2015-05-13T13:34:55-05:00 2014-06-30 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2013-07-01 450310159 Christian Unity Hospital Corporation CHRI 7013521620 164 West 13th Street Grafton ND 58257 Alan O'Neil CEO 7013521620 2015-05-13 1 LISA CHAFFEE CPA P00193453 7012398500 2015-05-13 2013 2016-03-07 17:11:31Z Unity Medical Center Alan O'Neil 164 West 13th Street Grafton ND 58257 8747609 0 X www.unitymedcenter.com X 1970 ND Unity Medical Center provides access to quality health care for the region. 8 7 120 31 0 0 473853 445827 7976691 8291378 740 1274 8630 9130 8459914 8747609 0 0 0 0 4940262 4888973 0 0 0 3610352 3919015 8550614 8807988 -90700 -60379 5395232 5002283 3404307 3068720 1990925 1933563 X Unity Medical Center provides access to quality health care for the region. 0 0 7514598 8291378 Unity Medical Center is a 17 bed healthcare facility, which provides emergency care, acute care services, outpatient services and clinical medical services to the residents of Grafton, North Dakota and surrounding communities. The facility provides outreach services such as physical therapy, respiratory therapy, and flu vaccination clinics to other employers in the area as well. For the fiscal year ended June 30, 2014 the medical center provided as part of its mission 440 acute days, 1396 swing bed days, 87 respite days and 9,612 clinic visits. The amount of charges foregone for services provided under the Organization's charity care policy was approximately $45,000 for the fiscal year. Total direct and indirect costs related to these foregone charges was $33,000, based on an average ratio of costs to gross charges. 7514598 1 1 0 0 0 0 0 0 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 12 0 1 120 1 0 0 0 0 0 0 0 0 0 0 X 8 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 0 1 1 1 0 X Alan O'Neil 7013529365 164 West 13th Street Grafton ND 58237 X Keith Zikmund President 1.00 X X 0 0 0 Jo Petersen Vice President 1.00 1.00 X X 0 0 0 JoAnn Lizakowski Secretary/Treasurer (July-September) 1.00 X X 0 0 0 Amy Vollrath Board MemberJuly- -Sept)/Secr./Treas. (Oct-June) 1.00 X X 0 0 0 Dale Martinson Board Member (July-September) 1.00 X 0 0 0 Vicki Ham Board Member 0.50 X 0 0 0 Pastor Chris Gaule Board Member 0.50 X 0 0 0 Mary Houdek Board Member 0.50 X 0 0 0 Roger Gorder Board Member 0.50 X 0 0 0 Dr Linda Fillipi Physician/Medical Staff Pr 41.00 X 191167 0 7037 Everett Butler CEO (July-March) 40.00 X 148041 0 454 Rachel Ray CFO/Interim CEO (March-May) 40.00 X 66083 0 109 Alan O'Neil CEO (June) 40.00 X 0 0 0 Dr Joshua Omotunde MD 40.00 X 236916 0 18475 Dr Anthony Kotnik MD 40.00 X 181959 0 17847 Rodney Sigvaldson PA 61.00 X 143931 0 17847 968097 0 61769 5 0 1 0 DMS 26273 Network Place Chicago IL 606731262 Mobile Services 280740 Altru PO Box 13780 Grand Forks ND 582083780 EPIC, Telepharmacy, etc. 129478 St Paul Radiology PO Box 2923 Indianapolis IN 462062923 Radiology Readings 127357 Sieman's PO Box 121102 Dallas TX 753121102 Services & Re-Agents 101951 4 62233 249043 134551 445827 Net Patient Serv. Rev. 621300 8114360 8114360 EHR 900099 106000 106000 Misc income 900099 65618 65618 Auxiliary Income 900099 5400 5400 8291378 1274 1274 9130 0 9130 9130 9130 8747609 8291378 0 10404 414991 194735 220256 3723359 3180410 542949 480872 397232 83640 269751 220333 49418 3850 3850 42621 42621 756938 739261 17677 30700 30700 528729 445264 83465 126616 126616 146398 145949 449 30299 22327 7972 2854 2854 118949 118949 465326 465326 67951 67951 Medical Supplies 903629 903629 Provision for Bad Debts 560268 560268 Communications 37798 37798 Dues and Subscriptions 20030 5858 14172 76059 9308 66751 8807988 7514598 1293390 0 347892 472186 1688190 1818570 109984 108042 30405 12722 10231586 7692660 2878749 2538926 340012 51837 5395232 5002283 1015759 795566 2135000 2085000 253548 78854 0 109300 3404307 3068720 X 1877635 1831868 113290 101695 1990925 1933563 5395232 5002283 X -60379 3017 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 11369 5400 8417 8352 0 43017 43017 7424829 5275443 2149386 2511109 2236456 274653 252631 180761 71870 2538926 Estimated third party payor settlements 109300 109300 X 8181941 -560268 -560268 8742209 5400 5400 8747609 8239303 0 8239303 568685 568685 8807988 Part IV, Line 1b: There is an auxiliary which operates under the EIN of the Hospital. 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 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 990T) 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 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 in the F/S -560,268. Part XI, Line 4b - Other Adjustments: Auxiliary Revenue 5,400. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts reported in Revenue in the F/S 560,268. Auxiliary expenses 8,417. 