GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2017
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2017-04-01 to 2018-03-31
- Filed
- 2019-02-15
- IRS object ID
- 201920469349302322
- Schema version
- 2017v2.3
- 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 L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2019-02-15T17:16:59-06:00 | ReturnTs |
| Tax Period End | 2018-03-31 | 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 | 2017-04-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | GOOD | BusinessNameControlTxt |
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVENUE | AddressLine1Txt |
| City | RUGBY | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | PATRICK BRANCO | PersonNm |
| Person Title | CEO | PersonTitleTxt |
| Phone | 7017765261 | PhoneNum |
| Signature | 2019-02-15 | 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 | 2019-02-15 | PreparationDt |
Filing Security Information FilingSecurityInformation
IP Address IPAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| I Pv4 Address | 216.54.158.12 | IPv4AddressTxt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| IP | 2019-02-15 | IPDt |
| IP Tm | 15:45:05 | IPTm |
| IP Timezone | CS | IPTimezoneCd |
| Filing License Type | P | FilingLicenseTypeCd |
| At Submission Creation Device Id | DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 | AtSubmissionCreationDeviceId |
| At Submission Filing Device Id | 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 | AtSubmissionFilingDeviceId |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2017 | TaxYr |
| Build TS | 2019-02-21 02:37:17Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | PATRICK BRANCO | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVENUE | AddressLine1Txt |
| City | RUGBY | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $29,249,422 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.HAMC.COM | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1905 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 10 | VotingMembersIndependentCnt |
| Total Employee | 470 | TotalEmployeeCnt |
| Total Volunteers | 112 | TotalVolunteersCnt |
| Total Gross UBI | $25,223 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | -$50,933 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $430,178 | PYContributionsGrantsAmt |
| CY Contributions Grants | $1,726,886 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $24,266,616 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $26,664,519 | CYProgramServiceRevenueAmt |
| PY Investment Income | $482,314 | PYInvestmentIncomeAmt |
| CY Investment Income | $317,109 | CYInvestmentIncomeAmt |
| PY Other Revenue | $334,069 | PYOtherRevenueAmt |
| CY Other Revenue | $540,908 | CYOtherRevenueAmt |
| PY Total Revenue | $25,513,177 | PYTotalRevenueAmt |
| CY Total Revenue | $29,249,422 | 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 | $18,190,041 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $19,287,308 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $37,812 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $9,701,458 | PYOtherExpensesAmt |
| CY Other Expenses | $10,438,000 | CYOtherExpensesAmt |
| PY Total Expenses | $27,891,499 | PYTotalExpensesAmt |
| CY Total Expenses | $29,725,308 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | -$2,378,322 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$475,886 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $13,734,434 | TotalAssetsBOYAmt |
| Total Assets EOY | $10,891,477 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $6,768,342 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $3,937,977 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $6,966,092 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $6,953,500 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $25,271,331 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $26,639,296 | RevenueAmt |
| Desc | GOOD SAMARITAN HOSPITAL ASSOCIATION (GSHA) IS A NONPROFIT HEALTH CARE ORGANIZATION, OWNED BY OVER THIRTY AREA CHURCHES REPRESENTING ALL THE LOCAL DENOMINATIONS OF THE CHRISTIAN FAITH. THE AREA CHURCHES AT AN ANNUAL MEETING EVERY FALL ELECT A BOARD OF TRUSTEES. THIS BOARD IS THE LEGAL GOVERNING BODY THAT IS RESPONSIBLE FOR THE ASSOCIATION. GSHA'S PRIMARY FOCUS IS HEALTHCARE WITHIN AND AROUND THE COMMUNITY OF RUGBY, ND. GSHA HAS 25 LICENSED ACUTE/SWING BEDS AS A CRITICAL ACCESS HOSPITAL, 3 RURAL HEALTH CLINICS, ALONG WITH A SURGICAL CLINIC, 55 MEDICARE SKILLED NURSING HOME BEDS, 63 BASIC CARE BEDS, AND 37 ASSISTED LIVING APARTMENTS. WE ALSO SERVICE THE COMMUNITY THROUGH A HOSPITAL BASED HOSPICE. GSHA PROVIDES NUMEROUS COMMUNITY AND SOCIAL PROGRAMS INCLUDING BUT NOT LIMITED TO THE FOLLOWING: CHARITY CARE $264,268 GROSS CHARGES FORGONE DURING THE YEAR ENDED 3/31/2018, REDUCED FEE FLU SHOT CLINICS, DIABETIC EDUCATION PROGRAM, PUBLIC HEALTHCARE EDUCATIONAL AND INFORMATIONAL NOTICES, TESTING AND INFORMATION DURING HEALTH SHOWS AND COMMUNITY EVENTS, AMBULANCE VOLUNTEERS, PROVIDES EMT COURSES FOR AMBULANCES, EDUCATIONAL OUTREACH FOR SCHOOL SYSTEM, PROVIDES SENIOR CITIZEN MEALS AT MINIMAL FEE, FREE BLOOD PRESSURE CHECKS, COMMUNITY EDUCATION, PHYSICAL THERAPY, PROVIDES MEETING ROOM FOR VARIOUS ORGANIZATIONS AND CHURCHES, CPR TRAINING, WELLNESS PROGRAMS, SPONSOR LPN/RN SCHOOL PROGRAM THROUGH CONSORTIUM OF FACILITIES AND COLLEGES. | Desc |
