2016-08-09T08:56:01-05:00 2015-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2015-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 JENI SCHWENZFEIER CFO 7012658461 2016-07-29 1 KACIE MCEWEN P01599614 6123764500 2015 2016-12-15 16:53:06Z EVERETT BUTLER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 12942700 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE. 9 5 206 25 0 0 103348 142978 12001556 12695744 3074 3520 88765 100458 12196743 12942700 0 0 0 0 6111446 6679213 0 0 31181 5933211 6026671 12044657 12705884 152086 236816 5941998 6176422 2083605 2080105 3858393 4096317 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 11385063 0 12695744 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED ACUTE CARE HOSPITAL, 50-BED NURSING HOME, AND 20-UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24-HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY. THE ASSOCIATION ALSO PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. 11385063 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 1 0 0 0 1 34 0 206 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X JENI SCHWENZFEIER 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 TOM FORD PRESIDENT 1.00 1.00 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 1.00 X X 0 0 0 TOM O'TOOLE SECRETARY/TREASURER 1.00 1.00 X X 0 0 0 LORETTA BERNHOFT BOARD MEMBER 1.00 X 0 0 0 DR ALLAN LINDEMANN BOARD MEMBER AND PHYSICIAN 40.00 X 0 0 0 DALE O'HARA BOARD MEMBER 1.00 1.00 X 0 0 0 KENNETH SCHWANDT BOARD MEMBER/CONTRACT PHARMACIST 7.00 X 22750 0 0 DEAN STEINWAND BOARD MEMBER 1.00 X 0 0 0 DR KULVINDER SUMRA BOARD MEMBER AND PHYSICIAN 40.00 X 0 0 0 JENI SCHWENZFEIER CFO 30.00 X 70192 0 15059 EVERETT BUTLER CEO 32.00 X 121980 0 1432 214922 0 16491 1 0 0 0 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 493169 DMMS PO BOX 206143 DALLAS TX 75320 MOBILE IMAGING 393433 INDER V KHOKHA MD PC PO BOX 380 CAVALIER ND 58220 SURGEON SERVICES 360749 ARL PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 277628 PASTOREK CONSTRUCTION 106 6TH STREET EAST GRAFTON ND 58237 CARPENTRY/ CONSTRUCTION 269810 9 63896 79082 53896 142978 NET PATIENT REVENUE 621110 12558346 12558346 ANCILLARY REVENUES 621110 137398 137398 12695744 3520 3520 1750 0 1750 1750 1750 OTHER INCOME 900099 92550 92550 AUXILIARY INCOME 900099 6158 6158 98708 12942700 12695744 0 103978 X 231413 22750 208663 5186002 4701515 453306 31181 139262 123937 15325 722158 635703 86455 400378 345886 54492 1825 1825 47339 47339 2826347 2607345 219002 24854 534 24320 196842 178025 18817 194 194 273233 224942 48291 39657 13289 26368 22086 22086 586921 586921 93235 40183 53052 MEDICAL SUPPLIES 1209292 1208827 465 PROVISION FOR BAD DEBT 313771 313771 FOOD EXPENSE 147670 147670 EQUIPMENT RENTAL & REPA 146009 143655 2354 97396 68024 29372 12705884 11385063 1289640 31181 234190 484449 1664287 2157591 141609 152121 123822 164058 14812295 12030157 2684782 2782138 799224 321598 294084 114467 5941998 6176422 1232245 1457911 57214 0 14723 15240 683342 517278 96081 89676 2083605 2080105 X 3858393 4096317 3858393 4096317 5941998 6176422 X 236816 1108 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 639 639 0 PART II-B, LINE 1: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. 1 8973 6158 7266 7865 1 X 160304 160304 6288028 5139158 1148870 622608 365797 256811 7728667 6525202 1203465 12688 12688 2782138 X 12617501 -313771 -313771 12931272 11428 11428 12942700 12384847 0 12384847 321037 321037 12705884 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2015 AND 2014 TOTALED $15,240 AND $14,723, RESPECTIVELY. PART X, LINE 2: THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -313,771. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 3,520. DONATIONS AND OTHER INCOME 1,750. AUXILIARY INCOME 6,158. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 313,771. AUXILIARY EXPENSES 7,266. 1 1 X 1 X 1 X 0 1 1 0 0 12732 0 12732 0.00100 1389577 490498 899079 0.07260 1402309 490498 911811 0.07360 12710 12710 0.00100 22000 22000 0.00180 2767712 2371422 396290 0.03200 2802422 2371422 431000 0.03480 4204731 2861920 1342811 0.10840 2000 2000 0.00020 600 600 0.00000 2600 2600 0.00020 1 313771 25102 4055140 4111860 -56720 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 456013474 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 14 1 0 1 1 X WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ X 1 14 1 WWW.CAVALIERHOSPITAL.COM/ABOUT-US/ 0 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/ABOUT-US X X X 1 0 X X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESSMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1) A SURVEY OF AREA RESIDENTS, INCLUDING HEALTH CARE PROFESSIONALS WHO WORK AT PCMH, PCPH, ALTRU CLINIC AND OTHER HEALTH ORGANIZATIONS;2) COMMUNITY LEADERS REPRESENTING THE BROADER INTERESTS OF THE COMMUNITY TOOK PART IN ONE-ON-ONE KEY INFORMANT INTERVIEWS;3) THE COMMUNITY GROUP, COMPRISED OF COMMUNITY LEADERS AND AREA RESIDENTS, WAS CONVENED TO DISCUSS AREA HEALTH NEEDS AND INFORM THE ASSESMENT PROCESS; AND4) A WIDE RANGE OF SECONDARY SOURCES OF DATA WERE EXAMINED, PROVIDING INFORMATION OF A MULTITUDE OF MEASURES INCLUDING DEMOGRAPHICS; HEALTH CONDITIONS, INDICATORS, AND OUTCOMES; RATES OF PREVENTIVE MEASURES; RATES OF DISEASE; AND AT-RISK BEHAVIOR. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC HEALTH. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: RELATED TO ITS 2011 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL TOOK THE FOLLOWING ACTIONS IN 2015:1. PROVIDER SHORTAGES: DR. LINDEMANN WAS HIRED AS A FULL-TIME ON-STAFF PHYSICIAN IN 2013. LAURA ERMER WAS HIRED AS A FULL TIME ON-STAFF PHYSICIAN'S ASSISTANT IN 2014. SEE ALSO THE PARAGRAPH BELOW REGARDING CLINIC SERVICES. 2. ASSISTED LIVING: THE BOARD OF DIRECTORS HAS CHOSEN NOT TO PURSUE THIS NEED ANY FURTHER DUE TO COST CONSTRAINTS. 3. NUTRITIONAL EDUCATION: A FULL-TIME DIETICIAN HAS BEEN HIRED TO PERFORM OUTPATIENT, INPATIENT, AND OUTPATIENT CONSULTS/VISITS. SHE ALSO WORKS AT THE NURSING HOME TO PROVIDE DIETARY OVERSIGHT OF RESIDENTS. 4. CHILDREN'S HEALTH NEEDS: THESE NEEDS CONTINUE TO BE MET BY A FAMILY PRACTICE PROVIDER WHO IS ON-STAFF OR ON-CALL 24 HOURS A DAY, 7 DAYS A WEEK. BY ADDING DR. LINDEMANN AND LAURA ERMER TO THE MEDICAL STAFF, THIS GIVES FAMILIES MORE CHOICES IN THEIR PRIMARY CARE PROVIDER. SEE ALSO THE PARAGRAPH BELOW REGARDING CLINIC SERVICES. THE DUPLICATION OF SERVICES HAS BEEN ADDRESSES BETWEEN PEMBINA CLINICARE AND ALTRU CLINIC. AS OF 1/1/2016, THE TWO CLINICS MERGED AND CLINICARE NOW PROVIDES ALL PRIMARY CARE IN THE SERVICE AREA AND ALTRU PROVIDES SPECIALTY CARE IN THE SERVICE AREA. RELATED TO ITS 2014 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL DETERMINED THE TOP FIVE COMMUNITY HEALTH NEEDS IN 2015:1. COST & ADEQUACY OF HEALTH INSURANCE: UPON REVIEW OF THIS ITEM, IT WAS DETERMINED THAT WE AS AN ORGANIZATION, ARE NOT ABLE TO ADDRESS THIS ISSUE. IT IS A NATIONAL