HAZEN MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2014
View the entire original 990 at ProPublica ↗
- Organization
- HAZEN MEMORIAL HOSPITAL ASSOCIATION (EIN 45-0308379)
- Tax period
- 2014-07-01 to 2015-06-30
- Filed
- 2016-04-11
- IRS object ID
- 201621029349300112
- Schema version
- 2014v6.0
- 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 ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2016-04-11T10:52:09-05:00 | ReturnTs |
| Tax Period End | 2015-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1Txt |
| City | FARGO | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 581082545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2014-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450308379 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | HAZE | BusinessNameControlTxt |
| Phone | 7017482225 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Darrold Bertsch | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017482225 | PhoneNum |
| Signature | 2016-04-01 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | LISA CHAFFEE CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012398500 | PhoneNum |
| Preparation | 2016-04-01 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2014 | TaxYr |
| Build TS | 2016-08-17 19:52:53Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Darrold Bertsch | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $13,521,326 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.sakmedcenter.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1943 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | Operation of a hospital, clinic, and an elderly care facility. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 165 | TotalEmployeeCnt |
| Total Volunteers | 93 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $481,595 | PYContributionsGrantsAmt |
| CY Contributions Grants | $652,883 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $11,780,020 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $12,823,196 | CYProgramServiceRevenueAmt |
| PY Investment Income | -$23,593 | PYInvestmentIncomeAmt |
| CY Investment Income | $12,906 | CYInvestmentIncomeAmt |
| PY Other Revenue | $31,048 | PYOtherRevenueAmt |
| CY Other Revenue | $31,473 | CYOtherRevenueAmt |
| PY Total Revenue | $12,269,070 | PYTotalRevenueAmt |
| CY Total Revenue | $13,520,458 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $4,500 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $2,000 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $6,188,086 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $7,132,632 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $5,074,890 | PYOtherExpensesAmt |
| CY Other Expenses | $5,058,860 | CYOtherExpensesAmt |
| PY Total Expenses | $11,267,476 | PYTotalExpensesAmt |
| CY Total Expenses | $12,193,492 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,001,594 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $1,326,966 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $7,805,109 | TotalAssetsBOYAmt |
| Total Assets EOY | $11,244,196 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $1,459,004 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $1,938,457 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $6,346,105 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $9,305,739 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | Provide high quality care that is measured and continuously improved. Provide individualized care that exceeds expectations of those we serve. Strengthen partnerships with providers to enhance coordination of care and improve system performance. Be a steward of resources. Committ to service excellence. Be a vital contributor to our area communities. Recognize the value of each employee and provide opportunities for personal growth and development that complement the needs of the organization. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $8,162,432 | ExpenseAmt |
| Grant | $2,000 | GrantAmt |
| Revenue | $10,808,149 | RevenueAmt |
| Desc | Sakakawea Medical Center (SMC) is a 25 bed critical care access hospital providing services in the following areas - acute care, surgery, intermediate and skilled swing bed, emergency room with trauma level V certification, home health, and hospice. Services provided by the ancillary departments include physical therapy, occupational therapy, radiology, digital mammography, bone density, ultrasound, CT, nuclear med, MRI, laboratory, respiratory therapy, cardiac rehab, EKG, EEG, sleep studies, and thallium stress tests. Based on charges foregone Sakakawea Medical Center provided $30,760 in charity care. Also available to all self-pay patients, regardless of financial status, is a 30% discount policy for timely payments. SMC is a participating provider for Medicare, Medicaid, Blue Cross Blue Shield and other insurances.Sakakawea Medical Center reaches out to the communities in the service area through programs such as falls prevention classes, CPR education, ACLS classes, PALS classes, grief support groups, smoking cessation classes, occupational health, free blood pressure checks, a Christmas giving tree project, and health career presentations to high schools. Wellness screenings are provided to area schools and businesses. SMC provides community education programs on requested topics free of charge. It is important for Sakakawea Medical Center to serve our communities by providing all of their health care needs. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $883,567 | ExpenseAmt |
| Revenue | $1,098,021 | RevenueAmt |
| Desc | Senior Suites is a basic care facility that was completed in April 1997, it is adjacent to Sakakawea Medical Center. Senior Suites can accommodate 34 residents with single or double rooms. It features a licensed beauty shop, activity room, spacious commons areas and an enclosed nurse's station. The rooms are set up like suites, hence the name "Senior Suites." The facility is available to those in the senior population that requires a minimal amount of supervision, but do not require 24 hour services. The residents are provided with assistance for daily living and medication administration. Resident care census days totaled 9,243 this year. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,292,030 | ExpenseAmt |
