2022-05-12T12:23:17-05:00 2021-06-30 450250958 Eide Bailly LLP 1730 Burnt Boat Loop Ste 100 Bismarck ND 585030886 990 2020-07-01 450222079 Jacobson Memorial Hospital Care Center JACO 7015842792 601 E St N Elgin ND 58533 Theo Stoller CEO 7015842792 2022-05-12 1 Theo Stoller 999009999 Lisa Chaffee CPA P00193453 7012551091 2022-05-12 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Theo Stoller 601 E St N Elgin ND 58533 13559749 0 X www.jacobsonhospital.org X 1949 ND To provide quality healthcare to advance the health of patients and communities we serve. 9 9 116 15 0 0 692306 2641917 9543932 10899612 2853 8420 270 -45 10239361 13549904 0 0 0 0 4916375 5541338 0 0 0 5034839 5505035 9951214 11046373 288147 2503531 10466605 10807762 6817086 4654852 3649519 6152910 X 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. 0 0 9373403 10899612 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. 9373403 1 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 15 0 1 116 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 0 X Scott Ostenson 7015847236 601 E St N Elgin ND 58533 Leslie Niederman Chairperson 1.00 X X 0 0 0 Joel Klein Vice Chair 1.00 X X 0 0 0 Julie Armijo Secretary 1.00 X X 0 0 0 Ann Hertz Director 1.00 X 0 0 0 Marcy Haase Director 1.00 X 0 0 0 Ron Bartz Director 1.00 X 0 0 0 Patrick Diehl Director 1.00 X 0 0 0 Dennis Sabin Director 1.00 X 0 0 0 JoAnn Schatz Director 1.00 X 0 0 0 Theo Stoller CEO/Administrator 40.00 X 224884 0 11377 Scott Ostenson CFO 40.00 X 107156 0 7522 Carey Rivinius DNP 32.00 X 138540 0 22072 Carrie Gerving FNP 32.00 X 133895 0 21811 Rhonda Schmidt FNP 32.00 X 114981 0 21592 Elizabeth Sundberg MD 32.00 X 218358 0 13107 Jolene Engelhart FNP 32.00 X 111316 0 19426 1049130 0 116907 9 0 1 1 Medical Solutions PO Box 310737 Des Moines IA 50331 Travel Nurses 632571 Avant PO Box 744554 Atlanta GA 30374 Travel Nurses 516511 ARL INC 7205 68th Ave SW Elgin ND 58533 Contracted Physician 361725 Titan Nurse Staffing 2110 S 169th Plaza Omaha NE 68130 Travel Nurses 202987 4 2634917 7000 2641917 Net Patient Revenue 623000 10255206 10255206 Pharmacy Revenue 446110 404922 404922 Management Revenue 900099 135256 135256 Other Revenue 900099 104228 104228 10899612 8420 8420 9800 9845 -45 -45 -45 13549904 10899612 0 8375 X 330779 330779 106371 106371 3969376 3611225 358151 93633 84466 9167 716847 676863 39984 324332 279221 45111 5450 5450 65234 65234 2939142 2499666 439476 49399 49399 199808 151792 48016 15013 15013 186908 172828 14080 49009 35548 13461 26155 14333 11822 99384 90092 9292 607437 550644 56793 69378 69378 Medical Supplies 946091 946091 Dues and Subscriptions 103748 55204 48544 Food 96163 96163 Collections 22156 22156 24560 2896 21664 11046373 9373403 1672970 0 5293695 3539869 1189354 2072107 116475 132223 53936 102863 12764413 8262994 3097705 4501419 181440 198281 534000 261000 10466605 10807762 574387 613054 3036377 1744737 655 655 2427467 2296406 778200 6817086 4654852 X 3649519 6152910 3649519 6152910 10466605 10807762 2503531 -140 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 927 927 0 Part II-B, Line 1: Jacobson Memorial Hospital is a member of the North Dakota Hospital Association. A portion of the dues paid are used for lobbying activities. 0 1 X 13294 13294 7345378 4376641 2968737 4204163 3473884 730279 1201578 412469 789109 4501419 X 13559609 -140 -140 13559749 -9845 -9845 13549904 11056218 9845 9845 11046373 0 11046373 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. 1 1 X 1 X 1 X 0 1 0 0 9000 9000 0.00080 492199 334949 157250 0.01420 501199 334949 166250 0.01500 2570293 2196657 373636 0.03380 2570293 2196657 373636 0.03380 3071492 2531606 539886 0.04880 1 156220 21871 4240924 4198935 41989 X 1 1 1 1 Jacobson Memorial Hospital Care Center 601 E St N Elgin ND 58553 www.jacobsonhospital.org 5014 X X X X Jacobson Memorial Hospital Care Center 1 0 0 1 X X X X X X X X X 19 1 0 1 1 X See Part V, Section C X 1 19 1 www.jacobsonhospital.org/About-Us.html 0 1 X 100.000000000000 200.000000000000 X X 1 1 X X X 1 X www.jacobsonhospital.org/Patients-Visitors.html X www.jacobsonhospital.org/Patients-Visitors.html X www.jacobsonhospital.org/Patients-Visitors.html X X X X X 1 X 0 X X X X 1 X 0 1 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 3 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 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. X X 0 0 0 0 0 0 0 0 0 Theo Stoller CEO/Administrator 224884 0 0 0 0 0 1461 0 9931 0 236276 0 0 0 Elizabeth Sundberg MD 218358 0 0 0 0 0 615 0 12506 0 231479 0 0 0 Carey Rivinius DNP 138540 0 0 0 0 0 2970 0 19116 0 160626 0 0 0 Carrie Gerving FNP 133895 0 0 0 0 0 2708 0 19116 0 155719 0 0 0 Part I, Line 3 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. Crystal Stoller Family member of Officer Theo Stoller 106371 Compensation as Lab Director 0 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. Jacobson Memorial Hospital Foundation PO Box 367 Elgin ND 58533 208145158 To support Jacobson Memorial Hospital ND 501(c)(3) Line 7 Jacobson Memorial Hospital Care Center 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 0