2015-07-31T09:13:27-05:00 2014-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 JENI SCHWENZFEIER CFO 7012658461 2015-07-30 1 DARRYN MCGARVEY P00958683 6123764500 2014 2016-02-25 16:41:14Z EVERETT BUTLER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 12196743 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND PROVISION OF ACUTE CARE, LONG-TERM, AND ELDERLY CONGREGATE HOUSING FOR THE COMMUNITY. 9 5 200 23 0 0 59352 103348 11278249 12001556 2901 3074 1050 88765 11341552 12196743 0 0 0 0 5894297 6111446 0 0 30514 5260793 5933211 11155090 12044657 186462 152086 5511072 5941998 1851476 2083605 3659596 3858393 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 THAT PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE 0 0 10814038 0 12001556 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 24 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.THE ASSOCIATION RECENTLY PARTICIPATED/CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSEMENT TO DETERMINE FURTHER NEEDS IDENTIFIED BY THE COMMUNITY. THE RESULTS OF THIS ASSSMENT ARE POSTED ON THE FACILITY'S WEBSITE, WWW.CAVALIERHOSPITAL.COM.PEMBINA COUNTY MEMORIAL HOSPITAL WORKS COLLABORATIVELY WITH THE PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION TO RAISE MONEY TO PURCHASE NEW EQUIPMENT FOR PATIENT AND RESIDENT AREAS. WITHOUT DONATIONS AND GRANTS THROUGH THE FOUNDATION, MANY PROJECTS WOULD NOT BE ABLE TO BE COMPLETED. EXAMPLES OF ITEMS PURCHASED/DONATED THROUGH THE FOUNDATION IN 2014 INCLUDE THE REMODEL OF THE CHEMOTHERAPY TREATMENT AREA, NEW CLINIC EXAM TABLES, AND A SECURE COURTYARD FOR THE NURSING HOME RESIDENTS OF WEDGEWOOD MANOR. 10814038 1 1 0 1 0 0 0 0 1 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 0 0 0 0 0 1 1 0 0 0 1 32 0 200 1 0 0 0 0 0 0 0 0 0 0 X 9 5 0 0 1 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 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 1.00 X X 0 0 0 TOM O'TOOLE SECRETARY/TREASURER 1.00 X X 0 0 0 LORETTA BERNHOFT BOARD MEMBER 1.00 X 0 0 0 DR ALLAN LINDEMANN BOARD MEMBER AND PHYSICIAN 51.00 X 0 0 0 DALE O'HARA BOARD MEMBER 1.00 X 0 0 0 KENNETH SCHWANDT BOARD MEMBER AND CONTRACT PHARMACIST 7.00 X 21000 0 0 DEAN STEINWAND BOARD MEMBER 1.00 X 0 0 0 DR KULVINDER SUMRA BOARD MEMBER AND PHYSICIAN 51.00 X 0 0 0 JENI SCHWENZFEIER CFO 40.00 X 43797 0 1826 EVERETT BUTLER INTERIM CEO (AFTER 8/15/14) 40.00 X 34868 0 0 TANYA SHARP CEO (THROUGH 8/15/14) 40.00 X 92833 0 10388 192498 0 12214 0 0 0 0 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 465877 ARL PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 291754 ST PAUL RADIOLOGY 166 EAST 4TH STREET ST PAUL MN 55101 RADIOLOGIST READINGS 186590 DAKOTA TRAVEL NURSE 1200 COLLINS AVENUE MANDAN ND 58554 AGENCY NURSE 160102 4 30891 72457 103348 NET PATIENT REVENUE 621110 11758171 11758171 ANCILLARY REVENUES 621110 243385 243385 12001556 3074 3074 3675 0 3675 3675 3675 OTHER INCOME 900099 77652 77652 AUXILIARY INCOME 900099 7438 7438 85090 12196743 12001556 0 91839 X 496466 312754 183712 4494370 4052419 411437 30514 137419 120021 17398 636763 572118 64645 346428 300202 46226 716 716 52831 52831 2697507 2451815 245692 30110 230 29880 61696 58805 2891 3790 3790 305042 254124 50918 32886 28095 4791 20126 20126 556736 556736 63944 33490 30454 MEDICAL SUPPLIES 1073740 1069698 4042 PROVISION FOR BAD DEBT 651646 651646 FOOD EXPENSE 165355 165355 EQUIPMENT RENTAL & REPA 104762 100254 4508 112324 66150 46174 12044657 10814038 1200105 30514 15646 234190 2498709 1664287 144262 141609 44542 123822 14128022 11443240 2436474 2684782 180393 799224 191046 294084 5511072 5941998 1521337 1232245 71546 57214 14715 14723 243878 683342 96081 1851476 2083605 X 3659596 3858393 3659596 3858393 5511072 5941998 X 152086 47430 -719 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 498 498 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 8254 7438 6719 8973 1 X 160304 160304 5811461 4959801 851660 612741 331559 281182 7436195 6151880 1284315 107321 107321 2684782 X 11515872 47430 47430 11468442 728301 728301 12196743 11386292 0 11386292 658365 658365 12044657 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, 2014 AND 2013 TOTALED $14,723 AND $14,715, 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. THE ASSOCIATION'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. THE TAX RETURNS FOR THE YEARS 2011 TO 2013 ARE OPEN TO EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 651,646. AUXILIARY REVENUES 7,438. INVESTMENT INCOME 3,074. DONATIONS AND OTHER INCOME 3,675. CONTRIBUTIONS FOR LONG-LIVED ASSETS 62,468. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 651,646. AUXILIARY EXPENSES 6,719. 1 1 1 X 1 X 0 1 0 1 1 32411 32411 0.00280 1931097 453272 1477825 0.12970 1963508 453272 1510236 0.13250 2457489 1937950 519539 0.04560 2457489 1937950 519539 0.04560 4420997 2391222 2029775 0.17810 3550 3550 0.00030 4460 4460 0.00040 8010 8010 0.00070 1 651646 52132 3722745 4026611 -303866 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 0 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 1 1 X X 1 X X X X 1 0 X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT 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 11: RELATED TO ITS 2012 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL TOOK THE FOLLOWING ACTIONS IN 2014:1. 