2020-04-01T13:58:27-05:00 2019-06-30 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2018-07-01 450308379 Hazen Memorial Hospital Association HAZE 7017482225 510 8th Avenue NE Hazen ND 58545 Darrold Bertsch CEO 7017482225 2020-03-27 1 Lisa Chaffee CPA P00193453 7012551091 2020-03-27 24.116.79.108 2020-03-27 13:16:06 CD P 66CC91E6B7F11C4783FFFA5645E675327CB67316 EF8EACA1B72D76ADAD76BDF99E17664A67561866 2018 2020-11-19 02:30:22Z Sakakawea Medical Center Darrold Bertsch 510 8th Avenue NE Hazen ND 58545 16592477 0 X www.smcnd.org X 1943 ND To be the preeminent providers of innovative and collaborative healthcare services. 10 9 175 88 0 0 802103 586051 15925629 15796940 24459 70150 148053 133681 16900244 16586822 4500 18000 0 0 7763089 8115306 0 0 0 8015771 8453463 15783360 16586769 1116884 53 40840371 39206345 28881050 27556221 11959321 11650124 X Working together as partners to enhance the lives of area residents by providing a neighborhood of patient centered healthcare services that promote wellness, prevention, and care coordination. 0 0 12862498 18000 14388643 Sakakawea Medical Center (SMC) is a 13 bed critical access hospital providing services in the following areas - acute care, observation, surgery, intermediate and skilled swing bed, emergency room with trauma level V certification, Saturday convenience clinic, and hospice. Services provided by the ancillary departments include physical therapy, occupational therapy, radiology, 3D mammography, bone density, ultrasound, CT, nuclear med, MRI, laboratory, respiratory therapy, cardiac rehab, EKG, Holter Monitor, and thallium stress tests. Based on charges foregone Sakakawea Medical Center provided $67,869 in charity care. Also available to all self-pay patients, regardless of financial status, is a 30% discount policy for timely payments. SMC is a participating provider for Medicare, Medicaid, Blue Cross Blue Shield and other insurances.Sakakawea Medical Center reaches out to the communities in the service area through programs such as falls prevention classes, CPR education, ACLS classes, PALS classes, grief support groups, smoking cessation classes, occupational health, free blood pressure checks, a Christmas giving tree project, a Community Care nurse and health career presentations to high schools. SMC sponsors several community events that promote good health and wellness education including Healthy Halloween Bash, Women's World of Wellness and Mammography Marathon. Wellness screenings are provided to area schools and businesses. SMC provides community education programs on requested topics free of charge. It is important for Sakakawea Medical Center to serve our communities by providing all of their health care needs. 1061101 1408297 Senior Suites is a basic care facility that was completed in April 1997. It is adjacent to Sakakawea Medical Center. Senior Suites can accommodate 34 residents with single or double rooms. It features a licensed beauty shop, activity room, spacious commons areas and an enclosed nurse's station. The rooms are set up like suites, hence the name "Senior Suites." The facility is available to those in the senior population that require a minimal amount of supervision, but do not require 24 hour services. The residents are provided with assistance for daily living and medication administration. Resident care census days totaled 9,872 this year. 13923599 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 17 0 1 175 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 1 1 0 0 0 1 1 0 1 1 1 0 0 0 X Renae Snyder 7017482225 510 8th Avenue NE Hazen ND 58545 X Christie Obenauer President 2.00 X X 0 0 0 Fred Stern Vice President 1.50 X X 0 0 0 Myria Perry Secretary/Treasurer 1.50 X X 0 0 0 Don Lyn Erickson Director 1.50 X 0 0 0 Mark Gerde Director 1.50 X 0 0 0 Robin Richter Director 1.50 X 0 0 0 Sienna Sailer Director 1.50 X 0 0 0 Beverly Huber Director 1.50 X 0 0 0 Todd Lindquist Director 1.50 X 0 0 0 Keith Johnson Director 1.50 X 0 0 0 Darrold Bertsch CEO 19.60 X 151060 0 78000 Renae Snyder CFO 40.00 X 88918 0 4372 Carl Miller CRNA 36.00 X 150534 0 29479 Alyssa Kelsch Pharmacist 40.00 X 120209 0 13448 Marcie Schulz Director of Patient Care 40.00 X 109541 0 26885 Michael Schmit Surgeon 40.00 X 313842 0 26087 Jen Hetzler Physical Therapist 40.00 X 102558 0 5341 1036662 0 183612 6 0 1 1 Dr Thomas Kaspari MD PC 1351 51st Ave SW Hazen ND 58545 ER Physician Services 136870 1 11600 574451 586051 Patient and Resident Services 621400 15378490 15378490 Other Program Revenue 623000 294896 294896 Cafeteria 623000 72642 72642 Education 623000 50912 50912 15796940 73742 73742 126748 0 126748 126748 126748 3592 -3592 -3592 -3592 8996 2063 6933 6933 16586822 15796940 0 203831 X 15000 15000 3000 3000 325473 325473 70763 70763 6480593 5973744 506849 207579 192369 15210 555103 501023 54080 475795 426628 49167 69498 69498 1963191 1871255 91936 33557 33557 286981 129582 157399 104318 104318 663592 639999 23593 63672 59230 4442 448224 331463 116761 2394725 1770909 623816 223562 8343 215219 Medical Supplies 1225685 1225685 Bad Debt Expense 530490 530490 Food 149736 149736 Dues & Subscriptions 75540 52285 23255 220692 42858 177834 16586769 13923599 2663170 0 8322 3876 5780341 5259542 1560593 1920354 366543 332580 91491 112368 36168984 7718596 30355028 28450388 600845 1224525 1435677 1117526 641531 785186 40840371 39206345 858389 955686 9648354 9430283 17774307 17170252 600000 0 28881050 27556221 X 10456520 10464937 1452801 1135187 50000 50000 11959321 11650124 40840371 39206345 X 53 -309250 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2789 2789 0 Part II-B, Line 1: The organization pays dues to NDHA and AHA and a portion of those membership fee is attributable to lobbying. 