUED ACCESS TO HEALTHCARE SERVICES IN THE "COMMUNITY" OF KITTSON COUNTY INCREASE SPECIALTY SERVICES IN OUR CLINICS ELDER CARE AND SERVICES NEEDED TO "AGE IN PLACE" OPIOID ABUSE SOCIAL MEDIA EDUCATION TO STUDENTS AND PARENTS (BULLYING, TRAFFICKING) CONTAINMENT OF HEALTHCARE COSTSUPON REVIEW OF THE 10 TOP ISSUES IDENTIFIED, KITTSON HEALTHCARE WILL THE FOLLOWING PRIORITY AREAS TO WORK ON OVER THE NEXT 3 YEARS.PRIORITY 1: MENTAL HEALTH SERVICESGOAL: INCREASE MENTAL HEALTH SERVICES TO OUR SERVICE AREA TO INCLUDE BOTH ADULTS AND YOUTH SERVICES.GOAL: INCREASE PHQ-9 ASSESSMENTS ON BOTH ADULTS AND YOUTH IN OUR MEDICAL CLINICS TO HELP IDENTIFY MENTAL HEALTH CONCERNS.TIMEFRAME: FALL/SPRING, 2019-2020 AND ONGOINGPRIORITY 2: SUICIDE PREVENTION AND EDUCATIONGOAL: PROVIDE SUICIDE EDUCATION AND SUPPORT TO OUR PROVIDERS, FRONTLINE NURSING STAFF AND TO OUR COMMUNITY.TIMEFRAME: FALL/SPRING OF 2019-2020PRIORITY 3: VAPING AND TOBACCO USEGOAL: PROVIDE EDUCATION AND SUPPORT TO SCHOOLS' STAFF AND STUDENTS (INCLUDING PARENTS AND COMMUNITY) REGARDING THE DANGERS AND LONG-TERM EFFECTS OF VAPING AND TOBACCO USE.GOAL: PROVIDE SMOKING CESSATION SUPPORT THROUGH OUR MEDICAL CLINICS IN HALLOCK AND KARLSTAD.TIMEFRAME: FALL/SPRING, 2019-2020 AND ONGOINGPRIORITY 4: OBESITYGOAL: PROMOTE HEALTHY LIFESTYLES THROUGH PUBLIC EDUCATION.GOAL: COLLABORATE WITH THE SCHOOLS TO ENCOURAGE HEALTHY LIFE STYLES IN OUR YOUTH.GOAL: COLLABORATE WITH WORKPLACES TO ENCOURAGE AND EDUCATE EMPLOYEES ABOUT THE BENEFITS OF HEALTHY BEHAVIORS AND LIFESTYLES.TIMEFRAME: FALL/SPRING, 2019-2020 AND ONGOINGPUBLIC INPUT IS ALWAYS WELCOME. 1 1 - KITTSON MEMORIAL CLINIC OF KARLSTAD 205 ROOSEVELT AVENUE WEST KARLSTAD MN 56372 RURAL HEALTH CLINIC PART I, LINE 3C: TO QUALIFY FOR FINANCIAL ASSISTANCE, AN INDIVIDUAL MUST:(A) RECEIVE EMERGENCY MEDICAL CARE OR MEDICALLY NECESSARY CARE AT THE HOSPITAL;(B) HAVE TOTAL INCOME LESS THAN OR EQUAL TO 200 PERCENT OF FEDERAL POVERTY GUIDELINES;(C) APPLY FOR MEDICAID; AND(D) SUBMIT A COMPLETE COMMUNITY CARE (FINANCIAL ASSISTANCE) APPLICATION, INCLUDING REQUIRED DOCUMENTATION. PART I, LINE 6A: THE ANNUAL COMMUNITY BENEFIT REPORT IS MADE AVAILABLE UPON REQUEST. PART I, LINE 7: THE ORGANIZATION USED THE FOLLOWING METHODS TO DETERMINE THE COST AMOUNTS IN PART I, LINE 7:LINES 7A AND 7B - CHARITY CARE AND MEDICAID WERE DERIVED FROM INTERNAL REPORTS. COSTS WERE CALCULATED USING THE COST TO CHARGE RATIO FROM WORKSHEET 2 FROM THE IRS.LINES 7E AND 7G - COMMUNITY HEALTH IMPROVEMENT SERVICES AND SUBSIDIZED HEALTH SERVICES AMOUNTS ARE ACTUAL COSTS. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED IN PART I, LINE 7G INCLUDE COSTS AND REVENUES ASSOCIATED WITH HALLOCK RURAL HEALTH CLINIC, KARLSTAD RURAL HEALTH CLINIC, EMERGENCY ROOM SERVICES, AND CARDIAC REHABILIATION SERVICES. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE CENTER ANALYZES ITS COLLECTION HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 3: THE ORGANIZATION HAS NOT IDENTIFIED A METHOD TO REASONABLY ESTIMATE THE PORTION OF OUR BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER OUR FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES" SECTION IN NOTE 1 (PAGE 8) TO THE FINANCIAL STATEMENTS FOR INFORMATION ABOUT THE CALCULATION OF BAD DEBTS. PART III, LINE 8: THE MEDICARE SHORTFALL REPORTED IN PART III, LINE 7 IS DUE TO THE NON-ALLOWABLE/NON-REIMBURASABLE COSTS PER THE MEDICARE COST REPORT AND WOULDN'T NECESSARILY BE CONSIDERED COMMUNITY BENEFIT IN NATURE.THE MEDICARE ALLOWABLE COSTS REPORTED IN PART III, LINE 6 WERE DERIVED USING THE FY 2019 FILED MEDICARE COST REPORT. PART III, LINE 9B: COLLECTION EFFORTS ARE MADE BY CONTACTING THE PATIENT THROUGH WRITTEN CORRESPONDENCE AND PHONE CALLS. IF, THROUGHOUT THESE CONVERSATIONS, THE COLLECTOR AND PATIENT DISCUSS THAT THE PATIENT IS NOT ABLE TO AFFORD PAYMENTS AS REQUIRED BY OUR POLICY, THE PATIENT IS ENCOURAGED TO APPLY FOR CHARITY CARE. AN APPLICATION, PLAIN LANGUAGE SUMMARY, AND FAP ARE SENT TO THE PATIENT TO REVIEW AND COMPLETE. ACCORDING TO FEDERAL POVERTY GUIDELINES, THE PATIENT MAY QUALIFY FOR ALL OR A PERCENT OF CHARGES WRITTEN OFF THEIR ACCOUNT. PATIENTS MUST APPLY FOR MEDICAID PRIOR TO QUALIFYING FOR CHARITY CARE. ADDITIONAL INFORMATION IS OFFERED TO HELP THEM APPLY FOR STATE FUNDED PROGRAMS. PART VI, LINE 2: PUBLIC HEALTH CONDUCTS A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). THIS INFORMATION IS THEN SHARED WITH FACILITY MANAGEMENT AND THE BOARD OF DIRECTORS. GOING FORWARD, A CHNA WILL BE CONDUCTED EVERY THREE YEARS TO MAKE THIS ASSESSMENT.IN ADDITION TO CONDUCTING THE CHNA EVERY THREE YEARS, KITTSON INFORMALLY LISTENS TO THE PUBLIC'S REQUEST FOR SERVICES. THROUGH OUR PUBLIC HEALTH AND SCHOOL HEALTH WORK, WE ARE CONTINUALLY ASSESSING THE HEALTH NEEDS OF THE COMMUNITY AND MEETING THE NEEDS AT THE TIME. FOR EXAMPLE, KITTSON HELD PUBLIC MEETINGS WITH COUNSELORS WHEN THE COMMUNITY HAD A NEED FOR ADDITIONAL SUPPORT AND INFORMATION REGARDING SUICIDE. PART VI, LINE 3: IF A PATIENT IS UNABLE TO PAY THEIR BILL, THE