2022-04-28T13:40:25-05:00 2021-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-07-01 450306787 CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION CAVA 7012566172 909 SECOND STREET LANGDON ND 58249 JEFF STANLEY CEO 7012566172 2022-04-28 1 JEFF STANLEY 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-04-28 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z LANGDON PRAIRIE HEALTH JEFF STANLEY 909 SECOND STREET LANGDON ND 58249 14821982 0 X HTTPS://WWW.LPH.HOSPITAL/ X 1969 ND RURAL HEALTHCARE FACILITY PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES. 6 6 113 6 0 0 1143081 3520923 10002012 10848630 15385 52516 246017 370277 11406495 14792346 0 0 0 0 4988021 4772067 0 0 0 4322122 5315485 9310143 10087552 2096352 4704794 17676887 86296549 6869805 70358224 10807082 15938325 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 7651207 0 10903123 PROVIDE PATIENT HEALTHCARE SERVICES INCLUDING HOSPITAL AND CLINIC TO SURROUNDING COMMUNITY. THE ORGANIZATION PROVIDED APPROXIMATELY $50,000 OF CHARITY CARE DURING THE YEAR ENDED 06/30/2021. 7651207 1 1 0 0 0 0 0 0 0 0 1 0 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 14 0 113 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X MARGARET FONTANA 7012566172 909 SECOND STREET LANGDON ND 58249 JERRY NOWATZKI PRESIDENT 1.00 X X 0 0 0 JAY DUBOIS VICE PRESIDENT 1.00 X X 0 0 0 DAWN ROPPEL SECRETARY 1.00 X X 0 0 0 KATHRYN KOPF TREASURER 1.00 X X 0 0 0 RUNA ANDERSON DIRECTOR 1.00 X 0 0 0 TODD GETTE DIRECTOR (TERM 4/21) 1.00 X 0 0 0 KAREN RING DIRECTOR (TERM 9/20) 1.00 X 0 0 0 SHAUNA SCHNEIDER DIRECTOR 1.00 X 0 0 0 JANINE WITZEL DIRECTOR (TERM 11/20) 1.00 X 0 0 0 JEFF STANLEY CEO 40.00 X 223278 0 10787 WILLIAM VAN NOY CFO (TERM 2/21) 40.00 X 169365 0 11766 CHARLES EMERSON CMO (TERM 9/20) 40.00 X 189617 0 8560 DARLA RODER COO 40.00 X 122132 0 15124 JAMIE NIENHUIS CNO 40.00 X 105195 0 13306 ALLAN SCROGGINS INTERIM CFO (BEG. 3/21) 40.00 X 0 0 0 DAVID KAVISH PHARMACIST 40.00 X 119700 0 3901 COURTNEY SHORT FNP 40.00 X 125753 0 899 MARK HILL FNP 40.00 X 177930 0 15685 1232970 0 80028 8 0 1 0 JOHNSON CONTROLS INC DEPT CH 10320 PALATINE IL 600550320 HVAC SYSTEM AND SERVICE 1991543 NATIONAL MEDICAL RESOURCES INC 2792 E BROADWAY AVE BISMARCK ND 58501 PROVIDER CONTRACT SERVICES 593710 CEPHEID 904 CARRIBEAN DR SUNNYVALE CA 94089 LABORATORY SERVICES 593346 OK COMPUTER 525 WEST MAINE STREET ENID OK 73701 IT CONTRACT SERVICES 185315 AGILITI HEALTH INC PO BOX 851313 MINNEAPOLIS MN 55485 LABORATORY SERVICES 159911 6 3518933 1990 3520923 NET PATIENT REVENUE 621400 10009320 10009320 340B PHARMACY REVENUE 621400 652319 652319 LANGDON COUNTY AMBULANCE 621910 186991 186991 10848630 82152 82152 14024 0 14024 14024 14024 29636 -29636 -29636 -29636 356253 54493 301760 356253 14792346 10903123 0 368300 X 766244 96214 670030 3325594 3124356 201238 43320 43320 351388 304287 47101 285521 227076 58445 38939 38939 155757 155757 2159391 1613833 545558 55522 11531 43991 207374 207374 137481 106610 