2019-08-09T17:29:51-05:00 2018-09-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-10-01 410724034 KITTSON MEMORIAL HOSPITAL KITT 2188433612 PO BOX 700 HALLOCK MN 56728 JENI SCHWENZFEIER CFO 2188433612 2019-08-09 1 RYAN ENGEBRETSON P01585625 6123764500 67.137.57.251 2019-08-09 10:03:17 CD P 3018D2C7A8EF8E88940F980D8F52F9F97466C021 9C1DED54EE6A56468881F41BE7A7DD662CF8FCB7 2017 2019-02-21 02:37:17Z KITTSON MEMORIAL HEALTHCARE CENTER JENI SCHWENZFEIER 1010 S BIRCH AVE HALLOCK MN 56728 15330546 0 X WWW.KITTSONHC.ORG X 1919 MN KITTSON ENSURES THAT NORTHWESTERN MINNESOTA RESIDENTS HAVE ACCESS TO HEALTH SERVICES. 5 5 259 10 11767 -6998 261096 131285 14498564 15120138 15256 1834 86962 53843 14861878 15307100 16145 6116 0 0 9106213 9383804 0 0 758 5639201 6151004 14761559 15540924 100319 -233824 9718845 8848483 5171817 4491135 4547028 4357348 X CARING FOR FRIENDS AND NEIGHBORS, KITTSON MEMORIAL HEALTHCARE CENTER PROVIDES AND COOPERATES WITH OTHERS TO ENSURE THAT RESIDENTS HAVE ACCESS TO SERVICES NECESSARY TO MAINTAIN THEIR HEALTH AND WELL-BEING. 0 0 11429866 6116 15120138 KITTSON MEMORIAL HEALTHCARE CENTER (KMHC) PROVIDES SERVICE TO EMERGENCY, ACUTE, AND CLINIC PATIENTS. ALL PATIENTS ARE TREATED IN AN EMERGENCY SETTING REGARDLESS OF ABILITY TO PAY OR FINANCIAL CLASS STATUS. KMHC HOME HEALTH PROVIDES MEDICAL AND PERSONAL ASSISTANCE TO THOSE PATIENTS WHO ARE HOME BOUND. THIS VALUED SERVICE PROVIDES AREA RESIDENTS WITH THE ASSISTANCE THEY NEED TO LIVE INDEPENDENTLY WHETHER IT BE HOUSEKEEPING SERVICES, MEDICATION DISPENSION, OR DAILY DRESSING CHANGES. KMHC'S ASSISTED LIVING COMPLEX PROVIDES THOSE AREA RESIDENTS WITH OPTIONS TO ASSIST IN THEIR TRANSGRESSION FROM LIVING INDEPENDENTLY TO CONGREGATE DINING WITH OTHER ASSISTED LIVING RESIDENTS, MEDICATION DISPENSION ASSISTANCE, AND ACCESS TO ACTIVITIES IN THE NURSING HOME. RESIDENTS ARE ALSO ABLE TO "COME AND GO" AS THEY PLEASE WITH ACCESS TO THEIR OWN TRANSPORTATION OR TRANSPORTATION MAY BE ARRANGED. 11429866 1 0 0 1 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 12 0 259 1 1 1 0 0 0 0 1 1 0 0 0 0 X 5 5 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X JENI SCHWENZFEIER 2188433612 1010 SOUTH BIRCH AVENUE HALLOCK MN 56728 JON BLOMQUIST THROUGH 318 PRESIDENT 1.00 X X 700 0 0 STEVE GROSZ THROUGH 718 VICE PRESIDENT 1.00 X X 2370 0 0 LEE PEMBERTON THROUGH 318 SECRETARY 1.00 X X 16294 0 0 TODD JOHNSON THROUGH 718 TREASURER 1.00 X X 1656 0 0 CHARLIE BERNSTROM BOARD MEMBER 1.00 X 0 0 0 JANELLE CRAIGMILE BOARD MEMBER 1.00 X 898 0 0 CEDRIC GUSTAFSON BOARD MEMBER 1.00 X 0 0 0 BOB JASZCZAK BOARD MEMBER 1.00 X 0 0 0 DR ROLAND LARTER BOARD MEMBER 1.00 X 600 0 0 RICHARD MORTENSON BOARD MEMBER 