2017-05-09T12:06:01-05:00 2016-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2015-07-01 770637498 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC MCKE 7018423000 516 N MAIN WATFORD CITY ND 58854 DANIEL KELLY CEO 7018423000 2017-05-04 1 TERRI REXRODE CPA MST P00096513 9206620016 2017-05-04 2015 2021-01-29 14:40:06Z DANIEL KELLY 516 N MAIN WATFORD CITY ND 58854 23813040 0 X WWW.MCKENZIEHEALTH.COM X 2004 ND HEALTH CARE SERVICE PROVIDER 9 9 225 45 498538 -19995 14441994 7587619 15724909 15451871 487863 3591 498149 469874 31152915 23512955 0 0 0 0 7677910 8157714 0 0 0 11177285 11036600 18855195 19194314 12297720 4318641 33569129 37740642 7613719 7466591 25955410 30274051 X MCKENZIE COUNTY HEALTHCARE SYSTEMS IS A FAITH-BASED ORGANIZATION DEDICATED TO PROFESSIONAL, COMPASSIONATE AND QUALITY HEALTHCARE. 0 0 9434371 0 8725295 MCKENZIE COUNTY HEALTHCARE SYSTEMS PROVIDES 24 HOUR X 7 DAYS A WEEK SERVICES. MCHS PROVIDED IN-PATIENT, OBSERVATION, AND SWING BED - HOSPITAL- TOTAL INPATIENT ADMISSIONS - 104. TOTAL SWING BED ADMISSIONS - 23. MCHS OFFERS VARIOUS OTHER SERVICES. THEY OFFER ENDOSCOPIC EXAMS ONCE A MONTH BY A CONTRACTED PROVIDER. TOTAL OUTPATIENT SURGERIES - 43. THE EMERGENCY ROOM IS OPEN 24 HOURS A DAY, 7 DAYS A WEEK. DUE TO DECREASED OIL ACTIVITY THE NUMBER OF VISITS HAS DECREASED. TOTAL EMERGENCY ROOM VISITS - 3,479. THE LABORATORY IS LOCATED WITHIN THE HOSPITAL FACILITY. BIRTHDAY LAB SCREENINGS ARE AVAILABLE TO THE COMMUNITY AT THE HOSPITAL AT A REDUCED RATE. TOTAL LABORATORY PROCEDURES - 85,592. ANNUAL HEALTH SCREENING PROCEDURES - 8,615. NUMBER OF MEMBERS TAKING ADVANTAGE OF BIRTHDAY SCREENINGS - 444. 3657074 0 3893510 THE MCKENZIE COUNTY HEALTHCARE SYSTEM (MCHS) GOOD SHEPHERD HOME (GSH) IS A 47 BED SKILLED NURSING HOME WITH AN ATTACHED 9-BED BASIC CARE UNIT. THE GSH OFFERS DAY CARE AND/OR RESPITE CARE FOR THOSE CARING FOR A LOVED ONE IN THEIR HOME. A DEMENTIA SUPPORT GROUP IS OFFERED TO FAMILIES. THEY MAINTAIN REGULAR RESIDENT FAMILY COUNCIL MEETINGS. ALONG WITH QUALIFIED NURSING CARE AND STAFF, SOCIAL SERVICES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, RESTORATIONAL NURSING, LAUNDRY, HOUSEKEEPING, BEAUTICIAN SERVICES, AND ACTIVITY PROGRAMS ARE OFFERED. VISITORS ARE ALWAYS WELCOME AS WELL AS CHILDREN. CHILDREN ARE WELCOME TO VISIT AND PLAY ON THE FENCED OUTDOOR PLAYGROUND EQUIPMENT. PASTORAL CARE AND CHAPEL ARE OFFERED 7 DAYS A WEEK. ACTIVITIES INCLUDE BIRTHDAY PARTIES, MUSICAL GROUPS, BAKING, AND BUS TRIPS. THE SKILLED NURSING TOTAL PERCENT OF OCCUPANCY HAS BEEN 92.8%. THE BASIC CARE UNIT TOTAL PERCENT OF OCCUPANCY HAS BEEN 79.9%. 2044849 0 2095029 THE MCHS CLINIC (RURAL HEALTH CLINIC) MAINTAINS THE SAME MISSION AS THE HOSPITAL. IT PROVIDES CARE MONDAY THRU FRIDAY. THE MEDICAL DIRECTOR, AUGMENTED BY LOCUM PHYSICIANS, PROVIDE EMERGENCY ROOM COVERAGE AT THE HOSPITAL 24 HOURS A DAY X 7 DAYS A WEEK. THE PROVIDERS ALSO MAKE VISITS TO THE GOOD SHEPHERD HOME WEEKLY. THE VISITING NURSE PROGRAM HAS BEEN A GREAT ASSET TO THE CLINIC, PROVIDING CARE TO HOMEBOUND PATIENTS WITHIN OUR COMMUNITY. 