2019-02-15T17:16:59-06:00 2018-03-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2017-04-01 450226419 GOOD SAMARITAN HOSPITAL ASSOCIATION GOOD 7017765261 800 SOUTH MAIN AVENUE RUGBY ND 583682118 PATRICK BRANCO CEO 7017765261 2019-02-15 1 MICHAEL J PETERSON CPA P01833529 2187224705 2019-02-15 216.54.158.12 2019-02-15 15:45:05 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 9747BB8E0DC0E78824B7C9EDF76D609BB7F00C05 2017 2019-02-21 02:37:17Z HEART OF AMERICA MEDICAL CENTER PATRICK BRANCO 800 SOUTH MAIN AVENUE RUGBY ND 583682118 29249422 0 X WWW.HAMC.COM X 1905 ND PROVIDE QUALITY MEDICAL CARE BASED ON THE NEEDS AND DEMOGRAPHICS OF NORTH CENTRAL NORTH DAKOTA. 10 10 470 112 25223 -50933 430178 1726886 24266616 26664519 482314 317109 334069 540908 25513177 29249422 0 0 0 0 18190041 19287308 0 0 37812 9701458 10438000 27891499 29725308 -2378322 -475886 13734434 10891477 6768342 3937977 6966092 6953500 X TO DELIVER COMPASSIONATE CARE BY ADVANCING THE PHYSICAL AND SPIRITUAL WELL-BEING OF THE COMMUNITIES WE SERVE THROUGH SMART MEDICINE AND EXCEPTIONAL SERVICE. 0 0 25271331 0 26639296 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. 25271331 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 X 48 0 1 470 1 1 1 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X LEE HOLTER 7017765261 800 S MAIN AVENUE RUGBY ND 583682118 RICHARD ANDERSON TRUSTEE 1.00 X 0 0 0 CHRISTINE BUBACH TRUSTEE 1.00 X 0 0 0 ARLAND GEISZLER TRUSTEE 1.00 X 0 0 0 WILLIAM GRIFFIN TRUSTEE 1.00 1.00 X 0 0 0 PATRICIA HEGGEN TRUSTEE 1.00 X 0 0 0 ANNETTE LEIER TRUSTEE 1.00 X 0 0 0 JASON LEE TRUSTEE 1.00 X 0 0 0 BONITA LINDSETH TRUSTEE 1.00 X 0 0 0 ANDREW SHAE CHAIRMAN 1.50 X X 0 0 0 KRIS THIEL VICE CHAIRMAN 1.50 X X 0 0 0 PATRICK BRANCO CEO/SECRETARY 40.00 1.00 X 277502 0 28427 RICHARD BALAND CFO/TREASURER 40.00 X 0 0 0 AMANDA LOUGHMAN CFO/TREASURER (THRU DECEMBER) 40.00 1.00 X 110812 0 12028 RONALD SKIPPER SURGEON 40.00 X 344758 0 28003 STEVEN SCHONEBERG SURGEON 40.00 X 230107 0 29237 CAMMY TOWNSEND MIDLEVEL PROVIDER 40.00 X 226153 0 14514 CHELSEY WYATT MID LEVEL PROVIDER 40.00 X 221321 0 19606 RYAN BRANTL PHYSICIAN 40.00 X 173280 0 2209 1583933 0 134024 18 0 1 0 NATIONAL MEDICAL RESOURCE 2792 E BROADWAY AVE BISMARCK ND 58501 PHYSICIAN SERVICES 585015 MIKE SWANSON CONSTRUCTION 6250 24TH AVE NE RUGBY ND 58368 CONSTRUCTION 449076 BE SMITH PO BOX 219241 KANSAS CITY MO 64121 PHYSICIAN SERVICES 127359 WIPFLI LLP PO BOX 3160 MILWAUKEE WI 53201 ACCOUNTING SERVICES 115610 4 1472198 254688 1726886 PATIENT SERVICE REVENUE 621400 24218472 24218472 PHARMACY SERVICES 900099 1408842 1408842 PT/OT SERVICES 621400 360714 360714 ALS SERVICES 621400 101113 101113 RENTAL REVENUE 623000 69832 69832 505546 480323 25223 26664519 16317 16317 300792 0 300792 300792 300792 EMPLOYEE DAYCARE REVENUE 900099 164042 164042 CAFETERIA SERVICES 900099 148236 148236 228630 228630 540908 29249422 26639296 25223 858017 562284 562284 16351724 14550485 1768149 33090 170915 151307 19264 344 1032219 916204 113931 2084 1170166 1008749 159123 2294 82189 82189 1800263 1465627 334636 66652 66652 1934490 1400210 534280 321317 308891 12426 735321 693810 41511 324964 238486 86478 9678 9678 204549 204549 975705 975705 201303 201303 