HAZEN MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- HAZEN MEMORIAL HOSPITAL ASSOCIATION (EIN 45-0308379)
- Tax period
- 2012-07-01 to 2013-06-30
- Filed
- 2014-02-05
- IRS object ID
- 201420369349300617
- Schema version
- 2012v2.1
- 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) |
|---|---|---|
| Timestamp | 2014-02-05T11:11:43-06:00 | Timestamp |
| Tax Period End Date | 2013-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450250958 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1 |
| City | FARGO | City |
| State | ND | State |
| ZIP Code | 581082545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450308379 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | HAZE | NameControl |
| Phone | 7017482225 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Darrold Bertsch | Name |
| Title | Administrator | Title |
| Phone | 7017482225 | Phone |
| Date Signed | 2014-02-03 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LISA CHAFFEE CPA | Name |
| PTIN | P00193453 | PTIN |
| Phone | 7012398500 | Phone |
| Date Prepared | 2014-02-03 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Darrold Bertsch | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 11354239 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | www.sakmedcenter.org | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1943 | YearFormation |
| State Legal Domicile | ND | StateLegalDomicile |
| Activity Or Mission Description | Operation of a hospital, clinic, and an elderly care facility. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 11 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 10 | NbrIndependentVotingMembers |
| Total Nbr Employees | 166 | TotalNbrEmployees |
| Total Nbr Volunteers | 95 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 295214 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 237672 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 10386024 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 11068985 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 13377 | InvestmentIncomePriorYear |
| Investment Income Current Year | 19403 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 19314 | OtherRevenuePriorYear |
| Other Revenue Current Year | 26737 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 10713929 | TotalRevenuePriorYear |
| Total Revenue Current Year | 11352797 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 2000 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 2000 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 5878756 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 5928198 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 4738843 | OtherExpensePriorYear |
| Other Expenses Current Year | 4728377 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 10619599 | TotalExpensesPriorYear |
| Total Expenses Current Year | 10658575 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 94330 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 694222 | RevenuesLessExpensesCY |
| Total Assets BOY | 6461461 | TotalAssetsBOY |
| Total Assets EOY | 7179795 | TotalAssetsEOY |
| Total Liabilities BOY | 1969155 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 1910110 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 4492306 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 5269685 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | 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. Commit 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. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 7134312 | Expense |
| Grants | 2000 | Grants |
| Revenue | 9033111 | Revenue |
| Description | 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 IV 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 $91,043 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 Senior Day Out, 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. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 757227 | Expense |
| Revenue | 969949 | Revenue |
| Description | 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 9,418 this year. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1248291 | Expense |
| Revenue | 1042870 | Revenue |
| Description | To insure 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 and also space is provided in the clinic for visiting specialists. This saves the patients from having to drive up to 70 miles to receive specialty health care. The clinic is staffed with physicians and mid-level providers. A sliding fee scale charity care program is available to patients who qualify financially. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 9139830 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 1 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 1 | ReportProgRelInvest |
| Report Other Assets | 1 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 1 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 0 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 13 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 166 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 11 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 10 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 0 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Renae Snyder | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7017482225 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (15 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Christie Obenauer | |||||||
| President | 2.00 | X | X | 0 | 0 | 0 | |
| Fred Stern | |||||||
| Vice President | 1.50 | X | X | 0 | 0 | 0 | |
| Myria Perry | |||||||
| Secretary/Treasurer | 1.50 | X | X | 0 | 0 | 0 | |
