GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2012-04-01 to 2013-03-31
- Filed
- 2014-02-14
- IRS object ID
- 201420459349302027
- 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
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2014-02-14T14:55:55-06:00 | Timestamp |
| Tax Period End Date | 2013-03-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 7601 FRANCE AVENUE SOUTH SUITE 400 | AddressLine1 |
| City | MINNEAPOLIS | City |
| State | MN | State |
| ZIP Code | 55435 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-04-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HOSPITAL ASSOCIATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | GOOD | NameControl |
| Phone | 7017765261 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN ANENUE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JEFFREY LINGERFELT | Name |
| Title | CEO | Title |
| Phone | 7017765261 | Phone |
| Date Signed | 2014-02-14 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TIM A RITTER CPA | Name |
| PTIN | P00732856 | PTIN |
| Phone | 9525483400 | Phone |
| Date Prepared | 2014-02-14 | 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 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | JEFFREY LINGERFELT | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN ANENUE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 22892630 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.HAMC.COM | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1905 | YearFormation |
| State Legal Domicile | ND | StateLegalDomicile |
| Activity Or Mission Description | PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 10 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 7 | NbrIndependentVotingMembers |
| Total Nbr Employees | 462 | TotalNbrEmployees |
| Total Nbr Volunteers | 159 | TotalNbrVolunteers |
| Total Gross UBI | 69954 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 23367 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 692374 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 438009 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 23022546 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 21962606 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 277324 | InvestmentIncomePriorYear |
| Investment Income Current Year | 204076 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 19187 | OtherRevenuePriorYear |
| Other Revenue Current Year | 251216 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 24011431 | TotalRevenuePriorYear |
| Total Revenue Current Year | 22855907 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 15062964 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 15633870 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 64063 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 8089764 | OtherExpensePriorYear |
| Other Expenses Current Year | 8312873 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 23152728 | TotalExpensesPriorYear |
| Total Expenses Current Year | 23946743 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 858703 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -1090836 | RevenuesLessExpensesCY |
| Total Assets BOY | 15681866 | TotalAssetsBOY |
| Total Assets EOY | 15305948 | TotalAssetsEOY |
| Total Liabilities BOY | 4901844 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 5384708 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 10780022 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 9921240 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 19747059 | Expense |
| Revenue | 21895636 | Revenue |
| Description | GOOD SAMARITAN HOSPITAL ASSOCIATION (GSHA) IS A NONPROFIT HEALTH CARE ORGANIZATION, OWNED BY OVER THIRTY AREA CHURCHES REPRESENTING ALL OF THE LOCAL DENOMINATIONS OF THE CHRISTIAN FAITH. THE AREA CHURCHES AT AN ANNUAL MEETING EVERY FALL ELECT A BOARD OF TRUSTEES. THIS BOARD IS THE LEGAL GOVERNING BODY THAT IS RESPONSIBLE FOR THE ASSOCIATION. GSHA PRIMARY FOCUS IS HEALTHCARE WITHIN AND AROUND THE COMMUNITY OF RUGBY, ND. GSHA HAS 25 LICENSED ACUTE/SWING BEDS AS A CRITICAL ACCESS HOSPITAL, 3 RURAL HEALTH CLINICS ALONG WITH A SURGICAL CLINIC, 80 MEDICARE SKILLED NURSING HOME BEDS, 68 BASIC CARE BEDS, AND 37 ASSISTED LIVING APARTMENTS. WE ALSO SERVICE THE COMMUNITY THROUGH A HOSPITAL BASED HOSPICE. GSHA PROVIDES NUMEROUS COMMUNITY AND SOCIAL PROGRAMS INCLUDING BUT NOT LIMITED TO THE FOLLOWING: CHARITY CARE $343,259 GROSS CHARGES FORGONE DURING THE YEAR ENDED 3/31/2013, DIABETIC EDUCATION PROGRAM, LIFELINE, PUBLIC HEALTHCARE EDUCATIONAL AND INFORMATIONAL NOTICES, TESTING AND INFORMATION DURING HEALTH SHOWS AND COMMUNITY EVENTS, AMBULANCE VOLUNTEERS, PROVIDES EMT COURSES FOR AMBULANCES, EDUCATIONAL OUTREACH FOR SCHOOL SYSTEM, PROVIDES SENIOR CITIZEN MEALS AT MINIMAL FEE, FREE BLOOD PRESSURE CHECKS, COMMUNITY EDUCATION, PHYSICAL THERAPY, PROVIDES MEETING ROOM FOR VARIOUS ORGANIZATIONS AND CHURCHES, CPR TRAINING, WELLNESS PROGRAMS, SPONSOR LPN/RN SCHOOL PROGRAM THROUGH CONSORTIUM OF FACILITIES AND COLLEGES. | Description |
