CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION: Form 990, tax year 2019
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- Organization
- CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION (EIN 45-0306787)
- Tax period
- 2019-07-01 to 2020-06-30
- Filed
- 2021-05-11
- IRS object ID
- 202101319349302655
- Schema version
- 2019v5.2
- 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 K
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2021-05-11T11:55:20-05:00 | ReturnTs |
| Tax Period End | 2020-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 390758449 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 LONDON ROAD SUITE 200 | AddressLine1Txt |
| City | DULUTH | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55812 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2019-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450306787 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CAVALIER COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
| Business Name Line2 | ASSOCIATION | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | CAVA | BusinessNameControlTxt |
| Phone | 7012566177 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 SECOND STREET | AddressLine1Txt |
| City | LANGDON | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58249 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JEFF STANLEY | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7012566177 | PhoneNum |
| Signature | 2021-05-07 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MICHAEL J PETERSON CPA | PreparerPersonNm |
| PTIN | P01833529 | PTIN |
| Phone | 2187224705 | PhoneNum |
| Preparation | 2021-05-07 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2019 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JEFF STANLEY | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 SECOND STREET | AddressLine1Txt |
| City | LANGDON | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58249 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $11,406,495 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.CAVALIERCOUNTYHOSPITAL.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1969 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | RURAL HEALTHCARE FACILITY PROVIDING ACCESS TO QUALITY HEALTHCARE SERVICES. | ActivityOrMissionDesc |
| Voting Members Governing Body | 7 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 7 | VotingMembersIndependentCnt |
| Total Employee | 111 | TotalEmployeeCnt |
| Total Volunteers | 8 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $677,840 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,143,081 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $8,036,408 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $10,002,012 | CYProgramServiceRevenueAmt |
| PY Investment Income | $13,841 | PYInvestmentIncomeAmt |
| CY Investment Income | $15,385 | CYInvestmentIncomeAmt |
| PY Other Revenue | $1,115,726 | PYOtherRevenueAmt |
| CY Other Revenue | $246,017 | CYOtherRevenueAmt |
| PY Total Revenue | $9,843,815 | PYTotalRevenueAmt |
| CY Total Revenue | $11,406,495 | 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 | $4,457,589 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $4,988,021 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $4,237,174 | PYOtherExpensesAmt |
| CY Other Expenses | $4,322,122 | CYOtherExpensesAmt |
| PY Total Expenses | $8,694,763 | PYTotalExpensesAmt |
| CY Total Expenses | $9,310,143 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $1,149,052 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $2,096,352 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $11,303,103 | TotalAssetsBOYAmt |
| Total Assets EOY | $17,676,887 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $2,539,945 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,869,805 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $8,763,158 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $10,807,082 | NetAssetsOrFundBalancesEOYAmt |
| Mission | 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. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $6,474,956 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $10,002,012 | RevenueAmt |
| Desc | PROVIDE PATIENT HEALTHCARE SERVICES INCLUDING HOSPITAL AND CLINIC TO SURROUNDING COMMUNITY. THE ORGANIZATION PROVIDED APPROXIMATELY $64,000 OF CHARITY CARE DURING THE YEAR ENDED 06/30/2020. | Desc |
| Total Program Service Expenses | $6,474,956 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | Yes (1) | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | 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 | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| 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 | 0 | 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 | 0 | RelatedOrganizationCtrlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 8 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 111 | 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 | 7 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 7 | 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 | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | 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 | Yes (1) | 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
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CHRISTOPER CARTER CONTROLLER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7012566177 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 SECOND STREET | AddressLine1Txt |