| Total Program Service Expenses | $25,271,331 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | Yes (1) | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | Yes (1) | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 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 | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| Info In Schedule O Part V | Yes (X) | InfoInScheduleOPartVInd |
| IRP Document | 48 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 470 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | Yes (1) | UnrelatedBusIncmOverLimitInd |
| Form990 T Filed | Yes (1) | Form990TFiledInd |
| 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 |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 10 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | 0 | 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 | LEE HOLTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7017765261 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S MAIN AVENUE | AddressLine1Txt |
| City | RUGBY | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (18 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| RICHARD ANDERSON | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| CHRISTINE BUBACH | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| ARLAND GEISZLER | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| WILLIAM GRIFFIN | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | 1.00 | ||
| PATRICIA HEGGEN | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| ANNETTE LEIER | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| JASON LEE | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| BONITA LINDSETH | ||||||||
| TRUSTEE | 1.00 | Yes (X) | $0 | $0 | $0 | |||
| ANDREW SHAE | ||||||||
| CHAIRMAN | 1.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| KRIS THIEL | ||||||||
| VICE CHAIRMAN | 1.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| PATRICK BRANCO | ||||||||
| CEO/SECRETARY | 40.00 | $277,502 | $0 | $28,427 | 1.00 | Yes (X) | ||
| RICHARD BALAND | ||||||||
| CFO/TREASURER | 40.00 | $0 | $0 | $0 | Yes (X) | |||
| AMANDA LOUGHMAN | ||||||||
| CFO/TREASURER (THRU DECEMBER) | 40.00 | $110,812 | $0 | $12,028 | 1.00 | Yes (X) | ||
| RONALD SKIPPER | ||||||||
| SURGEON | 40.00 | $344,758 | $0 | $28,003 | Yes (X) | |||
| STEVEN SCHONEBERG | ||||||||
| SURGEON | 40.00 | $230,107 | $0 | $29,237 | Yes (X) | |||
| CAMMY TOWNSEND | ||||||||
| MIDLEVEL PROVIDER | 40.00 | $226,153 | $0 | $14,514 | Yes (X) | |||
| CHELSEY WYATT | ||||||||
| MID LEVEL PROVIDER | 40.00 | $221,321 | $0 | $19,606 | Yes (X) | |||
| RYAN BRANTL | ||||||||
| PHYSICIAN | 40.00 | $173,280 | $0 | $2,209 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,583,933 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $134,024 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 18 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (4 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| NATIONAL MEDICAL RESOURCE | |||||
| 2792 E BROADWAY AVE | BISMARCK | ND | 58501 | PHYSICIAN SERVICES | $585,015 |
| MIKE SWANSON CONSTRUCTION | |||||
| 6250 24TH AVE NE | RUGBY | ND | 58368 | CONSTRUCTION | $449,076 |
| BE SMITH | |||||
| PO BOX 219241 | KANSAS CITY | MO | 64121 | PHYSICIAN SERVICES | $127,359 |
| WIPFLI LLP | |||||
| PO BOX 3160 | MILWAUKEE | WI | 53201 | ACCOUNTING SERVICES | $115,610 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 4 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $1,472,198 | RelatedOrganizationsAmt |
| All Other Contributions | $254,688 | AllOtherContributionsAmt |
| Total Contributions | $1,726,886 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (5 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| PATIENT SERVICE REVENUE | 621400 | $24,218,472 | $24,218,472 |
| PHARMACY SERVICES | 900099 | $1,408,842 | $1,408,842 |
| PT/OT SERVICES | 621400 | $360,714 | $360,714 |
| ALS SERVICES | 621400 | $101,113 | $101,113 |
| RENTAL REVENUE | 623000 | $69,832 | $69,832 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $505,546 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $480,323 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $25,223 | UnrelatedBusinessRevenueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $26,664,519 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $16,317 | TotalRevenueColumnAmt |
| Exclusion | $16,317 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $300,792 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $300,792 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $300,792 | TotalRevenueColumnAmt |
