PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (EIN 45-6013474)
- Tax period
- 2016-01-01 to 2016-12-31
- Filed
- 2017-08-01
- IRS object ID
- 201732139349300623
- Schema version
- 2016v3.0
- 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 L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-08-01T09:53:13-05:00 | ReturnTs |
| Tax Period End | 2016-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 410746749 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CLIFTONLARSONALLEN LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 220 SOUTH SIXTH STREET SUITE 300 | AddressLine1Txt |
| City | MINNEAPOLIS | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55402 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 456013474 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEMBINA COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | PEMB | BusinessNameControlTxt |
| Phone | 7012658461 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JENI SCHWENZFEIER | PersonNm |
| Person Title | CFO | PersonTitleTxt |
| Phone | 7012658461 | PhoneNum |
| Signature | 2017-07-27 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | RYAN ENGEBRETSON | PreparerPersonNm |
| PTIN | P01585625 | PTIN |
| Phone | 6123764500 | PhoneNum |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 67.137.57.251 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2017-07-27 | IPDt |
| IP Tm | 10:45:29 | IPTm |
| IP Timezone | CD | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | 4A6DB1B1FC9DBA9B5F2864C6E754A05CFDE1F644 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 04722FD5EDB86B5C651CCDD44AB35AA37EEDD5A5 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | EVERETT BUTLER | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $15,089,741 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CAVALIERHOSPITAL.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1976 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 6 | VotingMembersIndependentCnt |
| Total Employee | 197 | TotalEmployeeCnt |
| Total Volunteers | 37 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $142,978 | PYContributionsGrantsAmt |
| CY Contributions Grants | $124,384 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $12,695,744 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $14,792,795 | CYProgramServiceRevenueAmt |
| PY Investment Income | $3,520 | PYInvestmentIncomeAmt |
| CY Investment Income | $1,134 | CYInvestmentIncomeAmt |
| PY Other Revenue | $100,458 | PYOtherRevenueAmt |
| CY Other Revenue | $171,428 | CYOtherRevenueAmt |
| PY Total Revenue | $12,942,700 | PYTotalRevenueAmt |
| CY Total Revenue | $15,089,741 | 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 | $6,679,213 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,169,602 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $33,363 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $6,026,671 | PYOtherExpensesAmt |
| CY Other Expenses | $7,233,627 | CYOtherExpensesAmt |
| PY Total Expenses | $12,705,884 | PYTotalExpensesAmt |
| CY Total Expenses | $14,403,229 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $236,816 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $686,512 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $6,176,422 | TotalAssetsBOYAmt |
| Total Assets EOY | $7,354,082 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $2,080,105 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $2,570,583 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $4,096,317 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $4,783,499 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $12,806,395 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $14,792,795 | RevenueAmt |
| Desc | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME, AND 20-UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24-HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY. THE ASSOCIATION ALSO PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. | Desc |
| Total Program Service Expenses | $12,806,395 | 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 | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | 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 | 0 | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| 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 | Yes (1) | 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 | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 29 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 197 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| 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 | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 6 | 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 | 0 | 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 | 0 | 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 | JENI SCHWENZFEIER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7012658461 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (13 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|---|
| TOM FORD | |||||||