196330 0 328793 HORIZON ASSISTED LIVING PROVIDES ASSISTED AND INDEPENDENT LIVING SERVICES. IT CONSISTS OF 15 APARTMENTS THAT PROVIDE A 24 HOUR CALL SYSTEM TO HEALTH CARE PERSONNEL. THE STAFF IS DEDICATED TO HELPING SENIORS LIVE AT THEIR HIGHEST LEVEL OF INDEPENDENCE AND ABILITY. ITS PERCENT OF OCCUPANCY IS CURRENTLY AT 95.5%. 295400 0 0 WELLNESS CENTER 491730 0 328793 15628024 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 33 0 225 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X DANIEL KELLY 7018423000 516 NORTH MAIN STREET WATFORD CITY ND 58854 MYRON HOVET DIRECTOR 1.00 2.00 X 0 0 0 TAMMY JAMES DIRECTOR 1.00 X 0 0 0 NANCY JELLESED DIRECTOR 1.00 X 0 0 0 LARRY LARSEN DIRECTOR 1.00 X 0 0 0 NEAL SHIPMAN DIRECTOR 1.00 X 0 0 0 JULIE WISNESS DIRECTOR (THRU NOVEMBER) 1.00 X 0 0 0 PATSY LEVANG PRESIDENT 2.00 2.00 X X 0 0 0 KELLY PETERSON VICE PRESIDENT 2.00 2.00 X X 0 0 0 MICHON SAX SECRETARY 2.00 X X 0 0 0 SCOTT SWENSON TREASURER 2.00 X X 0 0 0 DANIEL KELLY CEO 40.00 10.00 X 283423 0 27546 SUSIE CURTIS CFO (BEG APRIL) 40.00 X 0 0 0 KENNETH COX CFO (THRU OCTOBER) 40.00 X 153000 0 0 WILLIAM VANNOY CFO (THRU APRIL) 40.00 X 36030 0 3653 CHERYL FAULKNER CNO 40.00 X 90978 0 15829 MICHAEL CURTIS CAO 40.00 X 102671 0 23942 DR GARY RAMAGE PHYSICIAN 40.00 X 303467 0 46078 969569 0 117048 4 0 1 0 CPI GROUP 7400 E ORCHARD RD STE 270 GREENWOOD VILLAGE CO 80111 CONTRUCTION SERVICES 2654031 PRIME TIME HEALTHCARE AMER NATL BANK PO BOX 3544 OMAHA NE 68103 ARCHITECTUAL SERVICES 295109 WIPFLI CPAS & CONSULTANTS PO BOX 3160 MILWAUKEE WI 53201 CONTRACT E.R. DOCTORS 266780 3 3421812 3628759 537048 7587619 HOSPITAL PATIENT SERVICE REVENUE 621400 8529453 8529453 NURSING HOME SERVICE REVENUE 621400 3893510 3893510 CLINIC SERVICE REVENUE 621400 2095029 2095029 WELLNESS CENTER 621400 605086 504250 100836 ASSISTED LIVING SERVICE REVENUE 621400 328793 328793 15451871 3591 3591 38176 38176 453061 300085 152976 152976 -5712 158688 EHR INCENTIVE 621400 100657 100657 340 B REVENUE 621400 95185 95185 CAFETERIA AND DIETARY REVENUE 900099 25207 25207 57673 57673 278722 23512955 15042627 498538 384171 X 733296 733296 6057111 5296319 760792 85397 80876 4521 775782 530646 245136 506128 382422 123706 32140 2580 29560 60000 60000 3949141 3230583 718558 103076 103076 1410993 1117595 293398 323083 222310 100773 324532 321506 3026 56893 21626 35267 21733 16987 4746 155078 155078 1229823 1229823 53253 53253 BAD DEBT & COLLECTION 2777009 2777009 EQUIPMENT RENTAL & MAIN 223571 157799 65772 TAXES AND FEES 70547 70547 RECRUITMENT 47343 47343 198385 84865 113520 19194314 15628024 3566290 0 600 740 1123131 