2019-05-15T11:25:44-05:00 2018-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-07-01 770637498 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC MCKE 7018423000 709 4TH AVENUE NE WATFORD CITY ND 58854 DANIEL KELLY CEO 7018423000 2019-05-14 1 TERRI REXRODE CPA MST P00096513 9206620016 2019-05-14 74.87.127.216 2019-05-14 08:06:20 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z X DANIEL KELLY 709 4TH AVENUE NE WATFORD CITY ND 58854 27723691 0 X WWW.MCKENZIEHEALTH.COM X 2004 ND HEALTH CARE SERVICE PROVIDER. 9 9 210 45 251855 -132800 4424608 9454505 15527427 16958938 -83076 25841 420345 566306 20289304 27005590 0 0 0 0 8441338 9054012 0 0 0 9428784 10318302 17870122 19372314 2419182 7633276 67521366 112115780 34828133 71789271 32693233 40326509 X MCKENZIE COUNTY HEALTHCARE SYSTEMS IS A FAITH-BASED ORGANIZATION DEDICATED TO PROFESSIONAL, COMPASSIONATE AND QUALITY HEALTHCARE. 0 0 9498681 0 10798851 MCKENZIE COUNTY HEALTHCARE SYSTEMS PROVIDES 24 HOUR X 7 DAYS A WEEK SERVICES. MCHS PROVIDED IN-PATIENT, OBSERVATION, AND SWING BED SERVICES - HOSPITAL- TOTAL INPATIENT/OBSERVATION DAYS - 296. TOTAL SWING BED DAYS - 750. MCHS OFFERS VARIOUS OTHER SERVICES. THEY OFFER ENDOSCOPIC EXAMS ONCE A MONTH BY A CONTRACTED PROVIDER. TOTAL OUTPATIENT SURGERIES - 164. THE EMERGENCY ROOM IS OPEN 24 HOURS A DAY, 7 DAYS A WEEK. TOTAL EMERGENCY ROOM VISITS - 4,035. THE LABORATORY IS LOCATED WITHIN THE HOSPITAL FACILITY. BIRTHDAY LAB SCREENINGS ARE AVAILABLE TO THE COMMUNITY AT THE HOSPITAL AT A REDUCED RATE. NUMBER OF MEMBERS TAKING ADVANTAGE OF BIRTHDAY SCREENINGS - 601. TOTAL OUTPATIENT PROCEDURES - 59,316. VOLUME INCREASED DUE TO POPULATION INCREASE. 3070773 0 3491097 THE MCKENZIE COUNTY HEALTHCARE SYSTEM (MCHS) GOOD SHEPHERD HOME (GSH) IS A 42 BED SKILLED NURSING HOME WITH AN ATTACHED 9-BED BASIC CARE UNIT. BASIC CARE WAS CLOSED DUE TO CONSTRUCTION IN FEBRUARY 2018 AND WILL REOPEN IN JULY 2019. THE GSH OFFERS DAY CARE AND/OR RESPITE CARE FOR THOSE CARING FOR A LOVED ONE IN THEIR HOME. A DEMENTIA SUPPORT GROUP IS OFFERED TO FAMILIES. THEY MAINTAIN REGULAR RESIDENT FAMILY COUNCIL MEETINGS. ALONG WITH QUALIFIED NURSING CARE AND STAFF, SOCIAL SERVICES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, RESTORATIONAL NURSING, LAUNDRY, HOUSEKEEPING, BEAUTICIAN SERVICES, AND ACTIVITY PROGRAMS ARE OFFERED. VISITORS ARE ALWAYS WELCOME AS WELL AS CHILDREN. CHILDREN ARE WELCOME TO VISIT AND PLAY ON THE FENCED OUTDOOR PLAYGROUND EQUIPMENT. PASTORAL CARE AND CHAPEL ARE OFFERED 7 DAYS A WEEK. ACTIVITIES INCLUDE BIRTHDAY PARTIES, MUSICAL GROUPS, BAKING, AND BUS TRIPS. THE SKILLED NURSING TOTAL PERCENT OF OCCUPANCY HAS BEEN 76.6%. THE BASIC CARE UNIT TOTAL PERCENT OF OCCUPANCY HAS BEEN 35.5%. 