| City | LANGDON | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58249 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (18 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Former Ofcr Director TrusteeFormerOfcrDirectorTrusteeInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd | OfficerOfficerInd | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd |
|---|---|---|---|---|---|---|---|---|
| CHRISS WYATT | ||||||||
| FORMER CEO | 40.00 | Yes (X) | $264,483 | $0 | $0 | |||
| COURTNEY SHORT | ||||||||
| FNP | 40.00 | $105,496 | $0 | $5,528 | Yes (X) | |||
| MARK HILL | ||||||||
| FNP | 40.00 | $101,133 | $0 | $6,863 | Yes (X) | |||
| RICHARD FROMME | ||||||||
| CFO | 40.00 | $105,391 | $0 | $3 | Yes (X) | |||
| ANGELA KOBEL | ||||||||
| CFO (THRU AUGUST) | 40.00 | $64,210 | $0 | $28 | Yes (X) | |||
| JEFF STANLEY | ||||||||
| CEO | 40.00 | $199,050 | $0 | $3,665 | Yes (X) | |||
| WILLIAM VAN NOY | ||||||||
| CFO | 40.00 | $17,453 | $0 | $0 | Yes (X) | |||
| CHARLES EMERSON | ||||||||
| CMO | 40.00 | $283,454 | $0 | $11,792 | Yes (X) | |||
| DARLA RODER | ||||||||
| COO | 40.00 | $103,105 | $0 | $15,157 | Yes (X) | |||
| JAMIE NIENHUIS | ||||||||
| CNO | 40.00 | $87,824 | $0 | $13,479 | Yes (X) | |||
| DAWN ROPPEL | ||||||||
| PRESIDENT | 1.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | ||
| JAY DUBOIS | ||||||||
| VICE PRESIDENT | 1.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | ||
| SHAUNA SCHNEIDER | ||||||||
| TREASURER | 1.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | ||
| JERRY NOWATZKI | ||||||||
| SECRETARY | 1.00 | $0 | $0 | $0 | Yes (X) | Yes (X) | ||
| DAROL HOFFMAN | ||||||||
| DIRECTOR (THRU NOVEMBER) | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| KATHRYN KOPF | ||||||||
| DIRECTOR | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| KAREN RING | ||||||||
| DIRECTOR | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| JANINE WITZEL | ||||||||
| DIRECTOR | 1.00 | $0 | $0 | $0 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,331,599 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $56,515 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 7 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | Yes (1) | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (3 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| NATIONAL MEDICAL RESOURCES INC | |||||
| 2792 E BROADWAY AVE | BISMARCK | ND | 58501 | PROVIDER CONTRACT SERVICES | $401,343 |
| NXC IMAGING | |||||
| 2118 4TH AVE S | MINNEAPOLIS | MN | 554042642 | IMAGING CONTRACT SERVICES | $280,213 |
| JOHNSON CONTROLS INC | |||||
| DEPT CH 10320 | PALATINE | IL | 600550320 | EQUIP. MAINT. AND REPAIR SERVICES | $196,859 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 3 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $1,101,163 | GovernmentGrantsAmt |
| All Other Contributions | $41,918 | AllOtherContributionsAmt |
| Total Contributions | $1,143,081 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| NET PATIENT REVENUE | 621400 | $8,964,864 | $8,964,864 |
| 340B PHARMACY REVENUE | 621400 | $1,037,148 | $1,037,148 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $10,002,012 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,385 | TotalRevenueColumnAmt |
| Exclusion | $15,385 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $15,212 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $15,212 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $15,212 | TotalRevenueColumnAmt |
| Exclusion | $15,212 | ExclusionAmt |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $230,805 | TotalRevenueColumnAmt |
| Exclusion | $230,805 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $230,805 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $11,406,495 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $10,002,012 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $261,402 | 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 | $799,216 | TotalAmt |
| Program Services | $198,273 | ProgramServicesAmt |
| Management And General | $600,943 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,569,127 | TotalAmt |
| Program Services | $2,868,960 | ProgramServicesAmt |
| Management And General | $700,167 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $66,955 | TotalAmt |
| Program Services | $46,347 | ProgramServicesAmt |
| Management And General | $20,608 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $249,432 | TotalAmt |
| Program Services | $176,614 | ProgramServicesAmt |
| Management And General | $72,818 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $303,291 | TotalAmt |
| Program Services | $198,204 | ProgramServicesAmt |
| Management And General | $105,087 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $53,755 | TotalAmt |
| Management And General | $53,755 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $215,019 | TotalAmt |
| Management And General | $215,019 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $963,795 | TotalAmt |
| Program Services | $764,508 | ProgramServicesAmt |
| Management And General | $199,287 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $184,287 | TotalAmt |
| Program Services | $13,982 | ProgramServicesAmt |
| Management And General | $170,305 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $183,891 | TotalAmt |
| Management And General | $183,891 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $138,091 | TotalAmt |
| Program Services | $19,463 | ProgramServicesAmt |
| Management And General | $118,628 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $60,115 | TotalAmt |
| Program Services | $37,115 | ProgramServicesAmt |