67124 537 67661 66403 721 67124 66117 286 66403 65690 427 66117 65405 285 65690 0.00000 0.73900 0.26100 0 0 23092 23092 27154741 4753340 22401401 7335362 2755245 4580117 1655789 210011 1445778 28450388 X 15727201 -848641 -848641 16575842 10980 10980 16586822 16036398 0 16036398 550371 550371 16586769 Part V, Line 4: The Medical Center's policy is to maintain sufficient financial stability for the operations of Medical Center. Interest income is to be transferred to the temporarily restricted endowment funds until the Board determines how the funds are to be used. In establishing this policy, the Medical Center considered the long-term expected return on its endowments. The spending policy states that distributions of earnings can be made if the Board of Directors deems it prudent to do so taking into account certain statutory factors included in the UPMIFA. Distributions may be made at least annually, but do not need to be done. Part X, Line 2: The Medical Center is organized as a 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 Medical Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Medical Center is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Medical Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. 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. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts Reported in Expenses on 990 -530,490. Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,151. Part XI, Line 4b - Other Adjustments: Net Auxiliary Revenue Not Included in Audited Financials 10,980. Part XII, Line 4b - Other Adjustments: Auxiliary Expenses Not Included in Audited Financials 19,881. Provision for Bad Debts Reported in Revenue on Audited Financials 530,490. 1 1 X 1 X 1 X 1 1 1 0 0 79000 79000 0.00480 617650 239577 378073 0.02280 696650 239577 457073 0.02760 96064 96064 0.00580 66564 18485 48079 0.00290 65 65 0.00000 162693 18485 144208 0.00870 859343 258062 601281 0.03630 1 306 306 0.00000 2 6228 6228 0.00040 9 15794 15794 0.00100 3 778 778 0.00000 15 23106 23106 0.00140 0 530490 26524 7171100 7282715 -111615 X 1 1 1 1 Sakakawea Medical Center 510 8th Ave NE Hazen ND 58545 www.smcnd.org 5024A X X X X Hazen Memorial Hospital Association 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X See Pg 8 Supplemental Information X See Pg 8 Supplemental Information X 1 18 1 See Pg 8 Supplemental Information 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X https://www.smcnd.org/assets/docs/caring_program_policy.pdf X https://www.smcnd.org/assets/docs/caring_program_policy.pdf X https://www.smcnd.org/assets/docs/caring_program_policy.pdf X X X X X X 1 X 0 X X X 1 X 0 0 Hazen Memorial Hospital Association Part V, Section B, Line 5: Community surveys were conducted beginning in October 2018. Community meetings were held in October 2018 and March 2019. Additionally, key informant interviews were conducted in October 2018 by the Center for Rural Health. Organizations participating in the meetings included Sakakawea Medical Center, Coal Country Community Health Clinics, Knife River Care Center, Mercer County Ambulance, Southwestern District Health Unit, Hilltop Home of Comfort, and UND Center for Rural Health. Hazen Memorial Hospital Association Part V, Section B, Line 6b: Organizations participating include Coal Country Community Health Clinics, Knife River Care Center, Mercer County Ambulance, Southwestern District Health Unit, Hilltop Home of Comfort, and UND Center for Rural Health. Hazen Memorial Hospital Association Part V, Section B, Line 11: Due to the timing of the current CHNA and IS the organization was not able to address the needs identified in the most recent CHNA. In FY19 the organization addressed the needs identified in the last CHNA as follows:Projects and programs implemented to address needs identified in the 2016 Community Health Needs AssessmentAlthough meeting the healthcare needs of the communities we serve is a collaborative effort, each Local Health Provider involved in the collaborative CHNA and Implementation Plan has specific areas of expertise that govern their agency and the way they do business.Adequate child care services:Energy Capital Cooperative Child Care's (ECCCC) New Bethel Center opened on May 30, 2017 and was founded by eight employers that recognized the child care struggle that their employees and the community faced. ECCCC's founding partners include Sakakawea Medical Center (SMC); Coal Country Community Health Center (CCCHC); Knife River Care Center (KRCC); Dakota Gasification Company (lead agency); North American Coal