2017-05-15T11:27:32-05:00 2016-06-30 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2015-07-01 450310159 CHRISTIAN UNITY HOSPITAL CORPORATION CHRI 7013529365 164 WEST 13TH STREET GRAFTON ND 58257 ALAN O'NEIL CHIEF EXECUTIVE OFFICER 7013529365 2017-05-10 1 TIM A RITTER CPA P00732856 9525483400 2017-05-10 2015 2021-01-29 14:40:06Z UNITY MEDICAL CENTER ALAN O'NEIL 164 WEST 13TH STREET GRAFTON ND 58257 11112881 0 X WWW.UNITYMEDCENTER.COM X 1970 ND PROVIDE ACCESS TO QUALITY HEALTH CARE FOR THE REGION. 9 8 137 30 0 0 561684 504334 9340742 10494096 0 276 40548 114175 9942974 11112881 0 0 0 0 5422362 6106998 0 0 0 4188390 4351146 9610752 10458144 332222 654737 5266243 5516233 3000458 2595711 2265785 2920522 X UNITY MEDICAL CENTER PROVIDES ACCESS TO QUALITY HEALTH CARE FOR THE REGION. 0 0 8691226 0 10552598 UNITY MEDICAL CENTER IS A 14 BED HEALTHCARE FACILITY, WHICH PROVIDES EMERGENCY CARE, ACUTE CARE SERVICES, OUTPATIENT SERVICES AND CLINICAL MEDICAL SERVICES TO THE RESIDENTS OF GRAFTON, NORTH DAKOTA AND SURROUNDING COMMUNITIES. THE FACILITY PROVIDES OUTREACH SERVICES SUCH AS PHYSICAL THERAPY, RESPIRATORY THERAPY, AND FLU VACCINATION CLINICS TO OTHER EMPLOYERS IN THE AREA AS WELL. FOR THE FISCAL YEAR ENDED JUNE 30, 2016 THE MEDICAL CENTER PROVIDED AS PART OF ITS MISSION 613 ACUTE DAYS, 961 SWING BED DAYS, 56 RESPITE DAYS AND 11,253 CLINIC VISITS. THE AMOUNT OF CHARGES FOREGONE FOR SERVICES PROVIDED UNDER THE ORGANIZATION'S CHARITY CARE POLICY WAS APPROXIMATELY $40,100 FOR THE FISCAL YEAR. TOTAL DIRECT AND INDIRECT COSTS RELATED TO THESE FOREGONE CHARGES WAS $29,700, BASED ON AN AVERAGE RATIO OF COSTS TO GROSS CHARGES. 8691226 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 32 0 1 137 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X ALAN O'NEIL 7013529365 164 WEST 13TH STREET GRAFTON ND 58257 TOM CAMPBELL BOARD MEMBER 1.50 X 0 0 0 RUSSELL CARIGNAN BOARD MEMBER 1.50 X 0 0 0 ROGER GORDER BOARD MEMBER 1.50 X 0 0 0 MARY HOUDEK BOARD MEMBER (THRU JANUARY) 1.50 X 0 0 0 TODD MORGAN BOARD MEMBER 1.50 X 0 0 0 DR JOSHUA OMOTUNDE BOARD MEMBER 40.00 X 274463 0 25639 HEIDI PAULSON BOARD MEMBER 1.50 X 0 0 0 JO PETERSON PRESIDENT 2.00 1.00 X X 0 0 0 PASTOR CHRIS GAULE VICE PRESIDENT 2.00 X X 0 0 0 AMY VOLLRATH SECRETARY/TREASURER 1.50 X X 0 0 0 ALAN O'NEIL CHIEF EXECUTIVE OFFICER 40.00 X 159994 0 2859 RACHEL RAY CHIEF FINANCIAL OFFICER 40.00 X 70693 0 7670 MIRIAM ANDERSON FAMILY NURSE PRACTITIONER 40.00 X 153911 0 17285 DR LINDA FILLIPI PHYSICIAN 40.00 X 139298 0 10214 MARCIA KETTERLING FAMILY NURSE PRACTITIONER 40.00 X 166200 0 14988 DR ELIZABETH SUNDBERG