2024-05-14T15:58:21-05:00 2023-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-07-01 450306787 CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION CAVA 7012566172 909 SECOND STREET LANGDON ND 58249 WAYNE REID CEO 7012566172 2024-05-10 1 WAYNE REID 999009999 1 MICHAEL J PETERSON CPA P01833529 2187224705 2024-05-10 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z LANGDON PRAIRIE HEALTH WAYNE REID 909 SECOND STREET LANGDON ND 58249 15702445 0 X HTTPS://WWW.LPH.HOSPITAL X 1969 ND RURAL HEALTHCARE FACILITY PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES. 8 8 100 7 0 0 448980 72679 13202121 13848087 -124806 -13512 636735 330150 14163030 14237404 2110 9932 0 0 5828173 6016839 0 0 0 6946019 8099208 12776302 14125979 1386728 111425 18125944 18667941 1357303 1738497 16768641 16929444 STANDING PROUDLY ON THE TRADITIONS AND PERSEVERANCE OF OUR MANY HOSPITAL FOUNDERS, CCMH IS DEDICATED TO EXCEL AT PROVIDING HIGH QUALITY, COMPASSIONATE HEALTHCARE TO ALL THAT WE SERVE. 0 0 10961871 9932 13848087 PROVIDE PATIENT HEALTHCARE SERVICES INCLUDING HOSPITAL AND CLINIC TO SURROUNDING COMMUNITY. THE ORGANIZATION PROVIDED APPROXIMATELY $19,196 OF CHARITY CARE DURING THE YEAR ENDED 06/30/2023. 10961871 1 1 0 1 0 0 0 0 0 0 1 1 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 36 0 100 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X JEFFREY HUNDMAN 7012566172 909 SECOND STREET LANGDON ND 58249 JAY DUBOIS PRESIDENT 1.00 X X 0 0 0 DAWN ROPPEL SECRETARY - THRU 12/2022 1.00 X X 0 0 0 SHERRY BUCHWEITZ SECRETARY 1.00 X X 0 0 0 KATHRYN KOPF VICE PRESIDENT 1.00 X X 0 0 0 STEVE HART TREASURER 1.00 X X 0 0 0 RUNA ANDERSON DIRECTOR 1.00 X 0 0 0 STEVEN PARKES DIRECTOR 1.00 X 0 0 0 CHYRISSE REGEHR DIRECTOR 1.00 X 0 0 0 SHAUNA SCHNEIDER DIRECTOR 1.00 X 0 0 0 JEFF STANLEY CEO - THRU 11/2022 40.00 X 236819 0 4765 OSCAR FERNANDEZ CMO - THRU 10/2022 40.00 X 303516 0 9015 RORY RATZLAFF CMO 10.00 X 0 0 0 DARLA RODER INTERIM CEO & COO 40.00 X 142926 0 12054 JAMIE NIENHUIS CNO - THRU 4/2023 40.00 X 110736 0 8730 MICHELLE SKILLINGS CNO 40.00 X 0 0 0 MARGARET FONTANA CFO 40.00 X 186167 0 8820 COURTNEY SHORT (HCE) FNP 40.00 X 183245 0 910 KARLA PARKES (HCE) FNP 40.00 X 164868 0 10782 MA NEIREZA MEDALLO LAB TECH 40.00 X 140659 0 6840 JOSEPH SANDERS AMBULANCE DIRECTOR 40.00 X 138427 0 5737 ALLAN SCROGGINS FORMER CFO 0.00 X 127749 0 0 1735112 0 67653 10 1 1 0 NATIONAL MEDICAL RESOURCES INC 2792 E BROADWAY AVE BISMARCK ND 58501 PROVIDER CONTRACT SERVICES 935549 CARDINAL HEALTH 110 LLC 7000 CARDINAL PL DUBLIN OH 43017 PHARMACEUTICAL SERVICES 713338 SANFORD HEALTH 1305 W 18TH ST SIOUX FALLS SD 57117 PROVIDER CONTRACT SERVICES 680668 JOHNSON CONTROLS INC DEPT CH 10320 PALATINE IL 600550320 CONSTRUCTION SERVICES 626409 MCKESSON 6555 STATE HWY 161 IRVING TX 75039 340B PROGRAM CONSULTING SERVICES 341311 20 9472 63207 72679 NET PATIENT REVENUE 621400 12960185 12960185 340B PHARMACY REVENUE 621400 727824 727824 LANGDON COUNTY AMBULANCE 621910 160078 160078 13848087 