JACOBSON MEMORIAL HOSPITAL CARE CENTER: Form 990, tax year 2020
View the entire original 990 at ProPublica ↗
- Organization
- JACOBSON MEMORIAL HOSPITAL CARE CENTER (EIN 45-0222079)
- Tax period
- 2020-07-01 to 2021-06-30
- Filed
- 2022-05-12
- IRS object ID
- 202221329349303492
- Schema version
- 2020v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-05-12T12:23:17-05:00 | ReturnTs |
| Tax Period End | 2021-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1730 Burnt Boat Loop Ste 100 | AddressLine1Txt |
| City | Bismarck | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 585030886 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2020-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450222079 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | JACO | BusinessNameControlTxt |
| Phone | 7015842792 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Theo Stoller | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7015842792 | PhoneNum |
| Signature | 2022-05-12 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | Theo | PersonFirstNm |
| Person Last | Stoller | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Lisa Chaffee CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012551091 | PhoneNum |
| Preparation | 2022-05-12 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 2 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2020 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Theo Stoller | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $13,559,749 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.jacobsonhospital.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1949 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | To provide quality healthcare to advance the health of patients and communities we serve. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 116 | TotalEmployeeCnt |
| Total Volunteers | 15 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $692,306 | PYContributionsGrantsAmt |
| CY Contributions Grants | $2,641,917 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $9,543,932 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $10,899,612 | CYProgramServiceRevenueAmt |
| PY Investment Income | $2,853 | PYInvestmentIncomeAmt |
| CY Investment Income | $8,420 | CYInvestmentIncomeAmt |
| PY Other Revenue | $270 | PYOtherRevenueAmt |
| CY Other Revenue | -$45 | CYOtherRevenueAmt |
| PY Total Revenue | $10,239,361 | PYTotalRevenueAmt |
| CY Total Revenue | $13,549,904 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $4,916,375 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $5,541,338 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $5,034,839 | PYOtherExpensesAmt |
| CY Other Expenses | $5,505,035 | CYOtherExpensesAmt |
| PY Total Expenses | $9,951,214 | PYTotalExpensesAmt |
| CY Total Expenses | $11,046,373 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $288,147 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $2,503,531 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $10,466,605 | TotalAssetsBOYAmt |
| Total Assets EOY | $10,807,762 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,817,086 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $4,654,852 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $3,649,519 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $6,152,910 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To advance the health of patients and communities we serve through a culture of leadership, continuous improvement and accountability. Jacobson Memorial Hospital Care Center (JMHCC) understands the relationship that exists between body, mind and the human spirit. We believe that respect, integrity, quality, commitment and accountability are the foundation by which a healthcare provider should practice in accordance with respect of this relationship. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $9,373,403 | ExpenseAmt |
| Revenue | $10,899,612 | RevenueAmt |
| Desc | Jacobson Memorial Hospital Care Center (JMHCC) is a 25 bed non-profit hospital organization in Elgin, North Dakota. The Board of Directors is made up of community members from the surrounding areas served by JMHCC. JMHCC's primary activity is to provide health care to Grant County. It provides acute care services, ER, swing bed, and clinical services. JMHCC also provides a wide range of outpatient services such as physical, speech and occupational therapy and cardiac rehab. JMHCC provides non-emergency services through clinics in the communities of Elgin, Glen Ullin, and Richardton, in addition to the emergency services it provides in Elgin. | Desc |
| Total Program Service Expenses | $9,373,403 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 15 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 116 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Scott Ostenson | PersonNm |
| Phone | 7015847236 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| Leslie Niederman | |||||||
| Chairperson | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Joel Klein | |||||||
| Vice Chair | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Julie Armijo | |||||||
| Secretary | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Ann Hertz | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Marcy Haase | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Ron Bartz | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Patrick Diehl | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Dennis Sabin | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| JoAnn Schatz | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Theo Stoller | |||||||
| CEO/Administrator | 40.00 | Yes (X) | $224,884 | $0 | $11,377 | ||
| Scott Ostenson | |||||||
| CFO | 40.00 | Yes (X) | $107,156 | $0 | $7,522 | ||
| Carey Rivinius | |||||||
| DNP | 32.00 | $138,540 | $0 | $22,072 | Yes (X) | ||
| Carrie Gerving | |||||||
| FNP | 32.00 | $133,895 | $0 | $21,811 | Yes (X) | ||
| Rhonda Schmidt | |||||||
| FNP | 32.00 | $114,981 | $0 | $21,592 | Yes (X) | ||
| Elizabeth Sundberg | |||||||
| MD | 32.00 | $218,358 | $0 | $13,107 | Yes (X) | ||
| Jolene Engelhart | |||||||
| FNP | 32.00 | $111,316 | $0 | $19,426 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,049,130 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $116,907 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 9 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Medical Solutions | |||||
| PO Box 310737 | Des Moines | IA | 50331 | Travel Nurses | $632,571 |
| Avant | |||||
| PO Box 744554 | Atlanta | GA | 30374 | Travel Nurses | $516,511 |
| ARL INC | |||||
| 7205 68th Ave SW | Elgin | ND | 58533 | Contracted Physician | $361,725 |
| Titan Nurse Staffing | |||||
| 2110 S 169th Plaza | Omaha | NE | 68130 | Travel Nurses | $202,987 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $2,634,917 | GovernmentGrantsAmt |
| All Other Contributions | $7,000 | AllOtherContributionsAmt |
| Total Contributions | $2,641,917 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (4 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Net Patient Revenue | 623000 | $10,255,206 | $10,255,206 |
| Pharmacy Revenue | 446110 | $404,922 | $404,922 |
| Management Revenue | 900099 | $135,256 | $135,256 |
| Other Revenue | 900099 | $104,228 | $104,228 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $10,899,612 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $8,420 | TotalRevenueColumnAmt |
| Exclusion | $8,420 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $9,800 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $9,845 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -$45 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$45 | TotalRevenueColumnAmt |
| Exclusion | -$45 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $13,549,904 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $10,899,612 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $8,375 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $330,779 | TotalAmt |
| Management And General | $330,779 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $106,371 | TotalAmt |
| Program Services | $106,371 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,969,376 | TotalAmt |
| Program Services | $3,611,225 | ProgramServicesAmt |
| Management And General | $358,151 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $93,633 | TotalAmt |
| Program Services | $84,466 | ProgramServicesAmt |
| Management And General | $9,167 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $716,847 | TotalAmt |
| Program Services | $676,863 | ProgramServicesAmt |
| Management And General | $39,984 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $324,332 | TotalAmt |
| Program Services | $279,221 | ProgramServicesAmt |
| Management And General | $45,111 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $5,450 | TotalAmt |
| Management And General | $5,450 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $65,234 | TotalAmt |
| Management And General | $65,234 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,939,142 | TotalAmt |
| Program Services | $2,499,666 | ProgramServicesAmt |
| Management And General | $439,476 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $49,399 | TotalAmt |
| Management And General | $49,399 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $199,808 | TotalAmt |
| Program Services | $151,792 | ProgramServicesAmt |
| Management And General | $48,016 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,013 | TotalAmt |
| Management And General | $15,013 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $186,908 | TotalAmt |
| Program Services | $172,828 | ProgramServicesAmt |
| Management And General | $14,080 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $49,009 | TotalAmt |
| Program Services | $35,548 | ProgramServicesAmt |
| Management And General | $13,461 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,155 | TotalAmt |
| Program Services | $14,333 | ProgramServicesAmt |
| Management And General | $11,822 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $99,384 | TotalAmt |
| Program Services | $90,092 | ProgramServicesAmt |
| Management And General | $9,292 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $607,437 | TotalAmt |
| Program Services | $550,644 | ProgramServicesAmt |
| Management And General | $56,793 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $69,378 | TotalAmt |
| Management And General | $69,378 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $946,091 | $946,091 | |
| Dues and Subscriptions | $103,748 | $55,204 | $48,544 |
| Food | $96,163 | $96,163 | |
| Collections | $22,156 | $22,156 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,560 | TotalAmt |
| Program Services | $2,896 | ProgramServicesAmt |
| Management And General | $21,664 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $11,046,373 | TotalAmt |
| Program Services | $9,373,403 | ProgramServicesAmt |