| Exclusion | $300,792 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | ExclusionExclusionAmt |
|---|---|---|---|
| EMPLOYEE DAYCARE REVENUE | 900099 | $164,042 | $164,042 |
| CAFETERIA SERVICES | 900099 | $148,236 | $148,236 |
Miscellaneous Revenue MiscellaneousRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $228,630 | TotalRevenueColumnAmt |
| Exclusion | $228,630 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $540,908 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $29,249,422 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $26,639,296 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $25,223 | UnrelatedBusinessRevenueAmt |
| Exclusion | $858,017 | ExclusionAmt |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $562,284 | TotalAmt |
| Management And General | $562,284 | ManagementAndGeneralAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $16,351,724 | TotalAmt |
| Program Services | $14,550,485 | ProgramServicesAmt |
| Management And General | $1,768,149 | ManagementAndGeneralAmt |
| Fundraising | $33,090 | FundraisingAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $170,915 | TotalAmt |
| Program Services | $151,307 | ProgramServicesAmt |
| Management And General | $19,264 | ManagementAndGeneralAmt |
| Fundraising | $344 | FundraisingAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,032,219 | TotalAmt |
| Program Services | $916,204 | ProgramServicesAmt |
| Management And General | $113,931 | ManagementAndGeneralAmt |
| Fundraising | $2,084 | FundraisingAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,170,166 | TotalAmt |
| Program Services | $1,008,749 | ProgramServicesAmt |
| Management And General | $159,123 | ManagementAndGeneralAmt |
| Fundraising | $2,294 | FundraisingAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $82,189 | TotalAmt |
| Management And General | $82,189 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,800,263 | TotalAmt |
| Program Services | $1,465,627 | ProgramServicesAmt |
| Management And General | $334,636 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $66,652 | TotalAmt |
| Management And General | $66,652 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,934,490 | TotalAmt |
| Program Services | $1,400,210 | ProgramServicesAmt |
| Management And General | $534,280 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $321,317 | TotalAmt |
| Program Services | $308,891 | ProgramServicesAmt |
| Management And General | $12,426 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $735,321 | TotalAmt |
| Program Services | $693,810 | ProgramServicesAmt |
| Management And General | $41,511 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $324,964 | TotalAmt |
| Program Services | $238,486 | ProgramServicesAmt |
| Management And General | $86,478 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $9,678 | TotalAmt |
| Management And General | $9,678 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $204,549 | TotalAmt |
| Program Services | $204,549 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $975,705 | TotalAmt |
| Program Services | $975,705 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $201,303 | TotalAmt |
| Management And General | $201,303 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| BAD DEBT EXPENSE | $1,438,753 | $1,438,753 | |
| ACUTE DRUGS | $1,287,581 | $1,287,581 | |
| RAW FOOD | $466,170 | $460,307 | $5,863 |
| LAB AND TESTING EXPENSE | $122,051 | $122,051 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $467,014 | TotalAmt |
| Program Services | $48,616 | ProgramServicesAmt |
| Management And General | $418,398 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,725,308 | TotalAmt |
| Program Services | $25,271,331 | ProgramServicesAmt |
| Management And General | $4,416,165 | ManagementAndGeneralAmt |
| Fundraising | $37,812 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $61,737 | BOYAmt |
| EOY | $602,590 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $206,167 | BOYAmt |
| EOY | $36,184 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,775,178 | BOYAmt |
| EOY | $2,474,073 | EOYAmt |
Oth Notes Loans Receivable Net OthNotesLoansReceivableNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $226,993 | BOYAmt |
| EOY | $0 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $190,692 | BOYAmt |
| EOY | $192,412 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $35,179 | BOYAmt |
| EOY | $25,779 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $26,342,250 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $20,697,657 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,607,639 | BOYAmt |
| EOY | $5,644,593 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $27,836 | BOYAmt |
| EOY | $67,361 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,603,013 | BOYAmt |
| EOY | $1,848,485 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,734,434 | BOYAmt |