| Total Program Service Expense | 19747059 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 1 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 1 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | 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 | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 1 | 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 | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transaction Related Entity | 1 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 62 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Number Of Employees | 462 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| 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 | 10 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 7 | 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 | 1 | 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 | 1 | 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 | JEFFREY LINGERFELT | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7017765261 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S MAIN AVENUE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (17 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Average Hours Per Week RelatedAverageHoursPerWeekRelated | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|---|
| RICHARD ANDERSON | ||||||||
| TRUSTEE | 1.00 | 1.00 | X | 0 | 0 | 0 | ||
| ARLYSS BERGRUD | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| BRETT MCATEE | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| JOHN MCCLINTOCK JR | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| TOM MOLLER JR | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| JON NELSON | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| STACEY SCHMITT | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| MARK SCHAAN | ||||||||
| TRUSTEE | 1.00 | X | 0 | 0 | 0 | |||
| WES BLACK | ||||||||
| CHAIRMAN | 1.50 | X | 0 | 0 | 0 | X | ||
| RUSTY GEBHARDT | ||||||||
| VICE CHAIRMAN | 1.50 | X | 0 | 0 | 0 | X | ||
| BRIAN SELLAND | ||||||||
| TRUSTEE/PHYSICIAN (THRU JANUARY) | 40.00 | X | 236115 | 0 | 32906 | |||
| BONNIE KUEHNEMUND | ||||||||
| COMPTROLLER/TREASURER | 40.00 | 89559 | 0 | 9543 | X | |||
| JEFFREY LINGERFELT | ||||||||
| CEO/SECRETARY | 40.00 | 1.00 | 164869 | 0 | 15434 | X | ||
| RONALD SKIPPER | ||||||||
| SURGEON | 40.00 | 348858 | 0 | 20833 | X | |||
| HUBERT SEILER | ||||||||
| PHYSICIAN | 40.00 | 158552 | 0 | 21849 | X | |||
| JULIA GARCIA | ||||||||
| PHYSICIAN | 40.00 | 231593 | 0 | 24609 | X | |||
| TAMMIE HARDER | ||||||||
| MIDLEVEL PROVIDER | 40.00 | 130105 | 0 | 9135 | X | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 1359651 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 134309 | TotalOtherCompensation |
| Number Individuals GT100 K | 10 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| DAKOTA TRAVEL NURSE INC | |||||
| 3015 MEMORIAL HWY | MANDAN | ND | 58554 | CONTRACT NURSING SERVICES | 620233 |
| DIVERSIFIED MED RESOURCE | |||||
| 1104 WALNUT STREET EAST | DEVILS LAKE | ND | 58301 | ER PHYSICIAN SERVICES | 421760 |
| MIKE SWANSON CONSTRUCTION | |||||
| 6250 24TH AVE NE | RUGBY | ND | 58368 | CONSTRUCTION | 411414 |
| DMS HEALTH TECHNOLOGIES | |||||
| 26273 NETWORK PLACE | CHICAGO | IL | 60673 | NUCLEAR IMAGING SERVICES | 364203 |
| DEANE ZIMMERMAN | |||||
| 3621 11TH AVE S | MOORHEAD | MN | 56560 | ANESTHESIA CONTRACT SERVICES | 193050 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 5 | NumberOfContractorsGT100K |
| Related Organizations | 197906 | RelatedOrganizations |
| Government Grants | 71848 | GovernmentGrants |
| All Other Contributions | 168255 | AllOtherContributions |
| Total Contributions | 438009 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (5 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| PATIENT SERVICE REVENUE | 621610 | 21058958 | 21058958 |
| PT/OT SERVICES | 621610 | 271206 | 271206 |
| PHARMACY SERVICES | 900099 | 189509 | 189509 |
| ALS SERVICES | 621610 | 123891 | 123891 |
| RENTAL REVENUE | 531110 | 97094 | 97094 |
Total Oth Program Service Revenue TotalOthProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 221948 | TotalRevenueColumn |
| Related Or Exempt Function Income | 154978 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 66970 | UnrelatedBusinessRevenue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 21962606 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 202076 | TotalRevenueColumn |
| Exclusion | $202,076 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 50793 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 36723 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 14070 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 14070 | TotalRevenueColumn |
| Unrelated Business Revenue | 2984 | UnrelatedBusinessRevenue |
| Exclusion | $11,086 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 2000 | 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 | 2000 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 2000 | TotalRevenueColumn |
| Exclusion | $2,000 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | ExclusionExclusionAmount |
|---|---|---|---|
| CAFETERIA SERVICES | 900099 | 149469 | $149,469 |
| INSURANCE REIMBURSEMENT | 900099 | 43791 | $43,791 |
Miscellaneous Revenue MiscellaneousRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 43886 | TotalRevenueColumn |
| Exclusion | $43,886 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 237146 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 22855907 | TotalRevenueColumn |
