GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2015-04-01 to 2016-03-31
- Filed
- 2017-02-15
- IRS object ID
- 201730469349300613
- Schema version
- 2015v3.0
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-02-15T07:05:30-06:00 | ReturnTs |
| Tax Period End | 2016-03-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 390758449 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Wipfli LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 7601 France Avenue South Suite 400 | AddressLine1Txt |
| City | Minneapolis | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55435 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-04-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOOD | BusinessNameControlTxt |
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Patrick Branco | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017765261 | PhoneNum |
| Signature | 2017-02-13 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Tim A Ritter CPA | PreparerPersonNm |
| PTIN | P00732856 | PTIN |
| Phone | 9525483400 | PhoneNum |
| Preparation | 2017-02-13 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Patrick Branco | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $27,158,185 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.hamc.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1905 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. | ActivityOrMissionDesc |
| Voting Members Governing Body | 11 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 11 | VotingMembersIndependentCnt |
| Total Employee | 470 | TotalEmployeeCnt |
| Total Volunteers | 147 | TotalVolunteersCnt |
| Total Gross UBI | $62,209 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$32,301 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $848,692 | PYContributionsGrantsAmt |
| CY Contributions Grants | $306,456 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $24,866,541 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $25,110,932 | CYProgramServiceRevenueAmt |
| PY Investment Income | $581,780 | PYInvestmentIncomeAmt |
| CY Investment Income | $282,595 | CYInvestmentIncomeAmt |
| PY Other Revenue | $300,317 | PYOtherRevenueAmt |
| CY Other Revenue | $335,090 | CYOtherRevenueAmt |
| PY Total Revenue | $26,597,330 | PYTotalRevenueAmt |
| CY Total Revenue | $26,035,073 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $16,680,277 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $16,823,604 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $74,201 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,838,788 | PYOtherExpensesAmt |
| CY Other Expenses | $10,072,073 | CYOtherExpensesAmt |
| PY Total Expenses | $26,519,065 | PYTotalExpensesAmt |
| CY Total Expenses | $26,895,677 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $78,265 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$860,604 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $17,473,165 | TotalAssetsBOYAmt |
| Total Assets EOY | $15,845,503 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,954,037 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,494,189 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $10,519,128 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $9,351,314 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $22,615,850 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $25,048,723 | RevenueAmt |
| Desc | GOOD SAMARITAN HOSPITAL ASSOCIATION IS A NONPROFIT HEALTH CARE ORGANIZATION, OWNED BY OVER THIRTY AREA CHURCHES REPRESENTING ALL OF THE LOCAL DENOMINATIONS OF THE CHRISTIAN FAITH. THE AREA CHURCHES AT AN ANNUAL MEETING EVERY FALL ELECT A BOARD OF TRUSTEES. THIS BOARD IS THE LEGAL GOVERNING BODY THAT IS RESPONSIBLE FOR THE ASSOCIATION. GOOD SAMARITAN HOSPITAL ASSOCIATION'S (GSHA) PRIMARY FOCUS IS HEALTHCARE WITHIN AND AROUND THE COMMUNITY OF RUGBY, ND. GSHA HAS 25 LICENSED ACUTE/SWING BEDS AS A CRITICAL ACCESS HOSPITAL, 3 RURAL HEALTH CLINICS ALONG WITH A SURGICAL CLINIC, 60 MEDICARE SKILLED NURSING HOME BEDS, 63 BASIC CARE BEDS, AND 37 ASSISTED LIVING APARTMENTS. WE ALSO SERVICE THE COMMUNITY THROUGH A HOSPITAL BASED HOSPICE. GSHA PROVIDES NUMEROUS COMMUNITY AND SOCIAL PROGRAMS INCLUDING BUT NOT LIMITED TO THE FOLLOWING: CHARITY CARE $106,232 GROSS CHARGES FORGONE DURING THE YEAR ENDED 3/31/2016, DIABETIC EDUCATION PROGRAM, PUBLIC HEALTHCARE EDUCATIONAL AND INFORMATIONAL NOTICES, TESTING AND INFORMATION DURING HEALTH SHOWS AND COMMUNITY EVENTS, AMBULANCE VOLUNTEERS, PROVIDES EMT COURSES FOR AMBULANCES, EDUCATIONAL OUTREACH FOR SCHOOL SYSTEM, PROVIDES SENIOR CITIZEN MEALS AT MINIMAL FEE, FREE BLOOD PRESSURE CHECKS, COMMUNITY EDUCATION, PHYSICAL THERAPY, PROVIDES MEETING ROOM FOR VARIOUS ORGANIZATIONS AND CHURCHES, CPR TRAINING, WELLNESS PROGRAMS, SPONSOR LPN/RN SCHOOL PROGRAM THROUGH CONSORTIUM OF FACILITIES AND COLLEGES. | Desc |