| EOY | $10,891,477 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,516,160 | BOYAmt |
| EOY | $1,672,820 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $226,068 | BOYAmt |
| EOY | $0 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $849,319 | BOYAmt |
| EOY | $734,000 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $26,271 | BOYAmt |
| EOY | $20,064 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $753,209 | BOYAmt |
| EOY | $426,429 | EOYAmt |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $88,206 | BOYAmt |
| EOY | $76,000 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,309,109 | BOYAmt |
| EOY | $1,008,664 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,768,342 | BOYAmt |
| EOY | $3,937,977 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,408,055 | BOYAmt |
| EOY | $6,345,985 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $558,037 | BOYAmt |
| EOY | $607,515 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,966,092 | BOYAmt |
| EOY | $6,953,500 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,734,434 | BOYAmt |
| EOY | $10,891,477 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | -$475,886 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $413,816 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $49,478 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $3,050 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $3,050 | 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 | GOOD SAMARITAN HOSPITAL ASSOCIATION IS A MEMBER OF SEVERAL ORGANIZATIONS THAT TAKE PART IN LOBBYING. THESE ORGANIZATIONS INCLUDE THE NORTH DAKOTA HOSPITAL ASSOCIATION, THE NATIONAL RURAL HEALTH, AND THE NORTH DAKOTA LONG TERM CARE ASSOCIATION. A PORTION OF THE DUES PAID TO THE VARIOUS ORGANIZATIONS IS FOR LOBBYING COSTS. THESE VARIOUS ORGANIZATIONS ADVOCATE ON BEHALF OF THEIR MEMBERS BY SUPPORTING LEGISLATION THAT IS IN THEIR COLLECTIVE INTERESTS. THESE ORGANIZATIONS WORK TO ENSURE THAT LAWS AND REGULATIONS PROVIDE A REASONABLE AND EQUITABLE ENVIRONMENT IN WHICH HEALTH CARE FACILITIES CAN PROVIDE AFFORDABLE, HIGH QUALITY CARE. | ExplanationTxt |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 0 | AgentTrusteeEtcInd |
| Incl Escrow Custodial Acct Liab | Yes (1) | InclEscrowCustodialAcctLiabInd |
| Explanation Provided | Yes (X) | ExplanationProvidedInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $137,447 | OtherCostOrOtherBasisAmt |
| Book Value | $137,447 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $11,990,367 | OtherCostOrOtherBasisAmt |
| Depreciation | $9,385,145 | DepreciationAmt |
| Book Value | $2,605,222 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $14,214,436 | OtherCostOrOtherBasisAmt |
| Depreciation | $11,312,512 | DepreciationAmt |
| Book Value | $2,901,924 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $5,644,593 | TotalBookValueLandBuildingsAmt |
Other Assets Org OtherAssetsOrgGrp (2 entries)
| DescDesc | Book ValueBookValueAmt |
|---|---|
| BENEFICIAL INTEREST IN ASSETS HELD BY OTHERS | $1,846,594 |
| ASSETS LIMITED AS TO USE | $1,891 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Other Assets | $1,848,485 | TotalBookValueOtherAssetsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (2 entries)
| DescDesc | AmtAmt |
|---|---|
| LINE OF CREDIT | $749,800 |
| CAPITAL LEASE | $258,864 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $1,008,664 | TotalLiabilityAmt |
| Total Rev Etc Audited Fincl Stmt | $26,166,953 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $413,816 | NetUnrealizedGainsInvstAmt |
| Revenue Not Reported | $413,816 | RevenueNotReportedAmt |
| Revenue Subtotal | $25,753,137 | RevenueSubtotalAmt |
| Other Revenues Not Included | $3,496,285 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | $3,496,285 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $29,249,422 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $27,724,931 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $27,724,931 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $2,000,377 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $2,000,377 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $29,725,308 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (3 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART IV, LINE 2B: | THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF THE HOSPITAL'S LONG-TERM CARE FACILITY, SWING-BED UNITES, AND BASIC CARE FACILITY, AS WELL AS DAMAGE DEPOSITS. |
| PART XI, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 1,438,753. 340B EXPENSE INCLUDED IN REVENUE FOR FINANCIAL STATEMENTS 561,624. CONTRIBUTIONS RECORDED TO NET ASSETS 23,710. CONTRIBUTION FROM RELATED PARTY 1,472,198. |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | BAD DEBT EXPENSE 1,438,753. 340B EXPENSES INCLUDED IN REVENUE FOR FINANCIAL STATEMENTS 561,624. |
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 |
