2023-09-22T16:38:07-05:00 2023-03-31 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2022-04-01 450226419 Good Samaritan Hospital Association GOOD 7017765261 800 South Main Avenue Rugby ND 583682118 Erik Christenson CEO 7017765261 2023-09-21 1 Erik Christenson 999009999 1 Lisa Chaffee CPA P00193453 7012551091 2023-09-21 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z Heart of America Medical Center Erik Christenson 800 South Main Avenue Rugby ND 583682118 37554250 0 X www.hamc.com X 1905 ND Provide quality medical care based on the needs and demographics of north central North Dakota. 9 6 348 45 0 0 7780704 3678984 26886234 28239433 215310 184937 56850 5450896 34939098 37554250 50000 50000 0 0 17678310 17782748 68088 80466 80466 9344911 10777804 27141309 28691018 7797789 8863232 21983981 34054250 5222779 5159564 16761202 28894686 X To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. 0 0 24395299 50000 28239433 Good Samaritan Hospital Association (GSHA) is a nonprofit health care organization, owned by 20 area churches representing all the local denominations of the Christian faith. The area churches at an annual meeting every year elect a board of trustees. This board is the legal governing body that is responsible for the Association. GSHA's primary focus is healthcare within and around the community of Rugby, ND. GSHA is a 25 bed licensed acute/swing bed critical access hospital, 3 rural health clinics (Rugby, Dunseith, Maddock), along with an Operating Room, and provider based surgical clinic & pain clinic, 33 skilled nursing home beds (2 in layaway), 60 basic care beds, and 37 assisted living apartments. We also service the community through a robust hospital-based hospice program. GHSA was impacted by COVID as we continued to see increased charity care due to patients being impacted with COVID. We continued to provide COVID testing to the community, and our infection control nurse was working with public health to improve the community's awareness. The CEO performed numerous health updates on the radio to educate the community about the public health emergency and changes that were coming from CMS. GSHA provides numerous community and social programs including, but not limited to the following: Charity Care - the estimated cost of providing charity care services was $141,000 during the year ended March 31, 2023 (calculated by multiplying the ratio of cost to gross charges for the Organization by the gross uncompensated charges associated with providing charity care to patients), reduced fee flu shot clinics, diabetic education program, chronic care management, public healthcare educational and informational notices, testing and information during health shows and community events, ambulance volunteers at the local events, provided EMT courses for ambulance services, educational outreach for school system, provides senior citizen meals, free blood pressure checks, community education, physical therapy, provided meeting room for various organizations and churches, CPR training, wellness programs. We also worked to build relationships with the affiliated CNA/LPN/RN school programs through a consortium of facilities and colleges. Ambulance Service is operated by the hospital association as the community was unable to sustain as a volunteer service. We staff the ambulance 24/7 and answer all 911 calls in our area as well as perform community service when someone is unable to make it to the hospital. The crew has gone to homes for blood draws. We subsize some of the expenses of operating this ambulance department with a mill levy and a state grant. 24395299 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 40 0 1 348 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Erik Christenson 7017765261 800 South Main Avenue Rugby ND 583682118 Ronald Skipper MD ER Provider 40.00 X 353901 0 33872 Cammy Kelsch FNP-C ER Provider 66.50 X 304230 0 36681 Steven Schoneberg MD Physician 40.00 X 266875 0 29259 Chelsey Wyatt CRNA 40.00 X 250487 0 28692 Josalynne Hoff Rue MD Physician 40.00 X 244378 0 35097 Dustin Hager COO & Provider 40.00 X 192752 0 34670 Erik Christenson Secretary - CEO 58.00 2.00 X 115389 0 33418 Melissa Shepard Treasurer - CFO 58.00 2.00 X 134475 0 12118 Will Griffin - President (April-July)/Trustee (as of July) 1.00 X X 0 0 0 Wayne Trottier - Vice Chair (April-July)/President (Aug-March) 1.00 X X 0 0 0 Michael Graner - Trustee (until Aug)/Vice Chair (Aug-March) 1.00 X X 0 0 0 Travis Maddock Trustee (as of May) 1.00 X 0 0 0 Annette Leier Trustee (April-Oct) 1.00 X 0 0 0 Craig Zachmeier Trustee 1.00 X 0 0 0 Lisa Thorp Trustee (Nov-March) 1.00 X 0 0 0 Kolin Johnson Trustee 1.00 X 0 0 0 Deanna Marchus Trustee (April-Oct) 1.00 1.00 X 0 0 0 Kim Bott Trustee 1.00 X 0 0 0 Tanner Johnson Trustee 1.00 X 0 0 0 1862487 0 243807 20 0 1 0 Building Systems Holding LLC 2201 12th St N Fargo ND 58102 Design, Consultant, Engineering 230000 Shen Milson & Wilke LLC 417 Fifth Ave New York NY 10016 Design, Consultant, Engineering 150649 