2018-07-11T12:52:25-05:00 2017-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2017-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 JENI SCHWENZFEIER CFO AND CO-CEO 7012658461 2018-06-29 1 RYAN ENGEBRETSON P01585625 6123764500 2017 2022-09-23 18:48:47Z LISA LETEXIER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 17177105 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. 10 7 193 40 0 0 124384 419179 14792795 15252702 1134 22591 171428 1482633 15089741 17177105 0 0 0 0 7169602 7122757 0 0 37180 7233627 8367154 14403229 15489911 686512 1687194 7354082 8814414 2570583 2343721 4783499 6470693 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 13336387 0 15252702 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME, A RURAL HEALTH CLINIC, AND 20-UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24-HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY. THE ASSOCIATION ALSO PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. 13336387 1 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 25 0 193 1 0 0 0 0 0 0 0 0 0 0 X 10 7 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JENI SCHWENZFEIER 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 TOM FORD PRESIDENT 5.00 1.00 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 5.00 0.00 X X 0 0 0 TOM O'TOOLE SECRETARY/TREASURER 5.00 1.00 X X 0 0 0 LORETTA BERNHOFT BOARD MEMBER 5.00 0.00 X 0 0 0 DALE O'HARA BOARD MEMBER 5.00 1.00 X 0 0 0 NICOLE SAFRANSKI BOARD MEMBER 5.00 0.00 X 0 0 0 KENNETH SCHWANDT BOARD MEMBER/CONTRACT PHARMACIST 7.00 0.00 X 21000 0 0 DR KULVINDER SUMRA BOARD MEMBER AND CONTRACTED PHYSICIAN 40.00 0.00 X 0 0 0 DWIGHT THOMPSON BOARD MEMBER 5.00 0.00 X 0 0 0 DARLENE WATSON BOARD MEMBER 5.00 1.00 X 0 0 0 EVERETT BUTLER CEO (THROUGH 6/15/17) 30.00 0.00 X 83281 0 3442 LISA LETEXIER CO-CEO 40.00 0.00 X 120619 0 9271 JENI SCHWENZFEIER CFO AND CO-CEO 40.00 0.00 X 106426 0 13905 LAURA ERMER PHYSICIAN ASSISTANT 40.00 0.00 X 143256 0 7105 474582 0 33723 3 0 1 0 ALTRU HEALTH SYSTEMS PO BOX 1370 GRAND FORKS ND 58208 THERAPY SERVICES, PHYSICIAN SERVICES, IT 711799 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 522297 INDER V KHOKHA MD PC PO BOX 380 CAVALIER ND 58220 SURGEON SERVICES 471948 DMS PO BOX 206143 DALLAS TX 75320 MOBILE IMAGING 337343 ST PAUL RADIOLOGY 166 E 4TH ST ST PAUL MN 55101 RADIOLOGY SERVICES 226447 6 400000 19179 419179 NET PATIENT REVENUE 621110 15132207 15132207 ANCILLARY REVENUES 621110 120495 120495 15252702 2802 2802 54995 0 54995 54995 54995 19789 0 19789 19789 19789 340B REVENUE 446110 1278407 1278407 OTHER INCOME 900099 149231 149231 1427638 17177105 15252702 0 1505224 X 357943 21000 336943 5433555 4862606 533769 37180 172821 141373 31448 759232 621955 137277 399206 335203 64003 9611 9611 37918 37918 3471591 3193920 277671 28127 150 27977 123701 76674 47027 2050 2050 339737 288999 50738 22496 14903 7593 55732 55732 646465 646465 93063 45702 47361 MEDICAL SUPPLIES 2533728 2057570 476158 PROVISION FOR BAD DEBT 533618 533618 EQUIPMENT RENTAL & REPA 194249 192798 1451 FOOD EXPENSE 165971 165971 109097 81748 27349 15489911 13336387 2116344 37180 361516 1068437 2533776 2283287 252434 228150 157844 160651 16597656 13116354 3398044 3481302 442016 1326815 208452 265772 7354082 8814414 1073999 1186963 15604 16300 930839 769958 378021 370500 172120 0 2570583 2343721 X 4783499 6470693 4783499 6470693 7354082 8814414 1687194 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1639 1639 0 PART II-B, LINE 1: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. 