1945702 0 2212028 THE MCHS CLINIC (RURAL HEALTH CLINIC) MAINTAINS THE SAME MISSION AS THE HOSPITAL. IT PROVIDES CARE MONDAY THRU FRIDAY. THE MEDICAL DIRECTOR, AUGMENTED BY LOCUM PHYSICIANS, PROVIDE EMERGENCY ROOM COVERAGE AT THE HOSPITAL 24 HOURS A DAY X 7 DAYS A WEEK. THE PROVIDERS ALSO MAKE VISITS TO THE GOOD SHEPHERD HOME WEEKLY. THE VISITING NURSE PROGRAM HAS BEEN A GREAT ASSET TO THE CLINIC, PROVIDING CARE TO HOMEBOUND PATIENTS WITHIN OUR COMMUNITY. 269812 0 306743 HORIZON ASSISTED LIVING PROVIDES ASSISTED AND INDEPENDENT LIVING SERVICES. IT CONSISTS OF 15 APARTMENTS THAT PROVIDE A 24 HOUR CALL SYSTEM TO HEALTH CARE PERSONNEL. THE STAFF IS DEDICATED TO HELPING SENIORS LIVE AT THEIR HIGHEST LEVEL OF INDEPENDENCE AND ABILITY. ITS PERCENT OF OCCUPANCY IS CURRENTLY AT 81%. 394851 0 0 WELLNESS CENTER 664663 0 306743 15179819 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 38 0 210 1 1 1 0 0 0 0 0 0 0 0 0 X 9 9 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X DANIEL KELLY 7018423000 709 4TH AVENUE NE WATFORD CITY ND 58854 MYRON HOVET DIRECTOR 1.00 2.00 X 0 0 0 TAMMY JAMES DIRECTOR 1.00 X 0 0 0 NANCY JELLESED DIRECTOR 1.00 X 0 0 0 LARRY LARSEN DIRECTOR 1.00 X 0 0 0 NEAL SHIPMAN DIRECTOR 1.00 X 0 0 0 PATSY LEVANG PRESIDENT 2.00 2.00 X X 0 0 0 KELLY PETERSON VICE PRESIDENT 2.00 2.00 X X 0 0 0 MICHON SAX SECRETARY 2.00 X X 0 0 0 SCOTT SWENSON TREASURER 2.00 X X 0 0 0 DANIEL KELLY CEO 40.00 10.00 X 475146 0 7969 SUSIE CURTIS CFO 40.00 X 83171 0 3773 CHERYL FAULKNER CNO 40.00 X 104500 0 8732 MICHAEL CURTIS CAO 40.00 X 125572 0 8409 DR GARY RAMAGE PHYSICIAN 40.00 X 331557 0 12856 1119946 0 41739 4 0 1 0 JE DUNN 800 WASHINGTON AVE N STE 600 MINNEAPOLIS MN 55401 CONSTRUCTION SERVICES 38899029 NORTHLAND FAMILY PHYSICIANS 1451 44TH AVE S UNIT A GRAND FORKS ND 58201 CONTRACT ER PHYSICAN SERVICES 1660239 CPI GROUP 7400 E ORCHARD RD STE 270 GREENWOOD VILLAGE CO 80111 ARCHITECTUAL SERVICES 811448 GUARDIAN HEALTHCARE PROVIDERS 105 WESTPARK DRIVE SUITE 100 BRENTWOOD TN 37027 TRAVEL NURSING 505808 SANFORD HEALTH IT PO BOX 5074 SIOUX FALLS SD 57117 TECHNICAL SUPPORT 478013 17 2811256 6270045 373204 9454505 HOSPITAL PATIENT SERVICE REVENUE 621400 10461062 10461062 NURSING HOME SERVICE REVENUE 621400 3491097 3491097 CLINIC SERVICE REVENUE 621400 2212028 2212028 WELLNESS CENTER 621400 488008 379021 108987 ASSISTED LIVING SERVICE REVENUE 621400 306743 306743 16958938 25841 25841 273394 273394 468223 718101 -249878 -249878 -127166 -122712 340 B REVENUE 621400 281912 281912 EHR INCENTIVE 621400 55877 55877 CAFETERIA AND DIETARY REVENUE 900099 17548 17548 187453 187453 542790 27005590 16808719 251855 490511 X 838651 838651 6653174 5645542 1007632 137211 88732 48479 916158 563076 353082 508818 401631 107187 21177 21177 52923 52923 3856068 3234089 621979 47960 47960 359766 185311 174455 1000 1000 364856 364064 792 90231 31034 59197 39050 18276 