HAZEN MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- HAZEN MEMORIAL HOSPITAL ASSOCIATION (EIN 45-0308379)
- Tax period
- 2009-07-01 to 2010-06-30
- Filed
- 2011-04-05
- IRS object ID
- 201110959349300111
- Schema version
- 2009v1.7
- 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 G
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-04-05T13:42:41-05:00 | Timestamp |
| Tax Period End Date | 2010-06-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
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 | 2009-07-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450308379 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Association | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | HAZE | NameControl |
| Phone | 7017482225 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Darrold Bertsch | Name |
| Title | Administrator | Title |
| Phone | 7017482225 | Phone |
| Date Signed | 2011-03-31 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LISA CHAFFEE CPA | Name |
| Phone | 7012398500 | Phone |
| Date Prepared | 2011-03-31 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Sakakawea Medical Center Senior Sui | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Darrold Bertsch | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 10329546 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.sakmedcenter.org | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1943 | YearFormation |
| State Legal Domicile | ND | StateLegalDomicile |
| Activity Or Mission Description | Operation of a hospital, clinic, and an elderly care facility. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 9 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 9 | NbrIndependentVotingMembers |
| Total Nbr Employees | 167 | TotalNbrEmployees |
| Total Nbr Volunteers | 65 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 149759 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 187816 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 9059696 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 10090479 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 57357 | InvestmentIncomePriorYear |
| Investment Income Current Year | 21575 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 20286 | OtherRevenuePriorYear |
| Other Revenue Current Year | 22487 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 9287098 | TotalRevenuePriorYear |
| Total Revenue Current Year | 10322357 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 2700 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 2000 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 4769695 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 5431615 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 4375211 | OtherExpensePriorYear |
| Other Expenses Current Year | 4525423 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 9147606 | TotalExpensesPriorYear |
| Total Expenses Current Year | 9959038 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 139492 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 363319 | RevenuesLessExpensesCY |
| Total Assets BOY | 5942397 | TotalAssetsBOY |
| Total Assets EOY | 6685642 | TotalAssetsEOY |
| Total Liabilities BOY | 2302886 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 2650878 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 3639511 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 4034764 | NetAssetsOrFundBalancesEOY |
| Mission Description | Provide high quality care that is measured and continuously improved. Provide individualized care that exceeds expectations of those we serve. Strengthen partnerships with providers to enhance coordination of care and improve system performance. Be a steward of resources. Commit to service excellence. Be a vital contributor to our area communities. Recognize the value of each employee and provide opportunities for personal growth and development that complement the needs of the organization. | MissionDescription |
| Significant New Program Services | 1 | SignificantNewProgramServices |
| Significant Change | 1 | SignificantChange |
| Expense | 6229439 | Expense |
| Grants | 2000 | Grants |
| Revenue | 8045563 | Revenue |
| Description | Sakakawea Medical Center (SMC) is a 25 bed critical care access hospital providing services in the following areas - acute care, surgery, intermediate and skilled swing bed, emergency room with trauma level IV certification, home health, and hospice. Services provided by the ancillary departments include physical therapy, occupational therapy, radiology, digital mammography, bone density, ultrasound, CT, nuclear med, MRI, laboratory, respiratory therapy, cardiac rehab, EKG, EEG, sleep studies, and thalium stress tests. SMC served 17,365 patients this reporting period.Based on charges foregone Sakakawea Medical Center provided $51,767 in charity care. Sakakawea Medical Center has a charity care policy which provides an 80% discount to patients who qualify financially. Also available to all self pay patients, regardless of financial status, is a 30% discount policy for timely payments. SMC is a participatingProvider for Medicare, Medicaid, Blue Cross Blue Shield and other insurances.Sakakawea Medical Center reaches out to the communities in the service area through programs such as senior day out, grief support groups, smoking cessation classes, occupational health, women's health classes, a Christmas giving tree project, and health career presentations to high schools. Wellness screenings are provided to area schools and businesses. SMC provides community education programs on requested topics free of charge. It is important for Sakakawea Medical Center to serve our communities by providing all of their health care needs. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 741820 | Expense |
| Revenue | 912467 | Revenue |