417810 7274200 6797392 2479076 1545922 65830 -7366 233836 56944 59071 86335 34781286 10710098 21369918 24071188 139448 199596 824019 4572081 33569129 37740642 1908449 2053006 240349 139692 5404773 5225745 60148 48148 7613719 7466591 X 17952672 20441761 8002738 9832290 25955410 30274051 33569129 37740642 4318641 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2111 2111 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF AMERICAN HOSPITAL ASSOCIATION, NORTH DAKOTA HOSPITAL ASSOCIATION, AND NORTH DAKOTA LONG TERM CARE ASSOCIATION. A PORTION OF MEMBERSHIP DUES TO THE ABOVE LISTED ASSOCIATIONS IS USED FOR LOBBYING. THESE ASSOCIATIONS ADVOCATE ON BEHALF OF ITS MEMBERS FOR IMPROVING EFFICIENCY AND ACCESSIBILITY OF THE HEALTHCARE DELIVERY SYSTEMS AND THE HEALTH STATUS OF NORTH DAKOTA'S POPULATION. 1468457 1468457 20372890 5616484 14756406 6486139 5093614 1392525 6453800 6453800 24071188 ALATU - DONOR RESTRICTED 1557302 ALATU - BOARD RESTRICTED CAPITAL IMPROVEMENT 3014779 4572081 POSTRETIREMENT BENEFIT OBLIGATION 48148 48148 19138016 485192 485192 18652824 4860131 4860131 23512955 16648927 231622 231622 16417305 2777009 2777009 19194314 PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 300,085. NET ASSETS RELEASED FROM RESTRICTIONS 185,107. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,777,009. RESTRICTED CONTRIBUTIONS AND PLEDGES 2,014,659. REVENUE INCLUDED IN EXPENSES 68,463. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 300,085. REVENUE INCLUDED IN EXPENSES -68,463. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,777,009. 1 1 X 1 X 1 X 1 1 0 0 7050 7050 0.00040 2699322 2668779 30543 0.00190 2706372 2668779 37593 0.00230 2510621 2427723 82898 0.00500 2510621 2427723 82898 0.00500 5216993 5096502 120491 0.00730 17213 17213 0.00100 17213 17213 0.00100 0 2478808 247881 3001819 2955447 46372 X 1 1 1 1 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 516 N MAIN WATFORD CITY ND 58854 HTTP://MCKENZIEHEALTH.COM/ 5051A X X X X X SWING BED UNIT MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE SUPPLMENTAL INFORMATION X X 1 15 1 SEE SUPPLEMENTAL INFORMATION 1 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X X X X X X 1 X 0 X X X X 1 X 1 0 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 5: APPROXIMATELY 350 PRINTED SURVEYS WERE DISTRIBUTED TO AREA RESIDENTS THROUGH VARIOUS CHANNELS THROUGHOUT THE COMMUNITY. 54 SURVEYS WERE RETURNED AND THE HOSPITAL IDENTIFIED SOME INFORMATION GAPS BASED ON THE DEMOGRAPHIC INFORMATION FROM THE SURVEYS RETURNED COMPARED TO TOTAL DEMOGRAPHIC INFORMATION. THEN INFORMATION INTERVIEWS WERE CONDUCTED. INTERVIEWS WERE 2 HOURS LONG AND CONDUCTED WITH 12 MEMBERS CHOSEN FROM THE COMMUNITY. INCLUDED AMONG THOSE INTERVIEWED WAS A PUBLIC HEALTH NURSE, PUBLIC SERVANTS, SCHOOL ADMINISTRATORS, THE COUNTY SHERIFF, BUSINESS PERSONS AND