PHYSICIAN 40.00 X 170719 0 12145 1135278 0 90800 6 0 1 0 DMS 26283 NETWORK PLACE CHICAGO IL 60673 MOBILE SERVICES 312815 CRL 7505 METROL BOULEVARD STE MN 55439 RADIOLOGY READINGS 130471 ALTRU PO BOX 13780 GRAND FORKS ND 58208 EPIC TELEPHARMACY 115221 SIEMAN'S PO BOX 121102 DALLAS TX 75312 REAGENT TESTING SERVICES 107986 4 41695 346742 115897 504334 NET PATIENT SERVICE REVENUE 621300 10377301 10377301 OTHER MEDICAL SERVICES REVENUE 621300 116795 116795 10494096 276 276 EHR INCENTIVE REVENUE 621300 58502 58502 55673 55673 114175 11112881 10552598 0 55949 5251309 4246341 1004968 750 750 500928 405063 95865 354011 286262 67749 14682 14682 49010 49010 989489 970412 19077 53322 53322 582724 505949 76775 114531 114531 164907 142988 21919 37981 24404 13577 25 25 120772 120772 339051 293985 45066 104297 104297 MEDICAL SUPPLIES 1077237 1077237 PROVISION FOR BAD DEBT 541125 541125 COMMUNICATIONS 100360 33245 67115 DUES AND SUBSCRIPTIONS 25698 13383 12315 35935 30060 5875 10458144 8691226 1766918 0 180694 170620 589668 969557 1828094 0 0 1775283 117184 115636 36325 51311 10627410 8388806 2334301 2238604 179977 195222 5266243 5516233 949776 623993 2035000 1937150 15682 34568 3000458 2595711 X 2206938 2861675 58847 58847 2265785 2920522 5266243 5516233 654737 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 1882 1882 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF AMERICAN HOSPITAL ASSOCIATION, NORTH DAKOTA HOSPITAL ASSOCIATION, AND NORTH DAKOTA MEDICAL 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. 43017 43017 7784594 6001546 1783048 2778310 2387260 391050 21489 21489 2238604 10571756 0 10571756 541125 541125 11112881 9917019 0 9917019 541125 541125 10458144 PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 541,125. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBT 541,125. 1 1 X 1 X 1 X 1 1 1 0 0 44258 44258 0.00450 714016 646527 67489 0.00680 758274 646527 111747 0.01130 2500 2500 0.00030 3121720 2930757 190963 0.01930 3124220 2930757 193463 0.01960 3882494 3577284 305210 0.03090 0 397349 39735 4851527 5636750 -785223 X 1 1 1 1 CHRISTIAN UNITY HOSPITAL CORPORATION 164 WEST 13TH STREET GRAFTON ND 58257 WWW.UNITYMEDICALCENTER.COM 5020 X X X X RURAL HOSPITAL CHRISTIAN UNITY HOSPITAL CORPORATION 1 0 0 1 X X X X X X X X X 15 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X 1 15 1 SEE SUPPLEMENTAL INFORMATION 1 0 1 X 100.000000000000 200.000000000000 X 1 1 X X X X X 1 X SEE PART V, PAGE 7 X SEE PART V, PAGE 7 X SEE PART V, PAGE 7 X X X X X 1 X 0 X X X X X 1 X 0 0 CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 5: ONE-ON-ONE INTERVIEWS