| Related Or Exempt Function Income | 21895636 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 69954 | UnrelatedBusinessRevenue |
| Exclusion | $452,308 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 279141 | Total |
| Management And General | 279141 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 13011479 | Total |
| Program Services | 11323613 | ProgramServices |
| Management And General | 1639032 | ManagementAndGeneral |
| Fundraising | 48834 | Fundraising |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 177048 | Total |
| Program Services | 118785 | ProgramServices |
| Management And General | 57584 | ManagementAndGeneral |
| Fundraising | 679 | Fundraising |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1222558 | Total |
| Program Services | 822147 | ProgramServices |
| Management And General | 395747 | ManagementAndGeneral |
| Fundraising | 4664 | Fundraising |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 943644 | Total |
| Program Services | 639635 | ProgramServices |
| Management And General | 300468 | ManagementAndGeneral |
| Fundraising | 3541 | Fundraising |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 45567 | Total |
| Management And General | 45567 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 56766 | Total |
| Management And General | 56766 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1816087 | Total |
| Program Services | 1713730 | ProgramServices |
| Management And General | 102357 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 68238 | Total |
| Management And General | 68238 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1938862 | Total |
| Program Services | 1448380 | ProgramServices |
| Management And General | 490182 | ManagementAndGeneral |
| Fundraising | 300 | Fundraising |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 6148 | Total |
| Management And General | 6148 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 684414 | Total |
| Program Services | 635481 | ProgramServices |
| Management And General | 48933 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 250641 | Total |
| Program Services | 171556 | ProgramServices |
| Management And General | 73040 | ManagementAndGeneral |
| Fundraising | 6045 | Fundraising |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 6635 | Total |
| Program Services | 425 | ProgramServices |
| Management And General | 6210 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 124711 | Total |
| Program Services | 84353 | ProgramServices |
| Management And General | 40358 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 817950 | Total |
| Program Services | 546994 | ProgramServices |
| Management And General | 270956 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 234653 | Total |
| Management And General | 234653 | ManagementAndGeneral |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices |
|---|---|---|
| BAD DEBT EXPENSE | 877053 | 877053 |
| RAW FOOD | 482882 | 482882 |
| MISC MEDICAL EXPENSE | 478649 | 478649 |
| ACUTE DRUGS | 403376 | 403376 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20241 | Total |
| Management And General | 20241 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 23946743 | Total |
| Program Services | 19747059 | ProgramServices |
| Management And General | 4135621 | ManagementAndGeneral |
| Fundraising | 64063 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1466 | BOY |
| EOY | 1741 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 342350 | BOY |
| EOY | 179873 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4387692 | BOY |
| EOY | 3744593 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 503614 | BOY |
| EOY | 500414 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 180758 | BOY |
| EOY | 149591 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 43055 | BOY |
| EOY | 45867 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 22089962 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 17788842 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4178622 | BOY |
| EOY | 4301120 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4772453 | BOY |
| EOY | 5111081 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1093523 | BOY |
| EOY | 1146835 | EOY |
Intangible Assets IntangibleAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 178333 | BOY |
| EOY | 124833 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 15681866 | BOY |
| EOY | 15305948 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1879417 | BOY |
| EOY | 1995447 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 81717 | BOY |
| EOY | 24999 | EOY |
Escrow Account Liability EscrowAccountLiability
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 26762 | BOY |
| EOY | 22564 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2362910 | BOY |
| EOY | 2708275 | EOY |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 551038 | BOY |
| EOY | 633423 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4901844 | BOY |
| EOY | 5384708 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10420896 | BOY |
| EOY | 9512302 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 359126 | BOY |
| EOY | 408938 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 10780022 | BOY |