1 7195 3881 6490 4586 1 X 160304 160304 7218187 5654470 1563717 678289 433555 244734 8509490 7028329 1481161 31386 31386 3481302 X 16165901 -533618 -533618 16699519 477586 477586 17177105 14956293 0 14956293 533618 533618 15489911 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2017 AND 2016 TOTALED $16,300 AND $15,604, RESPECTIVELY. PART X, LINE 2: THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -533,618. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 2,802. RENTAL INCOME 54,995. CONTRIBUTIONS FOR LONG-LIVED ASSETS 400,000. GAIN ON DISPOSAL OF PPE 19,789. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 533,618. 1 1 X 1 X 1 X 0 1 1 0 0 43475 43475 0.00280 1497935 1901258 0 0.00000 1541410 1901258 43475 0.00280 45510 45510 0.00290 27000 27000 0.00170 3718301 3529448 188853 0.01220 25 25 0.00000 3790836 3529448 261388 0.01680 5332246 5430706 304863 0.01960 5000 5000 0.00030 1000 1000 0.00010 1500 1500 0.00010 7500 7500 0.00050 1 533618 42689 4965286 5042621 -77335 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 456013474 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 17 1 0 1 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X 1 17 1 HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X X X X X X 1 0 X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1) A SURVEY OF AREA RESIDENTS, INCLUDING HEALTH CARE PROFESSIONALS WHO UTILIZE SERVICES PROVIDED BY AND/OR WORK AT PEMBINA COUNTY MEMORIAL HOSPITAL, WEDGEWOOD MANOR, CLINICARE, AND PEMBINA COUNTY PUBLIC HEALTH.2) COMMUNITY LEADERS REPRESENTING THE BROADER INTERESTS OF THE COMMUNITY TOOK PART IN ONE-ON-ONE KEY INFORMANT INTERVIEWS;3) THE COMMUNITY GROUP, COMPRISED OF COMMUNITY LEADERS AND AREA RESIDENTS, WAS CONVENED TO DISCUSS AREA HEALTH NEEDS AND INFORM THE ASSESMENT PROCESS; AND4) A WIDE RANGE OF SECONDARY SOURCES OF DATA WERE EXAMINED, PROVIDING INFORMATION OF A MULTITUDE OF MEASURES INCLUDING DEMOGRAPHICS; HEALTH CONDITIONS, INDICATORS, AND OUTCOMES; RATES OF PREVENTIVE MEASURES; RATES OF DISEASE; AND AT-RISK BEHAVIOR. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: AN IMPLEMENTATION PLAN HAS BEEN DEVELOPED BASED ON THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS CONDUCTED IN 2017. THE CHNA WAS CONDUCTED IN COLLABORATION WITH PEMBINA COUNTY PUBLIC HEALTH TO DETERMINE THE MOST PRESSING HEALTH NEEDS OF PEMBINA COUNTY. THE TOP NEEDS IDENTIFIED IN THE CHNA PROCESS INCLUDES: - ADULT AND YOUTH DRUG USE AND ABUSE AND AVAILABILITY OF SUBSTANCE ABUSE TREATMENT AND SERVICES - ATTRACTING AND RETAINING YOUNG FAMILIES - ASSISTED LIVING OPTIONS - MENTAL HEALTH SERVICESTHE PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) BOARD OF DIRECTORS HAS DETERMINED THAT THE FOLLOWING HEALTH NEEDS IDENTIFIED IN THE CHNA SHOULD BE ADDRESSED THROUGH THE IMPLEMENTATION STRATEGY NOTED FOR EACH SUCH NEED:1. ASSISTED LIVING OPTIONSKEY OBJECTIVE: PROVIDE ADDITIONAL HOUSING OPTIONS FOR SENIORS AS THEY TRANSITION FROM HOME TO OTHER MEANS OF CARE/ASSISTANCE.STRATEGIES: - CONDUCT FEASIBILITY STUDY OF BUILDING A NEW COMPLEX TO HOUSE ASSISTED LIVING RESIDENTS - CONDUCT FEASIBILITY STUDY OF CONVERTING "X NUMBER" OF CURRENT CONGREGATE HOUSING APARTMENTS TO ASSISTED LIVING APARTMENTS - COMMUNITY FUNDRAISING PROJECT VIABILITY/REALITY2. BEHAVIORAL HEALTH SERVICESKEY OBJECTIVE: INCREASE ACCESSIBILITY TO BEHAVIOR HEALTH SERVICESSTRATEGIES: - RESEARCH VIABILITY OF HIRING A NURSE PRACTITIONER, SPECIALIZING IN BEHAVIORAL