| Revenue | $917,026 | RevenueAmt |
| Desc | To ensure the need for quality health care is met in SMC's service area, Sakakawea Medical Center began managing a rural health clinic in July 2007. The clinic is located directly across the street from the hospital. This provides primary health care for our patients. The clinic is staffed with two physicians and two mid-level providers. A sliding fee scale charity care program is available to patients who qualify financially. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $10,338,029 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | Yes (1) | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | Yes (1) | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | 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 | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | Yes (1) | 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 | 0 | 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 | 0 | 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 | 16 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 165 | 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 | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | 0 | 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 | 0 | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | 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 | Renae Snyder | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017482225 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (15 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| Christie Obenauer | |||||||
| President | 2.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Fred Stern | |||||||
| Vice President | 1.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Myria Perry | |||||||
| Secretary/Treasurer | 1.50 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Don Lyn Erickson | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Mark Gerde | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Robin Richter | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Sienna Sailer | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Beverly Huber | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Kimberly Kessler | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Todd Lindquist | |||||||
| Director | 1.50 | Yes (X) | $0 | $0 | $0 | ||
| Darrold Bertsch | |||||||
| CEO | 19.60 | Yes (X) | $106,416 | $0 | $65,000 | ||
| Renae Snyder | |||||||
| CFO | 40.00 | Yes (X) | $72,552 | $0 | $3,617 | ||
| Robert Volk | |||||||
| Midlevel | 40.00 | $103,951 | $0 | $21,520 | Yes (X) | ||
| Carl Miller | |||||||
| CRNA | 36.00 | $124,979 | $0 | $16,126 | Yes (X) | ||
| Rodney Zimmerman | |||||||
| Family Practice Physician | 40.00 | $268,864 | $0 | $24,459 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $676,762 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $130,722 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 4 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (3 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Neenan Company LLLP | |||||
| 2607 Midpoint Drive | Fort Collins | CO | 80525 | Archistruction | $719,662 |
| Dr Thomas Kaspari | |||||
| 1351 51st Ave SW | Hazen | ND | 58545 | ER Physician Services | $126,725 |
| Eide Bailly LLP | |||||
| 4310 17th Ave S | Fargo | ND | 58103 | Accounting Fees | $100,538 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 3 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $38,614 | GovernmentGrantsAmt |
| All Other Contributions | $614,269 | AllOtherContributionsAmt |
| Total Contributions | $652,883 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient and Resident Services | 621400 | $12,199,791 | $12,199,791 |
| Other Program Revenue | 623000 | $525,016 | $525,016 |
| Education | 623000 | $74,849 | $74,849 |
| Cafeteria | 623000 | $23,540 | $23,540 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $12,823,196 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $11,842 | TotalRevenueColumnAmt |
| Exclusion | $11,842 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $23,828 | 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 | $23,828 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $23,828 | TotalRevenueColumnAmt |
| Exclusion | $23,828 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,064 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $1,064 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,064 | TotalRevenueColumnAmt |
| Exclusion | $1,064 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Fundraising Gross Income | $8,513 | FundraisingGrossIncomeAmt |
| Fundraising Direct Expenses | $868 | FundraisingDirectExpensesAmt |
Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $7,645 | TotalRevenueColumnAmt |
| Exclusion | $7,645 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $13,520,458 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $12,823,196 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $44,379 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Grants To Domestic Individuals GrantsToDomesticIndividualsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,000 | TotalAmt |
| Program Services | $2,000 | ProgramServicesAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $269,905 | TotalAmt |
| Management And General | $269,905 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $67,671 | TotalAmt |
| Program Services | $67,671 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,754,370 | TotalAmt |
| Program Services | $5,293,706 | ProgramServicesAmt |
| Management And General | $460,664 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $179,981 | TotalAmt |