Corporation; Union State Bank; Coyote Station; and Hazen Public Schools. The New Bethel Center is a licensed child care center with a capacity of 72 children ages infant to 12 years. The partners have guaranteed spots for their employees, but many spots are available for the members of the community as well. The center offers extended hours of operation to accommodate shift-working parents.Availability of behavioral health services (mental health & substance abuse/treatment):CCCHC spearheads the effort to address mental health and substance abuse issues and relies on the partners to assist by providing additional resources for programming, education, as well as tapping into financial and staffing availability. In addition, CCCHC, SMC & KRCC continue to screen all clinic, emergency room, hospital, basic care, long term care and visiting nurse admits for depression by incorporating the PHQ2 and PHQ9 screening criteria for all initial patient encounters. Should a patient screen positive on the PHQ9, referrals are made for appropriate follow-up and/or intervention.Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and behavioral therapies for the treatment of addiction/substance use disorders; and can help some people to sustain recovery. CCCHC offers and has expended the MAT program offered to three days per week in Beulah and two days per month at Killdeer.With the increase in demand for Drug & Alcohol Evaluation and Intervention, an additional full-time Licensed Addiction Counselor (LAC) was hired by CCCHC in 2018. The additional staffing of a LAC allows Substance Use Disorders, as-well-as Mental Health services to be available daily at the CCCHC Beulah Clinic. CCCHC anticipates that two additional part-time LAC's will begin employment in the Spring of 2019 upon completion of construction of a new behavioral health unit facilitating expansion of services and co-location with primary care. CCCHC also partners with several organizations through a consortium for training addiction counselors in both rural and urban ND. TAAP, Training Academy of Addiction Professionals, prepares addiction trainees to demonstrate minimum competence and skill set for addiction counseling leading to a LAC. In addition, CCCHC has increased the availability of visiting psychologists from four days per month to six days per month in Beulah and is currently exploring tele-behavioral health services to assist in meeting the additional needs of the community.Custer Health manages and operates a syringe exchange program (SEP) in North Dakota called the "Mandan Good Neighbor Project". The program is a community-based public health program that provides comprehensive harm reduction services for people who inject drugs (PWID). In addition to needle exchange, Custer Health has provided training and Nasal Narcan (when available) for local law enforcement to include the City of Beulah and the Oliver County Sheriff's Department.In 2016-2017, Beulah Public School District contacted CCCHC for assessment and assistance with behavioral health for the school and a pilot project was implemented for case management of behavioral health issues within the walls of the school. The project increased access to students in grades K - 12. Since then, CCCHC is facilitating resource mapping and development framework for sustainability and replication of the program in additional school districts for the 2019-2020 school year. Integrating Mental Health Physical Health and Continuity of Care Together (IMPACT) program, has been implemented within the Beulah School District to include the purchase of a license to implement BIMAS-2. BIMAS-2 offers Universal Screening through an online web-based data management system that measures social, emotional and behavioral functioning in youth and adolescents, and allows users to manipulate data in real time to assist in evidence-based decision-making within a comprehensive behavior health care model of service delivery. Areas assessed within the BIMAS-2 include conduct, negative affect, cognitive/attention, social and academic functioning. Beulah School District has now completed 75% of all Universal Screenings. In addition, a needs assessment was completed with the Hazen School District and a license for BIMAS-2 purchased with the implementation of IMPACT; Universal Screening is now in progress for the Hazen School District.Additionally, education and training has been delivered for the implementation of a Multi-tiered Systems of Support (MTSS) for youth and adolescents. MTSS is a framework used to provide targeted support to struggling students. It focuses on the "whole" child and supports academic growth and achievement including behavior, social and emotional needs, and attendance. Joint Task Force meetings have been implemented between Beulah and Hazen School Districts with CCCHC's team for further implementation of the IMPACT program. A full-time LSW/IMPACT Program Coordinator is providing care coordination and case management for Beulah and will be expanding into Hazen in 2019. A Psychologist and LICSW are currently providing mental health services at the Beulah School District as