115003 115003 27162 0 27162 27162 27162 1304973 31553 1465041 0 -160068 31553 -128515 -128515 302988 302988 302988 14237404 13848087 0 316638 X 9932 9932 838863 671738 167125 4422605 3541499 881106 51988 41630 10358 349827 280132 69695 353556 283118 70438 39293 39293 76360 76360 4028556 3161833 866723 97716 691 97025 85842 20166 65676 378487 1647 376840 179495 146020 33475 55886 44368 11518 42426 33459 8967 749539 591127 158412 92612 518 92094 MEDICAL SUPPLIES 1431183 1431089 94 REPAIRS & MAINTENANCE 283266 283250 16 BAD DEBT EXPENSE 223131 223131 EQUIPMENT RENTAL 105808 102566 3242 229608 93957 135651 14125979 10961871 3164108 0 8014 8414 5379625 5048783 1835529 2073506 251060 262959 124985 242040 17028897 9656891 7498102 7372006 2444718 2492861 583911 1167372 18125944 18667941 707633 864059 649670 447066 0 427372 1357303 1738497 X 14323923 14436583 2444718 2492861 16768641 16929444 18125944 18667941 X 111425 233829 -232594 48143 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2034 2034 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF NORTH DAKOTA HOSPITAL ASSOCIATION. A PORTION OF MEMBERSHIP DUES IS USED FOR LOBBYING. THESE ASSOCIATIONS ADVOCATE ON BEHALF OF ITS MEMBERS FOR IMPROVING EFFICIENCY AND ACCESSIBILITY OF THE HEALTHCARE DELIVERY SYSTEMS AND THE HEALTH STATUS OF NORTH DAKOTA'S POPULATION. 13167 13167 11537896 5122635 6415261 108688 106897 1791 5134190 4427359 706831 234956 234956 7372006 BENEFICIAL INTEREST IN ASSETS HELD BY FOUNDATION 2492861 F 2492861 ASSETS LIMITED AS TO USE - MEDICARE 740000 RIGHT OF USE ASSETS - OPERATING LEASE 427372 1167372 OPERATING LEASE OBLIGATIONS 427372 427372 14238170 233829 233829 14004341 233063 233063 14237404 13892916 0 13892916 233063 233063 14125979 PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 223,131. GRANTS RECORDED AS REVENUE 9,932. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 223,131. GRANTS RECORDED AS REVENUE 9,932. 1 1 X 1 X 1 X 1 1 0 1 1 13398 13398 0.00100 629699 848254 0 0.00000 643097 848254 13398 0.00100 4258410 967480 3290930 0.23690 4258410 967480 3290930 0.23690 4901507 1815734 3304328 0.23790 0 184297 0 8401126 8140719 260407 X 1 1 1 1 CAVALIER COUNTY MEMORIAL HOSPITAL 909 2ND STREET LANGDON ND 58249 WWW.LPH.HOSPITAL 5029 X X X X CAVALIER COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 21 1 0 1 1 X SEE SUPPLEMENTARY INFO X 1 21 1 SEE SUPPLEMENTARY INFO 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X 1 X SEE SUPPLEMENTARY INFO X SEE SUPPLEMENTARY INFO X SEE SUPPLEMENTARY INFO X X X X X X 1 X 0 X X X X X 1 X 0 0 CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE METHODOLOGY TO CONDUCT THIS ASSESSMENT TAKES A COMPREHENSIVE APPROACH TO ASSESS COMMUNITY HEALTH NEEDS, PERFORM SEVERAL INDEPENDENT DATA ANALYSES BASED ON SECONDARY SOURCE DATA, AUGMENT THIS WITH LOCAL EXPERT ADVISOR OPINIONS, AND RESOLVE ANY DATA INCONSISTENCY OR DISCREPANCIES BY REVIEWING THE COMBINED OPINIONS FORMED FROM LOCAL EXPERT ADVISORS. THE HOSPITAL RELIES ON