PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2013
View the entire original 990 at ProPublica ↗
- Organization
- PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (EIN 45-6013474)
- Tax period
- 2013-01-01 to 2013-12-31
- Filed
- 2014-07-08
- IRS object ID
- 201431899349300013
- Schema version
- 2013v3.0
- 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 D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2014-07-08T09:32:57-05:00 | ReturnTs |
| Tax Period End | 2013-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1 |
| City | FARGO | City |
| State | ND | State |
| ZIP Code | 581082545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2013-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 456013474 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital Association | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | PEMB | BusinessNameControlTxt |
| Phone | 7012658461 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain St E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Tanya Sharp | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7012658461 | PhoneNum |
| Signature | 2014-06-25 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | LISA CHAFFEE CPA | PreparerPersonNm |
| PTIN | P00302874 | PTIN |
| Phone | 7012398500 | PhoneNum |
| Preparation | 2014-06-25 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2013 | TaxYr |
| Build TS | 2015-11-30 17:44:51Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Tanya Sharp | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain St E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $11,341,552 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.cavalierhospital.com | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1976 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | Provision of acute care, long-term, and elderly congregate housing for the community. | ActivityOrMissionDesc |
| Voting Members Governing Body | 8 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 5 | VotingMembersIndependentCnt |
| Total Employee | 214 | TotalEmployeeCnt |
| Total Volunteers | 110 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $187,440 | PYContributionsGrantsAmt |
| CY Contributions Grants | $59,352 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $11,575,991 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $11,278,249 | CYProgramServiceRevenueAmt |
| PY Investment Income | $3,679 | PYInvestmentIncomeAmt |
| CY Investment Income | $2,901 | CYInvestmentIncomeAmt |
| PY Other Revenue | $18,891 | PYOtherRevenueAmt |
| CY Other Revenue | $1,050 | CYOtherRevenueAmt |
| PY Total Revenue | $11,786,001 | PYTotalRevenueAmt |
| CY Total Revenue | $11,341,552 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $5,538,835 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $5,894,297 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $27,273 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $5,750,353 | PYOtherExpensesAmt |
| CY Other Expenses | $5,260,793 | CYOtherExpensesAmt |
| PY Total Expenses | $11,289,188 | PYTotalExpensesAmt |
| CY Total Expenses | $11,155,090 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $496,813 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $186,462 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $5,262,362 | TotalAssetsBOYAmt |
| Total Assets EOY | $5,511,072 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $1,787,633 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $1,851,476 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $3,474,729 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $3,659,596 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | The mission of Pembina County Memorial Hospital and Wedgewood Manor is to provide a family centered approach to the delivery of health services and to promote a healthy lifestyle to those we serve in Cavalier and the surrounding communities. The vision that guides Pembina County Memorial Hospital and Wedgewood Manor is to develop a family centered integrated healthcare organization which provides services that meet the needs of the region, thereby making us their provider of choice. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $9,371,262 | ExpenseAmt |
| Revenue | $11,278,249 | RevenueAmt |
| Desc | Pembina County Memorial Hospital Association is a 24 bed acute care hospital, 50 bed nursing home, 20-unit congregate housing project (Country Estates), and clinic located in Cavalier, North Dakota. The facility provides quality medical and long-term care to residents of the surrounding area without regard to the individuals' ability to pay for services received. The Association also provides health education and other services to the community. The Association provides health care services to patients who meet certain criteria under its Charity Care Policy without charge or at amounts less than established rates. Since the Association does not pursue collection of these amounts, they are not reported as patient service revenue. The estimated cost of providing charity care was $3,000 for December 31, 2013. This was calculated by multiplying the ratio of cost to gross charges for the Association by the gross uncompensated charges associated with providing charity care to its patients. | Desc |