| Total Program Service Expenses | $22,615,850 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | 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 | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | 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 | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| 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 | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | 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 | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 48 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 470 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| 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 | 11 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 11 | 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 | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | 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 | Patrick Branco | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Avenue | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (21 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| Richard Anderson | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Wes Black | ||||||||
| Trustee (Thru October) | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Christine Bubach | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Arland Geiszler | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Sandy Hageness | ||||||||
| Trustee (Thru February) | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Patricia Heggen | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Bonita Lindseth | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Stacey Schmitt | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Andrew Shae | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Pat Tracy | ||||||||
| Trustee | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| Jon Nelson | ||||||||
| Chairman | 1.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| John Mcclintock Jr | ||||||||
| Vice Chairman | 1.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| Mark Schaan | ||||||||
| Vice Chairman | 1.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | 1.00 | |
| Patrick Branco | ||||||||
| CEO/Secretary | 40.00 | $28,007 | $0 | $574 | Yes (X) | 1.00 | ||
| Jeffrey Lingerfelt | ||||||||
| CEO/Secretary (Thru November) | 40.00 | $201,302 | $0 | $46,824 | Yes (X) | 1.00 | ||
| Amanda Loughman | ||||||||
| CFO/Treasurer | 40.00 | $92,804 | $0 | $3,244 | Yes (X) | 1.00 | ||
| Ronald Skipper | ||||||||
| Surgeon | 40.00 | $346,015 | $0 | $22,278 | Yes (X) | |||
| Steven Schoneberg | ||||||||
| Physician | 40.00 | $227,110 | $0 | $24,647 | Yes (X) | |||
| Ashley Kremer | ||||||||
| Physician | 40.00 | $207,121 | $0 | $25,911 | Yes (X) | |||
| Cammy Townsend | ||||||||
| Midlevel Provider | 40.00 | $198,070 | $0 | $16,252 | Yes (X) | |||
| Steven Arnold | ||||||||
| Midlevel Provider | 40.00 | $169,007 | $0 | $24,252 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,469,436 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $163,982 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 15 | 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 |
|---|---|---|---|---|---|
| Dakota Travel Nurse | |||||
| 502 W Main St | Mandan | ND | 58554 | Contract Nursing | $1,208,165 |
| Ron Beare | |||||
| 2669 Meadow Creek Cir | Fargo | ND | 58104 | CRNA Services | $195,800 |
| Avant Healthcare | |||||
| Po Box 60839 | Charlotte | NC | 28260 | Contract Nursing | $182,434 |
| DMS IMAGING | |||||
| PO Box 86 | Minneapolis | MN | 55486 | Nuclear Imaging Services | $164,692 |
| Mike Swanson Construction | |||||
| 6250 24th Ave NE | Rugby | ND | 58368 | Construction Services | $121,710 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 6 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $12,476 | RelatedOrganizationsAmt |
| All Other Contributions | $293,980 | AllOtherContributionsAmt |
| Total Contributions | $306,456 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (5 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient Service Revenue | 621400 | $23,075,170 | $23,075,170 |
| Pharmacy Services | 900099 | $1,277,531 | $1,277,531 |
| PT/OT Services | 621400 | $310,339 | $310,339 |
| Rental Revenue | 623000 | $87,471 | $87,471 |
| ALS Services | 621400 | $73,973 | $73,973 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $286,448 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $224,239 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $62,209 | UnrelatedBusinessRevenueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $25,110,932 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $79,389 | TotalRevenueColumnAmt |
| Exclusion | $79,389 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $1,249,918 | SecuritiesAmt |
| Other | $76,400 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $1,123,112 | SecuritiesAmt |
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $126,806 | SecuritiesAmt |
| Other | $76,400 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $203,206 | TotalRevenueColumnAmt |
| Exclusion | $203,206 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| Employee Daycare Revenue | 900099 | $171,226 | $171,226 |