BAD DEBT EXPENSE 1438753 1438753 ACUTE DRUGS 1287581 1287581 RAW FOOD 466170 460307 5863 LAB AND TESTING EXPENSE 122051 122051 467014 48616 418398 29725308 25271331 4416165 37812 61737 602590 206167 36184 2775178 2474073 226993 0 190692 192412 35179 25779 26342250 20697657 5607639 5644593 27836 67361 4603013 1848485 13734434 10891477 2516160 1672820 226068 0 849319 734000 26271 20064 753209 426429 88206 76000 2309109 1008664 6768342 3937977 X 6408055 6345985 558037 607515 6966092 6953500 13734434 10891477 X -475886 413816 49478 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 3050 3050 0 PART II-B, LINE 1: 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. 0 1 X 137447 137447 11990367 9385145 2605222 14214436 11312512 2901924 5644593 BENEFICIAL INTEREST IN ASSETS HELD BY OTHERS 1846594 ASSETS LIMITED AS TO USE 1891 1848485 LINE OF CREDIT 749800 CAPITAL LEASE 258864 1008664 26166953 413816 413816 25753137 3496285 3496285 29249422 27724931 0 27724931 2000377 2000377 29725308 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. 1 1 X 1 X 1 X 1 1 0 0 219029 219029 0.00770 5846411 6125238 0 0.00000 6065440 6125238 219029 0.00770 3917946 3513233 404713 0.01430 3917946 3513233 404713 0.01430 9983386 9638471 623742 0.02200 0 1219031 365709 8109165 8069219 39946 X 1 1 1 1 HEART OF AMERICA MEDICAL CENTER 800 S MAIN AVE RUGBY ND 583682118 WWW.HAMC.COM 5046 X X X X X RURAL HEART OF AMERICA MEDICAL CENTER 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X HTTPS://WWW.HAMC.COM/CHNA/ X SEE SUPPLEMENTAL INFORMATION X X 1 15 0 1 0 1 X 150.000000000000 250.000000000000 1 1 X X X X X 1 X HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF X HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF X HTTPS://WWW.HAMC.COM/UPLOADS/4/NOTICEOFAVAILABIILTYOFCHARITYCARE82017.PDF X X X X X 1 X 0 X 1 X 0 0 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. 8 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 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. X X X X 1 0 0 0 0 0 0 0 0 PATRICK BRANCO CEO/SECRETARY 224069 0 25245 0 28188 0 6674 0 21753 0 305929 0 0 0 RONALD SKIPPER SURGEON 287244 0 0 0 57514 0 4694 0 23309 0 372761 0 0 0 STEVEN SCHONEBERG SURGEON 210483 0 0 0 19624 0 5635 0 23602 0 259344 0 0 0 CAMMY TOWNSEND MIDLEVEL PROVIDER 223060 0 0 0 3093 0 5424 0 9090 0 240667 0 0 0 CHELSEY WYATT MID LEVEL PROVIDER 200642 0 5000 0 15679 0 0 0 19606 0 240927 0 0 0 RYAN BRANTL PHYSICIAN 173280 0 0 0 0 0 0 0 2209 0 175489 0 0 0 PART I, LINE 4A AMANDA LOUGHMAN RECEIVED A SEVERANCE PAYMENT. A CITY OF RUGBY NORTH DAKOTA HEALTH CARE FACILITY REVENUE BONDS SERIES 2013 456002152 2013-09-19 1215000 IMPROVEMENTS TO HOSPITAL AND CLINIC 0 0 0 A 481000 1215000 15000 1200000 2013 0 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 JULIE BAUSTAD FAMILY MEMBER OF BOARD MEMBER RICHARD ANDERSON 10412 EMPLOYMENT 0 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. GOOD SAMARITAN HEALTH SERVICES FOUNDATION 800 SOUTH MAIN AVE RUGBY ND 58368 363513553 FUNDRAISING FOR GOOD SAMARITAN HOSPITAL ASSOCIATION ND 501(C)(3) LINE 7 GOOD SAMARITAN HOSPITAL ASSOCIATION 1 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 1 GOOD SAMARITAN HEALTH SERVICES FOUNDATION C 1472198 CASH