2017-11-08T10:27:56-06:00 2017-04-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2016-05-01 113686120 Coal Country Community Health Center COAL 7018737788 1312 Highway 49 N Beulah ND 585236038 Darrold Bertsch CEO 7018737788 2017-10-26 1 LISA CHAFFEE CPA P00193453 7012398500 2017-10-26 198.135.124.76 2017-10-26 13:09:20 CD P 66CC91E6B7F11C4783FFFA5645E675327CB67316 385FD7544B689D76E9DA9F221308BA92DD4DD75D 2016 2021-01-29 14:40:06Z X Darrold Bertsch 1312 Highway 49 N Beulah ND 585236038 11541837 0 X www.coalcountryhealth.com X 2003 ND CCCHC provides and promotes quality health care to the medically underserved population in the North Dakota counties of Mercer, Dunn, and Oliver. 11 11 125 11 0 0 2089318 2696142 7535596 8845695 0 0 0 0 9624914 11541837 0 0 0 0 4224796 6035796 0 0 12263 3635238 4252888 7860034 10288684 1764880 1253153 7047850 8500632 695618 895247 6352232 7605385 X CCCHC creates access to affordable high quality preventative and primary care for all, especially medically under-served populations in Dunn, Mercer, and Oliver counties. The organization links the established medical clinics of Beulah, Center, Killdeer, and Hazen together and efficiently uses resources available to meet the increasingly complex needs of delivering rural health and improving the health status of all. 1 0 8621522 8845695 Coal Country Community Health Center is part of a family of nearly 1,400 health centers nationally that provide care to more than 24 million people in the United States. Community health centers are local, non-profit health care providers serving low income and medically underserved communities. Also known as Federally-Qualified Health Centers (FQHCs), they are located in areas where care is needed, and improve access to care for millions of Americans. Their costs of care rank among the lowest, and their focus on prevention reduces the need for more expensive in-patient and specialty care, saving billions of dollars for taxpayers. The focus of the care we provide can be summed up in one word - community. Coal Country is governed by a board of members from the communities we serve, and every decision they make has the best interest of the community in mind. Our medical staff and support staff are also your neighbors, helping us truly understand you and the health care issues that are important to you.The team of providers delivers primary care for the entire community. Funded by a federal grant, our sliding fee scale allows patients to pay according to their individual ability. This and other efforts ensure that no one in the community goes without proper health care services. That's what we're all about.Coal Country Community Health Center, with clinics in Beulah, Center, Hazen, and Killdeer, is a member of the PrimeCare Health Group. Furthermore, Coal Country remains a member of the other health care networks in the region.At Coal Country Community Health Center, our top priority is to provide complete health care services for the entire community.With a background in every area of medicine, our primary care physicians provide continuing and comprehensive care, from preventative care to diagnosis and treatment of health conditions.For more focused care, we bring in specialists to our clinic in Beulah,all the while continuing to oversee your total care.Our ongoing medical care of all levels includes the areas of::: Acute and chronic disease:: Adult care medicine:: Emergency medicine:: Geriatrics:: Mental health:: Medicated Assisted Therapy:: Obstetrics:: Occupational medicine:: Pediatrics:: Prenatal care:: Sports medicine:: Women's healthSpecialists from Bismarck regularly visit our clinics to provide treatment in the areas of::: Audiology:: Ear, nose and throat:: General surgery:: Mental health:: Obstetrics and Gynecology:: Orthopedics 8621522 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 26 0 1 125 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X Dovie Borth 7018737788 1312 Hwy 49 N Beulah ND 585236038 Dr DJ Erickson Chair 1.00 X X 0 0 0 Keith Johnson Vice Chair 1.00 X X 0 0 0 Arlene Helling Secretary 1.00 X X 0 0 0 Gordon Hoffner Treasurer 1.00 X X 0 0 0 Ann Mahoney Director/Executive Committ 1.00 X 0 0 0 Kimberly Kessler Director 1.00 X 0 0 0 Aaron Rudningen Director 1.00 X 0 0 0 Sienna Sailer Director 1.00 X 0 0 0 Scott Solem Director 1.00 X 0 0 0 Fred Stern Director 1.00 X 0 0 0 Jody Doe Director 1.00 X 0 0 0 Darrold Bertsch CEO 20.80 X 225477 0 27359 Dovie Borth CFO 40.00 X 89658 0 10145 Aaron Garman MD Physician 40.00 X 293266 0 29175 Orlan Jackson DO Physician 24.00 X 178570 0 24058 Jacinta-Jon Klindworth MD Physician 40.00 X 221849 0 28763 Rodney Zimmerman Physician 40.00 X 127062 0 16446 Burton Mollman Physician Assistant 40.00 X 112482 0 15051 1248364 0 150997 6 0 1 0 Greenway EHS PO Box 203658 Dallas TX 753203658 Software Subscription, Support, Licenses 153217 Northern Plains Laboratory 3502 