TIOGA MEDICAL CENTER: Form 990, tax year 2017
View the entire original 990 at ProPublica ↗
- Organization
- TIOGA MEDICAL CENTER (EIN 45-0308484)
- Tax period
- 2017-07-01 to 2018-06-30
- Filed
- 2018-11-20
- IRS object ID
- 201823249349300227
- 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 | 2018-11-20T10:53:21-06:00 | 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 | 450308484 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tioga Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | TIOG | BusinessNameControlTxt |
| Phone | 7016643305 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 159 | AddressLine1Txt |
| City | Tioga | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58852 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Randall K Pederson | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7016643305 | PhoneNum |
| Signature | 2018-11-19 | 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 | 2018-11-19 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 216.147.170.229 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2018-11-19 | IPDt |
| IP Tm | 16:21:55 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 66CC91E6B7F11C4783FFFA5645E675327CB67316 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | B602D594AFD2B0B327E07A06F36CA6A7E42546D0 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2017 | TaxYr |
| Build TS | 2019-02-21 02:37:17Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Randall K Pederson | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 159 | AddressLine1Txt |
| City | Tioga | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58852 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $13,081,430 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.tiogahealth.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1960 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | Health care and nursing care services | ActivityOrMissionDesc |
| Voting Members Governing Body | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 165 | TotalEmployeeCnt |
| Total Volunteers | 150 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $746,767 | PYContributionsGrantsAmt |
| CY Contributions Grants | $815,371 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $11,306,637 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $11,974,774 | CYProgramServiceRevenueAmt |
| PY Investment Income | $39,829 | PYInvestmentIncomeAmt |
| CY Investment Income | $194,526 | CYInvestmentIncomeAmt |
| PY Other Revenue | $85,111 | PYOtherRevenueAmt |
| CY Other Revenue | $96,759 | CYOtherRevenueAmt |
| PY Total Revenue | $12,178,344 | PYTotalRevenueAmt |
| CY Total Revenue | $13,081,430 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $500 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $500 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $6,453,294 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,438,409 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $5,199,636 | PYOtherExpensesAmt |
| CY Other Expenses | $5,554,330 | CYOtherExpensesAmt |
| PY Total Expenses | $11,653,430 | PYTotalExpensesAmt |
| CY Total Expenses | $12,993,239 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $524,914 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $88,191 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $18,809,085 | TotalAssetsBOYAmt |
| Total Assets EOY | $18,332,324 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $8,846,987 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,387,108 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $9,962,098 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $9,945,216 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | The mission of Tioga Medical Center is to address the health care needs of the community through providing quality health care and promoting education and wellness. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $5,974,582 | ExpenseAmt |
| Revenue | $7,040,417 | RevenueAmt |
| Desc | Tioga Medical Center provides delivery of healthcare services over eastern Williams county, Burke County and western Mountrail county of the state of North Dakota.Requirements of the IRS community benefit standard for tax-exempt organizations are integral to Tioga Medical Center's larger charitable mission of improving health and quality of life. Specifically, an independent board including community leaders, business experts and consumer representatives governs Tioga Medical Center. The Board has a history of commitment to acting with the highest integrity. For example:-Policies on confidentiality of patient and corporate information are reviewed annually as a component of mandatory education, and a confidentiality statement is signed and/or reviewed annually by all employees and board members.-Board members and key employees review and sign a conflict of interest statement annually.-Tioga Medical Center's code of conduct is published in its employee handbook and included in general orientation of all new employees and volunteers.Tioga Medical Center also makes medical care accessible to the entire community it serves. Tioga Medical Center operates a 24 hour emergency room and provides emergency care regardless of ability to pay. Tioga Medical Center had 1,435 emergency room visits during the past fiscal year. Tioga Medical Center provides clinical services needed to operate the emergency room.In addition, Tioga Medical Center provides non-emergency services to the community it serves. It makes these services accessible to the community through participation in government programs like Medicare and Medicaid and by offering assistance through the Tioga Medical Center's uncompensated care program.Tioga Medical Center's uncompensated care (charity care) program provides free services to patients who lack the resources to be fully responsible for the health care they receive. The uncompensated care program is designed to ensure the entire community served by Tioga Medical Center has access to needed healthcare services. The Tioga Medical Center administration oversees services delivered under the uncompensated care program, including assessing community