HEALTHCARE ADMINISTRATORS. MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 7D: CHNA WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/04/3-CHNA-FINAL-REPORT-3.PDFIMPLEMENTATION STRATEGY WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/04/IMPLEMENTATION-STRATEGY-PLANNING.PDF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 11: SEE ATTACHMENT MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 16I: IN ADDITION TO PROVIDING THE FULL POLICY UPON REQUEST, A SUMMARY OF THE POLICY IS POSTED IN THE EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE. UPON ADMISSION THE PATIENTS RECEIVE A BROCHURE IN A PACKET REFERENCING THE FINANCIAL ASSISTANCE POLICY. THE PATIENTS ALSO RECEIVE INFORMATION IN THEIR FIRST BILLING INVOICE REGARDING THE FINANCIAL ASSISTANCE POLICY.FAP WEBSITE:HTTP://MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/03/CHARITY-CARE-APPLICATION-PROCESS.PDFFAP APPLICATION WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/04/SLIDING-FEE-SCHEDULE-APPLICATION-1.PDFFAP PLAIN LANGUAGE:HTTP://MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/03/CHARITY-CARE-APPLICATION-PROCESS.PDF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 22D: THE MAXIMUM AMOUNT CHARGED TO A PATIENT UNDER THE FINANCIAL ASSISTANCE POLICY FOR EMERGENCY AND MEDICALLY NECESSARY CARE IS 80% OF THE GROSS CHARGES. THIS IS BASED ON THE LOWEST DISCOUNT UNDER THE CHARITY CARE POLICY OF 20%. THE HOSPITAL WILL REVIEW THE PROPOSED METHODS TO DETERMINE AMOUNTS GENERALLY BILLED TO DETERMINE IF ITS DISCOUNT UNDER THE FINANCIAL ASSISTANCE POLICY MEETS THE REQUIREMENTS OF 501(R). MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 23: THE HOSPITAL HAS NOT DETERMINED THE AMOUNT GENERALLY BILLED UNDER THE VARIOUS PROPOSED METHODS OF CALCULATION. THEREFORE, IT IS POSSIBLE A PATIENT UNDER THE FINANCIAL ASSISTANCE POLICY COULD HAVE PAID MORE THAN THE AMOUNT GENERALLY BILLED. THE HOSPITAL WILL REVIEW THE VARIOUS METHODS TO DETERMINE AMOUNTS GENERALLY BILLED TO ENSURE IT IS IN COMPLIANCE WITH SECTION 501(R). MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 24: ALL INDIVIDUALS ELIGIBLE UNDER THE HOSPITAL FINANCIAL ASSISTANCE POLICY ARE PROVIDED A DISCOUNT FOR EMERGENCY AND OTHER MEDICALLY NECESSARY CARE. THE FINANCIAL ASSISTANCE POLICY DOES NOT APPLY TO ELECTIVE PROCEDURES. THEREFORE, FAP-ELIGIBLE PATIENTS WITHOUT INSURANCE MAY BE CHARGED GROSS CHARGES ON ELECTIVE PROCEDURES. 5 1 - MCKENZIE COUNTY CLINIC 525 N MAIN ST WATFORD CITY ND 58854 RURAL HEALTH CENTER 2 - GOOD SHEPHERD HOME 709 4TH AVE NE WATFORD CITY ND 58854 LT CARE & BASIC CARE 3 - CONNIE WOLD WELLNESS CENTER 200 8TH ST NE WATFORD CITY ND 58854 WELLNESS CENTER 4 - HORIZONS 705 4TH AVE NE WATFORD CITY NE 58854 ASSISTED LIVING COMPLEX 5 - HERITAGE MANOR 709 4TH AVE NE WATFORD CITY NE 58854 APARTMENT COMPLEX PART I, LINE 7: THE ORGANIZATION UTILIZES THEIR COST REPORT TO DETERMINE THE COST-TO-CHARGE RATIO. THE COST REPORT IS BASED OFF OF THE INTERNAL REPORTING SYSTEM USED BY THE ORGANIZATION. PART I, LINE 7G: THE ORGANIZATION INCLUDED THE OPERATIONS OF THEIR RURAL HEALTH CLINIC IN THE SUBSIDIZED SERVICES CALCULATION. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,777,009. PART III, LINE 2: THIS IS THE AMOUNT OF BAD DEBT EXPENSE RECORDED ON THE FINANCIAL STATEMENTS AT THE COST-TO-CHARGE RATIO. PART III, LINE 3: IT IS ESTIMATED THAT 10 PERCENT OF THE BAD DEBT EXPENSE RECORDED BY THE ORGANIZATION IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATIN'S FINANCIAL ASSISTANCE POLICY. PART III, LINE 4: PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT AND RESIDENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FOR UNINSURED PATIENTS AND AMOUNTS PATIENTS AND RESIDENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABLILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH SYSTEMS ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 9B: THE ORGANIZATION DOES NOT COLLECT ON ACCOUNTS THAT HAVE A FINANCIAL ASSISTANCE APPLICATION IN REVIEW OR THAT HAS BEEN APPROVED. IF THE ACCOUNT IS NOT COMPLETELY WRITTEN OFF (BASED ON THE SLIDING FEE SCHEDULE) AND THEY DO NOT FOLLOW THROUGH ON THEIR PAYMENT PLAN FOR THE BALANCE, THAT WOULD BE THE ONLY TIME THE ACCOUNT WAS OUTSOURCED TO COLLECTIONS. PART VI, LINE 2: SEPARATE EVALUATIONS ARE COMPLETED ANNUALLY FOR THE CRITICAL ACCESS HOSPITAL AND THE RURAL HEALTH CLINIC. AT THIS TIME SERVICES AND STATISTICS ARE REVIEWED. EACH REPORT IS PRESENTED TO THE MEDICAL STAFF MEMBERS AND BOARD OF DIRECTORS. CURRENT SERVICES ARE DISCUSSED ALONG WITH THE NEEDS NOT CURRENTLY BEING MET. MANAGERS OF EACH DEPARTMENT ANNUALLY REVIEW THEIR SERVICES WITH THE BUDGETING PROCESS AND DISCUSS POSSIBLE PROJECTION OF NEW SERVICES. ONCE A NEED IS DETERMINED, IT IS DISCUSSED ON A DEPARTMENTAL LEVEL, INFORMATION IS GATHERED AND PRESENTED TO THE CEO/CFO FOR APPROVAL. MCHS HOLDS THEIR ANNUAL MEETING FOR THE PUBLIC IN THE FALL OF EACH CALENDAR YEAR. THIS IS AN OPEN MEETING ALLOWING THE PUBLIC TO VOICE CONCERNS AND SUGGESTIONS. PART VI, LINE 3: THE MCHS CHARITY CARE POLICY IS POSTED IN THE HOSPITAL AND CLINIC ADMISSIONS AREAS AND EMERGENCY ROOM. COPIES OF THE POLICY AND APPLICATIONS ARE AVAILABLE IN EACH RECEPTION AREA OF THE HOSPITAL AND CLINIC. INFORMATION IS SENT OUT TO ALL PATIENTS WITH THEIR FIRST STATEMENT. IF A BILL IS UNPAID, AFTER TWO STATEMENTS HAVE BEEN SENT, A BILLING EMPLOYEE WILL ATTEMPT TO REACH THE RESPONSIBLE PARTY BY PHONE TO DISCUSS INSTALLMENT PLANS, CHARITY CARE, AND/OR DISCUSS VARIOUS GOVERNMENT BENEFITS SUCH AS MEDICAID. THE MCHS BUSINESS OFFICES ALSO HAVE THE APPLICATIONS AT ALL TIMES. THE BUSINESS OFFICE STAFF WILL COUNSEL ANYONE WHO PRESENTS THEMSELVES WITH OVERDUE BALANCES AND