| EOY | 9921240 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 15681866 | BOY |
| EOY | 15305948 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expenses | -1090836 | ReconcilationRevenueExpenses |
| Reconciliation Unrealized Invest | 232054 | ReconciliationUnrealizedInvest |
| Reconcilation Other Changes | 0 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| 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 Consolidated | X | FinancialStatementConsolidated |
| 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 C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $3,683 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 3683 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1: | ReturnReference |
| Explanation | GOOD SAMARITAN HOSPITAL ASSOCIATION IS A MEMBER OF SEVERAL ORGANIZATIONS THAT TAKE PART IN LOBBYING. THESE ORGANIZATIONS INCLUDE THE NORTH DAKOTA HOSPITAL ASSOCIATION, THE AHA, AND THE NORTH DAKOTA LTC ASSOCIATION. A PORTION OF THE DUES PAID TO THE VARIOUS ORGANIZATIONS IS FOR LOBBYING COSTS. THESE VARIOUS ORGANIZATIONS ADVOCATE ON BEHALF OF THEIR MEMBERS BY SUPPORTING LEGISLATION THAT IS IN THEIR COLLECTIVE INTERESTS. THESE ORGANIZATIONS WORK TO ENSURE THAT LAWS AND REGULATIONS PROVIDE A REASONABLE AND EQUITABLE ENVIRONMENT IN WHICH HEALTH CARE FACILITIES CAN PROVIDE AFFORDABLE, HIGH QUALITY CARE. | Explanation |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 1 | AgentTrusteeEtc |
| Beginning Balance | 67474 | BeginningBalance |
| Ending Balance | 67474 | EndingBalance |
| Included On FS | 1 | IncludedOnFS |
| Explanation In Part XIII | X | ExplanationInPartXIII |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 137447 | OtherCostOrOtherBasis |
| Book Value | 137447 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 10154782 | OtherCostOrOtherBasis |
| Depreciation | 8361541 | Depreciation |
| Book Value | 1793241 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 11722000 | OtherCostOrOtherBasis |
| Depreciation | 9427301 | Depreciation |
| Book Value | 2294699 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 75733 | OtherCostOrOtherBasis |
| Book Value | 75733 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 4301120 | TotalOfBookValueLandBuildings |
Other Securities OtherSecurities (2 entries)
| DescriptionDescription | Book ValueBookValue | Method Of ValuationMethodOfValuation |
|---|---|---|
| CERTIFICATE OF DEPOSIT | 737897 | F |
| INTEREST IN NET ASSETS OF FOUNDATION | 408938 | F |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Securities | 1146835 | TotalOfBookValueSecurities |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 22247631 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | 232054 | NetUnrealizedGainsInvestments |
| Other Revenues | 36723 | OtherRevenues |
| Revenue Not Rptd F990 | 268777 | RevenueNotRptdF990 |
| Revenue Subtotal | 21978854 | RevenueSubtotal |
| Other Revenues Not Included | 877053 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 877053 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 22855907 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 23106413 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 36723 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 36723 | ExpensesNotRptdF990 |
| Expenses Subtotal | 23069690 | ExpensesSubtotal |
| Other Expenses Not Included | 877053 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 877053 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 23946743 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (6 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| PART IV, LINE 2B: | THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF THE HOSPITAL'S LONG-TERM CARE FACILITY, SWING-BED UNITS, AND BASIC CARE FACILITY, AS WELL AS DAMAGE DEPOSITS. | |
| PART X, LINE 2: | IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, ASC TOPIC 740-10, INCOME TAXES, REQUIRES AN ORGANIZATION TO ASSESS WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. MANAGEMENT DOES NOT BELIEVE THE ORGANIZATION HAS ANY MATERIAL UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS. THE ORGANIZATION'S FEDERAL RETURNS FOR TAX YEARS 2009 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. | DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: |
| RENTAL EXPENSES 36,723. | PART XI, LINE 2D - OTHER ADJUSTMENTS: | |
| BAD DEBT EXPENSE 877,053. | PART XI, LINE 4B - OTHER ADJUSTMENTS: | |
| RENTAL EXPENSES 36,723. | PART XII, LINE 2D - OTHER ADJUSTMENTS: | |