needs, approving eligibility criteria and monitoring the effectiveness of the program in providing community access to medical care.Tioga Medical Center maintains records to identify and monitor the level of care provided under the uncompensated care program. These records include the amount of charges foregone for services and supplies furnished under its charity care program. Tioga Medical Center had costs for charity care for the year ended June 30, 2018 of approximately $18,000.Tioga Medical Center takes its mission to improve the health and quality of life of the people it serves a step further by reaching out to meet the broad needs of the community. It strives to identify the community needs beyond basic healthcare, and then respond to them, aiming to make a positive, life-enhancing difference in the community. For example, many employees and Board members of Tioga Medical Center are actively involved in volunteer organizations that serve to protect the community, such as the Tioga Fire & Ambulance Department. As a small community, it is vital for people to come to the aid, as volunteers, when people are in need of assistance. Tioga Medical Center allows its employees to leave the workplace to tend to the emergency needs of the community we serve.The Tioga Medical Center, located at Tioga, North Dakota, is a provider of integrated healthcare delivery services consisting of a 25 bed Medicare designated Critical Access Hospital (CAH). The Tioga Medical Center CAH is a Level V designated trauma center. Within the CAH, acute care services are provided, along with swingbed services. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,275,723 | ExpenseAmt |
| Revenue | $2,758,210 | RevenueAmt |
| Desc | Attached to the CAH is a 30 bed skilled nursing facility. This facility provides skilled and long term care services to its residents. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $2,724,667 | ExpenseAmt |
| Revenue | $1,893,745 | RevenueAmt |
| Desc | The Medical Center also operates three clinics located in Tioga, Ray, and Powers Lake. These clinics are Medicare and Medicaid designated provider-based rural health clinics. Within the clinics, they employ one Family Medicine Physician, two Physician Assistants and two Family Nurse Practitioner. These practitioners provide physician related services at these clinics, as well as to the CAH and SNF. | Desc |
Prog Srvc Accom Acty Other ProgSrvcAccomActyOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $227,710 | ExpenseAmt |
| Grant | $500 | GrantAmt |
| Revenue | $282,402 | RevenueAmt |
| Desc | Finally, attached to the Nursing home is a 22 unit independent living unit. The organization also has a Foundation that distributes scholarships. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Prog Srvc Expense | $227,710 | TotalOtherProgSrvcExpenseAmt |
| Total Other Prog Srvc Grant | $500 | TotalOtherProgSrvcGrantAmt |
| Total Other Prog Srvc Revenue | $282,402 | TotalOtherProgSrvcRevenueAmt |
| Total Program Service Expenses | $11,202,682 | 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 | Yes (1) | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | 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 | 0 | 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 | 0 | 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 | 11 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 165 | 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 | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | 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 | 0 | 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 | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | 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 | Ryan Mickelsen | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7016643305 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 159 | AddressLine1Txt |
| City | Tioga | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58852 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 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 |
|---|---|---|---|---|---|---|---|
| James Booth | |||||||
| Chair | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Harlan Germundson | |||||||
| Vice-Chair (July-March) | 0.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Brodie Odegaard - Director | |||||||
| (July-March)/Vice Chair (April-June) | 0.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Brian Longie | |||||||
| Secretary/Treasurer | 0.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Kirk Odegaard | |||||||
| Director | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Scott Sundhagen | |||||||
| Director | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Carolyn Eide | |||||||
| Director | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Brandon Hauge | |||||||
| Director (Apr-Jun) | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Arlene Grubb | |||||||
| Director | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Lee Olson | |||||||
| Director | 0.50 | Yes (X) | $0 | $0 | $0 | ||
| Randall K Pederson | |||||||
| President/CEO | 40.00 | Yes (X) | $142,377 | $0 | $10,253 | ||
| Ryan Mickelsen | |||||||
| VP/CFO/COO | 40.00 | Yes (X) | $115,181 | $0 | $9,721 | ||
| Robert Rotering | |||||||
| Physician | 40.00 | $371,060 | $0 | $14,077 | Yes (X) | ||
| Jeffrey Moberg Jr | |||||||
| Physician Assistant | 40.00 | $258,050 | $0 | $13,537 | Yes (X) | ||
| Nancy Carlson | |||||||
| Nurse Practitioner | 32.00 | $162,135 | $0 | $6,731 | Yes (X) | ||
| Lorena Mitchell | |||||||
| Nurse Practitioner | 40.00 | $200,000 | $0 | $7,034 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,248,803 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $61,353 | 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 | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Mowbray & Sons | |||||
| PO Box 878 | Minot | ND | 58702 | Construction | $531,913 |
| Reishus Construction | |||||
| PO Box 69 | Mohall | ND | 58761 | Construction | $178,440 |
| Avant | |||||
| PO Box 60839 | Charlotte | NC | 28260 | Contracted Nursing Services | $147,501 |
| HA Thompson and Sons | |||||