| Percent150 | Yes (X) | Percent150Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent250 | Yes (X) | Percent250Ind |
| 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 | $219,029 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $219,029 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00770 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $5,846,411 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $6,125,238 | 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 | $6,065,440 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $6,125,238 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $219,029 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00770 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,917,946 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,513,233 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $404,713 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01430 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,917,946 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $3,513,233 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $404,713 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01430 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $9,983,386 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $9,638,471 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $623,742 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02200 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,219,031 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $365,709 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $8,109,165 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $8,069,219 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $39,946 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S MAIN AVE | AddressLine1Txt |
| City | RUGBY | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 583682118 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.HAMC.COM | WebsiteAddressTxt |
| State License | 5046 | 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 |
| Emergency Room Other | Yes (X) | EmergencyRoomOtherInd |
| Other | RURAL | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HEART OF AMERICA MEDICAL CENTER | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | 0 | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | HTTPS://WWW.HAMC.COM/CHNA/ | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | SEE SUPPLEMENTAL INFORMATION | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Rpt Available Thru Other Method | Yes (X) | RptAvailableThruOtherMethodInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | 0 | StrategyPostedWebsiteInd |
| Strategy Attached | Yes (1) | StrategyAttachedInd |
| 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 | 150.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 250.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| 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 |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Other Method | Yes (X) | OtherMethodInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| Communtity Notified FAP | Yes (X) | CommuntityNotifiedFAPInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| None Made | Yes (X) | NoneMadeInd |
| 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 (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| HEART OF AMERICA MEDICAL CENTER | PART V, SECTION B, LINE 5: IN FISCAL YEAR 2016 GOOD SAMARITAN HOSPITAL ASSOCIATION INVITED BOARD MEMBERS, PROVIDERS, TOP MANAGEMENT AND KEY COMMUNITY MEMBERS TO PARTICIPATE IN A DAY-LONG SWOT (STRENGTHS, WEAKNESSES, OPPORTUNITIES, THREATS) ANALYSIS MEETING. KEY COMMUNITY MEMBERS PARTICIPATING INCLUDED MEMBERS OF THE CHAMBER OF COMMERCE AND THE LOCAL MEDIA. |
| HEART OF AMERICA MEDICAL CENTER | PART V, SECTION B, LINE 7D: HTTPS://RURALHEALTH.UND.EDU/PROJECTS/COMMUNITY-HEALTH-NEEDS-ASSESSMENT/REPORTS |
| HEART OF AMERICA MEDICAL CENTER | PART V, SECTION B, LINE 11: NEEDS IDENTIFIED IN THE 2016 CHNA AND PREVIOUS CHNAS, ADDRESSED IN HEART OF AMERICA IMPLEMENTATION STRATEGY INCLUDE: MAKING RADIOLOGY SERVICES AVAILABLE AT THE DUNSEITH CLINIC; ESTABLISHING A CANCER CARE SUITE FOR THE ADMINISTRATION OF CHEMOTHERAPY BY 2017; AND PROVIDING PSYCHOLOGICAL CARE THROUGH TELEPSYCH SERVICES. HAMC HOPED TO EXPAND ITS COMMUNITY/CHARITY CARE GUIDELINES TO INCLUDE FAMILIES WHOSE INCOME EXCEEDS 300% OF FEDERAL POVERTY GUIDELINES, HOWEVER THE POLICY REMAINS AT 250% OF FPG. THE HOSPITAL'S FINANCIAL SITUATION IMPACTED THE DECISION NOT TO RAISE THE GUIDELINES IN 2016-17. |
| HEART OF AMERICA MEDICAL CENTER | PART V, SECTION B, LINE 15E: THE HOSPITAL PROVIDED INFORMATION ON MEDICAID ELIGIBILTY. |
| SCHEDULE H, PART V, LINE 16I | THE ORGANIZATION DID NOT TRANSLATE INTO ANY OTHER LANGUAGE OUTSIDE OF ENGLISH. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 8 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (8 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - HEART OF AMERICA NURSING FACILITY | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | SKILLED LONG TERM CARE FACILITY |