| Management And General | $23,000 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $92,471 | TotalAmt |
| Program Services | $92,471 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $612,457 | TotalAmt |
| Program Services | $612,457 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $74,366 | TotalAmt |
| Management And General | $74,366 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES | $923,050 | $920,554 | $2,496 |
| BAD DEBT EXPENSE | $325,306 | $325,306 | |
| REPAIRS & MAINTENANCE | $196,013 | $96,360 | $99,653 |
| DUES & SUBSCRIPTIONS | $107,909 | $11,148 | $96,761 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $191,597 | TotalAmt |
| Program Services | $93,194 | ProgramServicesAmt |
| Management And General | $98,403 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,310,143 | TotalAmt |
| Program Services | $6,474,956 | ProgramServicesAmt |
| Management And General | $2,835,187 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $230,701 | BOYAmt |
| EOY | $110,166 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,453,510 | BOYAmt |
| EOY | $9,963,738 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $788,939 | BOYAmt |
| EOY | $858,962 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $10,773 | BOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $134,895 | BOYAmt |
| EOY | $184,903 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $106,208 | BOYAmt |
| EOY | $62,107 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $12,945,026 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $8,799,291 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,174,373 | BOYAmt |
| EOY | $4,145,735 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,403,704 | BOYAmt |
| EOY | $2,351,276 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,303,103 | BOYAmt |
| EOY | $17,676,887 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $757,660 | BOYAmt |
| EOY | $623,113 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $4,730,626 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,187,482 | BOYAmt |
| EOY | $1,019,878 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $190,230 | BOYAmt |
| EOY | $126,531 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $121,300 | BOYAmt |
| EOY | $47,497 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $283,273 | BOYAmt |
| EOY | $322,160 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,539,945 | BOYAmt |
| EOY | $6,869,805 | 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 | $6,207,454 | BOYAmt |
| EOY | $8,455,806 | EOYAmt |
Donor Restriction Net Assets DonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,555,704 | BOYAmt |
| EOY | $2,351,276 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,763,158 | BOYAmt |
| EOY | $10,807,082 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $11,303,103 | BOYAmt |
| EOY | $17,676,887 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $2,096,352 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | -$52,428 | 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) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| 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) |
|---|---|---|
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $458 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $458 | 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 | THE NORTH DAKOTA HOSPITAL ASSOCIATION HAS DETERMINED THAT 8.7% OF CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION'S ANNUAL MEMBERSHIP DUES PAID ARE TREATED AS LOBBYING EXPENSES. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,167 | OtherCostOrOtherBasisAmt |
| Book Value | $13,167 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $7,874,010 | OtherCostOrOtherBasisAmt |
| Depreciation | $5,082,777 | DepreciationAmt |
| Book Value | $2,791,233 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,453,914 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,716,514 | DepreciationAmt |
| Book Value | $737,400 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $603,935 | OtherCostOrOtherBasisAmt |
| Book Value | $603,935 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $4,145,735 | TotalBookValueLandBuildingsAmt |
Other Securities OtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | BENEFICIAL INTEREST IN ASSETS HELD BY FOUNDATION | Desc |
| Book Value | $2,351,276 | BookValueAmt |
| Method Valuation | F | MethodValuationCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Securities | $2,351,276 | TotalBookValueSecuritiesAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| OTHER LONG-TERM DEBT | $143,298 |
| DUE TO THIRD PARTIES | $178,862 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $322,160 | TotalLiabilityAmt |
| Total Rev Etc Audited Fincl Stmt | $11,081,189 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $11,081,189 | RevenueSubtotalAmt |
| Other Revenues Not Included | $325,306 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $325,306 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $11,406,495 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $8,984,837 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $8,984,837 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $325,306 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $325,306 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $9,310,143 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 325,306. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 325,306. |