| Cafeteria Services | 900099 | $119,936 | $119,936 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $43,928 | TotalRevenueColumnAmt |
| Exclusion | $43,928 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $335,090 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $26,035,073 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $25,048,723 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $62,209 | UnrelatedBusinessRevenueAmt |
| Exclusion | $617,685 | ExclusionAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $309,021 | TotalAmt |
| Management And General | $309,021 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,029,782 | TotalAmt |
| Program Services | $11,925,308 | ProgramServicesAmt |
| Management And General | $2,044,484 | ManagementAndGeneralAmt |
| Fundraising | $59,990 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $220,733 | TotalAmt |
| Program Services | $188,294 | ProgramServicesAmt |
| Management And General | $31,487 | ManagementAndGeneralAmt |
| Fundraising | $952 | FundraisingAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,146,368 | TotalAmt |
| Program Services | $978,346 | ProgramServicesAmt |
| Management And General | $163,092 | ManagementAndGeneralAmt |
| Fundraising | $4,930 | FundraisingAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,117,700 | TotalAmt |
| Program Services | $957,940 | ProgramServicesAmt |
| Management And General | $155,072 | ManagementAndGeneralAmt |
| Fundraising | $4,688 | FundraisingAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,168 | TotalAmt |
| Management And General | $3,168 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,470 | TotalAmt |
| Management And General | $55,470 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,289,122 | TotalAmt |
| Program Services | $2,223,627 | ProgramServicesAmt |
| Management And General | $65,495 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $145,603 | TotalAmt |
| Management And General | $145,603 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,099,133 | TotalAmt |
| Program Services | $1,387,537 | ProgramServicesAmt |
| Management And General | $708,437 | ManagementAndGeneralAmt |
| Fundraising | $3,159 | FundraisingAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $376,124 | TotalAmt |
| Program Services | $355,008 | ProgramServicesAmt |
| Management And General | $21,116 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $691,726 | TotalAmt |
| Program Services | $664,811 | ProgramServicesAmt |
| Management And General | $26,915 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $303,446 | TotalAmt |
| Program Services | $139,680 | ProgramServicesAmt |
| Management And General | $163,284 | ManagementAndGeneralAmt |
| Fundraising | $482 | FundraisingAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $6,119 | TotalAmt |
| Program Services | $3,956 | ProgramServicesAmt |
| Management And General | $2,163 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $132,409 | TotalAmt |
| Program Services | $132,409 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,150,283 | TotalAmt |
| Program Services | $1,150,283 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $246,453 | TotalAmt |
| Management And General | $246,453 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Acute Drugs | $1,086,070 | $1,086,070 | |
| Bad Debt Expense | $769,758 | $769,758 | |
| Raw Food | $492,249 | $486,485 | $5,764 |
| Lab and Testing Expense | $108,316 | $108,316 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $116,624 | TotalAmt |
| Program Services | $58,022 | ProgramServicesAmt |
| Management And General | $58,602 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,895,677 | TotalAmt |
| Program Services | $22,615,850 | ProgramServicesAmt |
| Management And General | $4,205,626 | ManagementAndGeneralAmt |
| Fundraising | $74,201 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $386,218 | BOYAmt |
| EOY | $98,413 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $459,026 | BOYAmt |
| EOY | $972,235 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,535,180 | BOYAmt |
| EOY | $3,222,203 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $216,598 | BOYAmt |
| EOY | $252,850 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $163,493 | BOYAmt |
| EOY | $179,520 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $126,478 | BOYAmt |
| EOY | $170,892 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $25,321,880 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $19,780,860 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,879,036 | BOYAmt |
| EOY | $5,541,020 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $360,909 | BOYAmt |
| EOY | $343,031 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,757,232 | BOYAmt |
| EOY | $695,102 | EOYAmt |
Intangible Assets IntangibleAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,833 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,571,162 | BOYAmt |
