PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2012
View the entire original 990 at ProPublica ↗
- Organization
- PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (EIN 45-6013474)
- Tax period
- 2012-01-01 to 2012-12-31
- Filed
- 2013-10-21
- IRS object ID
- 201332949349300538
- Schema version
- 2012v2.1
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-10-21T14:43:37-05:00 | Timestamp |
| Tax Period End Date | 2012-12-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450250958 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1 |
| City | FARGO | City |
| State | ND | State |
| ZIP Code | 581082545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2012-01-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 456013474 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital Association | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | PEMB | NameControl |
| Phone | 7012658461 | Phone |
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 |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Everett Butler | Name |
| Title | CEO | Title |
| Phone | 7012658461 | Phone |
| Date Signed | 2013-09-27 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LISA CHAFFEE CPA | Name |
| PTIN | P00302874 | PTIN |
| Phone | 7012398500 | Phone |
| Date Prepared | 2013-09-27 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2012 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Everett Butler | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| 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 | 11786001 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | www.cavalierhospital.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1976 | YearFormation |
| State Legal Domicile | ND | StateLegalDomicile |
| Activity Or Mission Description | Provision of acute care, long-term, and elderly congregate housing for the community. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 6 | NbrIndependentVotingMembers |
| Total Nbr Employees | 212 | TotalNbrEmployees |
| Total Nbr Volunteers | 58 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 149922 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 187440 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 10878550 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 11575991 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -6132 | InvestmentIncomePriorYear |
| Investment Income Current Year | 3679 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 12526 | OtherRevenuePriorYear |
| Other Revenue Current Year | 18891 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 11034866 | TotalRevenuePriorYear |
| Total Revenue Current Year | 11786001 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 5696453 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 5538835 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 17567 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 5114108 | OtherExpensePriorYear |
| Other Expenses Current Year | 5750353 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 10810561 | TotalExpensesPriorYear |
| Total Expenses Current Year | 11289188 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 224305 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 496813 | RevenuesLessExpensesCY |
| Total Assets BOY | 4768279 | TotalAssetsBOY |
| Total Assets EOY | 5262362 | TotalAssetsEOY |
| Total Liabilities BOY | 1791265 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 1787633 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 2977014 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 3474729 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | 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. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 9719690 | Expense |
| Revenue | 11593702 | Revenue |
| Description | 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 $87,000 for the year ended December 31, 2012. 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. | Description |
| Total Program Service Expense | 9719690 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 1 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 1 | ReportOtherAssets |
| Report Other Liabilities | 0 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 1 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 1 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 27 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 212 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 6 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Everett Butler CEO | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7012658461 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 301 Mountain St E | AddressLine1 |
| City | Cavalier | City |
| State | ND | State |
| ZIP Code | 58220 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (11 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation |
|---|---|---|---|---|---|---|
| Tom Ford | ||||||
| President | 1.00 | X | X | 0 | 0 | 0 |
| Tom Vaughn | ||||||
| Vice President | 1.00 | X | X | 0 | 0 | 0 |
| Lois Coggon | ||||||
| Secretary/Treasurer | 1.00 | X | X | 0 | 0 | 0 |
| Dr KS Sumra | ||||||
| Director/Medical Staff Rep | 1.00 | X | 0 | 0 | 0 | |
| Dale O'Hara | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Ken Schwandt | ||||||
| Director | 1.00 | X | 19250 | 0 | 0 | |
| Dean Steinwand | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Loretta Bernhoft | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Tom O'Toole | ||||||
| Director | 1.00 | X | 0 | 0 | 0 | |
| Everett Butler | ||||||
| CEO | 40.00 | X | 73593 | 0 | 0 | |
| Tanya Sharp | ||||||
| CFO | 40.00 | X | 61865 | 0 | 11838 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 154708 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 11838 | TotalOtherCompensation |
| Number Individuals GT100 K | 0 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 0 | TotalCompGT150K |
| Compensation From Other Sources | 1 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (3 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| Park River Clinic | |||||