| Management And General | $1,672,970 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,293,695 | BOYAmt |
| EOY | $3,539,869 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,189,354 | BOYAmt |
| EOY | $2,072,107 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $116,475 | BOYAmt |
| EOY | $132,223 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $53,936 | BOYAmt |
| EOY | $102,863 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $12,764,413 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $8,262,994 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,097,705 | BOYAmt |
| EOY | $4,501,419 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $181,440 | BOYAmt |
| EOY | $198,281 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $534,000 | BOYAmt |
| EOY | $261,000 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,466,605 | BOYAmt |
| EOY | $10,807,762 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $574,387 | BOYAmt |
| EOY | $613,054 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,036,377 | BOYAmt |
| EOY | $1,744,737 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $655 | BOYAmt |
| EOY | $655 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,427,467 | BOYAmt |
| EOY | $2,296,406 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $778,200 | BOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,817,086 | BOYAmt |
| EOY | $4,654,852 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,649,519 | BOYAmt |
| EOY | $6,152,910 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,649,519 | BOYAmt |
| EOY | $6,152,910 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,466,605 | BOYAmt |
| EOY | $10,807,762 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $2,503,531 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$140 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $927 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $927 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part II-B, Line 1: | FormAndLineReferenceDesc |
| Explanation | Jacobson Memorial Hospital is a member of the North Dakota Hospital Association. A portion of the dues paid are used for lobbying activities. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtcInd |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,294 | OtherCostOrOtherBasisAmt |
| Book Value | $13,294 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $7,345,378 | OtherCostOrOtherBasisAmt |
| Depreciation | $4,376,641 | DepreciationAmt |
| Book Value | $2,968,737 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,204,163 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,473,884 | DepreciationAmt |
| Book Value | $730,279 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,201,578 | OtherCostOrOtherBasisAmt |
| Depreciation | $412,469 | DepreciationAmt |
| Book Value | $789,109 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $4,501,419 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $13,559,609 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$140 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | -$140 | RevenueNotReportedAmt |
| Revenue Subtotal | $13,559,749 | RevenueSubtotalAmt |
| Other Revenues Not Included | -$9,845 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | -$9,845 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $13,549,904 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $11,056,218 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | $9,845 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $9,845 | ExpensesNotReportedAmt |
| Expenses Subtotal | $11,046,373 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $11,046,373 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 2b: | The Hospital acts as custodian for the funds of the swing bed patients. These funds are included in cash and cash equivalents and accounts payable in the consolidated financial statements. Patient trust funds totaled $655 at June 30, 2021 and 2020. |
| Part X, Line 2: | JMHCC believes 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. JMHCC would recognize future accrued interest and penalties related to unrecognized tax liabilities in income tax expense if such interest and penalties are incurred. |
| Part XI, Line 4b - Other Adjustments: | Rental Expenses -9,845. |
| Part XII, Line 2d - Other Adjustments: | Rental Expenses 9,845. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | 0 | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | 0 | AnnualCommunityBnftReportInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $9,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $9,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00080 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $492,199 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $334,949 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $157,250 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01420 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $501,199 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $334,949 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $166,250 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01500 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,570,293 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,196,657 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $373,636 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03380 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,570,293 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,196,657 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $373,636 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.03380 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,071,492 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,531,606 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $539,886 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04880 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | Yes (1) | BadDebtExpenseReportedInd |