WIPFLI LLP 11 Scott Street Wausau WI 54402 Feasibility Study/Master Plan for Bldg P 149354 Jerry Turner 15739 W Hwy 2770 Stone Lake WI 54876 Owners Representative/Project Manager 138392 Mike Swanson Construction 6250 24th Ave NE Rugby ND 58368 General Construction 101875 5 1453251 2000121 225612 3678984 Patient Service Revenue 621400 25131611 25131611 Pharmacy Revenue 456110 2040154 2040154 Daycare Services 812900 174998 174998 Cafeteria Revenue 722514 82051 82051 810619 810619 28239433 184937 184937 55500 0 55500 55500 55500 Employee Retention Credit 900099 5395396 5395396 5395396 37554250 28239433 0 5635833 50000 50000 551698 179223 372475 278203 278203 14112450 12496820 1615630 265212 236368 28844 1534360 1368478 165882 1040825 905208 135617 68892 68892 530904 530904 80466 80466 2025150 1595000 430150 33576 33576 371298 231877 139421 32989 32989 1077059 967718 109341 84445 63650 20795 88477 41523 46954 56650 56650 1387550 1222871 164679 236606 236606 Medical Supplies 3299314 3299314 Repairs & Maintenance 761919 761919 Food 409938 409938 Dues and Subscriptions 48602 3660 44942 264435 226879 37556 28691018 24395299 4215253 80466 7614046 7624770 3325728 2665542 249502 233578 238223 319007 22717731 12021010 7856020 10696721 138603 139693 105277 114222 2456582 12260717 21983981 34054250 2608100 3698588 755090 0 217795 0 18361 16892 1148979 0 474454 1444084 5222779 5159564 X 15905005 23669988 856197 5224698 16761202 28894686 21983981 34054250 X 8863232 -51215 3321467 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 3992 1 0 0 0 3992 0 Part II-B, Line 1: Good Samaritan Hospital Association participates in lobbying via membership dues to the following organizations: AHA, NDHA, and NDLTCA. These various organizations advocate on behalf of their members by supporting legislation that is in the collective interests. These organizations work to ensure that laws and regulations are fair and equitable and that healthcare facilities are able to provide affordable and high quality care in rural areas. In FY23 we had a state representative, Mr. Jon Nelson, on our New Building Steering Committee as we were utilizing community members to advise the GSHA Executive Board regarding our new hospital and exploring purposes for the older facility. Additionally, we had the pleasure of having Senator Hoeven and Representative Armstrong at the groundbreaking ceremony for the new hospital site. The groundbreaking ceremony was also well attended by the community and employees from the USDA. We utilized this ceremony to highlight the benefits of a new hospital structure for the community. The state and federal legislators have been very supportive of our new building project and they have provided guidance regarding opportunities available for rural healthcare organizations. 1 62648 32502 38152 56998 1 X 137447 137447 8545162 6569445 1975717 7759929 5451565 2308364 6275193 6275193 10696721 Beneficial Interest in Assets Held by Others 4775550 Third Party Settlements 541256 Insurance Receivable 850000 Employee Retention Credit Receivable 5395396 Finance Lease (net of accumulated amortization) 660297 Operating Lease 38218 12260717 Special Assessments Payable 11541 Insurance Payable 850000 Related Party 210 Operating Lease Liability 52670 Finance Lease Liability 529663 1444084 X 40736350 -51215 3265817 3214602 37521748 32502 32502 37554250 28602866 0 28602866 88152 88152 28691018 Part IV, Line 1b: The Auxiliary is operated by volunteers under the Good Samaritan Hospital Association. The funds are maintained by this volunteer organization, segregated funds are utilized for various activities and to provide the patients and residents with a gift shop. The Auxiliary has a governing Board that determines where these funds are utilized. Part IV, Line 2b: The Organization acts as custodian for the funds of the nursing facility residents and Haaland Estates residents. Part X, Line 2: The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Change in interest in net assets of Foundation 3,315,817. Grants given out included in revenue on financial statements -50,000. Part XI, Line 4b - Other Adjustments: Auxillary Revenue 32,502. Part XII, Line 4b - Other Adjustments: Auxillary Expenses 38,152. Grants given out included in revenue on financial statements 50,000. X X X X X X 1 Catholic Development Group LLC 1020 1st Ave N Fargo ND 58102 Campaign director for the Build 2024 project 0 0 80466 0 80466 ND Schedule G, part I, line 2b, column (iv) The organization paid money to Catholic Development Group LLC in order to raise funds towards building of a new hospital building. The related Foundation is the recipient of the funds being raised and so no gross receipts are reported in schedule G, part I, line 2b, column (iv). The Foundation's mission is to support the mission of Good Samaritan Hospital Association. 