| Description | Senior suites is a basic care facility that was completed in April 1997, it is adjacent to Sakakawea Medical Center. Senior suites can accommodate 34 residents with single or double rooms. It features a licensed beauty shop, activity room, spacious commons areas and an enclosed nurse's station. The rooms are set up like suites, hence the name "senior suites." the facility is available to those in the senior population that requires a minimal amount of supervision, but do not require 24 hour services. The residents are provided with assistance for daily living and medication administration. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 1692508 | Expense |
| Revenue | 1132449 | Revenue |
| Description | To insure the need for quality health care is met in SMC's service area, Sakakawea Medical Center began managing two rural health clinics in July 2007. One clinic is located in Beulah and one in Hazen. This provides primary health care for our patients and also space is provided in the clinics for visiting specialists. This saves the patients from having to drive up to 70 miles to receive specialty health care. The clinics are staffed with physicians and mid-level providers. A sliding fee scale charity care program is available to patients who qualify financially. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 8663767 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| 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 | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| 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 | 1 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | 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 | 1 | DisregardedEntity |
| Related Entity | 0 | 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 | 14 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 167 | 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 |
| Nbr Voting Governing Body Members | 9 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 9 | 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 | 0 | 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 | 0 | 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 | Renae Snyder | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7017482225 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (14 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Christie Obenauer | |||||||
| President | 2.00 | X | X | 0 | 0 | 0 | |
| Jan Rudolf | |||||||
| Vice President | 1.50 | X | X | 0 | 0 | 0 | |
| Beverly Huber | |||||||
| Secretary/Treasurer | 1.50 | X | X | 0 | 0 | 0 | |
| Lori Kuschel | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Rick Miller | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Lynn Oelke | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Myria Perry | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Sienna Sailer | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Fred Stern | |||||||
| Director | 1.50 | X | 0 | 0 | 0 | ||
| Darrold Bertsch | |||||||
| CEO | 40.00 | X | 42052 | 0 | 3174 | ||
| Renae Snyder | |||||||
| CFO | 40.00 | X | 52166 | 0 | 2752 | ||
| Jim Marshall | |||||||
| Interim Admin(to 7-24-09) | 40.00 | X | 76350 | 0 | 0 | ||
| Wayne Martin | |||||||
| ER Physician | 40.00 | 182057 | 0 | 8995 | X | ||
| Melvin Yarlott | |||||||
| Surgeon | 24.00 | 125126 | 0 | 10020 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 477751 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 24941 | TotalOtherCompensation |
| Number Individuals GT100 K | 2 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 1 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (4 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| St Alexius Medical Center | |||||
| PO Box 5510 | Bismarck | ND | 58506 | Management Services | 510442 |
| Mondak Imaging | |||||
| 11 South 7th St Suite 241 | Miles City | MT | 59301 | MRI Services | 210936 |
| DMS Imaging | |||||
| PO Box 86 | Minneapolis | MN | 55486 | Medical Imaging | 178532 |
| Cypress Health Systems | |||||
| 791 Eastside Road | Deer Lodge | MT | 59722 | Management Services | 146148 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 4 | NumberOfContractorsGT100K |
| All Other Contributions | 187816 | AllOtherContributions |
| Total Contributions | 187816 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (4 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| Patient and Resident S | 621400 | 9930060 | 9930060 |
| Other Program Revenue | 623000 | 85582 | 85582 |
| Education | 623000 | 57859 | 57859 |
| Cafeteria | 623000 | 16978 | 16978 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 10090479 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 20700 | TotalRevenueColumn |
| Exclusion | $20,700 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 12371 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 12371 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 12371 | TotalRevenueColumn |
| Exclusion | $12,371 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 875 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 875 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 875 | TotalRevenueColumn |
| Exclusion | $875 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 17305 | GrossIncomeFundraisingEvents |
| Fundraising Direct Expenses | 7189 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 10116 | TotalRevenueColumn |
| Exclusion | $10,116 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 10322357 | TotalRevenueColumn |
| Related Or Exempt Function Income | 10090479 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $44,062 | ExclusionAmount |
Grants To Domestic Individuals GrantsToDomesticIndividuals
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2000 | Total |
| Program Services | 2000 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 173652 | Total |
