HAZEN MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2017
View the entire original 990 at ProPublica ↗
- Organization
- HAZEN MEMORIAL HOSPITAL ASSOCIATION (EIN 45-0308379)
- Tax period
- 2017-07-01 to 2018-06-30
- Filed
- 2019-04-16
- IRS object ID
- 201921069349300812
- Schema version
- 2017v2.3
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2019-04-16T11:11:17-05:00 | ReturnTs |
| Tax Period End | 2018-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1Txt |
| City | FARGO | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 581082545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2017-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450308379 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | HAZE | BusinessNameControlTxt |
| Phone | 7017482225 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Darrold Bertsch | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017482225 | PhoneNum |
| Signature | 2019-04-08 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | LISA CHAFFEE CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012398500 | PhoneNum |
| Preparation | 2019-04-08 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 199.247.44.142 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2019-04-08 | IPDt |
| IP Tm | 17:29:35 | IPTm |
| IP Timezone | CD | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 66CC91E6B7F11C4783FFFA5645E675327CB67316 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 3F1B4C4A1C1F32CA3CD03C05270CE62742EA9E6E | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2017 | TaxYr |
| Build TS | 2019-02-21 02:37:17Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Darrold Bertsch | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $16,903,237 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.smcnd.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1943 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | To be the preeminent providers of innovative and collaborative healthcare services. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 164 | TotalEmployeeCnt |
| Total Volunteers | 84 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $598,815 | PYContributionsGrantsAmt |
| CY Contributions Grants | $802,103 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $13,335,230 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $15,925,629 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$211,920 | PYInvestmentIncomeAmt |
| CY Investment Income | $24,459 | CYInvestmentIncomeAmt |
| PY Other Revenue | $75,304 | PYOtherRevenueAmt |
| CY Other Revenue | $148,053 | CYOtherRevenueAmt |
| PY Total Revenue | $13,797,429 | PYTotalRevenueAmt |
| CY Total Revenue | $16,900,244 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $2,000 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $4,500 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $7,386,984 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,763,089 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $5,930,046 | PYOtherExpensesAmt |
| CY Other Expenses | $8,015,771 | CYOtherExpensesAmt |
| PY Total Expenses | $13,319,030 | PYTotalExpensesAmt |
| CY Total Expenses | $15,783,360 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $478,399 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,116,884 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $41,048,395 | TotalAssetsBOYAmt |
| Total Assets EOY | $40,840,371 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $29,889,063 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $28,881,050 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $11,159,332 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $11,959,321 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | 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. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | Yes (1) | SignificantChangeInd |
| Expense | $12,402,469 | ExpenseAmt |
| Grant | $4,500 | GrantAmt |
| Revenue | $14,511,384 | RevenueAmt |
| Desc | 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. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,038,522 | ExpenseAmt |
| Revenue | $1,414,245 | RevenueAmt |
| Desc | 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 10,306 this year. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $13,440,991 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | Yes (1) | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | Yes (1) | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | 0 | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 20 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 164 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | 0 | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | 0 | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Renae Snyder | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017482225 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (18 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| Christie Obenauer | |||||||
| President | 2.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Fred Stern | |||||||
| Vice President | 1.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Myria Perry | |||||||
| Secretary/Treasurer | 1.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Don Lyn Erickson | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Mark Gerde | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Robin Richter | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Sienna Sailer | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Beverly Huber | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Kimberly Kessler | |||||||
| Director (Jul-May) | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Todd Lindquist | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Keith Johnson | |||||||
| Director (as of Jun 2018) | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Darrold Bertsch | |||||||
| CEO | 19.60 | Yes (X) | $149,426 | $0 | $78,000 | ||
| Renae Snyder | |||||||
| CFO | 40.00 | Yes (X) | $85,813 | $0 | $3,776 | ||
| Carl Miller | |||||||
| CRNA | 36.00 | $144,423 | $0 | $28,001 | Yes (X) | ||
| Alyssa Kelsch | |||||||
| Pharmacist | 40.00 | $114,221 | $0 | $9,243 | Yes (X) | ||
| Marcie Schulz | |||||||
| Director of Patient Care | 40.00 | $106,650 | $0 | $25,450 | Yes (X) | ||
| Michael Schmit | |||||||
| Surgeon | 40.00 | $296,195 | $0 | $24,877 | Yes (X) | ||
| Kim Myklebust | |||||||
| Family Nurse Practitioner | 36.00 | $113,518 | $0 | $26,224 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,010,246 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $195,571 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 6 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp
Contractor Name ContractorName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Dr Thomas Kaspari | PersonNm |
Contractor Address ContractorAddress
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1351 51st Ave SW | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Services | ER Physician Services | ServicesDesc |
| Compensation | $164,370 | CompensationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 1 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $802,103 | AllOtherContributionsAmt |