| 2 - HAALAND ESTATES BASIC CARE | ||||
| 1025 3RD AVE SE | RUGBY | ND | 58368 | BASIC CARE FACILITY |
| 3 - RUGBY EMERGENCY MEDICAL SERVICES | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | AMBULANCE |
| 4 - HAALAND ESTATES ASSISTED LIVING | ||||
| 1025 3RD AVE SE | RUGBY | ND | 58368 | ASSISTED LIVING FACILITY |
| 5 - HEART OF AMERICA HOSPICE | ||||
| 800 S MAIN AVE | RUGBY | ND | 58368 | HOSPICE |
| 6 - RUGBY CLINIC | ||||
| 880 S MAIN AVE | RUGBY | ND | 58368 | RURAL HEALTH CLINIC |
| 7 - DUNSEITH CLINIC | ||||
| 215 MAIN ST SE | DUNSEITH | ND | 58329 | RURAL HEALTH CLINIC |
| 8 - MADDOCK CLINIC | ||||
| 301 ROOSEVELT AVE | MADDOCK | ND | 58348 | RURAL HEALTH CLINIC |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | HEART OF AMERICA MEDICAL CENTER USES A SLIDING FEE SCHEDULE BASED OF FPG. THERE IS 100% BENEFIT AT 150% FPG, 80% BENEFIT AT 175% FPG, 60% BENEFIT AT 200% FPG, 40% BENEFIT AT 225% FPG, 20% BENEFIT AT 250% FPG, AND 0% BENEFIT FOR THOSE GREATER THAN 250% FPG. |
| PART I, LINE 7: | THE COSTING METHOD USED IS THE COST TO CHARGES RATIO FOR ALL BUT SUBSIDIZED SERVICES. SUBSIDIZED SERVICES USES THE ACTUAL COSTS PER THE COST REPORT FILED BY THE ORGANIZATION. |
| PART I, LINE 7G: | THERE WERE NO PHYSICIAN CLINICS INCLUDED IN THE SUBSIDIZED HEALTH SERVICES. THE SERVICES ON THIS LINE CONSIST OF A DIABETES EDUCATION PROGRAM, OPERATION OF AN EMERGENCY ROOM, AMBULANCE SERVICES, AND TWO RURAL HEALTH CLINICS. |
| 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 $ 1,438,753. |
| SCHEDULE H, PART I, LINE 6 | THE ORGANIZATION FILES A COMMUNITY BENEFIT REPORT ONCE EVERY 3 YEARS. |
| PART II, COMMUNITY BUILDING ACTIVITIES: | THERE WERE NO SPECIFIC COMMUNITY BUILDING ACTIVITIES DURING THE YEAR ENDED MARCH 31, 2018. THE HOSPITAL PLANS TO HOLD A HEALTH FAIR FOR THE COMMUNITY IN 2019. PARTICIPATE IN THE COUNTY FAIR HELD IN RUGBY PROVIDING HEALTH CARE LITERATURE AND BLOOD PRESSURE SCREENINGS. |
| 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 AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY FINANCIAL ASSISTANCE POLICY IS DETERMINED BY THE ORGANIZATION USING INFORMATION AVAILABLE TO MAKE AN EDUCATED ESTIMATE. |
| PART III, LINE 4: | THE FINANCIAL STATEMENTS DO NOT HAVE BAD DEBT EXPENSE FOOTNOTE. THIS IS THE PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY FOOTNOTE. PATIENT AND RESIDENT ACCOUNTS RECEIVABLE PRIMARILY CONSIST OF UNCOLLATERALIZED PATIENT AND RESIDENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYER AGREEMENTS. THE ORGANIZATION BILLS THIRD-PARTY PAYERS ON THE PATIENTS OR RESIDENTS' BEHALF, OR IF A PATIENT OR RESIDENT IS UNINSURED, THE PATIENT OR RESIDENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYER, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS OR RESIDENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS OR RESIDENTS' RESPONSIBILITY. PAYMENTS ON PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENT.IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE ORGANIZATION 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. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS AND RESIDENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYER HAS NOT YET PAID, OR FOR PAYERS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY.FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS AND RESIDENTS WITHOUT INSURANCE AND PATIENTS AND RESIDENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS OR RESIDENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. |
| PART III, LINE 8: | MEDICARE REVENUE AND ALLOWABLE COSTS WERE OBTAINED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING MARCH 2018. |
| PART III, LINE 9B: | OUR ACCOUNTS ARE WORKED EFFECTIVELY AND THOROUGHLY WITH SELF PAY STATEMENTS PRINTED MONTHLY ONCE INSURANCES HAVE MET THEIR OBLIGATIONS. THE GOAL IS TO OBTAIN PAYMENT IN FULL, ESTABLISH ACCEPTABLE PAYMENT ARRANGEMENTS, LOOK AT OTHER APPROPRIATE AGENCIES OR LOW INCOME PROGRAMS, OR OFFER THE CHARITY CARE PROGRAM IF NEEDED. IN THE COLLECTION PROCESS, THE BILL GUARANTOR IS REMINDED THEY MAY QUALIFY FOR OUR CHARITY CARE PROGRAM AND ARE GIVEN INFORMATION ON HOW TO APPLY. OUR CHARITY PROGRAM IS INCOME BASED, AND USES 150% OF THE FEDERAL POVERTY GUIDELINES. IF THEY QUALIFY THE BILL IS WRITTEN OFF 100% TO CHARITY CARE. REFERRAL TO A COLLECTION AGENCY AND WRITE OFF OF BAD DEBT HAPPENS ONCE IT IS DETERMINED THAT THE PATIENT IS UNCOOPERATIVE WITH NON-PAYMENT, SKIP ACCOUNTS, OR IS UNWILLING TO APPLY FOR THE CHARITY CARE PROGRAM, AND THERE IS NO OTHER VALID REASON TO HOLD THE ACCOUNT FURTHER. |
| PART VI, LINE 2: | HEART OF AMERICA MEDICAL CENTER SERVES A SMALLER COMMUNITY WHERE PROVIDERS KNOW THEIR PATIENTS. GSHA BOARD MEMBERS LIVE IN THE COMMUNITIES WE SERVE. WE EXPECT BOARD MEMBERS TO BRING BACK CONCERNS OF THEIR COMMUNITIES SO WE CAN PRIORITIZE THE NEEDS. WE ALSO RECEIVE VALUABLE COMMUNITY FEEDBACK FROM OUR EXTREMELY ACTIVE HOSPITAL AUXILIARY BOARD AND DOZENS OF VOLUNTEERS WHO CONTRIBUTE THOUSANDS OF HOURS TO THE HOSPITAL AND OUR LONG-TERM CARE AND BASIC CARE FACILITIES. COMMUNITY MEETINGS WILL BE HELD IN THE PROCESS OF GATHERING INFORMATION FOR THE 2019 CHNA, QUESTIONS WILL BE SENT OUT SOLICITING INPUT FROM THE LOCAL AND SURROUNDING COMMUNITIES. |
| PART VI, LINE 3: | GOOD SAMARITAN HOSPITAL ASSOCIATION, DOING BUSINESS AS HEART OF AMERICA MEDICAL CENTER, PROVIDES MEDICAL CARE REGARDLESS OF PATIENTS' ABILITY TO PAY. WE PROVIDE INFORMATION ON FEDERAL, STATE AND LOCAL PAYMENT ASSISTANCE PROGRAMS PRIOR TO THE RENDERING OF SERVICES OR, IN EMERGENCY SITUATIONS, AS SOON AS IS APPROPRIATE. HAMC COMMUNITY (CHARITY) CARE IS AVAILABLE FOR INPATIENT AND OUTPATIENT HOSPITAL SERVICES, CLINIC SERVICES AND SWING BED CARE. SOCIAL WORK STAFF PROVIDE PATIENTS WITH THIS INFORMATION. PATIENTS CAN ALSO FIND COMMUNITY CARE INFORMATION ON OUR WEBSITE AND IT'S ALSO INCLUDED WITH INFORMATION ON OUR PROMPT PAYMENT DISCOUNT PROGRAM. STAFF MEMBERS PROCESSING SELF-PAY BILLS ENCOURAGE PATIENTS TO APPLY FOR COMMUNITY CARE AND OUR THIRD-ARTY COLLECTION COMPANY ENCOURAGES PATIENTS TO APPLY FOR COMMUNITY CARE IF THEY ARE EXPERIENCING FINANCIAL HARDSHIPS. |
| PART VI, LINE 4: | HEART OF AMERICA MEDICAL CENTER IS A CRITICAL ACCESS HOSPITAL LOCATED IN RUGBY, N.D. HEART OF AMERICA JOHNSON CLINICS ARE LOCATED IN RUGBY AND DUNSEITH, AND MADDOCK, N.D., SERVING PEOPLE WITHIN A 50-MILE RADIUS OF RUGBY. THE CLOSEST TERTIARY FACILITY IS 65 MILES TO THE WEST. OUR PRIMARY SERVICE AREA IS PIERCE COUNTY AND PORTIONS OF BENSON, MCHENRY, ROLETTE AND BOTTINEAU COUNTIES. ACCORDING TO THE 2010 U.S. CENSUS THE POPULATION IN PIERCE COUNTY WAS 4,357 OF WHICH THE VAST MAJORITY WERE CAUCASIAN (3.9 PERCENT WERE NATIVE AMERICAN) AND 27.2 PERCENT WERE AGE 62 OR OLDER. MAJOR EMPLOYERS IN RUGBY ARE THE HOSPITAL, RUGBY MANUFACTURING ,THE PUBLIC SCHOOLS AND PIERCE COUNTY. |
| PART VI, LINE 5: | GOOD SAMARITAN HOSPITAL ASSOCIATION IS OWNED BY 32 MEMBER CHURCHES LOCATED THROUGHOUT OUR SERVICE AREA. THE GSHA BOARD OF DIRECTORS RESIDE IN OUR PRIMARY SERVICE AREA, ARE ENGAGED IN VARIOUS OCCUPATIONS AND ACTIVITIES AND ARE ELECTED BY GSHA MEMBER CHURCHES. THROUGH HEART OF AMERICA JOHNSON CLINICS, HEART OF AMERICA MEDICAL CENTER HAS A PRESENCE RUGBY, DUNSEITH, TOWNER AND MADDOCK, PROVIDING OUR PATIENTS WITH HEALTH CARE SERVICES CLOSE TO HOME. OUR NEW CANCER CARE CENTER/INFUSION SUITES, OPENED TO THE PUBLIC IN THE FALL OF 2017. THE PUSH FOR THE CANCER TREATMENT SUITE WAS A RESPONSE BY THE HOSPITAL'S GOVERNING BOARD BASED ON COMMUNITY HEALTH NEEDS ASSESSMENT CONDUCTED BY THE HOSPITAL WHICH IDENTIFIED ACCESS TO CANCER TREATMENT AS A COMMUNITY PRIORITY. WE HAVE INCREASED PATIENT ACCESSIBILITY TO SPECIALTY SERVICES BY PARTNERING WITH SPECIALTY CLINICS AND PROVIDERS TO OFFER OPHTHALMOLOGY, PODIATRY, AUDIOLOGY AND MENTAL HEALTH SERVICES AND RECENTLY RELOCATED THOSE SERVICES IN ONE SECTION OF OUR FACILITY TO PROVIDE PRIVACY AND EASE OF ACCESS. HEART OF AMERICA HOSPICE PROVIDES PERSONALIZED, END-OF-LIFE CARE AND SERVICES FOR LOCAL HOSPICE PATIENTS AND THEIR FAMILIES IN A 50-MILE RADIUS OF RUGBY. WITHOUT HAMC, THERE WILL BE NO HOSPITAL, NO EMERGENCY ROOM, NO RURAL HEALTH CLINICS, NO SURGICAL CLINIC, NO SKILLED NURSING CARE FACILITY, NO BASIC CASE FACILITY, NO ASSISTED LIVING FACILITY, NO WELLNESS CENTER IN OUR SERVICE AREA. WE OPERATE MOST OF THESE PROGRAMS AT A LOSS, BUT WE CONTINUE TO OFFER THEM TO SERVE THE NEEDS OF THE PEOPLE WHO LIVE HERE. |
| PART VI, LINE 6: | GSHA IS NOT PART OF AN AFFILIATED HEALTHCARE SYSTEM, HOWEVER, AS A STANDALONE CRITICAL ACCESS HOSPITAL WE PROVIDE HIGH-QUALITY CARE FOR OUR PATIENTS VIA RURAL HEALTH NETWORK AGREEMENTS WITH TRINITY MEDICAL CENTER IN MINOT AND MEDCENTER ONE IN BISMARCK, N.D. THESE AGREEMENTS ENHANCE OUR PATIENTS' CONTINUITY OF CARE BY IDENTIFYING AND FORMING PROCESSES THAT FACILITATE PATIENT REFERRALS AND EASY TRANSFER BETWEEN FACILITIES AND ENHANCE COMMUNICATION BETWEEN PROVIDERS. GSHA IS PIGGY-BACKING ON ALTRU'S EPIC SYSTEM AND ON JAN. 1, 2016, HAMC, WITH SEVERAL OTHER HOSPITALS, WENT LIVE AS AN ACCOUNTABLE CARE ORGANIZATION. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Compensation Committee | Yes (X) | CompensationCommitteeInd |
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| 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 (6 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| PATRICK BRANCO | ||||||||||||||
| CEO/SECRETARY | $224,069 | $0 | $25,245 | $0 | $28,188 | $0 | $6,674 | $0 | $21,753 | $0 | $305,929 | $0 | $0 | $0 |
| RONALD SKIPPER | ||||||||||||||
| SURGEON | $287,244 | $0 | $0 | $0 | $57,514 | $0 | $4,694 | $0 | $23,309 | $0 | $372,761 | $0 | $0 | $0 |
| STEVEN SCHONEBERG | ||||||||||||||
| SURGEON | $210,483 | $0 | $0 | $0 | $19,624 | $0 | $5,635 | $0 | $23,602 | $0 | $259,344 | $0 | $0 | $0 |
| CAMMY TOWNSEND | ||||||||||||||