| Management And General | 173652 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4544625 | Total |
| Program Services | 4262737 | ProgramServices |
| Management And General | 281888 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 117981 | Total |
| Program Services | 21194 | ProgramServices |
| Management And General | 96787 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 254911 | Total |
| Program Services | 63800 | ProgramServices |
| Management And General | 191111 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 340446 | Total |
| Program Services | 307645 | ProgramServices |
| Management And General | 32801 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15979 | Total |
| Management And General | 15979 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 560 | Total |
| Management And General | 560 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 29702 | Total |
| Management And General | 29702 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1536023 | Total |
| Program Services | 1442517 | ProgramServices |
| Management And General | 93506 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 20725 | Total |
| Program Services | 206 | ProgramServices |
| Management And General | 20519 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1165234 | Total |
| Program Services | 1023684 | ProgramServices |
| Management And General | 141550 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 347767 | Total |
| Program Services | 347767 | ProgramServices |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 22364 | Total |
| Program Services | 16761 | ProgramServices |
| Management And General | 5603 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 66048 | Total |
| Program Services | 18698 | ProgramServices |
| Management And General | 47350 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 513603 | Total |
| Program Services | 513603 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 107616 | Total |
| Program Services | 11281 | ProgramServices |
| Management And General | 96335 | ManagementAndGeneral |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Bad Debt Expense | 532809 | 532809 | |
| Miscellaneous | 60847 | 37723 | 23124 |
| Dues & Subscriptions | 55779 | 41573 | 14206 |
| Collections Expense | 29379 | 29379 | |
| Auxiliary Expenses | 19769 | 19769 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1219 | Total |
| Management And General | 1219 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 9959038 | Total |
| Program Services | 8663767 | ProgramServices |
| Management And General | 1295271 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2086 | BOY |
| EOY | 4410 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1069946 | BOY |
| EOY | 1582348 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1715067 | BOY |
| EOY | 1610880 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 221780 | BOY |
| EOY | 268761 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32894 | BOY |
| EOY | 35336 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 8360223 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 6034607 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2329986 | BOY |
| EOY | 2325616 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 390632 | EOY |
Investments Program Related InvestmentsProgramRelated
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 193751 | BOY |
| EOY | 231297 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 376887 | BOY |
| EOY | 236362 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5942397 | BOY |
| EOY | 6685642 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 731405 | BOY |
| EOY | 1091577 | EOY |
Deferred Revenue DeferredRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 41416 | BOY |
Loans From Officers Directors LoansFromOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1497625 | BOY |
| EOY | 1481162 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 32440 | BOY |
| EOY | 78139 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2302886 | BOY |
| EOY | 2650878 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3395760 | BOY |
| EOY | 3753467 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 193751 | BOY |
| EOY | 231297 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 50000 | BOY |
| EOY | 50000 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3639511 | BOY |
| EOY | 4034764 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5942397 | BOY |
| EOY | 6685642 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 0 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| 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
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 23092 | OtherCostOrOtherBasis |
| Book Value | 23092 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 5255253 | OtherCostOrOtherBasis |
| Depreciation | 4025783 | Depreciation |
| Book Value | 1229470 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2968432 | OtherCostOrOtherBasis |
| Depreciation | 1966155 | Depreciation |
| Book Value | 1002277 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 113446 | OtherCostOrOtherBasis |
| Depreciation | 42669 | Depreciation |
| Book Value | 70777 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 2325616 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | Capital Lease Obligations | Description |
| Amount | $78,139 | Amount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 78139 | TotalOfAmounts |
| Total Revenue | 10322357 | TotalRevenue |
| Total Expenses | 9959038 | TotalExpenses |
| Excess Or Deficit For Year | 363319 | ExcessOrDeficitForYear |
| Prior Period Adjustments | -12107 | PriorPeriodAdjustments |
| Other | $44,041 | OtherAmount |
| Total Adjustments | 31934 | TotalAdjustments |
| Excess Or Deficit Per FS | 395253 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 10232257 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 10232257 | RevenueSubtotal |