PRESENT THE ABOVE OPTIONS. PART VI, LINE 4: MCKENZIE COUNTY HEALTHCARE SERVICES SERVES MCKENZIE COUNTY. MCKENZIE COUNTY IS THE LARGEST COUNTY IN THE STATE OF NORTH DAKOTA. IT IS VERY RURAL AND INCLUDES PART OF THE FORT BERTHOLD RESERVATION. MCKENZIE COUNTY HOSPITAL IS THE ONLY HEALTHCARE SYSTEM WITHIN A 45 MILE RADIUS. THE COUNTY'S POPULATION WAS ESTIMATED IN 2010 AT 6,380. THE MEDIAN HOUSEHOLD INCOME IN 2010 WAS REPORTED AT $48,480. 100% OF THE POPULATION WAS REPORTED BELOW THE POVERTY LEVEL IN 2010. THE RUGGED TERRAIN, WINTER CONDITIONS, INCREASED OIL ACTIVITY, AND RECREATIONAL ACTIVITIES HAVE ALL ADDED TO THE INCREASED NUMBER OF EMERGENCY ROOM VISITS. WITH THE RECENT OIL ACTIVITY IN THE STATE, MCKENZIE COUNTY IS EXPERIENCING A RAPID INCREASE IN POPULATION, NEW BUSINESSES, HOUSING PROJECTS, AND IMPROVED WAGE SCALES. WITH THIS RAPID GROWTH, MCHS IS EXPERIENCING AN INFLUX IN EMERGENCY ROOM SERVICES, SHORTAGE OF PHYSICIANS AND NURSES, AS WELL AS GROWING BAD DEBT EXPENSES RELATED TO MEDICAL SERVICES PROVIDED TO UNINSURED WORKERS AND PATIENTS THAT DO NOT HAVE A PERMANENT RESIDENCE TO SEND BILLS TO. PART VI, LINE 5: THE MCKENZIE COUNTY BOARD OF DIRECTORS IS MADE UP OF VOLUNTEER MEMBERS FROM THE LOCAL COMMUNITY OF WATFORD CITY AND THE SURROUNDING AREAS. MCHS DOES EXTEND PRIVILEGES TO ALL PHYSICIANS IN THE AREA. SPECIALISTS WILL ALSO VISIT THE LOCAL HOSPITAL AND CLINIC TO EXPAND THE PRESENT SERVICES. SURPLUS FUNDS ARE APPLIED FOR THE PURPOSES EDUCATION, INCREASING PATIENT SERVICES, WELLNESS, AND PREVENTATIVE CARE TO ITS CLIENTS. MCKENZIE COUNTY HEALTHCARE SYSTEMS AND THE MCKENZIE COUNTY HEALTHCARE SYSTEMS BENEFIT FUND TOGETHER ENGAGED IN THE BUILDING AND FUNDING OF A NEW WELLNESS CENTER. THE WELLNESS CENTER OPENED IN MARCH 2013. THE WELLNESS CENTER HOUSES A NEW PHYSICAL THERAPY DEPARTMENT TO BETTER UTILIZE A THERAPY POOL AND HAS INCREASED THE PRESENT SQUARE FOOTAGE OF THE HOSPITAL. PREVENTION IS A KEY WORD TODAY. THE WELLNESS CENTER PROVIDES EDUCATION AND EXERCISE TO ITS MEMBERS. IT WILL HELP IMPROVE OR PREVENT DISEASES LIKE DIABETES, HIGH BLOOD PRESSURE, OBESITY, DEPRESSION, AND MANY NOT LISTED. PART VI, LINE 6: N/A X X X 0 0 0 0 0 0 0 0 0 DANIEL KELLY CEO 245060 0 38363 0 0 0 19293 0 8253 0 310969 0 0 0 KENNETH COX CFO (THRU OCTOBER) 153000 0 0 0 0 0 0 0 0 0 153000 0 0 0 DR GARY RAMAGE PHYSICIAN 302779 0 688 0 0 0 11183 0 34895 0 349545 0 0 0 LESLIE KELLY SPOUSE OF CEO 47123 EMPLOYEE SALARY 0 SAMUEL KELLY SON OF CEO 23082 EMPLOYEE SALARY 0 DANIELLE KELLY DAUGHTER OF CEO 10377 EMPLOYEE SALARY 0 FORM 990, PART VI, SECTION A, LINE 2 MICHAEL CURTIS AND SUSIE CURTIS HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11 THE MCHS CEO AND CFO REVIEW AND APPROVE THE FORM 990. THE BOARD OF DIRECTORS RECEIVE A COPY OF THE FINAL FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C AN INTERESTED