| Program Services | $46,143 | ProgramServicesAmt |
| Management And General | $133,838 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $442,291 | TotalAmt |
| Program Services | $112,142 | ProgramServicesAmt |
| Management And General | $330,149 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $418,414 | TotalAmt |
| Program Services | $378,415 | ProgramServicesAmt |
| Management And General | $39,999 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,740 | TotalAmt |
| Management And General | $9,740 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,520 | TotalAmt |
| Management And General | $13,520 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,602 | TotalAmt |
| Management And General | $55,602 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,962,133 | TotalAmt |
| Program Services | $1,830,560 | ProgramServicesAmt |
| Management And General | $131,573 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $34,522 | TotalAmt |
| Program Services | $2,701 | ProgramServicesAmt |
| Management And General | $31,821 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $270,766 | TotalAmt |
| Program Services | $127,213 | ProgramServicesAmt |
| Management And General | $143,553 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $379,556 | TotalAmt |
| Program Services | $379,413 | ProgramServicesAmt |
| Management And General | $143 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $54,647 | TotalAmt |
| Program Services | $41,800 | ProgramServicesAmt |
| Management And General | $12,847 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $13,697 | TotalAmt |
| Program Services | $5,837 | ProgramServicesAmt |
| Management And General | $7,860 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $349,336 | TotalAmt |
| Program Services | $349,336 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $111,037 | TotalAmt |
| Program Services | $11,006 | ProgramServicesAmt |
| Management And General | $100,031 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $1,015,191 | $1,015,191 | |
| Bad Debt Expense | $469,816 | $469,816 | |
| Food | $126,585 | $126,585 | |
| Dues & Subscriptions | $79,807 | $53,413 | $26,394 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $112,905 | TotalAmt |
| Program Services | $25,081 | ProgramServicesAmt |
| Management And General | $87,824 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $12,193,492 | TotalAmt |
| Program Services | $10,338,029 | ProgramServicesAmt |
| Management And General | $1,855,463 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,581 | BOYAmt |
| EOY | $7,328 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,238,611 | BOYAmt |
| EOY | $2,912,178 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,391,256 | BOYAmt |
| EOY | $1,361,975 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $324,678 | BOYAmt |
| EOY | $372,250 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $41,385 | BOYAmt |
| EOY | $62,588 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $10,387,054 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $7,425,349 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,744,897 | BOYAmt |
| EOY | $2,961,705 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $870,054 | BOYAmt |
| EOY | $876,662 | EOYAmt |
Investments Program Related InvestmentsProgramRelatedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $465,182 | BOYAmt |
| EOY | $2,107,427 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $723,465 | BOYAmt |
| EOY | $582,083 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,805,109 | BOYAmt |
| EOY | $11,244,196 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $952,950 | BOYAmt |
| EOY | $1,010,017 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | $39,943 | EOYAmt |
Loans From Officers Directors LoansFromOfficersDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $492,690 | BOYAmt |
| EOY | $326,407 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,364 | BOYAmt |
| EOY | $562,090 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,459,004 | BOYAmt |
| EOY | $1,938,457 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,815,518 | BOYAmt |
| EOY | $7,132,622 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $480,587 | BOYAmt |
| EOY | $2,123,117 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $50,000 | BOYAmt |
| EOY | $50,000 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,346,105 | BOYAmt |
| EOY | $9,305,739 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,805,109 | BOYAmt |
| EOY | $11,244,196 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $1,326,966 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $1,632,668 | 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 | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $65,405 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $285 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $65,690 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $64,983 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $422 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $65,405 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $63,893 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $1,090 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $64,983 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $62,933 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $960 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $63,893 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $61,518 | BeginningYearBalanceAmt |
| Investment Earnings Or Losses | $1,415 | InvestmentEarningsOrLossesAmt |
| End Year Balance | $62,933 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Prmnnt Endowment Balance EOY | 0.76120 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.23880 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $23,092 | OtherCostOrOtherBasisAmt |
| Book Value | $23,092 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,787,927 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,753,727 | DepreciationAmt |
