2018-11-06T16:54:18-06:00 2018-04-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2017-05-01 113686120 Coal Country Community Health Center COAL 7018737788 1312 Highway 49 N Beulah ND 585236038 Darrold Bertsch CEO 7018737788 2018-10-25 1 LISA CHAFFEE CPA P00193453 7012398500 2018-10-25 38.134.125.46 2018-10-25 14:59:54 CD P 66CC91E6B7F11C4783FFFA5645E675327CB67316 3F1B4C4A1C1F32CA3CD03C05270CE62742EA9E6E 2017 2018-06-14 16:35:46Z Darrold Bertsch 1312 Highway 49 N Beulah ND 585236038 13013717 0 X www.coalcountryhealth.com X 2003 ND CCCHC provides and promotes quality health care to the medically underserved population in the North Dakota counties of Mercer, Dunn, and Oliver. 11 11 134 11 0 0 2696142 2606233 8845695 10407484 0 0 0 0 11541837 13013717 0 10000 0 0 6035796 6908652 0 0 0 4252888 4596098 10288684 11514750 1253153 1498967 8500632 10532893 895247 1428541 7605385 9104352 X CCCHC creates access to affordable high quality preventative and primary care for all, especially medically under-served populations in Dunn, Mercer, and Oliver counties. The organization links the established medical clinics of Beulah, Center, Killdeer, and Hazen together and efficiently uses resources available to meet the increasingly complex needs of delivering rural health and improving the health status of all. 1 0 9721480 10000 10407484 Coal Country Community Health Center is part of a family of nearly 1,400 health centers nationally that provide care to more than 27 million people in the United States. Community health centers are local, non-profit health care providers serving low income and medically underserved communities. Also known as Federally-Qualified Health Centers (FQHCs), they are located in areas where care is needed, and improve access to care for millions of Americans. Their costs of care rank among the lowest, and their focus on prevention reduces the need for more expensive in-patient and specialty care, saving billions of dollars for taxpayers. The focus of the care we provide can be summed up in one word - community. Coal Country is governed by a board of members from the communities we serve, and every decision they make has the best interest of the community in mind. Our medical staff and support staff are also your neighbors, helping us truly understand you and the health care issues that are important to you.The team of providers delivers primary care for the entire community. Funded by a federal grant, our sliding fee scale allows patients to pay according to their individual ability. This and other efforts ensure that no one in the community goes without proper health care services. That's what we're all about.Coal Country Community Health Center, with clinics in Beulah, Center, Hazen, and Killdeer, is a member of the PrimeCare Health Group. Furthermore, Coal Country remains a member of the other health care networks in the region.At Coal Country Community Health Center, our top priority is to provide complete health care services for the entire community.With a background in every area of medicine, our primary care physicians provide continuing and comprehensive care, from preventative care to diagnosis and treatment of health conditions.For more focused care, we bring in specialists to our clinic in Beulah,all the while continuing to oversee your total care.Our ongoing medical care of all levels includes the areas of::: Acute and chronic disease:: Adult care medicine:: Emergency medicine:: Geriatrics:: Mental health:: Medicated Assisted Therapy:: Obstetrics:: Occupational medicine:: Pediatrics:: Prenatal care:: Sports medicine:: Women's healthSpecialists from Bismarck regularly visit our clinics to provide treatment in the areas of::: Audiology:: Ear, nose and throat:: General surgery:: Mental health:: Obstetrics and Gynecology:: Orthopedics 9721480 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 1 134 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Dovie Borth 7018737788 1312 Hwy 49 N Beulah ND 585236038 Dr DJ Erickson Chair 1.00 X X 0 0 0 Keith Johnson Vice Chair 1.00 X X 0 0 0 Arlene Helling Secretary/Treasurer 1.00 X X 0 0 0 Gordon Hoffner Director 1.00 X 0 0 0 Ann Mahoney Director/Executive Committee 1.00 X 0 0 0 Kimberly Kessler Director 1.00 X 0 0 0 Aaron Rudningen Director 1.00 X 0 0 0 Sienna Sailer Director 1.00 X 0 0 0 Scott Solem Director 1.00 X 0 0 0 Fred Stern Director/Executive Committee 1.00 X 0 0 0 Jody Doe Director 1.00 X 0 0 0 Darrold Bertsch CEO 21.40 X 253384 0 32258 Dovie Borth CFO 40.00 X 98813 0 11637 Aaron Garman MD Physician/Medical Director 40.00 X 341121 0 30946 Orlan Jackson DO Physician 24.00 X 