PERSON IS DEFINED AS ANY DIRECTOR, PRINCIPAL OFFICER, AND ANYONE WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST WITH RESPECT TO ALL ENTITIES IN THE HEALTHCARE SYSTEM. AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND WILL BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS. THE CONFLICT WILL BE REVIEWED BY THE REMAINING BOARD AND WILL DETERMINE IF A CONFLICT EXISTS. IF A CONFLICT EXISTS, THE INTERESTED PERSON MUST ABSTAIN FROM VOTING ON THE ISSUE AND THE REMAINING BOARD MEMBERS WILL DETERMINE IF THE TRANSACTION IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND IF IT IS FAIR AND REASONABLE. THIS IS ACCOMPLISHED THROUGH ANNUAL REVIEW AND A SIGNED STATEMENT STATING THAT THE INTERESTED PERSON HAS OBTAINED A COPY OF THE POLICY AND HAS READ AND UNDERSTANDS THE POLICY, AND HAS AGREED TO COMPLY WITH THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A MEMBERS OF THE BOARD OF TRUSTEES REVIEW STATE-WIDE SALARY SURVEY INFORMATION AND OTHER FORM 990'S WHEN DETERMINING ANY WAGE CHANGES. THE CEO HAS AN ANNUAL EVALUATION COMPLETED EACH YEAR. THE CEO HAS THE OPPORTUNITY TO GIVE A PROPOSAL TO THE BOARD AT HIS EVALUATION. ANY CHANGE OR REVISION IS RECORDED IN THE BOARD MINUTES. AN ADDENDUM TO THE TERMS OF EMPLOYMENT IS SIGNED BY THE BOARD PRESIDENT AND CEO FOR THE PERSONNEL FILE. THE CEO APPROVES THE CFO COMPENSATION BASED UPON SURVEY DATA ON AN ANNUAL BASIS. THE RESULTS ARE DOCUMENTED IN THE CFO'S ANNUAL EVALUATION PAPERWORK. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G EMERGENCY ROOM PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,545,596. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,545,596. ACUTE CARE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 337,121. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 337,121. CLINIC MD PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 376,207. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 376,207. NURSING HOME PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 650,666. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 650,666. OTHER CONTRACTOR SERVICES: PROGRAM SERVICE EXPENSES 320,993. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 320,993. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 718,558. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 718,558. THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 709 4TH AVE NE WATFORD CITY ND 58854 363431210 TO SUPPORT THE MCKENZIE COUNTY HEALTHCARE SYSTEMS ND 501(C)(3) LINE 7 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 MCKENZIE COUNTY HEALTHCARE SYSTEMS PROPERTIES 516 N MAIN ST WATFORD CITY ND 58854 462905447 PROPERTY MANAGEMENT ND MCKENZIE COUNTY HEALTHCARE SYSTEMS INC C 1.00000 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 0 1 0 THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC C 3421812 ACTUAL