SECONDARY SOURCE DATA, AND MOST SECONDARY SOURCES USE THE COUNTY AS THE SMALLEST UNIT OF ANALYSIS. LOCAL EXPERT AREA RESIDENTS WERE ASKED TO NOTE IF THEY PERCEIVED THE PROBLEMS OR NEEDS IDENTIFIED BY SECONDARY SOURCES EXISTED IN THEIR PORTION OF THE COUNTY. NPUT WAS OBTAINED FROM THE REQUIRED THREE MINIMUM SOURCES AND EXPANDED TO INCLUDE OTHER REPRESENTATIVE GROUPS. THE HOSPITAL ASKED ALL THOSE PARTICIPATING IN THE WRITTEN COMMENT SOLICITATION PROCESS TO SELF-IDENTIFY INTO ANY OF THE FOLLOWING REPRESENTATIVE CLASSIFICATIONS, WHICH ARE DETAILED IN AN APPENDIX TO THIS REPORT. CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: CAVALIER COUNTY MEMORIAL HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT WITH QHR HEALTH.PART V, LINE 7A:HTTPS://WWW.LPH.HOSPITAL/COMMUNITY-HEALTH-NEEDS-ASSESSMENTPART V, LINE 10:HTTPS://WWW.LPH.HOSPITAL/COMMUNITY-HEALTH-NEEDS-ASSESSMENT CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: THE 2021 SIGNIFICANT HEALTH NEEDS IDENTIFIED FOR CAVALIER COUNTY ARE:1. BEHAVIORAL HEALTH:A. HOSPITAL SERVICES, PROGRAMS, AND RESOURCES AVAILABLE TO RESPOND TO THIS NEED INCLUDE:BEHAVIORAL MENTAL HEALTH TASK FORCE A LOCAL GROUP THAT CONSISTS OF REPRESENTATIVES FROM PUBLIC HEALTH, LAW ENFORCEMENT, SOCIAL SERVICES, THE BOARD OF EDUCATION, AND LPH; DEPRESSION SCREENINGS ARE PERFORMED DURING EVERY VISIT AT THE PRIMARY CARE CLINIC; TELE-PSYCHIATRY OFFERINGS.B. IMPACT OF ACTIONS TAKEN SINCE THE IMMEDIATE PRESEDING CHNA: ALCOHOLICS ANONYMOUS (AA) SERVICES ARE NOW PROVIDED AT WALHALLA CLINIC; LPH HAS A PROVIDER TRAINED IN CHILD BEHAVIORAL HEALTH; WALHALLA CLINIC OFFERS A ROBUST MEDICAL MARIJUANA PROGRAM TO LIMIT OPIOID USE AMONG CHRONIC PAIN PATIENTS.C. ADDITIONALLY, THE HOSPITAL PLANS TO TAKE THE FOLLOWING STEPS TO ADDRESS THIS NEED:ADD ALCOHOLICS ANONYMOUS/NARCOTICS ANONYMOUS (AA/NA) SERVICES;INCREASE EDUCATION AND AWARENESS ON MENTAL HEALTH IN THE COMMUNITY; WORK WITH ADDICTION COUNSELORS IN THE AREA TO CONNECT AA/NA PARTICIPANTS WITH THEIR SERVICES; EXPLORE POTENTIAL SCREENING PROTOCOLS FOR DRUG/SUBSTANCE/ALCOHOL USE; INCREASE EDUCATION FOR PHYSICIANS TO BE AWARE OF COUNSELORS THAT THEY CAN REFER PATIENTS TO; CONTINUE WORK WITH THE BEHAVIORAL MENTAL HEALTH TASK FORCE; EXPLORE THE DEVELOPMENT OF A SUBOXONE TREATMENT PROGRAM THROUGH A CERTIFIED PROVIDER; DEVELOP AND SUPPORT PROVIDERS WHO ARE INTERESTED IN BEHAVIORAL HEALTH. 2. CHRONIC DISEASE MANAGEMENT:A. HOSPITAL SERVICES, PROGRAMS, AND RESOURCES AVAILABLE TO RESPOND TO THIS NEED INCLUDE: CARAVAN HEALTH COLLABORATIVE LPH ACCOUNTABLE CARE ORGANIZATION (ACO); COMPREHENSIVE PRIMARY CARE SERVICES; CHRONIC CARE MANAGEMENT SERVICES CHRONIC DISEASE PATIENTS RECEIVE PHONE CALLS EVERY OTHER WEEK FROM HEALTHCARE PROFESSIONALS TO REVIEW HOW THEIR CARE IS GOING; TRANSITIONAL CARE MANAGEMENT SERVICES PATIENTS DISCHARGED FROM THE HOSPITAL WITH A CHRONIC CONDITION RECEIVE A CALL TO ENSURE A FOLLOW-UP APPOINTMENT IS SCHEDULED AT THE CLINIC; LPH PROVIDERS CONDUCT ANNUAL WELLNESS VISITS; POPULATION