| Total Program Service Expenses | $9,371,262 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | Yes (1) | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 14 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 214 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 8 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 5 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tanya Sharp CEO | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7012658461 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain St E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (12 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|---|
| Tom Ford | |||||||
| President | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Tom Vaughn | |||||||
| Vice President | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Lois Coggon | |||||||
| Secretary/Treasurer (Jan-June) | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Tom O'Toole | |||||||
| Dir.(Jan-June)/Sec./Treas.(July-Dec) | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 |
| Dr KS Sumra | |||||||
| Director/Medical Staff Rep | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |
| Dale O'Hara | |||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |
| Ken Schwandt | |||||||
| Director | 1.00 | 0.00 | Yes (X) | $22,750 | $0 | $0 | |
| Dean Steinwand | |||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |
| Loretta Bernhoft | |||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | |
| Everett Butler | |||||||
| CEO (Jan-Sept) | 40.00 | 0.00 | Yes (X) | $50,127 | $0 | $0 | |
| Tanya Sharp | |||||||
| CFO (Jan-Aug)/CEO (Sept-Dec) | 40.00 | 0.00 | Yes (X) | $80,090 | $0 | $13,386 | |
| Jeni Schwenzfeier | |||||||
| CFO (Sept-Dec) | 18.00 | 0.00 | Yes (X) | $9,824 | $0 | $295 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $162,791 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $13,681 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | 0 | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1 | CityContractorAddress/USAddress/City | StateContractorAddress/USAddress/State | ZIP CodeContractorAddress/USAddress/ZIPCode | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Park River Clinic | |||||
| PO BOX 380 | Cavalier | ND | 58220 | Physician Services | $527,881 |
| DMS | |||||
| PO Box 86 | Minneapolis | MN | 55846 | Mobile Imaging Services | $352,721 |
| Altru Health System | |||||
| PO BOX 13780 | Grand Forks | ND | 58208 | Therapy Services & Lab Pathology | $196,148 |
| ARL | |||||
| PO Box 380 | Cavalier | ND | 58220 | Contracted Physician | $166,670 |
| Dakota Travel Nurse | |||||
| 502 W Main | Mandan | ND | 58554 | Agency Nurses | $148,871 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 6 | CntrctRcvdGreaterThan100KCnt |
| All Other Contributions | $59,352 | AllOtherContributionsAmt |
| Total Contributions | $59,352 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Patient Service Revenue | 622110 | $11,038,910 | $11,038,910 |
| Supporting Revenue | 900099 | $234,162 | $234,162 |
| Auxiliary Revenue | 900099 | $5,177 | $5,177 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $11,278,249 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,901 | TotalRevenueColumnAmt |
| Exclusion | $2,901 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $1,050 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $1,050 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,050 | TotalRevenueColumnAmt |
| Exclusion | $1,050 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $11,341,552 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $11,278,249 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $3,951 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $176,956 | TotalAmt |
| Program Services | $22,750 | ProgramServicesAmt |
| Management And General | $154,206 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $31,468 | TotalAmt |
| Program Services | $31,468 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,550,234 | TotalAmt |
| Program Services | $3,739,229 | ProgramServicesAmt |
| Management And General | $785,325 | ManagementAndGeneralAmt |
| Fundraising | $25,680 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $120,919 | TotalAmt |
| Program Services | $100,359 | ProgramServicesAmt |
| Management And General | $20,550 | ManagementAndGeneralAmt |
| Fundraising | $10 | FundraisingAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $691,242 | TotalAmt |
| Program Services | $562,760 | ProgramServicesAmt |
| Management And General | $128,450 | ManagementAndGeneralAmt |
| Fundraising | $32 | FundraisingAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $323,478 | TotalAmt |
| Program Services | $262,928 | ProgramServicesAmt |
| Management And General | $58,999 | ManagementAndGeneralAmt |
| Fundraising | $1,551 | FundraisingAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $70 | TotalAmt |
| Management And General | $70 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,688 | TotalAmt |
| Management And General | $28,688 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,379,581 | TotalAmt |
| Program Services | $2,171,821 | ProgramServicesAmt |