WITH EIGHT KEY INFORMANTS WERE CONDUCTED IN PERSON IN GRAFTON ON MARCH 16TH OR BY PHONE FOR THOSE UNAVAILABLE. A REPRESENTATIVE FROM THE CENTER FOR RURAL HEALTH CONDUCTED THE INTERVIEWS. INTERVIEWS WERE HELD WITH SELECTED MEMBERS OF THE COMMUNITY GROUP AS WELL AS OTHER KEY INFORMANTS WHO COULD PROVIDE INSIGHTS INTO THE COMMUNITY'S HEALTH NEEDS. INCLUDED AMONG THE INFORMANTS WERE PUBLIC HEALTH PROFESSIONALS WITH SPECIAL KNOWLEDGE IN PUBLIC HEALTH ACQUIRED THROUGH SEVERAL YEARS OF DIRECT EXPERIENCE IN THE COMMUNITY, INCLUDING WORKING WITH MEDICALLY UNDERSERVED, LOW INCOME, AND MINORITY POPULATIONS, AS WELL AS WITH POPULATIONS WITH CHRONIC DISEASES.TOPICS COVERED DURING THE INTERVIEWS INCLUDED THE GENERAL HEALTH NEEDS OF THE COMMUNITY, THE GENERAL HEALTH OF THE COMMUNITY, COMMUNITY CONCERNS, DELIVERY OF HEALTH CARE BY LOCAL PROVIDERS, AWARENESS OF HEALTH SERVICES OFFERED LOCALLY, BARRIERS TO RECEIVING HEALTH SERVICES, AND SUGGESTIONS FOR IMPROVING COLLABORATION WITHIN THE COMMUNITY. A SURVEY WAS DISTRIBUTED TO GATHER FEEDBACK FROM THE COMMUNITY. THE SURVEY WAS NOT INTENDED TO BE A SCIENTIFIC OR STATISTICALLY VALID SAMPLING OF THE POPULATION. RATHER, IT WAS DESIGNED TO BE AN ADDITIONAL TOOL FOR COLLECTING QUALITATIVE DATA FROM THE COMMUNITY AT LARGE SPECIFICALLY; INFORMATION RELATED TO COMMUNITY-PERCEIVED HEALTH NEEDS. A COPY OF THE SURVEY INSTRUMENT IS INCLUDED IN APPENDIX A.THE COMMUNITY MEMBER SURVEY WAS DISTRIBUTED TO A VARIETY OF RESIDENTS OF WALSH COUNTY, AND WAS DESIGNED TO: -LEARN OF THE GOOD THINGS IN THE COMMUNITY AND THE COMMUNITY'S CONCERNS; -UNDERSTAND PERCEPTIONS AND ATTITUDES ABOUT THE HEALTH OF THE COMMUNITY, AND HEAR SUGGESTIONS FOR IMPROVEMENT; AND -LEARN MORE ABOUT HOW LOCAL HEALTH SERVICES ARE USED BY RESIDENTS. SPECIFICALLY, THE SURVEY COVERED THE FOLLOWING TOPICS: RESIDENTS' PERCEPTIONS ABOUT COMMUNITY ASSETS, LEVELS OF COLLABORATION WITHIN THE COMMUNITY, BROAD AREAS OF COMMUNITY AND HEALTH CONCERNS, NEED FOR HEALTH SERVICES, CONCERNS ABOUT THE DELIVERY OF HEALTH CARE IN THE COMMUNITY, BARRIERS TO USING LOCAL HEALTH CARE, PREFERENCES FOR USING LOCAL HEALTH CARE VERSUS TRAVELING TO OTHER FACILITIES, USE OF PREVENTIVE CARE, USE OF PUBLIC HEALTH SERVICES, SUGGESTIONS TO IMPROVE COMMUNITY HEALTH, AND BASIC DEMOGRAPHIC INFORMATION. TO PROMOTE AWARENESS OF THE ASSESSMENT PROCESS, PRESS RELEASES LED TO PUBLISHED ARTICLES IN FOUR NEWSPAPERS IN WALSH COUNTY INCLUDING IN THE COMMUNITIES OF GRAFTON, PARK RIVER, FORDVILLE, EDMORE, AND ADAMS. ADDITIONALLY, INFORMATION WAS PUBLISHED IN THE WALSH COUNTY HEALTH DISTRICT NEWSLETTER AND ON THE UMC AND