1 1 X 1 X 1 X 1 1 0 0 141000 141000 0.00490 141000 141000 0.00490 8061 8061 0.00030 5606435 3673219 1933216 0.06740 5614496 3673219 1941277 0.06770 5755496 3673219 2082277 0.07260 1 551568 137892 6225292 6255837 -30545 X 1 1 1 1 Heart of America Medical Center 800 S Main Ave Rugby ND 583682118 www.hamc.com 5046 X X X X Heart of America Medical Center 1 0 0 1 X X X X X X X X X 21 1 0 1 1 X https://www.hamc.com/CHNA/ X See Part V, Page 8 X 1 21 1 https://www.hamc.com/CHNA/ 0 1 X 200.000000000000 300.000000000000 1 1 X X X X 1 X https://www.hamc.com/patient-forms#CCP X https://www.hamc.com/patient-forms#CCP X https://www.hamc.com/patient-forms#CCP X X X X X X 1 X 0 X X X X 1 X 0 0 Heart of America Medical Center Part V, Section B, Line 5: Our initial task force involved public health, city government, local school, pastoral and HAMC representation. Our community meetings involved those areas along with agricultural, business owners, first responders, and social services representation from our service area. We collaborated with Lake Region District Health Unit for conducting our CHNA. The representative from our local office attended task force meetings, distributed surveys to patients, was involved in press releases and participated in community meetings. Surveys were available online as well as paper in several locations. Throughout the process, task force and community meetings were held intermittently from September 2021 through January 2022. CRH conducted community interviews for informational purposes. Heart of America Medical Center Part V, Section B, Line 6b: Lake Region District Health Unit & UND Center for Rural Health Heart of America Medical Center Part V, Section B, Line 11: The Hospital will address the following needs from the most recently conducted CHNA: attaining and retaining young families/having enough daycare services, availability of mental health services, and not enough healthcare staff in general. The organization will not address cost of health insurance, jobs with livable ages, and affordable housing needs due to limited resources and the need to allocate significant resources to the three priority health needs identified above.In the current year the facility has taken actions to address the following:-Availability of mental health services: The organization attempted to recruit a mental health therapist. The offer was turned down as the individual received an offer from another organization as it is a highly competitive environment. Primary care providers are providing most mental health services to increase awareness to the community so those individuals can reach out to their providers. Rugby has a mental health specialist coming to Rugby as they are working to secure a location up in the Main Street district. -Attaining and retaining young families/having enough daycare services: We added staff and expanded the rooms to accommodate a few more children. We offer a daycare stipend for licensed daycare facilities outside of our own for staff to still utilize daycare facilities around the community.-Not enough healthcare staff in general: There continues to be a struggle for recruitment and retention of staff for all healthcare facilities. We have expanded our recruitment strategies as well as offered education reimbursement opportunities. We implemented a sign on bonus as well as a referral bonus. We increased our wages to be competitive in the market and attempted to minimize the impacts of contract labor nursing and CNA coverage. Heart of America Medical Center Part V, Section B, Line 15e: As part of the application process the patient will provide name, demographic information, occupation, employer, spouses demographic information, dependent information, and insurance information. Documentation that may be required to assist with processing of application to include pay stubs, itemized income and expenses, verification from welfare agency, verification from unemployment or workers compensation, or income tax returns as supporting documentation. Part V, Line 7b: Other Website:https://ruralhealth.und.edu/projects/community-health-needs-assessment/reports 7 1 - Heart of America Nursing Facility 800 S Main Ave Rugby ND 58368 Long-term Skilled Care Nursing Facility 2 - Haaland Estates Basic Care 1025 3rd Ave SE Rugby ND 58368 Basic Care Nursing Facility 3 - Haaland Estates Assisted Living 1025 3rd Ave SE Rugby ND 58368 Assisted Living Facility 4 - Heart of America Johnson Clinic 800 S Main Ave Rugby ND 58368 Rural Health Clinic 5 - Heart of America Johnson Clinic 215 Main St SE Dunseith ND 58329 Rural Health Clinic 6 - Heart of America Johnson Clinic 301 Roosevelt Ave Maddock ND 58348 Rural Health Clinic 7 - Heart of America Hospice 800 S Main Ave Rugby ND 58368 Hospice care Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Community Health Improvement Services, line 7e, reflects actual expenses recorded to the general ledger. Subsidized health services, line 7g, were calculated based on information from the Cost Report. Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concession based on its historical collection experience with this class of patients. Part III, Line 3: The Organization estimated the implicit price concessions attributable to patients who likely would qualify for financial assistance by applying the percentage of financial assistance applications sent out but not received back or not completed. Part III, Line 4: The footnote to the Organization's financial statements related to implicit price concessions can be found on page 14-15 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs were obtained from the Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.Good Samaritan Hospital Association is a critical access hospital and is reporting a Medicare shortfall due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit. Part III, Line 9b: Our accounts are worked effectively and thoroughly with self-pay statements printed monthly once insurances have met their obligations. The goal is to obtain payment in full, establish acceptable payment arrangements, and look at other appropriate agencies or low income programs, or offer the charity care program if needed. In the collection process, the bill guarantor is reminded they may qualify for our charity care program and are given information on how to apply. Our third party collection company also offers charity care during collection calls. The statements explain who to call for a charity care application. Our charity program is income based and patients have 120 days to submit a financial assistance application, and uses 200% of the Federal poverty guidelines. If they qualify, the bill is written off 100% to charity care. Once approved they qualify for assistance for 6 months before and 6 months after of the approval date. After 120 days in collections, the account is written to bad debt. At least 30 days before we take extraordinary collection action we send notification. Up to 240 days we accept application and stop collection actions and reverse the collection effort. Part VI, Line 2: Heart of America Medical Center and its associated facilities serves a smaller community where providers know their patients. GSHA board members live in the communities we serve. We expect board members to bring back concerns of their communities so we can prioritize the needs. We also receive valuable community feedback from the HAMC Auxiliary Board and dozens of volunteers who contribute thousands of hours to the hospital and our long-term care and basic care facilities. Part VI, Line 3: Good Samaritan Hospital Association, doing business as Heart of America Medical Center, provides medical care regardless of patients' ability to pay. We provide information on federal, state and local payment assistance programs prior to the rendering of services or, in emergency situations, as soon as is appropriate. HAMC Community (Charity) Care is available for inpatient and outpatient hospital services, clinic services and swing bed care. Social work staff provide patients with this information. Patients can also find Community Care information on our website and it's also included with information on our Prompt Payment Discount program. Staff members processing self-pay bills encourage patients to apply for Community Care and our third-party collection company encourages patients to apply for Community Care if they are experiencing financial hardships. Part VI, Line 4: Heart of America Medical Center is a 25 bed Critical Access Hospital Designated Level V trauma center, Chemotherapy/infusion suite, surgical suite, pharmacy, lab, and radiology (including MRI on site). Outpatient services include wellness center, sports medicine, pain clinic, and diabetes education. Also, located in Rugby, N.D is the LTC nursing home and the separate campus at Haaland Estates which includes 60 basic care beds with a memory care unit and a 37-bed assisted living apartment building. Heart of America Johnson Clinics are in Rugby, Dunseith, and Maddock, N.D., serving people within a 50-mile radius of Rugby. The closest tertiary facility is 65 miles to the west. Our primary service area is Pierce County and portions of Benson, McHenry, Rolette, Wells, Towner, Sheridan, and Bottineau counties. According to the Fiscal Year 2022 CHNA, HAMC is providing crucial medical services to more than 13,000 people in their service area. Roughly 300 employees make HAMC the largest employer in the region. HAMC has a significant economic impact on the region with the annual payroll utilized in the region which also leads to additional jobs and income for the region as they interact with other sectors of the local economy. The population in Pierce County is 3,945, of which the majority have insurance via employers 71%, 13% Medicare, 12% self-insured, 6% Indian Health Services (IHS), 4% Medicaid, 3% Veterans Choice, 3% No insurance, 6% Other. Major employers in Rugby and Pierce County are the HAMC, Rugby Manufacturing, and the public schools. Part VI, Line 5: Good Samaritan Hospital Association is sponsored by 14 member churches located throughout our service area. The GSHA board of directors reside in our primary service area, are