| Management And General | $207,760 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $34,874 | TotalAmt |
| Program Services | $34,874 | ProgramServicesAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $120,726 | TotalAmt |
| Program Services | $32,172 | ProgramServicesAmt |
| Management And General | $88,554 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $221,131 | TotalAmt |
| Management And General | $221,131 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $251,834 | TotalAmt |
| Program Services | $251,834 | ProgramServicesAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $48,697 | TotalAmt |
| Program Services | $39,317 | ProgramServicesAmt |
| Management And General | $9,380 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $28,565 | TotalAmt |
| Program Services | $25,568 | ProgramServicesAmt |
| Management And General | $2,997 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $14,068 | TotalAmt |
| Program Services | $14,068 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $568,744 | TotalAmt |
| Program Services | $568,744 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,327 | TotalAmt |
| Program Services | $55,327 | ProgramServicesAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $1,130,076 | $1,130,076 | |
| Bad Debt Expense | $273,834 | $273,834 | |
| Recruitment | $27,963 | $3,963 | $24,000 |
| Credit/Collection Expen | $21,116 | $21,116 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,499 | TotalAmt |
| Program Services | $29,054 | ProgramServicesAmt |
| Management And General | $26,445 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,155,090 | TotalAmt |
| Program Services | $9,371,262 | ProgramServicesAmt |
| Management And General | $1,756,555 | ManagementAndGeneralAmt |
| Fundraising | $27,273 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $369,376 | BOYAmt |
| EOY | $15,646 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,629,105 | BOYAmt |
| EOY | $2,498,709 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $69,550 | BOYAmt |
| EOY | $144,262 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $15,224 | BOYAmt |
| EOY | $44,542 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $13,322,769 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $10,886,295 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,640,476 | BOYAmt |
| EOY | $2,436,474 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $165,931 | BOYAmt |
| EOY | $180,393 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $372,700 | BOYAmt |
| EOY | $191,046 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,262,362 | BOYAmt |
| EOY | $5,511,072 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,296,317 | BOYAmt |
| EOY | $1,521,337 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $50,511 | BOYAmt |
| EOY | $71,546 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $14,143 | BOYAmt |
| EOY | $14,715 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $426,662 | BOYAmt |
| EOY | $243,878 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,787,633 | BOYAmt |
| EOY | $1,851,476 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,474,729 | BOYAmt |
| EOY | $3,659,596 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,474,729 | BOYAmt |
| EOY | $3,659,596 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,262,362 | BOYAmt |
| EOY | $5,511,072 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $186,462 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$1,595 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| 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) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | Yes (1) | AgentTrusteeEtcInd |
| Beginning Balance | $6,659 | BeginningBalanceAmt |
| Additions During Year | $5,177 | AdditionsDuringYearAmt |
| Distributions During Year | $3,582 | DistributionsDuringYearAmt |
| Ending Balance | $8,254 | EndingBalanceAmt |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $160,304 | OtherCostOrOtherBasisAmt |
| Book Value | $160,304 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $5,798,469 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,788,020 | DepreciationAmt |
| Book Value | $1,010,449 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $6,898,129 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,785,869 | DepreciationAmt |
| Book Value | $1,112,260 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $465,867 | OtherCostOrOtherBasisAmt |
| Depreciation | $312,406 | DepreciationAmt |
| Book Value | $153,461 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,436,474 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $11,062,541 | TotalRevEtcAuditedFinclStmtAmt |
| Other Revenue | -$273,834 | OtherRevenueAmt |
| Revenue Not Reported | -$273,834 | RevenueNotReportedAmt |
| Revenue Subtotal | $11,336,375 | RevenueSubtotalAmt |
| Other Revenues Not Included | $5,177 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $5,177 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $11,341,552 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $10,877,674 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $10,877,674 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $277,416 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $277,416 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $11,155,090 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 1b: | A small auxiliary operates under the Hospital's EIN. |