WCHD WEBSITES AND ON KXPO RADIO IN GRAFTON. APPROXIMATELY 1,000 COMMUNITY MEMBER SURVEYS WERE AVAILABLE FOR DISTRIBUTION IN WALSH COUNTY. THE SURVEYS WERE DISTRIBUTED BY COMMUNITY GROUP MEMBERS AND AT UNITY MEDICAL CENTER, FIRST CARE HEALTH CENTER, WALSH COUNTY HEALTH AND WIC, BANKS, SENIOR CITIZEN MEAL SITES, NURSING HOMES, THE COURTHOUSE, AND AREA BUSINESS OFFICES. TO HELP ENSURE ANONYMITY, INCLUDED WITH EACH SURVEY WAS A POSTAGE-PAID RETURN ENVELOPE TO THE CENTER FOR RURAL HEALTH. IN ORDER TO MAKE THE SURVEY AVAILABLE AS WIDELY AS POSSIBLE RESIDENTS COULD ALSO REQUEST A SURVEY BY CALLING WALSH COUNTY HEALTH DISTRICT, UNITY MEDICAL CENTER OR FIRST CARE HEALTH CENTER. THE SURVEY WAS OPEN FROM FEBRUARY 22, 2016 TO MARCH 30, 2016; 444 PAPER SURVEYS WERE RETURNED. CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 6A: FIRST CARE HEALTH CENTER CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 6B: WALSH COUNTY PUBLIC HEALTH CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 11: SEE PAGE 49 OF THE ATTACHED 2016 CHNA. WEBSITE ADDRESS FOR CHNA AND IMPLEMENTATION STRATEGY:WWW.UNITYMEDCENTER.COM/ABOUT-US/HIPAA.HTML CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 15E: PATIENTS WHO DO NOT PAY AFTER 90 DAYS MEET WITH THE PATIENT ACCOUNT REPRESENTATIVE AND GO OVER THEIR AVAILABLE OPTIONS INCLUDING FINANCIAL ASSISTANCE. THE ORGANIZATION POSTS THE EMTALA LAW IN THEIR EMERGENCY ROOM. THE ORGANIZATION IS ALSO WEIGHING THEIR OPTIONS OF HOW TO MAKE THEIR FINANCIAL ASSISTANCE POLICY MORE WIDELY AVAILABLE TO THE PUBLIC INCLUDING THE POSSIBILITY OF POSTING THE POLICY ON THEIR WEBSITE. CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 16I: FAP WWW.UNITYMEDCENTER.COM/ABOUT-US/HIPAA.HTMLFAP APPLICATIONWWW.UNITYMEDCENTER.COM/ABOUT-US/HIPAA.HTMLFAP PLAIN LANGUAGE SUMMARYWWW.UNITYMEDCENTER.COM/ABOUT-US/HIPAA.HTML CHRISTIAN UNITY HOSPITAL CORPORATION PART V, SECTION B, LINE 22D: THE ORGANIZATION USED THE "LOOK-BACK METHOD" USING A COMBINATION OF MEDICARE, MEDICAID, AND PRIVATE INSURERS TO DETERMINE AMOUNTS GENERALLY BILLED. 1 1 - GRAFTON FAMILY CLINIC 155 WEST 14TH STREET GRAFTON ND 58257 RURAL HEALTH CLINIC PART I, LINE 3C: THE ORGANIZATION DOES FOLLOW THE FEDERAL POVERTY GUIDELINES (FPG) WHEN DETERMINING DISCOUNTED CARE, BUT THEY HAVE SET UP THREE DIFFERENT RANGES WITHIN THE GUIDELINES. A PATIENT WILL PAY 30%, 60% OR 80% OF THEIR BILL DEPENDING UPON WHERE THEIR INCOME FALLS. THE PATIENT IS RESPONSIBLE FOR 30% OF THEIR BILL IF THEIR INCOME IS 100% TO 132% OF THE FPG. THE PATIENT IS RESPONSIBLE FOR 60% OF THEIR BILL IF THEIR INCOME FALLS BETWEEN 133% TO 166% OF