30871 59753 26747 33006 10518 9958 560 75082 59214 15868 821859 648162 173697 68221 120 68101 MEDICAL SUPPLIES 924990 924990 REPAIRS & MAINTENANCE 255994 254447 1547 EQUIPMENT RENTAL 91362 90182 1180 NON-MEDICAL SUPPLIES 71331 58438 12893 181911 51722 130189 10087552 7651207 2436345 0 110166 10881 9963738 6472412 858962 1495870 184903 173223 62107 282874 17142081 9621150 4145735 7520931 2351276 2777725 0 67562633 17676887 86296549 623113 826900 4730626 1442480 1019878 842274 126531 61437 47497 0 322160 67185133 6869805 70358224 X 8455806 13160600 2351276 2777725 10807082 15938325 17676887 86296549 X 4704794 426449 X X 0 1 X 1 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13167 13167 8534730 4780362 3754368 5089429 4840788 248641 3504755 3504755 7520931 ASSETS LIMITED AS TO USE - MEDICARE 67562633 67562633 DUE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 67185133 67185133 14792346 0 14792346 0 14792346 10087552 0 10087552 0 10087552 1 1 X 1 X 1 X 1 1 0 1 1 49337 49337 0.00490 221585 363305 0 0.00000 270922 363305 49337 0.00490 3308594 854669 2453925 0.24330 3308594 854669 2453925 0.24330 3579516 1217974 2503262 0.24820 0 0 6127444 6063485 63959 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 18 1 0 1 1 X SEE SUPPLEMENTARY INFO X 1 18 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 HOSPITAL'S CHNA INCLUDED COMMUNITY INPUT THROUGH SURVEYS, A COMMUNITY GROUP, AND ONE-ON-ONE INTERVIEWS. THE PROCESS WAS OVERSEEN BY A COMMITTEE CONSISTING OF LEADERS FROM CAVALIER COUNTY MEMORIAL HOSPITAL, CAVALIER COUNTY HEALTH DISTRICT, AND A COMMUNITY REPRESENTATIVE. THE HOSPITAL DISTRIBUTED A BROAD COMMUNITY SURVEY TO THE COMMUNITY MEMBERS. 33 OUT OF 82 SURVEYS WERE COMPLETED AND RETURNED. THE CHNA REPORT CONTAINS VARIOUS DEMOGRAPHIC INFORMATION OF THE SURVEY PARTICIPANTS. IN ADDITION, A COMMUNITY GROUP CONSISTING OF SEVEN COMMUNITY MEMBERS MET ON MULTIPLE OCCASIONS TO PROVIDE INPUT. FINALLY, ONE-ON-ONE INTERVIEWS WERE HELD WITH FIVE KEY COMMUNITY MEMBERS TO OBTAIN THEIR INPUT. CAVALIER COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: CAVALIER COUNTY MEMORIAL HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT WITH CAVALIER COUNTY HEALTH DEPARTMENT.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: CAVALIER COUNTY MEMORIAL HOSPITAL, IN PARTNERSHIP WITH CAVALIER COUNTY HEALTH DEPARTMENT, CONDUCTED A CHNA OF THE AREAS IN WHICH WE SERVE. THE INTENTION WAS TO DISCOVER THE WANTS, NEEDS AND DESIRES OF OUR POPULATION AS IT RELATES TO HEALTH CARE RELATED ISSUES. THIS PROJECT WAS ENTERED INTO WITH THE UNDERSTANDING THAT MANY SOCIAL FACTORS AFFECT THE OVERALL HEALTH OF THE COMMUNITY. FOR THIS REASON, A VARIETY OF QUESTIONS WERE ASKED TO GAIN A FULL UNDERSTANDING OF COMMUNITIES' VALUES AS IT RELATES TO THEIR HEALTH CARE DECISIONS. TO ENTICE INDIVIDUALS TO PARTICIPATE. CCMH USED ITS PERSONAL FUNDS TO PURCHASE PRIZES, FOR A RANDOM DRAWING FROM ALL THAT PARTICIPATED. WHILE THERE WERE MANY MORE AREAS OF OPPORTUNITY, CCMH