| Part IV, Line 2b: | The Association holds funds under an agency relationship for the residents of Wedgewood Manor and Country Estates. The funds are shown as cash and a corresponding liability in accounts payable in the accompanying balance sheets. Funds held as of December 31, 2013 and 2012 totaled $14,715 and $14,143. |
| Part X, Line 2: | The Association is organized as a North Dakota nonprofit corporation and has been recognized by the Internal Revenue Service as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Association is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Association is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Association has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Association believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Association would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. |
| Part XI, Line 2d - Other Adjustments: | Provision for Bad Debts -273,834. |
| Part XI, Line 4b - Other Adjustments: | Auxiliary Revenues 5,177. |
| Part XII, Line 4b - Other Adjustments: | Auxiliary Expenses 3,582. Provision for Bad Debts 273,834. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $3,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,671,681 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,664,489 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $7,192 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00070 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,674,681 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,664,489 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $10,192 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00100 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $225 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $225 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $771,259 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $400,958 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $370,301 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03400 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $771,484 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $400,958 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $370,526 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03400 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,446,165 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,065,447 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $380,718 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03500 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $273,834 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $21,907 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $3,125,600 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $3,236,428 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$110,828 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain St E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| CHNA Conducted | 12 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | http://www.cavalierhospital.com/about-us/ | OwnWebsiteURLTxt |
| Rpt Available Upon Request | Yes (X) | RptAvailableUponRequestInd |
| Adopt Implementation Strategy | Yes (X) | AdoptImplementationStrategyInd |
| Exec Implementation Strategy | Yes (X) | ExecImplementationStrategyInd |
| Prioritize Health Needs | Yes (X) | PrioritizeHealthNeedsInd |
| All Needs Addressed | 0 | AllNeedsAddressedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Used Deter Elig Free Care | Yes (1) | FPGUsedDeterEligFreeCareInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Used Determ Elig Dscnt Care | Yes (1) | FPGUsedDetermEligDscntCareInd |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| Income Level | Yes (X) | IncomeLevelInd |
| Other Factors | Yes (X) | OtherFactorsInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| Available On Request | Yes (X) | AvailableOnRequestInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Other Actions Taken | Yes (X) | OtherActionsTakenInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Lowest Negotiated Rates | Yes (X) | LowestNegotiatedRatesInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Pembina County Memorial Hospital | Part V, Section B, Line 3: Surveys were given to patients who received care in the hospital and/or clinic in January and February of 2011. Surveys were also available online and marketed throughout the community. In addition, all staff members of the facility completed a survey to reflect on what patients tell them about the care that was provided. Lastly, local community leaders were identified for further input to identify community needs. These efforts were coordinated through the UND Center for Rural Health. |
| Pembina County Memorial Hospital | Part V, Section B, Line 6i: The implementation strategy is available at: http://www.cavalierhospital.com/about-us/ |
| Pembina County Memorial Hospital | Part V, Section B, Line 7: The CHNA identified a need for additional housing options through assisted living. Additional assisted living options have been explored but were determined to not be financially feasible at this time. |
| Pembina County Memorial Hospital | Part V, Section B, Line 12i: Family size is also used to determine amounts charged to patients. |
| Pembina County Memorial Hospital | Part V, Section B, Line 14g: A summary of the Financial Assistance Policy is posted on the hospital's website, attached to billing invoices, and provided to patients upon admission to the hospital. |
| Pembina County Memorial Hospital | Part V, Section B, Line 18e: If a patient calls in with questions regarding their bill, the financial assitance policy is discussed with the patient. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1 | CityUSAddress/City | StateUSAddress/State | ZIP CodeUSAddress/ZIPCode | FacilityFacilityTxt |
|---|---|---|---|---|
| Clinicare | ||||
| 301 Mountain St E | Cavalier | ND | 58220 | Clinic Services |
| Wedgewood Manor | ||||
| 804 Main Street West | Cavalier | ND | 58220 | Long Term Care Services |
| Country Estates | ||||
| 107 Bjornson Drive | Cavalier | ND | 58220 | Independent Living |
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | The Organization uses a sliding scale based on family size and the federal poverty income guidelines (FPG) when determining whether an individual is eligible for discounted or free care. If the individual's family size and income are below the national poverty guidelines then they would be eligible for 100% charity care allowance. Individuals with income between 100 and 133% of the FPG, receive a 70% discount. From 133-166% of the FPG a 40% discount is applied and from 166-200% of the FPG, a 20% discount is applied. |
| Part I, Line 7: | The Organization used an average overall ratio of costs to gross charges which addresses all patient segments in order to calculate the amount in Part I, line 7, Row a. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. The cost of Community Health Improvement Services on line 7e was based on actual costs. The cost for subsidized health services on line 7g was determined using the Medicare cost report. |
| Part I, Ln 7 Col(f): | For the purpose of calculating the percentage on Part I, line 7f, $273,834 of bad debt expense was backed out of total operating expenses. |
| Part II, Community Building Activities: | N/A |
| Part III, Line 4: | Costing Methodology for Determining Amount of Organization's Bad Debt Expense Attributable to Patients Eligible under the Organization's Charity Care Policy:8.0% of the individuals in Pembina County fall below the federal poverty levels according to the 2010 Census data. Care is given to individuals regardless of their ability to pay and if the individual's family size and income are below the federal poverty guidelines then they would be eligible for 100% charity care allowance. Therefore the Organization estimates that 8.0% of the bad debt expense is attributable to patients eligible under the Organization's charity care policy. This is a community benefit and a reasonable estimate based on the demographics of the area the Organization serves.Footnote from Organization's Financial Statements: The footnote that describes bad debt expense is found on page 7 of the attached audit report. |
| Part III, Line 8: | All of the Medicare shortfall should be treated as a community benefit. The Organization treats individuals regardless of the ability to pay. Most of the Medicare shortfall comes from the nursing home. The elderly are an underserved population and it is a community benefit to be able to treat them at the local nursing home.Medicare allowable costs of care are based on the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. |
| Part III, Line 9b: | Charity care and financial assistance applications must be completed in their entirety. If an application is incomplete, it is returned to the guarantor and collection efforts/actions resume if the completed application is not returned. Upon receipt of a complete application, collection efforts may be reversed if a patient is eligible for charity care and/or financial assistance. Charity Care applications are reviewed and approved by the Business Office manager and the CEO or CFO. A determination of eligibility for financial assistance is documented. Partial charity care discounts may apply. If a patient is known to be financially struggling or has filed a charity care application in the past, the charity care application is mailed with their 60 day invoice from the Hospital. If a patient is determined to qualify for financial assistance, all collection practices are stopped. |
| Part VI, Line 2: | An annual review of the Rural Healthcare Clinic and Urgent Care is done by the CEO, board members and key medical staff members. The review evaluates services and helps to determine whether to add or remove services. The leaders within the Organization are always available for community members' ideas and opinions. These ideas and opinions are properly brought to the attention of the review committee and evaluated. In addition, the Organization conducted a Community Health Needs Assessment which was completed in 2012. A second Community Health Needs Assessment is scheduled to be completed in 2014. |