PATIENT IS ENCOURAGED TO APPLY FOR CHARITY CARE. AN APPLICATION IS SUBSEQUENTLY SENT TO COMPLETE, ALONG WITH A COPY OF OUR FAP AND PLAIN LANGUAGE SUMMARY (A NOTICE IS INCLUDED IN THEIR MONTHLY STATEMENT TO CONTACT US REGARDING CHARITY CARE IF THEY ARE UNABLE TO PAY THEIR BILL). WE ARE ADDITIONALY ABLE TO PROVIDE PATIENTS WITH CONTACT INFORMATION AT THE COUNTY FOR QUALIFICATION/APPLICATION INFORMATION REGARDING GOVERNMENTAL FINANCIAL ASSISTANCE. INFORMATION REGARDING CHARITY CARE IS ALSO AVAILABLE IN THE ADMISSION AREA OF THE CLINIC. PART VI, LINE 4: KMHC PRIMARILY SERVES THE RESIDENTS OF KITTSON COUNTY, WHICH IS LOCATED IN NORTHWEST MINNESOTA, WITH A POPULATION OF APPROXIMATELY 4,500. THIS IS A VERY RURAL AREA WITH 4.1 PERSONS PER SQUARE MILE. THE MEDIAN HOUSEHOLD INCOME IS $52,304 WITH 6.4% OF THE POPULATION BELOW POVERTY LEVELS. PART VI, LINE 5: KITTSON MANAGERS DELIVER COMMUNITY MEALS ON WHEELS FOR ONE MONTH EACH YEAR; SUPPORT A VIRTUAL "RELAY FOR LIFE" EVENT; PROVIDE AMBULANCE STAND-BY SERVICES AT LOCAL PUBLIC HIGH SCHOOL SPORTING VENTS; PROVIDE FREE BLOOD PRESSURE CHECKS AT VARIOUS AREA EVENTS THROUGHOUT THE YEAR; PROVIDE FINANCIAL CONTRIBUTIONS TO HELP FUND TWO AREA PUBLIC SCHOOLS' "AFTER PROM PARTY" EVENTS; PROVIDE TO AREA CHARITIES FOR THEIR FUNDRAISING EVENTS, LAB TESTING CERTIFICATES AS DOOR OR RAFFLE PRIZES; FREE AND REDUCED CARE; HEALTH INFORMATION BOOTH AT FOUR DAY COUNTY FAIR. KITTSON HEALTHCARE ALSO PROVIDES SERVICES THAT OTHER PRIVATE ENTITITES TYPICALLY WON'T CONSIDER PROVIDING SUCH AS ASSISTED LIVING SERVICES, NURSING HOME SERVICES, ELDERLY WAIVERED SERVICES, COMMUNITY FITNESS, AMBULANCE SERVICES, ETC. AS THERE IS LITTLE VOLUME AND MINIMAL FINANCIAL RETURN. HOWEVER, KITTSON HEALTHCARE'S GOVERNING BOARD VIEWS THESE SERVICES AS ESSENTIAL IN MEETING THE NEEDS AND SERVING THE RESIDENTS OF KITTSON COUNTY. PART VI, LINE 6: N/A 0 EDUCATIONAL ASSISTANCE 1 5450 SCHOLARSHIP FUNDS ARE GENERALLY PAID DIRECTLY TO FINANCIAL INSTITUTIONS.IN THE EVENT THAT A STUDENT PAYS SOMETHING AND REQUESTS REIMBURSEMENT, THEINDIVIDUAL IS REIMBURSED UPON SUBMISSION OF AN INVOICE FOR EXPENSES PAID. X X X 0 0 0 0 0 0 0 0 0 ASHLEY RIVERA CEO (THROUGH FEB 2019) 225141 0 0 0 0 0 4678 0 28864 0 258683 0 0 0 JULIE JOHNSON NURSE PRACTITIONER 119104 0 8163 0 0 0 20974 0 27167 0 175408 0 0 0 AMANDA PINNOCK NURSE PRACTITIONER 105760 0 9449 0 0 0 5775 0 32213 0 153197 0 0 0 JAMES SURDY MEDICAL DOCTOR 335422 0 0 0 0 0 23996 0 17870 0 377288 0 0 0 KAREN WARNER PHYSICIAN ASSISTANT 