2020-06-03T08:56:39-05:00 2019-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2018-07-01 770637498 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC MCKE 7018423000 709 4TH AVENUE NE WATFORD CITY ND 58854 DANIEL KELLY CEO 7018423000 2020-06-02 1 MICHAEL J PETERSON CPA P01833529 2187224705 2020-06-02 71.13.38.61 2020-06-02 13:19:44 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 2018 2021-01-29 14:40:06Z DANIEL KELLY 709 4TH AVENUE NE WATFORD CITY ND 58854 28463870 0 X WWW.MCKENZIEHEALTH.COM X 2004 ND HEALTH CARE SERVICE PROVIDER. 10 10 253 45 339000 0 9454505 3155508 16958938 23686488 25841 14735 566306 726853 27005590 27583584 0 50 0 0 9054012 11260469 0 0 0 10318302 19555007 19372314 30815526 7633276 -3231942 112115780 115957319 71789271 78862752 40326509 37094567 X MCKENZIE COUNTY HEALTHCARE SYSTEMS IS A FAITH-BASED ORGANIZATION DEDICATED TO PROFESSIONAL, COMPASSIONATE AND QUALITY HEALTHCARE. 0 0 18333277 50 16826989 MCKENZIE COUNTY HEALTHCARE SYSTEMS PROVIDES 24 HOUR X 7 DAYS A WEEK SERVICES. MCHS PROVIDED IN-PATIENT, OBSERVATION, AND SWING BED SERVICES - HOSPITAL- TOTAL INPATIENT/OBSERVATION DAYS - 468. TOTAL SWING BED DAYS - 639. MCHS OFFERS VARIOUS OTHER SERVICES. THEY OFFER ENDOSCOPIC EXAMS ONCE A MONTH BY A CONTRACTED PROVIDER. TOTAL OUTPATIENT SURGERIES - 136. THE EMERGENCY ROOM IS OPEN 24 HOURS A DAY, 7 DAYS A WEEK. TOTAL EMERGENCY ROOM VISITS - 5,158. THE LABORATORY IS LOCATED WITHIN THE HOSPITAL FACILITY. BIRTHDAY LAB SCREENINGS ARE AVAILABLE TO THE COMMUNITY AT THE HOSPITAL AT A REDUCED RATE. NUMBER OF MEMBERS TAKING ADVANTAGE OF BIRTHDAY SCREENINGS - 581. TOTAL OUTPATIENT PROCEDURES - 19,906. VOLUME INCREASED DUE TO POPULATION INCREASE. 4410555 0 4048177 THE MCKENZIE COUNTY HEALTHCARE SYSTEM (MCHS) GOOD SHEPHERD HOME (GSH) IS A 47 BED SKILLED NURSING HOME WITH AN ATTACHED 9-BED BASIC CARE UNIT. BASIC CARE WAS CLOSED DUE TO CONSTRUCTION IN FEBRUARY 2018 AND WILL REOPEN IN JULY 2020. THE GSH OFFERS DAY CARE AND/OR RESPITE CARE FOR THOSE CARING FOR A LOVED ONE IN THEIR HOME. A DEMENTIA SUPPORT GROUP IS OFFERED TO FAMILIES. THEY MAINTAIN REGULAR RESIDENT FAMILY COUNCIL MEETINGS. ALONG WITH QUALIFIED NURSING CARE AND STAFF, SOCIAL SERVICES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, RESTORATIONAL NURSING, LAUNDRY, HOUSEKEEPING, BEAUTICIAN SERVICES, AND ACTIVITY PROGRAMS ARE OFFERED. VISITORS ARE ALWAYS WELCOME AS WELL AS CHILDREN. CHILDREN ARE WELCOME TO VISIT AND PLAY ON THE FENCED OUTDOOR PLAYGROUND EQUIPMENT. PASTORAL CARE AND CHAPEL ARE OFFERED 7 DAYS A WEEK. ACTIVITIES INCLUDE BIRTHDAY PARTIES, MUSICAL GROUPS, BAKING, AND BUS TRIPS. THE SKILLED NURSING TOTAL PERCENT OF OCCUPANCY HAS BEEN 75.10%. THE BASIC CARE UNIT TOTAL PERCENT OF OCCUPANCY HAS BEEN 0% WHILE THE SPACE IS CLOSED FOR RENOVATIONS. 