HEALTH NURSE AVAILABLE ON STAFF; LPH CONDUCTS AN ANNUAL HEALTH FAIR WITH OVER 30 DIFFERENT VENDORS; LPH CONDUCTS WOMEN'S HEALTH DAY AND MEN'S HEALTH DAY TO PROVIDE SCREENING SERVICES; COVID-19 PREVENTION AND EDUCATION SERVICES; TELEMEDICINE APPOINTMENTS ARE AVAILABLE ACROSS A RANGE OF SERVICE LINES; CAVALIER COUNTY SENIOR MEALS AND SERVICES AND THE FOUNDATION PROVIDE FREE MEALS FOR TWO WEEKS AFTER DISCHARGE TO MEDICARE PATIENTS; SCREENING SERVICES: BLOOD PRESSURE MONITORING; BONE DENSITY TESTING; COLONOSCOPIES; DIABETES MANAGEMENT; DOT YEARLY PHYSICALS; LAB TESTING; MAMMOGRAPHY; SPORTS PHYSICALS; WELLNESS CHECK-UPS; VISITING OUTREACH PROVIDERS; CARDIOLOGY; DERMATOLOGY; OB/GYN; ONCOLOGY; ORTHOPEDICS; PAIN MANAGEMENT; GI.B. ADDITIONALLY, THE HOSPITAL PLANS TO TAKE THE FOLLOWING STEPS TO ADDRESS THIS NEED: WORK WITH COMMERCIAL INSURANCES TO BROADEN CHRONIC CARE MANAGEMENT SERVICES TO ALL PATIENTS; INCREASE EDUCATION AND AWARENESS AROUND CHRONIC DISEASES ON SOCIAL MEDIA; INITIATE COMMUNITY PARAMEDIC PROGRAM, INCLUDING DISEASE MONITORING AND MEDICATION MANAGEMENT FOR CHF AND COPD; EXPLORE POTENTIAL PROGRAMS TO PROVIDE CARE IN A PATIENT'S HOME AS AN ALTERNATIVE TO LONG-TERM CARE; EVALUATE THE POTENTIAL OF INCREASING SPECIALTY ROTATIONS FOR SERVICES THAT ARE HEAVILY UTILIZED.3. ACCESS TO HEALTHCARE SERVICES: A. HOSPITAL SERVICES, PROGRAMS, AND RESOURCES AVAILABLE TO RESPOND TO THIS NEED INCLUDE: WEEKEND CLINIC HOURS; 24-HOUR EMERGENCY CARE AND SWING BED SERVICES; TELEMEDICINE APPOINTMENTS ARE AVAILABLE ACROSS A RANGE OF SERVICE LINES; VISITING OUTREACH PROVIDERS; CARDIOLOGY; DERMATOLOGY; OB/GYN; ONCOLOGY; ORTHOPEDICS; PAIN MANAGEMENT; GI; FINANCIAL ASSISTANCE POLICY FOR PATIENTS UP TO 200% OF THE FEDERAL POVERTY LINE; PRICE TRANSPARENCY PRICE ESTIMATOR TOOL AVAILABLE ON THE HOSPITAL'S WEBSITE; SCREENING FOR FINANCIAL ASSISTANCE POLICY IS INCLUDED ON ALL STATEMENTS AND APPLICATIONS ARE INCLUDED WITH PATIENT PACKETS; BILLING SUPPORT STAFF AVAILABLE ONSITE AT LPH; SOCIAL WORKER ON STAFF TO HELP CONNECT PATIENTS TO AVAILABLE RESOURCES; HOSPITAL-BACKED LOANS FOR PATIENTS THROUGH CHOICE FINANCIAL BANK; FREE HEALTH SCREENINGS FOR EMPLOYEES DURING HEALTHCARE WORKER APPRECIATION WEEK; OUTREACH CLINIC IN WALHALLA; LPH CONDUCTS AN ANNUAL HEALTH FAIR WHERE FREE HEALTH SCREENINGS ARE PROVIDED; AGREEMENT WITH THE UNIVERSITY OF NORTH DAKOTA TO TRAIN AND RECRUIT MEDICAL, NURSING, AND PHYSICIAN ASSISTANT STUDENTS; ON THE HORIZON: LPH'S COMMUNITY MAGAZINE PROVIDES STORIES FROM PATIENTS AND FEATURES INFORMATION ABOUT HOSPITAL SERVICES AND HEALTH TIPS.B. IMPACT OF ACTIONS TAKEN SINCE THE IMMEDIATELY PRECEDING CHNA: UPDATED FINANCIAL ASSISTANCE POLICY; OPTIMIZED HOSPITAL WEBSITE TO BE MORE USER-FRIENDLY AND TO PROVIDE CLEAR INFORMATION ON SERVICES AVAILABLE; IMPROVED HOSPITAL SIGNAGE TO SUPPORT COMMUNITY AWARENESS AND WAYFINDING.C. ADDITIONALLY, THE HOSPITAL PLANS TO TAKE THE FOLLOWING STEPS TO ADDRESS THIS NEED: ADD EARLY AND LATE WEEKDAY HOURS AT THE