| Total Contributions | $802,103 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient and Resident Services | 621400 | $15,280,771 | $15,280,771 |
| Other Program Revenue | 623000 | $512,091 | $512,091 |
| Cafeteria | 623000 | $68,095 | $68,095 |
| Education | 623000 | $64,672 | $64,672 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $15,925,629 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $22,459 | TotalRevenueColumnAmt |
| Exclusion | $22,459 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $142,294 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $142,294 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $142,294 | TotalRevenueColumnAmt |
| Exclusion | $142,294 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $3,600 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,600 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $2,000 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,000 | TotalRevenueColumnAmt |
| Exclusion | $2,000 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Fundraising Gross Income | $7,152 | FundraisingGrossIncomeAmt |
| Fundraising Direct Expenses | $1,393 | FundraisingDirectExpensesAmt |
Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $5,759 | TotalRevenueColumnAmt |
| Exclusion | $5,759 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $16,900,244 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $15,925,629 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $172,512 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,500 | TotalAmt |
| Program Services | $4,500 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $320,285 | TotalAmt |
| Management And General | $320,285 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $133,422 | TotalAmt |
| Program Services | $133,422 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,066,420 | TotalAmt |
| Program Services | $5,525,783 | ProgramServicesAmt |
| Management And General | $540,637 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $204,649 | TotalAmt |
| Program Services | $186,246 | ProgramServicesAmt |
| Management And General | $18,403 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $589,830 | TotalAmt |
| Program Services | $536,790 | ProgramServicesAmt |
| Management And General | $53,040 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $448,483 | TotalAmt |
| Program Services | $403,659 | ProgramServicesAmt |
| Management And General | $44,824 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,831 | TotalAmt |
| Management And General | $11,831 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $78,198 | TotalAmt |
| Management And General | $78,198 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,723,373 | TotalAmt |
| Program Services | $1,579,560 | ProgramServicesAmt |
| Management And General | $143,813 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $58,605 | TotalAmt |
| Management And General | $58,605 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $316,336 | TotalAmt |
| Program Services | $137,639 | ProgramServicesAmt |
| Management And General | $178,697 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $606,888 | TotalAmt |
| Program Services | $606,888 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $38,026 | TotalAmt |
| Program Services | $32,208 | ProgramServicesAmt |
| Management And General | $5,818 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $448,468 | TotalAmt |
| Program Services | $1,322 | ProgramServicesAmt |
| Management And General | $447,146 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,312,707 | TotalAmt |
| Program Services | $2,312,707 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $208,850 | TotalAmt |
| Program Services | $8,795 | ProgramServicesAmt |
| Management And General | $200,055 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $1,174,577 | $1,174,577 | |
| Bad Debt Expense | $549,052 | $549,052 | |
| Food | $136,795 | $136,795 | |
| Dues & Subscriptions | $121,345 | $58,165 | $63,180 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $230,720 | TotalAmt |
| Program Services | $52,883 | ProgramServicesAmt |
| Management And General | $177,837 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,783,360 | TotalAmt |
| Program Services | $13,440,991 | ProgramServicesAmt |
| Management And General | $2,342,369 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,275 | BOYAmt |
| EOY | $8,322 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,862,111 | BOYAmt |
| EOY | $5,780,341 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,575,612 | BOYAmt |
| EOY | $1,560,593 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $398,555 | BOYAmt |
| EOY | $366,543 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $93,297 | BOYAmt |
| EOY | $91,491 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $35,655,039 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $5,300,011 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,824,220 | BOYAmt |
| EOY | $30,355,028 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,614,059 | BOYAmt |
| EOY | $600,845 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,753,942 | BOYAmt |
| EOY | $1,435,677 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $913,324 | BOYAmt |
| EOY | $641,531 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,048,395 | BOYAmt |
| EOY | $40,840,371 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $998,263 | BOYAmt |
| EOY | $858,389 | EOYAmt |
Loans From Officers Directors LoansFromOfficersDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,980,208 | BOYAmt |
| EOY | $9,648,354 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,188,007 | BOYAmt |
| EOY | $17,774,307 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $722,585 | BOYAmt |
| EOY | $600,000 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $29,889,063 | BOYAmt |
| EOY | $28,881,050 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,338,987 | BOYAmt |
| EOY | $10,456,520 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,770,345 | BOYAmt |
| EOY | $1,452,801 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $50,000 | BOYAmt |
| EOY | $50,000 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,159,332 | BOYAmt |
| EOY | $11,959,321 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,048,395 | BOYAmt |
| EOY | $40,840,371 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,116,884 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$316,895 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $66,403 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $721 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $67,124 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $66,117 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $286 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $66,403 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $65,690 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $427 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $66,117 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $65,405 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $285 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $65,690 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $64,983 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $422 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $65,405 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Prmnnt Endowment Balance EOY | 0.74490 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.25510 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $23,092 | OtherCostOrOtherBasisAmt |