138663 0 5234 0 0 0 16966 0 20113 0 180976 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE (COMPRISED OF THE BOARD OFFICERS) CAN ACT ON BEHALF OF THE FULL BOARD IN CERTAIN CIRCUMSTANCES. FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP IN THE ASSOCIATION SHALL BE ANY NATURAL PERSON OF LEGAL AGE PURCHASING ONE OR MORE MEMBERSHIP SHARES OF THE CORPORATION FOR THE SUM OF $50.00 EACH. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS ARE ALLOWED TO VOTE FOR MEMBERS OF THE BOARD AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWED THE PROPOSED FROM 990 AND PRESENTED TO THE GOVERNING BOARD OF DIRECTORS FOR THEIR APPROVAL. UPON APPROVAL BY THE GOVERNING BOARD, THE 990 WAS THEN FILED. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE BOARD'S POLICY TO AVOID ANY POSSIBLE APPEARANCE OF IMPROPRIETY OR BREACH OF THE MEMBER'S FIDUCIARY RESPONSIBILITY BY HAVING BOARD MEMBERS ANNUALLY ACKNOWLEDGE ANY POTENTIAL BUSINESS OR PERSONAL CONFLICTS IN REGARDS TO KITTSON MEMORIAL'S BUSINESS AFFAIRS. IT IS NOT THE INTENTION OF THIS POLICY TO PRECLUDE A BOARD MEMBER FROM BEING INVOLVED IN THE DISCUSSION OF A SUBJECT WHERE THE BOARD MEMBER HAS A CONFLICT OF INTEREST. HOWEVER, DISCRETION SHOULD BE EXERCISED AND THE BOARD MEMBER IS EXPECTED TO ABSTAIN FROM VOTING ON THE MATTER. THE CONFLICT OF INTEREST POLICY IS SIGNED ANNUALLY AT THE BOARD'S REGULAR MEETING IN JANUARY. THIS STATEMENT IS RETAINED BY THE PRESIDENT AND A COPY FILED IN THE CEO'S OFFICE. THE PRESIDENT IS RESPONSIBLE TO CALL INTO QUESTION A POSSIBLE CONFLICT OF INTEREST OF A PARTICULAR BOARD MEMBER WHEN APPLICABLE IN THE EVENT THE BOARD MEMBER DOES NOT DECLARE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY A MAJORITY VOTE OF THE BOARD OF DIRECTORS. THE GOVERNING BOARD REVIEWS SALARY SURVEY INFORMATION FROM THE MN HOSPITAL ASSOCIATION AND OFFERS COMPETITIVE WAGES BASED ON THE SURVEY. THE DOCUMENTATION OF SUCH DECISION IS RECORDED AND FILED ON THE EMPLOYEE'S HR FILE. OTHER OFFICERS' COMPENSATION IS DETERMINED BY THE CEO. THE CEO REVIEWS SALARY SURVEY INFOMRATION FROM THE MN HOSPTIAL ASSOCAITON AND OFFERS THE KEY EMPLOYEE'S COMPETITIVE WAGES BASED ON THE SURVEY. THE DOCUMENTATION OF SUCH DECISION IS RECORDED AND FILED ON THE EMPLOYEE'S HR FILE. COMPENSATION WAS LAST REVIEWED IN 2020. FORM 990, PART VI, SECTION C, LINE 19 KITTSON MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 2,074,318. MANAGEMENT AND GENERAL EXPENSES 286,287. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,360,605.