| EOY | $4,370,237 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,473,165 | BOYAmt |
| EOY | $15,845,503 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,050,310 | BOYAmt |
| EOY | $2,101,461 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $105,929 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,064,991 | BOYAmt |
| EOY | $968,313 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $24,617 | BOYAmt |
| EOY | $24,744 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,986,581 | BOYAmt |
| EOY | $434,303 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $164,109 | BOYAmt |
| EOY | $146,369 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $663,429 | BOYAmt |
| EOY | $2,713,070 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,954,037 | BOYAmt |
| EOY | $6,494,189 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,987,639 | BOYAmt |
| EOY | $8,799,866 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $531,489 | BOYAmt |
| EOY | $551,448 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,519,128 | BOYAmt |
| EOY | $9,351,314 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $17,473,165 | BOYAmt |
| EOY | $15,845,503 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$860,604 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$327,169 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $19,959 | 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) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| 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
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $2,879 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $2,879 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part II-B, Line 1: | FormAndLineReferenceDesc |
| Explanation | GOOD SAMARITAN HOSPITAL ASSOCIATION IS A MEMBER OF SEVERAL ORGANIZATIONS THAT TAKE PART IN LOBBYING. THESE ORGANIZATIONS INCLUDE THE NORTH DAKOTA HOSPITAL ASSOCIATION, THE NATIONAL RURAL HEALTH, AND THE NORTH DAKOTA LONG TERM CARE ASSOCIATION. A PORTION OF THE DUES PAID TO THE VARIOUS ORGANIZATIONS IS FOR LOBBYING COSTS. THESE VARIOUS ORGANIZATIONS ADVOCATE ON BEHALF OF THEIR MEMBERS BY SUPPORTING LEGISLATION THAT IS IN THEIR COLLECTIVE INTERESTS. THESE ORGANIZATIONS WORK TO ENSURE THAT LAWS AND REGULATIONS PROVIDE A REASONABLE AND EQUITABLE ENVIRONMENT IN WHICH HEALTH CARE FACILITIES CAN PROVIDE AFFORDABLE, HIGH QUALITY CARE. | ExplanationTxt |
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 | $137,447 | OtherCostOrOtherBasisAmt |
| Book Value | $137,447 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $11,173,040 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,045,951 | DepreciationAmt |
| Book Value | $2,127,089 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,891,155 | OtherCostOrOtherBasisAmt |
| Depreciation | $10,734,909 | DepreciationAmt |
| Book Value | $3,156,246 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $120,238 | OtherCostOrOtherBasisAmt |
| Book Value | $120,238 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $5,541,020 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Investment Obligation Receivable | Desc |
| Book Value | $4,370,237 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $4,370,237 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (4 entries)
| DescDesc | AmtAmt |
|---|---|
| Due from Foundation to Haaland | $537,484 |
| Due to third-part reimbursement program | $252,000 |
| Line of Credit | $1,422,667 |
| Capital Lease | $500,919 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $2,713,070 | TotalLiabilityAmt |
| Total Rev Etc Audited Fincl Stmt | $24,783,238 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $9,920 | NetUnrealizedGainsInvstAmt |
| Other Revenue | -$1,261,755 | OtherRevenueAmt |
| Revenue Not Reported | -$1,251,835 | RevenueNotReportedAmt |
| Revenue Subtotal | $26,035,073 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $26,035,073 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $25,633,922 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $25,633,922 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $1,261,755 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $1,261,755 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $26,895,677 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 2b: | The Association holds funds under an agency relationship for the residents of the hospital's long-term care facility, swing-bed unites, and basic care facility, as well as damage deposits. |
| Part XI, Line 2d - Other Adjustments: | Bad Debt Expense -769,758. 340B Expense Included in Revenue for Financial Statements -491,997. |