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 | Yes (1) | 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 | $64,218 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $64,218 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00690 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,288,334 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $8,696,861 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $0 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00000 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,352,552 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $8,696,861 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $64,218 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00690 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,943,250 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $287,938 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,655,312 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.28520 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $2,943,250 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $287,938 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,655,312 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.28520 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $7,295,802 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $8,984,799 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,719,530 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.29210 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $325,306 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $65,061 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $4,986,437 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $4,982,434 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $4,003 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | Yes (X) | CostToChargeRatioInd |
| 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 | CAVALIER COUNTY MEMORIAL HOSPITAL | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 2ND STREET | AddressLine1Txt |
| City | LANGDON | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58249 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.CAVALIERCOUNTYHOSPITAL.COM | WebsiteAddressTxt |
| State License | 5029 | 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 | CAVALIER COUNTY MEMORIAL HOSPITAL | 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 |
| CHNA Conducted | 18 | 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 SUPPLEMENTARY INFO | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 18 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | SEE SUPPLEMENTARY INFO | 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 |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| 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 | SEE SUPPLEMENTARY INFO | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | SEE SUPPLEMENTARY INFO | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | SEE SUPPLEMENTARY INFO | 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 |
| Other Publicity | Yes (X) | OtherPublicityInd |
| 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 |
| Other Actions Taken | Yes (X) | OtherActionsTakenInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Prospective Medicare Medicaid | Yes (X) | ProspectiveMedicareMedicaidInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (10 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART V, LINE 7A: | WWW.CAVALIERCOUNTYHOSPITAL.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT |
| PART V, LINE 10: | WWW.CAVALIERCOUNTYHOSPITAL.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENT |
| PART V, LINE 16A, FAP WEBSITE: | HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE |
| PART V, LINE 16B, FAP APPLICATION WEBSITE: | HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE |
| PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE: | HTTPS://WWW.CAVALIERCOUNTYHOSPITAL.COM/INSURANCEASSISTANCE |
| PART V, 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. |
| PART V, LINE 6B: | CAVALIER COUNTY MEMORIAL HOSPITAL CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT WITH CAVALIER COUNTY HEALTH DEPARTMENT. |
| PART V, 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 ADDITION, 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 2020 FISCAL YEAR, JULY 2019-JUNE 2020, 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. |
| PART V, 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. |
| PART V, LINE 20E: | ALL PATIENTS RECEIVE LETTERS AFTER NONPAYMENT THAT INCLUDE A PLAIN LANGUAGE SUMMARY OF OUR FINANCIAL ASSISTANCE PLAN. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 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 |
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 IS CALCULATED UTILIZING DIRECT BAD DEBT COSTS FROM NONPAYMENT AFTER CONTRACTUAL DISCOUNTS AND PAYMENTS HAVE BEEN RECEIVED. THE STANDARD FORMULA FOR ACCOUNTS RECEIVABLE HAS BEEN UTILIZED FOR ANY OUTSTANDING ACCOUNTS AFTER CONTRACTUAL DISCOUNTS WERE TAKEN. |
| PART III, LINE 3: | DUE TO THE FACT THAT THE FINANCIAL ASSISTANCE PROGRAM WAS NOT CONSISTENTLY FOLLOWED AND SOME PATIENTS WERE LIKELY NOT ADEQUATELY INFORMED, WE BELIEVE APPROXIMATELY 20% OF BAD DEBT WOULD HAVE QUALIFIED. |
| PART III, LINE 4: | FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED AGAINST THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. |
| 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: | CAVALIER COUNTY MEMORIAL HOSPITAL HAS BEGUN A FAMILY AND PATIENT ADVISORY COUNCIL SO THAT MEMBERS OF THE COMMUNITY CAN MEET WITH LEADERS TO DISCUSS OPTIONS FOR GROWTH AND HEALTH CARE CONCERNS. CCMH HAS ALSO BEGUN THE PROCESS OF ENGAGING IN AN ACCOUNTABLE CARE ORGANIZATION TO IMPROVE UPON ITS MISSION AND VISION BY HELPING MANAGE OUR POPULATIONS HEALTH ON AN ONGOING BASIS RATHER THAN THE ACUTE EPISODES ALONE. |