1 1 X 1 X 1 X 0 1 1 0 0 33000 33000 0.00400 503847 451028 52819 0.00640 536847 451028 85819 0.01040 2650 2650 0.00030 1650178 1372544 277634 0.03370 1652828 1372544 280284 0.03400 2189675 1823572 366103 0.04440 0 560268 55467 3185664 3207579 -21915 X 1 1 1 1 Christian Unity Hospital Corporation 164 West 13th Street Grafton ND 58257 www.unitymedcenter.com 5020 X X X X Christian Unity Hospital Corporation 1 1 X X X X X X X X 12 1 0 1 X www.unitymedcenter.com X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X 1 1 X X 1 0 X X 1 X 0 1 Christian Unity Hospital Corporation Part V, Section B, Line 3: We had individuals from different aspects of the community including, Public Schools, Daycare Providers, County Health, Mental Health Community, and other various businesses. Christian Unity Hospital Corporation Part V, Section B, Line 6i: The Implementation Strategy can be found at: http://www.unitymedcenter.com/. Christian Unity Hospital Corporation Part V, Section B, Line 7: Two of the needs identified in the CHNA which are not being addressed were kidney dialysis and dermatology. Kidney dialysis requires a substantial financial outlay and the number of dialysis patients in our study does not support a dialysis unit, but, potentially, we could have a visiting physician address this issue. We have not been able to find a visiting physician to address this issue. As of June 2014, we were still not able to find anyone in our area to provide dermatology services here, however UMC is proud that they will begin offering dermatology services on a part time basis in May 2015. During the year, the organization began to address the need for increased colorectal cancer screenings. Our UMC employee, who was working on this, was out for an extended period of time, due to medical leave, and this was set aside. The Community Relations Committee plans to begin the education process through articles and brochures in the near future. Christian Unity Hospital Corporation Part V, Section B, Line 14g: Patients who do not pay after 90 days meet with the Patient Account Representative and go over their available options including financial assistance. The organization posts the EMTALA law in their emergency room. The organization is also weighing their options of how to make their financial assistance policy more widely available to the public including the possibility of posting the policy on their website. Christian Unity Hospital Corporation Part V, Section B, Line 22: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. FAP-eligible patients without insurance may be charged gross charges on elective procedures. 1 Grafton Family Clinic 155 West 14th Street Grafton ND 58257 Rural Health Clinic Part I, Line 3c: The Organization does follow the Federal Poverty Guidelines (FPG) when determining discounted care, but they have set up three different ranges within the Guidelines. A patient will pay 30%, 60% or 80% of their bill depending upon where their income falls. The patient is responsible for 30% of their bill if their income is 100% to 132% of the FPG. The patient is responsible for 60% of their bill if their income falls between 133% to 166% of the FPG. The patient is responsible for 80% of their bill if their income falls between 167% and 200% of the FPG. If the individual falls below the minimum criteria, that person is eligible for 100% charity care allowance, or free care. Part I, Line 7: The organization used the following to determine the costs for Part I, Line 7:Row a: An average ratio of cost to gross charges which addresses all patient segmentsRow b: Unreimbursed Medicaid was calculated using the costing methods to prepare the cost reports.Row e: An estimate of actual costs were used based on the General LedgerRow g: The cost for subsidized health services was determined using the Medicare Cost Report. Part I, Line 7g: The amount of costs attributable to a rural health clinic is $1,610,019. Part I, Ln 7 Col(f): The amount of bad debt expense removed from the denominator is $560,268. Part III, Line 2: Discounts and payments are taken into account when determining bad debt expense. Payments on a previously written off account are recorded as a recovery of bad debt expense and they reduce bad debt expense. Part III, Line 3: 9.9% of the individuals in Walsh County, North Dakota (in which the Hospital is located) fall below the federal poverty levels according to Census.gov. Therefore, the organization estimates that 9.9% of the bad debt expense at cost is attributable to patients eligible under the organization's charity care policy. Care is given to individuals regardless of their ability to pay and so therefore this is a community benefit. Part III, Line 4: Footnote from organization's financial statements: The footnote that describes bad debt expense is found on page 9 of the attached audit report. 