1.00 X 700 0 0 SANDRA NELSON THROUGH 718 BOARD MEMBER 1.00 X 0 0 0 MARLENE PEARSON BOARD MEMBER 1.00 X 0 0 0 SANDY WILSON BOARD MEMBER 1.00 X 0 0 0 DEREK HOLT CFO 40.00 X 0 0 0 ASHLEY RIVERA CEO/CFO 40.00 X 132032 0 7900 PAUL ANDERSON THROUGH 318 PHYSICIANS ASSISTANT 32.00 X 154076 0 14556 JULIE JOHNSON NURSE PRACTITIONER 32.00 X 131823 0 2500 THOMAS LOHSTRETER THROUGH 418 MEDICAL DOCTOR 40.00 X 423249 0 10318 JAMES SURDY MEDICAL DOCTOR 40.00 X 422706 0 14394 KAREN WARNER PHYSICIANS ASSISTANT 40.00 X 155025 0 1600 1442129 0 51268 6 0 1 0 DIAGNOSTIC MEDICAL SYSTEMS 26273 NETWORK PLACE CHICAGO IL 60673 CT, MAMMOGRAPHY, MRI, ULTRASOUND 420348 ALTRU HEALTH SYSTEM PO BOX 13780 GRAND FORKS ND 58206 OUTREACH THERAPY 320953 AGILITI HEALTH INC PO BOX 851313 MINNEAPOLIS MN 55485 EQUIPMENT MAINTENANCE 156933 HITNER HEATING & COOLING PO BOX 2722 FARGO ND 58108 EQUIPMENT MAINTENANCE 149417 4 18266 113019 131285 PATIENT & RESIDENT SERVICE REVENU 622110 15120138 15120138 15120138 20298 20298 6592 0 6592 6592 6592 18464 -18464 -18464 -18464 4542 18266 4982 -440 -440 277 0 277 277 CAFETERIA INCOME 722210 25117 11767 13350 MISCELLANEOUS 900099 22118 22118 FITNESS CENTER INCOME 713940 179 179 47414 15307100 15120138 11767 43910 X 6116 6116 376638 75328 301310 7419359 6331030 1088329 145232 116043 29189 917011 46723 870288 525564 453010 72554 61044 504 60540 190061 190061 1886067 1658277 227790 100627 876 99751 819739 560955 258784 379494 25126 354368 334000 71206 262794 91553 67863 23690 71865 46722 25143 145657 27487 118170 744114 744114 99908 99908 MEDICAL SUPPLIES 545664 545664 BAD DEBT EXPENSE 359671 359671 FOOD 220846 211266 9580 OTHER EXPENSES 100694 81885 18051 758 15540924 11429866 4110300 758 711 711 2577958 2019814 1573822 1504979 26887 12241 204371 194337 132686 135919 16645462 13137206 4027353 3508256 1175057 1246226 0 226000 9718845 8848483 1399346 1583964 63586 0 5945 6706 3036233 2724954 250707 175511 416000 0 5171817 4491135 X 4547028 4306801 547 50000 4547028 4357348 9718845 8848483 X -233824 -6168 50312 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 5908 5908 0 PART II-B, LINE 1: THE ORGANIZATION PAYS DUES TO THE MINNESOTA HOSPITAL ASSOCIATION, A PORTION OF WHICH IS SPENT ON LOBBYING ON BEHALF OF ITS MEMBERS. 1 10442 11151 14648 6946 1 X 0 50000 547 50547 1.00000 0 0 12985 12985 8698405 6895644 1802761 461150 300311 160839 7354935 5941251 1413684 117987 117987 3508256 X 14952411 -359671 -359671 15312082 -4982 -4982 15307100 15186235 4982 4982 15181253 359671 359671 15540924 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE CENTER HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF THE NURSING FACILITY. PART X, LINE 