| Other Revenues Not Included | 90100 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 90100 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 10322357 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 9937269 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 9937269 | ExpensesSubtotal |
| Other Expenses Not Included | 21769 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 21769 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 9959038 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (4 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | The Medical Center 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 Medical Center undergoes an annual analysis of its various tax positions, assessing the likelihood of these positions being upheld upon examination with relevant tax authorities, as defined by the accounting principles generally accepted in the United States of America. The Medical Center believes that it is compliant with all IRS tax regulations and as of June 30, 2010 has not recorded a tax liability for a tax uncertainty. The Medical Center will recognize future interest and penalties related to unrecognized tax benefits in income tax expense if incurred. Under normal circumstances, the Medical Center is no longer subject to Federal and state tax examinations by tax authorities for years before 2007. |
| Part XI, Line 8 - Other Adjustments: | Change in interest in Net assets of Sakakawea Medical Center Foundation: 37546. Change in Net assets of Sakakawea Medical Center Auxiliary: 6495. | |
| Part XII, Line 4b - Other Adjustments: | Auxiliary Revenue: 22463. Special Events Expense Recorded in Revenue on Form 990: -7189. Contributions Recorded in Net Assets for Financial Statements: 10000. Transfer from Related Organization Recorded in Net Assets for Financials: 64826. | |
| Part XIII, Line 4b - Other Adjustments: | Auxiliary Expenses: 28958. Special Events Expense Recorded in Revenue on Form 990: -7189. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | Turkey Dinner | NameOfEvent1 |
| Gross Receipts Event1 | 14762 | GrossReceiptsEvent1 |
| Gross Revenue Event1 | 14762 | GrossRevenueEvent1 |
| Other Direct Expenses Event1 | 6815 | OtherDirectExpensesEvent1 |
| Total Number Of Other Events | 3 | TotalNumberOfOtherEvents |
| Gross Receipts Other Events | 2543 | GrossReceiptsOtherEvents |
| Gross Revenue Other Events | 2543 | GrossRevenueOtherEvents |
| Other Direct Expenses Other Events | 374 | OtherDirectExpensesOtherEvents |
| Gross Receipts Total | 17305 | GrossReceiptsTotal |
| Gross Revenue Total Events | 17305 | GrossRevenueTotalEvents |
| Other Direct Expenses Total Events | 7189 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 7189 | DirectExpenseSummaryEvents |
| Net Income Summary | 10116 | NetIncomeSummary |
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 |
| Pcent150 | X | Pcent150 |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCare |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 0 | ExpensesExceededBudget |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 51768 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 51768 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00550 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 357275 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 266262 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 91013 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00970 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 409043 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 266262 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 142781 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01520 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 12925 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 12925 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00140 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1942814 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1090357 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 852457 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.09040 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1955739 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1090357 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 865382 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.09180 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2364782 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1356619 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1008163 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.10700 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $343,334 | BadDebtExpenseAmount |
| Amount Attributable To | 2000 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 3055087 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 3119357 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -64270 | 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 |
Form990 Schedule H Part V Form990ScheduleHPartV (4 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours | OtherOther | Er OtherErOther |
|---|---|---|---|---|---|---|---|
| Sakakawea Medical Center (dba) | |||||||
| 510 8th AVE NE | Hazen | ND | 58545 | X | X | Basic Care Facility | |
| Sakakawea Hazen Clinic | |||||||
| 813 7th St NE | Hazen | ND | 58545 | Clinic | X | ||
| Sakakawea Beulah Clinic | |||||||
| 1101 3rd Ave NW | Beulah | ND | 58523 | Clinic | X | ||
| Senior Suites at Sakakawea | |||||||
| 813 7th St NE | Hazen | ND | 58545 | Senior Living | X | ||
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Income Based Criteria | Part I, Line 3c: If a patient qualifies for charity care based on family income, $5.00 of their bill is discounted for every $1 paid on their account. There is no policy for discounted care but uninsured patients receive a 30% discount for prompt payments, regardless of family income. In July 2010, the charity care policy was amended. Under the new policy if a patient falls within FPG guidelines (sliding scale) a discount will be applied according to a schedule, before requiring a payment. | IncomeBasedCriteria |
| Costing Method Used | Part I, Line 7: The cost to charge ratio was taken from the current year's cost report Worksheet S-10. This worksheet includes all patient segments. | CostingMethodUsed |
| Subsidized Health Services Expln | Part I, Line 7g: Hazen Memorial Hospital Association operates two rural clinics which operate at a loss. If these clinics did not offer their services in each of these communities the service would be limited in the community. | SubsidizedHealthServicesExpln |
| Percent Of Total Expense Expln | Part I, Line 7f: Financial statement footnote describing bad debt expense: The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects managements 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.For the purposes of calculating the percentage on Part 1, Line F, $343,334 was backed out of total operating expenses. | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: Payments and discounts are posted to patient bills. Any remaining balances are billed to the patient through monthly statements. If no payments are received from the patient at the end of the fifth month, the account is turned over to a collection agency and the balance on the account is written off as a bad debt. The bad debt expense is shown on the monthly financial statements.There is most likely some patients in bad debt who would qualify for charity care, but they have not completed the application and remitted the required payment. SMC requires a payment to receive the benefit of X5 discount for charity care. Using the last three fiscal years' ratios of charity care to overall revenue, the estimated amount would be .0058 percent of bad debt, or approximately $2,000. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: 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 CMS. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: If a patient has applied for charity care previously, an application is sent with the monthly statement. The application requesting financial information was required each time a new bill was incurred. The new policy effective 7/1/10 requires a new application only every six months. | DebtCollectionPolicy |
| Needs Assessment | Part VI, Line 2: Sakakawea Medical Center consults with local physicians to see what the community healthcare needs are. The SMC staff participates in local and regional organizations and activities including Chamber of Commerce and economic development boards. The CEO routinely attends city council and county commission meetings to solicit input and engage in dialogue relating to healthcare needs and services. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: Charity care information is sent with the monthly statements to all uninsured patients as well as patients that are not making adequate monthly payments. Approximately 100 notices are sent out per month with the statements. Inpatients and surgical patients are informed at time of admission about charity care. A social worker visits with all self pay inpatients to inform them about the charity care, Medicaid (state program), and self pay discount policies. Brochures are being printed that describe our charity care and discount policies. The brochures will be placed in waiting rooms, ER, the clinics and admitting offices. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: Hazen Memorial Hospital Association serves the communities in Mercer County and the surrounding area, including the towns of Hazen, Beulah, Stanton, Zap, Golden Valley, Center and Pick City. Sakakawea Medical Center, located in Hazen, is the only hospital in the county. The nearest hospital is located more than 60 away. Attached to the hospital is Senior Suites, a basic care facility. The Association manages two rural health clinics, one in Hazen and one in Beulah. The combined total population of the county is approximately 8,214. The average annual wage in Mercer County for 2009 was $52,384. The current unemployment rate is 3.7%. Sakakawea Medical Center's payer mix for this fiscal year included 10% uninsured patients and 4% Medicaid patients. All patients presenting to the facility are cared for regardless of their ability to pay. | CommunityInformation |
| Other Information | Part VI, Line 6: Sakakawea Medical Center provides a variety of health and wellness services to our service area. The organization subsidizes primary care services provided at the Sakakawea Beulah Clinic and the Sakakawea Hazen Clinic, insuring that primary care is available in the local communities. SMC also subsidizes home health services to insure those residents who are homebound have the health care they need. The emergency room is staffed 24 hours a day and is available to all regardless of ability to pay. The board of directors is comprised of county-wide volunteers; two are from Hazen, five from Beulah, one from Pick City and one from Stanton. Medical privileges are extended to all physicians in the county. Surplus funds are invested back into the facility through equipment upgrades. Recent investments include digital mammography, new endoscopy equipment for the OR, electric boilers replaced fuel oil, a 16 slice CT replaced a 2 slice CT, a new chemistry analyzer, OR table, bladder scanner, upgraded telemetry system, a sleep study program, and new flooring and paint throughout the facility. More continuing education is being offered to the staff by means of webinars and workshops. An employee assistance program is available for staff and family members which provides free confidential assessments, counseling, or referral services by trained professionals. | OtherInformation |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| 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