2776327 0 2548220 THE MCHS CLINIC (RURAL HEALTH CLINIC) MAINTAINS THE SAME MISSION AS THE HOSPITAL. IT PROVIDES CARE MONDAY THROUGH FRIDAY. A FULL-TIME CONTRACTED LOCUM PHYSICIAN GROUP PROVIDE EMERGENCY ROOM COVERAGE AT THE HOSPITAL 24 HOURS A DAY X 7 DAYS A WEEK AS WELL AS 7 DAY A WEEK URGENT CARE COVERAGE FROM 8A TO 8P UTILIZING MID-LEVEL PROVIDERS. RHC PROVIDERS, DR. RAMAGE, DR. LOONEY, DR. MUDORF, JESSICA HEGGEN, AND JANICE GREEN ALSO MAKE VISITS TO THE GOOD SHEPHERD HOME WEEKLY. BOTH THE VALUE BASED PROGRAM INVOLVEMENT AS WELL AS OUR VISITING NURSE PROGRAM HAVE BEEN A GREAT ASSET TO THE CLINIC, PROVIDING CARE TO HOMEBOUND PATIENTS WITHIN OUR COMMUNITY. 255193 0 234226 HORIZON ASSISTED LIVING PROVIDES ASSISTED AND INDEPENDENT LIVING SERVICES. IT CONSISTS OF 15 APARTMENTS THAT PROVIDE A 24 HOUR CALL SYSTEM TO HEALTH CARE PERSONNEL. THE STAFF IS DEDICATED TO HELPING SENIORS LIVE AT THEIR HIGHEST LEVEL OF INDEPENDENCE AND ABILITY. ITS PERCENT OF OCCUPANCY IS CURRENTLY AT 59.30% 394851 0 0 WELLNESS CENTER 650044 0 234226 26170203 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 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 1 1 1 0 0 1 49 0 253 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 10 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X DANIEL KELLY 7018423000 709 4TH AVENUE NE WATFORD CITY ND 58854 MONTY BULZOMI DIRECTOR 1.00 X 0 0 0 VIRGINIA CEYNAR DIRECTOR 1.00 X 0 0 0 JAN DODGE DIRECTOR 1.00 2.00 X 0 0 0 TAMMY JAMES DIRECTOR 1.00 X 0 0 0 NANCY JELLESED DIRECTOR 1.00 X 0 0 0 LARRY LARSEN DIRECTOR (THRU NOV) 1.00 2.00 X 0 0 0 NEAL SHIPMAN DIRECTOR 1.00 X 0 0 0 PATSY LEVANG PRESIDENT 2.00 2.00 X X 0 0 0 MYRON HOVET VICE PRESIDENT 2.00 2.00 X X 0 0 0 KELLY PETERSON VICE PRESIDENT (THRU NOV) 2.00 2.00 X X 0 0 0 MICHON SAX SECRETARY 2.00 X X 0 0 0 SCOTT SWENSON TREASURER 2.00 X X 0 0 0 DANIEL KELLY CEO 40.00 10.00 X 495748 0 22193 SUSIE CURTIS CFO 40.00 X 97546 0 3998 CHERYL FAULKNER CNO 40.00 X 110949 0 11397 MICHAEL CURTIS CAO 40.00 X 123938 0 17730 DR GARY RAMAGE PHYSICIAN 40.00 X 343420 0 17548 1171601 0 72866 4 0 1 0 JE DUNN 800 WASHINGTON AVE N STE 600 MINNEAPOLIS MN 55401 CONSTRUCTION SERVICES 9604456 RURAL MEDICAL PARTNERS 4956 CURRAN COURT GRAND FORKS ND 58201 CONTRACT MEDICAL STAFF 1995235 HANNAHERS 3803 MAIN AVE FARGO ND 58103 INTERIOR DESIGN 618797 GE HEALTHCARE PO BOX 96483 CHICAGO IL 60693 IT SERVICES 544960 EQUALIZE RCM SERVICES PO BOX 679005 DALLAS TX 75267 MEDICAL BILLING SERVICES 535764 37 1875001 