HEALTH, TO PROVIDE SERVICES IN CLINICARE. - BEHAVIOR HEALTH COALITION CONTINUES TO BE VERY ACTIVE IN COMMUNITY EDUCATION AND AWARENESS.OTHER NEEDS IDENTIFIED IN THE CHNA BUT NOT ADDRESSED IN THIS PLAN: 1. ADULT AND YOUTH DRUG USE AND ABUSE AND AVAILABILITY OF SUBSTANCE ABUSE TREATMENT AND SERVICES - BEHAVIOR HEALTH SERVICES/TREATMENT OPTIONS ANTICIPATED TO BECOME AVAILABLE IN THE COMMUNITY (SEE ABOVE) - PRESCRIPTION DRUG TAKE-BACK PROGRAM IMPLEMENTED IN 20172. ATTRACTING AND RETAINING YOUNG FAMILIES - PCMHA CONTINUES TO BE AN ACTIVE PARTICIPANT IN COMMUNITY RECRUITMENT EFFORTS. - PCMHA CONTINUES TO OFFER COMPETITIVE WAGES AND BENEFITS TO RECRUIT AND RETAIN FAMILIES.CHNA 2014 ISSUES ADDRESSED IN 2017:1. COST AND ADEQUACY OF HEALTH INSURANCE: WHILE PCMHA HAS LITTLE IMPACT ON THIS NATIONAL ISSUE, PCMHA IS DILIGENT IN OFFERING AFFORDABLE HEALTHCARE INSURANCE FOR EMPLOYEES (AND THEIR FAMILIES) OF PCMHA.2. MENTAL HEALTH - INCLUDING ALCOHOL USE AND ABUSE: CONTINUE WORKING WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION IN PROVIDING EDUCATION RESOURCES TO COMMUNITY RESIDENTS. SEVERAL EVENTS HELD THROUGHOUT 2017 INCLUDES: - PRESCRIPTION DRUG TAKE BACK DATES HELD IN EVERY TOWN IN PEMBINA COUNTY - 9/18/17 DRUGS IN SOCIETY. (CAVALIER CINEMA) AWARENESS AND ADVOCATE FOR ACTION AGAINST DRUG CRISIS. PCMHA SPONSOR/ADVOCATE - 9/25/17 (CAVALIER SCHOOL) MCKENZIE DARLING SPEAKER ON SUICIDE AWARENESS - STUDENT SESSION. PCMHA SPONSOR/ADVOCATE - 9/25/17 (CAVALIER SCHOOL) MCKENZIE DARLING SPEAKER ON SUICIDE AWARENESS - ADULT SESSION. PCMHA SPONSOR/ADVOCATE - 12/17 FRANK WHITE, PROFESSOR AT UNIVERSITY OF NORTH DAKOTA, COMMUNITY EDUCATION ON MENTAL HEALTH, DRUG DEPENDENCE, SUICIDE PREVENTION. PCMHA SPONSOR/ADVOCATEPCMHA IS ALSO RESEARCHING OPTIONS TO BRING PROFESSIONAL SERVICES TO AN OUTPATIENT/CLINIC SETTING IN CAVALIER. 3. ELEVATED RATE OF ADULT OBESITY: KACI SHARP, LRD CONTINUES TO OFFER SERVICES ON AN OUTPATIENT BASIS AS WELL AS CONTINUES DEVELOPMENT OF EDUCATION MATERIALS AND OPPORTUNITIES FOR AREA RESIDENTS. 4. NOT ENOUGH JOBS WITH LIVABLE WAGES: WHILE PCMHA HAS LITTLE IMPACT ON THIS ISSUE, PCMHA IS DILIGENT IN PROVIDING COMPETITIVE WAGES FOR ALL STAFF. WAGES ARE REVIEWED ANNUALLY AND COMPARED TO THE ND HOSPITAL ASSOCIATION WAGE SURVEY REPORTS.5. LACK OF RESOURCES FOR ELDERLY TO STAY IN THEIR HOMES: PCMHA CONTINUES TO PARTNER WITH PEMBINA COUNTY PUBLIC HEALTH IN PROVIDING UPDATES TO THE "DIRECTORY OF PEMBINA COUNTY RESOURCES AND SERVICES FOR SENIOR CITIZENS"A. HTTP://PEMBINACOUNTYND.GOV/IMAGE/CACHE/PEMBINA_COUNTY_DOCUMENT_OF_RESOURCES_DRAFTEDOCX.PDFB. RECENTLY UPDATED 2/17 (LINK IS ON OUR WEBSITE)CHNA 2011 ISSUES ADDRESSED IN 2017:1. PROVIDER SHORTAGES: IN JULY OF 2017, KIM FORD, FNP WAS ADDED TO THE CLINICARE MEDICAL STAFF TO MEET THE GROWING NEEDS OF PRIMARY CARE IN PEMBINA COUNTY. PCMHA ALSO CONTINUES TO WORK WITH THE ALTRU SPECIALTY CLINIC OF CAVALIER TO BRING SPECIALTY SERVICES TO THE RESIDENTS OF PEMBINA COUNTY.2. CHILDREN'S HEALTH NEEDS: THESE NEEDS CONTINUE TO BE MET BY A FAMILY PRACTICE PROVIDER WHO IS ON-STAFF OR ON-CALL 24 HOURS A DAY, 7 DAYS A WEEK. ADDING KIM FORD, FNP, TO THE MEDICAL STAFF IN 2017 PROVIDES ADDITIONAL CHOICES IN PRIMARY CARE PROVIDERS, INCLUDING CHILDREN'S HEALTH NEEDS. 