| MIDLEVEL PROVIDER | $223,060 | $0 | $0 | $0 | $3,093 | $0 | $5,424 | $0 | $9,090 | $0 | $240,667 | $0 | $0 | $0 |
| CHELSEY WYATT | ||||||||||||||
| MID LEVEL PROVIDER | $200,642 | $0 | $5,000 | $0 | $15,679 | $0 | $0 | $0 | $19,606 | $0 | $240,927 | $0 | $0 | $0 |
| RYAN BRANTL | ||||||||||||||
| PHYSICIAN | $173,280 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $2,209 | $0 | $175,489 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 4A | FormAndLineReferenceDesc |
| Explanation | AMANDA LOUGHMAN RECEIVED A SEVERANCE PAYMENT. | 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 RUGBY NORTH DAKOTA HEALTH CARE FACILITY REVENUE BONDS SERIES 2013 | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 456002152 | BondIssuerEIN |
| Bond Issued | 2013-09-19 | BondIssuedDt |
| Issue Price | $1,215,000 | IssuePriceAmt |
| Purpose | IMPROVEMENTS TO HOSPITAL AND CLINIC | 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 | $481,000 | RetiredAmt |
| Total Proceeds | $1,215,000 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $15,000 | IssuanceCostsFromProceedsAmt |
| Capital Expenditures | $1,200,000 | CapitalExpendituresAmt |
| Substantial Completion | 2013 | SubstantialCompletionYr |
| Current Refunding | 0 | CurrentRefundingInd |
| Advance Refunding | 0 | AdvanceRefundingInd |
| 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 | Yes (1) | 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 | Yes (1) | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JULIE BAUSTAD | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | FAMILY MEMBER OF BOARD MEMBER RICHARD ANDERSON | RelationshipDescriptionTxt |
| Transaction | $10,412 | TransactionAmt |
| Transaction | EMPLOYMENT | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART V, LINE 16B | HAMC IS A 49% OWNER IN A RETAIL PHARMACY LOCATED IN OUR CLINIC BUILDING. |
| FORM 990, PART VI, SECTION A, LINE 6 | GSHA IS OWNED BY THE LOCAL CHURCHES WHOSE DELEGATES VOTE AT THE ANNUAL MEETING ON ELECTION OF THE GSHA BOARD MEMBERS AND OTHER PERTINENT BUSINESS AS PRESENTED AT THE ANNUAL MEETING. THERE ARE NO MEMBERSHIP FEES. ANY LOCAL CHURCH WISHING TO BE A MEMBER OF GSHA CAN DO SO THRU VOTE AT THE ANNUAL MEETING. |
| FORM 990, PART VI, SECTION A, LINE 7A | EACH MEMBER CHURCH HAS UP TO TWO VOTING DELEGATES AT OUR ANNUAL MEETING WHERE THE BOARD OF DIRECTORS ARE ELECTED TO SERVE ON THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | AT THE ANNUAL MEETING THE VOTING DELEGATES FROM THE CHURCHES WILL VOTE ON CHANGES TO BY-LAWS OR ARTICLES OF INCORPORATION. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE CEO AND CFO WILL REVIEW AND APPROVE THE 990 PRIOR TO FILING WITH THE INTERNAL REVENUE SERVICE. AFTER FILING THE FORM WILL BE PRESENTED TO THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION B, LINE 12C | A CONFLICT OF INTEREST STATEMENT IS REVIEWED ANNUALLY. IT IS MONITORED DURING YEAR. A MEMBER WILL ABSTAIN FROM VOTING ON AN ISSUE IF A CONFLICT OF INTEREST IN THE MATTER IS PRESENT. CEO RECEIVES AND REVIEWS THE RESPONSES REGARDING THE ANNUAL DISCLOSURE. |
| FORM 990, PART VI, SECTION B, LINE 15 | COMPARATIVE DATA IS REVIEWED AND INCORPORATED INTO THE REVIEW PROCESS SUCH AS LOOKING AT STATE WAGE SURVEY DATA. FOR THE CEO, EACH BOARD MEMBER COMPLETES THEIR OWN EVALUATION FORM. THE HUMAN RESOURCE COMMITTEE REVIEWS THE RESPONSES AND MAKES A RECOMMENDATION TO THE FULL BOARD. FULL BOARD DECIDES ON ANY CHANGES TO THE CEO COMPENSATION. REVIEW IS DONE ANNUALLY AT TIME OF ANNIVERSARY DATE OF CONTRACT. BOARD TYPICALLY DOES NOT APPROVE WAGES FOR OTHER POSITIONS. CEO APPROVES THE CFO WAGES. COMPARATIVE DATA IS USED THROUGHOUT THE FACILITY AND INCORPORATED INTO THE ANNUAL REVIEW OF EMPLOYEE WAGES DONE BY THE DEPARTMENT HEAD OR SUPERVISOR. WAGES ARE COMPARED TO THE NDHA ANNUAL SALARY SURVEY REPORT AT THE TIME OF THEIR ANNUAL REVIEW. |
| FORM 990, PART VI, SECTION C, LINE 19 | THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. |
| FORM 990, PART XI, LINE 9: | CHANGE IN INTEREST IN FOUNDATION 49,478. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HEALTH SERVICES FOUNDATION | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVE | AddressLine1Txt |
| City | RUGBY | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58368 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | FUNDRAISING FOR GOOD SAMARITAN HOSPITAL ASSOCIATION | PrimaryActivitiesTxt |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Exempt Code Section | 501(C)(3) | ExemptCodeSectionTxt |
| Public Charity Status | LINE 7 | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HOSPITAL ASSOCIATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 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 | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HEALTH SERVICES FOUNDATION | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionTypeTxt |
| Involved | $1,472,198 | InvolvedAmt |
| Method Of Amount Determination | CASH | MethodOfAmountDeterminationTxt |