| BAD DEBT EXPENSE 877,053. | PART XII, LINE 4B - OTHER ADJUSTMENTS: |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 255683 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 255683 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01110 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1319651 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1156486 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 163165 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00710 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1575334 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1156486 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 418848 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01820 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 20556 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 20556 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00090 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 500 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 500 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 291064 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 291064 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01260 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1352 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 1352 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 313472 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 313472 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01360 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1888806 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1156486 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 732320 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.03180 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $652,954 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 3935535 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 6219915 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -2284380 | 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 | 1 | 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 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S MAIN AVE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | 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 | HEART OF AMERICA MEDICAL CENTER | 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 |
| Identifying Process | X | IdentifyingProcess |
| Needs Assessment Conducted | 12 | NeedsAssessmentConducted |
| Take Into Account | 1 | TakeIntoAccount |
| Other Facilities | 0 | OtherFacilities |
| CHNA Widely Available | 1 | CHNAWidelyAvailable |
| Own Website | X | OwnWebsite |
| On Request | X | OnRequest |
| Other Method | X | OtherMethod |
| Adopt Implement Strategy | X | AdoptImplementStrategy |
| Execute Implement Strategy | X | ExecuteImplementStrategy |
| Prioritize Health Needs | X | PrioritizeHealthNeeds |
| Prioritize Services | X | PrioritizeServices |
| All Needs Addressed | 0 | AllNeedsAddressed |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTax |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 100.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 200.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Medical Indigency | X | MedicalIndigency |
| Insurance Status | X | InsuranceStatus |
| Uninsured Discount | X | UninsuredDiscount |
| Medicaid Medicare | X | MedicaidMedicare |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Posted On Website | X | PostedOnWebsite |
| Attached To Invoices | X | AttachedToInvoices |
| Posted In Emergency Room | X | PostedInEmergencyRoom |
| Posted In Admission Office | X | PostedInAdmissionOffice |
| Provided On Admission | X | ProvidedOnAdmission |
| Available On Request | X | AvailableOnRequest |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notify Before Discharge | X | NotifyBeforeDischarge |
| Notified All Patients | X | NotifiedAllPatients |
| Documented Determination | X | DocumentedDetermination |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Medicare Rate | X | MedicareRate |
| 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 | 8 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (8 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| HEART OF AMERICA NURSING FACILITY | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | SKILLED LONG TERM CARE FACILITY |
| HAALAND ESTATES BASIC CARE | ||||
| 1025 3RD AVE SE | RUGBY | ND | 58368 | BASIC CARE FACILITY |
| RUGBY EMERGENCY MEDICAL SERVICES | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | AMBULANCE |
| HAALAND ESTATES ASSISTED LIVING | ||||
| 1025 3RD AVE SE | RUGBY | ND | 58368 | ASSISTED LIVING FACILITY |
| HEART OF AMERICA HOSPICE | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | HOSPICE |
| RUGBY CLINIC | ||||
| 880 S MAIN AVE | RUGBY | ND | 58368 | RURAL HEALTH CLINIC |
| DUNSEITH CLINIC | ||||
| 215 MAIN ST SE | DUNSEITH | ND | 58329 | RURAL HEALTH CLINIC |
| MADDOCK CLINIC | ||||
| 301 ROOSEVELT AVE | MADDOCK | ND | 58348 | RURAL HEALTH CLINIC |
Form990 Schedule H Part VI Form990ScheduleHPartVI (18 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 3C: HEART OF AMERICA MEDICAL CENTER USES A SLIDING FEE SCHEDULE BASED OF FPG. THERE IS 100% BENEFIT AT 100% FPG, 80% BENEFIT AT 125% FPG, 60% BENEFIT AT 150% FPG, 40% BENEFIT AT 175% FPG, 20% BENEFIT AT 200% FPG, AND 0% BENEFIT FOR THOSE GREATER THAN 200% FPG. | ||
| PART I, LINE 7: THE COSTING METHOD USE IS THE COST TO CHARGES RATIO. | ||
| PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES CARDIAC REHAB, OCCUPATIONAL THERAPY, AND SPEECH THERAPY. | ||
| 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 $ 877053. | ||
| PART II: NO SPECIFIC COMMUNITY BUILDING ACTIVITIES DURING YEAR ENDING MARCH 2013. | ||