BELIEVES THAT IT WILL TAKE A COMMUNITY EFFORT TO ACCOMPLISH MANY OF THESE GOALS, AND WANT TO PARTNER WITH THE COMMUNITY ON ANY INITIATIVE THAT INDIVIDUALS OR OTHER ORGANIZATIONS WOULD LIKE TO FOCUS ATTENTION. THREE AREAS OF CONCERN WERE IDENTIFIED: ABILITY TO RETAIN PRIMARY CARE PROVIDERS, DEPRESSION/ANXIETY AND ALCOHOL USE AND ABUSE. CCMH HAS BEGUN A FOCUS ON IMPROVING PROVIDER AVAILABILITY, EDUCATION AND RECRUITING NEW PROVIDERS IN WAYS THAT HAVE NOT BEEN DONE PREVIOUSLY, SUCH AS ADDING SERVICES (COLONOSCOPY) AND TELEHEALTH SERVICES. CCMH IS ALSO DEDICATED TO IMPROVING THE LIVES OF THE COMMUNITY THROUGH OVERALL WELLNESS. WE HAVE CREATED A MENTAL HEALTH TASK FORCE WHICH MEETS MONTHLY (LESS OFTEN WITH COVID) WHICH PROVIDES COUNSELING SERVICES WEEKLY TO AREA SCHOOLS, DISCUSS' VAPING WITH STUDENT ATHLETES, PROVIDES DRUG DEACTIVATION BAGS, PERSONAL STORIES OF ADDICTION, TOBACCO CESSATION TRAINING AND PROMOTIONAL CAMPAIGNS. WE HAVE IMPLEMENTED DEPRESSION SCREENING QUESTIONS AND AVAILABILITY FOR ASSISTANCE. WE HAVE PROMOTED SERVICES TO HELP WITH DEPRESSION AND ALCOHOL USE AND ABUSE. PART OF THIS IS MAKING THE PUBLIC AWARE OF THE SERVICES OFFERED AND ENCOURAGING THEM TO UTILIZE LOCAL FACILITIES. THROUGHOUT THE 2021 FISCAL YEAR, JULY 2020-JUNE 2021, CCMH CONTINUED OFFERING A SERIES OF CHARITY EVENTS THAT ENCOURAGE AN ACTIVE LIFE-STYLE UNTIL COVID RESULTED IN THE CANCELLATION OF EVENTS. CCMH HOPES TO IMPACT CHANGE WITHIN THE COMMUNITY THAT IT SERVES AND PROMOTE INCREASED SERVICES AND AVAILABILITY AS COVID REDUCES.LANGDON PRAIRIE HEALTH, IN PARTNERSHIP WITH CAVALIER COUNTY HEALTH DEPARTMENT CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT IN TAX YEAR 2018 TO IDENTIFY AND ADDRESS ANY NEEDS EXPRESSED BY THE COMMUNITY, TO AID LPH IN FUTURE DECISIONS AND STRATEGIC PLANNING. THE TAX YEAR 2018 CHNA WAS FACILITATED BY THE ND CENTER FOR RURAL HEALTH, WHO ALSO SOLICITATED INPUT FROM THE AREA COMMUNITY MEMBERS AND HEALTHCARE PROFESSIONALS AS WELL AS AN ANALYSIS OF COMMUNITY RELATED DATA. THIRTY THREE (33) COMMUNITY MEMBERS COMPLETED THE SURVEY, WITH 82% OF THOSE RESPONDENTS RESIDING IN THE LANGDON ZIP CODE. SEVEN TOPICS WERE PRESENTED AND THE TOP 5 PRIORITIES/CONCERNS ARE AS FOLLOWS:- "BEING ABLE TO SEE THE SAME PROVIDER OVER TIME", LANGDON PRAIRIE HEALTH HAS HIRED AND SECURED "HOMEGROWN" PROVIDERS THAT HAVE COMMITTED TO STAYING/REMAINING IN LANGDON INDEFINITELY.-NOT ENOUGH PROVIDERS" - SECURED 4 NURSE PRACTITIONERS AND 1 FULLTIME MD. RECRUITED 1 FULLTIME MD TO REPLACE THE CURRENT MD WHEN HE RETIRES.-"POOR QUALITY OF CARE" AN AGREEMENT WAS SECURED BETWEEN LANGDON PRAIRIE HEALTH AND PRESS GANEY TO MONITOR PATIENT SATISFACTION, WITH CURRENT SCORES AT 90% FOR INPATIENT, OUTPATIENT, SWING BED AND CLINIC SERVICES.-NOT AFFORDABLE" - PRICE TRANSPARENCY WAS MANDATED BY CMS IN 2021 WHICH ENABLED US TO NOTE THAT OUR PRICES ARE WITHIN OUR COMPETITORS MARKET, OUR CHARITY CARE POLICY WAS REVISED, AND ALL EFFORTS ARE MADE TO IDENTIFY AND ASSIST PATIENTS THAT HAVE OUTSTANDING BALANCES OR HAVE FAILED MEDICAID ELIGIBILITY.