2017-08-01T09:53:13-05:00 2016-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2016-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 JENI SCHWENZFEIER CFO 7012658461 2017-07-27 1 RYAN ENGEBRETSON P01585625 6123764500 67.137.57.251 2017-07-27 10:45:29 CD P 4A6DB1B1FC9DBA9B5F2864C6E754A05CFDE1F644 04722FD5EDB86B5C651CCDD44AB35AA37EEDD5A5 2016 2021-01-29 14:40:06Z EVERETT BUTLER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 15089741 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. 9 6 197 37 0 0 142978 124384 12695744 14792795 3520 1134 100458 171428 12942700 15089741 0 0 0 0 6679213 7169602 0 0 33363 6026671 7233627 12705884 14403229 236816 686512 6176422 7354082 2080105 2570583 4096317 4783499 X 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. 0 0 12806395 0 14792795 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. 12806395 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 29 0 197 1 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JENI SCHWENZFEIER 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 TOM FORD PRESIDENT 1.00 1.00 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 1.00 X X 0 0 0 TOM O'TOOLE SECRETARY/TREASURER 1.00 1.00 X X 0 0 0 LORETTA BERNHOFT BOARD MEMBER 1.00 X 0 0 0 DR ALLAN LINDEMANN BOARD MEMBER/PHYSICIAN (THRU MAR 2016) 40.00 X 0 0 0 DALE O'HARA BOARD MEMBER 1.00 1.00 X 0 0 0 NICOLE SAFRANSKI BOARD MEMBER 1.00 X 0 0 0 KENNETH SCHWANDT BOARD MEMBER/CONTRACT PHARMACIST 7.00 X 19250 0 0 DEAN STEINWAND BOARD MEMBER (THRU FEB 2016) 1.00 X 0 0 0 DWIGHT THOMPSON BOARD MEMBER 1.00 X 0 0 0 DR KULVINDER SUMRA BOARD MEMBER AND PHYSICIAN 40.00 X 0 0 0 JENI SCHWENZFEIER CFO 30.00 X 71318 0 15980 EVERETT BUTLER CEO 32.00 X 137949 0 4600 228517 0 20580 1 0 0 0 ALTRU HEALTH SYSTEMS PO BOX 1370 GRAND FORKS ND 58208 THERAPY SERVICES, PHYSICIAN SERVICES, IT 980772 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 493489 INDER V KHOKHA MD PC PO BOX 380 CAVALIER ND 58220 SURGEON SERVICES 435865 DMS PO BOX 206143 DALLAS TX 75320 MOBILE IMAGING 422766 PASTOREK CONSTRUCTION 106 6TH STREET EAST GRAFTON ND 58237 CARPENTRY/CONSTRUCTION 342836 7 98546 25838 3607 124384 NET PATIENT REVENUE 621110 14675496 14675496 ANCILLARY REVENUES 621110 117299 117299 14792795 1134 1134 56345 0 56345 56345 56345 OTHER INCOME 900099 108148 108148 AUXILIARY INCOME 900099 6935 6935 115083 15089741 14792795 0 172562 X 742585 512739 229846 4994389 4427110 534073 33206 162714 141287 21427 849799 711641 138158 420115 358304 61811 22629 22629 38990 38990 3348540 3076600 271940 28734 28734 179153 132437 46716 1112 1112 320589 270776 49813 28017 12778 15147 92 27317 27317 601896 601896 106196 44943 61253 MEDICAL SUPPLIES 1450168 1449744 424 PROVISION FOR BAD DEBT 632172 632172 EQUIPMENT RENTAL & REPA 185962 183402 2560 FOOD EXPENSE 163944 163944 98208 59305 38838 65 14403229 12806395 1563471 33363 484449 361516 2157591 2533776 152121 252434 164058 157844 16030101 12632057 2782138 3398044 321598 442016 114467 208452 6176422 7354082 1457911 1073999 15240 15604 517278 1225589 89676 83271 0 172120 2080105 2570583 X 4096317 4783499 4096317 4783499 6176422 7354082 X 686512 670 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1472 1472 0 PART II-B, LINE 1: 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. 1 7865 6935 7605 7195 1 X 160304 160304 7105876 5390036 1715840 671637 398939 272698 8063217 6843082 1220135 29067 29067 3398044 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 172120 172120 X 14300852 -632172 -632172 14933024 156717 156717 15089741 13763452 0 13763452 639777 639777 14403229 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. 1 1 X 1 X 1 X 0 1 1 0 0 47429 47429 0.00340 1591524 258571 1332953 0.09680 1638953 258571 1380382 0.10020 20500 20500 0.00150 12000 12000 0.00090 3094755 2667118 427637 0.03110 3127255 2667118 460137 0.03350 4766208 2925689 1840519 0.13370 6900 6900 0.00050 6900 6900 0.00050 1 632172 50574 5221074 5304368 -83294 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 456013474 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ X 1 14 1 WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/6514/4917/6310/FINANCIAL_ASSISTANCE_P X HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/8214/4916/3478/FINANCIAL_ASSISTANCE_A X HTTP://WWW.CAVALIERHOSPITAL.COM/FILES/4614/4925/3909/PLAIN_LANGUAGE_SUMMARY X X X X X X 1 0 X X X 1 X 0 0 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. 3 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 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. PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 493489 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 RITA VAUGHN FAMILY MEMBER OF TOM VAUGHN, A BOARD MEMBER 30752 EMPLOYEE COMPENSATION 0 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. PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION 301 MOUNTAIN STREET EAST CAVALIER ND 58220 300052569 FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR ND 501(C)(3) LINE 12A, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0