2019-01-30T09:02:40-06:00 2018-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2017-07-01 410307617 Hendricks Community Hospital Assn & Retirement Home HEND 5072753134 PO Box 106 Hendricks MN 56136 Jeff Gollaher CEO 5072753134 2019-01-29 1 Kim Hunwardsen CPA P00484560 6122536500 2019-01-29 8.39.233.75 2019-01-29 13:28:09 CS P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC F9BEE9501A3B4F00F190E63700B8BF2BC70C7B96 2017 2019-02-21 02:37:17Z Jeff Gollaher PO Box 106 Hendricks MN 56136 14341718 0 X www.hendrickshosp.org X 1941 MN Provision of healthcare 9 8 224 75 0 0 58168 96475 14227621 13806010 40460 326403 64506 68507 14390755 14297395 7944 27095 0 0 7940137 8005963 0 0 0 5794408 6313852 13742489 14346910 648266 -49515 16886090 17637117 2062558 2805245 14823532 14831872 X Hendricks Community Hospital Assn & Retirement Home strives to provide the highest quality health and residential care in a Christian environment. 0 0 12865158 27095 13823527 Hendricks Community Hospital, a 24-bed hospital, 58-bed long-term care facility, 16-unit senior rental housing facility, and home health agency promotes health of the community by providing a variety of health care services. The facility had 74 acute, 49 swing bed, 10 transitional bed and 22 long-term care facility admissions for the year ended June 30, 2018; 470 visits to the Emergency Room; and 140 surgical cases (including ambulatory). The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Continued on Schedule O.Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as patient and resident service revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $15,000 for the year ended June 30, 2018. The estimated cost of providing these services was $12,000 for the year ended June 30, 2018, based on average ratio of cost to gross charges. 12865158 1 0 0 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 42 0 1 224 1 0 0 0 0 0 0 0 0 0 0 X 9 8 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 MN X Julie Hogie 5072753134 PO Box 106 Hendricks MN 56136 Allen Molascon President 3.00 X X 660 0 0 Mark VanEck Vice President 2.00 X X 630 0 0 Julie Leibfried Secretary 2.00 X X 460 0 0 Vince Robinson Treasurer 2.00 X X 480 0 0 Norris Patrick Director 2.00 X 380 0 0 Sharon Vettrus Director (thru Aug 2017) 2.00 X 280 0 0 Miriam Iverson Director 2.00 X 520 0 0 James Ness Director 2.00 X 540 0 0 Dean Nielsen Director 2.00 X 460 0 0 John Engels Director (as of Aug 2017) 2.00 X 0 0 0 Jeff Gollaher CEO 40.00 X 170369 0 19115 Julie Hogie Business Office Manager 40.00 X 65619 0 13370 Tabb McCluskey Physician/Medical Director 40.00 X 169234 0 40311 Grant Eyjolfson Physician 40.00 X 329094 0 40974 Tomasz Lis Physician 40.00 X 405538 0 41838 Kathryn Christensen Nurse Practitioner 40.00 X 116904 0 5765 1261168 0 161373 5 0 1 0 A'viands LLC PO Box 743357 Atlanta GA 303743357 Contracted dietary services 860212 WMG Lyfjaberg LLC 603 S Dakota St PO Box 523 Milbank SD 57252 Locum/ER providers 556281 2 12400 69860 14215 96475 Net patient & resident service re 622110 13735417 13735417 70593 70593 13806010 19547 19547 9102 0 9102 9102 9102 345830 38974 306856 306856 306856 5463 12400 3976 1487 1487 41774 1373 40401 40401 AR Interest 900099 17517 17517 17517 14297395 13823527 0 377393 X 27095 27095 272893 272893 40279 40279 5760628 5573378 187250 157189 148059 9130 1350074 1233746 116328 424900 394283 30617 57570 57570 2510453 2390601 119852 30403 1034 29369 741343 700301 41042 17570 17570 295859 293000 2859 89939 84058 5881 23804 23804 628009 628009 221119 221119 Repairs and Maintenance 678391 599361 79030 Medical Supplies 492611 492611 MN Care Tax 270048 270048 Bad Debt Expense 62486 62486 194247 155483 38764 14346910 12865158 1481752 0 3143177 1255403 1703331 1628866 25000 50931 98880 262404 276868 84215 62916 25435474 13023600 9744383 12411874 1624171 1924268 121929 25991 78600 0 16886090 17637117 1230514 1338871 27042 26042 50000 490304 755002 950028 2062558 2805245 X 14823532 14831872 14823532 14831872 16886090 17637117 X -49515 58451 -596 X 0 1 X 1 0 X 1 97714 41953 41357 98310 1 X 94512 94512 12072024 7732134 4339890 6292590 5291466 1001124 6976348 6976348 12411874 Construction payable 930934 Estimated third-party payor settlements 19094 950028 X 14226090 -30725 -30725 14256815 40580 40580 14297395 14276201 0 14276201 70709 70709 14346910 Part IV, Line 1b: The assets of Hendricks Hospital Auxiliary are held by Hendricks Community Hospital Association. The Auxiliary uses the EIN of the Hospital, therefore the activity is reported on Form 990 of the Hospital. The ending balance for the Auxiliary was $93,136. In addition, the Hospital holds funds on behalf of its residents. The amount held at the end of the year for residents was $5,174. Part IV, Line 2b: The organization holds security deposits. Part X, Line 2: The Association is organized as a Minnesota not-for-profit 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 Association is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Association is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Association 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 Association believes 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 consolidated financial statements. The Association 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: Bad debt expense reported