2: THE CENTER IS ORGANIZED AS A MINNESOTA 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 CENTER UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THESE POSITIONS BEING UPHELD UPON EXAMINATION WITH RELEVANT TAX AUTHORITIES, AS DEFINED BY ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA. THE CENTER BELIEVES THAT IT IS COMPLIANT WITH ALL IRS TAX REGULATIONS AND AS OF SEPTEMBER 30, 2018 AND 2017 HAS NOT RECORDED LIABILITIES FOR INCOME TAXES. THE CENTER WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES IN INCOME TAX EXPENSE IF INCURRED. PART XI, LINE 2D - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS -359,671. PART XI, LINE 4B - OTHER ADJUSTMENTS: GOLF TOURNAMENT EXPENSE -4,982. PART XII, LINE 2D - OTHER ADJUSTMENTS: GOLF TOURNAMENT EXPENSE 4,982. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR UNCOLLECTIBLE ACCOUNTS 359,671. GOLF TOURNAMENT 22808 18266 4542 640 1962 1465 915 22808 18266 4542 640 1962 1465 915 4982 -440 1 1 X 1 X 1 X 1 1 0 1 1 5706 5706 0.00040 890462 695184 195278 0.01260 896168 695184 200984 0.01300 10065613 8747218 1318395 0.08480 10065613 8747218 1318395 0.08480 10961781 9442402 1519379 0.09780 0 359671 2828124 3692718 -864594 X 1 1 1 1 KITTSON MEMORIAL HEALTHCARE CENTER 1010 SOUTH BIRCH AVENUE HALLOCK MN 56728 WWW.KMHC.NET 371450 X X X X KITTSON MEMORIAL HEALTHCARE CENTER 1 0 0 1 X X X X X X X X 15 1 0 0 1 X SEE PART V, SECTION B, LINE 7D. X X 1 15 1 SEE PART V, SECTION B, LINE 7D. 0 1 X 100.000000000000 200.000000000000 X 1 1 X X X X 1 X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X HTTPS://KITTSONHC.ORG/PREPARE-FOR-YOUR-NEXT-VISIT/#FINANCES X X X X X 1 X 0 X X X 1 X 0 0 KITTSON MEMORIAL HEALTHCARE CENTER PART V, SECTION B, LINE 5: IN THE 2015 ASSESSMENT, COMPLETED BY SEPTEMBER 2016, WE REVIEWED OUR ASSESSMENT AND IMPLEMENTATION PLAN FROM 2013 AND REVIEWED THE CURRENT DATA FOR HEALTH TRENDS FOR OUR COUNTY. WE ALSO DID A SELECTED MAILING OF "QUALITY OF LIFE" SURVEYS TO A TARGETED AUDIENCE THROUGHOUT THE COUNTY. THE TARGET LIST OF INDIVIDUALS INCLUDED SCHOOL SUPERINTENDENTS, COUNTY SOCIAL SERVICES STAFF, SENIOR CITIZEN CENTERS AROUND THE COUNTY, THE MAYORS OF ALL THE COMMUNITIES IN THE COUNTY, PUBLIC HEALTH STAFF, AND THE COUNTY ADMINISTRATOR. WE REQUESTED THEIR OPINIONS ON IMPORTANT SERVICES THAT THEY WOULD LIKE TO SEE ADDED TO OUR FACILITY OR MAINTAINED BY OUR FACILITY. KITTSON MEMORIAL HEALTHCARE CENTER PART V, SECTION B, LINE 7D: HTTPS://WWW.KMHC.NET/COMMUNITY-NEEDS--- EMERGENCY-PREPAREDNESS.HTML KITTSON MEMORIAL HEALTHCARE CENTER PART V, SECTION B, LINE 11: KITTSON HEALTHCARE CONTINUES TO ADDRESS AND ATTAIN GOALS RELATED TO THE COMMUNITY HEALTH NEEDS ASSESSMENT'S IMPLEMENTATION PLAN. A NEW/REVISED CHNA WILL TAKE PLACE IN CALENDAR YEAR 2019.EMERGENCY ROOM SERVICES HAVE CONTINUED 24 HOURS A DAY AND 7 DAYS A WEEK. SIGNIFICANT PROGRESS HAS BEEN MADE IN SECURING RETAIL PHARMACY IN KITTSON COUNTY, PARTICULARLY IN HALLOCK. IN JULY OF 2019, KITTSON HEALTHCARE WILL BE OPENING A RETAIL PHARMACY AT THEIR HALLOCK LOCATION, WHILE THE LOCAL PHARMACIST IN HALLOCK TRANSITIONS INTO RETIREMENT. KITTSON HEALTHCARE IS ALSO ADDRESSING ADDITIONAL MENTAL HEALTH NEEDS AND IS WORKING WITH NORTHWEST MENTAL HEALTH CENTER TO EXPAND PROVIDER AVAILIBILITY TO RESIDENTS OF KITTSON COUNTY. PUBLIC HEALTH CONTINUES TO IDENTIFY PROGRAMS OF NEED SUCH AS SMOKING CESSATION, OBSESITY, DIABETIC PREVETNTION, ELDERLY WAIVER SERVICES, ETC.KITTSON MEMORIAL STAFF FOLLOW THE AMERICAN CANCER RECOMMENDATIONS FOR CANCER SCREENINGS. WE CONTINUE TO OFFER ENDOSCOPY SERVICES AT OUR FACILITY ONE DAY A MONTH, WITH ADDITIONAL DAYS OPTIONAL DEPENDING ON THE NEED OF OUR RESIDENTS. WE ALSO CONTINUE TO OFFER DIGITAL MAMMOGRAPHY EVERY OTHER WEEK. THESE SERVICES ARE VITALLY IMPORTANT FOR OUR RESIDENTS SO THAT THEY DO NOT HAVE TO DRIVE 45-60 MILES AWAY FOR TESTING. CANCER PREVENTION AND SCREENING INFORMATION IS DISSEMINATED TO COUNTY RESIDENTS THROUGH THE COUNTY FAIR AND ARTICLES IN THE LOCAL NEWSPAPERS.USE OF SEATBELTS IS STRESSED TO ALL AGE GROUPS IN ALL OF THE SCHOOLS WITHIN THE COUNTY. POSTERS ABOUT SEATBELTS ARE DISPLAYED IN CLINIC EXAM ROOMS IN OF OUR CLINICS IN HALLOCK AND KARLSTAD. ONE OF THE COMMUNITY HEALTH NURSES IS TRAINED IN SEAT BELT/CAR SEAT SAFETY FOR NEW PARENTS AND GIVES INSTRUCTIONS AS REQUESTED. ALL OF OUR PREGNANT MOTHERS GIVE BIRTH AT FACILITIES OUTSIDE OF OUR COUNTY, BUT WE PROVIDE THIS SERVICE TO PARENTS WHO ARE FOSTERING CHILDREN, ADOPTING, OR WANT A REVIEW OF CAR SEAT SAFETY.BOTH THE CNHA AND THE IMPLEMENTATION PLAN WERE FORMETLY ADOPTED BY THE BOARD AND APPROVAL IS REFLECTED IN THE MEETING MINUTES. 1 1 - KITTSON MEMORIAL CLINIC OF KARLSTAD 205 ROOSEVELT AVENUE WEST KARLSTAD MN 56372 RURAL HEALTH CLINIC PART I, LINE 3C: TO QUALIFY FOR FINANCIAL ASSISTANCE, AN INDIVIDUAL MUST:(A) RECEIVE MEDICALLY NECESSARY CARE AT THE HOSPITAL;(B) HAVE TOTAL INCOME LESS THAN OR EQUAL TO 200 PERCENT OF FEDERAL POVERTY GUIDELINES;(C) APPLY FOR MEDICAID; AND(D) SUBMIT A COMPLETE COMMUNITY CARE (FINANCIAL ASSISTANCE) APPLICATION, INCLUDING REQUIRED DOCUMENTATION. PART I, LINE 6A: THE ANNUAL COMMUNITY BENEFIT REPORT IS MADE AVAILABLE UPON REQUEST. PART I, LINE 7: THE ORGANIZATION USED THE FOLLOWING METHODS TO DETERMINE THE COST AMOUNTS IN PART I, LINE 7:LINES 7A AND 7B - CHARITY CARE AND MEDICAID WERE DERIVED FROM INTERNAL REPORTS. COSTS WERE CALCULATED USING THE COST TO CHARGE RATIO FROM WORKSHEET 2 FROM THE IRS.LINES 7E AND 7G - COMMUNITY HEALTH IMPROVEMENT SERVICES AND SUBSIDIZED HEALTH SERVICES AMOUNTS ARE ACTUAL COSTS. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED IN PART I, LINE 7G INCLUDE COSTS AND REVENUES ASSOCIATED WITH HALLOCK RURAL HEALTH CLINIC, KARLSTAD RURAL HEALTH CLINIC, EMERGENCY ROOM SERVICES, AND CARDIAC REHABILIATION SERVICES. PART III, LINE 2: IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE CENTER ANALYZES ITS COLLECTION HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE CENTER RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. PART III, LINE 3: THE ORGANIZATION HAS NOT IDENTIFIED A METHOD TO REASONABLY ESTIMATE THE PORTION OF OUR BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER OUR FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES" SECTION IN NOTE 1 (PAGE 8) TO THE FINANCIAL STATEMENTS FOR INFORMATION ABOUT THE CALCULATION OF BAD DEBTS. PART III, LINE 8: THE MEDICARE SHORTFALL REPORTED IN PART III, LINE 7 IS DUE TO THE NON-ALLOWABLE/NON-REIMBURASABLE COSTS PER THE MEDICARE COST REPORT AND WOULDN'T NECESSARILY BE CONSIDERED COMMUNITY BENEFIT IN NATURE.THE MEDICARE ALLOWABLE COSTS REPORTED IN PART III, LINE 6 WERE DERIVED USING THE FY 2018 FILED MEDICARE COST REPORT. PART III, LINE 9B: COLLECTION EFFORTS ARE MADE BY CONTACTING THE PATIENT THROUGH WRITTEN CORRESPONDENCE AND PHONE CALLS. IF, THROUGHOUT THESE CONVERSATIONS, THE COLLECTOR AND PATIENT DISCUSS THAT THE PATIENT IS NOT ABLE TO AFFORD PAYMENTS AS REQUIRED BY OUR POLICY, THE PATIENT IS ENCOURAGED TO APPLY FOR CHARITY CARE. AN APPLICATION, PLAIN LANGUAGE SUMMARY, AND FAP ARE SENT TO THE PATIENT TO REVIEW AND COMPLETE. ACCORDING TO FEDERAL POVERTY GUIDELINES, THE PATIENT MAY QUALIFY FOR ALL OR A PERCENT OF CHARGES WRITTEN OFF THEIR ACCOUNT. PATIENTS MUST APPLY FOR MEDICAID PRIOR TO QUALIFYING FOR CHARITY CARE. ADDITIONAL INFORMATION IS OFFERED TO HELP THEM APPLY FOR STATE FUNDED PROGRAMS. PART VI, LINE 2: PUBLIC HEALTH CONDUCTS A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). THIS INFORMATION IS THEN SHARED WITH FACILITY MANAGEMENT AND THE BOARD OF DIRECTORS. GOING FORWARD, A CHNA WILL BE CONDUCTED EVERY THREE YEARS TO MAKE THIS ASSESSMENT.IN ADDITION TO CONDUCTING THE CHNA EVERY THREE YEARS, KITTSON INFORMALLY LISTENS TO THE PUBLIC'S REQUEST FOR SERVICES. THROUGH OUR PUBLIC HEALTH AND SCHOOL HEALTH WORK, WE ARE CONTINUALLY ASSESSING THE HEALTH NEEDS OF THE COMMUNITY AND MEETING THE NEEDS AT THE TIME. FOR EXAMPLE, KITTSON HELD PUBLIC MEETINGS WITH COUNSELORS WHEN THE COMMUNITY HAD A NEED FOR ADDITIONAL SUPPORT AND INFORMATION REGARDING SUICIDE. PART VI, LINE 3: IF A PATIENT IS UNABLE TO PAY THEIR BILL, THE PATIENT IS ENCOURAGED TO APPLY FOR CHARITY CARE. AN APPLICATION IS SUBSEQUENTLY SENT TO COMPLETE, ALONG WITH A COPY OF OUR FAP AND PLAIN LANGUAGE SUMMARY (A NOTICE IS INCLUDED IN THEIR MONTHLY STATEMENT TO CONTACT US REGARDING CHARITY CARE IF THEY ARE UNABLE TO PAY THEIR BILL). WE ARE ADDITIONALY ABLE TO PROVIDE PATIENTS WITH CONTACT INFORMATION AT THE COUNTY FOR QUALIFICATION/APPLICATION INFORMATION REGARDING GOVERNMENTAL FINANCIAL ASSISTANCE. INFORMATION REGARDING CHARITY CARE IS ALSO AVAILABLE IN THE ADMISSION AREA OF THE CLINIC. PART VI, LINE 4: KMHC PRIMARILY SERVES THE RESIDENTS OF KITTSON COUNTY, WHICH IS LOCATED IN NORTHWEST MINNESOTA, WITH A POPULATION OF APPROXIMATELY 4,500. THIS IS A VERY RURAL AREA WITH 4.1 PERSONS PER SQUARE MILE. THE MEDIAN HOUSEHOLD INCOME IS $52,304 WITH 6.4% OF THE POPULATION BELOW POVERTY LEVELS. PART VI, LINE 5: KITTSON MANAGERS DELIVER COMMUNITY MEALS ON WHEELS FOR ONE MONTH EACH YEAR; SUPPORT A VIRTUAL "RELAY FOR LIFE" EVENT; PROVIDE AMBULANCE STAND-BY SERVICES AT LOCAL PUBLIC HIGH SCHOOL SPORTING VENTS; PROVIDE FREE BLOOD PRESSURE CHECKS AT VARIOUS AREA EVENTS THROUGHOUT THE YEAR; PROVIDE FINANCIAL CONTRIBUTIONS TO HELP FUND TWO AREA PUBLIC SCHOOLS' "AFTER PROM PARTY" EVENTS; PROVIDE TO AREA CHARITIES FOR THEIR FUNDRAISING EVENTS, LAB TESTING CERTIFICATES AS DOOR OR RAFFLE PRIZES; FREE AND REDUCED CARE; HEALTH INFORMATION BOOTH AT FOUR DAY COUNTY FAIR. KITTSON HEALTHCARE ALSO PROVIDES SERVICES THAT OTHER PRIVATE ENTITITES TYPICALLY WON'T CONSIDER PROVIDING SUCH AS ASSISTED LIVING SERVICES, NURSING HOME SERVICES, ELDERLY WAIVERED SERVICES, COMMUNITY FITNESS, AMBULANCE SERVICES, ETC. AS THERE IS LITTLE VOLUME AND MINIMAL FINANCIAL RETURN. HOWEVER, KITTSON HEALTHCARE'S GOVERNING BOARD VIEWS THESE SERVICES AS ESSENTIAL IN MEETING THE NEEDS AND SERVING THE RESIDENTS OF KITTSON COUNTY. PART VI, LINE 6: N/A 0 EDUCATIONAL ASSISTANCE 2 6116 SCHOLARSHIP FUNDS ARE GENERALLY PAID DIRECTLY TO FINANCIAL INSTITUTIONS.IN THE EVENT THAT A STUDENT PAYS SOMETHING AND REQUESTS REIMBURSEMENT, THEINDIVIDUAL IS REIMBURSED UPON SUBMISSION OF AN INVOICE FOR EXPENSES PAID. X X X 0 0 0 0 0 0 0 0 0 PAUL ANDERSON THROUGH 318 PHYSICIANS ASSISTANT 117576 0 0 0 36500 0 14556 0 0 0 168632 0 0 0 THOMAS LOHSTRETER THROUGH 418 MEDICAL DOCTOR 347549 0 0 0 75700 0 10318 0 0 0 433567 0 0 0 JAMES SURDY MEDICAL DOCTOR 385506 0 0 0 37200 0 14394 0 0 0 437100 0 0 0 KAREN WARNER PHYSICIANS ASSISTANT 117825 0 0 0 37200 0 1600 0 0 0 156625 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE (COMPRISED OF THE BOARD OFFICERS) CAN ACT ON BEHALF OF THE FULL BOARD IN CERTAIN CIRCUMSTANCES. FORM 990, PART VI, SECTION A, LINE 4 THE METHOD USED FOR THE MEMBERS TO ADOPT, AMEND OR REPEAL THE EXISTING BYLAWS CHANGED FROM AT LEAST 50 MEMBERS WITH VOTING RIGHTS TO AT LEAST 20. FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP IN THE ASSOCIATION SHALL BE ANY NATURAL PERSON OF LEGAL AGE PURCHASING ONE OR MORE MEMBERSHIP SHARES OF THE CORPORATION FOR THE SUM OF $50.00 EACH. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS ARE ALLOWED TO VOTE FOR MEMBERS OF THE BOARD AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION B, LINE 11B THE CFO REVIEWED THE PROPOSED FROM 990 AND PRESENTED TO THE GOVERNING BOARD OF DIRECTORS FOR THEIR APPROVAL. UPON APPROVAL BY THE GOVERNING BOARD, THE 990 WAS THEN FILED. FORM 990, PART VI, SECTION B, LINE 12C IT IS THE BOARD'S POLICY TO AVOID ANY POSSIBLE APPEARANCE OF IMPROPRIETY OR BREACH OF THE MEMBER'S FIDUCIARY RESPONSIBILITY BY HAVING BOARD MEMBERS ANNUALLY ACKNOWLEDGE ANY POTENTIAL BUSINESS OR PERSONAL CONFLICTS IN REGARDS TO KITTSON MEMORIAL'S BUSINESS AFFAIRS. IT IS NOT THE INTENTION OF THIS POLICY TO PRECLUDE A BOARD MEMBER FROM BEING INVOLVED IN THE DISCUSSION OF A SUBJECT WHERE THE BOARD MEMBER HAS A CONFLICT OF INTEREST. HOWEVER, DISCRETION SHOULD BE EXERCISED AND THE BOARD MEMBER IS EXPECTED TO ABSTAIN FROM VOTING ON THE MATTER. THE CONFLICT OF INTEREST POLICY IS SIGNED ANNUALLY AT THE BOARD'S REGULAR MEETING IN JANUARY. THIS STATEMENT IS RETAINED BY THE PRESIDENT AND A COPY FILED IN THE CEO'S OFFICE. THE PRESIDENT IS RESPONSIBLE TO CALL INTO QUESTION A POSSIBLE CONFLICT OF INTEREST OF A PARTICULAR BOARD MEMBER WHEN APPLICABLE IN THE EVENT THE BOARD MEMBER DOES NOT DECLARE A CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS DETERMINED BY A MAJORITY VOTE OF THE BOARD OF DIRECTORS. THE GOVERNING BOARD REVIEWS SALARY SURVEY INFORMATION FROM THE MN HOSPITAL ASSOCAITION AND OFFERS COMPETITIVE WAGES BASED ON THE SURVEY. THE DOCUMENTATION OF SUCH DECISION IS RECORDED AND FILED ON THE EMPLOYEE'S HR FILE. OTHER OFFICERS' COMPENSATION IS DETERMINED BY THE CEO. THE CEO REVIEWS SALARY SURVEY INFOMRATION FROM THE MN HOSPTIAL ASSOCAITON AND OFFERS THE KEY EMPLOYEE'S COMPETITIVE WAGES BASED ON THE SURVEY. THE DOCUMENTATION OF SUCH DECISION IS RECORDED AND FILED ON THE EMPLOYEE'S HR FILE. COMPENSATION WAS LAST REVIEWED IN 2019. FORM 990, PART VI, SECTION C, LINE 19 KITTSON MEMORIAL HOSPITAL'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 1,658,277. MANAGEMENT AND GENERAL EXPENSES 227,790. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,886,067. FORM 990, PART XI, LINE 9: ENDOWMENT FROM DONOR, PERMANENTLY RESTRICTED FOR NURSING SCHOLARSHIP 50,312.