ISSUE, AND A 3 PARTY INSURANCE CARRIER ISSUE. HOWEVER, WE DID VISIT WITH JOHNSON & MCCANN WHO ADMINISTERS OUR EMPLOYEE BENEFIT PLAN, AND THEY ARE EXPERIENCING HIGH HEALTH INSURANCE COSTS AMONGST ALL OF THEIR CLIENTS. WE DID HAVE JOHNSON & MCCANN COME ONSITE AND PROVIDE EMPLOYEE FORUMS REGARDING UTILIZATION OF THE HEALTH PLAN AND CORRESPONDING INCREASES IN OUR FACILITY HEALTH INSURANCE PLAN.2. MENTAL HEALTH, INCLUDING ALCOHOL USE & ABUSE: THE HOSPITAL HAS DEVELOPED A RESOURCE BOOK ON MENTAL HEALTH AND BEGAN OFFERING CLASSES OPEN TO THE PUBLIC TO ACCOMPANY THE BOOK. ADDITIONAL TRAINING HAS BEEN OFFERED TO THE COMMUNITY REGARDING EMERGENT MENTAL HEALTH ASSISTANCE. 3. OBESITY: PCMH HAS RECENTLY HIRED A FULL-TIME DIETICIAN/DIABETIC EDUCATOR THAT PROVIDES OUTPATIENT, INPATIENT, AND RESIDENT CARE VISITS/GUIDELINES ON DIET.4. NOT ENOUGH JOBS WITH LIVABLE WAGES: PCMH HAS WORKED WITH THE PEMBINA COUNTY JDA REGARDING FINANCING VARIOUS PROJECTS WHICH HAVE CREATED ADDITIONAL EMPLOYMENT OPPORTUNITIES WITHIN PCMH. PCMH HAS ALSO ADJUSTED ENTRY LEVEL POSITION WAGES FOR NEW AND EXISTING EMPLOYEES. THESE POSITIONS INCLUDE CRAS, HOUSEKEEPING, AND DIETARY.5. LACK OF RESOURCES FOR ELDERLY TO STAY IN THEIR HOMES: A BOOKLET OF RESOURCES HAS BEEN DEVELOPED FOR THE ELDERLY. THIS COMPREHENSIVE RESOURCE BOOK IS INTENDED TO ASSIST THE ELDERLY WITH TRANSPORTATION NEEDS, MEAL/FOOD ASSISTANCE, FAITH IN ACTION RESOURCES, LOCAL HEALTHCARE SERVICES AVAILABLE, ETC. PROVIDERS IN THE SERVICE AREA MEET JOINTLY TO DISCUSS FURTHER IMPROVEMENT OF THIS ISSUE AND ENHANCEMENT OF THE CURRENT BOOKLET/RESOURCES AVAILABLE. 3 1 - CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC 2 - WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME 3 - COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING PART I, LINE 7: THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, DIABETIC EDUCATION, CLINIC, AND EMERGENCY ROOM. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 313,771. PART II, COMMUNITY BUILDING ACTIVITIES: PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS. DURING 2015, HOSPITAL STAFF PROVIDED FIRST AID AND CPR CLASSES FOR YOUTH CAMPS/CLASSES AND ALSO DEVELOPED A RESOURCE BOOK ON MENTAL HEALTH WHICH ACCOMPANIED CLASSES OPEN TO THE COMMUNITY. PART III, LINE 2: IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: 8.0% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2010 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE THE ORGANIZATION ESTIMATES THAT 8.0% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. PART III, LINE 4: SEE THE "PATIENT AND RESIDENT RECEIVABLES NOTE ON PAGE 8 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERELY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFITY TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERIVCES. PART III, LINE 9B: CHARITY CARE AND FINANCIAL ASSISTANCE APPLICATIONS MUST BECOMPLETED IN THEIR ENTIRETY. IF AN APPLICATION IS INCOMPLETE, IT ISRETURNED TO THE GUARANTOR AND COLLECTION EFFORTS/ACTIONS RESUME IF THECOMPLETED APPLICATION IS NOT RETURNED. UPON RECEIPT OF A COMPLETEAPPLICATION, COLLECTION EFFORTS MAY BE REVERSED IF A PATIENT IS ELIGIBLEFOR CHARITY CARE AND/OR FINANCIAL ASSISTANCE. CHARITY CARE APPLICATIONSARE REVIEWED AND APPROVED BY THE BUSINESS OFFICE MANAGER AND THE CEO ORCFO. A DETERMINATION OF ELIGIBILITY FOR FINANCIAL ASSISTANCE ISDOCUMENTED. PARTIAL CHARITY CARE DISCOUNTS MAY APPLY. IF A PATIENT ISKNOWN TO BE FINANCIALLY STRUGGLING OR