| PO BOX 380 | Cavalier | ND | 58220 | Physician Services | 569390 |
| DMS | |||||
| PO Box 8070 | Fargo | ND | 58109 | Mobile imaging services | 342218 |
| Altru Health System | |||||
| PO BOX 1370 | Grand Forks | ND | 58208 | PT & OT Therapy Services | 205225 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 3 | NumberOfContractorsGT100K |
| All Other Contributions | 187440 | AllOtherContributions |
| Total Contributions | 187440 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (3 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| Patient service revenu | 622110 | 11407129 | 11407129 |
| Supporting revenue | 900099 | 163855 | 163855 |
| Auxiliary revenue | 900099 | 5007 | 5007 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 11575991 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 3679 | TotalRevenueColumn |
| Exclusion | $3,679 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 1180 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 0 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 1180 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 1180 | TotalRevenueColumn |
| Exclusion | $1,180 | ExclusionAmount |
Other Revenue Misc OtherRevenueMisc
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Finance Charge Income | Description |
| Business Code | 900099 | BusinessCode |
| Total Revenue Column | 17711 | TotalRevenueColumn |
| Related Or Exempt Function Income | 17711 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Other Revenue | 17711 | TotalOtherRevenue |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 11786001 | TotalRevenueColumn |
| Related Or Exempt Function Income | 11593702 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $4,859 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | X | InfoInScheduleOPartIX |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 166545 | Total |
| Program Services | 19250 | ProgramServices |
| Management And General | 147295 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4308547 | Total |
| Program Services | 3549083 | ProgramServices |
| Management And General | 743585 | ManagementAndGeneral |
| Fundraising | 15879 | Fundraising |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 116420 | Total |
| Program Services | 94155 | ProgramServices |
| Management And General | 21757 | ManagementAndGeneral |
| Fundraising | 508 | Fundraising |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 647590 | Total |
| Program Services | 546402 | ProgramServices |
| Management And General | 101085 | ManagementAndGeneral |
| Fundraising | 103 | Fundraising |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 299733 | Total |
| Program Services | 243375 | ProgramServices |
| Management And General | 55281 | ManagementAndGeneral |
| Fundraising | 1077 | Fundraising |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3213 | Total |
| Management And General | 3213 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 35429 | Total |
| Management And General | 35429 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2236727 | Total |
| Program Services | 2077144 | ProgramServices |
| Management And General | 159583 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 29408 | Total |
| Program Services | 29408 | ProgramServices |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 142307 | Total |
| Program Services | 58381 | ProgramServices |
| Management And General | 83926 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 174602 | Total |
| Management And General | 174602 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 228695 | Total |
| Program Services | 228695 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 35574 | Total |
| Program Services | 30069 | ProgramServices |
| Management And General | 5505 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 110238 | Total |
| Program Services | 108015 | ProgramServices |
| Management And General | 2223 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 44140 | Total |
| Program Services | 44140 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 580315 | Total |
| Program Services | 580315 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 87627 | Total |
| Program Services | 87627 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Medical Supplies | 1494842 | 1494842 | |
| Bad Debt Expense | 467070 | 467070 | |
| Dues/Subscriptions/Lice | 27064 | 14252 | 12812 |
| Credit/Collection Expen | 22767 | 22767 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 30335 | Total |
| Program Services | 24700 | ProgramServices |
| Management And General | 5635 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 11289188 | Total |
| Program Services | 9719690 | ProgramServices |
| Management And General | 1551931 | ManagementAndGeneral |
| Fundraising | 17567 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 206334 | BOY |
| EOY | 355233 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1406227 | BOY |
| EOY | 1629105 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 73830 | BOY |
| EOY | 69550 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 23922 | BOY |
| EOY | 15224 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 12957885 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 10317409 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2861571 | BOY |
| EOY | 2640476 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 115415 | BOY |
| EOY | 165931 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 80980 | BOY |
| EOY | 386843 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4768279 | BOY |
| EOY | 5262362 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1135592 | BOY |
| EOY | 1296317 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 50511 | EOY |
Escrow Account Liability EscrowAccountLiability
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13980 | BOY |
| EOY | 14143 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 641693 | BOY |
| EOY | 426662 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1791265 | BOY |