| Book Value | $1,034,200 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,106,287 | OtherCostOrOtherBasisAmt |
| Depreciation | $2,593,105 | DepreciationAmt |
| Book Value | $513,182 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,469,748 | OtherCostOrOtherBasisAmt |
| Depreciation | $78,517 | DepreciationAmt |
| Book Value | $1,391,231 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,961,705 | TotalBookValueLandBuildingsAmt |
Invst Program Related Org InvstProgramRelatedOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Interest in Net Assets of Sakakawea Medical Center Foundation | Desc |
| Book Value | $2,107,427 | BookValueAmt |
| Method Valuation | F | MethodValuationCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Program Rltd | $2,107,427 | TotalBookValueProgramRltdAmt |
Other Assets Org OtherAssetsOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Patronage Credit Asset | Desc |
| Book Value | $582,083 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $582,083 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| Construction Payables | $412,090 |
| Estimated Third Party Payor Settlements | $150,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $562,090 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $14,679,486 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | $1,172,429 | OtherRevenueAmt |
| Revenue Not Reported | $1,172,429 | RevenueNotReportedAmt |
| Revenue Subtotal | $13,507,057 | RevenueSubtotalAmt |
| Other Revenues Not Included | $13,401 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $13,401 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $13,520,458 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $11,719,852 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $11,719,852 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $473,640 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $473,640 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $12,193,492 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part V, Line 4: | The Medical Center's policy is to maintain sufficient financial stability for the operations of Medical Center. Interest income is to be transferred to the temporarily restricted endowment funds until the Board determines how the funds are to be used. In establishing this policy, the Medical Center considered the long-term expected return on its endowments. The spending policy states that distributions of earnings can be made if the Board of Directors deems it prudent to do so taking into account certain statutory factors included in the UPMIFA. Distributions may be made at least annually, but do not need to be done. |
| Part X, Line 2: | The Medical Center is organized as a North Dakota nonprofit corporation 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 Medical Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Medical Center is subject to income tax on any net income that is derived from business activities that are unrelated to its exempt purpose. The Medical Center has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990-T) with the IRS. The Medical 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 Medical 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 Reported in Revenue on Audited Financials -469,816. Change in Interest in Net Assets of Sakakawea Medical Center Foundation 1,642,245. |
| Part XI, Line 4b - Other Adjustments: | Auxiliary Revenue Not Included in Audited Financials 13,401. |
| Part XII, Line 4b - Other Adjustments: | Auxiliary Expenses Not Included in Audited Financials 3,824. Provision for Bad Debts Reported in Revenue on Audited Financials 469,816. |
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 |
Free Care Oth Percentage FreeCareOthPercentageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Free Care Other | 125.000000000000 | FreeCareOtherPct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $22,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $22,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00190 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $217,138 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $214,750 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,388 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00020 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $239,138 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $214,750 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $24,388 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00210 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $13,897 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $13,897 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00120 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $47,214 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $19,168 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $28,046 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00240 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,541,996 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,014,000 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $527,996 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04500 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,603,107 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,033,168 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $569,939 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04860 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,842,245 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,247,918 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $594,327 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05070 | TotalExpensePct |
Economic Development EconomicDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $1,575 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,575 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Health Improvement Advocacy HealthImprovementAdvocacyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 10 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $12,723 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $12,723 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00110 | TotalExpensePct |