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 and Medicaid Services.Christian Unity Hospital Corporation provides medically necessary care to all regardless of the ability to pay. Providing services to those eligible for Medicare is a benefit to the community as elderly are a charitable class. Therefore all of the shortfall should be treated as a community benefit. Part III, Line 9b: If an incomplete financial assistance application has been submitted, the Patient Accounts Representative will work with the patient to gather any missing or outstanding items. Any collection actions are stopped after the patient submits an application for financial assistance until it is determined whether or not the individual is eligible for financial assistance. If the patient qualifies for financial assistance, any collection actions already taken against the individual would be reversed. The Patient Accounts Representative documents whether or not the individual is eligible for financial assistance. Part VI, Line 2: We finalized our community health needs assessment early in FY2013 and our board of directors adopted an implementation strategy as a result of the findings at that time. We have community members from different backgrounds/occupations that serve on our Board of Directors. They are open to listening to other community members regarding health care needs. These are brought to the Board and considered at that time. UMC also brings in specialty doctors to our rural health clinic to enhance the services that are already offered. We offer services such as oncology, psychiatry, etc. UMC is proud that they will begin offering dermatology services, on a part time basis in May 2015. This has been a need brought to us over and over throughout the years. We have an individual in the community that will begin seeing patients in the Grafton Family Clinic. Part VI, Line 3: A sign near the entrance to the emergency room indicates we "provide medical care for those who cannot afford to pay." Another posting states that "the facility is legally obligated to serve the community." For those patients who do not pay on their balances, we contact them by phone. They visit with our Patient Account Representative. The Representative discusses payment arrangements, eligibility for certain programs, such as Medicaid, and then charity care, if necessary. If we cannot get those patients to come in and talk, we try to make arrangements over the phone and through the mail, if necessary. Part VI, Line 4: Grafton is a rural community of approximately 4,284 residents located in Walsh County, North Dakota. The median household income for Walsh County is $44,139 for 2006-2010 per the US Census Data. 9.9% of individuals in the Walsh County fall below the poverty level. Unity Medical Center serves the population of Grafton and several surrounding smaller communities. The area is also served by a hospital in Park River and a hospital in Grand Forks. Approximately 7.5% of the hospital's business in FY 2014 was to private pay individuals. Approximately 8.6% of our business was to Medicaid recipients. We also have a Migrant Health office in the community to serve migrant workers. Part VI, Line 5: The Unity Medical Center (UMC) governing body is comprised of persons who reside in our primary service area. The board members are neither contractors, or family members of the organization. Medical staff privileges are extended to those qualified physicians in our community who have applied for and been granted medical privileges, per our credentialing process. Surplus funds, when available, are used to purchase equipment or make purchases to improve the building structure for the purpose of improving patient care. Unity Medical Center Foundation also assists the hospital with capital purchases.UMC offers 24 hour access to emergency room care, which is available to all individuals, regardless of their ability to pay for the care. UMC offers acute care, swing bed care, general surgery, as well as many outpatient services. UMC does participate in education of healthcare professionals. We take approximately 2-3 medical students per year and several Physical Therapy students throughout the year from the University of North Dakota. We do training for students from technical schools, as well, as requested. UMC is the only hospital and clinic in the community; therefore, we are a viable part of this community. UMC offers programs such as diabetes screenings, flu vaccination clinics, free blood pressure checks, KIDS UMC (education for young children), etc. UMC also has a representative on the Mayor's Committee of Wellness for the