part of MTSS.Lack of employees to fill positions:All agencies are addressing the workforce shortage by actively supporting local programs such as the Dakota Practical Nursing Program that is offered in Hazen. The Dakota Nursing Program allows local individuals to achieve a personal career goal through non-traditional means and eliminates the need for students to travel away from home to obtain a career in nursing. The program directly address the region's nursing workforce shortage and is offered through Bismarck State College. During the program, students are on campus at SMC four days a week. Clinicals begin in December and go through the completion of the program in July and are held at multiple healthcare facilities within the area, providing students with the best learning experience possible. Since the implementation of the program in 2012, 25 students have graduated with an additional 3 students that will potentially graduate in the Summer of 2019.Each Local Health Provider within the collaborative actively participates to present health occupations at the Dunn, Mercer and Oliver County Scrubs Camp which is a one-day, hands-on opportunity for high school students designed to increase awareness, interest, and understanding of health careers available. Through creative and interactive activities, Scrubs Camp provides an opportunity for students to experience first-hand, the challenges, opportunities and rewards of health careers while learning about the skills and education that are required to become a health professional.In order to increase efficiency in hiring and retention and to ensure consistency and compliance in the recruitment and selection process, a collaborative effort between SMC, CCCHC & KRCC has resulted in the combining of resources to provide for a Shared Human Resource professional that coordinates the recruitment of professional health care staff for the area and administers formal agreements initiated with recruitment firms for physicians.Furthermore, SMC and CCCHC have partnered together to locally facilitate the Medical Assistant program offered through Dakota College at Bottineau and had two Medical Assistants graduate in the summer of 2016. One of the Medical Assistants is currently employed full-time at CCCHC.In 2018, CCCHC hired two additional full-time mid-level family practice providers to their team of health care professionals. Kelsey Striefel, DNP, is practicing at the CCCHC Hazen Clinic; and Kayla Ternes, PA-C, sees patients at the CCCHC Beulah Clinic site. Hazen Memorial Hospital Association Part V, Section B, Line 13h: Sakakawea Medical Center offers two separate programs for discounted care. The self-pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 30% to 100% of charges. The program is available for uninsured patients as well as co-pays and deductibles for insured patients.The self-pay discounts program cannot be combined with the charity care program. However, the Hospital counsels all self-pay individuals to determine if their potential charity care discount would result in a better discount if they apply for charity care. The patients that use the self-pay discount are typically the patients that do not want to submit their financial information or patients that would not qualify under the charity care policy. Hazen Memorial Hospital Association Part V, Section B, Line 15e: An individual must complete an application and submit supporting documentation such as check stubs or an income tax return. All of the staff in the Business Office billing department are able to assist individuals with any questions they have regarding the application process. Hazen Memorial Hospital Association Part V, Section B, Line 16j: In addition to the full FAP being available upon request, information referencing the FAP is attached to the billing invoices, as well as posted in the admissions office, emergency rooms and waiting rooms. Schedule H, Part V, Line 11 continued... Obesity/overweight:Physical inactivity, obesity and overweight are being addressed cooperatively and with individual campaigns. All of the Local Health Providers offer Worksite Wellness Programs for employees and their families. In addition, CCCHC, SMC and Custer Health participate in corporate and community wellness events by offering health screenings, health awareness and educational seminars for individuals and community groups. On April 30, 2018 the Energy Wellness Center opened in Beulah, ND and offers a full range of activities to include wellness and fitness classes for individuals and groups. The state-of-the-art facility enables the community to become healthier in all aspects of life and provides year-round recreation to the citizens of the tri-county area delivering new exercise and education programs for the community. Amenities include basketball court, cardio deck, community room, daycare, golf simulator, group exercise studio, lobby, locker rooms, racquetball court, indoor walking/running track, and weight room.In an effort to improve the overall health of the population that we serve, the Local Health Providers continue to facilitate the Population Health