179812 0 26604 Jacinta-Jon Klindworth MD Physician 40.00 X 248008 0 32289 Rodney Zimmerman Physician 40.00 X 197499 0 30727 Michelle Placke Physician 40.00 X 242825 0 32582 1561462 0 197043 10 0 1 0 Beulah Drug 147 W Main Beulah ND 58523 Contract Pharmacy Dispensing Fees 919844 Corval Management Services Inc 1633 Eustis St St Paul MN 55108 Pre-Construction for Beulah Clinic Expan 319478 Sakakawea Medical Center 510 8th Avenue NE Hazen ND 58545 Rent, Shared HR/Fiscal, Nursing 212518 Greenway EHS PO Box 203658 Dallas TX 753203658 Software Subscription, Support, Licenses 156225 Hazen Drug 30 Main Street Hazen ND 58545 Contract Pharmacy Dispensing Fees 145805 6 2578453 27780 2606233 Patient Service Revenue 621110 6759196 6759196 340B Program Revenue 621110 3211513 3211513 Other Program Revenue 621110 436775 436775 10407484 13013717 10407484 0 0 10000 10000 268233 268233 5326573 4996049 330524 207059 158104 48955 710004 591161 118843 396783 286489 110294 6305 6305 82129 82129 555639 457231 98408 65261 65261 538386 260036 278350 150440 150440 267888 266537 1351 53933 36043 17890 36061 14774 21287 206 206 196423 196423 29075 29075 Medical Supplies 2044728 2044728 Bad Debt Expense 223823 223823 Licenses 63481 61726 1755 Dues and Subscriptions 36974 3917 33057 245346 114233 131113 11514750 9721480 1793270 0 5769240 6672600 993047 1356205 67531 57608 87272 97447 3555360 1288765 1514656 2266595 68886 82438 8500632 10532893 895247 1428541 895247 1428541 X 7605385 9104352 7605385 9104352 8500632 10532893 1498967 0 X 0 1 X 1 1 1 X 1573181 1508859 2089318 2696142 2606233 10473733 1573181 1508859 2089318 2696142 2606233 10473733 10473733 10473733 40107910 1.00000 1.00000 X 1311802 326722 985080 33173 11254 21919 1209683 872699 336984 1000702 78090 922612 2266595 X 12789894 -223823 -223823 13013717 0 13013717 11290927 0 11290927 223823 223823 11514750 Part X, Line 2: The Health Center is organized as a North Dakota nonprofit organization 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 Health Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health Center is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Health 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 Health 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 Health 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 -223,823. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts 223,823. 1 Wellness Center Foundation PO BOX 968 Beulah ND 58523 473641154 501(c)(3) 10000 Promote physical activity 1 0 Part I, Line 2: Coal Country Community Health Center participated in a needs assessment for community needs. One need identified was for an all seasons exercise facility to promote physical activity for all age groups throughout the year. CCCHC's board of directors approved a donation to the Wellness Center Foundation, run by the community of Beulah ND. The donation went toward the walking path to ensure that CCCHC patients have access to a low impact activity within the wellness center. CCCHC monitored the construction of the facility and ensured donated funds were used in accordance with the wishes of CCCHC's Board of Directors. X X X X 0 0 0 0 0 1 0 0 0 Darrold Bertsch CEO 249539 0 0 0 3845 0 10399 0 19897 0 283680 0 0 0 Aaron Garman MD Physician/Medical Director 279110 0 61201 0 810 0 10979 0 20760 0 372860 0 0 0 Orlan Jackson DO Physician 176248 0 0 0 3564 0 7050 0 17578 0 204440 0 0 0 Jacinta-Jon Klindworth MD Physician 211005 0 36033 0 970 0 9447 0 23634 0 281089 0 0 0 Rodney Zimmerman Physician 183308 0 10000 0 4191 0 8881 0 18943 0 225323 0 0 0 Michelle Placke Physician 215777 0 15721 0 11327 0 8704 0 25048 0 276577 0 0 0 Part I, Line 6 An annual management team incentive program was started in FY2014 with the first annual payment occurring in August 2014 for fiscal year ending 04/30/2014. This program was continued for FY2018. The incentive payment is based on a combination of ten clinical and financial performance measures relating to the patient population and the health center. The ten measures are: 1. Diabetes Control > National Average 2. Blood Pressure Control > National Average 3. Cholesterol Treatment > National Average 4. Adult Weight Screening & Follow-up > National Average 5. Childhood Immunizations > National Average 6. Days in AR < 55 7. Days Cash on Hand > 90 8. Net Profit Margin > 5% 9. Long Term Debt to Equity < .25 10. Medical Cost Per Medical Patient < National Average Of the 10 measures, only net profit margin could potentially be considered as compensation contingent on net earnings. Only the measures met for the current fiscal year are included in the calculation