| Lorina Kuschel | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Don Lyn Erickson | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Mark Gerde | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Robin Richter | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Sienna Sailer | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Beverly Huber | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Kimberly Kessler | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Todd Lindquist | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Darrold Bertsch | |||||||
| CEO | 40.00 | X | 190467 | 0 | 23492 | ||
| Renae Snyder | |||||||
| CFO | 40.00 | X | 64083 | 0 | 3581 | ||
| Ronald Schmitz | |||||||
| CRNA | 40.00 | 198419 | 0 | 13407 | X | ||
| Rodney Zimmerman | |||||||
| Physician, MD, Family Practice | 40.00 | 246222 | 0 | 24973 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 699191 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 65453 | TotalOtherCompensation |
| Number Individuals GT100 K | 3 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 1 | CompensationFromOtherSources |
| Number Of Contractors GT100 K | 0 | NumberOfContractorsGT100K |
| Government Grants | 26422 | GovernmentGrants |
| All Other Contributions | 211250 | AllOtherContributions |
| Total Contributions | 237672 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (4 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | ExclusionExclusionAmount |
|---|---|---|---|---|
| Patient and Resident Services | 621400 | 10749197 | 10749197 | |
| Other Program Revenue | 623000 | 246727 | 246727 | |
| Education | 623000 | 50006 | 50006 | |
| Cafeteria | 623000 | 23055 | $23,055 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 11068985 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 11203 | TotalRevenueColumn |
| Exclusion | $11,203 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 19882 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 19882 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 19882 | TotalRevenueColumn |
| Exclusion | $19,882 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 8200 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 0 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 8200 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 8200 | TotalRevenueColumn |
| Exclusion | $8,200 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 7428 | GrossIncomeFundraisingEvents |
| Fundraising Direct Expenses | 1116 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 6312 | TotalRevenueColumn |
| Exclusion | $6,312 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Gaming | 869 | GrossIncomeGaming |
| Gaming Direct Expenses | 326 | GamingDirectExpenses |
Net Income From Gaming NetIncomeFromGaming
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 543 | TotalRevenueColumn |
| Exclusion | $543 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 11352797 | TotalRevenueColumn |
| Related Or Exempt Function Income | 11045930 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $69,195 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2000 | Total |
| Program Services | 2000 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 264788 | Total |
| Management And General | 264788 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4786860 | Total |
| Program Services | 4482036 | ProgramServices |
| Management And General | 304824 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 154509 | Total |
| Program Services | 39621 | ProgramServices |
| Management And General | 114888 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 371883 | Total |
| Program Services | 97753 | ProgramServices |
| Management And General | 274130 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 350158 | Total |
| Program Services | 314700 | ProgramServices |
| Management And General | 35458 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 8100 | Total |
| Management And General | 8100 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 22678 | Total |
| Management And General | 22678 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 41479 | Total |
| Management And General | 41479 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1505559 | Total |
| Program Services | 1443465 | ProgramServices |
| Management And General | 62094 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 19072 | Total |
| Program Services | 136 | ProgramServices |
| Management And General | 18936 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 257552 | Total |
| Program Services | 106038 | ProgramServices |
| Management And General | 151514 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 383065 | Total |
| Program Services | 383065 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 41135 | Total |
| Program Services | 28393 | ProgramServices |
| Management And General | 12742 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 35917 | Total |
| Program Services | 12638 | ProgramServices |
| Management And General | 23279 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 486678 | Total |
| Program Services | 486678 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 88816 | Total |
| Program Services | 19200 | ProgramServices |
| Management And General | 69616 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Bad Debt Expense | 839771 | 839771 | |
| Medical Supplies | 682234 | 682234 | |
| Food | 127503 | 127503 | |
| Dues & Subscriptions | 56174 | 32655 | 23519 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 132644 | Total |
| Program Services | 41944 | ProgramServices |
| Management And General | 90700 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 10658575 | Total |
| Program Services | 9139830 | ProgramServices |
| Management And General | 1518745 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2207 | BOY |