Committee with representatives from each agency where the main objective is to improve population health through innovative and engaging projects. Through the Population Health Committee, the "JumpStart to Wellness" campaign was implemented and remains strong, addressing obesity and physical activity with various successful projects facilitated throughout the year (5K Color Walk/Run, Healthy Halloween Bash, Women's World of Wellness, Mercer County Fair, Mercer County parade, etc.).Breastfeeding has been identified as one of the six focal points of the CDC's Childhood Obesity Prevention Plan identifying that the duration of exclusive breastfeeding was inversely associated with the risk of elevated weight gain. To engage young families and teach successful breastfeeding techniques, local public health has trained a public health nurse as a CLC (Certified Lactation Consultant). The CLC provides counseling and lactation management during WIC, Beyond Birth Education, and Maternal and Child Health services.Transportation:Access to transportation contributes to the economic development, health, and quality of life of rural communities. Reliable transportation is needed for rural residents to access healthcare services, employment and educational opportunities, and social services. It is also important for accessing recreation and other activities of daily life. Though the Local Health Providers do not have the resources or expertise to address all transportation needs, we have come up with some viable solutions to address the transportation needs for patients seeking local healthcare services.CCCHC offers free transportation services to and from appointments at the Hazen and Beulah Clinic sites; with a full-time driver on staff, CCCHC owns and operates three agency vans. Patients can schedule transportation services when they schedule their next appointment.SMC works cooperatively with local transportation services to provide patients with vouchers that can be used for free rides to and from the medical center; once the patient uses the voucher, the transportation service turns the voucher into SMC for payment. SMC works with West River Transit to provide transportation services for the Beulah and Center communities, while Hazen Busing serves the community of Hazen. Delivery and availability of Health Services to include expanded appointment hours and cost of health care services:Patient Centered Medical Home (PCMH) model of healthcare has been incorporated into the operations of both SMC & CCCHC. The PCMH model proposes to improve primary care by focusing on the patient- provider relationship and strengthen this dynamic though a more comprehensive team approach to patient care and more active patient involvement. PCMH provides comprehensive care coordination to all patients at all points of care whether seen in the ER, admitted to the hospital, or seen in the clinics for primary care. A comprehensive care coordination committee has been formed by the Local Health Providers and meets monthly to review repeat admission and repeat ER visits with care coordination intervention from Custer Health, SMC, KRCC, and CCCHC including Community Care Coordination. Outcome data signifies a decrease in BCBS and Medicare unnecessary ER visits and potentially preventable admissions. The Local Health Providers continue to expand and enhance a Patient Centered Medical Neighborhood of care delivery throughout the tri-county service area. Health Tracks, a public health program, is for children birth-20 years of age who are on Medicaid. It is a preventive health program that can pay for many things including counseling, hearing and vision care, developmental screenings, immunizations, lab tests, dental care, and referrals to specialists. In 2018, Custer Health enhanced the community engagement of this program and increased their Health Tracks screenings by 58%.In addition, Custer Health and CCCHC have increased the provision of immunizations by working together to offer immunization clinics for students during local Parent/Teacher Conferences. Upon the completion of two successful years, Custer Health and CCCHC have expanded the program and now offer both fall and spring clinics for the Beulah and Hazen School Districts.FluFIT programs increase colorectal cancer screening rates by providing a take home fecal immunochemical test (FIT) to eligible patients when they receive their annual flu shot. Therefore, the annual flu shot campaign creates an opportunity to reach people who are also due for colorectal screening. Custer Health in conjunction with CCCHC and local area pharmacists, provide the FluFIT kits during October flu shot clinics offered within the service area. In 2018, 89 patients were screened on FluFit clinic day.To help remove barriers to the delivery and availability of health services, CCCHC is expanding the Beulah Clinic site. When completed, this project will enhance the way CCCHC provides medical care by doubling the clinic space to accommodate patient and staff needs. The expansion will also allow CCCHC to co-locate behavioral health and primary care and host additional visiting