1278617 1890 3155508 HOSPITAL PATIENT SERVICE REVENUE 621400 16219931 16219931 NURSING HOME SERVICE REVENUE 621400 4048177 4048177 CLINIC SERVICE REVENUE 621400 2548220 2548220 WELLNESS CENTER 621400 635934 514656 121278 ASSISTED LIVING SERVICE REVENUE 621400 234226 234226 23686488 14735 14735 771741 880286 -108545 -108545 -175656 67111 340 B REVENUE 621400 579120 579120 EHR INCENTIVE 621400 27938 27938 CAFETERIA AND DIETARY REVENUE 900099 26165 26165 202175 202175 835398 27583584 23657612 339000 431464 X 50 50 906106 906106 8583723 7884956 698767 189215 132908 56307 942194 666137 276057 639231 543778 95453 5228 5228 82786 82786 5257538 4267250 990288 48754 976 47778 263987 54858 209129 1877 1877 541258 533721 7537 115541 39137 76404 51282 27902 23380 1181851 1084067 97784 6168265 5743557 424708 170953 82913 88040 BAD DEBT & COLLECTION 3355170 3355170 PROGRAM SUPPLIES 1651124 1569432 81692 EQUIPMENT RENTAL & MAIN 372308 110251 262057 DUES AND SUBSCRIPTIONS 70061 21193 48868 217024 50070 166954 30815526 26170203 4645323 0 4180 35381 594982 1421268 11412648 10546776 2136591 4513060 37188 238161 135593 133582 110913993 18940809 87093691 91973184 200000 200000 10500907 6895907 112115780 115957319 7040831 4088040 27938 0 270663 420984 64332322 74236211 117517 117517 71789271 78862752 X 22549166 24590469 17777343 12504098 40326509 37094567 112115780 115957319 -3231942 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 2570 2570 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF NORTH DAKOTA HOSPITAL ASSOCIATION AND NORTH DAKOTA LONG TERM CARE ASSOCIATION. A PORTION OF MEMBERSHIP DUES TO THE ABOVE LISTED ASSOCIATIONS IS USED FOR LOBBYING. THESE ASSOCIATIONS ADVOCATE ON BEHALF OF ITS MEMBERS FOR IMPROVING EFFICIENCY AND ACCESSIBILITY OF THE HEALTHCARE DELIVERY SYSTEMS AND THE HEALTH STATUS OF NORTH DAKOTA'S POPULATION. 1144947 1144947 64307723 8706875 55600848 45428782 10233934 35194848 32541 32541 91973184 ASSETS RESTRICTED AS TO USE 6551812 CASH SURRENDER VALUE OF LIFE INSURANCE 344095 6895907 DUE TO RELATED PARTY 117517 117517 1 1 X 1 X 175.000000000000 1 X 248.000000000000 1 1 1 0 0 117959 117959 0.00430 2025289 2600718 0 0.00000 2143248 2600718 117959 0.00430 52517 52517 14917 14917 4061945 3005798 1056147 0.03850 4129379 3073232 1056147 0.03850 6272627 5673950 1174106 0.04280 34203 34203 0.00120 34203 34203 0.00120 1 3368591 0 5279544 5185128 94416 X 1 1 1 1 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 709 4TH AVE NE WATFORD CITY ND 58854 HTTP://MCKENZIEHEALTH.COM/ 5051A X X X X X SWING BED UNIT MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X SEE SUPPLEMENTAL INFORMATION X 1 18 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 175.000000000000 248.000000000000 X X X X 1 1 X X X 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X X X X X X X 1 X 0 X X X X 1 X 0 0 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 5: APPROXIMATELY 350 PRINTED SURVEYS WERE DISTRIBUTED TO AREA RESIDENTS THROUGH VARIOUS CHANNELS THROUGHOUT THE COMMUNITY. 