| Bad Debt Expense | $156,220 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $21,871 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $4,240,924 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $4,198,935 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $41,989 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58553 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.jacobsonhospital.org | WebsiteAddressTxt |
| State License | 5014 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 19 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | See Part V, Section C | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 19 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | www.jacobsonhospital.org/About-Us.html | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Other Criteria | Yes (X) | OtherCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicaid Medcr Prvt | Yes (X) | LookBackMedicaidMedcrPrvtInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | Yes (1) | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 5: To gather feedback from the community, residents of the county and local health care professionals were given the chance to participate in a survey. Approximately 79 community members and health care professionals took the survey. Additional information was collected through a Community Group comprised of community members and through key informant interviews with community leaders. Fourteen residents participated as a Community Group member, key informant interviewee, or both. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 6b: Custer Health |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 11: JMHCC conducted a CHNA during 2019. Needs identified are listed below:-Attracting and retaining young families-Availability of mental health services-Depression/anxiety for all ages-Ability to retain primary care providers (MD, DO, NP, PA) and nursesJMHCC will not directly address attracting and retaining young families. As we hire and retain employees, this will be a byproduct but not something we will focus on.JMHCC has implemented an ongoing marketing campaign to bring awareness to mental health and the availability of our services. This includes tele-psych services and treatment options for those suffering from opioid or other dependence.Retaining primary care providers has been challenging during COVID, but we have been able to keep all core staff of our providers. To accomplish this we have tried to reduce amounts of time on call and included retention bonuses during the last year. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 13h: Family size is also a factor in determining amounts charged to patients under the financial assistance policy. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency andother medically necessary care. FAP-eligible patients without insurance may be charged gross charges on elective procedures. |
| Part V, Section B, Line 7a: | http://www.jacobsonhospital.org/About-Us.html |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 3 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (3 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - Elgin Community Clinic | ||||
| 603 E St N | Elgin | ND | 58553 | Rural Health Clinic |
| 2 - Glen Ullin Family Medical Clinic | ||||
| 602 E Ash Ave | Glen Ullin | ND | 58631 | Rural Health Clinic |
| 3 - Richardton Clinic | ||||
| 215 3rd Ave W | Richardton | ND | 58652 | Rural Health Clinic |
Supplemental Information Detail SupplementalInformationDetail (11 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | The organization does offer free care under their charity care policy for people at 100% of the federal poverty guidelines, and they offer discounted care starting at 200% of the Federal Poverty Guidelines. Family size is also a factor in determining discounted 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. The cost for Medicaid, line 7b, and subsidized health services, line 7g, were determined using the Cost Report. |
| Part III, Line 2: | The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with this class of patients. |
| Part III, Line 3: | Approximately 14% of the individuals in Grant county are below the Federal Poverty Guidelines and so we estimate that approximately 14% of the total implicit price concessions is attributable to patients eligible for charity care. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on page 12-13 of the attached audited financial statements. |
| Part III, Line 8: | Medicare allowable costs were obtained from the 2019 Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services. |