| 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. |
| PART VI, LINE 4: | CAVALIER COUNTY MEMORIAL HOSPITAL'S COMMUNITY SERVICE AREA POPULATION IS APPROXIMATELY 3,700 RESIDENTS AND IS LOCATED 17 MILES SOUTH OF THE CANADIAN BORDER AND 60 MILES WEST OF THE MINNESOTA BORDER. THE COMMUNITY DEMOGRAPHICS ARE A MIX OF EVENLY PROPORTIONED GENDER WITH AN AVERAGE AGE OF 50 YEARS. |
| PART VI, LINE 5: | CAVALIER COUNTY MEMORIAL HOSPITAL (CCMH) CONSISTENTLY PROMOTES GOOD HEALTH THROUGHOUT OUR COMMUNITY WITH PLACEMENT OF MEDICAL EDUCATION ARTICLES IN OUR LOCAL NEWSPAPER. CCMH ALSO PROVIDES THE FOLLOWING SERVICES FREE OF CHARGE TO THE LOCAL SCHOOLS, EDUCATIONAL OPPORTUNITIES SUCH AS JOB SHADOWING, USE OF HOSPITAL FACILITIES FOR HEALTH CAREERS CLASS, AND THE USE OF OUR MEDICAL PROFESSIONALS TO SPEAK TO THEIR STUDENTS. CCMH ANNUALLY PROVIDES APPROXIMATELY $37,500 OF CHARITY CARE TO OUR COMMUNITY AND VARIOUS OTHER BENEFICIAL HEALTH RELATED SERVICES FOR MINIMAL PROFIT RETURNS AND/OR BREAK EVEN COST TO CHARGE RATES. SURPLUS REVENUES ARE REINVESTED BACK INTO THE FACILITY FOR PLANT UPGRADES AND NEW EQUIPMENT. CCMH PROVIDES TWO CLINICS TO THE COMMUNITY THAT PROVIDE FREE SERVICES DURING 3 DIFFERENT MONTHS THROUGHOUT THE YEAR. MEN'S HEALTH - JUNE, WOMEN'S HEALTH - OCTOBER, & CHILDREN'S HEALTH - MAY. FREE SCREENINGS AND DISCOUNTED DIAGNOSTIC CARE ARE PROVIDED TO THE COMMUNITY IN BOTH CLINICS. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | ND |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | Yes (1) | 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 (3 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHRISS WYATT | ||||||||||||||
| FORMER CEO | $0 | $0 | $0 | $0 | $264,483 | $0 | $0 | $0 | $0 | $0 | $264,483 | $0 | $0 | $0 |
| JEFF STANLEY | ||||||||||||||
| CEO | $186,550 | $0 | $12,500 | $0 | $0 | $0 | $0 | $0 | $3,665 | $0 | $202,715 | $0 | $0 | $0 |
| CHARLES EMERSON | ||||||||||||||
| CMO | $248,092 | $0 | $35,362 | $0 | $0 | $0 | $0 | $0 | $11,792 | $0 | $295,246 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 4A | FormAndLineReferenceDesc |
| Explanation | CHRIS WYATT LEFT CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION IN MAY 2018. CHRIS RECEIVED A DEFERRED COMPENSATION PAYOUT OF 264,483 DURING 2019. | ExplanationTxt |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CITY OF LANGDON NORTH DAKOTA | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 456002108 | BondIssuerEIN |
| CUSIP | 515679AL2 | CUSIPNum |
| Bond Issued | 2010-03-25 | BondIssuedDt |
| Issue Price | $2,500,000 | IssuePriceAmt |
| Purpose | HOSPITAL RENOVATION PROJECT | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $1,445,000 | RetiredAmt |
| Total Proceeds | $2,500,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $50,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $2,450,000 | CapitalExpendituresAmt |
| Substantial Completion | 2012 | SubstantialCompletionYr |
| Refunding Tax Exempt Bonds | 0 | RefundingTaxExemptBondsInd |
| Refunding Taxable Bonds | 0 | RefundingTaxableBondsInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | 0 | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | Yes (1) | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Written Proc To Monitor Reqs | 0 | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | 0 | ProceduresCorrectiveActionInd |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| DATE REBATE COMPUTATION PERFORMED | ISSUER NAME: CITY OF LANGDON, NORTH DAKOTA DATE THE REBATE COMPUTATION WAS PERFORMED: 02/28/2020 |
| PART IV, LINE 2C: | THE REBATE COMPUTATION WAS PERFORMED 03/30/2015. |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION B, LINE 11B | FORM 990 IS FIRST REVIEWED BY THE CONTROLLER AND MANAGEMENT TEAM. 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 WITHING THE BOARD MINUTES. IF ANY VARIANCES OF THE CONFLICT IN QUESTION ARE DISCOVERED THE BOARD WILL MAKE A DETERMINATION ON 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 EMENDED 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 162,961. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 162,961. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 56,604. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 56,604. LAB SERVICES: PROGRAM SERVICE EXPENSES 35,564. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 35,564. CONSULTATION SERVICES: PROGRAM SERVICE EXPENSES 246,241. MANAGEMENT AND GENERAL EXPENSES 123,311. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 369,552. OTHER SERVICES: PROGRAM SERVICE EXPENSES 263,138. MANAGEMENT AND GENERAL EXPENSES 75,976. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 339,114. |
| FORM 990, PART XI, LINE 9: | CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION -52,428. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CAVALIER COUNTY MEMORIAL HOSPITAL FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 909 2ND STREET | AddressLine1Txt |
| City | LANGDON | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58249 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363617578 | EIN |
| Primary Activities | TO SUPPORT THE HOSPITAL | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 12A, I | PublicCharityStatusTxt |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Controlled Organization | 0 | 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 | Yes (1) | 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 | 0 | 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 | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |