2019-12-04T17:35:35-06:00 2019-06-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2018-07-01 450308484 Tioga Medical Center TIOG 7016643305 PO Box 159 Tioga ND 58852 Randall K Pederson President & CEO 7016643305 2019-12-04 1 Lisa Chaffee CPA P00193453 7012398500 2019-12-04 216.147.181.45 2019-12-04 13:52:11 CS P 66CC91E6B7F11C4783FFFA5645E675327CB67316 66CC91E6B7F11C4783FFFA5645E675327CB67316 2018 2020-04-17 16:48:07Z Randall K Pederson PO Box 159 Tioga ND 58852 13069983 0 X www.tiogahealth.org X 1960 ND Health care and nursing care services 8 6 165 150 0 0 815371 577538 11974774 12268273 194526 104057 96759 120115 13081430 13069983 500 500 0 0 7438409 7536054 0 0 0 5554330 5479057 12993239 13015611 88191 54372 18332324 18169788 8387108 8167100 9945216 10002688 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 5981132 7170883 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 1,507 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, 2019 of approximately $9,000.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 swingbed services. 2520421 2829843 Attached to the CAH is a 30 bed skilled nursing facility. This facility provides skilled and long term care services to its residents. 2941530 1980621 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, two Physician Assistants and two Family Nurse Practitioner. These practitioners provide physician related services at these clinics, as well as to the CAH and SNF. 263279 500 286926 Finally, attached to the Nursing home is a 22 unit independent living unit. The organization also has a Foundation that distributes scholarships. 263279 500 286926 11706362 1 1 0 1 0 0 0 0 1 0 1 0 0 0 0 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 18 0 1 165 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 1 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 X James Booth Chairman 1.00 X X 0 0 0 Brodie Odegaard Vice Chairman 0.50 X X 0 0 0 Brian Longie - Secretary Treasurer (Jul-Apr) 0.50 X X 0 0 0 Arlene Grubb -DirectorJul-Apr Secretary/Treasurer (Apr-Jun) 0.50 X X 0 0 0 Kirk Odegaard Director (Jul-Apr) 0.50 X 0 0 0 Scott Sundhagen Director 0.50 X 0 0 0 Lee Olson Director 0.50 X 0 0 0 Carolyn Eide Director 0.50 X 0 0 0 Brandon Hauge Director 0.50 X 0 0 0 Seth Wisthoff Director (Apr-Jun) 0.50 X 0 0 0 Randall K Pederson President/CEO 40.00 X 203440 0 12761 Ryan Mickelsen VP/CFO/COO 40.00 X 151150 0 11305 Dr Robert Rotering Physician 40.00 X 375060 0 17043 Jeffrey Moberg Jr Physician Assistant 40.00 X 422406 0 17240 Nancy Carlson Nurse Practitioner 32.00 X 168827 0 6795 Lorena Mitchell Nurse Practitioner 40.00 X 197380 0 7119 1518263 0 72263 6 0 1 0 ICS Inc PO Box 13158 Grand Forks ND 58208 Construction 546822 Avant PO Box 744554 Atlanta GA 30374 Contracted Nursing Services 260782 DMS Imaging PO Box 670747 Dallas TX 75267 Imaging Services 171458 3 71246 506292 577538 Patient & Resident Revenue 621110 12060820 12060820 Other Revenue 900099 207453 207453 12268273 6577 6577 73667 73667 46448 0 46448 46448 46448 82130 15350 0 0 82130 15350 97480 97480 13069983 12268273 0 224172 500 500 385560 385560 284174 284174 5818892 5719964 98928 84576 84576 539003 514146 24857 423849 393495 30354 11028 11028 60954 60954 1106779 1106779 20836 20836 1131855 608877 522978 219191 203364 15827 27055 11377 15678 35941 6603 29338 151870 151870 926535 887587 38948 84254 84254 Medical Supplies 1011231 1011231 Bad Debt Expense 574421 574421 Avera E-Emergency 63144 63144 53963 53963 13015611 11706362 1309249 0 2191821 2192372 15000 0 1759166 1864314 77983 71450 76935 84695 23790242 11563999 12612371 12226243 1569048 1707714 30000 23000 18332324 18169788 865745 950071 2445 13745 7518918 7203284 8387108 8167100 X 9915216 9987688 30000 15000 9945216 10002688 18332324 18169788 54372 3100 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1905 0 0 0 1905 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 6221414 10697880 6171716 5005592 1166124 685179 336993 348186 12226243 X 12481936 3100 -591147 -588047 13069983 0 13069983 12424464 0 12424464 591147 591147 13015611 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 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 net income that is derived from business activities that are unrelated to their 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 in Expenses for Tax -574,421. Depreciation Included In Revenue -16,726. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts in Expenses for Tax 574,421. Depreciation Included in Revenue 16,726. 