| Part III, Line 9b: | Jacobson Memorial Hospital Care Center (JMHCC) has established a collections policy and procedure to facilitate effective and efficient collections for self-pay balances. When a patient submits an application for charity care, collection proceedings are stopped until a decision is made. If an application is determined to be incomplete, a letter is sent letting the patient know additional information is required. If we still do not receive the additional information in 30 days, the patient is sent a letter stating that their application for charity care has been declined and that collection proceedings could start again if payments are not made. When a complete application is received the finance committee meets, which includes the CEO, CFO, and two board members, and they determine if the patient qualifies for charity care and for how much of a discount. If it is determined that a patient is eligible for charity care they receive a letter stating so with a percentage that they qualified for and amount due. It is communicated that they are still expected to make payments. If a patient is sent to collections and later fills out a charity care application and is found to be eligible for a discount, we would pull the account back from collections and set up a payment plan with the patient. |
| Part VI, Line 2: | JMHCC obtains information about the needs of the community through a strategic planning committee made up of representatives from the service area including members of the board of directors, medical staff, hospital administration, hospital staff and community members. These individuals provide the hospital with insight on the issues facing the members of the community. JMHCC completed a community health needs assessment in the spring of 2020. The assessment was completed by the Center for Rural Health. |
| Part VI, Line 3: | Jacobson Memorial Hospital Care Center communicates information about the Charity Care Program to its patients and those living within its primary service area, identifies potential applicants and assists the patients that qualify for discounted services with the application process. Jacobson Memorial Hospital Care Center informs the general public within its primary service area of the availability of Charity Care through the following: includes the Charity Care policy in the Patient/Resident Payment Policy provided to all patients at the point of service or admission; posts the policy on community bulletin boards within the Jacobson Memorial Hospital Care Center facilities; posts the policy and information on the Jacobson Memorial Hospital Care Center website; releases general information at least annually in the legal newspaper located within Jacobson Memorial Hospital Care Center's primary service area; and other as deemed appropriate by the Administrator. |
| Part VI, Line 4: | According to data collected while preparing the Community Health Needs Assessment in the spring of 2020, approximately 29.9% of the population of Grant County is over age 65. The median household income in Grant County is significantly lower than for the rest of North Dakota - $50,962 compared to $63,473. Grant County had a population of 2,377 while the city of Elgin had a population of 642. There are no other hospitals that serve the community. In fact the next nearest hospital is roughly 80 miles away. |
| Part VI, Line 5: | Jacobson Memorial Hospital Care Center (JMHCC) has a Board of Directors made up of volunteers and members of the community. JMHCC does extend medical staff privileges to all qualified physicians serving in the community. Net increases in net assets are invested back into facilities and equipment in order to provide better patient care. In addition to our charity care policy, JMHCC provides many other services to meet the needs of those in Grant County which include:-provide office space so that we can continue to offer mental health services to the community on an outpatient basis.-participate in a number of community events every year including annual discounted lab services during hospital week.-participate in a Scrubs Camp sponsored by the Center for Rural Health and many other local health care organizations such as the New Leipzig ambulance and the local pharmacy, vision and dental practices.-operate a 24 hour emergency department that is available to anyone regardless of the ability to pay.-offer volunteer opportunities for capable area residents to come in and give our long term care residents and our swing-bed patients some activities to participate in. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (4 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Theo Stoller | ||||||||||||||
| CEO/Administrator | $224,884 | $0 | $0 | $0 | $0 | $0 | $1,461 | $0 | $9,931 | $0 | $236,276 | $0 | $0 | $0 |
| Elizabeth Sundberg | ||||||||||||||
| MD | $218,358 | $0 | $0 | $0 | $0 | $0 | $615 | $0 | $12,506 | $0 | $231,479 | $0 | $0 | $0 |
| Carey Rivinius | ||||||||||||||
| DNP | $138,540 | $0 | $0 | $0 | $0 | $0 | $2,970 | $0 | $19,116 | $0 | $160,626 | $0 | $0 | $0 |
| Carrie Gerving | ||||||||||||||
| FNP | $133,895 | $0 | $0 | $0 | $0 | $0 | $2,708 | $0 | $19,116 | $0 | $155,719 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Part I, Line 3 | FormAndLineReferenceDesc |