CLINIC; CONTINUE TO EXPAND TELEMEDICINE OFFERINGS; CONTINUE TO IMPROVE BILLING PROCESSES AT THE HOSPITAL; CONTINUE TO INVEST IN THE LOCAL COMMUNITY FOR NURSING STAFF. CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: PATIENTS WHO HAVE DIED AND HAVE NO ESTATE ARE DEEMED BY CCMH TO HAVE NO INCOME FOR THE PURPOSE OF DETERMINING CHARITY CARE ELIGIBILITY. CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: THE ORGANIZATION DID NOT TRANSLATE THE FAP INTO ANY OTHER LANGUAGE THAN THE ENGLISH. THERE IS LESS THAN 4% NON-ENGLISH SPEAKING POPULATION IN THE AREA THE HOSPITAL SERVES AND THERE IS NOT A REQUIREMENT TO TRANSLATE THE FAP.PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.LPH.HOSPITAL/INSURANCE-ASSISTANCEPART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.LPH.HOSPITAL/INSURANCE-ASSISTANCEPART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.LPH.HOSPITAL/INSURANCE-ASSISTANCE CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 20E: ALL PATIENTS RECEIVE LETTERS AFTER NONPAYMENT THAT INCLUDE A PLAIN LANGUAGE SUMMARY OF OUR FINANCIAL ASSISTANCE PLAN. 2 1 - LANGDON CLINIC 909 2ND STREET LANGDON ND 58249 OUTPATIENT PHYSICIAN CLINIC - RURAL HEALTH CLINIC 2 - WALHALLA CLINIC 301 5TH STREET WALHALLA ND 58282 OUTPATIENT PHYSICIAN CLINIC - RURAL HEALTH CLINIC PART I, LINE 3C: THE HOSPITAL USES THE FEDERAL POVERTY GUIDELINES ("FPG") AS THE PRIMARY BASIS FOR THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL ALSO USES THE PATIENT'S ADJUSTED GROSS INCOME FIGURE FROM THEIR INCOME TAX RETURN AND CHECK IT WITH THE FPG. THE HOSPITAL DOES NOT USE AN ASSET TEST. THE HOSPITAL REQUIRES APPLICANTS TO SUBMIT A MEDICAID DENIAL, THE PRIOR YEAR'S TAX FILING, AND 3 MONTHS OF INCOME VERIFICATION AS PART OF THE FINANCIAL ASSISTANCE APPLICATION PROCESS. PART I, LINE 7: COST TO CHARGE RATIO WAS DERIVED USING WORKSHEET 2 FROM THE IRS TO CALCULATED THE AMOUNTS INCLUDED IN SCHEDULE H, PART I, LINE 7A & 7B COMMUNITY HEALTH IMPROVEMENTS SERVICES & COMMUNITY BENEFIT OPERATIONS (LINE 7E) AND HEALTH PROFESSIONAL EDUCATION ARE REPORTED AT COST. PART I, LINE 7G: THE COSTS OF SUBSIDIZED HEALTH SERVICES ARE RELATED TO IP/OP OBSERVATION BEDS, THE AMOUNTS ARE DETERMINED USING A COMPLETED COST REPORT. THE UNIT REPORTED COSTS OF $4,258,410 WITH OFFSETTING REVENUE OF $967,480. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 233,829. PART III, LINE 2: THE ORGANIZATION'S BAD DEBT EXPENSE IS THE BAD DEBT EXPENSE LESS BAD DEBT RECOVERIES AS REPORTED ON THE FINANCIAL STATEMENTS MULTIPLIED BY THE COST TO CHARGE RATIO. PART III, LINE 3: THE ORGANIZATION HAS A VERY ROBUST FINANCIAL ASSISTANCE PROGRAM; THEREFORE, NO ESTIMATE IS MADE FOR BAD DEBT ATTRIBUTED TO FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. PART III, LINE 4: THE TEXT REGARDING THE ORGANIZATION'S BAD DEBT IS FOUND ON PAGE 12 OF THEIR ACCOMPANING FINANCIAL STATEMENTS. A PORTION OF THAT TEXT IS BELOW: GENERALLY, PATIENTS WHO ARE COVERED BY THIRD-PARTY PAYORS ARE RESPONSIBLE FOR RELATED DEDUCTIBLES