Franklin Avenue Bismarck ND 58502 Laboratory 135857 St Alexius Medical Center 900 East Broadway Bismarck ND 585065510 Rent, Radiology, PA 109844 Sakakawea Medical Center 510 8th Avenue NE Hazen ND 58545 Rent, Shared HR/Fiscal, Nursing Class 106236 Northland Healthcare Alliance 2223 East Rosser Avenue Bismarck ND 58501 High Speed Internet Services 103035 5 2689403 6739 2696142 Patient Service Revenue 621110 6361316 6361316 340B Program Revenue 621110 2331497 2331497 Other Program Revenue 621110 152882 152882 8845695 11541837 8845695 0 0 239648 239648 4769384 4465580 303804 173210 131480 41730 499787 427696 72091 353767 259393 94374 11711 11711 92704 92704 490461 401494 88967 60048 60048 569201 296441 272760 131534 131534 158748 157355 1393 40555 25484 15071 28385 11953 16432 2140 2140 186213 186213 28098 28098 Medical Supplies 1836119 1836119 Bad Debt Expense 279476 279476 Licenses 48958 48832 126 Dues and Subscriptions 38131 5682 32449 250406 86184 151959 12263 10288684 8621522 1654899 12263 4113569 5769240 1377370 993047 73388 67531 44786 87272 2627769 1113113 1382804 1514656 55933 68886 7047850 8500632 589240 895247 106378 0 695618 895247 X 6352232 7605385 6352232 7605385 7047850 8500632 1253153 0 X 0 1 X 1 1 1 X 1568568 1573181 1508859 2089318 2696142 9436068 1568568 1573181 1508859 2089318 2696142 9436068 9436068 9436068 33703703 1.00000 1.00000 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1311802 275359 1036443 13918 9085 4833 1099085 765474 333611 202964 63195 139769 1514656 X 11262361 -279476 -279476 11541837 0 11541837 10009208 0 10009208 279476 279476 10288684 Part X, Line 2: The Health Center is organized as a North Dakota nonprofit organization and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Health Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health Center is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Health Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Health Center believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Health Center would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts -279,476. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts 279,476. X X X X 0 0 0 0 0 1 0 0 0 Darrold Bertsch CEO 221616 0 0 0 3861 0 8585 0 16811 0 250873 0 0 0 Aaron Garman MD Physician 279226 0 13230 0 810 0 10793 0 19174 0 323233 0 0 0 Orlan Jackson DO Physician 176248 0 0 0 2322 0 7050 0 16274 0 201894 0 0 0 Jacinta-Jon Klindworth MD Physician 208809 0 12500 0 540 0 8964 0 20861 0 251674 0 0 0 Part I, Line 6 An annual management team incentive program was started in FY2014 with the first annual payment occurring in August 2014 for fiscal year ending 04/30/2014. This program was continued for FY2017. The incentive payment is based on a combination of ten clinical and financial performance measures relating to the patient population and the health center. The ten measures are: 1. Diabetes Control > National Average 2. Blood Pressure Control > National Average 3. Cholesterol Treatment > National Average 4. Adult Weight Screening & Follow-up > National Average 5. Childhood Immunizations > National Average 6. Days in AR < 55 7. Days Cash on Hand > 90 8. Net Profit Margin > 5% 9. Long Term Debt to Equity < .25 10. Medical Cost Per Medical Patient < National Average Of the 10 measures, only net profit margin could potentially be considered as compensation contingent on net earnings. Only the measures met for the current fiscal year are included in the calculation of the incentive payment. Each measure met receives a rating of 1%. A maximum incentive of 10% is allowed. The incentive payment calculation is based on the individual team member's base salary as of the end of the current fiscal year. For FY2016 paid in August 2016, Dovie Borth received a management team incentive payment of $6,499.60. The other three participants in the program do not meet the criteria for Part VII and are not listed in Part VII. Schedule J, Part II: As of 6/1/2013, Darrold became an employee of Coal Country Community Health Center (CCCHC) and still provides services to both Sakakawea Medical Center (SMC) and CCCHC. The compensation reported in Part VII, and Part II of Schedule J, reflects total compensation Darrold received from CCCHC for his services to both SMC and CCCHC. Compensation received just for services to CCCHC, includes $137,287 of wages and benefits. Form 990, Part III, line 2 CCCHC started serving a new access point in Hazen, ND on May 4, 2016. Form 990, Part VI, Section A, line 1 The Executive Committee shall consist of at least five (5) voting members, including the Chair, Vice Chair, Secretary, Treasurer, and one (1) at-large member. The Executive Director of the Corporation shall serve without voting powers. The Executive Committee shall have the power to transact all business of the Corporation during the interim between meetings of the Board of Directors, provided that any action so taken