engaged in various occupations and activities, and are elected by GSHA member churches. Through Heart of America Johnson Clinics, Heart of America Medical Center has a presence Rugby, Dunseith and Maddock, N.D., providing our patients with health care services close to home. We make specialty services in ophthalmology, podiatry, audiology, and mental health available to our patients through partnerships with specialty clinics and providers. We offer a shared OB service with Trinity which allows patients to see their primary care provider for up to 30 weeks. We offer state-of-the-art cancer treatment in our chemotherapy suite and recently added life-saving 3D mammography equipment to our radiology department. Heart of America Hospice provides personalized, holistic end-of-life care and services for local hospice patients and their families in a 60-mile radius of Rugby. Without GSHA we would be unable to offer the following service: hospital, 24hr emergency room, rural health clinics surgical clinic, skilled nursing care facility, basic case facility, assisted living facility, wellness/fitness center in our service area, leaving our patients and residents with a healthcare gap. We operate many of these programs at a loss, but we continue to offer them to serve the needs of the people who live in our communities and service area. For those providers that apply to HAMC they have privileges in our community once approved by the board of directors as presented by the medical staff at the Board meetings.GSHA offers cancer treatments to our patients and communities. This affords them the ability to stay closer to home in a time of vulnerability. GSHA operates a fully staffed ambulance department as the community did not have the ability to operate an ambulance service. This is not a cost reimbursed ambulance service due to the proximity of other ambulance services in other rural areas but provides a great need for our community in (245) 911 calls, and 151 transfers to tertiary facilities. GSHA participates in education reimbursement to staff to recruit and retain staff as well as bring new families to Rugby. GSHA offers a daycare fringe benefit to bring parents back into the workforce or to retain them when they start families affording them the opportunity to work and to utilize daycare services onsite. Being a community minded organization has caused some financial inefficiencies but being the largest employer in the community and region has put pressure on the organization to offer as much as they can and more.Surplus funds, if available, are used to improve the facility for patient care and upgrade the medical equipment on order to plan for our organization's future and the community to be prepared for the continuous changes in the healthcare model. Part VI, Line 6: GSHA is not part of an affiliated healthcare system, however, as a Critical Access Hospital we provide and promote high-quality care for our patients via rural health network agreements with Trinity Medical Center in Minot and Med Center One in Bismarck, N.D. These agreements enhance our patients' continuity of care by identifying and forming processes that facilitate patient referrals and easy transfer between facilities and enhance communication between providers. GSHA is affiliated with Altru's out of Grand Forks with the (EHR) Epic system. GSHA is participating in the BCBS ACO and a Medicare ACO to ensure our patients are receiving the appropriate care. 1 Good Samaritan Health Services Foundation 800 S Main Avenue Rugby ND 58368 363513553 501(c)(3) 50000 0 To support build 2024 capital campaign 1 0 Part I, Line 2: The Hospital gave the Foundation an allocation to be used to grow the capital campaign funds for the Build 2024 project. The proceeds were given to support the new building project for the updated Healthcare Campus. The Board approved the transfer to the Foundation per CEO contract agreement. X X X X 0 0 0 0 0 0 0 0 0 Ronald Skipper MD ER Provider 350201 0 3700 0 0 0 7201 0 29446 0 390548 0 0 0 Cammy Kelsch FNP-C ER Provider 300530 0 3700 0 0 0 7641 0 31726 0 343597 0 0 0 Steven Schoneberg MD Physician 258175 0 8700 0 0 0 6702 0 25111 0 298688 0 0 0 Chelsey Wyatt CRNA 246787 0 3700 0 0 0 1127 0 30340 0 281954 0 0 0 Josalynne Hoff Rue MD Physician 234596 0 8700 0 1082 0 5911 0 31664 0 281953 0 0 0 Dustin Hager COO & Provider 183944 0 8808 0 0 0 4357 0 31836 0 228945 0 0 0 Erik Christenson Secretary - CEO 111689 0 3700 0 0 0 3109 0 31778 0 150276 0 0 0 Sarah Christenson Family member of CEO 77985 Compensation 0 Lauren McClintock Family member of CEO 63453 Compensation 0 Carlie Johnson Family member of board member Tanner Johnson 48940 Compensation 0 Scott Brossart Family member of CEO 52563 Compensation 0 Ashley Griffin Family member of board member Will Griffin 24460 Compensation 0 Ally Graner Family member of board member Mike Graner 10803 Compensation 0 Form 990, Part VI, Section A, line 1a The Executive Committee consists of all the Board of Trustees residing in the