| Explanation | Theo Stoller, Administrator, was an employee of the Organization for all of the fiscal year. He became an employee of the Organization in May of 2020. Prior to May of 2020, Theo was compensated by an unrelated Organization, CHI St. Alexius Health. The Jacobson Memorial Hospital Board of Directors used the processes described in part I, question 3 to determine appropriate compensation for Theo. Any increases in compensation were communicated to CHI St. Alexius Health. CHI St. Alexius Health sent Jacobson Memorial a monthly bill for his wages earned at Jacobson Memorial for January through May of 2020. 2020 Calendar year Compensation reported for Theo in Part VII and on Schedule J, part II includes both amounts paid to CHI St. Alexius Health for his services from January through May, as well as the compensation he received from the Organization from May through December. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Crystal Stoller | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Family member of Officer Theo Stoller | RelationshipDescriptionTxt |
| Transaction | $106,371 | TransactionAmt |
| Transaction | Compensation as Lab Director | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1 | The Executive Committee shall consist of the Board Chairperson, Vice Chairperson, and the Secretary. The Executive Committee shall have power to transact all regular business of the hospital during the period between the meetings of the governing board, subject to any prior limitations imposed by the governing board and with the understanding that all matters of major importance will be referred to the governing board. It shall be the further duty of the Executive Committee to examine the monthly financial reports. Minutes of the Executive Committee meetings shall be submitted to the Board, and its actions shall be subject to approval or disapproval at the next regular board meeting. The board president only votes if there is a tie. |
| Form 990, Part VI, Section A, line 6 | There is one class of members. Each member pays a one-time fee of $10 for membership. |
| Form 990, Part VI, Section A, line 7a | Each member receives one vote to elect a director to the Hospital Board. Elections take place at the scheduled annual meeting which is held during the last quarter in the calendar year. |
| Form 990, Part VI, Section A, line 7b | The by-laws of the corporation may be amended by affirmative vote of a two-thirds (2/3) majority of the members present at the annual meeting or any special meeting of the corporation, provided, that a notice of such proposed amendments shall have been published in the notice calling the meeting, or, the by-laws may be amended by a vote of three-fourths (3/4) of the Board of Directors members. |
| Form 990, Part VI, Section B, line 11b | The CEO and CFO reviewed the Form 990 prior to submission and copies were provided to the board prior to filing. The board also reviews the Form 990 at the next scheduled board meeting. |
| Form 990, Part VI, Section B, line 12c | Yearly, Officers, Directors and key employees are given the Organization's Conflict of Interest Policy and a Conflict of Interest Acknowledgement Statement in which they must sign. It is the duty of an interested person to disclose the existence of a potential conflict of interest. If any individual discloses a possible conflict, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon by the remaining board or committee members to determine if in fact a conflict of interest exists. If it is found that a conflict exists the conflicted individual is asked to leave the meeting. The remaining board or committee members shall exercise due diligence in determining whether JMHCC can obtain with reasonable efforts a more advantageous transaction or arrangement from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably possible under circumstances not producing a conflict of interest, the Governing Board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in JMHCC's best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the transaction or arrangement. In this fiscal year each affected person signed the policy with no conflicts noted. |
| Form 990, Part VI, Section B, line 15 | The compensation of the Hospital Administrator is reviewed and approved by the independent Board of Directors. The Hospital obtains salary surveys from the Long Term Care Association and the North Dakota Hospital Association in deliberating the compensation amount. The compensation determination is presented and approved at a board meeting each year. Theo Stoller, CEO/Administrator, was employed by and compensated by CHI St. Alexius Health, an unrelated organization through May of 2020. In May of 2020 Theo became an employee of the Organization. 2020 Calendar year Compensation reported for Theo in Part VII and on Schedule J, part II includes both amounts paid to CHI St. Alexius Health for his services from January through May, as well as the compensation he received from the Organization from May through December. Compensation for the CFO is reviewed with salary surveys from the NDHA. The CEO does an annual evaluation of the CFO's performance. The CFO falls under the policy for merit based evaluation and raises are based on this. |
| Form 990, Part VI, Section C, line 19 | The Organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. |
| Form 990, Part IX, line 11g | Contracted Services: Program service expenses 2,499,666. Management and general expenses 439,476. Fundraising expenses 0. Total expenses 2,939,142. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Foundation | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 367 | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 208145158 | EIN |
| Primary Activities | To support Jacobson Memorial Hospital | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | Yes (1) | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |