2017-02-15T07:05:30-06:00 2016-03-31 390758449 Wipfli LLP 7601 France Avenue South Suite 400 Minneapolis MN 55435 990 2015-04-01 450226419 Good Samaritan Hospital Association GOOD 7017765261 800 South Main Avenue Rugby ND 583682118 Patrick Branco CEO 7017765261 2017-02-13 1 Tim A Ritter CPA P00732856 9525483400 2017-02-13 2015 2021-01-29 14:40:06Z Heart of America Medical Center Patrick Branco 800 South Main Avenue Rugby ND 583682118 27158185 0 X www.hamc.com X 1905 ND PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. 11 11 470 147 62209 -32301 848692 306456 24866541 25110932 581780 282595 300317 335090 26597330 26035073 0 0 0 0 16680277 16823604 0 0 74201 9838788 10072073 26519065 26895677 78265 -860604 17473165 15845503 6954037 6494189 10519128 9351314 X TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. 0 0 22615850 0 25048723 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. 22615850 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 48 0 1 470 1 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Patrick Branco 7017765261 800 S Main Avenue Rugby ND 583682118 Richard Anderson Trustee 1.00 X 0 0 0 Wes Black Trustee (Thru October) 1.00 X 0 0 0 Christine Bubach Trustee 1.00 X 0 0 0 Arland Geiszler Trustee 1.00 X 0 0 0 Sandy Hageness Trustee (Thru February) 1.00 X 0 0 0 Patricia Heggen Trustee 1.00 X 0 0 0 Bonita Lindseth Trustee 1.00 X 0 0 0 Stacey Schmitt Trustee 1.00 X 0 0 0 Andrew Shae Trustee 1.00 X 0 0 0 Pat Tracy Trustee 1.00 X 0 0 0 Jon Nelson Chairman 1.50 X X 0 0 0 John Mcclintock Jr Vice Chairman 1.50 X X 0 0 0 Mark Schaan Vice Chairman 1.50 1.00 X X 0 0 0 Patrick Branco CEO/Secretary 40.00 1.00 X 28007 0 574 Jeffrey Lingerfelt CEO/Secretary (Thru November) 40.00 1.00 X 201302 0 46824 Amanda Loughman CFO/Treasurer 40.00 1.00 X 92804 0 3244 Ronald Skipper Surgeon 40.00 X 346015 0 22278 Steven Schoneberg Physician 40.00 X 227110 0 24647 Ashley Kremer Physician 40.00 X 207121 0 25911 Cammy Townsend Midlevel Provider 40.00 X 198070 0 16252 Steven Arnold Midlevel Provider 40.00 X 169007 0 24252 1469436 0 163982 15 0 1 0 Dakota Travel Nurse 502 W Main St Mandan ND 58554 Contract Nursing 1208165 Ron Beare 2669 Meadow Creek Cir Fargo ND 58104 CRNA Services 195800 Avant Healthcare Po Box 60839 Charlotte NC 28260 Contract Nursing 182434 DMS IMAGING PO Box 86 Minneapolis MN 55486 Nuclear Imaging Services 164692 Mike Swanson Construction 6250 24th Ave NE Rugby ND 58368 Construction Services 121710 6 12476 293980 306456 Patient Service Revenue 621400 23075170 23075170 Pharmacy Services 900099 1277531 1277531 PT/OT Services 621400 310339 310339 Rental Revenue 623000 87471 87471 ALS Services 621400 73973 73973 286448 224239 62209 25110932 79389 79389 1249918 76400 1123112 0 126806 76400 203206 203206 Employee Daycare Revenue 900099 171226 171226 Cafeteria Services 900099 119936 119936 43928 43928 335090 26035073 25048723 62209 617685 309021 309021 14029782 11925308 2044484 59990 220733 188294 31487 952 1146368 978346 163092 4930 1117700 957940 155072 4688 3168 3168 55470 55470 2289122 2223627 65495 145603 145603 2099133 1387537 708437 3159 376124 355008 21116 691726 664811 26915 303446 139680 163284 482 6119 3956 2163 132409 132409 1150283 1150283 246453 246453 Acute Drugs 1086070 1086070 Bad Debt Expense 769758 769758 Raw Food 492249 486485 5764 Lab and Testing Expense 108316 108316 116624 58022 58602 26895677 22615850 4205626 74201 386218 98413 459026 972235 3535180 3222203 216598 252850 163493 179520 126478 170892 25321880 19780860 5879036 5541020 360909 343031 1757232 695102 17833 0 4571162 4370237 17473165 15845503 2050310 2101461 0 105929 1064991 968313 24617 24744 2986581 434303 164109 146369 663429 2713070 6954037 6494189 X 9987639 8799866 531489 551448 10519128 9351314 17473165 15845503 X -860604 -327169 19959 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2879 2879 0 Part II-B, Line 1: 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. 0 1 X 137447 137447 11173040 9045951 2127089 13891155 10734909 3156246 120238 120238 5541020 Investment Obligation Receivable 4370237 4370237 Due from Foundation to Haaland 537484 Due to third-part reimbursement program 252000 Line of Credit 1422667 Capital Lease 500919 2713070 24783238 9920 -1261755 -1251835 26035073 0 26035073 25633922 0 25633922 1261755 1261755 26895677 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. 1 1 1 X 1 X 1 1 0 1 1 84613 84613 0.00320 84613 84613 0.00320 17701 221 17480 0.00070 1000 1000 0.00000 5700751 3581332 2119419 0.08110 5719452 3581553 2137899 0.08180 5804065 3581553 2222512 0.08500 0 573747 0 6851326 7620936 -769610 X 1 1 1 1 HEART OF AMERICA MEDICAL CENTER 800 S Main Ave Rugby ND 583682118 www.hamc.com 5046 X X X X X Rural Heart Of America Medical Center 1 0 0 1 X X X X X X X 15 1 0 0 1 X See Supplemental Information X X 1 15 1 See Supplemental Information 1 0 1 X 150.000000000000 250.000000000000 1 1 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 1 X 0 0 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 8 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 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. X X X X X 0 1 0 0 0 0 0 0 0 Jeffrey Lingerfelt CEO/Secretary (Thru November) 200810 0 0 0 492 0 15124 0 31700 0 248126 0 0 0 Ronald Skipper Surgeon 344869 0 0 0 1146 0 3139 0 19139 0 368293 0 0 0 Steven Schoneberg Physician 226168 0 0 0 942 0 5687 0 18960 0 251757 0 0 0 Ashley Kremer Physician 207010 0 0 0 111 0 5250 0 20661 0 233032 0 0 0 Cammy Townsend Midlevel Provider 197975 0 0 0 95 0 5049 0 11203 0 214322 0 0 0 Steven Arnold Midlevel Provider 168902 0 0 0 105 0 4322 0 19930 0 193259 0 0 0 Part I, Line 4b Jeffrey Lingerfelt was included in a non-qualified retirement plan. The organization made a contribution of $10,000 during tax year 2015. A City of Rugby North Dakota Health Care Facility Revenue Bonds Series 2013 456002152 2013-09-19 1215000 Improvements to hospital and clinic 0 0 0 A 246687 1215000 15000 1200000 2013 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 JULIE BAUSTAD Family member of board member Richard Anderson 102704 Employment 0 Kristine Evenson Family Member of Officer Amanda Loughman 50556 Employment 0 Jodi Schaan Family member of board member Mark Schaan 45277 Employment 0 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. GOOD SAMARITAN HEALTH SERVICES FOUNDATION 800 South Main Ave Rugby ND 58368 363513553 Fundraising for Good Samaritan Hospital Association ND 501(c)(3) Line 7 Good Samaritan Hospital Association 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 1