| Book Value | $23,092 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $27,126,542 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,232,947 | DepreciationAmt |
| Book Value | $23,893,595 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,249,616 | OtherCostOrOtherBasisAmt |
| Depreciation | $1,975,625 | DepreciationAmt |
| Book Value | $4,273,991 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $2,255,789 | OtherCostOrOtherBasisAmt |
| Depreciation | $91,439 | DepreciationAmt |
| Book Value | $2,164,350 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $30,355,028 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Construction Payables | Desc |
| Amt | $600,000 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $600,000 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $16,027,535 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$862,317 | OtherRevenueAmt |
| Revenue Not Reported | -$862,317 | RevenueNotReportedAmt |
| Revenue Subtotal | $16,889,852 | RevenueSubtotalAmt |
| Other Revenues Not Included | $10,392 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $10,392 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $16,900,244 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $15,227,546 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $15,227,546 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $555,814 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $555,814 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $15,783,360 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 -549,052. Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,265. Contribution from Auxiliary Eliminated 5,000. |
| Part XI, Line 4b - Other Adjustments: | Net Auxiliary Revenue Not Included in Audited Financials 10,392. |
| Part XII, Line 4b - Other Adjustments: | Auxiliary Expenses Not Included in Audited Financials 6,762. Provision for Bad Debts Reported in Revenue on Audited Financials 549,052. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $52,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $52,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00330 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $347,900 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $227,049 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $120,851 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00770 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $399,900 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $227,049 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $172,851 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01100 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $100,603 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,500 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $98,103 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00620 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $68,045 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $16,272 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $51,773 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00330 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $78,036 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $29,587 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $48,449 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00310 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $246,684 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $48,359 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $198,325 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01260 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $646,584 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $275,408 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $371,176 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02360 | TotalExpensePct |
Economic Development EconomicDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $590 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $590 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Community Support CommunitySupportGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $3,841 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $3,841 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00020 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 8 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $18,754 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $18,754 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00120 | TotalExpensePct |
Workforce Development WorkforceDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 3 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $688 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $688 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 14 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $23,873 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $23,873 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00140 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $549,052 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $39,861 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,145,795 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,392,549 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$246,754 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Ave NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.smcnd.org | WebsiteAddressTxt |
| State License | 5024A | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | www.smcnd.org | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | www.coalcountryhealth.com | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | www.smcnd.org | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Other Criteria | Yes (X) | OtherCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Other Method | Yes (X) | OtherMethodInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | http://www.smcnd.org/financial-services/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | http://www.smcnd.org/financial-services/ | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | http://www.smcnd.org/financial-services/ | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Hazen Memorial Hospital Association | Part V, Section B, Line 5: A community survey, focus group, discussions with providers, individual interviews, and input from community leaders were all used to gather information. The Hospital involved and consulted the organizations listed in Part V, line 6b. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 6b: Also included were Custer Health, Coal Country Community Health Center, Knife River Care Center, Mercer County Ambulance, Southwestern District Health, Hilltop Home of Comfort, UND Center for Rural Health, and Prairie Health Partners. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 11: SMC has addressed each need that was identified in the most recently conducted FY16 CHNA. Some of these needs were identified in the previous CHNA as well. SMC has ongoing efforts to address those needs that are duplicated from the previous CHNA:CHNA Implementation Plan overview of some of the outcomes with the identified needs.Identified Need: Adequate child care services* Output/Outcome: 69 children currently enrolled in daycare cooperative in HazenIdentified Need: Availability of behavioral health services (mental health & substance abuse/treatment)* Output/Outcome: CCCHC has expanded the MAT (Medication Assisted Treatment) program three days/week in Beulah and 2 days/month in Killdeer location* Output/Outcome: Increase of psychologist from 2 days/month to 3 days/week through a combination of CCCHC contracted psychologist and visiting psychologist from Sanford Health.* Output/Outcome: Implementation of pilot project with Beulah School District. Currently facilitating resource mapping and development of framework for sustainability and replication to additional school districts for 2018-2019 school year. Implementation of case management for behavioral health within the walls of the school.* Output/Outcome: Continued participating with TAPP (Training Academy for Addiction Professionals) with completion of two student internships. Potential full-time LAC (Licensed Addiction Counselor) to be hired in May/June 2018 by CCCHC pending completion of prior obligatory employment.* Output/Outcome: 80% completion of needs assessment with Beulah School District.Identified Need: Lack of employees to fill positions* Output/Outcome: Formal agreement with recruitment firm for physician* Output/Outcome: Continued collaboration with SMC/KRCC/CCCHC for Dakota Nursing Program* Output/Outcome: Graduated two medical assistants and one is currently employed full-time with CCCHC.Identified Need: Obesity/Overweight* Output/Outcome: Healthy Halloween Bash collaborative with Custer Health/CCCHC/ KRCC/NDSU Extension and local healthcare organizations to include dental and chiropractic for the provision of education on physical activity and healthy Halloween snacks replacing unhealthy candy options with fun-filled physical activity and games focusing on physical activity.* Output/Outcome: During agency Sports Physicals, Custer Health (local public health) provides educational booths during extended clinic hours for sports physicals.* Output/Outcome: Various 5K Walk/Run events facilitated throughout all service delivery sites with collaboration from all of the healthcare organizations associated with the CHNA.Identified Need: Delivery and availability of Health Services to include expanded appointment hours and cost of health care services.* Comprehensive care coordination committee meets monthly to review repeat admission and repeat Emergency Room visits with care coordination intervention from Custer Health, CCCHC and SMC including Community Care Coordination. * Output/Outcome: Decreased in BCBS and Medicare potentially preventable ER visits and admissions.* Collaboration with Custer Health for the provision of school immunization clinics during Parent/Teacher conferences. 2nd year of successful implementation with Custer Health.* FluFIT facilitation between CCCHC, Custer Health and local pharmacy provider to increase cancer screening options for patients. |
| 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. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - Senior Suites at Sakakawea | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 813 7th St NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | Basic Care Facility | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 and health professionals education reflect actual expenses recorded to the general ledger. Subsidized health services costs were calculated based on information from the Medicare cost report. |
| 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. Based on the poverty level of the service area, 7.26%, the estimated amount of bad debt expense that is attributable to patients eligible under the organization's financial assistance policy would be approximately $39,861. |
| 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 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: | Hazen Memorial Hospital Association 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 8,465. The average per capita personal income in Mercer County for 2017 was $58,454. The current unemployment rate is 3.3%. Sakakawea Medical Center's payer mix for this fiscal year included 7% uninsured patients and 7% 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 health 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; three are from Hazen, six 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 nor are they family members of employees.Medical privileges are extended to all physicians in the county.Sakakawea Medical Center's Hospice staff is assisted by 54 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 completed a large parking lot and landscaping surrounding the new facility which was completed in 2016. 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (3 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Darrold Bertsch | ||||||||||||||
| CEO | $144,684 | $0 | $0 | $0 | $4,742 | $0 | $78,000 | $0 | $0 | $0 | $227,426 | $0 | $0 | $0 |
| Carl Miller | ||||||||||||||
| CRNA | $137,036 | $0 | $0 | $0 | $7,387 | $0 | $6,204 | $0 | $21,842 | $0 | $172,469 | $0 | $0 | $0 |
| Michael Schmit | ||||||||||||||
| Surgeon | $296,195 | $0 | $0 | $0 | $0 | $0 | $10,800 | $0 | $14,122 | $0 | $321,117 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 2017 Form W-2 from CCCHC. In the calendar year 2017, Darrold received $149,426 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. |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Union State Bank (USB) | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship With Org | Family ownership >35% of Union State Bank through Hazen Bancorporation HC | RelationshipWithOrgTxt |
| Loan Purpose | PACE Loan | LoanPurposeTxt |
| Loan To Organization | Yes (X) | LoanToOrganizationInd |
| Original Principal | $10,258,000 | OriginalPrincipalAmt |
| Balance Due | $9,648,354 | BalanceDueAmt |
| Default | 0 | DefaultInd |
| Board Or Committee Approval | Yes (1) | BoardOrCommitteeApprovalInd |
| Written Agreement | Yes (1) | WrittenAgreementInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $9,648,354 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| Jocelyn Bertsch | |||
| Wife of CEO | $74,386 | Employee Compensation | 0 |
| Bonnie Johnson | |||
| Wife of Board Member Keith Johnson | $59,036 | Employee Compensation | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part III, line 3 | The Home Health Program was discontinued in January 2018. |
| 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 2017 Form W-2 from CCCHC. In the calendar year 2017, Darrold received $149,426 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 1,504,972. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,504,972. Other Purchased Services: Program service expenses 74,588. Management and general expenses 143,813. Fundraising expenses 0. Total expenses 218,401. |
| Form 990, Part XI, line 9: | Change in Interest in Net Assets of Sakakawea Medical Center Foundation -318,265. Change in Net Assets of Hazen Memorial Hospital Auxiliary 1,370. |
Comments