2011-11-08T14:04:22-06:00 2010-12-31 EIDE BAILLY LLP 4310 17TH AVE S PO BOX 2545 FARGO ND 581082545 990 2010-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN ST E CAVALIER ND 58220 EVERETT BUTLER 7012658461 2011-10-27 1 LISA CHAFFEE CPA 7012398500 2011-10-20 2010 2016-03-07 17:11:31Z EVERETT BUTLER 301 MOUNTAIN ST E CAVALIER ND 58220 10493094 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND PROVISION OF ACUTE CARE, LONG-TERM, AND ELDERLY CONGREGATE HOUSING FOR THE COMMUNITY 9 6 204 73 0 0 28791 253128 10323415 10224826 3525 3500 21869 11640 10377600 10493094 0 0 0 0 5999508 5785788 0 0 28424 4583686 4496193 10583194 10281981 -205594 211113 4548711 4452328 2006749 1700929 2541962 2751399 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 8839770 10236016 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 25 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 COMMNUITY. CHARITY CARE FOR 2010 WAS $54,242. CHARITY CARE IS THE AMOUNT OF CHARGES FOREGONE BASED ON ESTABLISHED RATES. 8839770 1 1 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 0 0 0 1 27 0 1 204 1 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X EVERETT BUTLER CEO 7012658461 301 MOUNTAIN ST E CAVALIER ND 58220 GAIL MCMARTIN 1.00 X X 0 0 0 TOM FORD 1.00 X X 0 0 0 LOIS COGGON 1.00 X X 0 0 0 DALE O'HARA 1.00 X 0 0 0 TOM VAUGHN 1.00 X 0 0 0 KEN SCHWANDT 1.00 X 12000 0 0 H KHOUDOUD MD THROUGH 810 40.00 X X 222992 0 12817 DEAN STEINWAND 1.00 X 0 0 0 LORETTA BERNHOFT 1.00 X 0 0 0 DR KS SUMRA 1.00 X 0 0 0 EVERETT BUTLER 16.00 X 66136 0 0 TANYA SHARP 40.00 X 48624 0 7769 DR ELIAS DARIDO 40.00 X 320107 0 18028 669859 0 38614 2 0 1 1 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 PHYSICIAN SERVICES 455166 DMS PO BOX 8070 FARGO ND 58109 MOBILE IMAGING SERVICES 344807 ALTRU HEALTH SYSTEM PO BOX 1370 GRAND FORKS ND 58208 PT & OT THERAPY SERVICES 190781 3 127095 126033 253128 PATIENT SERVICE REVENU 900099 10094011 10094011 MISC. OTHER REVENUE 900099 124424 124424 AUXILIARY REVENUE 900099 6391 6391 10224826 3500 3500 450 450 450 450 FINANCE CHARGE INCOME 900099 11190 11190 11190 10493094 10236016 0 3950 370338 247809 122529 4381081 3647363 708197 25521 119651 99233 19889 529 608114 512138 95791 185 306604 251658 52757 2189 123 123 40528 40528 1732903 1598876 134027 26257 26257 1295516 1215570 79946 128871 128871 234375 234375 25956 18634 7322 15475 10513 4962 41579 41579 591115 591115 72200 72200 BAD DEBT EXPENSE 220839 220839 DUES/SUBSCRIPTIONS/LICE 32250 14114 18136 CREDIT/COLLECTION EXPEN 17910 17910 PROMOTIONS/ENTERTAINMEN 7640 7624 16 RECRUITMENT 5066 5066 7590 6897 693 10281981 8839770 1413787 28424 269555 113153 1234744 1481078 75078 74509 26651 33642 11813495 9155328 2851104 2658167 88579 77564 3000 14215 4548711 4452328 1325832 1312129 14215 680917 346585 0 28000 2006749 1700929 X 2541962 2751399 2541962 2751399 4548711 4452328 X 211113 -1676 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 7195 6391 4715 8871 1 160007 160007 5607134 4261798 1345336 5713434 4641816 1071618 332920 251714 81206 2658167 ESTIMATED 3RD PARTY PAYOR SETTLEMENTS 28000 28000 10493094 10281981 211113 -1676 -1676 209437 10486703 0 10486703 6391 6391 10493094 10277266 0 10277266 4715 4715 10281981 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, 2010 AND 2009 TOTALED $14,215 AND $11,783. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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 UNDERGOES AN ANNUAL ANALYSIS OF ITS VARIOUS TAX POSITIONS, ASSESSING THE LIKELIHOOD OF THESE POSITIONS BEING UPHELD WITH RELEVANT TAX AUTHORITIES, AS DEFINED BY THE ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA. THE ASSOCIATION BELIEVES THAT IS IT COMPLIANT WITH ALL IRS TAX REGULATIONS AND AS OF DECEMBER 31, 2010 HAS NOT RECORDED A TAX LIABILITY FOR A TAX UNCERTAINTY. THE ASSOCIATION WILL RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX LIABILITIES IN INCOME TAX EXPENSE IF INCURRED. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN AUXILIARY ASSETS -1,676. PART XII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY REVENUES 6,391. PART XIII, LINE 4B - OTHER ADJUSTMENTS: AUXILIARY EXPENSES 4,715. 1 1 X 1 X 1 X 0 1 1 0 0 41325 41325 0.00410 16222 16222 0.00160 57547 57547 0.00570 96 96 0.00000 96 96 57643 57643 0.00570 0 168248 15479 3339513 3290003 49510 X 0 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL

301 MOUNTAIN ST E CAVALIER ND 58220

X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 2 CLINICARE

301 MOUNTAIN ST E CAVALIER ND 58220

CLINIC SERVICES WEDGEWOOD MANOR

301 MOUNTAIN ST E CAVALIER ND 58220

LONG TERM CARE SERVICES PART I, LINE 3C: THE ORGANIZATION USES A SLIDING SCALE BASED ON FAMILY SIZE AND THE FEDERAL POVERTY INCOME GUIDELINES WHEN DETERMINING WHETHER AN INDIVIDUAL IS ELIGIBLE FOR DISCOUNTED OR FREE CARE. IF THE INDIVIDUALS FAMILY SIZE AND INCOME ARE BELOW THE NATIONAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. PART I, LINE 7: THE ORGANIZATION USED WORKSHEET 2 TO DETERMINE THE COST FOR PART I, LINE 7, ROW A. THE MEDICAID COST REPORT WAS USED TO CALCULATE THE AMOUNTS IN PART I, LINE 7, ROW B. THE COST LISTED ON PART I, LINE 7, ROW E IS BASED ON THE RATE OF PAY FOR THE INDIVIDUAL ATTENDING THE COMMUNITY HEALTH FAIR. PART I, L7 COL(F): FOR THE PURPOSE OF CALCULATING THE PERCENTAGE ON PART I, LINE 7F, $220,839 OF BAD DEBT EXPENSE WAS BACKED OUT OF TOTAL OPERATING EXPENSES. PART II: N/A PART III, LINE 4: BAD DEBT EXPENSE IS CALCULATED AT COST USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2.COSTING METHODOLOGY FOR DETERMINING AMOUNT OF ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZAION'S CHARITY CARE POLICY:9.2% 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 9.2% OF THE BAD DEBT EXPENSE AT COST IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT.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. PART III, LINE 8: MEDICARE ALLOWABLE COSTS ARE BASED ON TEH MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. PART VI, LINE 2: AN ANNUAL REVIEW OF 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 DELETE 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. 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 OUSTANDING MEDICAL BILLS: 1. PAYMENT IN FULL2. PAYMENT ARRANGEMENTS3. CHARITY CARE APPLICATIONALSO A PUBLIC NOTIFICATION IS VISIBLE AT THE MAIN RECEPTIONIST DESK AND ALL BUSINESS OFFICE STAFF CAN APPROPRIATELY ANSWER QUESTIONS IN REGARDS TO PAYMENT ON OUSTANDING 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: OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). THE US CENSUS FOR 2000 SHOWED A POPULATION OF 8,585 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $36,430, AND THE MEDIAN INCOME FOR A FAMILY WAS $45,338. THE PER CAPITA INCOME FOR THE COUNTY WAS $18,692. ABOUT 7.4% OF FAMILIES AND 9.2% OF THE POPULATION WERE 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 2010, OUR MEDICAL FACILITY TREATED 10,052 PATIENTS, 46% OF WHOM WERE AGE 70 AND OLDER. PART VI, LINE 6: 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 7: N/A X X 0 0 0 1 0 0 0 0 0 H KHOUDOUD MD THROUGH 810 212809 0 10183 0 0 0 6833 0 5984 0 235809 0 0 0 EVERETT BUTLER 66136 0 0 0 0 0 0 0 0 0 66136 0 0 0 DR ELIAS DARIDO 320107 0 0 0 0 0 12918 0 5111 0 338136 0 0 0 PART I, LINE 5 PHYSICIAN'S ARE ELIGIBLE FOR A PRODUCTION BONUS BASED ON GROSS REVENUES GENERATED. DR. HASSAN ABUL-KHOUDOUD RECEIVED A PRODUCTION BONUS OF $10,183. SUPPLEMENTAL INFORMATION PART III PART II: EVERETT BUTLER (CEO) IS COMPENSATED BY AN UNRELATED COMPANY, CHRISTIAN UNITY HOSPITAL CORPORATION, DBA UNITY MEDICAL CENTER. RITA VAUGHN FAMILY MEMBER OF DIRECTOR TOM VAUGHN 20858 COMPENSATION 0 DR K S SUMRA OWNER OF PARK RIVER CLINIC 455166 DR. SUMRA OWNS PARK RIVER CLINIC. PARK RIVER CLINIC PROVIDES INDEPENDENT CONTRACTOR PHYSICIAN SERVICES TO THE ORGANIZATION. 0 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS STOCKHOLDERS. THERE ARE NO DIFFERENT CLASSES 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 A, LINE 8B THERE ARE NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF 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 OCTOBER 2011 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 15 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 WAS LAST UNDERTAKEN IN 2010. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATIONS 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN AUXILIARY ASSETS -1,676. TOTAL TO FORM 990, PART XI, LINE 5: -1,676. KEN SCHWANDT'S COMPENSATION 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. PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION 301 MOUNTAIN STREET E CAVALIER ND 58220 300052569 FUNDRAISING FOR BENEFIT OF PEMBINA CO. MEMORIAL HOSPITAL & WEDGEWOOD MANOR ND 501(C)(3) 11A PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION 1 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION C PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION E PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION M PEMBINA COUNTY MEMORIAL HOSPITAL FOUNDATION O