2019-11-12T13:06:49-06:00 2018-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 KATIE WERNER CFO 7012658461 2019-11-12 1 RYAN ENGEBRETSON P01585625 6123764500 67.137.57.251 2019-11-12 07:44:44 CS P FCD06153B7C3F4186BBEFC76B30654521E54D624 A5795B2AF6391D8EE41853777EBEE033D1D6DDEC 2018 2020-03-31 21:24:44Z LISA LETEXIER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 18074242 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. 10 6 202 60 0 0 419179 111192 15252702 15662907 22591 10298 1482633 2289845 17177105 18074242 0 0 0 0 7122757 7923868 0 0 70767 8367154 8878354 15489911 16802222 1687194 1272020 8814414 10153333 2343721 2410620 6470693 7742713 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 15111894 0 15662907 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOICATION IS A 20 BED ACUTE CARE HOSPITAL, 50 BED NURSING HOME, A RURAL HEALTH CLINIC, AND 20 UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24 HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY. THE ASSOCIATION ALSO PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. 15111894 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 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 32 0 202 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 6 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X KATIE WERNER 7012656281 301 MOUNTAIN STREET EAST CAVALIER ND 58220 TOM FORD PRESIDENT 5.00 1.00 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 5.00 0.00 X X 0 0 0 TOM O'TOOLE SECRETARY 5.00 0.00 X X 0 0 0 LORETTA BERNHOFT BOARD MEMBER 5.00 0.00 X 0 0 0 DUANNE DERAAS BOARD MEMBER 5.00 0.00 X 0 0 0 NICOLE SAFRANSKI BOARD MEMBER 5.00 0.00 X 0 0 0 KENNETH SCHWANDT BOARD MEMBER AND CONTRACT PHARMACIST 5.00 0.00 X 19250 0 0 DR KULVINDER SUMRA BOARD MEMBER AND CONTRACT PHYSICIAN 40.00 0.00 X 0 0 0 DWIGHT THOMPSON BOARD MEMBER (THROUGH JUNE 2018) 5.00 0.00 X 0 0 0 MARK WAIND BOARD MEMBER 5.00 0.00 X 0 0 0 DARLENE WATSON BOARD MEMBER 5.00 1.00 X 0 0 0 LISA LETEXIER CO-CEO 40.00 1.00 X 121756 0 6644 JENI SCHWENZFEIER CFO AND CO-CEO 40.00 1.00 X 119952 0 5524 LAURA ERMER PHYSICIANS ASSISTANT 40.00 0.00 X 129399 0 5000 KIM FORD PHYSICIANS ASSISTANT 40.00 0.00 X 123777 0 0 514134 0 17168 4 0 0 0 DAKOTA TRAVEL NURSE - DTN STAFFING 1200 COLLINS AVE MANDAN ND 58554 AGENCY NURSES 574633 ALTRU HEALTH SYSTEMS PO BOX 1370 GRAND FORKS ND 58208 THERAPY SERVICES, PHYSICIAN SERVICES, IT 557938 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 530420 INDER V KHOKHA MD PC PO BOX 380 CAVALIER ND 58220 SURGEON SERVICES 460496 PASTOREK CONSTRUCTION 106 6TH STREET EAST GRAFTON ND 58237 CARPENTRY/CONSTRUCTION 379245 8 69482 41710 111192 NET PATIENT REVENUE 621110 15606870 15606870 ANCILLARY REVENUES 621110 56037 56037 15662907 10298 10298 54745 0 54745 54745 54745 340B REVENUE 446110 2028798 2028798 OTHER INCOME 900099 206302 206302 2235100 18074242 15662907 0 2300143 X 274876 246465 27222 1189 6192581 5552518 613266 26797 163896 146956 16231 709 841108 754171 83297 3640 451407 404750 44704 1953 16123 14456 1597 70 51892 46528 5139 225 3571578 3202421 353702 15455 32435 29083 3212 140 216774 194368 21468 938 23824 21362 2359 103 362813 325313 35930 1570 21354 19147 2115 92 40605 36408 4021 176 666126 597276 65968 2882 99130 88884 9817 429 MEDICAL SUPPLIES 2845256 2551172 281772 12312 PROVISION FOR BAD DEBT 448362 448362 EQUIPMENT RENTAL & REPA 186416 167148 18461 807 FOOD EXPENSE 178373 159936 17665 772 117293 105170 11615 508 16802222 15111894 1619561 70767 1068437 1835309 2283287 2654337 228150 188889 160651 153585 17354931 13783759 3481302 3571172 1326815 1484406 265772 265635 8814414 10153333 1186963 1255734 16300 13310 769958 809034 370500 332542 2343721 2410620 X 6470693 7742713 6470693 7742713 8814414 10153333 1272020 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1986 1986 0 PART II-B, LINE 1: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. 