| PO Box 1195 | Bismarck | ND | 58502 | Construction | $137,902 |
| ICS | |||||
| PO Box 13158 | Grand Forks | ND | 58208 | Construction | $137,406 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 6 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $135,418 | GovernmentGrantsAmt |
| All Other Contributions | $679,953 | AllOtherContributionsAmt |
| Total Contributions | $815,371 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient & Resident Revenue | 621110 | $11,765,994 | $11,765,994 |
| Other Revenue | 900099 | $208,780 | $208,780 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $11,974,774 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,837 | TotalRevenueColumnAmt |
| Exclusion | $2,837 | ExclusionAmt |
Royalties Revenue RoyaltiesRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $75,272 | TotalRevenueColumnAmt |
| Exclusion | $75,272 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $21,487 | 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 | $21,487 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,487 | TotalRevenueColumnAmt |
| Exclusion | $21,487 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $191,689 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $0 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $191,689 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $191,689 | TotalRevenueColumnAmt |
| Exclusion | $191,689 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $13,081,430 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $11,974,774 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $291,285 | ExclusionAmt |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $500 | TotalAmt |
| Program Services | $500 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $337,338 | TotalAmt |
| Management And General | $337,338 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $209,737 | TotalAmt |
| Program Services | $209,737 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,887,668 | TotalAmt |
| Program Services | $5,311,495 | ProgramServicesAmt |
| Management And General | $576,173 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $87,977 | TotalAmt |
| Program Services | $83,419 | ProgramServicesAmt |
| Management And General | $4,558 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $481,779 | TotalAmt |
| Program Services | $425,390 | ProgramServicesAmt |
| Management And General | $56,389 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $433,910 | TotalAmt |
| Program Services | $373,659 | ProgramServicesAmt |
| Management And General | $60,251 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,933 | TotalAmt |
| Management And General | $10,933 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $56,001 | TotalAmt |
| Management And General | $56,001 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $967,283 | TotalAmt |
| Program Services | $967,283 | ProgramServicesAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $48,873 | TotalAmt |
| Management And General | $48,873 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,129,641 | TotalAmt |
| Program Services | $601,568 | ProgramServicesAmt |
| Management And General | $528,073 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $214,270 | TotalAmt |
| Program Services | $197,706 | ProgramServicesAmt |
| Management And General | $16,564 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,085 | TotalAmt |
| Program Services | $12,412 | ProgramServicesAmt |
| Management And General | $9,673 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $31,227 | TotalAmt |
| Program Services | $22,979 | ProgramServicesAmt |
| Management And General | $8,248 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $162,879 | TotalAmt |
| Program Services | $162,879 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $878,058 | TotalAmt |
| Program Services | $878,058 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $91,113 | TotalAmt |
| Program Services | $47,149 | ProgramServicesAmt |
| Management And General | $43,964 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt |
|---|---|---|
| Medical Supplies | $998,521 | $998,521 |
| Bad Debt Expense | $875,300 | $875,300 |
| Avera E-Emergency | $34,627 | $34,627 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $33,519 | TotalAmt |
| Management And General | $33,519 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,993,239 | TotalAmt |
| Program Services | $11,202,682 | ProgramServicesAmt |
| Management And General | $1,790,557 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,001,428 | BOYAmt |
| EOY | $2,191,821 | EOYAmt |
Pledges And Grants Receivable PledgesAndGrantsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,000 | BOYAmt |
| EOY | $15,000 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,340,237 | BOYAmt |
| EOY | $1,759,166 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $73,029 | BOYAmt |
| EOY | $77,983 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $69,653 | BOYAmt |
| EOY | $76,935 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $23,249,834 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $10,637,463 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,625,252 | BOYAmt |
| EOY | $12,612,371 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,669,486 | BOYAmt |
| EOY | $1,569,048 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $30,000 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,809,085 | BOYAmt |
| EOY | $18,332,324 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $827,792 | BOYAmt |
| EOY | $865,745 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,235 | BOYAmt |
| EOY | $2,445 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,935,960 | BOYAmt |
| EOY | $7,518,918 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $81,000 | BOYAmt |
| EOY | $0 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,846,987 | BOYAmt |
| EOY | $8,387,108 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,917,098 | BOYAmt |
| EOY | $9,915,216 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $45,000 | BOYAmt |
| EOY | $30,000 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,962,098 | BOYAmt |