20774 3140 3140 1452495 1452495 115474 86445 29029 BAD DEBT & COLLECTION 2060699 2060699 PROGRAM SUPPLIES 983269 932063 51206 EQUIPMENT RENTAL & MAIN 483773 57646 426127 DUES AND SUBSCRIPTIONS 44630 11400 33230 341791 44176 297615 19372314 15179819 4192495 0 5214 4180 -41334 594982 5918840 11412648 1827882 2136591 41324 37188 79692 135593 99467247 12373556 51766038 87093691 200000 200000 7723710 10500907 67521366 112115780 8135665 7040831 83815 27938 26439568 64332322 169085 388180 34828133 71789271 X 22651215 22549166 10042018 17777343 32693233 40326509 67521366 112115780 7633276 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 2865 2865 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF AMERICAN HOSPITAL ASSOCIATION, NORTH DAKOTA HOSPITAL ASSOCIATION, AND NORTH DAKOTA LONG TERM CARE ASSOCIATION. A PORTION OF MEMBERSHIP DUES TO THE ABOVE LISTED ASSOCIATIONS IS USED FOR LOBBYING. THESE ASSOCIATIONS ADVOCATE ON BEHALF OF ITS MEMBERS FOR IMPROVING EFFICIENCY AND ACCESSIBILITY OF THE HEALTHCARE DELIVERY SYSTEMS AND THE HEALTH STATUS OF NORTH DAKOTA'S POPULATION. 1144947 1144947 27588281 6007778 21580503 16681982 6365778 10316204 54052037 54052037 87093691 ASSETS RESTRICTED AS TO USE 10245603 CASH SURRENDER VALUE OF LIFE INSURANCE 255304 10500907 POSTRETIREMENT BENEFIT OBLIGATION 270663 DUE TO RELATED PARTY 117517 388180 25662992 718101 718101 24944891 2060699 2060699 27005590 18029716 718101 718101 17311615 2060699 2060699 19372314 PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 718,101. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,060,699. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 718,101. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,060,699. 1 1 X 1 X 1 X 1 1 1 0 0 69418 69418 0.00400 2218440 2168906 49534 0.00290 2287858 2168906 118952 0.00690 48167 48167 4175210 2359314 1815896 0.10490 4223377 2407481 1815896 0.10490 6511235 4576387 1934848 0.11180 23789 23789 0.00140 23789 23789 0.00140 1 1655592 0 3172858 3051668 121190 X 1 1 1 1 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 516 N MAIN WATFORD CITY ND 58854 HTTP://MCKENZIEHEALTH.COM/ 5051A X X X X X SWING BED UNIT MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE SUPPLEMENTAL INFORMATION X X 1 15 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X X X X X X X 1 X 0 X X X X 1 X 0 0 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 5: APPROXIMATELY 350 PRINTED SURVEYS WERE DISTRIBUTED TO AREA RESIDENTS THROUGH VARIOUS CHANNELS THROUGHOUT THE COMMUNITY. 