| EOY | 4417 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 893845 | BOY |
| EOY | 2206796 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1471567 | BOY |
| EOY | 1514503 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 310286 | BOY |
| EOY | 305899 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 22573 | BOY |
| EOY | 30709 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 8548870 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 6824126 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2127913 | BOY |
| EOY | 1724744 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 460044 | BOY |
| EOY | 466254 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 299171 | BOY |
| EOY | 383892 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 873855 | BOY |
| EOY | 542581 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6461461 | BOY |
| EOY | 7179795 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 866702 | BOY |
| EOY | 955281 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 223169 | EOY |
Loans From Officers Directors LoansFromOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1033465 | BOY |
| EOY | 690004 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 68988 | BOY |
| EOY | 41656 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1969155 | BOY |
| EOY | 1910110 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4129242 | BOY |
| EOY | 4820810 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 313064 | BOY |
| EOY | 398875 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 50000 | BOY |
| EOY | 50000 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4492306 | BOY |
| EOY | 5269685 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6461461 | BOY |
| EOY | 7179795 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 694222 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 83157 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Separate | X | FinancialStatementSeparate |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 1 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| 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) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 63893 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 1090 | InvestmentEarningsOrLosses |
| End Of Year Balance | 64983 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 62933 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 960 | InvestmentEarningsOrLosses |
| End Of Year Balance | 63893 | EndOfYearBalance |
Current Year Minus2 Years CurrentYearMinus2Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 61518 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 1415 | InvestmentEarningsOrLosses |
| End Of Year Balance | 62933 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 0.00000 | BoardDesignatedEOYBalance |
| Permanent Endowment EOY Balance | 0.76940 | PermanentEndowmentEOYBalance |
| Term Endowment EOY Balance | 0.23060 | TermEndowmentEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 23092 | OtherCostOrOtherBasis |
| Book Value | 23092 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5614510 | OtherCostOrOtherBasis |
| Depreciation | 4491639 | Depreciation |
| Book Value | 1122871 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2852422 | OtherCostOrOtherBasis |
| Depreciation | 2278832 | Depreciation |
| Book Value | 573590 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 58846 | OtherCostOrOtherBasis |
| Depreciation | 53655 | Depreciation |
| Book Value | 5191 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 1724744 | TotalOfBookValueLandBuildings |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Interest in Net Assets of Sakakawea Medical Center Foundation | Description |
| Book Value | 383892 | BookValue |
| Method Of Valuation | F | MethodOfValuation |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Program Related | 383892 | TotalOfBookValueProgramRelated |
Other Assets OtherAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Patronage Credit Asset | Description |
| Book Value | 542581 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 542581 | TotalBookValueOtherAssets |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Capital Lease Obligations | Description |
| Amount | $41,656 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 41656 | TotalOfAmounts |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 10591605 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | -749050 | OtherRevenues |
| Revenue Not Rptd F990 | -749050 | RevenueNotRptdF990 |
| Revenue Subtotal | 11340655 | RevenueSubtotal |
| Other Revenues Not Included | 12142 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 12142 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 11352797 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 9814226 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 7442 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 7442 | ExpensesNotRptdF990 |
| Expenses Subtotal | 9806784 | ExpensesSubtotal |
| Other Expenses Not Included | 851791 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 851791 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 10658575 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (6 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Description of Intended Use of Endowment Funds: | 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. |
| Description of Uncertain Tax Positions Under FIN 48: | 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 -839,771. Change in Interest in Net Assets of Sakakawea Medical Center Foundation 84,721. Eliminating Journal Entry for Grant from Auxiliary to Hospital 6,000. | |