community. UMC brings in specialty doctors to our clinic in order to offer more necessary services to our patient population, i.e. oncology, psychiatry, etc. We offer volunteer opportunities for high school students and adults. We have fourteen members of our UMC Auxiliary Services that volunteer here every week for the benefit of the facility. Part VI, Line 6: N/A X X 0 0 0 1 0 0 0 0 0 Dr Linda Fillipi Physician/Medical Staff Pr 191167 0 0 0 0 0 0 0 7268 0 198435 0 0 0 Dr Joshua Omotunde MD 236916 0 0 0 0 0 0 0 28072 0 264988 0 0 0 Dr Anthony Kotnik MD 181959 0 0 0 0 0 0 0 24947 0 206906 0 0 0 Rodney Sigvaldson PA 143931 0 0 0 0 0 0 0 18053 0 161984 0 0 0 Part I, Line 3 The Organization bases salaries and wages on the ND Healthcare Survey. There is an annual performance evaluation completed and then a raise, up to 3%, (the percentage is agreed to by the Board of Directors) is given based on that evaluation. Part I, Line 5 Physician compensation is calculated monthly. Physicians earn 58 percent of gross revenues from gross professional charges. A City of Grafton 456002080 384455BF7 2008-04-23 2363560 Capital improvements to hospital 0 0 0 A 265000 2363560 47000 2316560 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 1 0 0 0 0 0 0 A 0 Form 990, Part VI, Section A, line 1 The Organization has an Executive Committee which is made up of the President, Vice President, Secretary, Treasurer and a Member at Large. The Executive Committee has the power to transact regular business in between board meetings. The Executive Committee has the responsibility to serve as the nominating committee. The Executive Committee was active in the past year with the retirement of one CEO and hiring of another. Form 990, Part VI, Section A, line 6 Membership in the corporation shall be either lifetime or annual, and shall be limited to adult individuals as follows: 1) Those individuals or companies contributing $100 to the corporation, or to the development fund of the Medical Center Corporation, shall, upon specific request, be entitled to a life membership. If an individual or company makes a contribution of $200 or more, they shall be entitled to designate one additional immediate family member or company employee (limited to two per family or company), respectively, for lifetime membership effective retroactively. 2) Those individuals residing in the Unity Medical Center service area shall be granted annual membership at no fee. They shall be granted annual membership status by showing proof of residing in the Corporation service area. Form 990, Part VI, Section A, line 7a Each member of the corporation in good standing shall be qualified to cast one vote on any issue that may properly come before any meeting of the members of the corporation, and to hold any office in the corporation to which he or she may be elected or appointed. Form 990, Part VI, Section B, line 11 The CFO & CEO will review a draft of the Form 990. Unity Medical Center will provide the board members with a link and a password to an electronic copy of the 990. Form 990, Part VI, Section B, line 12c Annually board members must sign a conflict of interest policy. If a board member believes that a conflict exists it is their responsibility to bring the conflict to the attention of the board. The board will determine if a conflict exists. Any board members with a conflict of interest must abstain from voting on any issues relating to the conflict. Form 990, Part VI, Section B, line 15 A formal evaluation is completed for both the CEO and CFO. Comparability data is used from the North Dakota Hospital Association. At budget time each year the board will approve a percentage increase. The deliberation and decision is documented in the board minutes. The process was last completed in June 2013. A new CEO was hired and began work in June 2014. The annual increase did not happen with the previous CEO, as he retired in March 2014. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are made available upon request. Form 990, Part VII: Director Compensation and Hours Devoted: Dr. Linda Fillipi does not receive compensation for being the Medical Staff President on the Board of Directors. The compensation she received reported in Part VII is in relation to her medical services as a physician. She devoted 1 hour per week to her position as a Board Member. Form 990, Part XI, line 9: Change in Auxiliary net assets 3,017. Unity Medical Center Foundation 164 West 13th Street Grafton ND 58237 363522304 Fundraising for Unity Medical Center ND 501(c)(3) Line 7 Christian Unity Hospital Corporation DBA Unity Medical Center 1 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 0 0 Unity Medical Center Foundation C 62233 Contribution amount per GL