54 SURVEYS WERE RETURNED AND THE HOSPITAL IDENTIFIED SOME INFORMATION GAPS BASED ON THE DEMOGRAPHIC INFORMATION FROM THE SURVEYS RETURNED COMPARED TO TOTAL DEMOGRAPHIC INFORMATION. THEN INFORMATION INTERVIEWS WERE CONDUCTED. INTERVIEWS WERE 2 HOURS LONG AND CONDUCTED WITH 12 MEMBERS CHOSEN FROM THE COMMUNITY. INCLUDED AMONG THOSE INTERVIEWED WAS A PUBLIC HEALTH NURSE, PUBLIC SERVANTS, SCHOOL ADMINISTRATORS, THE COUNTY SHERIFF, BUSINESS PERSONS AND HEALTHCARE ADMINISTRATORS. MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 7D: CHNA WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/04/3-CHNA-FINAL-REPORT-3.PDFIMPLEMENTATION STRATEGY WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2016/04/IMPLEMENTATION-STRATEGY-PLANNING.PDF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 11: AVAILABILITY OF SPECIALISTS: CONSISTENT ACTION AND RESOURCE DISPERSION HAS BEEN GIVEN TO OUR RECRUITMENT AND CONTRACTING OF SPECIALTY SERVICES. OUR TELE-HEALTH OPTIONS NOW INCLUDE DIETETICS, BEHAVIORAL HEALTH, GENETIC COUNSELING, AND RHEUMATOLOGY; OUR SPECIALTY CLINICS HOUSE ORTHOPEDIC SURGERY AND GENERAL SURGERY, AS WELL AS ROTATING OB/GYN AND ENT SERVICE LINES; AND OUR RURAL HEALTH CLINIC HAS BEEN ABLE TO ATTRACT AN INTERNAL MEDICINE PROVIDER.ABILITY TO RETAIN PHYSICIANS IN THE AREA: PHYSICIAN AND PROVIDER RECRUITMENT STAYS A PRIORITY FOR OUR FACILITY AND OUR COMMUNITY. HAVING RECENTLY GONE FROM ONE EMPLOYED PHYSICIAN TO FOUR (4) IN THE SPAN OF SIX MONTHS HAS INCREASED THE COMMUNITIES ABILITY TO FIND PROPER CARE, CLOSE TO HOME. MCHS CONTINUES TO ACTIVELY RECRUITMENT FOR PROVIDERS WHO ARE COMMITTED TO A HIGH-QUALITY LEVEL OF CARE IN A RURAL ENVIRONMENT. CONSISTENT TALKS AND PARTNERSHIPS WITH LOCAL AREA BUSINESS AND GOVERNMENTS KEEP COMMUNITY ATTRACTIVENESS AT TOP OF MIND AS OUR COMMUNITY GROWS. ADULT DRUG USE AND ABUSE: IN ADDITION TO THE OFFERING OF BEHAVIORAL HEALTH AND COUNSELING SERVICES VIA TELE-HEALTH, EACH CLINIC STAFF MEMBER HAS BEEN GIVEN TRAINING AND LITERATURE ON THE DRUG USE AND ABUSE PROBLEMS FACING OUR PATIENTS. MULTIPLE COMMUNITY CLASSES AND EVENT INVOLVEMENT HAVE ALLOWS US TO PROVIDE COMMUNITY OUTREACH THAT ALLOWS FOR DISPERSAL OF INFORMATION AS WELL AS THE OPPORTUNITY FOR THE COMMUNITY TO ASK QUESTIONS OF A TRUSTED KNOWLEDGE SOURCE. THE TRAINING ROOM LOCATED AT OUR NEW HOSPITAL FACILITY ALLOWS FOR AN INCREASE IN FOCUS TOWARDS EDUCATIONAL PROGRAMS AS IS SOMETHING THAT WILL HAVE A STRONG FOCUS GOING INTO THE COMING YEAR. MCKENZIE COUNTY HEALTHCARE SYSTEMS INC PART V, SECTION B, LINE 16J: IN ADDITION TO PROVIDING THE FULL POLICY UPON REQUEST, A SUMMARY OF THE POLICY IS POSTED IN THE EMERGENCY ROOMS, WAITING ROOMS, AND ADMISSIONS OFFICE. UPON ADMISSION THE PATIENTS RECEIVE A BROCHURE IN A PACKET REFERENCING THE FINANCIAL ASSISTANCE POLICY. THE PATIENTS ALSO RECEIVE INFORMATION IN THEIR FIRST BILLING INVOICE REGARDING THE FINANCIAL ASSISTANCE POLICY.FAP WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2018/04/FINANCIAL-ASSISTANCE-POLICY-03.06.18.PDFFAP APPLICATION WEBSITE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2018/01/2018-FINANCIAL-ASSISTANCE-APPLICATION.PDFFAP