AND COINSURANCE, WHICH VARY IN AMOUNT. THE HOSPITAL ALSO PROVIDES SERVICES TO UNINSURED PATIENTS AND OFFERS THOSE UNINSURED PATIENTS A DISCOUNT, EITHER BY POLICY OR LAW, FROM STANDARD CHARGES. THE HOSPITAL ESTIMATES THE TRANSACTION PRICE FOR PATIENTS WITH DEDUCTIBLES AND COINSURANCE AND FOR THOSE WHO ARE UNINSURED BASED ON HISTORICAL EXPERIENCE AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY CONTRACTUAL ADJUSTMENTS, DISCOUNTS, AND IMPLICIT PRICE CONCESSIONS. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO PATIENT SERVICE REVENUE IN THE PERIOD OF THE CHANGE. SUBSEQUENT CHANGES THAT ARE DETERMINED TO BE THE RESULT OF AN ADVERSE CHANGE IN THE PATIENT'S ABILITY TO PAY ARE RECORDED AS BAD DEBT EXPENSE. BAD DEBT EXPENSE FOR THE YEARS ENDED JUNE 30, 2023 AND 2022, WAS NOT SIGNIFICANT. CONSISTENT WITH THE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, THE HOSPITAL HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH OTHER UNINSURED BALANCES (I.E., COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN THE AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS THE HOSPITAL EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. THE HOSPITAL'S POLICY IS TO PROVIDE DISCOUNTS RANGING FROM 40 TO 100 PERCENT UNDER A SLIDING FEE SCHEDULE THAT IS BASED ON FAMILY SIZE AND INCOME IN RELATION TO FEDERAL POVERTY GUIDELINES. THIS POLICY DID NOT CHANGE IN 2023 AND 2022. PART III, LINE 8: CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: IF A PATIENT QUALIFIES FOR CHARITY CARE, A PERCENTAGE OF THEIR BILL IS WRITTEN OFF DEPENDING ON THEIR INCOME LEVEL. THE BALANCE THAT REMAINS IS SUBJECT TO OUR COLLECTION POLICY. IF A PAYMENT HAS NOT BEEN MADE FOR 2 MONTHS, A 1ST LETTER IS SENT STATING THAT THEY HAVE A MONTH TO MAKE A PAYMENT. IF A PAYMENT HAS NOT BEEN MADE AFTER THAT MONTH, A 2ND LETTER IS SENT OUT STATING THEY HAVE ANOTHER MONTH TO MAKE A PAYMENT. IF A PAYMENT HAS STILL NOT BEEN MADE, THEN THEY ARE TURNED OVER TO OUR COLLECTION AGENCY. PART VI, LINE 2: LANGDON PRAIRIE HEALTH ACTIVELY ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY BY EVALUATING THE PROGRESS AND SUCCESS OF PREVIOUS COMMUNITY NEEDS ASSESSMENTS, EVALUATING QUALITY METRICS, PATIENT SATISFACTION SURVEYS, AND ACO RESULTS. ALL DEPARTMENTS PARTICIPATE IN LPH'S QUALITY ASSURANCE PROGRAM WHICH MEASURES PATIENT SATISFACTION AND THE QUALITY OF THE SERVICES PROVIDED AND PROVIDES AN OPPORTUNITY FOR IMPROVING PROCESSES RESULTING IN IMPROVED HEALTHCARE FOR OUR COMMUNITY. PART VI, LINE 3: LANGDON PRAIRIE HEALTH OFFERS ASSISTANCE TO ALL PATIENTS THAT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. OUR WEBSITE, FACEBOOK PAGE, BILLING STATEMENTS COMMUNITY CALENDAR AND PATIENT HANDBOOK INDICATE WHO TO CONTACT IN ORDER TO APPLY. BUSINESS OFFICE STAFF ALSO MONITOR PATIENT ACCOUNTS THAT ARE DORMANT AND IN JEOPARDY OF COLLECTIONS, CONTACT THOSE PATIENTS AND OFFER ASSISTNCE IN THE APPLICATIONS PROCEES AS WELL. PART VI, LINE 4: CAVALIER COUNTY IS LOCATED IN THE STATE OF