2021-01-19T12:53:30-06:00 2020-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2019-07-01 410307617 Hendricks Community Hospital Assn & Retirement Home HEND 5072753134 PO Box 106 Hendricks MN 56136 Jeff Gollaher CEO 5072753134 2021-01-15 1 Kim Hunwardsen CPA P00484560 6122536500 2021-01-15 2019 2022-09-23 18:48:47Z Jeff Gollaher PO Box 106 Hendricks MN 56136 13786217 0 X www.hendrickshosp.org X 1941 MN Provision of healthcare 9 9 204 75 0 0 122318 299008 13589977 13406309 46676 39481 68744 38514 13827715 13783312 11335 4065 0 0 7465563 7897375 0 0 0 6800251 6670984 14277149 14572424 -449434 -789112 20969153 25272526 6552550 11624282 14416603 13648244 X Hendricks Community Hospital Assn & Retirement Home strives to provide the highest quality health and residential care in a Christian environment. 0 0 13666862 4065 13406309 Hendricks Community Hospital, a 24-bed hospital, 48-bed long-term care facility, 16-unit senior rental housing facility, and home health agency promotes health of the community by providing a variety of health care services. The facility had 60 acute, 63 swing bed, 34 transitional bed and 38 long-term care facility admissions for the year ended June 30, 2020; 419 visits to the Emergency Room; and 65 surgical cases (including ambulatory).The hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as patient and resident service revenue. The amount of charges foregone for services provided under the Hospital's charity care policy were approximately $61,273 for the year ended June 30, 2020. The estimated cost of providing these services was $49,630 for the year ended June 30, 2020 based on average ratio of cost to gross charges. 13666862 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 59 0 1 204 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 MN X Julie Hogie 5072753134 PO Box 106 Hendricks MN 56136 Tabb McCluskey DO Physician 40.00 X 292101 0 47942 Grant Eyjolfson MD Physician 40.00 X 263718 0 47086 Tomasz Lis MD Physician 40.00 X 256204 0 51844 Jeff Gollaher CEO 40.00 X 170075 0 21392 Kathryn Christensen NP Nurse Practitioner 40.00 X 124001 0 6049 Julie Hogie Business Office Manager 40.00 X 69695 0 15002 Vince Robinson Treasurer 2.00 X X 1190 0 0 Norris Patrick Director 2.00 X 1040 0 0 Allen Molascon President 3.00 X X 950 0 0 Dean Nielsen Director 2.00 X 950 0 0 James Ness Director 2.00 X 950 0 0 Mark VanEck Vice President 2.00 X X 870 0 0 John Engels Secretary 2.00 X X 720 0 0 Dawn Popowski Director 2.00 X 0 0 0 Miriam Iverson Director 2.00 X 0 0 0 1182464 0 189315 5 0 1 0 Wapiti Medical Group LLC 107 Flynn Dr Milbank SD 57252 Locum/ER Providers 571009 Elior Inc 300 S Tryon St Charlotte NC 28202 Contracted Dietary Services 365968 Fusion Medical Staffing LLC PO Box 82674 Lincoln NE 685012674 Contracted Nursing Service 100731 3 4864 259251 34893 299008 Net patient & resident service re 622110 13289713 13289713 116596 116596 13406309 16481 16481 5842 0 5842 5842 5842 23000 0 23000 23000 23000 2620 4864 562 2058 2058 32957 2343 30614 30614 13783312 13406309 0 77995 X 4065 4065 288495 288495 52531 52531 6126609 5957965 168644 159633 158957 676 839920 809600 30320 430187 402621 27566 73385 73385 2404945 2404487 458 29775 29775 211427 206506 4921 15238 15238 306920 306920 75098 68661 6437 23215 21225 1990 201563 184108 17455 1111271 1066649 44622 236834 216325 20509 Medical Supplies 825809 825809 Repairs and Maintenance 780756 749099 31657 MN Care Tax 80679 80679 294069 105642 188427 14572424 13666862 905562 0 3888874 9209769 2266238 1635702 129594 70259 215722 229760 59906 61235 26485601 14792470 12360573 11693131 2027818 2368293 20428 4377 20969153 25272526 1279423 1027925 27542 28042 5155074 5029272 0 1431800 90511 4107243 6552550 11624282 X 14416603 13648244 14416603 13648244 20969153 25272526 X -789112 -14121 34874 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 251 251 0 Part II-B, Line 1: MN Hospital Association dues for FYE 2020 were $8,089 of which 3.1% is related to lobbying activities; total attributed to lobbying is $250.76. 1 80559 36273 71147 45685 1 X 19500 91512 111012 15439102 8690024 6749078 10859270 6102446 4756824 76217 76217 11693131 Estimated third-party payor settlements 134895 Insurance Loss Liability 64000 Refundable Advance 3908348 4107243 X 13803208 -14121 64740 50619 13752589 30723 30723 13783312 14571567 0 14571567 857 857 14572424 Part IV, Line 1b: The assets of Hendricks Hospital Auxiliary are held by Hendricks Community Hospital Association. The Auxiliary uses the EIN of the Hospital, therefore the activity is reported on Form 990 of the Hospital. The ending balance for the Auxiliary was $44,509. In addition, the Hospital holds funds on behalf of its residents. The amount held at the end of the year for residents was $1,176. Part IV, Line 2b: The organization holds security deposits. Part X, Line 2: The Association 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 financial statements. The Association would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Elimination of auxiliary donations to the hospital 64,740. Part XI, Line 4b - Other Adjustments: Auxiliary revenue not included in financial statements 33,066. Auxiliary thrift shop expenses reported in revenue on Form 990 -2,343. Part XII, Line 4b - Other Adjustments: Auxiliary expenses not included in financial statements 562. Resident fund expenses not included in financial statements 295. 1 1 X 1 X 1 X 125.000000000000 1 1 0 1 1 12000 12000 0.00080 2991810 2840166 151644 0.01040 3003810 2840166 163644 0.01120 10605 10605 0.00070 49904 49904 0.00340 4939319 2522426 2416893 0.16590 4065 4065 0.00030 5003893 2522426 2481467 0.17030 8007703 5362592 2645111 0.18150 1 86075 12000 3067145 3084052 -16907 X 1 1 1 1 Hendricks Community Hospital Association 503 East Lincoln Hendricks MN 56136 www.hendrickshosp.org 00340 X X X X 2 provider based RHCs Hendricks Community Hospital Association 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X www.hendrickshosp.org X 1 18 1 www.hendrickshosp.org 0 1 X 100.000000000000 125.000000000000 X X X X 1 1 X X X 1 X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X www.hendrickshosp.org/patientinfo.html X X X X X X 1 X 0 X X X X 1 X 0 0 Hendricks Community Hospital Association Part V, Section B, Line 5: A community survey was distributed to all households in the HCHA service area & on-line completion was offered. A focus group meeting was held in March, 2019. Approximately 2,900 surveys were distributed with 284 returned for a rate of just under 10%. A total of 10 individuals participated in the focus group. Additional interviews were conducted for some community leaders that were unable to attend the focus group. Hendricks Community Hospital Association Part V, Section B, Line 11: Based on the Community Health Needs Assessment completed in June, 2019, the hospital governing board and facility leadership team identified the following as priority community health needs:1) Communication and Education - including awareness of services; health and wellness2) Mental HealthBoth of these needs are being addressed with an Implementation Strategy Action Plan developed in June, 2019 to be implemented during 2019-2021.The projected impact of communication and education is to increase understanding of services offered thru HCHA, and the goal established would be to expand outreach and education efforts in the community to positively impact the health and wellbeing of residents. A task force has been established to implement these efforts during the implementation period stated above.The projected impact of behavioral and mental health access is to increase awareness of resources available for those in need of mental health services, with a goal of providing a platform for members of the community to better understand mental health services and to participate in activities which improve mental health. A committee has also been established to implement these efforts during the implementation period stated above.There were no needs identified that are not being addressed. During the current year, the task force related to communication and education continues to meet to establish and proceed forward with improved communication and education for the community. The mental health committee continues in their efforts to improve access to mental health services. Hendricks Community Hospital Association Part V, Section B, Line 13h: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Hendricks Community Hospital Association Part V, Section B, Line 16j: Summaries of the financial assistance policy are posted in the hospital/clinic facilities, as well as waiting rooms and admission area. Billing statements to potentially eligible clients also include summary and contact information for obtaining the appropriate application. 2 1 - Hendricks Nursing Home 503 E Lincoln St Hendricks MN 56136 Long-term Care 2 - Lincoln Lane Villa 500 E Lincoln St Hendricks MN 56136 Senior Housing Part I, Line 3c: Discounted care eligibility is determined by utilizing asset and ability to pay information obtained from the patient or responsible party. Discounted care portion of the account is determined based on the patient's financial status and ability to pay the account. Part I, Line 7: Charity care is based on an overall cost to charge ratio addressing all patient segments. Community health improvement services, health professions education, and cash and in-kind contributions for community benefit expenses are based on actual expenses recorded to the general ledger. Subsidized health services are reported according to costs allocated to the relevant cost centers on the Medicare Cost Report. Part III, Line 2: The amount reported on line 2 represents implicit price concessions. The Association determines its estimate of implicit price concessions based on its historical collection experience with this class of patients and residents. A payment on an account previously written off reduces the implicit price concessions in the current year. Part III, Line 3: Implicit price concessions are determined based on a patient's payment history as well as current known financial status. Such expense is determined by a patient's non-payment status and non-probability of payment. Part III, Line 4: The footnote to the organization's financial statements addressing implicit price concessions may be found on page 10 and 11 of the attached audited financial statements. Part III, Line 8: The Hospital provides services to Medicare patients because access to healthcare and patient's health is important to the Hospital. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: Patients are classified in the poverty level utilizing the Federal poverty guidelines as also referenced in our facility collection policy. The guidelines are referenced when a patient fails to complete payment of his/her account in a timely manner. Prior to being turned over to a collection agency, a patient is offered 120 days to complete a charity care application, thereby allowing staff time to determine the income level of the patient and their qualification as a poverty level individual. If they so chose to not complete an application, their account will be referred to a collection agency. The hospital allows an additional 120 days for a patient to apply for financial assistance. If the patient is determined to be eligible for financial assistance, collection activities will cease. Part VI, Line 2: We are consistently addressing the additional services needs as voiced though the physicians who serve our clientele, as well as the clientele themselves.The recently completed community health needs assessment and implementation strategy has been established and is available on our website www.hendrickshosp.org Part VI, Line 3: Patient's insurance information is obtained upon admission, and those patients not having current third party coverage are informed of the ability to apply for medical assistance funding or visit with our business office staff and social service staff regarding alternative payments and the charity care options. In addition, the patient statements provide information related to contacting our business office personnel to complete alternative payment arrangements, i.e. charity care, Medicaid or planned payment schedule. Patients are offered an option of setting an appointment to meet with staff to complete such arrangements. These procedures are also detailed in our financial assistance/charity care policy. Part VI, Line 4: Hendricks Community Hospital serves a primarily rural population within a 30-mile radius of the community of Hendricks. The facility is located in Lincoln County, Minnesota, which is slated as one of the highest elderly population counties in the State. The average medican income for the county is $51,102 with the highst portion of the population being over 65 years of age. However, because of the high elderly population, many of those constituents are insured through federal government programs and do not necessarily relate to increased Medicaid levels. There is one other acute care facility in the county approximately 30 miles away. Our facility is also located within one mile of the South Dakota border, and a good margin of population served is located in that state. During the fiscal year ending 6/30/20, it was noted approximately 21% of our patients were insured through Medical Assistance programs, and approximately 10% were un-insured. Part VI, Line 5: The nine members of the association's Board of Directors represent varying communities within the 30-mile service area. The board members provide valuable input of the health care needs of the area served.Medical staff privileges are extended to qualified physicians within the service area as well as outlying areas to provide the optimum level of care for our constituents. These privileges are granted to several specialty physicians to eliminate the need for additional travel for our patients.The Association continually allocates funds to the improvement of the facilities and equipment utilized to provide the optimum service to our patients. Surplus funds are also provided to enhance community services with donations to service organizations who offer additional health-enhancing services to the residents of the area. The rural health clinics in the Hendricks community and neighboring Ivanhoe community provide for improved community access. Particularily in the Ivanhoe community it has proved beneficial to be able to offer services in their primary dwelling location.Emergency room services are available 24/7, and are offered regardless of payment source or ability to pay.The facility also participates