| Part XII, Line 4b - Other Adjustments: | Bad Debt Expense 769,758. 340B Expenses Included in Revenue for Financial Statements 491,997. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent150 | Yes (X) | Percent150Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent250 | Yes (X) | Percent250Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $84,613 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $84,613 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00320 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $84,613 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $84,613 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00320 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $17,701 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $221 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $17,480 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,700,751 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,581,332 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,119,419 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.08110 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,719,452 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,581,553 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,137,899 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.08180 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,804,065 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,581,553 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,222,512 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.08500 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $573,747 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $0 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,851,326 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $7,620,936 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$769,610 | 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 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.hamc.com | WebsiteAddressTxt |
| State License | 5046 | 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 |
| Emergency Room Other | Yes (X) | EmergencyRoomOtherInd |
| Other | Rural | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart Of America Medical Center | 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 |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | See Supplemental Information | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | See Supplemental Information | StrategyWebsiteURLTxt |
| Strategy Attached | Yes (1) | StrategyAttachedInd |
| 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 | 150.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 250.000000000000 | 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 |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | SEE PART V, PAGE 7 | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SEE PART V, PAGE 7 | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SEE PART V, PAGE 7 | 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 |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Heart Of America Medical Center | Part V, Section B, Line 5: In 2012, there were persons invited to one of the three focus groups included our mayor, a retired sheriff from the community, retired nurses and business owners, existing business owners, both retired and current teachers, and mothers of school-aged children. A survey was sent out to all healthcare professionals in our community, including those employed at our hospital or clinics, the eye clinic, and dental clinic. It was input from all of these individuals that created the community wide survey mailed to every household.In 2014 & 2015, the organization sent out small mail surveys to follow up on the questions that were asked in 2012. In 2016, the organization used the data from those surveys to lead a retreat involving Board Members, Providers, Top Management and Key Community Members (from Chamber of Commerce Director, Pierce County Tribune, and the local radio station). The retreat focused on conducting a SWOT analysis. |
| Heart Of America Medical Center | Part V, Section B, Line 7d: http://www.hamc.com/newsclassesevents/news/detail.asp?newsID=66 |
| Heart Of America Medical Center | Part V, Section B, Line 11: The CHNA and Implementation Strategy is attached for 2015. |
| Heart Of America Medical Center | Part V, Section B, Line 22d: The lookback Method based on past Medicare claims was utilized. |
| Schedule H, Part V, Line 16a - 16c | Part V, Line 16A, FAP Website: www.hamc.com/uploads/resources/1012/notice-of-community-care-march-2016.pdfPart V, Line 16B, FAP Application Website: www.hamc.com/uploads/resources/851/community-care-application-10-2015--sfs.pdfPart V, Line 16c, FAP Plain Language Summary Website: www.hamc.com/uploads/resources/941/plain-lang.pdf |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 8 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (8 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - HEART OF AMERICA NURSING FACILITY | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Skilled Long Term Care Facility |
| 2 - Haaland Estates Basic Care | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Basic Care Facility |
| 3 - Rugby Emergency Medical Services | ||||
| 800 S Main Ave | Rugby | ND | 58368 | Ambulance |
| 4 - Haaland Estates Assisted Living | ||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Assisted Living Facility |
| 5 - Heart of America Hospice | ||||
| 800 S Main Ave | rugby | ND | 58368 | Hospice |
| 6 - Rugby Clinic | ||||
| 880 S Main Ave | Rugby | ND | 58368 | Rural Health Clinic |
| 7 - Dunseith Clinic | ||||
| 215 Main St SE | Dunseith | ND | 58329 | Rural Health Clinic |
| 8 - Maddock Clinic | ||||
| 301 Roosevelt Ave | Maddock | ND | 58348 | rural Health Clinic |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | Heart of America Medical Center uses a sliding fee schedule based of FPG. There is 100% benefit at 150% FPG, 80% benefit at 175% FPG, 60% benefit at 200% FPG, 40% benefit at 225% FPG, 20% benefit at 250% FPG, and 0% benefit for those greater than 250% FPG. |
| Part I, Line 7: | The costing method used is the cost to charges ratio for all but subsidized services. Subsidized services uses the actual costs per the cost report filed by the organization. |
| Part I, Line 7g: | There were no physician clinics included in the subsidized health services. The services on this line consist of a diabetes education program, operation of an emergency room, and two rural health clinics. |
| 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 $ 769,758. |
| Schedule H, Part I, Line 6 | The organization files a community benefit report once every 3 years. |
| Part II, Community Building Activities: | No specific community building activities during year ending March 2016. |
| 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: | The amount of bad debt expense attributable to patients eligible under the organization's charity financial assistance policy is determined by the organization using information available to make an educated estimate. |
| Part III, Line 4: | The financial statements do not have bad debt expense footnote. This is the Patient Accounts Receivable and Credit Policy Footnote. Patient and resident accounts receivable primarily consist of uncollateralized patient and resident obligations that are stated at the amount management expects to collect from outstanding balances. These obligations are primarily from local residents, most of whom are insured under third-party payer agreements. The Organization bills third-party payers on the patients or residents' behalf, or if a patient or resident is uninsured, the patient or resident is billed directly. Once claims are settled with the primary payer, any secondary insurance is billed, and patients or residents are billed for copay and deductible amounts that are the patients or residents' responsibility. Payments on patient and resident accounts receivable are applied to the specific claim identified on the remittance advice or statement.In evaluating the collectability of patient and resident accounts receivable, the Organization 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. Specifically, for receivables associated with services provided to patients and residents who have third-party coverage, the Organization analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts for expected uncollectible deductibles and copayments on accounts for which the third-party payer has not yet paid, or for payers who are known to be having financial difficulties that make the realization of amounts due unlikely.For receivables associated with self-pay patients (which includes both patients and residents without insurance and patients and residents with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Organization records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients or residents are unable or unwilling to pay the portion of their bill for which they are financially responsible. |
| Part III, Line 8: | Medicare revenue and allowable costs were obtained from the Medicare Cost report for the Fiscal Year Ending March 2016. |
| Part III, Line 9b: | Our accounts are worked effectively and thoroughly with self pay statements printed monthly once insurances have met their obligations. The goal is to obtain payment in full, establish acceptable payment arrangements, look at other appropriate agencies or low income programs, or offer the charity care program if needed. In the collection process, the bill guarantor is reminded they may qualify for our charity care program and are given information on how to apply. Our charity program is income based, and uses 150% of the Federal poverty guidelines. If they qualify the bill is written off 100% to charity care. Referral to a collection agency and write off of bad debt happens once it is determined that the patient is uncooperative with non-payment, skip accounts, or is unwilling to apply for the charity care program, and there is no other valid reason to hold the account further. |