| PRESIDENT | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| TOM VAUGHN | |||||||
| VICE PRESIDENT | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| TOM O'TOOLE | |||||||
| SECRETARY/TREASURER | 1.00 | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| LORETTA BERNHOFT | |||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DR ALLAN LINDEMANN | |||||||
| BOARD MEMBER/PHYSICIAN (THRU MAR 2016) | 40.00 | Yes (X) | $0 | $0 | $0 | ||
| DALE O'HARA | |||||||
| BOARD MEMBER | 1.00 | 1.00 | Yes (X) | $0 | $0 | $0 | |
| NICOLE SAFRANSKI | |||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| KENNETH SCHWANDT | |||||||
| BOARD MEMBER/CONTRACT PHARMACIST | 7.00 | Yes (X) | $19,250 | $0 | $0 | ||
| DEAN STEINWAND | |||||||
| BOARD MEMBER (THRU FEB 2016) | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DWIGHT THOMPSON | |||||||
| BOARD MEMBER | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| DR KULVINDER SUMRA | |||||||
| BOARD MEMBER AND PHYSICIAN | 40.00 | Yes (X) | $0 | $0 | $0 | ||
| JENI SCHWENZFEIER | |||||||
| CFO | 30.00 | Yes (X) | $71,318 | $0 | $15,980 | ||
| EVERETT BUTLER | |||||||
| CEO | 32.00 | Yes (X) | $137,949 | $0 | $4,600 | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $228,517 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $20,580 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 1 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | 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 |
|---|---|---|---|---|---|
| ALTRU HEALTH SYSTEMS | |||||
| PO BOX 1370 | GRAND FORKS | ND | 58208 | THERAPY SERVICES, PHYSICIAN SERVICES, IT | $980,772 |
| PARK RIVER CLINIC | |||||
| PO BOX 380 | CAVALIER | ND | 58220 | PHYSICIAN SERVICES | $493,489 |
| INDER V KHOKHA MD PC | |||||
| PO BOX 380 | CAVALIER | ND | 58220 | SURGEON SERVICES | $435,865 |
| DMS | |||||
| PO BOX 206143 | DALLAS | TX | 75320 | MOBILE IMAGING | $422,766 |
| PASTOREK CONSTRUCTION | |||||
| 106 6TH STREET EAST | GRAFTON | ND | 58237 | CARPENTRY/CONSTRUCTION | $342,836 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 7 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $98,546 | RelatedOrganizationsAmt |
| All Other Contributions | $25,838 | AllOtherContributionsAmt |
| Noncash Contributions | $3,607 | NoncashContributionsAmt |
| Total Contributions | $124,384 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT REVENUE | 621110 | $14,675,496 | $14,675,496 |
| ANCILLARY REVENUES | 621110 | $117,299 | $117,299 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $14,792,795 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,134 | TotalRevenueColumnAmt |
| Exclusion | $1,134 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $56,345 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $56,345 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $56,345 | TotalRevenueColumnAmt |
| Exclusion | $56,345 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| OTHER INCOME | 900099 | $108,148 | $108,148 |
| AUXILIARY INCOME | 900099 | $6,935 | $6,935 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $115,083 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,089,741 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $14,792,795 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $172,562 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $742,585 | TotalAmt |
| Program Services | $512,739 | ProgramServicesAmt |
| Management And General | $229,846 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,994,389 | TotalAmt |
| Program Services | $4,427,110 | ProgramServicesAmt |
| Management And General | $534,073 | ManagementAndGeneralAmt |
| Fundraising | $33,206 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $162,714 | TotalAmt |
| Program Services | $141,287 | ProgramServicesAmt |
| Management And General | $21,427 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $849,799 | TotalAmt |
| Program Services | $711,641 | ProgramServicesAmt |
| Management And General | $138,158 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $420,115 | TotalAmt |
| Program Services | $358,304 | ProgramServicesAmt |
| Management And General | $61,811 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $22,629 | TotalAmt |
| Management And General | $22,629 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $38,990 | TotalAmt |
| Management And General | $38,990 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,348,540 | TotalAmt |
| Program Services | $3,076,600 | ProgramServicesAmt |
| Management And General | $271,940 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,734 | TotalAmt |
| Management And General | $28,734 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $179,153 | TotalAmt |
| Program Services | $132,437 | ProgramServicesAmt |
| Management And General | $46,716 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,112 | TotalAmt |
| Management And General | $1,112 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $320,589 | TotalAmt |
| Program Services | $270,776 | ProgramServicesAmt |
| Management And General | $49,813 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,017 | TotalAmt |