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Wayne Martin | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Base Compensation Filing Org | 182057 | 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 | 9297 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 191354 | 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 | Compensation for Jim Marshall, Interim Administrator thru 7-24-09, is received from Cypress Health Systems, an unrelated management company. Cypress Health Systems 791 Eastside Road Deer Lodge MT 59722 Jim devoted 40 hours a week to management of Hazen Memorial Hospital Association. Compensation Received from Management Company: Jim Marshall Compensation: $76,350 | Explanation |
Schedule L IRS990ScheduleL
Loan Table LoanTable (4 entries)
| Purpose Of LoanPurposeOfLoan | Loan To OrganizationLoanToOrganization | Original PrincipalOriginalPrincipalAmount | Balance DueBalanceDue | DefaultDefault | Approved By BoardApprovedByBoard | Written AgreementWrittenAgreement |
|---|---|---|---|---|---|---|
| Union State Bank | ||||||
| Bond Refinance | X | $663,689 | 565311 | 0 | 1 | 1 |
| Union State Bank | ||||||
| Software | X | $350,000 | 213452 | 0 | 1 | 1 |
| Union State Bank | ||||||
| New Boilers | X | $224,235 | 224235 | 0 | 1 | 1 |
| Union State Bank | ||||||
| Refinance Equipment | X | $506,000 | 478164 | 0 | 1 | 1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Balance Due | 1481162 | TotalBalanceDue |
Form990 Schedule L Part IV Form990ScheduleLPartIV
Name Of Interested Person NameOfInterestedPerson
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | Jim Marshall | NamePerson |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship | Father-in-law of Jim Marshall owns 50% of Cypress Health Systems | Relationship |
| Amount Of Transaction | 146148 | AmountOfTransaction |
| Description Of Transaction | Management Services | DescriptionOfTransaction |
| Sharing Of Revenues | 0 | SharingOfRevenues |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (10 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Form 990, Part III, line 2 | New Program Services | Sleep studies. |
| Form 990, Part III, line 3 | Changes in Program Services | Replace mammography machine with digital mammography. |
| Form 990, Part VI, Section A, line 3 | The Hospital had a management agreement with Cypress Health Systems, LLC (Manager). The Manager shall have authority and responsibility to conduct, supervise and effectively manage the day-to-day operations of the hospital. The Board of Directors of the hospital shall retain all authority placed in them by law and the hospital's bylaws. This agreement was mutually terminated 7-24-09. | |
| Form 990, Part VI, Section A, line 6 | Any person, firm, association, or corporation interested in the activities of this organization may become a member thereof, provided that he has first contributed at least $10.00 to the association at some time, and further provided that he has paid the annual membership dues hereinafter specified. It is also agreed in those cases in which a contribution equal to or exceeding $20.00 was given in the name of one individual, if that individual was married at the time of the contribution, both husband and wife shall be considered eligible for membership in the association subject to payment of the membership fee outlined in article I, section 3. | |
| Form 990, Part VI, Section A, line 7a | The members elect the Board of Directors on an annual basis. | |
| Form 990, Part VI, Section A, line 8b | All items discussed at committee meetings are brought to the full board for recommendations for board action. The organization does not have any committees that have the authority to act on behalf of the board. | |
| Form 990, Part VI, Section B, line 11 | Upon receipt of the draft form 990, a copy will be forwarded to the board members for their review and comment. | |
| Form 990, Part VI, Section B, line 12c | The board of directors is covered by the conflict of interest policy. Only one conflict has been disclosed this fiscal year by a member of the board of directors. The director who has acknowledged the conflict of interest is excused from the board meeting whenever there is discussion about the relevant issue. | |
| Form 990, Part VI, Section B, line 15a | For purposes of determining both the CEO and the CFO's compensation packages at Sakakawea Medical Center, a variety of resources are used. The organization takes into consideration what is appropriate compensation for those respective positions, based on their market. The organization uses salary surveys from the North Dakota hospital association. They take into consideration what recruiting firms recommend to the organization for typical compensation for those positions. The board of directors evaluates the CEO once per year and uses the above information for determining compensation. The CFO is evaluated by the CEO yearly and the compensation is based on the above information. | |
| Form 990, Part VI, Section C, line 19 | Available if specifically requested. |
Schedule R IRS990ScheduleR
Form990 Schedule R Part I Form990ScheduleRPartI
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Hazen Memorial Hospital Auxiliary | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 510 8th Avenue NE | AddressLine1 |
| City | Hazen | City |
| State | ND | State |
| ZIP Code | 58545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450308379 | EIN |
| Primary Activities | Fundraising for Hospital | PrimaryActivities |
| Legal Domicile State | ND | LegalDomicileState |
| Total Income | 22463 | TotalIncome |
| EOY Assets | 5611 | EOYAssets |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
Comments