1 1 X 1 X 1 X 0 0 0 9000 9000 0.00070 1264099 1143361 120738 0.00970 1273099 1143361 129738 0.01040 24914 24914 0.00200 77029 77029 0.00620 3580738 2735061 845677 0.06800 11050 11050 0.00090 3693731 2735061 958670 0.07710 4966830 3878422 1088408 0.08750 0 574421 37912 3116186 3137804 -21618 X 1 1 1 1 Tioga Medical Center Hospital 810 Welo Street Tioga ND 58852 www.tiogahealth.org 5048 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 100.000000000000 200.000000000000 1 1 X X X X 1 X See Part V, Section C X See Part V, Section C X See Part V, Section C 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 as these needs do not pertain to the services provided by Tioga Medical Center.To address the need of attracting and retaining young families, Tioga Medical Center has begun coordinating efforts with other organizations in the community to begin the development of a community calendar with contacts. Once the coordinated effort is complete, the Organization plans on advertising the events in a centrally located place both electronically on the TMC website and in hard copy form in the lobby of the clinic and hospital. The goal is to provide education to community members on what is available for children in our community. Tioga Medical Center will also pursue purchasing an electronic sign to help advertise to the community the events that are occuring.To address the need of youth depression and anxiety, Tioga Medical Center will add a green station for depression and anxiety during our annual color fun run/walk. During this fun run/walk, Tioga Medical Center has stations for different diseases to provide education and awareness to these diseases. Tioga Medical Center will provide education to the schools on puberty/ adolescence and how the hormone changes during this time can affect mental health. Tioga Medical Center will also pursue the purchase of an electronic sign to advertise mental health services provided at Tioga Medical Center including professional counseling services. 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. Part V, Section B, Line 16a, 16b, 16c: FAP:www.tiogahealth.orgFAP Application:www.tiogahealth.orgFAP Plain Language Summary:www.tiogahealth.org 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 I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $574,421. Part III, Line 2: Bad debt expense is reported net of discounts and contractual adjustments. A payment on an account which was previously written off reduces bad debt expense in the current year. Part III, Line 3: The estimated amount of the organization's bad debt expense 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 (6.6%) to the amount of bad debt expense. 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 bad debt. Part III, Line 4: The footnote to the Organization's financial statements can be found on pages 8 and 9 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 35,350 as of July 2018 according to census.gov. An estimated 9.6% of the population was 65 or older in 2018, and 6.6% were estimated below the poverty level in 2018. 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 Randall K Pederson President/CEO 202300 0 1140 0 0 0 5642 0 7119 0 216201 0 0 0 Ryan Mickelsen VP/CFO/COO 150010 0 1140 0 0 0 4185 0 7119 0 162454 0 0 0 Dr Robert Rotering Physician 349700 0 11140 0 14220 0 9923 0 7119 0 392102 0 0 0 Jeffrey Moberg Jr Physician Assistant 348380 0 74026 0 0 0 10121 0 7119 0 439646 0 0 0 Nancy Carlson Nurse Practitioner 167895 0 932 0 0 0 0 0 6795 0 175622 0 0 0 Lorena Mitchell Nurse Practitioner 196240 0 1140 0 0 0 0 0 7119 0 204499 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. Subsequent to the end of calendar year 2018, the Organization identified that this benefit should have been included in taxable compensation but was not. The Organization plans to amend necessary W-2s/W-3s and related federal and state payroll tax filings for the 2018 tax year to include the benefit in taxable income for 2018. Craig Odegaard Family of board members Brodie Odegaard & Kirk Odegaard 52126 Craig receives compensation as a maintenance employee. 0 Lori Olson Family of President & CEO Randall Pederson 72994 Lori receives compensation as a registered nurse. 0 Karen Pederson Family of President & CEO Randall Pederson 11738 Karen receives compensation as an activity aide. 0 Amanda Mickelsen Family of VP/CFO/COO Ryan Mickelsen 79257 Amanda receives compensation as a registered nurse. 0 Anna Nordloef Family of board member Seth Wisthoff 44439 Anna receives compensation as a registered nurse. 0 Lindsey Odegaard Family of board members Brodie Odegaard & Kirk Odegaard 23620 Lindsey receives compensation as a registered nurse. 0 Form 990, Part VI, Section A, line 1 Board Chair does not vote. Form 990, Part VI, Section A, line 2 Brodie Odegaard and Kirk Odegaard have a family relationship. 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. Form 990, Part VII, Section A Subsequent to the end of the 2018 calendar year, the Organization identified certain benefits that should have been taxable compensation to interested persons. The Organization will amend the necessary Form W-2s/W-3s and related federal and state payroll tax filings for the 2018 tax year. Compensation reported in Form 990, Part VII reflects amounts that will be shown on amended W-2s. Compensation reported in Form 990, Part IX reflects amounts actually treated as compensation during the fiscal year.