| Program Services | $12,778 | ProgramServicesAmt |
| Management And General | $15,147 | ManagementAndGeneralAmt |
| Fundraising | $92 | FundraisingAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $27,317 | TotalAmt |
| Program Services | $27,317 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $601,896 | TotalAmt |
| Program Services | $601,896 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $106,196 | TotalAmt |
| Program Services | $44,943 | ProgramServicesAmt |
| Management And General | $61,253 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $1,450,168 | $1,449,744 | $424 |
| PROVISION FOR BAD DEBT | $632,172 | $632,172 | |
| EQUIPMENT RENTAL & REPA | $185,962 | $183,402 | $2,560 |
| FOOD EXPENSE | $163,944 | $163,944 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $98,208 | TotalAmt |
| Program Services | $59,305 | ProgramServicesAmt |
| Management And General | $38,838 | ManagementAndGeneralAmt |
| Fundraising | $65 | FundraisingAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,403,229 | TotalAmt |
| Program Services | $12,806,395 | ProgramServicesAmt |
| Management And General | $1,563,471 | ManagementAndGeneralAmt |
| Fundraising | $33,363 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $484,449 | BOYAmt |
| EOY | $361,516 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,157,591 | BOYAmt |
| EOY | $2,533,776 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $152,121 | BOYAmt |
| EOY | $252,434 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $164,058 | BOYAmt |
| EOY | $157,844 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $16,030,101 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $12,632,057 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,782,138 | BOYAmt |
| EOY | $3,398,044 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $321,598 | BOYAmt |
| EOY | $442,016 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $114,467 | BOYAmt |
| EOY | $208,452 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,176,422 | BOYAmt |
| EOY | $7,354,082 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,457,911 | BOYAmt |
| EOY | $1,073,999 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,240 | BOYAmt |
| EOY | $15,604 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $517,278 | BOYAmt |
| EOY | $1,225,589 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $89,676 | BOYAmt |
| EOY | $83,271 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $172,120 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,080,105 | BOYAmt |
| EOY | $2,570,583 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,096,317 | BOYAmt |
| EOY | $4,783,499 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,096,317 | BOYAmt |
| EOY | $4,783,499 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,176,422 | BOYAmt |
| EOY | $7,354,082 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $686,512 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $670 | 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) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | 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 | $1,472 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $1,472 | 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 | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $7,865 | BeginningBalanceAmt |
| Additions During Year | $6,935 | AdditionsDuringYearAmt |
| Distributions During Year | $7,605 | DistributionsDuringYearAmt |
| Ending Balance | $7,195 | EndingBalanceAmt |
| 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 | $160,304 | OtherCostOrOtherBasisAmt |
| Book Value | $160,304 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $7,105,876 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,390,036 | DepreciationAmt |
| Book Value | $1,715,840 | BookValueAmt |
Leasehold Improvements LeaseholdImprovementsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $671,637 | OtherCostOrOtherBasisAmt |
| Depreciation | $398,939 | DepreciationAmt |
| Book Value | $272,698 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $8,063,217 | OtherCostOrOtherBasisAmt |
| Depreciation | $6,843,082 | DepreciationAmt |
| Book Value | $1,220,135 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $29,067 | OtherCostOrOtherBasisAmt |
| Book Value | $29,067 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $3,398,044 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS | Desc |
| Amt | $172,120 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $172,120 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $14,300,852 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$632,172 | OtherRevenueAmt |
| Revenue Not Reported | -$632,172 | RevenueNotReportedAmt |
| Revenue Subtotal | $14,933,024 | RevenueSubtotalAmt |