| PART III, LINE 4: THE FINANCIAL STATEMENTS DO NOT HAVE BAD DEBT EXPENSE FOOTNOTE. THIS IS THE PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY FOOTNOTE.PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD- PARTY PAYER AGREEMENTS. THE ORGANIZATION BILLS THIRD-PARTY PAYERS ON THE PATIENTS' OR RESIDENTS' BEHALF, OR IF A PATIENT OR RESIDENT IS UNINSURED, THE PATIENT OR RESIDENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYER, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS OR RESIDENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' OR RESIDENTS' RESPONSIBILITY. PAYMENTS ON PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENT.THE ORGANIZATION HAS A POLICY TO CHARGE INTEREST ON PAST-DUE ACCOUNTS WHERE THE PATIENT OR RESIDENT HAS NOT ENTERED INTO A PAYMENT PLAN OR HAS NOT MADE REQUIRED PAYMENTS UNDER SUCH PAYMENT PLAN.PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND ALLOWANCES FOR DOUBTFUL ACCOUNTS WHICH REFLECT MANAGEMENTS BEST ESTIMATE OF THE AMOUNTS THAT WONT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT AND RESIDENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND RESIDENTS AND AMOUNTS PATIENTS AND RESIDENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO A VALUATION ALLOWANCE.IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS AND RESIDENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS AND RESIDENTS WITHOUT INSURANCE AND PATIENTS AND RESIDENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS OR RESIDENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.IN ESTIMATING THE AMOUNT OF OUR BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER OUR CHARITY CARE POLICY, WE TOOK 2010 US CENSUS BUREAU POPULATION & POVERTY LEVEL STATISTICS FOR THE AREA IN WHICH WE SERVE---PRIMARILY A FIVE COUNTY AREA. FROM THOSE STATISTICS WE DETERMINED APPROXIMATELY 22.8% OF OUR MARKET POPULATION ARE AT THE POVERTY LEVEL BASED ON THE FPG. EVEN THOUGH OUR CHARITY CARE GUIDELINES ARE BASED ON 200% OF THE FPG, WE CHOSE TO BE CONSERVATIVE AND USED THE ESTIMATED 22.8% AT THE POVERTY LEVEL AND APPLIED IT TO OUR BAD DEBT EXPENSE. OUR BAD DEBT CONSISTS OF THOSE UNABLE TO PAY, BUT ALSO THOSE WHO JUST ARE UNWILLING TO PAY. | ||
| PART III, LINE 8: MEDICARE REVENUE AND ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING MARCH 2013.MEDICARE SHORTFALL IS THE RESULT OF THE HEALTHCARE SERVICES PROVIDED TO OUR PATIENTS WHICH ARE BEING REIMBURSED BY MEDICARE ON A FEE FOR SERVICE REIMBURSEMENT SUCH AS LABS, PROFESSIONAL SERVICES, AND SOME THERAPIES, OR TO OUR MEDICARE SKILLED LTC RESIDENTS. THE SHORTFALL IS ALL RELATED TO PATIENTS OR RESIDENTS WHO ARE COVERED BY MEDICARE AND THEREFORE ARE ELDERLY WHICH IS CONSIDERED TO BE A CHARITABLE CLASS. WE PROVIDE THE SERVICE TO PROMOTE QUALITY HEALTHCARE TO OUR ELDERLY WHO WOULD HAVE TROUBLE GOING ELSEWHERE TO RECEIVE THE SERVICES, EVEN THOUGH THERE IS A SHORTFALL IN THE MEDICARE OVERALL PAYMENT. WE BELIEVE 100% OF THE SHORTFALL IS A COMMUNITY BENEFIT. | ||
| PART III, LINE 9B: OUR ACCOUNTS ARE WORKED EFFECTIVELY AND THOROUGHLY WITH SELF PAY STATEMENTS PRINTED MONTHLY ONCE INSURANCES HAVE MET THEIR OBLIGATIONS. THE GOAL IS TO OBTAIN PAYMENT IN FULL, ESTABLISH ACCEPTABLE PAYMENT ARRANGEMENTS, LOOK AT OTHER APPROPRIATE AGENCIES OR LOW INCOME PROGRAMS, OR OFFER THE CHARITY CARE PROGRAM IF NEEDED. IN THE COLLECTION PROCESS, THE BILL GUARANTOR IS REMINDED THEY MAY QUALIFY FOR OUR CHARITY CARE PROGRAM AND ARE GIVEN INFORMATION ON HOW TO APPLY. OUR CHARITY PROGRAM IS INCOME BASED, AND USES 200% OF THE FEDERAL POVERTY GUIDELINES. IF THEY QUALIFY THE BILL IS WRITTEN OFF 100% TO CHARITY CARE. REFERRAL TO A COLLECTION AGENCY AND WRITE OFF OF BAD DEBT HAPPENS ONCE IT IS DETERMINED THAT THE PATIENT IS UNCOOPERATIVE WITH NON-PAYMENT, SKIP ACCOUNTS, OR IS UNWILLING TO APPLY FOR THE CHARITY CARE PROGRAM. AND THERE IS NO OTHER VALID REASON TO HOLD THE ACCOUNT FURTHER. | ||
| PART V, SECTION B, LINE 3: PERSONS INVITED TO ONE OF THE THREE FOCUS GROUPS INCLUDED OUR MAYOR, A RETIRED SHERIFF FROM THE COMMUNITY, RETIRED NURSES AND BUSINESS OWNERS, EXISTING BUSINESS OWNERS, BOTH RETIRED AND CURRENT TEACHERS, AND MOTHERS OF SCHOOL-AGED CHILDREN. A SURVEY WAS SENT OUT TO ALL HEALTHCARE PROFESSIONALS IN OUR COMMUNITY, INCLUDING THOSE EMPLOYED AT OUR HOSPITAL OR CLINICS, THE EYE CLINIC, AND DENTAL CLINIC. IT WAS INPUT FROM ALL OF THESE INDIVIDUALS THAT CREATED THE COMMUNITY WIDE SURVEY MAILED TO EVERY HOUSEHOLD. | HEART OF AMERICA MEDICAL CENTER | |
| PART V, SECTION B, LINE 5C: THE CHNA AND IMPLEMENTATION STRATEGY IS AVAILABLE ON THE ORGANIZATION'S WEBSITE:HTTP://WWW.HAMC.COM/UPLOADS/RESOURCES/141/CHNA-HAMC-2013-(2).PDF | HEART OF AMERICA MEDICAL CENTER | |
| PART V, SECTION B, LINE 7: ONE NEED IDENTIFIED WAS THE NEED FOR INTERNAL MEDICINE SPECIALISTS. THE ORGANIZATION HAD TWO INTERNAL MEDICINE SPECIALISTS LINED UP TO BE EMPLOYED AT THE FACILITY IN THE FALL OF 2013. HOWEVER, UNEXPECTED CIRCUMSTANCES CAUSED THESE DOCTORS TO NOT FOLLOW THROUGH. THE ORGANIZATION DOES HAVE AN INTERIM IM PHYSICIAN AT OUR FACILITY FOR THE NEXT THREE MONTHS WITH HOPES THAT HE WILL BECOME A LONG-TERM ADDITION TO THE ORGANIZATION'S STAFF. | HEART OF AMERICA MEDICAL CENTER | |
| PART V, SECTION B, LINE 11: HEART OF AMERICA MEDICAL CENTER USES A SLIDING FEE SCHEDULE BASED OF FPG. THERE IS 100% BENEFIT AT 100% FPG, 80% BENEFIT AT 125% FPG, 60% BENEFIT AT 150% FPG, 40% BENEFIT AT 175% FPG, 20% BENEFIT AT 200% FPG, AND 0% BENEFIT FOR THOSE GREATER THAN 200% FPG. | HEART OF AMERICA MEDICAL CENTER | |