- "DON'T KNOW ABOUT LOCAL SERVICES" LEGATO, OUR MARKETERS, DEVELOPED AN AFFORDABLE ADVERTISING CAMPAIGN AND ASSISTED US IN UTILIZING LOCAL ADVERTISING SERVICES AND MARKETING MATERIALS TO PROMOTE OUR LOCAL SERVICES. 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 - CAVALIER COUNTY MEMORIAL HOSPITAL 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 III, LINE 2: BAD DEBT EXPENSE WAS NOT TRACKED DURING THE FISCAL YEAR ENDED JUNE 30, 2021. 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 GET TURNED OVER TO OUR COLLECTION AGENCY. PART VI, LINE 2: LANGDON PRAIRIE HEALTH ASSESSES THE HEALTHCARE NEEDS OF THE COMMUNITY BY EVALUATING THE RESULTS AND PROGRESS OF PREVIOUS COMMUNITY NEEDS ASSESSMENTS AND DETERMINING IF THE PLANNED PROJECTS HAVE BEEN SUCCESSFUL. LPH HOLDS STAKEHOLDER MEETINGS MONTHLY AND ATTENDS AND PARTICIPATES IN FOCUS GROUP MEETINGS WITH THE LOCAL SENIOR CENTER, JDA, COMMUNITY COALITION COMMITTEE, FOOD BANK, AND CHAMBER OF COMMERCE. PATIENT SATISFACTION SURVEYS ARE DISTRIBUTED TO PATIENTS ON A ROUTINE BASIS THROUGH PRESS GANEY WITH THE RESULTS REVIEWED BY A PATIENT EXPERIENCE COMMITTEE WHO ADDRESS ANY HEALTHCARE CONCERNS IDENTIFIED. OUR POPULATION HEALTH NURSE PARTICIPATES IN, AND COMMUNICATES WITH, OTHER COMMUNITY LEADERS IN THE LANGDON COMMUNITY COLLABORATIVE. LPH ACTIVELY PARTICIPATES IN AN ACCOUNTABLE CARE ORGANIZATION WHICH FOCUSES ON COORDINATED CARE WITH A FOCUS ON PREVENTATIVE CARE, PREDICTING AND PREVENTING DISEASE PROGRESSION, AND INCREASES PATIENT ENGAGEMENT FOR OUR MEDICARE BENEFICIARIES. LPH HAS ALSO SECURED PLANS TO JOIN A COMMERCIAL ACO IN 2023. PART VI, LINE 3: WE HAVE OUR FAP ADVERTISED ON OUR WEBSITE. WE HAVE CONSPICUOUS SIGNS POSTED AT ALL ADMITTING AREAS REGARDING OUR FAP. ANY PATIENT THAT MAY BE ELIGIBLE IS OFFERED OUR APPLICATION/POLICY AT TIME OF ADMISSION. OUR FAP IS ADVERTISED WITH THE COMMUNITY CALENDAR IN THE LOCAL NEWSPAPER. WE HAVE A PATIENT INFORMATION HANDBOOK, WHICH DESCRIBES THE GOVERNMENT PROGRAMS SUCH AS MEDICARE AND MEDICAID. IT ALSO MENTIONS THAT WE OFFER CHARITY CARE AND TO CONTACT THE BUSINESS OFFICE MANAGER OR THE SOCIAL WORKER IF INTERESTED IN THIS PROGRAM. IN ADDITION, THE HOSPITAL HAS ALSO INCLUDED LETTERS WITH SUBSEQUENT STATEMENTS THAT OUTLINE THE FINANCIAL ASSISTANCE POLICY AND CONTACT INFORMATION FOR PATIENTS WHO ARE INTERESTED IN APPLYING FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: CAVALIER COUNTY IS A COUNTY IN THE U.S. STATE OF NORTH DAKOTA. IT IS SOUTH OF THE MANITOBA, CANADA-US BORDER. AS OF THE 2020 UNITED STATES CENSUS, THE POPULATION WAS 3,704. ITS COUNTY SEAT IS LANGDON. THE RACIAL MAKEUP OF THE COUNTY WAS 97.7% WHITE, 0.9% AMERICAN INDIAN, 0.2% ASIAN, 0.1% BLACK OR AFRICAN AMERICAN, 0.2% FROM OTHER RACES, AND 0.8% FROM TWO OR MORE RACES. THOSE OF HISPANIC OR LATINO ORIGIN MADE UP 0.6% OF THE POPULATION. IN TERMS OF ANCESTRY, 44.5% WERE GERMAN, 28.8% WERE NORWEGIAN, 10.8% WERE AMERICAN, 5.8% WERE IRISH, 5.7% WERE SWEDISH, AND 5.4% WERE ENGLISH.OF THE 1,818 HOUSEHOLDS, 21.8% HAD CHILDREN UNDER THE AGE OF 18 LIVING WITH THEM, 55.7% WERE MARRIED COUPLES LIVING TOGETHER, 4.0% HAD A FEMALE HOUSEHOLDER WITH NO HUSBAND PRESENT, 37.2% WERE NON-FAMILIES, AND 34.2% OF ALL HOUSEHOLDS WERE MADE UP OF INDIVIDUALS. THE AVERAGE HOUSEHOLD SIZE WAS 2.15 AND THE AVERAGE FAMILY SIZE WAS 2.74. THE MEDIAN AGE WAS 50.3 YEARS.THE MEDIAN INCOME FOR A HOUSEHOLD IN THE COUNTY WAS $48,786 AND THE MEDIAN INCOME FOR A FAMILY WAS $57,066. MALES HAD A MEDIAN INCOME OF $41,885 VERSUS $26,914 FOR FEMALES. THE PER CAPITA INCOME FOR THE COUNTY WAS $26,468. ABOUT 6.1% OF FAMILIES AND 8.2% OF THE POPULATION WERE BELOW THE POVERTY LINE, INCLUDING 12.8% OF THOSE UNDER AGE 18 AND 10.8% OF THOSE AGE 65 OR OVER.AREA: 1,510 MIFOUNDED: 1879POPULATION: 3,803 (2019)COUNTY SEAT: LANGDONUNEMPLOYMENT RATE: 2.7% (DEC 2021) PART VI, LINE 5: LANGDON PRAIRIE HEALTH SUPPORTS IT'S EXEMPT STATUS BY PROVIDING AND SUPPORTING THE PUBLIC WITH A WRITTEN FINANCIAL ASSISTANCE POLICY, EMERGENCY MEDICAL POLICY AND COMPLIES WITH ALL EMTALA REGULATIONS, WHICH PROVIDES EMERGENCY SERVICES TO ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. LPH ASSURES THAT PATIENTS THAT ARE ELIGIBLE FOR FINANCIAL ASSISTANCE ARE NOT CHARGED MORE THAN PATIENTS WHO HAVE INSURANCE AND DOES NOT BILL GROSS CHARGES TO PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE. LPH ALSO MAKES "REASONABLE EFFORTS" TO DETERMINE IF A PATIENT IS ELIGIBLE FOR FINANCIAL ASSISTANCE UNDER THE CURRENT LPH FINANCIAL POLICY. THE LPH BOARD OF DIRECTORS CONSISTS OF MEMBERS OF THE OUR LOCAL COMMUNITY WHO ARE RESPONSIBLE FOR THE FISCAL OVERSIGHT OF LPH. ANY SURPLUS FUNDS ARE USED TO IMPROVE THE FACILITY, EQUIPMENT AND PATIENT CARE. SURPLUS FUNDS ARE ALSO USED TO ADVANCE STAFF MEDICAL TRAINING AND EDUCATION. PART VI, LINE 7, REPORTS FILED WITH STATES ND X X 0 0 0 0 0 0 0 0 0 JEFF STANLEY CEO 195778 0 27500 0 0 0 6813 0 3974 0 234065 0 0 0 CHARLES EMERSON CMO (TERM 9/20) 189617 0 0 0 0 0 0 0 8560 0 198177 0 0 0 MARK HILL FNP 165469 0 12461 0 0 0 3918 0 11767 0 193615 0 0 0 WILLIAM VAN NOY CFO (TERM 2/21) 156990 0 12375 0 0 0 0 0 11766 0 181131 0 0 0 A CITY OF LANGDON NORTH DAKOTA 456002108 515679AL2 2010-03-25 2500000 HOSPITAL RENOVATION PROJECT 0 0 0 A 1630000 2500000 50000 2450000 2012 0 0 1 1 A 0 0 0 0 0 0 0 A 0 0 0 1 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF LANGDON, NORTH DAKOTA DATE THE REBATE COMPUTATION WAS PERFORMED: 02/28/2020 SCHEDULE K, PART IV, LINE 2C: THE REBATE COMPUTATION WAS PERFORMED 03/30/2015. 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 930,148. MANAGEMENT AND GENERAL EXPENSES 12,986. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 943,134. OTHER SERVICES: PROGRAM SERVICE EXPENSES 683,685. MANAGEMENT AND GENERAL EXPENSES 532,572. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,216,257. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 426,449.