| Part VI, Line 3: | A letter is received by all patients that have had their insurance processed and have the following options for payment of outstanding medical bills: 1. Payment in full2. Payment arrangements3. Charity Care ApplicationUninsured patients have the same above mentioned options when it comes to paying their bill.Also a public notification is visible at the main receptionist desk and all business office staff can appropriately answer questions in regards to payment on outstanding medical bills. When a patient inquires about their bill we are able to further discuss if they would meet the criteria and what further steps need to be taken for financial assistance. |
| Part VI, Line 4: | Pembina County Memorial Hospital Association is a 25-bed critical access hospital, 50-bed nursing home (Wedgewood Manor), a 20-unit congregate housing project (Country Estates), and clinic located in Cavalier, North Dakota.Our Organization serves Pembina County and the surrounding region (the north east corner of North Dakota). The US census for 2010 showed a population of 7,413 for Pembina County. The median income for a household in Pembina County was $48,502. The per capita income for the county was $27,019. 8.0% of the population is below the poverty line. We are considered a rural area; agriculture is our main industry. We are the only hospital in Pembina County; Cavalier and Walsh Counties (neighboring counties) also have medical facilities. |
| Part VI, Line 5: | Our organization serves Pembina County and the surrounding regions. It is our responsibility to provide quality healthcare within the community area that we serve. Our key leaders and volunteer board members are residents who live within the areas we service. We extend medical staff privileges to all qualified physicians in the community. If we have surplus funds, these dollars are used to improve patient care in many different areas within the organization. Surplus funds are used to upgrade existing equipment or to purchase new equipment to provide new services. The funds are also used to make improvements to the facility such as renovation of patient areas and departments. These improvements must be approved by upper management and depending upon the improvement, sometimes the Board of Directors must approve it as well. In a rural setting, it is crucial to be involved in the community, so Pembina County Memorial Hospital participates in the annual health fair, diabetic education and other events throughout the year. It is imperative to further our exempt status to continue to promote our services and quality of care within our service area. |
| Part VI, Line 6: | N/A |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Everett Butler | PersonNm |
| Title | CEO (Jan-Sept) | TitleTxt |
| Base Compensation Filing Org | $50,127 | BaseCompensationFilingOrgAmt |
| Compensation Based On Rltd Orgs | $0 | CompensationBasedOnRltdOrgsAmt |
| Bonus Filing Organization | $0 | BonusFilingOrganizationAmount |
| Bonus Related Organizations | $0 | BonusRelatedOrganizationsAmt |
| Other Compensation Filing Org | $0 | OtherCompensationFilingOrgAmt |
| Other Compensation Rltd Orgs | $0 | OtherCompensationRltdOrgsAmt |
| Deferred Compensation Flng Org | $0 | DeferredCompensationFlngOrgAmt |
| Deferred Comp Rltd Orgs | $0 | DeferredCompRltdOrgsAmt |
| Nontaxable Benefits Filing Org | $0 | NontaxableBenefitsFilingOrgAmt |
| Nontaxable Benefits Rltd Orgs | $0 | NontaxableBenefitsRltdOrgsAmt |
| Total Compensation Filing Org | $50,127 | TotalCompensationFilingOrgAmt |
| Total Compensation Rltd Orgs | $0 | TotalCompensationRltdOrgsAmt |
| Comp Report Prior990 Filing Org | $0 | CompReportPrior990FilingOrgAmt |
| Comp Report Prior990 Rltd Orgs | $0 | CompReportPrior990RltdOrgsAmt |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 3 | FormAndLineReferenceDesc |
| Explanation | For January - September: Pembina County Memorial Hospital Association does not pay compensation to the CEO directly. The CEO is compensated by an unrelated organization, Christian Unity Hospital Corporation, DBA Unity Medical Center. The Pembina County Memorial Hospital Association's Board of Directors uses the processes described in Part I, Question 3 to determine appropriate compensation for the CEO. Any increase in compensation is communicated to Unity Medical Center. Unity Medical Center sends Pembina County Memorial Hospital Association a monthly bill for his wages earned at Pembina. Effective September 2013: Tanya Sharp, CEO, is directly compensated by PCMH. The CEO salary is derived from reviewing the AHA salary survey and then discussed and approved by the Board. An annual review of salary and performance/goals will take place. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp (2 entries)
| Relationship DescriptionRelationshipDescriptionTxt | TransactionTransactionAmt | TransactionTransactionDesc | Sharing Of RevenuesSharingOfRevenuesInd |
|---|---|---|---|
| Rita Vaughn | |||
| Family Member of Director Tom Vaughn | $31,468 | Compensation | 0 |
| Dr K S Sumra | |||