| EOY | $9,945,216 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $18,809,085 | BOYAmt |
| EOY | $18,332,324 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $88,191 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$105,073 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtcInd |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $14,053 | OtherCostOrOtherBasisAmt |
| Book Value | $14,053 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Investment Cost Or Other Basis | $739,067 | InvestmentCostOrOtherBasisAmt |
| Other Cost Or Other Basis | $15,322,930 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,555,188 | DepreciationAmt |
| Book Value | $10,506,809 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,806,594 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,794,505 | DepreciationAmt |
| Book Value | $1,012,089 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,367,190 | OtherCostOrOtherBasisAmt |
| Depreciation | $287,770 | DepreciationAmt |
| Book Value | $1,079,420 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $12,612,371 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $12,101,057 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$105,073 | NetUnrealizedGainsInvstAmt |
| Other Revenue | -$875,300 | OtherRevenueAmt |
| Revenue Not Reported | -$980,373 | RevenueNotReportedAmt |
| Revenue Subtotal | $13,081,430 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $13,081,430 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $12,117,939 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $12,117,939 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $875,300 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $875,300 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $12,993,239 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 2b: | The Organization holds funds under an agency relationship for the residents of the nursing facility. Funds held as of June 30, 2018 and 2017 totaled $2,968 and $2,235. |
| 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 net income that is derived from business activities that are unrelated to their 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 990T) 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 in Expenses for Tax -875,300. |
| Part XII, Line 4b - Other Adjustments: | Provision for Bad Debts in Expenses for Tax 875,300. |
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 | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | 0 | FinancialAssistanceBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $18,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $18,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00150 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,347,406 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,189,040 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $158,366 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01310 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,365,406 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,189,040 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $176,366 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01460 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $69,129 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $200 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $68,929 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00570 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,401,914 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,529,779 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $872,135 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07200 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $14,188 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $14,188 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00120 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,485,231 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,529,979 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $955,252 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.07890 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,850,637 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,719,019 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,131,618 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09350 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $875,300 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $59,520 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $3,076,605 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $3,103,090 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$26,485 | 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 | Tioga Medical Center Hospital | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 810 Welo Street | AddressLine1Txt |
| City | Tioga | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58852 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.tiogahealth.org | WebsiteAddressTxt |
| State License | 5048 | 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 |
| Other | 3 provider based rural health clinics | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tioga Medical Center Hospital | 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 |
| 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 | See Part V, Section C | OwnWebsiteURLTxt |
| 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 | See Part V, Section C | 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 |
| 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 |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | See Part V, Section C | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | See Part V, Section C | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | See Part V, Section C | 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 |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare | Yes (X) | LookBackMedicareInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Tioga Medical Center Hospital | Part V, Section B, Line 5: Tioga Medical Center distributed health needs surveys to patients at the hospital and clinic. Surveys were distributed at the senior citizens center. Public meetings were advertised in the local paper inviting all community members to participate. Special invitations were sent to members of the Community Ambulance Service, the community dentist, pharmacist, local public health representatives, chiropractor, and a representative of a community group home. |