THE FPG. THE PATIENT IS RESPONSIBLE FOR 80% OF THEIR BILL IF THEIR INCOME FALLS BETWEEN 167% AND 200% OF THE FPG. IF THE INDIVIDUAL FALLS BELOW THE MINIMUM CRITERIA, THAT PERSON IS ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE, OR FREE CARE. PART I, LINE 7: THE ORGANIZATION USES THE MEDICARE COST REPORT IN DETERMINING THE COST-TO-CHARGE RATIO. PART I, LINE 7G: AMOUNTS USED FOR SUBSIDIZED SERVICES WERE CALCULATED USING DETAILED REPORT DATA KEPT BY THE ORGANIZATION. THE ORGANIZATION INCLUDED DATA FOR EMERGENCY SERVICES AND THEIR RURAL HEALTH CLINIC IN LINE 7G. THE AMOUNTS FOR RURAL HEALTH CLINIC WAS A COST OF 1,906,664 WITH OFFSETTING REVENUE OF 1,852,610. SUBSIDIZED SERVICES ARE DETERMINED BY THE ORGANIZATION DUE TO THE NEED IN THE COMMUNITY THAT CAN ONLY BE FILLED BY THE ORGANIZATION. 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 $ 541,125. PART III, LINE 2: THIS AMOUNT IS CALCULATED BY MULTIPLYING THE TOTAL CHARGES FOR SERVICES WRITTEN OFF AS BAD DEBT BY THE COST TO CHARGE RATIO. PART III, LINE 3: 9.9% OF THE INDIVIDUALS IN WALSH COUNTY, NORTH DAKOTA (IN WHICH THE HOSPITAL IS LOCATED) FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO CENSUS.GOV. THEREFORE, THE ORGANIZATION ESTIMATES THAT 9.9% OF THE BAD DEBT EXPENSE AT COST IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND SO THEREFORE THIS IS A COMMUNITY BENEFIT. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FOR UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.FINANCIAL STATEMENT FOOTNOTE 3 ACCOUNTS RECEIVABLE:THE ORGANIZATION'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS DECREASED FROM 70% OF SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2015, TO 68% SELF-PAY ACCOUNTS RECEIVABLE AT JUNE 30, 2016. THE ORGANIZATION DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR DOUBTFUL ACCOUNTS FROM THIRD-PARTY PAYERS, NOR DID IT HAVE SIGNIFICANT WRITE-OFFS FROM THIRD-PARTY PAYERS. THE ORGANIZATION HAS NOT SIGNIFICANTLY CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEARS 2016 OR 2015. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CENTERS FOR MEDICARE AND MEDICAID SERVICES.CHRISTIAN UNITY HOSPITAL CORPORATION PROVIDES MEDICALLY NECESSARY CARE TO ALL REGARDLESS OF THE ABILITY TO PAY. PROVIDING SERVICES TO THOSE ELIGIBLE FOR MEDICARE IS A BENEFIT TO THE COMMUNITY AS ELDERLY ARE A CHARITABLE CLASS. THEREFORE ALL OF THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. PART III, LINE 9B: IF AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION HAS BEEN SUBMITTED, THE PATIENT ACCOUNTS REPRESENTATIVE WILL WORK WITH THE PATIENT TO GATHER