2019-11-05T08:21:46-06:00 2019-04-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2018-05-01 113686120 Coal Country Community Health Center COAL 7018737788 1312 Highway 49 N Beulah ND 585236038 Darrold Bertsch CEO 7018737788 2019-11-04 1 Deb Nelson CPA P01264758 7012398500 2019-11-04 216.147.181.45 2019-11-04 08:22:59 CS P 66CC91E6B7F11C4783FFFA5645E675327CB67316 3F1B4C4A1C1F32CA3CD03C05270CE62742EA9E6E 2018 2020-04-17 16:48:07Z Darrold Bertsch 1312 Highway 49 N Beulah ND 585236038 12887438 0 X www.coalcountryhealth.com X 2003 ND CCCHC provides and promotes quality health care to the medically underserved population in the North Dakota counties of Mercer, Dunn, and Oliver. 11 10 132 12 0 0 2606233 2524057 10407484 10333133 0 0 0 30248 13013717 12887438 10000 0 0 0 6908652 7143408 0 0 0 4596098 5268148 11514750 12411556 1498967 475882 10532893 13591246 1428541 4011012 9104352 9580234 X CCCHC creates access to affordable high quality preventative and primary care for all, especially medically under-served populations in Dunn, Mercer, and Oliver counties. The organization links the established medical clinics of Beulah, Center, Killdeer, and Hazen together and efficiently uses resources available to meet the increasingly complex needs of delivering rural health and improving the health status of all. 1 0 10316081 10333133 Coal Country Community Health Center is part of a family of over 1,400 health centers nationally that provide care to more than 28 million people in the United States. Community health centers are local, non-profit health care providers serving low income and medically underserved communities. Also known as Federally-Qualified Health Centers (FQHCs), they are located in areas where care is needed, and improve access to care for millions of Americans. Their costs of care rank among the lowest, and their focus on prevention reduces the need for more expensive in-patient and specialty care, saving billions of dollars for taxpayers. (Continued on Schedule O)The focus of the care we provide can be summed up in one word - community. Coal Country is governed by a board of members from the communities we serve, and every decision they make has the best interest of the community in mind. Our medical staff and support staff are also your neighbors, helping us truly understand you and the health care issues that are important to you.The team of providers delivers primary care for the entire community. Funded by a federal grant, our sliding fee scale allows patients to pay according to their individual ability. This and other efforts ensure that no one in the community goes without proper health care services. That's what we're all about.Coal Country Community Health Center, with clinics in Beulah, Center, Hazen, and Killdeer, is a member of the PrimeCare Health Group. Furthermore, Coal Country remains a member of the other health care networks in the region.At Coal Country Community Health Center, our top priority is to provide complete health care services for the entire community.With a background in every area of medicine, our primary care physicians provide continuing and comprehensive care, from preventative care to diagnosis and treatment of health conditions.For more focused care, we bring in specialists to our clinic in Beulah,all the while continuing to oversee your total care.Our ongoing medical care of all levels includes the areas of::: Acute and chronic disease:: Adult care medicine:: Emergency medicine:: Geriatrics:: Mental health:: Medicated Assisted Therapy:: Obstetrics:: Occupational medicine:: Pediatrics:: Prenatal care:: Sports medicine:: Women's healthSpecialists from Bismarck regularly visit our clinics to provide treatment in the areas of::: Audiology:: Ear, nose and throat:: General surgery:: Mental health:: Obstetrics and Gynecology:: Orthopedics 10316081 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 1 132 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Dovie Borth 7018737788 1312 Hwy 49 N Beulah ND 585236038 Dr DJ Erickson Chair 1.00 X X 0 0 0 Keith Johnson Vice Chair 1.00 X X 0 0 0 Arlene Helling Secretary/Treasurer 1.00 X X 0 0 0 Ann Mahoney -Director Executive Committee 1.00 X 0 0 0 Gordon Hoffner Director 1.00 X 0 0 0 Fred Stern Director 1.00 X 0 0 0 Sienna Sailer Director 1.00 X 0 0 0 Jody Doe Director 1.00 X 0 0 0 Anna Mae Batke Director 1.00 X 0 0 0 Kathy Kelsch Director (Began June 2018) 1.00 X 0 0 0 Travis Jordan Director (Began June 2018) 1.00 X 0 0 0 Kimberly Kessler Director (Resigned May 2018) 1.00 X 0 0 0 Darrold Bertsch CEO 22.10 X 268033 0 34584 Dovie Borth CFO 34.30 X 94157 0 12132 Aaron Garman MD Physician 40.00 X 343432 0 32416 Jacinta-Jon Klindworth MD Physician 40.00 X 263887 0 35567 Michelle Placke Physician 38.60 X 245627 0 38954 Rodney Zimmerman Physician 39.90 X 201829 0 31300 Orlan Jackson DO Physician 24.00 X 184268 0 28859 1601233 0 213812 13 0 1 0 Corval Management Services Inc 1633 Eustis St St Paul MN 55108 Construction for Beulah Clinic Expansion 5058309 Beulah Drug 147 W Main Beulah ND 58523 Contract Pharmacy Dispensing Fees 878974 Sakakawea Medical Center 510 8th Avenue NE Hazen ND 58545 Shared Staff & Rent 287106 Greenway Health LLC PO Box 203658 Dallas TX 753203658 Software Subscription, Support, Licenses 185784 Hazen Drug 30 Main Street Hazen ND 58545 Contract Pharmacy Dispensing Fees 179445 6 2524057 2524057 Patient Service Revenue 621110 6479522 6479522 340B Program Revenue 621110 3412015 3412015 Other Program Revenue 621110 441596 441596 10333133 30248 0 30248 30248 30248 12887438 10333133 0 30248 270302 270302 5579518 5234394 345124 206245 155875 50370 697941 565178 132763 389402 277207 112195 7986 7986 94970 94970 529315 412531 116784 67337 67337 600014 319114 280900 295519 295519 296514 278326 18188 61167 36601 24566 23258 7208 16050 1 1 721872 665340 56532 35018 35018 Medical Supplies 2008336 2008336 Bad Debt Expense 209481 209481 Licenses 58692 54600 4092 Dues and Subscriptions 40501 5046 35455 218167 86843 131324 12411556 10316081 2095475 0 6672600 4169143 1356205 1082772 57608 53258 97447 125083 10092458 2010637 2266595 8081821 82438 79169 10532893 13591246 1428541 1216762 2794250 1428541 4011012 X 9104352 9580234 9104352 9580234 10532893 13591246 475882 0 X 0 1 X 1 1 1 X 1508859 2089318 2696142 2606233 2524057 11424609 1508859 2089318 2696142 2606233 2524057 11424609 11424609 30248 30248 11454857 44411612 0.99740 1.00000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 7089183 912305 6176878 33173 12910 20263 1869327 992436 876891 1100775 92986 1007789 8081821 X 12677956 -209482 -209482 12887438 0 12887438 12202074 0 12202074 209482 209482 12411556 Part X, Line 2: The Health Center is organized as a North Dakota nonprofit organization 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 Health Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health Center is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Health Center 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 Health 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 Health 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 -209,482. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts 209,482. X X X X 0 0 0 0 0 1 0 0 0 Darrold Bertsch CEO 263769 0 0 0 4264 0 10631 0 22045 0 300709 0 0 0 Aaron Garman MD Physician 278600 0 64022 0 810 0 10781 0 22481 0 376694 0 0 0 Jacinta-Jon Klindworth MD Physician 213292 0 49785 0 810 0 10624 0 25789 0 300300 0 0 0 Michelle Placke Physician 205696 0 26542 0 13389 0 9539 0 30639 0 285805 0 0 0 Rodney Zimmerman Physician 183282 0 14356 0 4191 0 7346 0 21103 0 230278 0 0 0 Orlan Jackson DO Physician 176248 0 4356 0 3664 0 7224 0 19711 0 211203 0 0 0 Part I, Line 6 An annual management team incentive program was started in FY2014 with the first annual payment occurring in August 2014 for fiscal year ending 04/30/2014. This program was continued for FY2019. The incentive payment is based on a combination of ten clinical and financial performance measures relating to the patient population and the health center. The ten measures are: 1. Diabetes Control > National Average 2. Blood Pressure Control > National Average 3. Cholesterol Treatment > National Average 4. Adult Weight Screening & Follow-up > National Average 5. Childhood Immunizations > National Average 6. Days in AR < 55 7. Days Cash on Hand > 90 8. Net Profit Margin > 5% 9. Long Term Debt to Equity < .50 10. Medical Cost Per Medical Patient < National Average Of the 10 measures, only net profit margin could potentially be considered as compensation contingent on net earnings. Only the measures met for the current fiscal year are included in the calculation of the incentive payment. Each measure met receives a rating of 1%. A maximum incentive of 10% is allowed. The incentive payment calculation is based on the individual team member's base salary/wages as of the end of the current fiscal year. Dovie Borth received a management team incentive payment of $8,830.20 for FY2018 which was paid in FY2019. The other four participants