Workforce Development WorkforceDevelopmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 3 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $1,253 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $1,253 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00010 | TotalExpensePct |
Total Communtity Building Acty TotalCommuntityBuildingActyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 15 | ActivitiesOrProgramsCnt |
| Total Community Benefit Expns | $15,551 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $15,551 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00130 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $469,816 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $29,129 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $4,346,501 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $4,425,627 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$79,126 | 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 | Sakakawea Medical Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Ave NE | AddressLine1Txt |
| City | Hazen | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.sakmedcenter.org | WebsiteAddressTxt |
| State License | 5024A | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | 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 |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 12 | 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.sakmedcenter.org | OwnWebsiteURLTxt |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 12 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | www.sakmedcenter.org | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 125.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Income Level Criteria | Yes (X) | IncomeLevelCriteriaInd |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Other Criteria | Yes (X) | OtherCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| 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.sakmedcenter.org/general_services/business_office.htm | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | http://www.sakmedcenter.org/general_services/business_office.htm | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | http://www.sakmedcenter.org/general_services/business_office.htm | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified Before Discharge | Yes (X) | FAPNotifiedBeforeDischargeInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Average Negotiated Rates | Yes (X) | AverageNegotiatedRatesInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Hazen Memorial Hospital Association | Part V, Section B, Line 5: A community survey, focus group, providers, representatives from public health, and individual interviews. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 6b: Also included were Custer Public Health Unit, Coal Country Community Health Centers, Knife River Care Center, and Mercer County Ambulance. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 11: SMC has addressed each need that was identified in each most recently conducted CHNA:1) Obesity, Physical Inactivity: Have initiated community and worksite wellness programs for all ages and are promoting physical activity, good nutrition and good health throughout the community. Have invested the resources to have on staff a "Certified Worksite Wellness Consultant" available for community business/organization wishing to initiate their own programs. 2) Mental Health Care Providers, Mental Health Issues: Coal Country Community Health Center is spearheading the effort to address these issues and relies on the collaborative partners (to include SMC) to assist by providing additional resources for programming, education, and as well as tapping into financial and staffing availability. In addition, both CCCHC and SMC have opted to screen all clinic and emergency room patients, hospital, basic care and home health care admits for depression by incorporating the PHQ2 and PHQ9 screening criteria for all initial patient encounters. If a patient screens positive on the PHQ9, referrals are made for appropriate follow-up and or intervention. In addition, visiting specialists (Psychologist) from Bismarck travel to our area on a regular basis to treat patients with Mental Health issues.3) Smoking: Medical Providers provide counseling and alternatives for their patients. Custer Health and NDDoH in conjunction with local providers, promote education and awareness campaigns. SMC has gone so far as to initiate a policy making the entire SMC campus smoke free.3) Diabetes: CCCHC and SMC have started a pre-diabetic course which is a 16 week course and has a post course after that. This has been very successful with all participants meeting their weight loss goals. In addition a Chronic Disease Support Group was implemented in June 2015 with monthly meetings scheduled at CCCHC.4) Uninsured residents: Charity care and sliding fee policy information and applications are available for download on the SMC website; and are available at the medical clinic and hospital business office. In conjunction, posts and bi-annual notices regarding the Charity Care Program and/or sliding fee policy are on Facebook and advertised in the local papers. HHS has awarded CCCHC funds to provide Health Insurance Marketplace Enrollment Assistance. An outreach & Enrollment Specialist is now on staff at CCCHC and is certified as an application counselor to enroll residents in our service area.5) Excessive drinking: This is a public health priority and is being spearheaded by Custer Health as outlined in the Custer Health 2015 - 2019 Community Health Improvement Plan - Mercer/Oliver CHIP, page 13.6) Number of primary care providers: SMC actively participates in events to recruit providers to our area. A collaborative effort between SMC, CCCHC & KRCC has resulted in the combining of resources to provide for a full time, Human Resources professional that is spearheading the effort to maintain, sustain and recruit healthcare staffing within the service area. 7) Awareness of local services: SMC has developed a Public Relations/Marketing Plan that is updated as needed. SMC continually works on promoting, advertising and distributing healthcare information through a variety of venues and media. In addition, SMC has created a Facebook site and program information is posted as appropriate. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 13h: Sakakawea Medical Center offers two separate programs for discounted care. The self-pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 20% to 100% of charges. Charges are discounted by 27% before the sliding fee scale is applied (for uninsured applicants only.) The program is available for uninsured patients as well as co-pays and deductibles for insured patients.The self-pay discounts program cannot be combined with the charity care program. However, the Hospital counsels all self-pay individuals to determine if their potential charity care discount would result in a better discount if they apply for charity care. The patients that use the self-pay discount are typically the patients that do not want to submit their financial information or patients that would not qualify under the charity care policy. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 15e: An individual must complete an application and submit supporting documentation such as check stubs or an income tax return. All of the staff in the Business Office billing department are able to assist individuals with any questions they have regarding the application process. |
| Hazen Memorial Hospital Association | Part V, Section B, Line 16i: In addition to the full FAP being available upon request, information referencing the FAP is provided in summary format on the clinic's website, attached to the billing invoices, as well as posted in the admissions office, emergency rooms and waiting rooms. |
| Part V, Section B, Line 16 | Financial Assistance Policy Website Availability |
| Hazen Memorial Hospital Association Part V, Section B, line 16a website: | http://www.sakmedcenter.org/general_services/business_office.htm |
| Hazen Memorial Hospital Association Part V, Section B, line 16b website: | http://www.sakmedcenter.org/general_services/business_office.htm |
| Hazen Memorial Hospital Association Part V, Section B, line 16c website: | http://www.sakmedcenter.org/general_services/business_office.htm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| Sakakawea Hazen Clinic | ||||
| 517 8th Ave NE | Hazen | ND | 58545 | Clinic |
| Senior Suites at Sakakawea | ||||
| 813 7th St NE | Hazen | ND | 58545 | Basic Care Facility |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | Sakakawea Medical Center offers two separate programs for discounted care. The self pay discount policy is available for uninsured patients regardless of income. A discount of 30% is allowed if regular monthly payments are remitted in a specified time frame. This program cannot be combined with the Charity Care program.The charity care program provides discounted care to patients based on family income according to FPG guidelines. The sliding fee scale allows discounts from 20% to 100% of charges. The program is available for uninsured patients as well as co-pays and deductibles for insured patients. |
| Part I, Line 7: | Charity care is based on the total direct and indirect costs related to providing services to patients and based on average ratios of cost to charges. Unreimbursed Medicaid was converted to cost using the cost-to-charge ratio derived from the relevant cost center on the Medicare cost report. Community health improvement services and health professionals education reflect actual expenses recorded to the general ledger. Subsidized health services costs were calculated based on information from the Medicare cost report. |
| Part I, Ln 7 Col(f): | For the purposes of calculating the percentage on Part 1, Line F, $469,816 of bad debt was backed out of total operating expenses. |
| Part II, Community Building Activities: | The CEO serves on two boards for economic development (Mercer County Economic Development and Hazen Community Development), one board for workforce development (Job Development Authority), eight boards for community health improvement advocacy (Community Health Association of the Mountain Plains States, National Rural Accountable Care Organization, North Dakota Hospital Association, Area Health Education Center, Mercer County Ambulance, Northland Healthcare Alliance, Technical Advisory Services, and Community Healthcare Association of the Dakotas). The Director of Patient Care serves on four boards (Bismarck State College Advisory Board, University of Mary Advisory Board, North Dakota CAH Quality, and North Dakota Risk Management Society). |
| Part III, Line 2: | Bad debt expense is reported at charges. Payments and discounts are posted to patient bills. |
| Part III, Line 3: | There are most likely some patients in bad debt who would qualify for charity care, but they have not completed the application and remitted the required payment. Based on the poverty level of the service area, 6.2%, the estimated amount of bad debt expense that is attributable to patients eligible under the organization's financial assistance policy would be approximately $29,129. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on page nine of the attached audited financial statements. |
| Part III, Line 8: | 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 Centers for Medicare & Medicaid Services. The costs themselves are a community benefit as the community would not receive these services if we did not provide them. |