| Tioga Medical Center Hospital | Part V, Section B, Line 6b: Tioga Medical Center's CHNA was conducted in collaboration with Upper Missouri Health District. |
| Tioga Medical Center Hospital | Part V, Section B, Line 11: Tioga Medical Center did not take action on the identified needs of Cost of Health Insurance: Tioga Medical Center is a participating provider in Medicaid Expansion, is an HPE provider (presumptive eligibility) as well as has an uncompensated plan in place that accepts applications up to 200% of poverty level.Tioga Medical Center is addressing teenage use and abuse of alcohol, drugs, and teen pregnancy thru partnerships with the school systems in our service area, partnerships with law enforcement in our service area, providing education to the youth in service area through informative guides and public lectures. Tioga Medical Center is addressing the need of services enabling elderly to stay in their home by partnering with Mercy Home Health Services to provide home health services, partnering with Wildrose Public Transportation to provide transportation services to the elderly in the community, as well as providing educational materials to the senior citizens organizations in our service area on these services.Tioga Medical Center implemented a Palliative Care program to provide assistance to individuals that are in need of greater care than can be provided in their home on a short-term basis. This program is designed to provide individuals a standardized way to let loved ones and first responders know what their wishes are if needed, utilizing a standard POST form (Physician Orders for Scope of Treatment). This program also provides information to individuals on services available to provide comfort and care to individuals and their families. |
| Tioga Medical Center Hospital | Part V, Section B, Line 16j: If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them.A charity care application is sent with patient statements after 90 days. |
| Part V, Section B, Line 7a: | CHNA:http://www.tiogahealth.org/community-health-needs-assessment-report/ |
| Part V, Section B, Line 10a: | Implementation Plan:http://www.tiogahealth.org/implementation-plan-2016-chna/ |
| Part V, Section B, Line 16a, 16b, 16c: | FAP:http://www.tiogahealth.org/2018-uncompensated-care-plan-2/FAP Application:http://www.tiogahealth.org/about-tmc/payment-policies/tioga-medical-center-request-for-determination-of-eligibility-for-uncompensated-services/FAP Plain Language Summary:http://www.tiogahealth.org/updated-01312018-uncompensated-care-plain-language-updated-4/ |
| 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 - Tioga Medical Center Long Term Care | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 810 Welo Street | AddressLine1Txt |
| City | Tioga | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58852 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | Long term care | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 7: | Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Health professionals education, line 7f, reflects actual expenses recorded to the general ledger. Medicaid, line 7b, and subsidized health services, line 7g, were calculated based on information from the Cost Report. Cash and in kind contributions, line 7i, was calculated based on wages paid to staff providing EMS services. |
| Part I, Ln 7 Col(f): | The amount of bad debt expense removed from the denominator of the calculation was $875,300. |
| Part III, Line 2: | Bad debt expense is reported net of discounts and contractual adjustments. A payment on an account which was previously written off reduces bad debt expense in the current year. |
| Part III, Line 3: | The estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's charity care policy was calculated by applying the estimated percentage of the service area below the poverty guideline (6.8%) to the amount of bad debt expense. This estimate is due to a lack of information received from patients who may otherwise be eligible for the Organization's financial assistance policy, however, because of missing information they are otherwise classified as bad debt. |
| 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 cost is based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.All of the Medicare shortfall should be treated as a community benefit. The Organization treats individuals regardless of the ability to pay. Most of the Medicare shortfall comes from the nursing home. The elderly are an underserved population who experience issues with access to healthcare services. It is a community benefit to be able to treat them at the local nursing home. |
| Part III, Line 9b: | The billing and collection policy applies to all patients. Every effort is made to determine if a patient may be eligible for charity care. No collection actions are taken if a patient is in the process of applying for charity care or has been accepted for charity care. Any personal portion due would follow normal collection procedures. |
| Part VI, Line 2: | In addition to a Community Health Needs Assessment conducted during FY 16, a formal needs assessment has been conducted where providers are able to bring identified needs to administration. The identified needs arereviewed by the physicians/providers as well. The request is analyzed to see if it can be cost-justified; then, the request is brought to the Board of Directors for approval. Mobile MRI services, Dexa Scan, Diabetes Education, In-house CT scanning, an OR remodel, eEmergency, the purchase of an ablasion machine, and the purchase of a diagnostic ultrasound have all been added in the past five years through this process. |