NORTH DAKOTA AND ACCORDING TO THE US CENSUS 2022 HAS A POPULATION OF APPROXIMATELY 3,362. PERSONS 65 YEARS AND OLDER MAKE UP 27.2% AND PERSONS UNDER 18% MAKE UP 29%. THE WHITE RACE MAKES UP APPROXIMATELY 96% WHILE THE HISPANIC OR LATINO MAKES UP 2.5. OF THE 1,153 HOUSEHOLDS THERE WERE 2.34 PERSONS LIVING IN EACH HOUSEHOLD. THE MEDIAN HOUSEHOLD INCOME WAS $60,284 AND 8% WERE CONSIDERED TO BE IN POVERTY. THE POPULATION PER SQUARE MILE IS 2.5 IN AN AREA OF 1,489. 6.3% PERSONS SUFFER FROM A DISABILITY AND 7.1% ARE UNINSURED. THE COUNTY WAS FOUNDED IN 1879 AND THE COUNTY SEAT IS LOCATED IN LANGDON. PART VI, LINE 5: LPH AND CLINICS FURTHER THEIR EXEMPT PURPOSE BY PROMOTING THE HEALTH OF THE COMMUNITY BY OFFERING SEVERAL PROGRAMS FOR FINANCIAL ASSISTANCE, OFFERING HEALTH FAIRS AND FREE AND REDUCED HEALTH ASSESSMENTS AND TESTING. CHARITY CARE IS OFFERED AND EMERGENCY SERVICES ARE PROVIDED REGARDLESS OF A PATIENT'S ABILITY TO PAY. ANY CONTRIBUTIONS MADE TO THE ORGANIZATION ARE TAX DEDUCTIBLE AND APPLIES FOR GRANTS TO PURCHASE NEEDED EQUIPMENT AND PROVIDE ADVANCED MEDICAL TRAINING. PART VI, LINE 7, REPORTS FILED WITH STATES ND X X 1 0 0 0 0 0 0 0 0 OSCAR FERNANDEZ CMO - THRU 10/2022 303516 0 0 0 0 0 0 0 9015 0 312531 0 0 0 JEFF STANLEY CEO - THRU 11/2022 236819 0 0 0 0 0 552 0 4213 0 241584 0 0 0 MARGARET FONTANA CFO 186167 0 0 0 0 0 927 0 7893 0 194987 0 0 0 COURTNEY SHORT (HCE) FNP 183245 0 0 0 0 0 0 0 910 0 184155 0 0 0 KARLA PARKES (HCE) FNP 164868 0 0 0 0 0 0 0 10782 0 175650 0 0 0 DARLA RODER INTERIM CEO & COO 142926 0 0 0 0 0 1273 0 10781 0 154980 0 0 0 ALLAN SCROGGINS FORMER CFO 0 0 0 0 127749 0 0 0 0 0 127749 0 0 0 PART I, LINE 4A OSCAR FERNANDEZ, CMO, RECEIVED A SEVERANCE PAYMENT FROM CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION OF $19,256 ON NOVEMBER 2, 2022. A CITY OF LANGDON NORTH DAKOTA 456002108 515679AL2 2010-03-25 2500000 HOSPITAL RENOVATION PROJECT 0 0 0 A 210000 2500000 50000 2450000 2012 0 0 1 1 A 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 A 0 SCHEDULE K, PART IV, LINE 2C: THE REBATE COMPUTATION WAS PERFORMED: -03/30/2015 -02/28/2020 FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS ONE CLASS OF MEMBERS. A MEMBER OF THE CORPORATION IS SOMEONE 18 YEARS OF AGE OR OLDER AND RESIDING IN THE CORPORATION'S SERVICE AREA (50 MILE RADIUS). A MEMBER MUST APPLY AND THE BOARD OF TRUSTEES HAS THE POWER TO REVIEW ELIGIBILITY AS APPROPRIATE. ONCE A MEMBER, THE PERSON HAS THE RIGHT TO ATTEND THE ANNUAL MEETING (NOVEMBER), RECEIVE A COPY OF THE ANNUAL REPORT AND VOTE ON MATTERS BROUGHT TO THE MEMBERS BY THE BOARD OF TRUSTEES. MEMBERS DO NOT VOTE ON THE BOARD OF TRUSTEES POSITIONS. FORM 990, PART VI, SECTION B, LINE 11B FORM 990 IS FIRST REVIEWED BY THE CHIEF FINANCIAL OFFICER. THE FINANCE COMMITTEE WILL LOOK AT THE RETURN FOLLOWING THE CFO. FINALLY, THE BOARD OF DIRECTORS WILL RECEIVE AN ELECTRONIC COPY OF THE FORM 990 PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS, OFFICERS, AND TRUSTEES OF THE ORGANIZATION ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. POTENTIAL OR POSSIBLE CONFLICTS OF INTEREST ARE REVIEWED AT THE BOARD LEVEL AND A DETERMINATION IS MADE. RESTRICTIONS AND/OR ADJUSTMENTS ARE DETERMINED AND THEN IMPLEMENTED PER BOARD DIRECTION. RESTRICTIONS AND/OR ADJUSTMENTS ARE DOCUMENTED WITHIN THE BOARD MINUTES. IF ANY VARIANCES OF THE CONFLICT IN QUESTION ARE DISCOVERED THE BOARD WILL MAKE A DETERMINATION ON THE ACTION TO BE TAKEN. ANY POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY MEMBER OF THE BOARD OF DIRECTORS SHALL BE DISCLOSED IN WRITING TO THE BOARD AND MADE A MATTER OF RECORD THROUGH AN ANNUAL DISCLOSURE AND ALSO WHEN THE INTEREST INVOLVED A SPECIFIC ISSUE OR TRANSACTION BEFORE THE BOARD. IF A CONFLICT ARISES AFTER A MEMBER HAS COMPLETED THE DISCLOSURE, THE MEMBER SHOULD COMPLETE AN AMENDED DISCLOSURE INCLUDING THE NEW CONFLICT. IF AN INDIVIDUAL HAS A CONFLICT OF INTEREST, THE ENTIRE BOARD OF DIRECTORS VOTES ON APPROVAL OR DISAPPROVAL OF THE TRANSACTION. THE MEMBER INVOLVED IN THE TRANSACTION REFRAINS FROM VOTING OR OTHERWISE ATTEMPTING TO EXERT ANY INFLUENCE ON THE OTHER MEMBERS THAT WILL AFFECT THEIR DECISION ON THE ISSUE. FORM 990, PART VI, SECTION B, LINE 15 THE PROCEDURE THAT CCMH UTILIZES TO DETERMINE ITS CEO'S COMPENSATION IS AS FOLLOWS. UPON EXPIRATION OF CEO'S CONTRACT, THE CCMH BOARD OF DIRECTORS (BOD) CALLS FOR AN EXECUTIVE SESSION TO DISCUSS THE CEO'S CONTINUED/DISCONTINUED EMPLOYMENT. UPON APPROVAL TO CONTINUE THE CEO'S EMPLOYMENT, THE BOD PRESENTS AND REVIEWS THE CURRENT NORTH DAKOTA PREVAILING WAGE DATA COMMENSURATE WITH CEO JOB DESCRIPTION. ONCE AN APPROPRIATE COMPENSATION FIGURE HAS BEEN NEGOTIATED AND ACCEPTED BY THE CEO, THE BOD PASSES A MOTION TO RATIFY THE COMPENSATION AGREEMENT BETWEEN THE BOD AND CEO. FINALLY, REQUIRED DELIVERABLES AND OTHER MEASURABLE INDICATORS ARE MEMORIALIZED IN A FORMAL AGREEMENT OR CONTRACT WITH THE CEO. THE PROCEDURES UTILIZED BY CCMH TO SET WAGES FOR SUBORDINATE OFFICERS AND ALL OTHER EMPLOYEES IS DETERMINED BY THE CEO WHO IS EMPOWERED BY THE BOD TO DO SO. THE CEO REVIEWED THE CURRENT NORTH DAKOTA JOB SERVICE EDITION AND NORTH DAKOTA HEALTHCARE ASSOCIATION WAGES/SALARY ADJUSTMENTS OF SUBORDINATE OFFICERS AND EMPLOYEES IS SUPPLIED TO THE BOARD UPON REQUEST. FINALLY, THE APPROPRIATE COMPENSATION AND OTHER DELIVERABLES ARE MEMORIALIZED IN A FORMAL OFFER LETTER EXTENDED TO THE EMPLOYEE. FORM 990, PART VI, SECTION C, LINE 19 CAVALIER COUNTY MEMORIAL HOSPITAL MAKES THEIR GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THE FINANCIAL STATEMENTS ARE ALSO PRESENTED ANNUALLY AT THE PUBLIC MEMBERS' MEETING. FORM 990, PART IX, LINE 11G PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 856,238. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 856,238. OTHER SERVICES: PROGRAM SERVICE EXPENSES 2,305,595. MANAGEMENT AND GENERAL EXPENSES 866,723. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,172,318. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 48,143.