| Other Revenues Not Included | $156,717 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $156,717 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $15,089,741 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $13,763,452 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $13,763,452 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $639,777 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $639,777 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $14,403,229 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART IV, LINE 1B: | A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. |
| PART IV, LINE 2B: | THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2016 AND 2015 TOTALED $15,604 AND $15,240, RESPECTIVELY. |
| PART X, LINE 2: | THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. |
| PART XI, LINE 2D - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE -632,172. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | INVESTMENT INCOME 1,134. RENTAL INCOME 56,345. AUXILIARY INCOME 6,935. CONTRIBUTIONS FOR LONG-LIVED ASSETS 92,303. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 632,172. AUXILIARY EXPENSES 7,605. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $47,429 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $47,429 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00340 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,591,524 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $258,571 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,332,953 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.09680 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,638,953 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $258,571 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,380,382 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10020 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $20,500 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $20,500 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00150 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $12,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $12,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00090 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,094,755 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,667,118 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $427,637 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03110 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,127,255 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,667,118 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $460,137 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03350 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,766,208 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,925,689 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,840,519 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.13370 | TotalExpensePct |
Coalition Building CoalitionBuildingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,900 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,900 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00050 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,900 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,900 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00050 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $632,172 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $50,574 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $5,221,074 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $5,304,368 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$83,294 | 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 | PEMBINA COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.CAVALIERHOSPITAL.COM | WebsiteAddressTxt |
| State License | 5009 | StateLicenseNum |
| Subordinate Hospital EIN | 456013474 | SubordinateHospitalEIN |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEMBINA COUNTY MEMORIAL HOSPITAL | 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 |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 14 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 14 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ | StrategyWebsiteURLTxt |
| 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 | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| 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 |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Other Method | Yes (X) | OtherMethodInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/6514/4917/6310/FINANCIAL_ASSISTANCE_P | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/8214/4916/3478/FINANCIAL_ASSISTANCE_A | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/4614/4925/3909/PLAIN_LANGUAGE_SUMMARY | 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 |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESSMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1) A SURVEY OF AREA RESIDENTS, INCLUDING HEALTH CARE PROFESSIONALS WHO WORK AT PCMH, PCPH, ALTRU CLINIC AND OTHER HEALTH ORGANIZATIONS;2) COMMUNITY LEADERS REPRESENTING THE BROADER INTERESTS OF THE COMMUNITY TOOK PART IN ONE-ON-ONE KEY INFORMANT INTERVIEWS;3) THE COMMUNITY GROUP, COMPRISED OF COMMUNITY LEADERS AND AREA RESIDENTS, WAS CONVENED TO DISCUSS AREA HEALTH NEEDS AND INFORM THE ASSESMENT PROCESS; AND4) A WIDE RANGE OF SECONDARY SOURCES OF DATA WERE EXAMINED, PROVIDING INFORMATION OF A MULTITUDE OF MEASURES INCLUDING DEMOGRAPHICS; HEALTH CONDITIONS, INDICATORS, AND OUTCOMES; RATES OF PREVENTIVE MEASURES; RATES OF DISEASE; AND AT-RISK BEHAVIOR. |