Rugby community plus the Chairman of the Board of Trustees. The Executive Committee shall have the power to transact all regular business of the hospital during the interim between meetings of the Board of Trustees and it shall refer to all matters of major importance to the Board. Form 990, Part VI, Section A, line 6 Membership in the corporation shall consist of such Lutheran congregations which are now members of this Association and such other congregations as shall from time to time apply for membership herein. The Congregational members of the Organization shall be represented by the following 4 specific designations: -4 From Rugby/Balta/Orrin -1 From Towner/Willow City -1 from Rolette/Wolford/Dunseith -1 from Leeds/Maddock The Board of Trustees shall also have at least one physician representative and, in its discretion, two members at large Trustees, one of whom shall have a background in legal or insurance and another who shall have a background in finance both of whom shall reside in the geographical region served by the Association. The physician representative shall be a non-voting representative appointed by the Board of Trustees. Form 990, Part VI, Section A, line 7a Each member church has up to three voting delegates at the annual meeting where the board of directors is elected to serve on the board. Form 990, Part VI, Section A, line 7b Amendments to the Articles of Incorporation must be voted on by a two-thirds majority vote of the members. Amendments to Bylaws must be voted on by a two-thirds majority vote of the Board of Trustees. Form 990, Part VI, Section B, line 11b The Board receives an electronic copy of the draft Form 990 prior to a board meeting to review. An overview of the 990 is provided as part of the financial summary for the Board during the actual board meeting to answer any questions they may have as well. A motion is made to approve the draft. Form 990, Part VI, Section B, line 12c Covered Persons: All employees, managers, medical staff, executive leadership, board members, volunteers, contractors, and others engaged in the work place. A conflict of Interest Statement must be signed by each board member and shall be dated no later than December 31st of each year. Determination of conflict: All employees and board members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Conflict review: Actual or potential board member conflicts of interest must be disclosed to the Corporate Compliance Committee (CCC). The CCC will handle reports or concerns of situations that may give rise to a conflict of interest with the assistance of legal counsel. The CCC will issue its decision to the Covered Persons in writing and will document and file its decision. Restrictions on those with a conflict: In self-dealing transactions the board member shall not participate in the board decision-making and shall make full disclosure of their interests. If the fairness of the transaction is questioned, the burden of establishing fairness falls upon the trustee involved and the board member must seek guidance and approval from the CCC prior to pursuing any business or personal activity that may constitute a conflict of interest. Form 990, Part VI, Section B, line 15 Comparative data is reviewed and incorporated into the review process such as looking at state wage survey data. For the CEO, each board member completes their own evaluation form. The human resource committee reviews the responses and makes a recommendation to the full board. The full board decides on any changes to CEO compensation. The review is done annually at time of anniversary date of contract. The board typically does not approve wages for other positions. The CEO approves the CFO wages. Comparative data is used throughout the facility and incorporated into the annual review of employee wages done by the department head or supervisor. Wages are compared to the NDHA annual salary survey report at the time of their annual review. Form 990, Part VI, Section C, line 19 These documents are available upon request. Financial statements are available for viewing by the public at all board meetings. Form 990, Part VI, Line 16b: The Organization is a 49% owner in a retail pharmacy located in the clinic building. The pharmacy bylaws requires an annual board meeting including representatives of the Hospital. The meeting evaluates the joint venture arrangement and assures the facility is not violating its tax exempt status. The pharmacy is organized and operating as a C-Corporation. Form 990, Part XI, line 9: Change in interest in net assets of Foundation 3,315,817. Change in interest in net assets of Auxillary 5,650. Good Samaritan Health Services Foundation 800 South Main Ave Rugby ND 58368 363513553 Fundraising for Good Samaritan Hospital Association ND 501(c)(3) Line 7 Good Samaritan Hospital Association 1 0 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 Good Samaritan Health Services Foundation C 1453251 Accrual Good Samaritan Health Services Foundation B 50000 Accrual