54 SURVEYS WERE RETURNED AND THE HOSPITAL IDENTIFIED SOME INFORMATION GAPS BASED ON THE DEMOGRAPHIC INFORMATION FROM THE SURVEYS RETURNED COMPARED TO TOTAL DEMOGRAPHIC INFORMATION. THEN INFORMATION INTERVIEWS WERE CONDUCTED. INTERVIEWS WERE 2 HOURS LONG AND CONDUCTED WITH 12 MEMBERS CHOSEN FROM THE COMMUNITY. INCLUDED AMONG THOSE INTERVIEWED WAS A PUBLIC HEALTH NURSE, PUBLIC SERVANTS, SCHOOL ADMINISTRATORS, THE COUNTY SHERIFF, BUSINESS PERSONS AND HEALTHCARE ADMINISTRATORS. MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 11: THE THREE MAIN AREAS OF CONCERN BROUGHT TO OUR ATTENTION DURING THE LAST CHNA REPORT IN 2019 HIGHLIGHTED: HOUSING, DOMESTIC ABUSE, AND HEALTHCARE STAFFING. MCHS CONTINUES TO ACTIVELY WORK WITH COMMUNITY AND CITY LEADERS ON HOUSING OPTIONS AND POTENTIAL PLANNING TO INCREASE THE AVAILABILITY OF SINGLE FAMILY HOUSING IN OUR COUNTY. THIS INVOLVEMENT IS BOTH VERBAL AS WELL AS THROUGH ACTIVE INVOLVEMENT IN COMMITTEES, SURVEYS, AND MISC. ENGAGEMENTS ASKED OF US BY CIVIC LEADERSHIP. AS OF EARLY 2019 AND ESTIMATED TO BE COMPLETED BY THE BEGINNING OF 2020, MCHS IS DEVELOPING LASTING RELATIONSHIPS WITH LOCAL HEALTH RESOURCES, SPECIFICALLY THOSE ADDRESSING DOMESTIC ABUSE AND VIOLENCE IN THE HOME. BY FACILITATING THESE ARRANGEMENTS MCHS AND ITS PARTNERSHIPS HOPE TO INCREASE LOCAL ACCESS AND AWARENESS OF DOMESTIC VIOLENCE MATERIAL THROUGH REFERRAL SOURCES, ONLINE EDUCATION, AND EDUCATIONAL BROCHURES TO BE LOCATED THROUGHOUT OUR HEALTHCARE FACILITY WHILE SIMULTANEOUSLY OFFERING DISCREET PACKAGING OF SUCH MATERIAL AND A PROFOUND SUPPORT AMONGST STAFF TO OFFER RESOURCES TO THOSE IN NEED. LASTLY, MCHS CONTINUES TO PUSH TOWARDS ITS RECRUITMENT OF EMPLOYED STAFF, SPECIFICALLY NURSING STAFF. A GOAL OF THE CHNA REPORT WAS TO EMPLOY AT LEAST 25% OF OUR OWN NURSING STAFF TO LESSEN OUR NEED TO LEAN ON TEMPORARY OR LONG TERM STAFFING ORGANIZATIONS. BY HIGHLIGHTING OUR EMPLOYMENT BENEFITS, ENRICHING OUR ORGANIZATIONAL CULTURE, STAYING COMPETITIVE, AND WORKING WITH THE COUNTY TO PROVIDE MORE HOUSING, WE ARE CONFIDENT THAT THE CONTINUED GROWTH OF MCHS WILL BE SUPPORTED BY OUR OWN, EMPLOYED, STAFF. MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 16J: IN ADDITION TO PROVIDING THE FULL POLICY UPON REQUEST, A