in revenue on financial statements -62,486. Expenses reported in contributions on financial statements -5,239. Auxiliary contributions to Hospital not reported on Form 990 37,000. Part XI, Line 4b - Other Adjustments: Auxiliary revenue not included in financial statements 41,953. Auxiliary Thrift shop expenses reported in revenue on Form 990 -1,373. Part XII, Line 4b - Other Adjustments: Auxiliary expenses not included in financial statements 2,576. Bad debt expense reported in revenue on financial statements 62,486. Expenses reported as contributions on financial statements 5,239. Resident fund expenses not included in financial statements 408. Hospice Tour of Tables 11522 8400 3122 2415 299 Hospice Golf Tournament 6341 4000 2341 626 636 17863 12400 5463 3041 935 3976 1487 1 1 X 1 X 1 X 125.000000000000 1 1 0 1 0 12000 12000 0.00080 3224390 2699716 524674 0.03670 3236390 2699716 536674 0.03750 12621 12621 0.00090 63312 63312 0.00440 4719671 2488618 2231053 0.15620 27095 27095 0.00190 4822699 2488618 2334081 0.16340 8059089 5188334 2870755 0.20090 0 62486 31243 3763696 3765610 -1914 X 1 1 1 1 Hendricks Community Hospital Association 503 East Lincoln Hendricks MN 56136 www.hendrickshosp.org 00340 X X X X 2 provider based RHCs Hendricks Community Hospital Association 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X www.hendrickshosp.org X 1 15 1 www.hendrickshosp.org 0 1 X 100.000000000000 125.000000000000 X X X X 1 1 X X X 1 X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X X X X X X 1 X 0 X X X X 1 X 0 0 Hendricks Community Hospital Association Part V, Section B, Line 5: Four focus groups were formulated to provide input in completion of the current Community Health Needs Assessment. Participants in those groups included business/community leaders, health care providers (including public health), seniors and young parents. A total of 24 individuals were interviewed. Hendricks Community Hospital Association Part V, Section B, Line 11: Members of the hospital board and facility leadership team have met to identify the top community health needs and conduct strategic planning. The team has rated the community health needs based on the ability of the facility to respond to the needs of the community. Team members continue to strategize on how best to address the objectives and needs as presented. The facility leadership teams are meeting on an on-going basis to move the strategies forward.Of the community health needs identified, the hospital will address: Awareness of Services; Staff Recognition, Affordable Care; Wellness Promotion, and Mental Health Needs.The Hospital will not address Drug and Alcohol Abuse since it is not feasible with current resources.The following updates took place during the fiscal year ending June 30, 2018:1. Expanding Market Strategiesa. Social media options implemented - utilizing facebook, community digital sign and facility website. Lung cancer screenings are promoted in news media.2. Foster Internal Culture of Appreciation & Developmenta. In addition to new employee orientation, in-house new staff group training is taking place on a monthly basis, as well as 30/60/90 day check-ins with new hires.b. Scholarship availabilities promoted.c. Encourage participation in Medi-Sota workshops and webinars3. Community Wellnessa. Dietary department is providing healthy meal choicesb. Discounted rate for staff to utilize community exercise center4. Mental Health Servicesa. Continued study is taking place for psychiatric tele-health servicesa. Law enforcement and area facility representatives have held meetings to study avenues of improving availability of mental health services.5. Financial Stewardshipa. Departmental year-to-date budgets are being distributed quarterly.b. Volunteer coordinator is regularly promoting utilization of volunteers Hendricks Community Hospital Association Part V, Section B, Line 13h: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Hendricks Community Hospital Association Part V, Section B, Line 16j: Summaries of the financial assistance policy are posted in the hospital/clinic facilities, as well as waiting rooms and admission area. Billing statements to potentially eligible clients also include summary and contact information for obtaining the appropriate application. 2 1 - Hendricks Nursing Home 503 E Lincoln St Hendricks MN 56136 Long term care 2 - Lincoln Lane Villa 500 E Lincoln St Hendricks MN 56136 Senior Housing Part I, Line 3c: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Part I, Line 7: Charity care is based on an overall cost to charge ratio addressing all patient segments. Community health improvement services, health professions education, and cash and in-kind contributions for community benefit expenses are based on actual expenses recorded to the general ledger. Subsidized health services are reported according to costs allocated to the relevant cost centers on the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $62,486. Part II, Community Building Activities: Many leaders and staff of the hospital are involved with local community groups like Kiwanis and other community clubs. Their involvement provides them the opportunity to get involved in speaking to community members on health topics and encouraging community involvement in other health activities, like blood drives. Funds were used to host an appreciation dinner and for physician recruitment. Part III, Line 2: Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces the bad debt expense in the current year. Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: Bad debt expense is determined based on a patient's payment history as well as current known financial status. Such expense is determined by a patient's non-payment status and non-probability of payment. Because of the nature of these accounts, it is found that at least 50% of these accounts would fall into the charity care status. Part III, Line 4: The footnote to the organization's financial statements that describes bad debt expense is located on page 7 of the attached financial statements. Part III, Line 8: The Hospital provides services to Medicare patients because access to healthcare and patient's health is important to the Hospital. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from 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 Services. Part III, Line 9b: Patients are classified in the poverty level utilizing the Federal poverty guidelines as also referenced in our facility collection policy. The guidelines are referenced when a patient fails to complete payment of his/her account in a timely manner. Prior to being turned over to a collection agency, a patient is offered 120 days to complete a charity care application, thereby allowing staff time to determine the income level of the patient and their qualification as a poverty level individual. If they so chose to not complete an application, their account would be referred to a collection agency. The Hospital allows an additional 120 days for a patient to apply for financial assistance. If the patient is determined to be eligible for financial assistance collection activities will cease. Part VI, Line 2: We are consistently addressing the additional service needs as voiced through the physicians who serve our clientele, as well as the clientele themselves.The community health needs assessment and implementation strategy have been completed and are available on our website at www.hendrickshosp.org. Part VI, Line 3: Patient's insurance information is obtained upon admission, and those patients not having current third party coverage are informed of the ability to apply for medical assistance funding or visit with our business office staff and social service staff regarding alternative payments and the charity care options. In addition, the patient statements provide information related to contacting our business office personnel to complete alternative payment arrangements, i.e. charity care, Medicaid or planned payment schedule. Patients are offered an option of setting an appointment to meet with staff to complete such arrangements. These procedures are also detailed in our financial assistance/charity care policy. Part VI, Line 4: Hendricks Community Hospital serves a primarily rural population within a 30-mile radius of the community of Hendricks. The facility is located in Lincoln County, Minnesota, which is slated as one of the highest elderly population counties in the State. The average median income for the county is $49,438 with the highest portion of the population being over 65 years of age. However, because of the high elderly population, many of those constituents are insured through federal government programs and do not necessarily relate to increased Medicaid levels. There is one other acute care facility in the county approximately 30 miles away. Our facility is also located within one-mile of the South Dakota border, and a good margin of population served is located in that state. During the fiscal year ending 6/30/18, it was noted approximately 22% of our patients were insured through Medical Assistance programs, and approximately 11% were un-insured. Part VI, Line 5: The nine members of the association's Board of Directors represent varying communities within the 30-mile service area. The board members provide valuable input of the health care needs of the area served.Medical staff privileges are extended to qualified physicians within the service area as well as outlying areas to provide the optimum level of care for our constituents. These privileges are granted to several specialty physicians to eliminate the need for additional travel for our patients.The Association continually allocates funds to the improvement of the facilities and equipment utilized to provide the optimum service to our patients. Surplus funds are also provided to enhance community services with donations to service organizations who offer additional health-enhancing services to the residents of the area. The rural health clinics in the Hendricks community and neighboring Ivanhoe community provide for improved community access. Particularily in the Ivanhoe community it has proved beneficial to be able to offer services in their primary dwelling location.Emergency room services are available 24/7, and are offered regardless of payment source or ability to pay.The facility also participates in the Minnesota SAGE and South Dakota All Women County programs which offer women yearly physical exams, including mammograms and pap smears at no cost to the patient.Facility staff is involved in community economic planning groups as well as community service organizations.Many area residents are involved as volunteers within our organization and participate on a daily basis enhancing the lives of the residents and patients in our facility. 