ANY MISSING OR OUTSTANDING ITEMS. ANY COLLECTION ACTIONS ARE STOPPED AFTER THE PATIENT SUBMITS AN APPLICATION FOR FINANCIAL ASSISTANCE UNTIL IT IS DETERMINED WHETHER OR NOT THE INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IF THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, ANY COLLECTION ACTIONS ALREADY TAKEN AGAINST THE INDIVIDUAL WOULD BE REVERSED. THE PATIENT ACCOUNTS REPRESENTATIVE DOCUMENTS WHETHER OR NOT THE INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: THROUGHOUT THE YEAR THE ORGANIZATION IS PROACTIVE IN DETERMINING WHAT NEEDS THEY CAN ADDRESS FOR THEIR COMMUNITY. IN BETWEEN CHNA'S THE ORGANIZATION CAN DETERMINE AREAS THAT THEY CAN ADDRESS. SOME EXAMPLES OF THESE AREAS ARE THE ORGANIZATION OBTAINED SERVICES FROM AN OUTREACH PODIATRIST. THE ORGANIZATION PURCHASED EQUIPMENT FOR HIM TO BE ABLE TO PERFORM SURGERIES IN OUR FACILITY, AS WELL AS SEE CLINIC PATIENTS. THE ORGANIZATION ALSO HAS DERMATOLOGY SERVICES AVAILABLE IN THEIR RURAL HEALTH CLINIC SEVERAL TIMES PER MONTH. THIS HAS BEEN VERY SUCCESSFUL. PART VI, LINE 3: A SIGN NEAR THE ENTRANCE TO THE EMERGENCY ROOM INDICATES WE "PROVIDE MEDICAL CARE FOR THOSE WHO CANNOT AFFORD TO PAY." ANOTHER POSTING STATES THAT "THE FACILITY IS LEGALLY OBLIGATED TO SERVE THE COMMUNITY." FOR THOSE PATIENTS WHO DO NOT PAY ON THEIR BALANCES, WE CONTACT THEM BY PHONE AND/OR THROUGH THE MAIL. THEY VISIT WITH OUR PATIENT ACCOUNT REPRESENTATIVE. THE REPRESENTATIVE DISCUSSES PAYMENT ARRANGEMENTS, ELIGIBILITY FOR CERTAIN PROGRAMS, SUCH AS MEDICAID, AND THEN CHARITY CARE, IF NECESSARY. IF WE CANNOT GET THOSE PATIENTS TO COME IN AND TALK, WE ATTEMPT TO MAKE ARRANGEMENTS OVER THE PHONE AND THROUGH THE MAIL, IF NECESSARY. WE DO HAVE SEVERAL PATIENTS WHO WILL NOT EVEN ATTEMPT TO COMPLETE FINANCIAL ASSISTANCE PAPERWORK. PART VI, LINE 4: GRAFTON IS A RURAL COMMUNITY OF APPROXIMATELY 4,284 RESIDENTS LOCATED IN WALSH COUNTY, NORTH DAKOTA. THE MEDIAN HOUSEHOLD INCOME FOR WALSH COUNTY IS $49,780, BELOW THE STATE AVERAGE OF $55,579. 9.9% OF INDIVIDUALS IN THE WALSH COUNTY FALL BELOW THE POVERTY LEVEL. UNITY MEDICAL CENTER SERVES THE POPULATION OF GRAFTON AND SEVERAL SURROUNDING SMALLER COMMUNITIES. THE AREA IS ALSO SERVED BY A HOSPITAL IN PARK RIVER AND A HOSPITAL IN GRAND FORKS. APPROXIMATELY 6% OF THE HOSPITAL'S BUSINESS IN FY 2016 WAS TO PRIVATE PAY INDIVIDUALS. APPROXIMATELY 4% OF OUR BUSINESS WAS TO MEDICAID RECIPIENTS. WE ALSO HAVE A MIGRANT HEALTH OFFICE LOCATED IN OUR COMMUNITY TO SERVE MIGRANTS. PART VI, LINE 5: THE UNITY MEDICAL CENTER (UMC) GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN OUR PRIMARY SERVICE AREA. THE BOARD MEMBERS ARE NEITHER CONTRACTORS, OR FAMILY MEMBERS OF THE ORGANIZATION. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO THOSE QUALIFIED PHYSICIANS IN OUR COMMUNITY WHO HAVE APPLIED FOR AND BEEN GRANTED MEDICAL PRIVILEGES, PER OUR CREDENTIALING PROCESS. SURPLUS FUNDS, WHEN AVAILABLE, ARE USED TO PURCHASE EQUIPMENT OR MAKE PURCHASES TO IMPROVE THE BUILDING STRUCTURE FOR THE PURPOSE OF IMPROVING PATIENT CARE OR FOR THE RETENTION OF QUALITY EMPLOYEES. UNITY MEDICAL CENTER FOUNDATION ALSO ASSISTS THE HOSPITAL WITH CAPITAL PURCHASES.UMC OFFERS 24 HOUR ACCESS TO EMERGENCY ROOM CARE, WHICH IS AVAILABLE TO ALL INDIVIDUALS, REGARDLESS OF THEIR ABILITY TO PAY FOR THE CARE. UMC OFFERS ACUTE CARE, SWING BED CARE, GENERAL SURGERY, AS WELL AS MANY OUTPATIENT SERVICES. UMC DOES PARTICIPATE IN EDUCATION OF HEALTHCARE PROFESSIONALS. WE TAKE APPROXIMATELY 2-3 MEDICAL STUDENTS PER YEAR AND SEVERAL PHYSICAL THERAPY STUDENTS THROUGHOUT THE YEAR FROM THE UNIVERSITY OF NORTH DAKOTA. WE DO TRAINING FOR STUDENTS FROM TECHNICAL SCHOOLS, AS WELL, AS REQUESTED. UMC IS THE ONLY HOSPITAL AND CLINIC IN THE COMMUNITY; THEREFORE, WE ARE A VIABLE PART OF THIS COMMUNITY. UMC OFFERS PROGRAMS SUCH AS DIABETES SCREENINGS, FLU VACCINATION CLINICS, FREE BLOOD PRESSURE CHECKS, EDUCATIONAL EVENTS FOR CENTURY ELEMENTARY STUDENTS AND WALSH COUNTY HEAD START STUDENTS, ETC. UMC ALSO HAS REPRESENTATIVE ON THE WALSH COUNTY WELLNESS COALITION COMMITTEE. UMC BRINGS IN SPECIALTY DOCTORS TO OUR CLINIC IN ORDER TO OFFER NECESSARY SERVICES TO OUR PATIENT POPULATION, I.E. ONCOLOGY, PSYCHIATRY, OBSTETRICS, ETC. WE OFFER VOLUNTEER OPPORTUNITIES FOR HIGH SCHOOL STUDENTS AND ADULTS. WE HAVE FOURTEEN MEMBERS OF OUR UMC AUXILIARY SERVICES THAT VOLUNTEER HERE EVERY WEEK FOR THE BENEFIT OF THE FACILITY. PART VI, LINE 6: N/A X X 0 0 0 1 0 0 0 0 0 DR JOSHUA OMOTUNDE BOARD MEMBER 131868 0 142595 0 0 0 0 0 25639 0 300102 0 0 0 ALAN O'NEIL CHIEF EXECUTIVE OFFICER 159994 0 0 0 0 0 0 0 2859 0 162853 0 0 0 MIRIAM ANDERSON FAMILY NURSE PRACTITIONER 153911 0 0 0 0 0 0 0 17285 0 171196 0 0 0 MARCIA KETTERLING FAMILY NURSE PRACTITIONER 166200 0 0 0 0 0 0 0 14988 0 181188 0 0 0 DR ELIZABETH SUNDBERG PHYSICIAN 170719 0 0 0 0 0 0 0 12145 0 182864 0 0 0 PART I, LINE 5 PHYSICIAN COMPENSATION IS CALCULATED MONTHLY. PHYSICIANS EARN 58 PERCENT OF GROSS REVENUES FROM GROSS PROFESSIONAL CHARGES. A CITY OF GRAFTON 456002080 384455BF7 2008-04-23 2363560 CAPITAL IMPROVEMENTS TO THE HOSPITAL 0 0 0 A 378560 2363560 47000 2316560 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 0 0 0 0 1 A 1 FORM 