| Part VI, Line 2: | Heart of America Medical Center serves a smaller community where providers know their patients. The GSHA Board of Directors live in and are members of the local and surrounding communities. We expect those board members to bring back concerns of their communities so we can prioritize the needs. On May 6, 2014, a community forum was held in Maddock. The CHNA survey was mailed on August 18, 2014, and a follow-up event was held in Maddock on September 10, 2014 to discuss the results. On March 30, 2015, CHNA surveys were sent to the Dunseith community with a follow up event to announce the survey results was held on April 22, 2015. In 2016, GSHA held a retreat for board members, community members, medical providers, and executive staff to determine which needs are prioritized. |
| Part VI, Line 3: | Our charity care policy and application is provided to all admits to our hospital upon admissions. This includes assistance contact information. At the Admission area there are brochures on charity care program and prompt payment discount which address our charity care program. Also in processing the self pay bills, the patient is encouraged to complete our charity care application if applicable to assist in taking care of their bill. Our Social Service Department is very involved with assisting our patients and residents with governmental benefits primarily North Dakota Medicaid. Our website includes our charity care policy, application, and summary. Our third party collection company also assists in encouraging patients to apply for charity care if they are experiencing financial hardship. |
| Part VI, Line 4: | Heart of America Medical Center (HAMC) is a rural Critical Access Hospital located in north central North Dakota with the closest tertiary facility 65 miles away to the west. The closest smaller hospital is 43 miles away. HAMC serves in whole or in part the counties of Pierce, Benson, McHenry, Rolette, and Bottineau counties. Our primary service area is about a 45 mile radius with a target population of approximately 16,000 people. Pierce County alone had a population of 4,404 in 2014 according to the US Census Bureau with 92.9% Caucasian and 22.8% age 65 or older. Rugby has a population of 2,911 based on 2014 census data. |
| Part VI, Line 5: | Good Samaritan Hospital Association (GSHA) is owned by 32 member churches located throughout our service area. The GSHA Board of Directors is voted in by the member churches and they are community members who reside in our primary service area - both Rugby and the surrounding satellite communities. They are not employees or contractors of GSHA, but serve in various occupations and involved in various community activities. GSHA extends medical staff privileges to all qualified physicians and mid-levels in the community and is continuously striving to bring in more providers in order to maintain providers to provide the care needed by our patients and promote health within our communities. When surplus funds are available they are used to purchase and upgrade equipment, and invested back into the facility and services we provide to maintain high quality patient care. We continually strive to meet the healthcare needs within our community and the surrounding area. Effective August 1, 2010 the family practice clinic in Rugby merged with GSHA in order to better meet the healthcare needs of our communities. This merger has strengthened our abilities to serve the communities by providing us with a better physician & mid-level recruitment platform and higher continuity of care. In striving to meet the needs of the communities we provide services including Assisted Living, Basic Care, Skilled Nursing, Medical & Surgical Hospital, Rural Health Clinics, Surgical Clinic, and numerous other outpatient services and therapies. We have lost money on some of these services such as Cardiac Rehab, our Clinics, and our Hospice program but continue to maintain these services because of the needs within the communities. If we did not provide services such as these, the services would be unavailable in the community. Patients would have to go out of town to get the services which is not always possible, so some would not have access to these services if we did not provide them. In the spring 2017, we expect to open our Cancer Care Center.Currently we are not involved much in community building activities. Being a small CAH facility with limited resources, our focus is more on health related programs and services needed within our community. If we did not provide the service, it would not be available within the community. |
| Part VI, Line 6: | GSHA is not part of any affiliated healthcare system; however, as a CAH we do have rural health network agreements with both Trinity Medical Center in Minot and MedCenter One in Bismarck in order to help and promote the availability of a range of high-quality care. They enhance the continuity of healthcare delivery among all levels of care needed by our patients by identifying and forming a process to facilitate patient referral and transfer between facilities and also enhance the communications between us. GSHA is piggy-backing on Altru's Epic system. January 1, 2016, we went live as an ACO with several other hospitals. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | 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 | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Jeffrey Lingerfelt | ||||||||||||||
| CEO/Secretary (Thru November) | $200,810 | $0 | $0 | $0 | $492 | $0 | $15,124 | $0 | $31,700 | $0 | $248,126 | $0 | $0 | $0 |
| Ronald Skipper | ||||||||||||||
| Surgeon | $344,869 | $0 | $0 | $0 | $1,146 | $0 | $3,139 | $0 | $19,139 | $0 | $368,293 | $0 | $0 | $0 |
| Steven Schoneberg | ||||||||||||||
| Physician | $226,168 | $0 | $0 | $0 | $942 | $0 | $5,687 | $0 | $18,960 | $0 | $251,757 | $0 | $0 | $0 |
| Ashley Kremer | ||||||||||||||
| Physician | $207,010 | $0 | $0 | $0 | $111 | $0 | $5,250 | $0 | $20,661 | $0 | $233,032 | $0 | $0 | $0 |
| Cammy Townsend | ||||||||||||||
| Midlevel Provider | $197,975 | $0 | $0 | $0 | $95 | $0 | $5,049 | $0 | $11,203 | $0 | $214,322 | $0 | $0 | $0 |
| Steven Arnold | ||||||||||||||
| Midlevel Provider | $168,902 | $0 | $0 | $0 | $105 | $0 | $4,322 | $0 | $19,930 | $0 | $193,259 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 4b | FormAndLineReferenceDesc |
| Explanation | Jeffrey Lingerfelt was included in a non-qualified retirement plan. The organization made a contribution of $10,000 during tax year 2015. | ExplanationTxt |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | City of Rugby North Dakota Health Care Facility Revenue Bonds Series 2013 | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 456002152 | BondIssuerEIN |
| Bond Issued | 2013-09-19 | BondIssuedDt |
| Issue Price | $1,215,000 | IssuePriceAmt |
| Purpose | Improvements to hospital and clinic | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $246,687 | RetiredAmt |
| Total Proceeds | $1,215,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $15,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $1,200,000 | CapitalExpendituresAmt |
| Substantial Completion | 2013 | SubstantialCompletionYr |
| Current Refunding | 0 | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | Yes (1) | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (3 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| JULIE BAUSTAD | |||
| Family member of board member Richard Anderson | $102,704 | Employment | 0 |
| Kristine Evenson | |||
| Family Member of Officer Amanda Loughman | $50,556 | Employment | 0 |
| Jodi Schaan | |||
| Family member of board member Mark Schaan | $45,277 | Employment | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 6 | GSHA is owned by the local churches whose delegates vote at the annual meeting on election of the GSHA Board members and other pertinent business as presented at the annual meeting. There are no membership fees. Any local church wishing to be a member of GSHA can do so thru vote at the annual meeting. |
| Form 990, Part VI, Section A, line 7a | Each member church has up to two voting delegates at our annual meeting where the board of directors are elected to serve on the Board of Directors. |
| Form 990, Part VI, Section A, line 7b | At the annual meeting the voting delegates from the churches will vote on changes to by-laws or articles of incorporation. |
| Form 990, Part VI, Section B, line 11 | The CEO and CFO review the 990 first and it is then sent electronically to all board members for their review. Any board member questions or discussion items are sent to administration via email prior to submission to the Internal Revenue Service. |
| Form 990, Part VI, Section B, line 12c | A Conflict of Interest Statement is reviewed annually. It is monitored during year. A member will abstain from voting on an issue if a conflict of interest in the matter is present. CEO receives and reviews the responses regarding the annual disclosure. |
| Form 990, Part VI, Section B, line 15 | Comparative data is reviewed and incorporated into the review process such as looking at state wage survey data. For the CEO, each board member completes their own evaluation form. The Human Resource Committee reviews the responses and makes a recommendation to the full board. Full board decides on any changes to the CEO compensation. Review is done annually at time of anniversary date of contract. Board typically does not approve wages for other positions. CEO approves the CFO wages. Comparative data is used throughout the facility and incorporated into the annual review of employee wages done by the department head or supervisor. Wages are compared to the NDHA annual salary survey report at the time of their annual review. |
| 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. |
| Form 990, Part XI, line 9: | Change in Interest in Foundation 19,959. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HEALTH SERVICES FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Ave | AddressLine1Txt |
| City | Rugby | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58368 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | Fundraising for Good Samaritan Hospital Association | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
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