2014-02-14T14:55:55-06:00 2013-03-31 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2012-04-01 450226419 GOOD SAMARITAN HOSPITAL ASSOCIATION GOOD 7017765261 800 SOUTH MAIN ANENUE RUGBY ND 583682118 JEFFREY LINGERFELT 7017765261 2014-02-14 1 TIM A RITTER CPA P00732856 9525483400 2014-02-14 2012 2015-11-30 17:44:51Z HEART OF AMERICA MEDICAL CENTER JEFFREY LINGERFELT 800 SOUTH MAIN ANENUE RUGBY ND 583682118 22892630 0 X WWW.HAMC.COM X 1905 ND PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. 10 7 462 159 69954 23367 692374 438009 23022546 21962606 277324 204076 19187 251216 24011431 22855907 0 0 0 0 15062964 15633870 0 0 64063 8089764 8312873 23152728 23946743 858703 -1090836 15681866 15305948 4901844 5384708 10780022 9921240 X TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. 0 0 19747059 21895636 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. 19747059 1 1 0 1 0 0 0 0 1 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 62 0 462 1 1 1 0 0 0 0 0 0 0 0 0 X 10 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X JEFFREY LINGERFELT 7017765261 800 S MAIN AVENUE RUGBY ND 583682118 RICHARD ANDERSON 1.00 1.00 X 0 0 0 ARLYSS BERGRUD 1.00 X 0 0 0 BRETT MCATEE 1.00 X 0 0 0 JOHN MCCLINTOCK JR 1.00 X 0 0 0 TOM MOLLER JR 1.00 X 0 0 0 JON NELSON 1.00 X 0 0 0 STACEY SCHMITT 1.00 X 0 0 0 MARK SCHAAN 1.00 X 0 0 0 WES BLACK 1.50 X X 0 0 0 RUSTY GEBHARDT 1.50 X X 0 0 0 BRIAN SELLAND 40.00 X 236115 0 32906 BONNIE KUEHNEMUND 40.00 X 89559 0 9543 JEFFREY LINGERFELT 40.00 1.00 X 164869 0 15434 RONALD SKIPPER 40.00 X 348858 0 20833 HUBERT SEILER 40.00 X 158552 0 21849 JULIA GARCIA 40.00 X 231593 0 24609 TAMMIE HARDER 40.00 X 130105 0 9135 1359651 0 134309 10 0 1 0 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 5 197906 71848 168255 438009 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 221948 154978 66970 21962606 202076 202076 50793 36723 14070 14070 2984 11086 2000 0 2000 2000 2000 CAFETERIA SERVICES 900099 149469 149469 INSURANCE REIMBURSEMENT 900099 43791 43791 43886 43886 237146 22855907 21895636 69954 452308 279141 279141 13011479 11323613 1639032 48834 177048 118785 57584 679 1222558 822147 395747 4664 943644 639635 300468 3541 45567 45567 56766 56766 1816087 1713730 102357 68238 68238 1938862 1448380 490182 300 6148 6148 684414 635481 48933 250641 171556 73040 6045 6635 425 6210 124711 84353 40358 817950 546994 270956 234653 234653 BAD DEBT EXPENSE 877053 877053 RAW FOOD 482882 482882 MISC MEDICAL EXPENSE 478649 478649 ACUTE DRUGS 403376 403376 20241 20241 23946743 19747059 4135621 64063 1466 1741 342350 179873 4387692 3744593 503614 500414 180758 149591 43055 45867 22089962 17788842 4178622 4301120 4772453 5111081 1093523 1146835 178333 124833 15681866 15305948 1879417 1995447 81717 24999 26762 22564 2362910 2708275 551038 633423 4901844 5384708 X 10420896 9512302 359126 408938 10780022 9921240 15681866 15305948 -1090836 232054 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3683 3683 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: 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. 1 67474 67474 1 X 137447 137447 10154782 8361541 1793241 11722000 9427301 2294699 75733 75733 4301120 CERTIFICATE OF DEPOSIT 737897 F INTEREST IN NET ASSETS OF FOUNDATION 408938 F 1146835 X 22247631 232054 36723 268777 21978854 877053 877053 22855907 23106413 36723 36723 23069690 877053 877053 23946743 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 36,723. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 877,053. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 36,723. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 877,053. 1 1 1 X 1 X 1 1 1 0 1 1 255683 255683 0.01110 1319651 1156486 163165 0.00710 1575334 1156486 418848 0.01820 20556 20556 0.00090 500 500 0.00000 291064 291064 0.01260 1352 1352 0.00010 313472 313472 0.01360 1888806 1156486 732320 0.03180 1 652954 0 3935535 6219915 -2284380 X 1 1 1 1 HEART OF AMERICA MEDICAL CENTER

800 S MAIN AVE RUGBY ND 583682118

X X X X HEART OF AMERICA MEDICAL CENTER 1 1 X X X X X X 12 1 0 1 X X X X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 8 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 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. HEART OF AMERICA MEDICAL CENTER 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. 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. LIST OF STATES RECEIVING COMMUNITY BENEFIT REPORT LINE 7 N/A X X X X X 1 1 0 0 0 0 0 0 0 BRIAN SELLAND 236115 0 0 0 0 0 14784 0 18122 0 269021 0 0 0 JEFFREY LINGERFELT 164869 0 0 0 0 0 3353 0 12081 0 180303 0 0 0 RONALD SKIPPER 348858 0 0 0 0 0 6855 0 13978 0 369691 0 0 0 HUBERT SEILER 158552 0 0 0 0 0 9202 0 12647 0 180401 0 0 0 JULIA GARCIA 231593 0 0 0 0 0 10631 0 13978 0 256202 0 0 0 PART I, LINES 4A-B IN 2013, BONNIE KUEHNEMUND AND DR. BRIAN SELLAND RECEIVED SEVERANCE PAY. BONNIE'S TOTALED $13,282 AND BRIAN'S TOTALED $54,239. 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 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. GOOD SAMARITAN HEALTH SERVICES FOUNDATION 800 SOUTH MAIN AVE RUGBY ND 58368 363513553 FUNDRAISING FOR GOOD SAMARITAN HOSPITAL ASSOCIATION ND 501(C)(3) LINE 7 GOOD SAMARITAN HOSPITAL ASSOCIATION 1 0 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 0 1 0 GOOD SAMARITAN HEALTH SERVICES FOUNDATION C 197906 COST TO AFFILIATED ENTITY