1 15095 7127 11964 10258 1 X 160304 160304 7218187 5894489 1323698 678289 469389 208900 8856830 7419881 1436949 441321 441321 3571172 X 17491355 0 17491355 582887 582887 18074242 16353860 0 16353860 448362 448362 16802222 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2018 AND 2017 TOTALED $13,310 AND $16,317 RESPECTIVELY. PART X, LINE 2: THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 10,298. RENTAL INCOME 54,745. GRANTS AND CONTRIBUTIONS FOR LONG-LIVED ASSETS 69,482. BAD DEBT EXPENSE 448,362. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 448,362. 1 1 X 1 X 1 X 0 0 0 36011 36011 0.00210 1968970 2306143 0 0.00000 2004981 2306143 36011 0.00210 37300 37300 0.00220 2500 2500 0.00010 3893383 3239972 653411 0.03890 3933183 3239972 693211 0.04120 5938164 5546115 729222 0.04330 900 900 0.00010 900 900 0.00010 1 448362 35869 5186526 5267171 -80645 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 456013474 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 1 1 X SEE PART V, SECTION B, LINE 7D X X 1 17 1 SEE PART V, SECTION B, LINE 7D 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X X X X X X 1 0 X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1) A SURVEY OF AREA RESIDENTS, INCLUDING HEALTH CARE PROFESSIONALS WHO UTILIZE SERVICES PROVIDED BY AND/OR WORK AT PEMBINA COUNTY MEMORIAL HOSPITAL, WEDGEWOOD MANOR, CLINICARE, AND PEMBINA COUNTY PUBLIC HEALTH.2) COMMUNITY LEADERS REPRESENTING THE BROADER INTERESTS OF THE COMMUNITY TOOK PART IN ONE-ON-ONE KEY INFORMANT INTERVIEWS;3) THE COMMUNITY GROUP, COMPRISED OF COMMUNITY LEADERS AND AREA RESIDENTS, WAS CONVENED TO DISCUSS AREA HEALTH NEEDS AND INFORM THE ASSESMENT PROCESS; AND4) A WIDE RANGE OF SECONDARY SOURCES OF DATA WERE EXAMINED, PROVIDING INFORMATION OF A MULTITUDE OF MEASURES INCLUDING DEMOGRAPHICS; HEALTH CONDITIONS, INDICATORS, AND OUTCOMES; RATES OF PREVENTIVE MEASURES; RATES OF DISEASE; AND AT-RISK BEHAVIOR. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THE ORGANIZATION'S COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT HTTPS://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: IN 2018, PCMHA CONTINUED TO WORK TOWARD ADDRESSING THE HEALTH NEEDS OF OUR COMMUNITY AS IDENTIFIED IN THE 2017 CHNA IN THE FOLLOWING WAYS:ASSISTED LIVING OPTIONS - RESEARCHED OPTIONS FOR CONSTRUCTING A NEW COMPLEX TO HOUSE ASSISTED LIVING RESIDENTS. RESULTS INDICATED THAT THIS OPTION IS NOT FEASIBLE DUE TO THE PROXIMITY OF THE FLOODPLAIN AND ASSOCIATED COSTS. DUE TO THOSE RESTRICTIONS, THE FOCUS WAS CHANGED TO UTILIZING EXISTING SPACE AND CONVERTING SOME OF THE CONGREGATE HOUSING APARTMENTS TO ASSISTED LIVING APARTMENTS. BEHAVIORAL HEALTH SERVICES - PCMHA CONTINUES TO PARTICIPATE IN THE PEMBINA COUNTY BEHAVIORAL HEALTH COALITION MEETINGS MONTHLY TO ADDRESS THE NEEDS OF OUR STAFF AND OUR COMMUNITY. RESEARCHED THE VIABILITY OF HIRING A NURSE PRACTITIONER SPECIALIZING IN BEHAVIORAL HEALTH; THIS DID NOT COME TO FRUITION. INSTEAD, INCREASED TELE-MED AVAILABILITY. OTHER ACTIVITIES SPONSORED BY PCMHA TO PROVIDE EDUCATION AND RESOURCES FOR THE COMMUNITY INCLUDE:- JANUARY 10, 2018 - SUBSTANCE ABUSE IN THE COMMUNITY - FRANK WHITE- APRIL 12, 2018 - TEEN MAZE AT THE CAVALIER SCHOOL (EVENT WITH DEMONSTRATIONS AND DISCUSSIONS LED BY PCMHA STAFF)- JULY 31, 2018 - DONATED PRIZES FOR WELLNESS BINGO- OCTOBER 12, 2018 - OPIOID ABUSE - FRANK WHITE- CONTINUE TO PARTICIPATE IN THE PRESCRIPTION DRUG TAKE-BACK PROGRAM- PALLIATIVE CARE - DOING EDUCATION ON ADVANCED