shall not conflict with the policies and express wishes of the Board of Directors, and that it shall refer all matters of major importance to the full Board of Directors, including any amendments to the Articles and Bylaws. Form 990, Part VI, Section A, line 4 The bylaws were amended during the 2017 fiscal year. In Article I, the mission of CCCHC was added under Section 3. Additional Board duties were added in Article II, Section 1 to include: evaluating Board performance for efficiency, effectiveness, and compliance; establishing and updating personnel policies and procedures; adopting and updating policies for financial management practices; approving the selection on an independent auditor; and attending to any matter that the Board determines to be in the best interest of the Corporation. Clarification was added to already existing duties as well. In Article II, Section 2, another clause was added stating that patient members on the board must have accessed the Corporation in the last 24 months to receive at least one or more in-scope services that generated a health center visit. Also, the Executive Director may only serve as a non-voting, ex-officio member of the Board. Article II, Section 5 was amended to state that vacancies will be filled by a majority vote of the Directors "then in office and present and voting at a meeting at which a quorum exists." Sections 10, 11, 14, and 17 were added to Article II. Section 10 says that the Board may conduct all or any part of a meeting in Executive Session for such purposes as it deems necessary and explains "Executive Session" in more detail. Section 11 states that minutes shall be kept for all Board and committee meetings and signed by the Secretary, approved by the Board, and kept at the office of the Corporation. In Section 14, paragraphs were added to give more detail on Conflicts of Interest and to state that "The Board shall establish, adopt, and periodically update a written Standards of Conduct..." A sentence was added to Section 15 stating that no individual director shall act for the Board except as may be specifically authorized by the Board. Section 17 was added stating that voting by proxy is prohibited. Article III, Section 2 added, "In no event shall any Director selected or appointed by any other party serve as Board Chair." Article III, Sections 3, 4, and 5 were amended to clarify the duties of Vice Chair, Secretary, and Treasurer. Section 5 was added to Article VII stating that "The Corporation may be dissolved in accordance with the laws of the State of North Dakota... and further outlines the procedures for dissolution. Form 990, Part VI, Section B, line 11b The Form 990 is presented to the board for review and signed by the CEO after approval. Form 990, Part VI, Section B, line 12c The conflict of interest and compensation disclosure statements are completed annually. All board members and officers of CCCHC are covered by the policy. The annual conflict of interest and compensation disclosure statements obtained from board members and officers of CCCHC are reviewed by the CEO and Administration staff of CCCHC. It is at this review that the determination is made as to whether a conflict exists. Actual conflicts of interest identified are brought before the Board Executive Committee or the entire Board, depending on the situation and circumstances. Board members and officers of CCCHC are required to recuse themselves from voting on issues where it has been determined that a conflict of interest does exist. If the conflict of interest is pervasive, the Board Executive Committee or the entire Board will determine if further actions are needed. In all situations, the Board will document the restrictions imposed or acted upon. Form 990, Part VI, Section B, line 15 To determine compensation, the organization uses the following salary surveys: National Community Health Center Association (NACHC), Community Healthcare Association of the Mountain Plain States (CHAMPS), Medical Group Management Association (MGMA), and state of ND. The board of directors determines the salary of the CEO. CEO Salary adjustments are documented on a payroll notification form, signed by the board chair and forwarded to the accounting department for entry into the accounting/payroll system. The board of directors approves an annual budget to provide guidance for expenditures which includes personnel salaries. In addition annual salary adjustments are presented to the board for approval. Personnel salary adjustments are documented on a payroll notification form signed by the CEO or Human Resources and forwarded to the accounting department for entry into the accounting/payroll system. The process for determining compensation is undertaken annually before the new fiscal year in May begins. Form 990, Part VI, Section C, line 19 The organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request.