| Owner of Park River Clinic | $527,881 | Dr. Sumra owns Park River Clinic. Park River Clinic provides independent contractor physician services to the Organization. | 0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1 | An Executive Committee exists which meets on an as needed basis between scheduled board meetings and it can take action as required on behalf of the board when it is not feasible to bring the full board together in time to address an issue. The committee annually recommends to the board appropriate compensation for the CEO. The Executive Committee also annually evaluates the performance of the board and reviews the bylaws and makes recommendations to the board concerning any necessary or appropriate changes to them. They also perform other duties and delegated responsibilities as the board may assign to the committee from time to time. |
| Form 990, Part VI, Section A, line 3 | Everett Butler, CEO of the organization, is employed by Christian Unity Hospital Corporation, DBA Unity Medical Center, an unrelated party. The amount of compensation he received for 2013 (January through September) was $50,127; the amount was paid to Unity Medical Center. |
| Form 990, Part VI, Section A, line 6 | The Organization has stockholders. There is one class of stockholders. Each stockholder has one vote during the annual meeting. |
| Form 990, Part VI, Section A, line 7a | The stockholders/members elect the Board of Directors and the rest of the voting power rests with the Board of Directors. |
| Form 990, Part VI, Section B, line 11 | The Form 990 is reviewed by the Board members and Finance Committee before it is filed. |
| Form 990, Part VI, Section B, line 12c | The process of disclosing conflicts of interest is gone through annually. Each Board member completes a form and discloses if they have a conflict of interest. The CEO and Board President review the disclosure forms and if a conflict arises as an issue, it is brought to the full Board for discussion on further action (if necessary), which may result in a consultation with an attorney. If the Board is voting on an issue where there is a conflict of interest, the person with the conflict of interest is asked to abstain from the vote. |
| Form 990, Part VI, Section B, line 15a | The process for determining compensation includes looking at state salary surveys from the American Hospital Association or North Dakota Hospital Association. For the CEO, the Executive Committee of the Board derives the compensation contract. The CFO's compensation is reviewed annually by the CEO. Changes to the CFO's salary may be based on American Hospital Association Surveys or other industry surveys and also budget approval by the Board of Directors. For others, the Board is not involved in the final compensation decision, but instead the CEO and CFO make the final compensation decisions. This process is done annually and was last undertaken in 2013. |
| Form 990, Part VI, Section C, line 19 | The Organization's governing documents, conflict of interest policy and financial statements are typically only shared with people whom the organization does business with. They are made available upon request for the general public. The financial statements are also attached to the Form 990 and made available to the public through the Form 990. |
| Form 990, Part VII, Section A, and Form 990, Schedule L, Part IV: | Ken Schwandt's Compensation: Ken Schwandt is not compensated as a member of the board. Ken Schwandt receives compensation from the Organization as an independent contractor for his consultant pharmacist services to the Organization. The transaction does not meet the reporting thresholds of Schedule L, Part IV and accordingly is not reported there. |
| Form 990, Part IX, line 11g | Medical Professional Fees: Program service expenses 1,455,534. Management and general expenses 3,179. Fundraising expenses 0. Total expenses 1,458,713. Maintenance and Repair Fees: Program service expenses 54,625. Management and general expenses 9,626. Fundraising expenses 0. Total expenses 64,251. Service and Service Contract Fees: Program service expenses 259,715. Management and general expenses 104,444. Fundraising expenses 0. Total expenses 364,159. Purchased Services: Program service expenses 344,472. Management and general expenses 20,250. Fundraising expenses 0. Total expenses 364,722. Non Medical Professional Fees: Program service expenses 11,339. Management and general expenses 70,261. Fundraising expenses 0. Total expenses 81,600. Rental/Lease Equipment Fees: Program service expenses 46,136. Management and general expenses 0. Fundraising expenses 0. Total expenses 46,136. |
| Form 990, Part XI, line 9: | Change in Auxiliary Assets -1,595. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital Foundation | BusinessNameLine1 |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain Street E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 300052569 | EIN |
| Primary Activities | Fundraising for benefit of Pembina Co. Memorial Hospital & Wedgewood Manor | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 11a, I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
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