| Part VI, Line 3: | If a patient does not have financial resources, the hospital asks if they have applied for medical assistance. Financial assistance is discussed with ER patients upon discharge and discussed upon admissions for all other services. Follow-up letters are sent separate from the bills on accounts that have not had payments for 90 days to remind patients that there is a charity care program available to them. |
| Part VI, Line 4: | The hospital's primary service area consists of residents in Williams County, with some residents of Mountrail/Burke Counties. The primary industries in this area are agriculture, oil, and tourism. Williams County had an estimated population of 33,349 as of July 2017 according to census.gov. An estimated 9.8% of the population was 65 or older in 2017, and 6.8% were estimated below the poverty level in 2017. |
| Part VI, Line 5: | Tioga Medical Center furthers its exempt purpose by promoting the health of the community through:* Medical staff privileges are extended to all community providers* Surplus funds are reinvested into equipment and facility upgrade* The next closest hospital is 30 miles away from the organization - sole provider in the immediate area* Provide emergency care regardless of a patient's ability to pay* Employees serve on a voluntary ambulance and fire department and the organization allows the employees to serve those duties without punching out* Therapy departments talk to coaches about sports injuries and educate coaches on caring for injuries* Educate senior citizen groups on medical awareness topics* Diabetes education services are provided to patients of Tioga Medical Center at no cost to the patient.*Collaboration with Williston State College to educate nurses |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Discretionary Spending Acct | Yes (X) | DiscretionarySpendingAcctInd |
| Housing Allowance Or Residence | Yes (X) | HousingAllowanceOrResidenceInd |
| Written Policy Ref T And E Expnss | Yes (1) | WrittenPolicyRefTAndEExpnssInd |
| Substantiation Required | Yes (1) | SubstantiationRequiredInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | 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 | Yes (1) | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (5 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Randall K Pederson | ||||||||||||||
| President/CEO | $121,575 | $0 | $2,080 | $0 | $18,722 | $0 | $3,219 | $0 | $7,034 | $0 | $152,630 | $0 | $0 | $0 |
| Robert Rotering | ||||||||||||||
| Physician | $358,980 | $0 | $12,080 | $0 | $0 | $0 | $7,044 | $0 | $7,034 | $0 | $385,138 | $0 | $0 | $0 |
| Jeffrey Moberg Jr | ||||||||||||||
| Physician Assistant | $249,232 | $0 | $2,080 | $0 | $6,738 | $0 | $6,503 | $0 | $7,034 | $0 | $271,587 | $0 | $0 | $0 |
| Nancy Carlson | ||||||||||||||
| Nurse Practitioner | $153,805 | $0 | $1,232 | $0 | $7,098 | $0 | $0 | $0 | $6,731 | $0 | $168,866 | $0 | $0 | $0 |
| Lorena Mitchell | ||||||||||||||
| Nurse Practitioner | $192,048 | $0 | $2,080 | $0 | $5,872 | $0 | $0 | $0 | $7,034 | $0 | $207,034 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 1a | The spending account is for a continuing medical education allowance. The doctors have an allowance of $4,000 per year for their continuing education. The board provides direction on the CME allowance. Review of the allowance is completed during each recruitment phase. An estimate is determined by the board based on a reasonable estimate provided by the recruiters. Total expenditures per person are reviewed and examined on an industry standard basis. These numbers are reevaluated each time a new doctor is recruited. Dr. Rotering lives in a Tioga Medical Center apartment. |
| Part I, Line 7 | All employees received a holiday bonus based on productive hours as well as a fiscal year end bonus based on productive hours. |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (4 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| Craig Odegaard | |||
| Family of board member Brodie Odegaard & Kirk Odegaard | $46,525 | Craig receives compensation as a maintenance employee. | 0 |
| Lori Olson | |||
| Family of President/CEO Randall Pederson | $64,745 | Lori receives compensation as a registered nurse. | 0 |
| Karen Pederson | |||
| Family of President/CEO Randall Pederson | $35,408 | Karen receives compensation as an activity aide. | 0 |
| Amanda Mickelsen | |||
| Family of VP/CFO/COO Ryan Mickelsen | $63,059 | Amanda receives compensation as a registered nurse. | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1 | Board Chair does not vote. |
| Form 990, Part VI, Section A, line 6 | An individual interested in becoming a member must complete an application and submit to the Board of Directors for approval. There is only one class. |
| Form 990, Part VI, Section A, line 7a | An annual meeting is held in March of each year in which the members may elect board members if applicable. The members also vote on approval of the audited financial statements. |
| Form 990, Part VI, Section A, line 8b | The Physician Interview Committee does not take minutes as the committee meets only for physician interviews. This committee reports their recommendation to the full Board of Directors. |
| Form 990, Part VI, Section B, line 11b | A copy of the return is given to each board member and discussed at a regular monthly meeting. The board must approve the form before it is signed by the facility's representative. |
| Form 990, Part VI, Section B, line 12c | The policy covers all board members and officers. The Administration will determine if a conflict exists. In the event of a conflict, said board members abstain from related motions/votes but may still participate in discussions. |
| Form 990, Part VI, Section B, line 15 | Annual salary survey results from the North Dakota Hospital Association are reviewed. Related organization's 990 compensation information is also reviewed. The compensation of the President/CEO and Vice President/CFO and relevant employees is examined by the Board of Directors and adjusted annually if deemed necessary. This process is documented in the board minutes. |
| Form 990, Part VI, Section C, line 19 | The governing documents, conflict of interest policy and financial statements are available to the public upon request. |
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