| Part XI, Line 4b - Other Adjustments: | Auxiliary Revenue 13,584. Fundraising Expense Reported in Revenue -1,116. Gaming Expense Reported in Revenue -326. | |
| Part XII, Line 2d - Other Adjustments: | Eliminating Journal Entry for Grant from Auxiliary to Hospital 6,000. Fundraising Expense Reported in Revenue 1,116. Gaming Expense Reported in Revenue 326. | |
| Part XII, Line 4b - Other Adjustments: | Auxiliary Expenses 12,020. Provision for Bad Debts 839,771. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
Other Percentage OtherPercentage
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Free Other Percentage | 125.000000000000 | FreeOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 62000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 62000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00630 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 158906 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 146262 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 12644 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00130 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 220906 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 146262 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 74644 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00760 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 18554 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 180 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 18374 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00190 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 53831 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 21470 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 32361 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00330 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1309569 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1018908 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 290661 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02960 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 685 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 685 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1382639 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1040558 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 342081 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03490 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1603545 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1186820 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 416725 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04250 | PercentOfTotalExpense |
Health Improvement Advocacy HealthImprovementAdvocacy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 6 | NumberOfActivitiesOrPrograms |
| Total Community Building Expense | 9592 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 9592 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00100 | PercentOfTotalExpense |
Total Total
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 6 | NumberOfActivitiesOrPrograms |
| Total Community Building Expense | 9592 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 9592 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00100 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $839,771 | BadDebtExpenseAmount |
| Amount Attributable To | 52066 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 3306731 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 3330704 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -23973 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 0 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Ave NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 1 | CHNAConducted |
| Community Definition | X | CommunityDefinition |
| Community Demographics | X | CommunityDemographics |
| Existing Resources | X | ExistingResources |
| How Data Obtained | X | HowDataObtained |
| Community Health Needs | X | CommunityHealthNeeds |
| Other Health Issues | X | OtherHealthIssues |
| Identifying Process | X | IdentifyingProcess |
| Consulting Process | X | ConsultingProcess |
| Information Gaps | X | InformationGaps |
| Needs Assessment Conducted | 12 | NeedsAssessmentConducted |
| Take Into Account | 1 | TakeIntoAccount |
| Other Facilities | 1 | OtherFacilities |
| CHNA Widely Available | 1 | CHNAWidelyAvailable |
| Own Website | X | OwnWebsite |
| Adopt Implement Strategy | X | AdoptImplementStrategy |
| Execute Implement Strategy | X | ExecuteImplementStrategy |
| Prioritize Health Needs | X | PrioritizeHealthNeeds |
| Prioritize Services | X | PrioritizeServices |
| All Needs Addressed | 1 | AllNeedsAddressed |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTax |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 125.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 200.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Other Factors | X | OtherFactors |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notify Before Discharge | X | NotifyBeforeDischarge |
| Notified All Patients | X | NotifiedAllPatients |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Average Negotiated Rates | X | AverageNegotiatedRates |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 2 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (2 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| Sakakawea Hazen Clinic | ||||
| 813 7th St NE | Hazen | ND | 58545 | Clinic |
| Senior Suites at Sakakawea | ||||
| 813 7th St NE | Hazen | ND | 58545 | Basic Care Facility |
Form990 Schedule H Part VI Form990ScheduleHPartVI (17 entries)
| ExplanationExplanation | IdentifierIdentifier |
|---|---|
| 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, health professionals education and contributions reflect actual expenses recorded to the general ledger. Subsidized health services costs were calculated based on information from the Medicare cost report. | |