PLAIN LANGUAGE:HTTPS://WWW.MCKENZIEHEALTH.COM/WP-CONTENT/UPLOADS/2018/05/UPDATED-PLAIN-LANGUAGE-05.07.18.PDF 5 1 - MCKENZIE COUNTY CLINIC 525 N MAIN ST WATFORD CITY ND 58854 RURAL HEALTH CENTER 2 - GOOD SHEPHERD HOME 709 4TH AVE NE WATFORD CITY ND 58854 LT CARE & BASIC CARE 3 - CONNIE WOLD WELLNESS CENTER 200 8TH ST NE WATFORD CITY ND 58854 WELLNESS CENTER 4 - HORIZONS 705 4TH AVE NE WATFORD CITY NE 58854 ASSISTED LIVING COMPLEX 5 - HERITAGE MANOR 709 4TH AVE NE WATFORD CITY NE 58854 APARTMENT COMPLEX PART I, LINE 7: THE ORGANIZATION UTILIZES THEIR COST REPORT TO DETERMINE THE COST-TO-CHARGE RATIO. THE COST REPORT IS BASED OFF OF THE INTERNAL REPORTING SYSTEM USED BY THE ORGANIZATION. PART I, LINE 7G: THE ORGANIZATION INCLUDED THE OPERATIONS OF THEIR SKILLED NURSING FACILITY IN THE SUBSIDIZED SERVICES CALCULATION. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 2,060,699. PART II, COMMUNITY BUILDING ACTIVITIES: N/A PART III, LINE 2: THIS IS THE AMOUNT OF BAD DEBT EXPENSE RECORDED ON THE FINANCIAL STATEMENTS AT THE COST-TO-CHARGE RATIO. PART III, LINE 3: THE ORGANIZATION IS DILIGENT TO EVALUATE EACH PATIENTS ABILITY TO PAY AND DISTINGUISH BETWEEN BAD DEBT AND CHARITY CARE. PART III, LINE 4: PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, WHICH REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO PATIENT AND RESIDENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FOR UNINSURED PATIENTS AND AMOUNTS PATIENTS AND RESIDENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF PATIENT AND RESIDENT ACCOUNTS RECEIVABLE, THE HEALTH SYSTEMS ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYER SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYER SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. PART III, LINE 9B: THE ORGANIZATION DOES NOT COLLECT ON ACCOUNTS THAT HAVE A FINANCIAL ASSISTANCE APPLICATION IN REVIEW OR THAT HAS BEEN APPROVED. IF THE ACCOUNT IS NOT COMPLETELY WRITTEN OFF (BASED ON THE SLIDING FEE SCHEDULE) AND THEY DO NOT FOLLOW THROUGH ON THEIR PAYMENT PLAN FOR THE BALANCE, THAT WOULD BE THE ONLY TIME THE ACCOUNT WAS OUTSOURCED TO COLLECTIONS. PART VI, LINE 2: SEPARATE EVALUATIONS ARE COMPLETED ANNUALLY FOR THE CRITICAL ACCESS HOSPITAL AND THE RURAL HEALTH CLINIC. AT THIS TIME SERVICES AND STATISTICS ARE REVIEWED. EACH REPORT IS PRESENTED TO THE MEDICAL STAFF MEMBERS AND BOARD OF DIRECTORS. CURRENT SERVICES ARE DISCUSSED ALONG WITH THE NEEDS NOT CURRENTLY BEING MET. MANAGERS OF EACH DEPARTMENT ANNUALLY REVIEW THEIR SERVICES WITH THE BUDGETING PROCESS AND DISCUSS POSSIBLE PROJECTION OF NEW SERVICES. ONCE A NEED IS DETERMINED, IT IS DISCUSSED ON A DEPARTMENTAL LEVEL, INFORMATION IS GATHERED AND PRESENTED TO THE CEO/CFO FOR APPROVAL. MCHS HOLDS THEIR ANNUAL MEETING