in the Minnesota SAGE and South Dakota All Women County programs which offer women yearly physical exams, including mammograms and pap smears at no cost to the patient.Facility staff is involved in community economic planning groups as well as community service organizations.Many area residents are involved as volunteers within our organization and participate on a daily basis enhancing the lives of the residents and patients in our facility. X X X 0 0 0 0 0 0 0 0 0 Tabb McCluskey DO Physician 292101 0 0 0 0 0 11200 0 36742 0 340043 0 0 0 Grant Eyjolfson MD Physician 263718 0 0 0 0 0 10983 0 36103 0 310804 0 0 0 Tomasz Lis MD Physician 256204 0 0 0 0 0 10877 0 40967 0 308048 0 0 0 Jeff Gollaher CEO 170075 0 0 0 0 0 6930 0 14462 0 191467 0 0 0 Grant Eyjolfson Employee Physician Recruitment X 50000 25000 0 1 1 Kathryn Christensen Employee Nurse Practioner Recruitment X 45000 20259 0 1 1 Tomasz Lis Employee Physician Recruitment X 50000 25000 0 1 1 70259 Katie Wendinger Family member of board member Dean Nielsen 39835 Employee Compensation 0 Betty Johnson Family member of board member Dean Nielsen 12696 Employee Compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee is composed of the President, Vice-President, Secretary and Treasurer of the governing board. Responsibilities include: A. General management and control of the affairs of the corporation. In addition to formal meetings, the committee has informal conferences about corporation activities. B. Shall have the power to transact all regular business of the hospital during the interim between the meetings of the Board of Directors provided any action taken shall not conflict with the policies and expressed wishes of the Board of Directors, and that it shall refer all matters of major importance to the Board of Directors. C. It shall cause to be prepared and submit to the Board of Directors at its last meeting before the end of the fiscal year, a budget showing the expected receipts and income and expense for the ensuing year. It shall be the further duty of the Executive Committee to examine the monthly financial reports and to require an explanation from the Administrator for any material variation from the budget. D. The Executive Committee shall evaluate in April annually or as deemed necessary, the Chief Executive Officer's performance and recommend his/her remuneration to the full Board of Directors. This committee shall meet as necessary. Form 990, Part VI, Section A, line 6 There is one class of membership. Membership is open to any natural person who is of legal voting age and a voting resident within the organization's primary service area. Form 990, Part VI, Section A, line 7a Each member receives one vote. Form 990, Part VI, Section B, line 11b The return is reviewed by the Business Office Manager and CEO, then by the Board of Directors before it is filed. Form 990, Part VI, Section B, line 12c The policy covers all officers, directors, and key employees. A conflict of interest form is signed upon orientation to the Board of Directors. The form is reviewed by the CEO and any potential conflicts are reviewed with the Board of Directors. If a conflict exists, the person with the conflict is restricted from voting on related matters. Conflict of interest forms are completed annually by board of directors and key employees. These are reviewed by the HR director, and compliance report submitted to the governing board. Form 990, Part VI, Section B, line 15a The Executive Committee reviews the CEO's compensation annually and compares to similar positions at other hospitals of similar size and geographic location. The Board of Directors reviews and approves the recommendations of the Executive Committee. The compensation of other officers is determined by the CEO. The officers and directors of the board receive a stipend for attending meetings. The fee structure is based on meetings attended. This compensation process is determined by board members and the fee schedule is discussed by the board annually. Form 990, Part VI, Section C, line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Form 990, Part IX, line 11g Contracted services: Program service expenses 1,043,767. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,043,767. Medical fees: Program service expenses 766,939. Management and general expenses 0. Fundraising expenses 0. Total expenses 766,939. Purchased services: Program service expenses 538,625. Management and general expenses 458. Fundraising expenses 0. Total expenses 539,083. Collection fees: Program service expenses 5,252. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,252. Recruitment: Program service expenses 49,904. Management and general expenses 0. Fundraising expenses 0. Total expenses 49,904. Form 990, Part XI, line 9: Change in net assets for Hendricks Hospital Auxiliary 34,579. Change in net assets for resident funds 295.