HAS FILED A CHARITY CARE APPLICATIONIN THE PAST, THE CHARITY CARE APPLICATION IS MAILED WITH THEIR 60 DAYINVOICE FROM THE HOSPITAL. IF A PATIENT IS DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ALL COLLECTION PRACTICES ARE STOPPED. PART VI, LINE 2: AN ANNUAL REVIEW OF THE RURAL HEALTHCARE CLINIC AND URGENT CARE IS DONE BY THE CEO, BOARD MEMBERS AND KEY MEDICAL STAFF MEMBERS. THE REVIEW EVALUATES SERVICES AND HELPS TO DETERMINE WHETHER TO ADD OR REMOVE SERVICES. THE LEADERS WITHIN THE ORGANIZATION ARE ALWAYS AVAILABLE FOR COMMUNITY MEMBERS' IDEAS AND OPINIONS. THESE IDEAS AND OPINIONS ARE PROPERLY BROUGHT TO THE ATTENTION OF THE REVIEW COMMITTEE AND EVALUATED. IN ADDITION, THE ORGANIZATION CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT IN 2014. PART VI, LINE 3: A LETTER IS RECEIVED BY ALL PATIENTS THAT HAVE HAD THEIR INSURANCE PROCESSED AND HAVE THE FOLLOWING OPTIONS FOR PAYMENT OF OUTSTANDING MEDICAL BILLS:1. PAYMENT IN FULL2. PAYMENT ARRANGEMENTS3. CHARITY CARE APPLICATIONUNINSURED PATIENTS HAVE THE SAME ABOVE MENTIONED OPTIONS WHEN IT COMES TO PAYING THEIR BILL.ALSO A PUBLIC NOTIFICATION IS VISIBLE AT THE MAIN RECEPTIONIST DESK AND ALL BUSINESS OFFICE STAFF CAN APPROPRIATELY ANSWER QUESTIONS IN REGARDS TO PAYMENT ON OUTSTANDING MEDICAL BILLS. WHEN A PATIENT INQUIRES ABOUT THEIR BILL WE ARE ABLE TO FURTHER DISCUSS IF THEY WOULD MEET THE CRITERIA AND WHAT FURTHER STEPS NEED TO BE TAKEN FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2010 SHOWED A POPULATION OF 7,413 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $51,613. THE PER CAPITA INCOME FOR THE COUNTY WAS $29,093. 9.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 493169 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 ARL ARL IS OWNED BY DR. ALLAN LINDEMANN, A BOARD MEMBER 277629 PAYMENT FOR DR. LINDEMANN'S PHYSICIAN SERVICES 0 RITA VAUGHN FAMILY MEMBER OF TOM VAUGHN, A BOARD MEMBER 31191 EMPLOYEE COMPENSATION 0 X 4 1615 DONOR'S PURCHASE PRICE X 16751 DONOR'S PURCHASE PRICE X 5 31662 DONOR'S PURCHASE PRICE X MINOR EQUIPMENT 2 3868 DONOR'S PURCHASE PRI 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. FORM 990, PART VI, SECTION A, LINE 6 ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7A ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. FORM 990, PART VI, SECTION B, LINE 11 THE CFO WILL REVIEW THE 990 WITH THE BOARD OF DIRECTORS; UPON APPROVAL OF THE RETURN, THE CFO WILL FILE THE 990 AS APPROVED. FORM 990, PART VI, SECTION B, LINE 12C THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT ARISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15A THE PROCESS FOR DETERMINING THE COMPENSATION INCLUDES LOOKING AT STATE SALARY SURVEYS FROM THE AMERICAN HOSPITAL ASSOCIATION OR NORTH DAKOTA HOSPITAL ASSOCIATION. FOR THE CEO, THE EXECUTIVE COMMITTEE OF THE BOARD DERIVES THE COMPENSATION CONTRACT. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON AMERICAN HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2015. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 2,607,345. MANAGEMENT AND GENERAL EXPENSES 219,002. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,826,347. FORM 990, PART XI, LINE 9: CHANGE IN AUXILIARY NET ASSETS 1,108. PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION 301 MOUNTAIN STREET EAST CAVALIER ND 58220 300052569 FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR ND 501(C)(3) LINE 11A, I N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0