1 City of Hendricks 207 S Division Street Hendricks MN 56136 416005227 City of Hendricks 20000 City street repairs 1 0 Part I, Line 2: The City of Hendricks received a $20,000 grant to be used for city street repairs due to damage from the construction equipment utilizing the streets during the Hospital's construction project. Other grants and assistance are given on an as needed basis with the board approval as part of the financial statement process. Grants are given for health and wellness and community improvements in the area as the administration and board deem appropriate. X X X 0 0 0 0 0 0 0 0 0 Jeff Gollaher CEO 170369 0 0 0 0 0 6969 0 12146 0 189484 0 0 0 Tabb McCluskey Physician/Medical Director 169234 0 0 0 0 0 7496 0 32815 0 209545 0 0 0 Grant Eyjolfson Physician 329094 0 0 0 0 0 10800 0 30174 0 370068 0 0 0 Tomasz Lis Physician 405538 0 0 0 0 0 10800 0 31038 0 447376 0 0 0 Grant Eyjolfson Employee Physician Recruitment X 100000 12500 0 1 1 Kathryn Christensen Employee Nurse Practioner Recruitment X 45000 38431 0 1 1 50931 Katie Wendinger Family member of board member Dean Nielsen 29349 Employee compensation 0 Betty Johnson Family member of board member Dean Nielsen 10930 Employee compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee is composed of the President, Vice-President, Secretary and Treasurer of the governing board. Responsibilities include: A. General management and control of the affairs of the corporation. In addition to formal meetings, the committee has informal conferences about corporation activities. B. Shall have the power to transact all regular business of the hospital during the interim between the meetings of the Board of Directors provided any action taken shall not conflict with the policies and expressed wishes of the Board of Directors, and that it shall refer all matters of major importance to the Board of Directors. C. It shall cause to be prepared and submit to the Board of Directors at its last meeting before the end of the fiscal year, a budget showing the expected receipts and income and expense for the ensuing year. It shall be the further duty of the Executive Committee to examine the monthly financial reports and to require an explanation from the Administrator for any material variation from the budget. D. The Executive Committee shall evaluate in April annually or as deemed necessary, the Chief Executive Officer's performance and recommend his/her remuneration to the full Board of Directors. This committee shall meet as necessary. Form 990, Part VI, Section A, line 2 Matt Amundson and George Jorgensen have a business relationship. Matt Amundson and Vince Robinson have a business relationship. Form 990, Part VI, Section A, line 6 There is one class of membership. Membership is open to any natural person who is of legal voting age and a voting resident within the organization's primary service area. Form 990, Part VI, Section A, line 7a Each member receives one vote. Form 990, Part VI, Section B, line 11b The return is reviewed by the Business Office Manager and CEO, then by the Board of Directors before it is filed. Form 990, Part VI, Section B, line 12c The policy covers all officers, directors, and key employees. A conflict of interest form is signed upon orientation to the Board of Directors. The form is reviewed by the CEO and any potential conflicts are reviewed with the Board of Directors. If a conflict exists, the person with the conflict is restricted from voting on related matters. Conflict of interest forms are completed annually by board of directors and key employees. These are reviewed by the HR director, and compliance report submitted to the governing board. Form 990, Part VI, Section B, line 15a The Executive Committee reviews the CEO's compensation annually and compares to similar positions at other hospitals of similar size and geographic location. The Board of Directors reviews and approves the recommendations of the Executive Committee. This process was last evaluated in 2016. The officers of the board receive a stipend for attending meetings. The fee structure is based on meetings attended. This compensation process is determined by board members and the fee schedule is discussed by the board annually. 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. Form 990, Part IX, line 11g Contracted services: Program service expenses 946,447. Management and general expenses 0. Fundraising expenses 0. Total expenses 946,447. Medical fees: Program service expenses 367,102. Management and general expenses 0. Fundraising expenses 0. Total expenses 367,102. Purchased services: Program service expenses 1,077,052. Management and general expenses 48,447. Fundraising expenses 0. Total expenses 1,125,499. Collection fees: Program service expenses 0. Management and general expenses 8,093. Fundraising expenses 0. Total expenses 8,093. Recruitment: Program service expenses 0. Management and general expenses 63,312. Fundraising expenses 0. Total expenses 63,312. Form 990, Part XI, line 9: Change in net assets for Hendricks Hospital Auxiliary -1,004. Change in net assets for resident funds 408.