2014-07-08T09:32:57-05:00 2013-12-31 450250958 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2013-01-01 456013474 Pembina County Memorial Hospital Association PEMB 7012658461 301 Mountain St E Cavalier ND 58220 Tanya Sharp CEO 7012658461 2014-06-25 1 LISA CHAFFEE CPA P00302874 7012398500 2014-06-25 2013 2015-11-30 17:44:51Z Tanya Sharp 301 Mountain St E Cavalier ND 58220 11341552 0 X www.cavalierhospital.com X 1976 ND Provision of acute care, long-term, and elderly congregate housing for the community. 8 5 214 110 0 0 187440 59352 11575991 11278249 3679 2901 18891 1050 11786001 11341552 0 0 0 0 5538835 5894297 0 0 27273 5750353 5260793 11289188 11155090 496813 186462 5262362 5511072 1787633 1851476 3474729 3659596 X The mission of Pembina County Memorial Hospital and Wedgewood Manor is to provide a family centered approach to the delivery of health services and to promote a healthy lifestyle to those we serve in Cavalier and the surrounding communities. The vision that guides Pembina County Memorial Hospital and Wedgewood Manor is to develop a family centered integrated healthcare organization which provides services that meet the needs of the region, thereby making us their provider of choice. 0 0 9371262 11278249 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. 9371262 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 14 0 1 214 1 0 0 0 0 0 0 0 0 0 0 X 8 5 0 1 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Tanya Sharp CEO 7012658461 301 Mountain St E Cavalier ND 58220 X Tom Ford President 1.00 0.00 X X 0 0 0 Tom Vaughn Vice President 1.00 0.00 X X 0 0 0 Lois Coggon Secretary/Treasurer (Jan-June) 1.00 0.00 X X 0 0 0 Tom O'Toole Dir.(Jan-June)/Sec./Treas.(July-Dec) 1.00 0.00 X X 0 0 0 Dr KS Sumra Director/Medical Staff Rep 1.00 0.00 X 0 0 0 Dale O'Hara Director 1.00 0.00 X 0 0 0 Ken Schwandt Director 1.00 0.00 X 22750 0 0 Dean Steinwand Director 1.00 0.00 X 0 0 0 Loretta Bernhoft Director 1.00 0.00 X 0 0 0 Everett Butler CEO (Jan-Sept) 40.00 0.00 X 50127 0 0 Tanya Sharp CFO (Jan-Aug)/CEO (Sept-Dec) 40.00 0.00 X 80090 0 13386 Jeni Schwenzfeier CFO (Sept-Dec) 18.00 0.00 X 9824 0 295 162791 0 13681 0 0 0 1 Park River Clinic PO BOX 380 Cavalier ND 58220 Physician Services 527881 DMS PO Box 86 Minneapolis MN 55846 Mobile Imaging Services 352721 Altru Health System PO BOX 13780 Grand Forks ND 58208 Therapy Services & Lab Pathology 196148 ARL PO Box 380 Cavalier ND 58220 Contracted Physician 166670 Dakota Travel Nurse 502 W Main Mandan ND 58554 Agency Nurses 148871 6 59352 59352 Patient Service Revenue 622110 11038910 11038910 Supporting Revenue 900099 234162 234162 Auxiliary Revenue 900099 5177 5177 11278249 2901 2901 1050 0 1050 1050 1050 11341552 11278249 0 3951 X 176956 22750 154206 31468 31468 4550234 3739229 785325 25680 120919 100359 20550 10 691242 562760 128450 32 323478 262928 58999 1551 70 70 28688 28688 2379581 2171821 207760 34874 34874 120726 32172 88554 221131 221131 251834 251834 48697 39317 9380 28565 25568 2997 14068 14068 568744 568744 55327 55327 Medical Supplies 1130076 1130076 Bad Debt Expense 273834 273834 Recruitment 27963 3963 24000 Credit/Collection Expen 21116 21116 55499 29054 26445 11155090 9371262 1756555 27273 369376 15646 1629105 2498709 69550 144262 15224 44542 13322769 10886295 2640476 2436474 165931 180393 372700 191046 5262362 5511072 1296317 1521337 50511 71546 14143 14715 426662 243878 1787633 1851476 X 3474729 3659596 3474729 3659596 5262362 5511072 X 186462 -1595 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 6659 5177 3582 8254 1 X 160304 160304 5798469 4788020 1010449 6898129 5785869 1112260 465867 312406 153461 2436474 X 11062541 -273834 -273834 11336375 5177 5177 11341552 10877674 0 10877674 277416 277416 11155090 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. 1 1 X 1 X 1 X 0 1 1 0 0 3000 3000 0.00030 1671681 1664489 7192 0.00070 1674681 1664489 10192 0.00100 225 225 0.00000 771259 400958 370301 0.03400 771484 400958 370526 0.03400 2446165 2065447 380718 0.03500 0 273834 21907 3125600 3236428 -110828 X 1 1 1 1 Pembina County Memorial Hospital 301 Mountain St E Cavalier ND 58220 X X X X Pembina County Memorial Hospital 1 1 X X X X X 12 1 0 1 X http://www.cavalierhospital.com/about-us/ X X X X 0 0 1 1 100.000000000000 1 200.000000000000 1 X X 1 1 X X 1 0 X X X X 1 X 0 0 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. 3 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 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 X X 0 0 0 0 0 0 0 0 0 Everett Butler CEO (Jan-Sept) 50127 0 0 0 0 0 0 0 0 0 50127 0 0 0 Part I, Line 3 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. Rita Vaughn Family Member of Director Tom Vaughn 31468 Compensation 0 Dr K S Sumra Owner of Park River Clinic 527881 Dr. Sumra owns Park River Clinic. Park River Clinic provides independent contractor physician services to the Organization. 0 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. Pembina County Memorial Hospital Foundation 301 Mountain Street E Cavalier ND 58220 300052569 Fundraising for benefit of Pembina Co. Memorial Hospital & Wedgewood Manor ND 501(c)(3) Line 11a, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0