FOR THE PUBLIC IN THE FALL OF EACH CALENDAR YEAR. THIS IS AN OPEN MEETING ALLOWING THE PUBLIC TO VOICE CONCERNS AND SUGGESTIONS. PART VI, LINE 3: THE MCHS CHARITY CARE POLICY IS POSTED IN THE HOSPITAL AND CLINIC ADMISSIONS AREAS AND EMERGENCY ROOM. COPIES OF THE POLICY AND APPLICATIONS ARE AVAILABLE IN EACH RECEPTION AREA OF THE HOSPITAL AND CLINIC. INFORMATION IS SENT OUT TO ALL PATIENTS WITH THEIR FIRST STATEMENT. IF A BILL IS UNPAID, AFTER TWO STATEMENTS HAVE BEEN SENT, A BILLING EMPLOYEE WILL ATTEMPT TO REACH THE RESPONSIBLE PARTY BY PHONE TO DISCUSS INSTALLMENT PLANS, CHARITY CARE, AND/OR DISCUSS VARIOUS GOVERNMENT BENEFITS SUCH AS MEDICAID. THE MCHS BUSINESS OFFICES ALSO HAVE THE APPLICATIONS AT ALL TIMES. THE BUSINESS OFFICE STAFF COUNSEL ANYONE WHO PRESENTS THEMSELVES WITH OVERDUE BALANCES AND PRESENT THE ABOVE OPTIONS. PART VI, LINE 4: MCKENZIE COUNTY HEALTHCARE SERVICES SERVES MCKENZIE COUNTY. MCKENZIE COUNTY IS THE LARGEST COUNTY IN THE STATE OF NORTH DAKOTA. IT IS VERY RURAL AND INCLUDES PART OF THE FORT BERTHOLD RESERVATION. MCKENZIE COUNTY HOSPITAL IS THE ONLY HEALTHCARE SYSTEM WITHIN A 45 MILE RADIUS. THE COUNTY'S POPULATION WAS ESTIMATED IN 2010 AT 6,380. THE MEDIAN HOUSEHOLD INCOME IN 2010 WAS REPORTED AT $48,480. 100% OF THE POPULATION WAS REPORTED BELOW THE POVERTY LEVEL IN 2010. THE RUGGED TERRAIN, WINTER CONDITIONS, INCREASED OIL ACTIVITY, AND RECREATIONAL ACTIVITIES HAVE ALL ADDED TO THE INCREASED NUMBER OF EMERGENCY ROOM VISITS. WITH THE RECENT OIL ACTIVITY IN THE STATE, MCKENZIE COUNTY IS EXPERIENCING A RAPID INCREASE IN POPULATION, NEW BUSINESSES, HOUSING PROJECTS, AND IMPROVED WAGE SCALES. WITH THIS RAPID GROWTH, MCHS IS EXPERIENCING AN INFLUX IN EMERGENCY ROOM SERVICES, SHORTAGE OF PHYSICIANS AND NURSES, AS WELL AS GROWING BAD DEBT EXPENSES RELATED TO MEDICAL SERVICES PROVIDED TO UNINSURED WORKERS AND PATIENTS THAT DO NOT HAVE A PERMANENT RESIDENCE TO SEND BILLS TO. PART VI, LINE 5: THE MCKENZIE COUNTY BOARD OF DIRECTORS IS MADE UP OF VOLUNTEER MEMBERS FROM THE LOCAL COMMUNITY OF WATFORD CITY AND THE SURROUNDING AREAS. MCHS DOES EXTEND PRIVILEGES TO ALL PHYSICIANS IN THE AREA. SPECIALISTS WILL ALSO VISIT THE LOCAL HOSPITAL AND CLINIC TO EXPAND THE PRESENT SERVICES. SURPLUS FUNDS ARE APPLIED FOR THE PURPOSES EDUCATION, INCREASING PATIENT SERVICES, WELLNESS, AND PREVENTATIVE CARE TO ITS CLIENTS. MCHS IS ALSO A PART OF A WORKSITE WELLNESS NORTH DAKOTA PROGRAM. IT ALLOWS THEIR CARDIAC WELLNESS MANAGER (RN) TO WORK CLOSELY IN THE STATE-WIDE PROGRAM THAT CAN GREATLY IMPROVE THE HEALTH OF EMPLOYEES, RESULTING IN LOWER HEALTH CARE COSTS, AND INCREASED PRODUCTIVITY AND MORALE. MCKENZIE COUNTY HEALTHCARE SYSTEMS AND THE MCKENZIE COUNTY HEALTHCARE SYSTEMS BENEFIT FUND TOGETHER ENGAGED IN THE BUILDING AND FUNDING OF A NEW WELLNESS