| PART VI, LINE 2: HEART OF AMERICA MEDICAL CENTER SERVES A SMALLER COMMUNITY WHERE PROVIDERS KNOW THEIR PATIENTS AND THE GSHA BOARD OF DIRECTORS LIVE IN AND ARE MEMBERS OF THE LOCAL AND SURROUNDING COMMUNITIES. FOR THE YEAR ENDING MARCH 2013 NEEDS WERE ASSESSED THROUGH A COMMUNITY HEALTH FORUM HELD BY FORUM FACILITATOR, BRAD GIBBENS, MPA FROM THE ND RURAL HOSPITAL FLEXIBILITY PROGRAM. IN MAY 2011, BRAD GIBBENS CREATED A FINAL REPORT BASED ON THE FORUM DISCUSSION AND SURVEYS. IN THE FALL OF 2012, FOCUS GROUPS WERE HELD TO ASSIST IN THE DEVELOPMENT OF A COMMUNITY WIDE SURVEY. IN DECEMBER 2012, A SURVEY WAS MAILED TO EACH HOUSEHOLD IN THE RUGBY AREA. RESULTS AND INPUT FROM THE SURVEYS WERE ANALYZED IN THE SPRING OF 2013. AN ACTION PLAN WAS DEVELOPED BASED ON BOTH THE FOCUS GROUPS AND THE SURVEYS. | ||
| PART VI, LINE 3: OUR CHARITY CARE POLICY AND APPLICATION IS PROVIDED TO ALL ADMITS TO OUR HOSPITAL UPON ADMISSIONS. THIS INCLUDES ASSISTANCE CONTACT INFORMATION. AT THE ADMISSION AREA THERE ARE BROCHURES ON CHARITY CARE PROGRAM AND PROMPT PAYMENT DISCOUNT WHICH ADDRESS OUR CHARITY CARE PROGRAM. ALSO IN PROCESSING THE SELF PAY BILLS, THE PATIENT IS ENCOURAGED TO COMPLETE OUR CHARITY CARE APPLICATION IF APPLICABLE TO ASSIST IN TAKING CARE OF THEIR BILL. OUR SOCIAL SERVICE DEPARTMENT IS ALSO VERY INVOLVED WITH ASSISTING OUR PATIENTS AND RESIDENTS WITH GOVERNMENTAL BENEFITS PRIMARILY NORTH DAKOTA MEDICAID. WE ARE ALSO UPDATING OUR WEBSITE TO INCLUDE INFORMATION ON OUR CHARITY CARE PROGRAM INCLUDING CONTACT INFORMATION AS WELL AS THE APPLICATION. | ||
| PART VI, LINE 4: HEART OF AMERICA MEDICAL CENTER (HAMC) IS A RURAL CRITICAL ACCESS HOSPITAL LOCATED IN NORTH CENTRAL NORTH DAKOTA WITH THE CLOSEST TERTIARY FACILITY 65 MILES AWAY TO THE WEST. THE CLOSEST SMALLER HOSPITAL IS 43 MILES AWAY. HAMC BASICALLY SERVES IN WHOLE OR IN PART THE COUNTIES OF PIERCE, BENSON, MCHENRY, ROLETTE, AND BOTTINEAU COUNTIES. OUR PRIMARY SERVICE AREA IS ABOUT A 45 MILES RADIUS WITH A TARGET POPULATION OF APPROXIMATELY 16,000 PEOPLE. PIERCE COUNTY ALONE HAD A POPULATION OF 4357 IN 2010 ACCORDING TO THE US CENSUS BUREAU WITH 94% WHITE PERSONS AND 24% AGE 65 OR OLDER. RUGBY HAS A POPULATION OF 2876 BASED ON 2010 CENSUS DATA. OF OUR HOSPITAL INPATIENTS, APPROXIMATELY 72% ARE MEDICARE AND 6% MEDICAID. WITHIN OUR MARKET AREA APPROXIMATELY 22.8% OF THE POPULATION IS BELOW THE FEDERAL POVERTY GUIDELINES. | ||
| PART VI, LINE 5: GOOD SAMARITAN HOSPITAL ASSOCIATION (GSHA) IS OWNED BY 32 MEMBER CHURCHES LOCATED THROUGHOUT OUR SERVICE AREA. THE GSHA BOARD OF DIRECTORS IS VOTED IN BY THE MEMBER CHURCHES AND THEY ARE COMMUNITY MEMBERS WHO RESIDE IN OUR PRIMARY SERVICE AREA -- BOTH RUGBY AND THE SURROUNDING SATELLITE COMMUNITIES. THEY ARE NOT EMPLOYEES OR CONTRACTORS OF GSHA, BUT SERVE IN VARIOUS OCCUPATIONS AND INVOLVED IN VARIOUS COMMUNITY ACTIVITIES. GSHA EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS AND MID-LEVELS IN THE COMMUNITY AND IS CONTINUOUSLY STRIVING TO BRING IN MORE PROVIDERS IN ORDER TO MAINTAIN PROVIDERS TO PROVIDE THE CARE NEEDED BY OUR PATIENTS AND PROMOTE HEALTH WITHIN OUR COMMUNITIES. WHEN SURPLUS FUNDS ARE AVAILABLE THEY ARE USED TO PURCHASE AND UPGRADE EQUIPMENT, AND INVESTED BACK INTO THE FACILITY AND SERVICES WE PROVIDE TO MAINTAIN HIGH QUALITY PATIENT CARE. WE CONTINUALLY STRIVE TO MEET THE HEALTHCARE NEEDS WITHIN OUR COMMUNITY AND THE SURROUNDING AREA. EFFECTIVE AUGUST 1, 2010 THE FAMILY PRACTICE CLINIC IN RUGBY MERGED WITH GSHA IN ORDER TO BETTER MEET THE HEALTHCARE NEEDS OF OUR COMMUNITIES. THIS MERGER HAS STRENGTHENED OUR ABILITIES TO SERVE THE COMMUNITIES BY PROVIDING US WITH A BETTER PHYSICIAN / MID-LEVEL RECRUITMENT PLATFORM AND HIGHER CONTINUITY OF CARE. IN STRIVING TO MEET THE NEEDS OF THE COMMUNITIES WE PROVIDE SERVICES INCLUDING ASSISTED LIVING, BASIC CARE, SKILLED NURSING, MEDICAL & SURGICAL HOSPITAL, RURAL HEALTH CLINICS, SURGICAL CLINIC, AND NUMEROUS OTHER OUTPATIENT SERVICES AND THERAPIES. WE HAVE LOST MONEY ON SOME OF THESE SERVICES SUCH AS CARDIAC REHAB, OUR CLINICS, AND OUR HOSPICE PROGRAM BUT CONTINUE TO MAINTAIN THESE SERVICES BECAUSE OF THE NEEDS WITHIN THE COMMUNITIES. IF WE DID NOT PROVIDE SERVICES SUCH AS THESE, THE SERVICES WOULD BE UNAVAILABLE IN THE COMMUNITY. PATIENTS WOULD HAVE TO GO OUT OF TOWN TO GET THE SERVICES WHICH IS NOT ALWAYS POSSIBLE, SO SOME WOULD NOT HAVE ACCESS TO THESE SERVICES IF WE DID NOT PROVIDE THEM. CURRENTLY WE ARE NOT INVOLVED MUCH IN COMMUNITY BUILDING ACTIVITIES. BEING A SMALL CAH FACILITY WITH LIMITED RESOURCES, OUR FOCUS IS MORE ON HEALTH RELATED PROGRAMS AND SERVICES NEEDED WITHIN OUR COMMUNITY. IF WE DID NOT PROVIDE THE SERVICE, IT WOULD NOT BE AVAILABLE WITHIN THE COMMUNITY. GSHA IS NOT PART OF ANY AFFILIATED HEALTHCARE SYSTEM; HOWEVER, AS A CAH WE DO HAVE RURAL HEALTH NETWORK AGREEMENTS WITH BOTH TRINITY MEDICAL CENTER IN MINOT AND MEDCENTER ONE IN BISMARCK IN ORDER TO HELP AND PROMOTE THE AVAILABILITY OF A RANGE OF HIGH-QUALITY CARE. THEY ENHANCE THE CONTINUITY OF HEALTHCARE DELIVERY AMONG ALL LEVELS OF CARE NEEDED BY OUR PATIENTS BY IDENTIFYING AND FORMING A PROCESS TO FACILITATE PATIENT REFERRAL AND TRANSFER BETWEEN FACILITIES AND ALSO ENHANCE THE COMMUNICATIONS BETWEEN US. GSHA IS ALSO PART OF A CONSORTIUM OF SMALLER CAH FACILITIES TO SHARE COMPUTER HARDWARE. THIS HAS ALLOWED US TO EXPAND OUR COMPUTER CAPABILITIES AT A LOWER COST WHICH PROVIDES THE OPPORTUNITY TO BETTER SERVE OUR PATIENTS AND MEET THEIR HEALTHCARE NEEDS. | ||