990, SCHEDULE K, PART V, LINE 2B THE ORGANIZATION QUALIFIES FOR AN EXCEPTION FOR REBATE UNDER THE TEMPORARY PERIOD EXCEPTION, SPECIFICALLY SECTION 148(C)(2)(C). FORM 990, PART VI, SECTION A, LINE 6 MEMBERSHIP IN THE CORPORATION SHALL BE EITHER LIFETIME OR ANNUAL, AND SHALL BE LIMITED TO ADULT INDIVIDUALS AS FOLLOWS: 1) THOSE INDIVIDUALS OR COMPANIES CONTRIBUTING $100 TO THE CORPORATION, OR TO THE DEVELOPMENT FUND OF THE MEDICAL CENTER CORPORATION, SHALL, UPON SPECIFIC REQUEST, BE ENTITLED TO A LIFE MEMBERSHIP. IF AN INDIVIDUAL OR COMPANY MAKES A CONTRIBUTION OF $200 OR MORE, THEY SHALL BE ENTITLED TO DESIGNATE ONE ADDITIONAL IMMEDIATE FAMILY MEMBER OR COMPANY EMPLOYEE (LIMITED TO TWO PER FAMILY OR COMPANY), RESPECTIVELY, FOR LIFETIME MEMBERSHIP EFFECTIVE RETROACTIVELY. 2) THOSE INDIVIDUALS RESIDING IN THE UNITY MEDICAL CENTER SERVICE AREA SHALL BE GRANTED ANNUAL MEMBERSHIP AT NO FEE. THEY SHALL BE GRANTED ANNUAL MEMBERSHIP STATUS BY SHOWING PROOF OF RESIDING IN THE CORPORATION SERVICE AREA. FORM 990, PART VI, SECTION A, LINE 7A EACH MEMBER OF THE CORPORATION IN GOOD STANDING SHALL BE QUALIFIED TO CAST ONE VOTE ON ANY ISSUE THAT MAY PROPERLY COME BEFORE ANY MEETING OF THE MEMBERS OF THE CORPORATION, AND TO HOLD ANY OFFICE IN THE CORPORATION TO WHICH HE OR SHE MAY BE ELECTED OR APPOINTED. FORM 990, PART VI, SECTION B, LINE 11 THE CFO & CEO WILL REVIEW A DRAFT OF THE FORM 990. UNITY MEDICAL CENTER WILL PROVIDE THE BOARD MEMBERS WITH A LINK AND A PASSWORD TO AN ELECTRONIC COPY OF THE 990. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY BOARD MEMBERS MUST SIGN A CONFLICT OF INTEREST POLICY. IF A BOARD MEMBER BELIEVES THAT A CONFLICT EXISTS IT IS THEIR RESPONSIBILITY TO BRING THE CONFLICT TO THE ATTENTION OF THE BOARD. THE BOARD WILL DETERMINE IF A CONFLICT EXISTS. ANY BOARD MEMBERS WITH A CONFLICT OF INTEREST MUST ABSTAIN FROM VOTING ON ANY ISSUES RELATING TO THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 A FORMAL EVALUATION IS COMPLETED FOR BOTH THE CEO AND CFO. COMPARABILITY DATA IS USED FROM THE NORTH DAKOTA HOSPITAL ASSOCIATION. AT BUDGET TIME EACH YEAR THE BOARD WILL APPROVE A PERCENTAGE INCREASE. THE DELIBERATION AND DECISION IS DOCUMENTED IN THE BOARD MINUTES. THE PROCESS WAS LAST COMPLETED IN JUNE 2015. 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 AND ANNOUNCES SUCH AT BOARD MEETINGS. UNITY MEDICAL CENTER FOUNDATION 164 WEST 13TH STREET GRAFTON ND 58237 363522304 FUNDRAISING FOR UNITY MEDICAL CENTER ND 501(C)(3) LINE 7 CHRISTIAN UNITY HOSPITAL CORPORATION DBA UNITY MEDICAL CENTER 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0