| EOY | 1787633 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2977014 | BOY |
| EOY | 3474729 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2977014 | BOY |
| EOY | 3474729 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4768279 | BOY |
| EOY | 5262362 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 496813 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 902 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
FS Audited Basis FSAuditedBasis
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Statement Separate | X | FinancialStatementSeparate |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | AuditCommittee |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 1 | AgentTrusteeEtc |
| Beginning Balance | 7561 | BeginningBalance |
| Additions During Year | 5007 | AdditionsDuringYear |
| Distributions During Year | 5909 | DistributionsDuringYear |
| Ending Balance | 6659 | EndingBalance |
| Included On FS | 1 | IncludedOnFS |
| Explanation In Part XIII | X | ExplanationInPartXIII |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 160304 | OtherCostOrOtherBasis |
| Book Value | 160304 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5699033 | OtherCostOrOtherBasis |
| Depreciation | 4600575 | Depreciation |
| Book Value | 1098458 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 6545935 | OtherCostOrOtherBasis |
| Depreciation | 5424055 | Depreciation |
| Book Value | 1121880 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 552613 | OtherCostOrOtherBasis |
| Depreciation | 292779 | Depreciation |
| Book Value | 259834 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 2640476 | TotalOfBookValueLandBuildings |
Other Assets OtherAssets (2 entries)
| DescriptionDescription | Book ValueBookValue |
|---|---|
| Resident trust funds | 14143 |
| Estimated third party payor settlements | 372700 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | 386843 | TotalBookValueOtherAssets |
| Footnote In Part XIII | X | FootnoteInPartXIII |
| Tot Revenue Etc Audited Fincl Stmt | 11313924 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | -467070 | OtherRevenues |
| Revenue Not Rptd F990 | -467070 | RevenueNotRptdF990 |
| Revenue Subtotal | 11780994 | RevenueSubtotal |
| Other Revenues Not Included | 5007 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 5007 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 11786001 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 10816209 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 10816209 | ExpensesSubtotal |
| Other Expenses Not Included | 472979 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 472979 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 11289188 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIII Form990ScheduleDPartXIII (6 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| 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, 2012 and 2011 totaled $14,143 and $13,980. | |
| 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. | Description of Uncertain Tax Positions Under FIN 48: |
| Bad Debts -467,070. | Part XI, Line 2d - Other Adjustments: | |
| Auxiliary revenues 5,007. | Part XI, Line 4b - Other Adjustments: | |
| Auxiliary expenses 5,909. Bad Debts 467,070. | Part XII, Line 4b - Other Adjustments: |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent100 | X | Pcent100 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent200 D | X | Pcent200D |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 87000 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 87000 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00800 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1652983 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1637981 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 15002 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00140 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1739983 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1637981 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 102002 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00940 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 792186 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 613658 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 178528 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01650 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 792186 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 613658 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 178528 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01650 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2532169 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2251639 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 280530 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02590 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $467,070 | BadDebtExpenseAmount |
| Amount Attributable To | 37366 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 3267456 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 3287209 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -19753 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital | BusinessNameLine1 |
Address Address
| 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 | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 100.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 200.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Other Factors | X | OtherFactors |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Notify Upon Admission | X | NotifyUponAdmission |
| Notified All Patients | X | NotifiedAllPatients |
| Documented Determination | X | DocumentedDetermination |
| Other Actions Taken | X | OtherActionsTaken |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Lowest Negotiated Rates | X | LowestNegotiatedRates |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 3 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (3 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| 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 |