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. |
| PEMBINA COUNTY MEMORIAL HOSPITAL | PART V, SECTION B, LINE 11: RELATED TO ITS 2011 AND 2014 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL TOOK THE FOLLOWING ACTIONS IN 2016:1. PROVIDER SHORTAGES/DUPLICATION OF SERVICES: PEMBINA COUNTY MEMORIAL HOSPITAL ASSN. AND ALTRU HEALTH SYSTEMS COMBINED EFFORTS TO STREAMLINE PROVIDER RECRUITMENT AND RETENTION IN THE COMMUNITY OF CAVALIER. EFFECTIVE JANUARY 1, 2016, ALTRU CLINIC OF CAVALIER PROVIDERS (AND EMPLOYEES) WERE ASSUMED BY PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION TO PROVIDE ONLY ONE CLINIC FOR PRIMARY CARE IN THE CAVALIER COMMUNITY. THE ALTRU SPECIALTY CLINIC WAS OPENED WHICH ALLOWS ALTRU TO EXCLUSIVELY FOCUS ON PROVIDING SPECIALTY SERVICES TO THE CAVALIER COMMUNITY. THESE COMBINED EFFORTS PROVIDES STABILITY FOR PRIMARY CARE AS WELL AS PROVIDES NEW OPPORTUNITIES FOR SPECIALTY CARE. IT ALSO PROVIDES ONE LOCATION FOR ALL ANCILLARY SERVICES OFFERED SUCH AS LAB, RADIOLOGY, THERAPY, ETC.2. NUTRITIONAL EDUCATION: PCMH CONTINUES TO GROW THE NUTRITIONAL COUNSELING DEPARTMENT BY SEEING AN INCREASE IN THE NUMBER OF VISITS ON AN OUTPATIENT BASIS. EFFORTS HAVE ALSO BEEN MADE TO EDUCATE CARDIAC REHAB PATIENTS ON NUTRITIONAL CHOICES.3. A BEHAVIOR HEALTH COMMITTEE HAS BEEN DEVELOPED WHICH CONSIST OF VARIOUS MEMBERS OF THE COMMUNITY WHO HAVE A VESTED INTEREST IN INCREASING MENTAL HEALTH AWARENESS IN THE COMMUNITY. 2016 WAS A PLANNING YEAR, WITH ACTION TAKING PLACE IN 2017. IN 2017, THE WORK GROUP IS PLANNING QUARTERLY PUBLIC EDUCATION EVENTS TO EDUCATE THE PUBLIC ON MENTAL HEALTH ISSUES/SITUATIONS/ETC. WHICH INCLUDES PRINTED INFORMATION, PROFESSIONAL SPEAKERS, ETC. DISCUSSION HAS ALSO BEEN HELD REGARDING MAKING THIS SOMETHING THAT CAN EASILY TRAVEL THROUGH THE COUNTY TO PROVIDE MORE AWARENESS AND MULTIPLE OPPORTUNITIES FOR EDUCATION. THE BEHAVIOR HEALTH COMMITTEE HAS ALSO DEVELOPED A PRINTED BOOKLET FOR MENTAL HEALTH RESOURCES THAT ARE AVAILABLE TO COMMUNITY MEMBERS. A CURRENT PCMH NURSE IS PURSUING A DEGREE AS A NURSE PRACTITIONER OF PSYCHIATRY. SHE WILL BE COMPLETED WITH HER COURSEWORK IN 2018. HER EMPLOYMENT IS CURRENTLY BEING DISCUSSED AS THE BEHAVIOR HEALTH WORKGROUP WOULD PREFER TO HAVE HER SEE PATIENTS IN THE CLINIC IN CAVALIER.RELATED TO ITS 2014 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL DETERMINED THE TOP FIVE COMMUNITY HEALTH NEEDS IN 2015:1. COST & ADEQUACY OF HEALTH INSURANCE: UPON REVIEW OF THIS ITEM, IT WAS DETERMINED THAT WE AS AN ORGANIZATION, ARE NOT ABLE TO ADDRESS THIS ISSUE. IT IS A NATIONAL ISSUE, AND A 3 PARTY INSURANCE CARRIER ISSUE. HOWEVER, WE DID VISIT WITH JOHNSON & MCCANN WHO ADMINISTERS OUR EMPLOYEE BENEFIT PLAN, AND THEY ARE EXPERIENCING HIGH HEALTH INSURANCE COSTS AMONGST ALL OF THEIR CLIENTS. WE DID HAVE JOHNSON & MCCANN COME ONSITE AND PROVIDE EMPLOYEE FORUMS REGARDING UTILIZATION OF THE HEALTH PLAN AND CORRESPONDING INCREASES IN OUR FACILITY HEALTH INSURANCE PLAN.2. MENTAL HEALTH, INCLUDING ALCOHOL USE & ABUSE: THE HOSPITAL HAS DEVELOPED A RESOURCE BOOK ON MENTAL HEALTH AND BEGAN OFFERING CLASSES OPEN TO THE PUBLIC TO ACCOMPANY THE BOOK. ADDITIONAL TRAINING HAS BEEN OFFERED TO THE COMMUNITY REGARDING EMERGENT MENTAL HEALTH ASSISTANCE. 3. OBESITY: PCMH HAS RECENTLY HIRED A FULL-TIME DIETICIAN/DIABETIC EDUCATOR THAT PROVIDES OUTPATIENT, INPATIENT, AND RESIDENT CARE VISITS/GUIDELINES ON DIET.4. NOT ENOUGH JOBS WITH LIVABLE WAGES: PCMH HAS WORKED WITH THE PEMBINA COUNTY JDA REGARDING FINANCING VARIOUS PROJECTS WHICH HAVE CREATED ADDITIONAL EMPLOYMENT OPPORTUNITIES WITHIN PCMH. PCMH HAS ALSO ADJUSTED ENTRY LEVEL POSITION WAGES FOR NEW AND EXISTING EMPLOYEES. THESE POSITIONS INCLUDE CRAS, HOUSEKEEPING, AND DIETARY.5. LACK OF RESOURCES FOR ELDERLY TO STAY IN THEIR HOMES: A BOOKLET OF RESOURCES HAS BEEN DEVELOPED FOR THE ELDERLY. THIS COMPREHENSIVE RESOURCE BOOK IS INTENDED TO ASSIST THE ELDERLY WITH TRANSPORTATION NEEDS, MEAL/FOOD ASSISTANCE, FAITH IN ACTION RESOURCES, LOCAL HEALTHCARE SERVICES AVAILABLE, ETC. PROVIDERS IN THE SERVICE AREA MEET JOINTLY TO DISCUSS FURTHER IMPROVEMENT OF THIS ISSUE AND ENHANCEMENT OF THE CURRENT BOOKLET/RESOURCES AVAILABLE. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - CLINICARE | ||||
| 301 MOUNTAIN STREET EAST | CAVALIER | ND | 58220 | RURAL HEALTH CLINIC |
| 2 - WEDGEWOOD MANOR | ||||
| 804 MAIN STREET WEST | CAVALIER | ND | 58220 | SKILLED NURSING HOME |
| 3 - COUNTRY ESTATES | ||||
| 107 BJORNSON DRIVE | CAVALIER | ND | 58220 | CONGREGATE HOUSING |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 7: | THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. |
| PART I, LINE 7G: | SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, CLINIC, AND EMERGENCY ROOM. |
| 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 $ 632,172. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. |