| PART VI, LINE 6: N/A - NOT PART OF AN AFFILIATED HEALTHCARE SYSTEM. | ||
| N/A | LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT | LINE 7 |
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 | 1 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 1 | 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 (5 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BRIAN SELLAND | ||||||||||||||
| TRUSTEE/PHYSICIAN (THRU JANUARY) | 236115 | 0 | 0 | 0 | 0 | 0 | 14784 | 0 | 18122 | 0 | 269021 | 0 | 0 | 0 |
| JEFFREY LINGERFELT | ||||||||||||||
| CEO/SECRETARY | 164869 | 0 | 0 | 0 | 0 | 0 | 3353 | 0 | 12081 | 0 | 180303 | 0 | 0 | 0 |
| RONALD SKIPPER | ||||||||||||||
| SURGEON | 348858 | 0 | 0 | 0 | 0 | 0 | 6855 | 0 | 13978 | 0 | 369691 | 0 | 0 | 0 |
| HUBERT SEILER | ||||||||||||||
| PHYSICIAN | 158552 | 0 | 0 | 0 | 0 | 0 | 9202 | 0 | 12647 | 0 | 180401 | 0 | 0 | 0 |
| JULIA GARCIA | ||||||||||||||
| PHYSICIAN | 231593 | 0 | 0 | 0 | 0 | 0 | 10631 | 0 | 13978 | 0 | 256202 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | PART I, LINES 4A-B | ReturnReference |
| Explanation | IN 2013, BONNIE KUEHNEMUND AND DR. BRIAN SELLAND RECEIVED SEVERANCE PAY. BONNIE'S TOTALED $13,282 AND BRIAN'S TOTALED $54,239. | Explanation |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (3 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| JULIE BAUSTAD | |||
| FAMILY MEMBER OF BOARD MEMBER RICHARD ANDERSON | 96767 | EMPLOYMENT | 0 |
| NANCY SCHNEIBEL | |||
| FAMILY MEMBER OF BOARD MEMBER STACIE SCHMITT | 43869 | EMPLOYMENT | 0 |
| JODI SCHAAN | |||
| FAMILY MEMBER OF BOARD MEMBER MARK SCHAAN | 52972 | EMPLOYMENT | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| Return ReferenceReturnReference | ExplanationExplanation |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 6 | GSHA IS OWNED BY THE LOCAL CHURCHES WHOSE DELEGATES VOTE AT THE ANNUAL MEETING ON ELECTION OF THE GSHA BOARD MEMBERS AND OTHER PERTINENT BUSINESS AS PRESENTED AT THE ANNUAL MEETING. THERE ARE NO MEMBERSHIP FEES. ANY LOCAL CHURCH WISHING TO BE A MEMBER OF GSHA CAN DO SO THRU VOTE AT THE ANNUAL MEETING. |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH MEMBER CHURCH HAS UP TO TWO VOTING DELEGATES AT OUR ANNUAL MEETING WHERE THE BOARD OF DIRECTORS ARE ELECTED TO SERVE ON THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | AT THE ANNUAL MEETING THE VOTING DELEGATES FROM THE CHURCHES WILL VOTE ON CHANGES TO BY-LAWS OR ARTICLES OF INCORPORATION. |
| FORM 990, PART VI, SECTION B, LINE 11 | THE CEO AND CFO REVIEW THE 990 FIRST AND IT IS THEN SENT ELECTRONICALLY TO ALL BOARD MEMBERS FOR THEIR REVIEW. AT FOLLOWING BOARD MEETING IT IS DISCUSSED AND APPROVED PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE. |
| FORM 990, PART VI, SECTION B, LINE 12C | A CONFLICT OF INTEREST STATEMENT IS REVIEWED ANNUALY FOR ALL BOARD TRUSTEES. IT IS MONITORED DURING YEAR. A TRUSTEE WILL ABSTAIN FROM VOTING ON AN ISSUE IF A CONFLICT OF INTEREST IN THE MATTER IS PRESENT. CEO RECEIVES AND REVIEWS THE RESPONSES REGARDING THE ANNUAL DISCLOSURE. |
| FORM 990, PART VI, SECTION B, LINE 15 | COMPARATIVE DATA IS REVIEWED AND INCORPORATED INTO THE REVIEW PROCESS SUCH AS LOOKING AT STATE WAGE SURVEY DATA. FOR THE CEO, EACH BOARD MEMBER COMPLETES THEIR OWN EVALUATION FORM. THE HUMAN RESOURCE COMMITTEE REVIEWS THE RESPONSES AND MAKES A RECOMMENDATION TO THE FULL BOARD. FULL BOARD DECIDES ON ANY CHANGES TO THE CEO COMPENSATION. REVIEW IS DONE ANNUALLY AT TIME OF ANNIVERSARY DATE OF CONTRACT. BOARD TYPICALLY DOES NOT APPROVE WAGES FOR OTHER POSITIONS. CEO APPROVES THE CFO WAGES. COMPARATIVE DATA IS USED THROUGHOUT THE FACILITY AND INCORPORATED INTO THE ANNUAL REVIEW OF EMPLOYEE WAGES DONE BY THE DEPARTMENT HEAD OR SUPERVISOR. WAGES ARE COMPARED TO THE NDHA ANNUAL SALARY SURVEY REPORT AT THE TIME OF THEIR ANNUAL REVIEW. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XII, LINE 2C: | FISCAL AND PHYSICAL COMMITTEE, A SUBCOMMITTEE OF THE FULL BOARD, REVIEWS FINANCIALS IN MORE DETAIL WITH FINAL REVIEW BEING DONE BY FULL BOARD. SELECTION OF INDEPENDENT ACCOUNTANT IS DETERMINED BY FULL BOARD UPON RECOMMENDATION OF THE F&P COMMITTEE. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HEALTH SERVICES FOUNDATION | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 58368 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | FUNDRAISING FOR GOOD SAMARITAN HOSPITAL ASSOCIATION | PrimaryActivities |
| Legal Domicile State | ND | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | LINE 7 | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HOSPITAL ASSOCIATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Org | 1 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 1 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 1 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 1 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HEALTH SERVICES FOUNDATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionType |
| Amount Involved | 197906 | AmountInvolved |
| Method Of Amt Determination | COST TO AFFILIATED ENTITY | MethodOfAmtDetermination |
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