SUMMARY OF THE POLICY IS POSTED IN THE EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE. UPON ADMISSION THE PATIENTS RECEIVE A BROCHURE IN A PACKET REFERENCING THE FINANCIAL ASSISTANCE POLICY. THE PATIENTS ALSO RECEIVE INFORMATION IN THEIR FIRST BILLING INVOICE REGARDING THE FINANCIAL ASSISTANCE POLICY.FAP WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2019/12/2019-2020-FINANCIAL-ASSISTANCE-POLICY-AND-PROCEDURE.PDFFAP APPLICATION WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2018/01/2018-FINANCIAL-ASSISTANCE-APPLICATION.PDFFAP PLAIN LANGUAGE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2018/05/UPDATED-PLAIN-LANGUAGE-05.07.18.PDF 5 1 - MCKENZIE COUNTY CLINIC 709 4TH AVE NE WATFORD CITY ND 58854 RURAL HEALTH CLINIC 2 - GOOD SHEPHERD HOME 709 4TH AVE NE WATFORD CITY ND 58854 LT CARE & BASIC CARE 3 - CONNIE WOLD WELLNESS CENTER 200 8TH ST NE WATFORD CITY ND 58854 WELLNESS CENTER 4 - HORIZONS 705 4TH AVE NE WATFORD CITY NE 58854 ASSISTED LIVING COMPLEX 5 - HERITAGE MANOR 709 4TH AVE NE WATFORD CITY NE 58854 APARTMENT COMPLEX PART I, LINE 7: THE ORGANIZATION UTILIZES THEIR COST REPORT TO DETERMINE THE COST-TO-CHARGE RATIO. THE COST REPORT IS BASED OFF OF THE INTERNAL REPORTING SYSTEM USED BY THE ORGANIZATION. PART I, LINE 7G: THE ORGANIZATION INCLUDED THE OPERATIONS OF THEIR SKILLED NURSING FACILITY IN THE SUBSIDIZED SERVICES CALCULATION. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,355,170. PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 2: THIS AMOUNT IS CALCULATED BY MULTIPLYING THE TOTAL CHARGES FOR SERVICES WRITTEN OFF AS BAD DEBT BY THE COST TO CHARGE RATIO. PART III, LINE 3: THE ORGANIZATION IS DILIGENT TO EVALUATE EACH PATIENTS ABILITY TO PAY AND DISTINGUISH BETWEEN BAD DEBT AND CHARITY CARE. PART III, LINE 4: PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT AND RESIDENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FOR UNINSURED PATIENTS AND AMOUNTS PATIENTS AND RESIDENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH SYSTEMS ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 9B: THE ORGANIZATION DOES NOT COLLECT ON ACCOUNTS THAT HAVE A FINANCIAL ASSISTANCE APPLICATION IN REVIEW OR THAT HAS BEEN APPROVED. IF THE ACCOUNT IS NOT COMPLETELY WRITTEN OFF (BASED ON THE SLIDING FEE SCHEDULE) AND THEY DO NOT FOLLOW THROUGH ON THEIR PAYMENT PLAN FOR THE BALANCE, THAT WOULD BE THE ONLY TIME THE ACCOUNT WAS OUTSOURCED TO COLLECTIONS. PART VI, LINE 2: SEPARATE EVALUATIONS ARE COMPLETED ANNUALLY FOR THE CRITICAL ACCESS HOSPITAL AND THE RURAL HEALTH CLINIC. AT THIS TIME SERVICES AND STATISTICS ARE REVIEWED. EACH REPORT IS PRESENTED TO