| PART III, LINE 2: | IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. |
| PART III, LINE 3: | 8.0% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2010 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE THE ORGANIZATION ESTIMATES THAT 8.0% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. |
| PART III, LINE 4: | SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 8 AND PAGE 9 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. |
| PART III, LINE 8: | ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERELY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFITY TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERIVCES. |
| PART III, LINE 9B: | CHARITY CARE AND FINANCIAL ASSISTANCE APPLICATIONS MUST BECOMPLETED IN THEIR ENTIRETY. IF AN APPLICATION IS INCOMPLETE, IT ISRETURNED TO THE GUARANTOR AND COLLECTION EFFORTS/ACTIONS RESUME IF THECOMPLETED APPLICATION IS NOT RETURNED. UPON RECEIPT OF A COMPLETEAPPLICATION, COLLECTION EFFORTS MAY BE REVERSED IF A PATIENT IS ELIGIBLEFOR CHARITY CARE AND/OR FINANCIAL ASSISTANCE. CHARITY CARE APPLICATIONSARE REVIEWED AND APPROVED BY THE BUSINESS OFFICE MANAGER AND THE CEO ORCFO. A DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE ISDOCUMENTED. PARTIAL CHARITY CARE DISCOUNTS MAY APPLY. IF A PATIENT ISKNOWN TO BE FINANCIALLY STRUGGLING OR HAS FILED A CHARITY CARE APPLICATIONIN THE PAST, THE CHARITY CARE APPLICATION IS MAILED WITH THEIR 60 DAYINVOICE FROM THE HOSPITAL. IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ALL COLLECTION PRACTICES ARE STOPPED. |
| PART VI, LINE 2: | IN ADDITION TO A CHNA CONDUCTED EVERY THREE YEARS, PCMH ASSESSES THE HEALTH CARE NEEDS OF ITS COMMUNITY BY THEIR REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD, REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD, AND CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. |
| PART VI, LINE 3: | A LETTER IS RECEIVED BY ALL PATIENTS THAT HAVE HAD THEIR INSURANCE PROCESSED AND HAVE THE FOLLOWING OPTIONS FOR PAYMENT OF OUTSTANDING MEDICAL BILLS:1. PAYMENT IN FULL2. PAYMENT ARRANGEMENTS3. CHARITY CARE APPLICATIONUNINSURED PATIENTS HAVE THE SAME ABOVE MENTIONED OPTIONS WHEN IT COMES TO PAYING THEIR BILL.ALSO A PUBLIC NOTIFICATION IS VISIBLE AT THE MAIN RECEPTIONIST DESK AND ALL BUSINESS OFFICE STAFF CAN APPROPRIATELY ANSWER QUESTIONS IN REGARDS TO PAYMENT ON OUTSTANDING MEDICAL BILLS. WHEN A PATIENT INQUIRES ABOUT THEIR BILL WE ARE ABLE TO FURTHER DISCUSS IF THEY WOULD MEET THE CRITERIA AND WHAT FURTHER STEPS NEED TO BE TAKEN FOR FINANCIAL ASSISTANCE. |
| PART VI, LINE 4: | PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2010 SHOWED A POPULATION OF 7,413 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $48,502. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,019. 8.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. |
| PART VI, LINE 5: | OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| PARK RIVER CLINIC | |||
| PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER | $493,489 | PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES | 0 |
| RITA VAUGHN | |||
| FAMILY MEMBER OF TOM VAUGHN, A BOARD MEMBER | $30,752 | EMPLOYEE COMPENSATION | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 1 | THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. |
| FORM 990, PART VI, SECTION A, LINE 6 | ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. |
| FORM 990, PART VI, SECTION A, LINE 7A | ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE CFO WILL REVIEW THE 990 WITH THE BOARD OF DIRECTORS; UPON APPROVAL OF THE RETURN, THE CFO WILL FILE THE 990 AS APPROVED. |
| FORM 990, PART VI, SECTION B, LINE 12C | THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT ARISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. |
| FORM 990, PART VI, SECTION B, LINE 15A | THE PROCESS FOR DETERMINING THE COMPENSATION INCLUDES LOOKING AT STATE SALARY SURVEYS FROM THE AMERICAN HOSPITAL ASSOCIATION OR NORTH DAKOTA HOSPITAL ASSOCIATION. FOR THE CEO, THE EXECUTIVE COMMITTEE OF THE BOARD DERIVES THE COMPENSATION CONTRACT. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON AMERICAN HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2016. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. |
| FORM 990, PART IX, LINE 11G | OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 3,076,600. MANAGEMENT AND GENERAL EXPENSES 271,940. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,348,540. |
| FORM 990, PART XI, LINE 9: | CHANGE IN AUXILIARY NET ASSETS 670. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 MOUNTAIN STREET EAST | AddressLine1Txt |
| City | CAVALIER | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58220 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 300052569 | EIN |
| Primary Activities | FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12A, I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | 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 | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
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