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 2014.2. ASSISTED LIVING: THE BOARD OF DIRECTORS HAS CHOSEN NOT TO PURSUE THIS NEED ANY FURTHER DUE TO COST CONSTRAINTS. 3. NUTRITIONAL EDUCATION: A NEW DIETICIAN WAS CONTRACTED TO PERFORM SERVICES AT THE HOSPITAL.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.RELATED TO ITS 2014 COMMUNITY HEALTH NEEDS ASSESSMENT, PEMBINA COUNTY MEMORIAL HOSPITAL IS IN THE PROCESS OF COMPLETING ITS IMPLEMENTATION PLAN. THE HOSPITAL AND PEMBINA COUNTY PUBLIC HEALTH CONTINUE TO WORK WITH THE CENTER FOR RURAL HEALTH IN COMPLETING THE IMPLEMENTATION STRATEGY. GRANT OPTIONS ARE BEING RESEARCHED TO APPLY FOR THE CONSENSUS COUNCIL FUNDS COMMUNITY INNOVATION GRANT. 3 CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING 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 $ 651,646. 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 2014, HOSPITAL STAFF ATTENDED PERSONAL PROTECTIVE EQUIPMENT TRAINING AND DECONTAMINATION TRAINING. 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 25-BED CRITICAL ACCESS HOSPITAL, 50-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2010 SHOWED A POPULATION OF 7,413 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $48,502. THE PER CAPITA INCOME FOR THE COUNTY WAS $27,019. 8.0% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGIONS. IT IS OUR RESPONSIBILITY TO PROVIDE QUALITY HEALTHCARE WITHIN THE COMMUNITY AREA THAT WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVICE. WE EXTEND MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. IF WE HAVE SURPLUS FUNDS, THESE DOLLARS ARE USED TO IMPROVE PATIENT CARE IN MANY DIFFERENT AREAS WITHIN THE ORGANIZATION. SURPLUS FUNDS ARE USED TO UPGRADE EXISTING EQUIPMENT OR TO PURCHASE NEW EQUIPMENT TO PROVIDE NEW SERVICES. THE FUNDS ARE ALSO USED TO MAKE IMPROVEMENTS TO THE FACILITY SUCH AS RENOVATION OF PATIENT AREAS AND DEPARTMENTS. THESE IMPROVEMENTS MUST BE APPROVED BY UPPER MANAGEMENT AND DEPENDING UPON THE IMPROVEMENT, SOMETIMES THE BOARD OF DIRECTORS MUST APPROVE IT AS WELL. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE COMMUNITY, SO PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN THE ANNUAL HEALTH FAIR, DIABETIC EDUCATION AND OTHER EVENTS THROUGHOUT THE YEAR. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA. PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A BOARD MEMBER 465877 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 ARL ARL IS OWNED BY DR. ALLAN LINDEMANN, A BOARD MEMBER 291754 PAYMENT FOR DR. LINDEMANN'S PHYSICIAN SERVICES 0 RITA VAUGHN FAMILY MEMBER OF TOM VAUGHN, A BOARD MEMBER 20384 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS INCLUDES THE PRESIDENT, VICE-PRESIDENT, SECRETARY/TREASURER, AND IMMEDIATE PAST PRESIDENT. THE EXECUTIVE COMMITTEE HAS THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY RESOLUTION OF THE BOARD: 1. MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD, WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS ARE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. 2. MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE CEO. 3. REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY OR APPROPRIATE CHANGES TO THE BYLAWS. 4. EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. 5. PERFORM SUCH OTHER DUTIES AND DELEGATED RESPONSIBILITIES AS THE BOARD MAY ASSIGN TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 1B: THE PRESIDENT OF THE BOARD OF DIRECTORS DOES NOT VOTE UNLESS THE RULING IS A TIE. IN THAT SITUATION, THE PRESIDENT'S VOTE MAY BREAK THE TIE. FORM 990, PART VI, SECTION A, LINE 4 THE BYLAWS WERE AMENDED ON FEBRUARY 25, 2014 TO CHANGE THE NUMBER OF BOARD MEMBERS FROM A MINIMUM OF NINE MEMBERS AND A MAXIMUM OF FIFTEEN MEMBERS TO A MINIMUM OF SEVEN MEMBERS AND A MAXIMUM OF ELEVEN MEMBERS. FORM 990, PART VI, SECTION A, LINE 6 ANYONE WHO PURCHASES A SHARE IN THE PEMBINA COUNTY MEMORIAL HOSPITAL CORPORATION IS A MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBERS ELECT THE BOARD OF DIRECTORS. OUTSIDE THE ELECTION OF THE BOARD OF DIRECTORS, THE ENTIRE VOTING POWER FOR ALL PURPOSES RESTS IN THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE CFO REVIEWED THE FORM 990 WITH THE BOARD OF DIRECTORS. 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 COMEPNSATION DECISION. THIS PROCESS IS DONE ANNUALLY AND WAS LAST UNDERTAKEN IN 2014. 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 2,451,815. MANAGEMENT AND GENERAL EXPENSES 245,692. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,697,507. FORM 990, PART XI, LINE 9: CHANGE IN AUXILIARY NET ASSETS -719. 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 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0