of the incentive payment. Each measure met receives a rating of 1%. A maximum incentive of 10% is allowed. The incentive payment calculation is based on the individual team member's base salary as of the end of the current fiscal year. For FY2017 paid in August 2017, Dovie Borth received a management team incentive payment of $8,043.98. The other three participants in the program do not meet the criteria for Part VII and are not listed in Part VII. Schedule J, Part II: As of 6/1/2013, Darrold became an employee of Coal Country Community Health Center (CCCHC) and still provides services to both Sakakawea Medical Center (SMC) and CCCHC. The compensation reported in Part VII, and Part II of Schedule J, reflects total compensation Darrold received from CCCHC for his services to both SMC and CCCHC. Compensation received just for services to CCCHC, includes $156,838 of wages and benefits. Form 990, Part III, line 2 Effective March 2018, CCCHC began providing Visiting Nurse Services to home bound or shut in patients. This service was previously provided by Sakakawea Medical Center (SMC) but SMC recently shut down its home health unit in favor of encouraging CCCHC to provide this service to the community. CCCHC assumed responsibility for providing these services when Medicare started accepting claims for these services from FQHCs in early 2018. This change is part of the overall collaborative effort between CCCHC and SMC to ensure the sustainability of quality health care in Dunn, Mercer and Oliver counties. Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of at least five (5) voting members, including the Chair, Vice Chair, Secretary, Treasurer, and one (1) at-large member. The Executive Director of the Corporation shall serve without voting powers. The Executive Committee shall have the power to transact all business of the Corporation during the interim between meetings of the Board of Directors, provided that any action so taken shall not conflict with the policies and express wishes of the Board of Directors, and that it shall refer all matters of major importance to the full Board of Directors, including any amendments to the Articles and Bylaws. Form 990, Part VI, Section B, line 11b The full copy of the Form 990 is provided to the board via email. The Form 990 is reviewed and approved by the board and signed by the CEO after approval. Form 990, Part VI, Section B, line 12c The conflict of interest and compensation disclosure statements are completed annually. All board members and officers of CCCHC are covered by the policy. The annual conflict of interest and compensation disclosure statements obtained from board members and officers of CCCHC are reviewed by the CEO and Administration staff of CCCHC. It is at this review that the determination is made as to whether a conflict exists. Actual conflicts of interest identified are brought before the Board Executive Committee or the entire Board, depending on the situation and circumstances. Board members and officers of CCCHC are required to recuse themselves from voting on issues where it has been determined that a conflict of interest does exist. If the conflict of interest is pervasive, the Board Executive Committee or the entire Board will determine if further actions are needed. In all situations, the Board will document the restrictions imposed or acted upon. Form 990, Part VI, Section B, line 15a To determine compensation, the organization uses the following salary surveys for both the CEO and CFO as well as other positions within the organization: National Community Health Center Association (NACHC), Community Healthcare Association of the Mountain Plain States (CHAMPS), Medical Group Management Association (MGMA), and state of ND. The board of directors determines the salary of the CEO. CEO Salary adjustments are documented on a payroll notification form, signed by the board chair and forwarded to the accounting department for entry into the accounting/payroll system. Compensation for the CFO is reviewed and approved by the CEO. The board of directors approves an annual budget to provide guidance for expenditures which includes personnel salaries. In addition, annual salary adjustments are presented to the board for approval. Personnel salary adjustments are documented on a payroll notification form signed by the CEO or Human Resources and forwarded to the accounting department for entry into the accounting/payroll system. The process for determining compensation is undertaken annually before the new fiscal year in May begins. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request.