THE MEDICAL STAFF MEMBERS AND BOARD OF DIRECTORS. CURRENT SERVICES ARE DISCUSSED ALONG WITH THE NEEDS NOT CURRENTLY BEING MET. MANAGERS OF EACH DEPARTMENT ANNUALLY REVIEW THEIR SERVICES WITH THE BUDGETING PROCESS AND DISCUSS POSSIBLE PROJECTION OF NEW SERVICES. ONCE A NEED IS DETERMINED, IT IS DISCUSSED ON A DEPARTMENTAL LEVEL, INFORMATION IS GATHERED AND PRESENTED TO THE CEO/CFO FOR APPROVAL. MCHS HOLDS THEIR ANNUAL MEETING FOR THE PUBLIC IN THE FALL OF EACH CALENDAR YEAR. THIS IS AN OPEN MEETING ALLOWING THE PUBLIC TO VOICE CONCERNS AND SUGGESTIONS. PART VI, LINE 3: THE MCHS CHARITY CARE POLICY IS POSTED IN THE HOSPITAL AND CLINIC ADMISSIONS AREAS AND EMERGENCY ROOM. COPIES OF THE POLICY AND APPLICATIONS ARE AVAILABLE IN EACH RECEPTION AREA OF THE HOSPITAL AND CLINIC. INFORMATION IS SENT OUT TO ALL PATIENTS WITH THEIR FIRST STATEMENT. IF A BILL IS UNPAID, AFTER TWO STATEMENTS HAVE BEEN SENT, A BILLING EMPLOYEE WILL ATTEMPT TO REACH THE RESPONSIBLE PARTY BY PHONE TO DISCUSS INSTALLMENT PLANS, CHARITY CARE, AND/OR DISCUSS VARIOUS GOVERNMENT BENEFITS SUCH AS MEDICAID. THE MCHS BUSINESS OFFICES ALSO HAVE THE APPLICATIONS AT ALL TIMES. THE BUSINESS OFFICE STAFF COUNSEL ANYONE WHO PRESENTS THEMSELVES WITH OVERDUE BALANCES AND PRESENT THE ABOVE OPTIONS. PART VI, LINE 4: MCKENZIE COUNTY HEALTHCARE SERVICES SERVES MCKENZIE COUNTY. MCKENZIE COUNTY IS THE LARGEST COUNTY IN THE STATE OF NORTH DAKOTA. IT IS VERY RURAL AND INCLUDES PART OF THE FORT BERTHOLD RESERVATION. MCKENZIE COUNTY HOSPITAL IS THE ONLY HEALTHCARE SYSTEM WITHIN A 45 MILE RADIUS. THE COUNTY'S POPULATION WAS ESTIMATED IN 2010 AT 6,380. THE MEDIAN HOUSEHOLD INCOME IN 2010 WAS REPORTED AT $48,480. 100% OF THE POPULATION WAS REPORTED BELOW THE POVERTY LEVEL IN 2010. THE RUGGED TERRAIN, WINTER CONDITIONS, INCREASED OIL ACTIVITY, AND RECREATIONAL ACTIVITIES HAVE ALL ADDED TO THE INCREASED NUMBER OF EMERGENCY ROOM VISITS. WITH THE RECENT OIL ACTIVITY IN THE STATE, MCKENZIE COUNTY IS EXPERIENCING A RAPID INCREASE IN POPULATION, NEW BUSINESSES, HOUSING PROJECTS, AND IMPROVED WAGE SCALES. WITH THIS RAPID GROWTH, MCHS IS EXPERIENCING AN INFLUX IN EMERGENCY ROOM SERVICES, SHORTAGE OF PHYSICIANS AND NURSES, AS WELL AS GROWING BAD DEBT EXPENSES RELATED TO MEDICAL SERVICES PROVIDED TO UNINSURED WORKERS AND PATIENTS THAT DO NOT HAVE A PERMANENT RESIDENCE TO SEND BILLS TO. PART VI, LINE 5: THE MCKENZIE COUNTY BOARD OF DIRECTORS IS MADE UP OF VOLUNTEER MEMBERS FROM THE LOCAL COMMUNITY OF WATFORD CITY AND THE SURROUNDING AREAS. MCHS DOES EXTEND PRIVILEGES TO ALL PHYSICIANS IN THE AREA. SPECIALISTS WILL ALSO VISIT THE LOCAL HOSPITAL AND CLINIC TO EXPAND