specialists to the area. The anticipated completion date of the clinic expansion is June 2019. In addition, CCCHC has extended clinic hours available for appointments. CCCHC Beulah Clinic now sees patients beginning at 7:30 a.m. on Mondays and Wednesdays. Phone lines are open at 7:00 a.m. for patients to call providing enhanced primary care access. Schedule H, Part V, Line 7a/b and Line 10 URL Links: Line 7a:https://www.smcnd.org/assets/docs/community_health.pdfLine 7b:https://coalcountryhealth.com/assets/docs/community_health.pdfLine 10:https://www.smcnd.org/assets/docs/implementation_plan.pdf 1 1 - Senior Suites at Sakakawea 813 7th St NE Hazen ND 58545 Basic Care Facility Part I, Line 3c: Sakakawea Medical Center offers two separate programs for discounted care. The self pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. This program cannot be combined with the Charity Care program.The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 30% to 100% of charges. The program is available for uninsured patients as well as co-pays and deductibles for insured patients. Part I, Line 7: Charity care is based on the total direct and indirect costs related to providing services to patients and based on average ratios of cost to charges. Unreimbursed Medicaid was converted to cost using the cost-to-charge ratio derived from the relevant cost center on the Medicare cost report. Community health improvement services, health professionals education, and cash and in-kind contributions for community benefit reflect actual expenses recorded to the general ledger. Part II, Community Building Activities: The CEO serves on one board for economic development - Mercer County Economic Development, one board for community support - Energy Capital Child Care Cooperative, six boards for community health improvement advocacy - Community Health Association of the Mountain Plains States, Caravan Health, North Dakota Hospital Association, Area Health Education Center, Knife River Care Center, and Community Healthcare Association of the Dakotas. The Director of Patient Care serves on four boards - Bismarck State College Advisory Board, University of Mary Advisory Board, ND Governor's Nursing Workforce, and North Dakota CAH Quality. The CFO, Surgeon, and Nurse Coordinator all serve on the Mercer County Ambulance Board. The HIM Director serves on the Dakota Central Social Service Board. Part III, Line 2: Bad debt expense is reported at charges. Payments and discounts are posted to patient bills. Part III, Line 3: There are most likely some patients in bad debt who would qualify for charity care, but they have not completed the application and remitted the required payment. We used charity care as a percentage of total revenues to figure that the estimated amount of bad debt expense that is attributable to patients eligible under the organization's financial assistance policy would be approximately $26,524. 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: Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare & Medicaid Services. The costs themselves are a community benefit as the community would not receive these services if we did not provide them. Part III, Line 9b: If a patient has applied for charity care previously, an application is sent with the monthly statement. Once it is determined that the patient is eligible, the charity care discount portion is written off. The organization does not send patient accounts to collections within the first 120 days of the date of the first invoice for a service. The organization allows the patient up to 240 days from the date of the first invoice for that service to complete the charity care application. If the patient account is with the collection agency within the 240 days of the first invoice and it is determined they qualify for charity care, the organization will notify the collection agency of the amount of charity care that applies to the account. The remaining patient portion then falls under the same collection practices of all other accounts. Our policy requires a new charity care application every six months. Part VI, Line 2: Sakakawea Medical Center consults with local physicians to identify community healthcare needs. The SMC staff participates in local and regional organizations and activities including Chamber of Commerce and economic development boards. The CEO routinely attends city council and county commission meetings to solicit input and engage in dialogue relating to healthcare needs and services.Sakakawea Medical Center has collaborated with other local providers to conduct a community health needs assessment which will inventory service delivery assets, identify needs and create a foundation for undertaking strategic initiatives. Part VI, Line 3: Charity care information is sent with the monthly statements to all uninsured patients as well as patients that are not making adequate monthly payments. Approximately 100 notices are sent out per month with the statements. Inpatients and surgical patients are informed at time of admission about charity care. A social worker visits with all self-pay inpatients to inform them about the charity care, Medicaid (state program), and self-pay discount policies. Brochures have been printed that describe our charity care and discount policies. The brochures are available in waiting rooms, ER, the clinics and admitting offices. In addition to these efforts, the financial assistance policy is also available on the website. Part VI, Line 4: Sakakawea Medical Center serves the communities in Mercer County and the surrounding area, including the towns of Hazen, Beulah, Stanton, Zap, Golden Valley, Center and Pick City. Sakakawea Medical Center, located in Hazen, is the only hospital in the county. The nearest hospital is located more than 60 miles away. Attached to the hospital is Senior Suites, a basic care facility. The combined total population of the county is approximately 8,685. The average per capita income in Mercer County for 2019 was $38,441. The current unemployment rate is 3.9%. Sakakawea Medical Center's payer mix for this fiscal year included 6% uninsured patients and 3% Medicaid patients. All patients presenting to the facility are cared for regardless of their ability to pay. Part VI, Line 5: As a critical access hospital, Sakakawea Medical Center provides a variety of health and wellness services to our service area. The organization subsidizes home care services to ensure those residents who are homebound have the health care they need. The emergency room is staffed 24 hours a day and is available to all regardless of ability to pay. The Board of Directors is comprised of county-wide volunteers; four are from Hazen, five from Beulah, and one from Stanton. The directors have various occupations including power plant manager, bank president, accounting supervisor, engineer, chiropractor, and business owner. The directors are not employed by SMC.Medical privileges are extended to all physicians in the county.Sakakawea Medical Center's Hospice staff is assisted by 58 volunteers from the area communities. The staff at Senior Suites, the basic care facility, is served by 30 community volunteers. Surplus funds are invested back into the facility through equipment purchases and facility improvements. This past year, SMC installed a Med Vac line and processing sink in the OR. Other equipment purchases included a hospice bed, a ventilator for Respiratory Therapy, Physical Therapy equipment and cardiac stress test equipment. SMC also purchased EPIC, an electronic medical record system, this included computers and various support software. Future surplus funds will be used to meet debt service requirements and any needed equipment additions or replacements. In addition, more continuing education is being offered to the staff by means of webinars and workshops. An employee assistance program is available for staff and family members which provides free confidential assessments, counseling, or referral services by trained professionals.Sakakawea Medical Center is investing in the future of healthcare professionals by implementing a nursing program. We are partnering with other health care providers in the county, a community health center and a nursing home, to offer Interactive Video Network (IVN) classes in our facility. Hands-on skill work and clinicals are taught by registered nurses employed by our organization. Upon completion of an 11 month program, students will receive a certificate in practical nursing. An additional 9 month program enables the students to receive an Associate Degree in Nursing and become eligible to test for their registered nurse license. Sakakawea Medical Center also supports state universities and high schools by offering rural medical experiences to area students. Throughout the year, students are provided with practice opportunities in nursing, lab, PT or the emergency room.Beginning in 2015, Sakakawea Medical Center is also assisting the Dakota College at Bottineau, ND with their Medical Assistant Program. Students study through on line courses provided by Dakota College. The hands-on skills are taught by registered nurses in our facility weekly. Students can complete a one year program for a diploma, or a two year program for a degree. 1 Sakakwea Medical Center Foundation 510 8th Ave NE Hazen ND 58545 450453816 501(c)(3) 15000 Cardiac Rehab Equipment and Senior Suites Furniture 1 0 Part I, Line 2: Fund are set aside in the Sakakwea Medical Center Foundation for specific purposes. Those funds are then requested by SMC to help purchase those items. SMC pays the vendors for the equipment. The Auxiliary is a part of SMC financial reporting on the Form 990. In the fiscal year the Auxiliary provided the grant to the Foundation. The Foundation then provided the funds back to SMC. X X X X X 0 1 0 0 0 0 0 0 0 Darrold Bertsch CEO 151060 0 0 0 0 0 78000 0 0 0 229060 0 0 0 Carl Miller CRNA 141216 0 0 0 9318 0 6694 0 22830 0 180058 0 0 0 Michael Schmit Surgeon 313842 0 0 0 0 0 11000 0 15132 0 339974 0 0 0 Part I, Line 4b SMC paid $78,000 in premiums for a 457(f) plan for Darrold Bertsch, CEO. This amount is reflected in Schedule J, Part II, deferred compensation. Schedule J, Part II: Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Schedule J, Part II reflects total base compensation, benefits and payroll taxes associated with this compensation on which SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2018 Form W-2 from CCCHC. In the calendar year 2018, Darrold received $151,060 from CCCHC related to the reimbursement of his services as SMC CEO. The deferred compensation reported in Part II are in relation to the 457(f) plan premiums SMC paid on his behalf. This deferred compensation is not included in the amount SMC reimburses CCCHC. Union State Bank (USB) Family ownership >35% of Union State Bank through Hazen Bancorporation HC PACE Loan X 10258000 9430283 0 1 1 9430283 Jocelyn Bertsch Wife of CEO 70763 Employee Compensation 0 Form 990, Part VI, Section A, line 1 There were 10 board of directors at fiscal year end, but the board president only votes to break a tie. The Executive Committee shall consist of the President, Vice President and Secretary/Treasurer of the Board. The CEO of the corporation shall serve without voting powers. The Executive Committee shall have the power to transact all business of the corporation during the interim between meetings of the Board of Directors, provided that any action so taken shall not conflict with the policies and express wishes of the Board of Directors, and that it shall refer all matters of major importance to the full Board of Directors. This committee shall meet as required. In the current fiscal year, the Executive Committee did not meet to make any decisions on behalf of the full governing board. Form 990, Part VI, Section A, line 6 Any person, firm, association, or corporation interested in the activities of this organization, and residing in the service area, may become a member thereof, provided that he has first made a contribution to the association at some time. Each member has one voting right. Form 990, Part VI, Section A, line 7a The members elect the Board of Directors on an annual basis. Form 990, Part VI, Section A, line 7b The members must also approve/disapprove the dissolution of the organization or the merger or consolidation of the organization with another corporation. Form 990, Part VI, Section A, line 8b All items discussed at committee meetings are brought to the full board for recommendations for board action. The organization did not have any committees that acted on behalf of the board. Form 990, Part VI, Section B, line 11b Upon receipt of the draft Form 990, a copy will be forwarded to the board members for their review and comment. Form 990, Part VI, Section B, line 12c The Board of Directors is covered by the conflict of interest policy. Only one conflict has been disclosed this fiscal year by a member of the Board of Directors. The director who has acknowledged the conflict of interest is excused from the board meeting whenever there is discussion about the relevant issue. Although the written policy as of June 30, 2016 did not address the officers of the organization, the officers do review and comply with the policy and disclose to the board of directors if a conflicts does exist. After the conflict is self-reported that officer abstains completely from the decision process of the issue at hand. Form 990, Part VI, Section B, line 15 The CEO was paid by an unrelated organization that annually used comparability data to review and determine his compensation. The decision was made by the Board of Directors from both the unrelated organization and Sakakawea Medical Center. For purposes of determining the CFO's compensation package at Sakakawea Medical Center, a variety of resources are used. The Organization takes into consideration what is appropriate compensation for that respective position, based on their market. The Organization uses salary surveys from the North Dakota Hospital Association and also refers to the public 990 information from similar sized hospitals in North Dakota. The CFO is evaluated by the CEO annually and the compensation is based on the above information. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financial statements are available if specifically requested. Form 990, Part VII: Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Schedule J, Part II reflects total base compensation, benefits and payroll taxes associated with this compensation on which SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2018 Form W-2 from CCCHC. In the calendar year 2018, Darrold received $151,060 from CCCHC related to the reimbursement of his services as SMC CEO. The deferred compensation reported in Part II are in relation to the 457(f) plan premiums SMC paid on his behalf. This deferred compensation is not included in the amount SMC reimburses CCCHC. Form 990, Part IX, line 11g Medical Purchased Services: Program service expenses 1,796,673. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,796,673. Other Purchased Services: Program service expenses 74,582. Management and general expenses 91,936. Fundraising expenses 0. Total expenses 166,518. Form 990, Part XI, line 9: Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,151. Change in Net Assets of Hazen Memorial Hospital Auxiliary 8,901.