| Part I, Line 7g: Hazen Memorial Hospital Association operates a rural clinic which operates at a loss. The costs included in subsidized health services attributable to clinics are $1,162,939. | |
| Part I, L7 Col(f): For the purposes of calculating the percentage on Part 1, Line F, $839,771 of bad debt was backed out of total operating expenses. | |
| Part II: The CEO is involved in five boards that promote the health of the communities: NDHA, NDRHA, AHEC, CHAD, and TASC . The director of patient care serves on the Bismarck State College Advisory Committee for the nursing program. | |
| Part III, Line 4: The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements.Part III, Line 2:Payments and discounts are posted to patient bills. Any remaining balances are billed to the patient through monthly statements. If no payments are received from the patient at the end of the fourth month, the account is turned over to a collection agency and the balance on the account is written off as a bad debt. The bad debt expense is shown on the monthly financial statements.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 $52,066. | |
| 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 V, Section B, Line 3: A community survey, focus group, providers and individual interviews. | Hazen Memorial Hospital Association |
| Part V, Section B, Line 4: Also included was a Federal Qualified Health Clinic, a long-term care facility and Public Health. | Hazen Memorial Hospital Association |
| Part V, Section B, Line 5c: The Community Needs Assessment is located on the facilities website url Sakmedcenter.org. | Hazen Memorial Hospital Association |
| Part V, Section B, Line 12h: 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 14g: 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. | Hazen Memorial Hospital Association |
| 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 8,486. The average annual wage in Mercer County for 2012 was $58,344. 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, seven 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 70 volunteers from the area communities. The staff at Senior Suites, the basic care facility, is served by 25 community volunteers. Surplus funds are invested back into the facility through equipment upgrades and building improvements. Recent investments include the purchase of a portable x-ray machine, microscopes for the lab, patient beds, and a computer server. 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. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | X | CompensationCommittee |
| Form990 Of Other Organizations | X | Form990OfOtherOrganizations |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (3 entries)
| TitleTitle | Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Darrold Bertsch | ||||||||||||||
| CEO | 166414 | 0 | 24053 | 0 | 0 | 0 | 7655 | 0 | 15884 | 0 | 214006 | 0 | 0 | 0 |
| Ronald Schmitz | ||||||||||||||
| CRNA | 198419 | 0 | 0 | 0 | 0 | 0 | 7656 | 0 | 5797 | 0 | 211872 | 0 | 0 | 0 |
| Rodney Zimmerman | ||||||||||||||
| Physician, MD, Family Practice | 246222 | 0 | 0 | 0 | 0 | 0 | 9586 | 0 | 15434 | 0 | 271242 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Supplemental Information | Identifier |
| Return Reference | Part III | ReturnReference |
| Explanation | For the month of June 2013, Darrold was compensated by Coal Country Community Health Center, an unrelated organization, for his services as CEO. Darrold's compensation for that month was $8,100. | Explanation |
Schedule L IRS990ScheduleL
Loan Table LoanTable (3 entries)
| Purpose Of LoanPurposeOfLoan | Loan To OrganizationLoanToOrganization | Original PrincipalOriginalPrincipalAmount | Balance DueBalanceDue | DefaultDefault | Approved By BoardApprovedByBoard | Written AgreementWrittenAgreement |
|---|---|---|---|---|---|---|
| Union State Bank | ||||||
| Bond Refinance | X | $663,689 | 408254 | 0 | 1 | 1 |
| Union State Bank | ||||||
| New Boilers | X | $224,235 | 39779 | 0 | 1 | 1 |
| Union State Bank | ||||||
| Refinance Equipment | X | $506,000 | 241971 | 0 | 1 | 1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | 690004 | TotalBalanceDue |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| Form 990, Part VI, Section A, line 1 | There were 11 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. | |
| Form 990, Part VI, Section B, line 15a | For purposes of determining both the CEO and the CFO's compensation packages at Sakakawea Medical Center, a variety of resources are used. The Organization takes into consideration what is appropriate compensation for those respective positions, 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 Board of Directors evaluates the CEO annually and uses the above information for determining compensation. The CFO is evaluated by the CEO annually and the compensation is based on the above information. In June 2013, the CEO was paid by an unrelated organization that used comparability data to review and determine his compensation. | |
| 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 IX, line 11g | Medical Purchased Services: Program service expenses 1,442,765. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,442,765. Other Purchased Services: Program service expenses 700. Management and general expenses 62,094. Fundraising expenses 0. Total expenses 62,794. | Other Fees |
| Form 990, Part XI, line 9: | Change in interest in Net assets of Sakakawea Medical Center Foundation 84,721. Change in Net assets of Hazen Memorial Hospital Auxiliary -1,564. | Changes in Net Assets or Fund Balances: |
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