THE PRESENT SERVICES. SURPLUS FUNDS ARE APPLIED FOR THE PURPOSES EDUCATION, INCREASING PATIENT SERVICES, WELLNESS, AND PREVENTATIVE CARE TO ITS CLIENTS. MCHS IS ALSO A PART OF A WORKSITE WELLNESS NORTH DAKOTA PROGRAM. IT ALLOWS THEIR CARDIAC WELLNESS MANAGER (RN) TO WORK CLOSELY IN THE STATE-WIDE PROGRAM THAT CAN GREATLY IMPROVE THE HEALTH OF EMPLOYEES, RESULTING IN LOWER HEALTH CARE COSTS, AND INCREASED PRODUCTIVITY AND MORALE. MCKENZIE COUNTY HEALTHCARE SYSTEMS AND THE MCKENZIE COUNTY HEALTHCARE SYSTEMS BENEFIT FUND TOGETHER ENGAGED IN THE BUILDING AND FUNDING OF A NEW WELLNESS CENTER. THE WELLNESS CENTER OPENED IN MARCH 2013. THE WELLNESS CENTER HOUSES A NEW PHYSICAL THERAPY DEPARTMENT TO BETTER UTILIZE A THERAPY POOL AND HAS INCREASED THE PRESENT SQUARE FOOTAGE OF THE HOSPITAL. PREVENTION IS A KEY WORD TODAY. THE WELLNESS CENTER PROVIDES EDUCATION AND EXERCISE TO ITS MEMBERS. IT WILL HELP IMPROVE OR PREVENT DISEASES LIKE DIABETES, HIGH BLOOD PRESSURE, OBESITY, DEPRESSION, AND MANY NOT LISTED. IN AN EFFORT TO ENHANCE SERVICES IN THE RURAL AREAS, MCKENZIE COUNTY HEALTHCARE PARTICIPATES IN SEVERAL PROGRAMS. THE RURAL ACCOUNTABLE CARE ORGANIZATION IS INTENDED TO BETTER SERVE OUR POPULATION BY IMPROVING HEALTHCARE, PATIENT SATISFACTION, AND REDUCING COSTS WHILE IMPROVING FINANCIAL PERFORMANCE AND SUSTAINABILITY. THE FRONTIER COMMUNITY HEALTHCARE INTEGRATION PROJECT (FCHIP) IS A DEMONSTRATION PROGRAM THAT ASSISTS OUR ORGANIZATION WITH PROVIDING TELEMEDICINE SERVICES TO OUR POPULATION IN ORDER TO PROVIDE ACCESS TO MORE SPECIALTY SERVICES TO THE RESIDENTS OF OUR COMMUNITIES. THESE PROGRAMS ARE AIMED AT INCREASING THE INTEGRATION AND COORDINATION OF CARE AMONGST PROVIDERS AND IMPROVE THE OVERALL QUALITY OF CARE FOR OUR HEALTHCARE COMMUNITY. PART VI, LINE 6: N/A X X X 0 1 0 0 0 0 0 0 0 DANIEL KELLY CEO 495748 0 0 0 0 0 20943 0 1250 0 517941 0 0 0 DR GARY RAMAGE PHYSICIAN 343420 0 0 0 0 0 13556 0 3992 0 360968 0 0 0 PART I, LINE 4B $92,500 WAS CONTRIBUTED TO A 457(F) PLAN FOR DANIEL KELLY. DANIEL KELLY CEO SPLIT DOLLAR LIFE INSURANCE POLICY X 92500 420984 0 1 1 420984 LESLIE KELLY SPOUSE OF CEO 53412 EMPLOYEE SALARY 0 SAMUEL KELLY SON OF CEO 75584 EMPLOYEE SALARY 0 DANIELLE KELLY DAUGHTER OF CEO 23855 EMPLOYEE SALARY 0 FORM 990, PART VI, SECTION A, LINE 2 MICHAEL CURTIS AND SUSIE CURTIS HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B THE MCHS CEO AND CFO REVIEW AND APPROVE THE FORM 990. THE BOARD OF DIRECTORS RECEIVE A COPY OF THE FINAL FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C AN INTERESTED PERSON IS DEFINED AS ANY DIRECTOR, PRINCIPAL OFFICER, AND ANYONE WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST WITH RESPECT TO ALL ENTITIES IN THE HEALTHCARE SYSTEM. AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND WILL BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS. THE CONFLICT WILL BE REVIEWED BY THE REMAINING BOARD AND WILL DETERMINE IF A CONFLICT EXISTS. IF A CONFLICT EXISTS, THE INTERESTED PERSON MUST ABSTAIN FROM VOTING ON THE ISSUE AND THE REMAINING BOARD MEMBERS WILL DETERMINE IF THE TRANSACTION IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND IF IT IS FAIR AND REASONABLE. THIS IS ACCOMPLISHED THROUGH ANNUAL REVIEW AND A SIGNED STATEMENT STATING THAT THE INTERESTED PERSON HAS OBTAINED A COPY OF THE POLICY AND HAS READ AND UNDERSTANDS THE POLICY, AND HAS AGREED TO COMPLY WITH THE POLICY. FORM 990, PART VI, SECTION B, LINE 15 MEMBERS OF THE BOARD OF TRUSTEES REVIEW STATE-WIDE SALARY SURVEY INFORMATION AND OTHER FORM 990'S WHEN DETERMINING ANY WAGE CHANGES. THE CEO HAS AN ANNUAL EVALUATION COMPLETED EACH YEAR. THE CEO HAS THE OPPORTUNITY TO GIVE A PROPOSAL TO THE BOARD AT HIS EVALUATION. ANY CHANGE OR REVISION IS RECORDED IN THE BOARD MINUTES. AN ADDENDUM TO THE TERMS OF EMPLOYMENT IS SIGNED BY THE BOARD PRESIDENT AND CEO FOR THE PERSONNEL FILE. THE CEO APPROVES THE CFO COMPENSATION BASED UPON SURVEY DATA ON AN ANNUAL BASIS. THE RESULTS ARE DOCUMENTED IN THE CFO'S ANNUAL EVALUATION PAPERWORK. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G EMERGENCY ROOM PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,183,891. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,183,891. CLINIC MD PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 945,538. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 945,538. NURSING HOME PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 237,741. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 237,741. OTHER CONTRACTOR SERVICES: PROGRAM SERVICE EXPENSES 1,157,300. MANAGEMENT AND GENERAL EXPENSES 990,288. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,147,588. ADULTS AND PEDS SERVICES: PROGRAM SERVICE EXPENSES 742,780. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 742,780. MCKENZIE COUNTY HEALTHCARE SYSTEMS PROPERTIES 709 4TH AVE NE WATFORD CITY ND 58854 462905447 PROPERTY MANAGEMENT ND 35336 683274 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 709 4TH AVE NE WATFORD CITY ND 58854 363431210 TO SUPPORT THE MCKENZIE COUNTY HEALTHCARE SYSTEMS ND 501(C)(3) LINE 7 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 0 0 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC C 1875001 ACTUAL THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC E 117517 ACTUAL