3 1 - CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC 2 - WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME 3 - COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING PART I, LINE 7: THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, CLINIC, AND EMERGENCY ROOM. PART II, COMMUNITY BUILDING ACTIVITIES: PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. PART III, LINE 2: IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: 8.0% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2010 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE THE ORGANIZATION ESTIMATES THAT 8.0% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 8 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFITY TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERIVCES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION.1. SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. 2. PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. A. THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. B. THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. C. THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. 3. ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME SHALL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $1.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: 1. REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD. 2. REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD. 3. CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. PART VI, LINE 3: NOTICES OF THE FAP ARE POSTED IN ALL WAITING AREAS, REGISTRATION AREAS, AND UPON DISCHARGE. PART VI, LINE 4: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2010 SHOWED A POPULATION OF 7,413 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $48,502. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,019. 8.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. 0 0 0 0 0 0 0 0 0 LAURA ERMER PHYSICIAN ASSISTANT 143256 0 0 0 0 0 5761 0 1344 0 150361 0 0 0 PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 522297 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 RITA VAUGHN FAMILY MEMBER OF TOM VAUGHN, A BOARD MEMBER 31039 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. FORM 990, PART VI, SECTION A, LINE 4 ARTICLE V - BOARD OF DIRECTORS, SECTION 1. C. ELECTION OF THE DIRECTORS WAS AMENDED IN AUGUST 2017 TO INCLUDE: ONE MEMBER OF THE BOARD SHALL BE AN EX OFFICIO MEMBER APPOINTED BY ALTRU HEALTH SYSTEM. THIS MEMBER SHALL BE GRANTED VOTING PRIVILEGES ON THE PEMBINA COUNTY HOSPITAL ASSOCIATION BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7A ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. IN ADDITION, ONE BOARD MEMBER SHALL BE APPOINTED BY ALTRU HEALTH SYSTEM. FORM 990, PART VI, SECTION B, LINE 11B FULL BOARD REVIEWS THE DRAFT OF THE 990 PRIOR TO FILING OF THE FINAL REPORT WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT ARISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15A THE PROCESS FOR DETERMINING THE COMPENSATION INCLUDES LOOKING AT STATE SALARY SURVEYS FROM THE AMERICAN HOSPITAL ASSOCIATION OR NORTH DAKOTA HOSPITAL ASSOCIATION. FOR THE CEO, THE EXECUTIVE COMMITTEE OF THE BOARD DERIVES THE COMPENSATION CONTRACT. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON AMERICAN HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2017. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 3,193,920. MANAGEMENT AND GENERAL EXPENSES 277,671. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,471,591. PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION 301 MOUNTAIN STREET EAST CAVALIER ND 58220 300052569 FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR ND 501(C)(3) LINE 12A, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0