in the program do not meet the criteria for Part VII and are not listed in Part VII. Schedule J, Part II: As of 6/1/2013, Darrold became an employee of Coal Country Community Health Center (CCCHC) and still provides services to both Sakakawea Medical Center (SMC) and CCCHC. The compensation reported in Part VII, and Part II of Schedule J, reflects total compensation Darrold received from CCCHC for his services to both SMC and CCCHC. Compensation received just for services to CCCHC, includes $167,801 of wages and benefits. The Union Bank Family Member of Board Member (Gordon Hoffner) owns > 35% of Union Bank Construction X 2794250 2794250 0 1 1 2794250 Form 990, Part III, line 2 CCCHC began providing mental health services in the Beulah and Hazen school districts during the 2018-2019 school year. The health center utilizes a comprehensive mental health screening tool at each school district as an approach for early identification of conditions that increase risk for substance or opioid use in adolescent patients. In the fall of 2018, Tobacco Treatment Specialists (TTS) began providing education and cessation counseling to patients seen at the health center. Patients are able to receive tobacco cessation counseling, support, and services through these specialists. A Certified Diabetic Educator (CDE) started providing diabetic education services in January 2019. The CDE promotes self-management to achieve individualized behavioral and treatment goals that reduce risks and optimize health outcomes. CCCHC began providing medical services at Hilltop Home of Comfort, the long term care facility, in Killdeer, ND in October 2018. CCCHC added a dedicated medical provider to provide services at Knife River Care Center, the long term care facility, in Beulah, ND. Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of at least five (5) voting members, including the Chair, Vice Chair, Secretary, Treasurer, and one (1) at-large member. The Executive Director 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, including any amendments to the Articles and Bylaws. Form 990, Part VI, Section B, line 11b The full copy of the Form 990 is provided to the board via email. The Form 990 is reviewed and approved by the board and signed by the CEO after approval. Form 990, Part VI, Section B, line 12c The conflict of interest and compensation disclosure statements are completed annually. All board members and officers of CCCHC are covered by the policy. The annual conflict of interest and compensation disclosure statements obtained from board members and officers of CCCHC are reviewed by the CEO and Administration staff of CCCHC. It is at this review that the determination is made as to whether a conflict exists. Actual conflicts of interest identified are brought before the Board Executive Committee or the entire Board, depending on the situation and circumstances. Board members and officers of CCCHC are required to recuse themselves from voting on issues where it has been determined that a conflict of interest does exist. If the conflict of interest is pervasive, the Board Executive Committee or the entire Board will determine if further actions are needed. In all situations, the Board will document the restrictions imposed or acted upon. Form 990, Part VI, Section B, line 15a To determine compensation, the organization uses the following salary surveys for both the CEO and CFO as well as other positions within the organization: National Community Health Center Association (NACHC), Community Healthcare Association of the Mountain Plain States (CHAMPS), Medical Group Management Association (MGMA), and state of ND. The board of directors determines the salary of the CEO. CEO Salary adjustments are documented on a payroll notification form, signed by the board chair and forwarded to the accounting department for entry into the accounting/payroll system. Compensation for the CFO is reviewed and approved by the CEO. The board of directors approves an annual budget to provide guidance for expenditures which includes personnel salaries. In addition, annual salary adjustments are presented to the board for approval. Personnel salary adjustments are documented on a payroll notification form signed by the CEO or Human Resources and forwarded to the accounting department for entry into the accounting/payroll system. The process for determining compensation is undertaken annually before the new fiscal year in May begins. 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.