DIRECTIVES- ANTIBIOTIC STEWARDSHIP - PAMPHLETS AND DISPLAYS FOR ANTIBIOTIC COMMITMENT AND FLU VACCINATION CLINICS DISTRIBUTED THROUGHOUT THE COMMUNITY INCLUDING THE SCHOOLS AND DAYCARE FACILITIES. - CARDIAC READY COMMUNITY - HANDS ONLY CPR DEMONSTRATIONS AND EDUCATION AT COMMUNITY EVENTS (JANUARY, APRIL, MAY X2, JUNE X2, AND JULY, 2018) 3 1 - CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC 2 - WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME 3 - COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING PART I, LINE 7: THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, RURAL HEALTH CLINIC, AND EMERGENCY ROOM. PART II, COMMUNITY BUILDING ACTIVITIES: PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. PART III, LINE 2: IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: 8.0% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2010 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE, THE ORGANIZATION ESTIMATES THAT 8.0% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 8 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFITY TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.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 THE CENTERS FOR MEDICARE AND MEDICAID SERIVCES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION.1. SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. 2. PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. A. THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. B. THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. C. THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. 3. ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME SHALL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $1.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: 1. REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD. 2. REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD. 3. CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. PART VI, LINE 3: NOTICES OF THE FAP ARE POSTED IN ALL WAITING AREAS, REGISTRATION AREAS, AND UPON DISCHARGE. PART VI, LINE 4: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2010 SHOWED A POPULATION OF 7,413 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $48,502. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,019. 8.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 530420 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 RITA VAUGHN WIFE OF TOM VAUGHN, A BOARD MEMBER 23657 EMPLOYEE COMPENSATION 0 KIM FORD DAUGHTER-IN-LAW OF TOM FORD, A BOARD MEMBER 123777 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. FORM 990, PART VI, SECTION A, LINE 6 ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7A ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. IN ADDITION, ONE BOARD MEMBER SHALL BE APPOINTED BY ALTRU HEALTH SYSTEM. FORM 990, PART VI, SECTION B, LINE 11B FULL BOARD REVIEWS THE DRAFT OF THE 990 PRIOR TO FILING OF THE FINAL REPORT WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT RAISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTOR'S. COMPARATIVE DATA IS GATHERED FROM THE ND HOSPITAL ASSOCIATION'S WAGE SURVEYS. A BLUE FORM IS GIVEN TO HR INDICATING ANY SALARY DECISIONS. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON NORTH DAKOTA HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2018. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 3,202,421. MANAGEMENT AND GENERAL EXPENSES 353,702. FUNDRAISING EXPENSES 15,455. TOTAL EXPENSES 3,571,578. PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION 301 MOUNTAIN STREET EAST CAVALIER ND 58220 300052569 FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR ND 501(C)(3) LINE 12A, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0