| Part III, Line 9b: | If a patient has applied for charity care previously, an application is sent with the monthly statement. Once determined the patient is eligible, the charity care discount portion is written off. The remaining patient portion then falls under the same collection practices of all other accounts. Our policy requires a new charity care application every six months. |
| Part VI, Line 2: | Sakakawea Medical Center consults with local physicians to identify community healthcare needs. The SMC staff participates in local and regional organizations and activities including Chamber of Commerce and economic development boards. The CEO routinely attends city council and county commission meetings to solicit input and engage in dialogue relating to healthcare needs and services.Sakakawea Medical Center has collaborated with other local providers to conduct a community health needs assessment which will inventory service delivery assets, identify needs and create a foundation for undertaking strategic initiatives. |
| Part VI, Line 3: | Charity care information is sent with the monthly statements to all uninsured patients as well as patients that are not making adequate monthly payments. Approximately 100 notices are sent out per month with the statements. Inpatients and surgical patients are informed at time of admission about charity care. A social worker visits with all self pay inpatients to inform them about the charity care, Medicaid (state program), and self pay discount policies. Brochures have been printed that describe our charity care and discount policies. The brochures are available in waiting rooms, ER, the clinics and admitting offices. |
| Part VI, Line 4: | Hazen Memorial Hospital Association serves the communities in Mercer County and the surrounding area, including the towns of Hazen, Beulah, Stanton, Zap, Golden Valley, Center and Pick City. Sakakawea Medical Center, located in Hazen, is the only hospital in the county. The nearest hospital is located more than 60 miles away. Attached to the hospital is Senior Suites, a basic care facility. The Association manages one rural health clinic in Hazen. The combined total population of the county is approximately 8,746. The average annual wage in Mercer County for 2014 was $62,712. The current unemployment rate is 4.3%. Sakakawea Medical Center's payer mix for this fiscal year included 10% uninsured patients and 4% Medicaid patients. All patients presenting to the facility are cared for regardless of their ability to pay. |
| Part VI, Line 5: | As a critical access hospital, Sakakawea Medical Center provides a variety of health and wellness services to our service area. The organization subsidizes primary care services provided at the Sakakawea Hazen Clinic, ensuring that primary care is available in the local communities. SMC also subsidizes home health services to ensure those residents who are homebound have the health care they need. The emergency room is staffed 24 hours a day and is available to all regardless of ability to pay. The Board of Directors is comprised of county-wide volunteers; three are from Hazen, six from Beulah, and one from Stanton. The directors have various occupations including power plant manager, bank vice president, accounting supervisor, engineer, chiropractor, and business owner. The directors are not employed by SMC nor are they family members of employees.Medical privileges are extended to all physicians in the county.Sakakawea Medical Center's Hospice staff is assisted by 65 volunteers from the area communities. The staff at Senior Suites, the basic care facility, is served by 18 community volunteers. The surgical program at Sakakawea Medical Center is assisted by 10 community volunteers. Surplus funds are invested back into the facility through equipment upgrades and building improvements. Recent investments include the purchase of a chest compression system, a hematology machine, a glidescope and cautery equipment for the operating room. In addition, more continuing education is being offered to the staff by means of webinars and workshops. An employee assistance program is available for staff and family members which provides free confidential assessments, counseling, or referral services by trained professionals.Sakakawea Medical Center is investing in the future of healthcare professionals by implementing a nursing program. We are partnering with other health care providers in the county, a community health center and a nursing home, to offer Interactive Video Network (IVN) classes in our facility. Hands-on skill work and clinicals are taught by registered nurses employed by our organization. Upon completion of an 11 month program, students will receive a certificate in practical nursing. An additional 9 month program enables the students to receive an Associate Degree in Nursing and become eligible to test for their registered nurse license. Sakakawea Medical Center also supports state universities and high schools by offering rural medical experiences to area students. Throughout the year, students are provided with practice opportunities in nursing, lab, PT or the emergency room.Beginning in 2015, Sakakawea Medical Center is also assisting the Dakota College at Bottineau, ND with their Medical Assistant Program. Students study through on line courses provided by Dakota College. The hands-on skills are taught by registered nurses in our facility weekly. Students can complete a one year program for a diploma, or a two year program for a degree. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | Yes (1) | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Darrold Bertsch | ||||||||||||||
| CEO | $106,416 | $0 | $0 | $0 | $0 | $0 | $65,000 | $0 | $0 | $0 | $171,416 | $0 | $0 | $0 |
| Rodney Zimmerman | ||||||||||||||
| Family Practice Physician | $268,864 | $0 | $0 | $0 | $0 | $0 | $7,819 | $0 | $16,685 | $0 | $293,368 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 4b | SMC paid $65,000 in premiums for a 457(f) plan for Darrold Bertsch, CEO. This amount is reflected in Schedule J, Part II, deferred compensation. |