Form990 Schedule H Part VI Form990ScheduleHPartVI (15 entries)
| ExplanationExplanation | IdentifierIdentifier |
|---|---|
| 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 for subsidized health services on line 7g was determined using the Medicare cost report. | |
| Part I, L7 Col(f): For the purpose of calculating the percentage on Part I, line 7f, $467,070 of bad debt expense was backed out of total operating expenses. | |
| Part II: 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 at cost 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.Financial Statement Footnote for Bad Debt Expense:The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients, residents, and third-party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients and residents due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision.Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year. | |
| 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: When an outstanding balance remains on a patient's account, steps are followed to ensure proper collection of the remaining balance. A letter is sent to the patient when insurance is processed or immediately if the patient is self pay. The letter gives the patient options of: paying the bill in full, requesting a payment agreement or requesting a charity care application. These statements are sent to the patient monthly. Another letter is sent at 60 days and 90 days. The 90 day letter also states if a signed payment agreement, charity care application or payment in full is not received the Hospital will refer the account to a collection agency. After 120 days, the remaining gross balance is sent to a collection agency to begin the collection process. The steps above are followed prior to referring to the collection agency. 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 V, Section B, Line 12h: 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. | Pembina County Memorial Hospital |
| 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 during 2011. The implementation strategy for the Community Health Needs Assessment was completed during 2012. | |
| 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. For the year 2012, our medical facility treated 9,859 patients, 48.2% of whom were age 70 and older. | |
| 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 | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Everett Butler | NamePerson |
| Title | CEO | Title |
| Base Compensation Filing Org | 73593 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 0 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 0 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 0 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 0 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 0 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 0 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 73593 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 0 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Supplemental Information | Identifier |
| Return Reference | Part III | ReturnReference |
| Explanation | Part II: 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. | Explanation |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (2 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| Rita Vaughn | |||
| Family member of director Tom Vaughn | 19250 | Compensation | 0 |
| Dr K S Sumra | |||
| Owner of Park River Clinic | 569390 | Dr. Sumra owns Park River Clinic. Park River Clinic provides independent contractor physician services to the Organization. | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (11 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| 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 | The CEO of the organization is employed by Christian Unity Hospital Corporation, DBA Unity Medical Center, an unrelated party. The amount of compensation for 2012 was $73,593, 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. This took place at the August 2013 board meeting. | |
| 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 2012. | |
| 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 IX, line 11g | Medical Professional Fees: Program service expenses 1,350,784. Management and general expenses 2,521. Fundraising expenses 0. Total expenses 1,353,305. Maintenance and Repair fees: Program service expenses 74,380. Management and general expenses 1,311. Fundraising expenses 0. Total expenses 75,691. Service and Service contract fees: Program service expenses 240,850. Management and general expenses 39,745. Fundraising expenses 0. Total expenses 280,595. Purchased Services: Program service expenses 347,706. Management and general expenses 20,798. Fundraising expenses 0. Total expenses 368,504. Non Medical Professional Fees: Program service expenses 17,533. Management and general expenses 95,208. Fundraising expenses 0. Total expenses 112,741. Rental/Lease Equipment Fees: Program service expenses 45,891. Management and general expenses 0. Fundraising expenses 0. Total expenses 45,891. | Other Fees |
| Form 990, Part XI, line 9: | Change in Auxiliary Assets 902. | Changes in Net Assets or Fund Balances: |
| Form 990, Part VII, Section A, and Form 990, Schedule L, Part IV | 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. | Ken Schwandt's compensation |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pembina County Memorial Hospital Foundation | BusinessNameLine1 |
Address US AddressUS
| 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 | PrimaryActivities |
| Legal Domicile State | ND | LegalDomicileState |
| Exempt Code Section | 501(c)(3) | ExemptCodeSection |
| Public Charity Status | Line 11a, I | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| Controlled Org | 0 | ControlledOrg |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Dividends Related Organization | 0 | DividendsRelatedOrganization |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Comments