| Schedule J, Part II: | Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Part II of Schedule J reflects total base compensation SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2014 Form W-2 from CCCHC. In the calendar year 2014, Darrold received $106,416 in base salary from CCCHC related to his services as SMC CEO. The non-taxable benefits reported in Part II are in relation to the 457(f) plan premiums paid on his behalf by SMC. |
Schedule L IRS990ScheduleL
Loans Btwn Org Interested Prsn LoansBtwnOrgInterestedPrsnGrp (2 entries)
| Relationship With OrgRelationshipWithOrgTxt | Loan PurposeLoanPurposeTxt | Loan To OrganizationLoanToOrganizationInd | Original PrincipalOriginalPrincipalAmt | Balance DueBalanceDueAmt | DefaultDefaultInd | Board Or Committee ApprovalBoardOrCommitteeApprovalInd | Written AgreementWrittenAgreementInd |
|---|---|---|---|---|---|---|---|
| Union State Bank (USB) | |||||||
| Board Pres. C. Obenauer constructively owns >35% of USB | Bond Refinance | Yes (X) | $663,689 | $268,461 | 0 | Yes (1) | Yes (1) |
| Union State Bank (USB) | |||||||
| Board Pres. C. Obenauer constructively owns >35% of USB | Refinance Equipment | Yes (X) | $506,000 | $57,946 | 0 | Yes (1) | Yes (1) |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | $326,407 | TotalBalanceDueAmt |
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Jocelyn Bertsch | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Wife of CEO | RelationshipDescriptionTxt |
| Transaction | $67,671 | TransactionAmt |
| Transaction | Employee Compensation | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1 | There were 10 board of directors at fiscal year end, but the board president only votes to break a tie. The Executive Committee shall consist of the President, Vice President and Secretary/Treasurer of the Board. The CEO 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. This committee shall meet as required. In the current fiscal year, the Executive Committee did not meet to make any decisions on behalf of the full governing board. |
| Form 990, Part VI, Section A, line 6 | Any person, firm, association, or corporation interested in the activities of this organization, and residing in the service area, may become a member thereof, provided that he has first made a contribution to the association at some time. Each member has one voting right. |
| Form 990, Part VI, Section A, line 7a | The members elect the Board of Directors on an annual basis. |
| Form 990, Part VI, Section A, line 7b | The members must also approve/disapprove the dissolution of the organization or the merger or consolidation of the organization with another corporation. |
| Form 990, Part VI, Section A, line 8b | All items discussed at committee meetings are brought to the full board for recommendations for board action. The organization did not have any committees that acted on behalf of the board. |
| Form 990, Part VI, Section B, line 11 | Upon receipt of the draft Form 990, a copy will be forwarded to the board members for their review and comment. |
| Form 990, Part VI, Section B, line 12c | The Board of Directors is covered by the conflict of interest policy. Only one conflict has been disclosed this fiscal year by a member of the Board of Directors. The director who has acknowledged the conflict of interest is excused from the board meeting whenever there is discussion about the relevant issue. Although the written policy as of June 30, 2015 did not address the officers of the organization, the officers do review and comply with the policy and disclose to the board of directors if a conflicts does exist. After the conflict is self-reported that officer abstains completely from the decision process of the issue at hand. |
| Form 990, Part VI, Section B, line 15 | The CEO was paid by an unrelated organization that used comparability data to review and determine his compensation. For purposes of determining the CFO's compensation package at Sakakawea Medical Center, a variety of resources are used. The Organization takes into consideration what is appropriate compensation for that respective position, based on their market. The Organization uses salary surveys from the North Dakota Hospital Association and also refers to the public 990 information from similar sized hospitals in North Dakota. The CFO is evaluated by the CEO annually and the compensation is based on the above information. |
| Form 990, Part VI, Section C, line 19 | The Organization's governing documents, conflict of interest policy, and financial statements are available if specifically requested. |
| Form 990, Part VII: | Darrold Bertsch, CEO, is an employee of Coal Country Community Health Center (CCCHC) and provides CEO services to both SMC and CCCHC. However, as an employee of CCCHC, Darrold now receives his W-2 from CCCHC. Sakakawea Medical Center reimburses CCCHC for part of Darrold's salary based on a contract. The compensation reported in Part VII of the core form and Part II of Schedule J reflects total base compensation SMC reimbursed CCCHC for his services solely to SMC, which was reported on his 2014 Form W-2 from CCCHC. In the calendar year 2014, Darrold received $106,416 in base salary from CCCHC related to his services as SMC CEO. The non-taxable benefits reported in Part VII column f are in relation to the 457(f) plan premiums paid on his behalf by SMC. |
| Form 990, Part IX, line 11g | Medical Purchased Services: Program service expenses 1,735,993. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,735,993. Other Purchased Services: Program service expenses 94,567. Management and general expenses 131,573. Fundraising expenses 0. Total expenses 226,140. |
| Form 990, Part XI, line 9: | Change in Interest in Net Assets of Sakakawea Medical Center Foundation 1,642,245. Change in Net Assets of Hazen Memorial Hospital Auxiliary -9,577. |
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