CENTER. THE WELLNESS CENTER OPENED IN MARCH 2013. THE WELLNESS CENTER HOUSES A NEW PHYSICAL THERAPY DEPARTMENT TO BETTER UTILIZE A THERAPY POOL AND HAS INCREASED THE PRESENT SQUARE FOOTAGE OF THE HOSPITAL. PREVENTION IS A KEY WORD TODAY. THE WELLNESS CENTER PROVIDES EDUCATION AND EXERCISE TO ITS MEMBERS. IT WILL HELP IMPROVE OR PREVENT DISEASES LIKE DIABETES, HIGH BLOOD PRESSURE, OBESITY, DEPRESSION, AND MANY NOT LISTED. IN AN EFFORT TO ENHANCE SERVICES IN THE RURAL AREAS, MCKENZIE COUNTY HEALTHCARE PARTICIPATES IN SEVERAL PROGRAMS. THE RURAL ACCOUNTABLE CARE ORGANIZATION IS INTENDED TO BETTER SERVE OUR POPULATION BY IMPROVING HEALTHCARE, PATIENT SATISFACTION, AND REDUCING COSTS WHILE IMPROVING FINANCIAL PERFORMANCE AND SUSTAINABILITY. THE FRONTIER COMMUNITY HEALTHCARE INTEGRATION PROJECT (FCHIP) IS A DEMONSTRATION PROGRAM THAT ASSISTS OUR ORGANIZATION WITH PROVIDING TELEMEDICINE SERVICES TO OUR POPULATION IN ORDER TO PROVIDE ACCESS TO MORE SPECIALTY SERVICES TO THE RESIDENTS OF OUR COMMUNITIES. THESE PROGRAMS ARE AIMED AT INCREASING THE INTEGRATION AND COORDINATION OF CARE AMONGST PROVIDERS AND IMPROVE THE OVERALL QUALITY OF CARE FOR OUR HEALTHCARE COMMUNITY. PART VI, LINE 6: N/A X X X 0 1 0 0 0 0 0 0 0 DANIEL KELLY CEO 269079 0 206067 0 0 0 6594 0 1375 0 483115 0 0 0 DR GARY RAMAGE PHYSICIAN 331250 0 307 0 0 0 12856 0 0 0 344413 0 0 0 PART I, LINE 4B $100,000 WAS CONTRIBUTED TO A 457(F) PLAN FOR DANIEL KELLY. LESLIE KELLY SPOUSE OF CEO 47236 EMPLOYEE SALARY 0 SAMUEL KELLY SON OF CEO 64544 EMPLOYEE SALARY 0 DANIELLE KELLY DAUGHTER OF CEO 26680 EMPLOYEE SALARY 0 FORM 990, PART VI, SECTION A, LINE 2 MICHAEL CURTIS AND SUSIE CURTIS HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION B, LINE 11B THE MCHS CEO AND CFO REVIEW AND APPROVE THE FORM 990. THE BOARD OF DIRECTORS RECEIVE A COPY OF THE FINAL FORM 990 BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C AN INTERESTED PERSON IS DEFINED AS ANY DIRECTOR, PRINCIPAL OFFICER, AND ANYONE WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST WITH RESPECT TO ALL ENTITIES IN THE HEALTHCARE SYSTEM. AN INTERESTED PERSON MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND WILL BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS. THE CONFLICT WILL BE REVIEWED BY THE REMAINING BOARD AND WILL DETERMINE IF A CONFLICT EXISTS. IF A CONFLICT EXISTS, THE INTERESTED PERSON MUST ABSTAIN FROM VOTING ON THE ISSUE AND THE REMAINING BOARD MEMBERS WILL DETERMINE IF THE TRANSACTION IS IN THE HOSPITAL'S BEST INTEREST, FOR ITS OWN BENEFIT, AND IF IT IS FAIR AND REASONABLE. THIS IS ACCOMPLISHED THROUGH ANNUAL REVIEW AND A SIGNED STATEMENT STATING THAT THE INTERESTED PERSON HAS OBTAINED A COPY OF THE POLICY AND HAS READ AND UNDERSTANDS THE POLICY, AND HAS AGREED TO COMPLY WITH THE POLICY. FORM 990, PART VI, SECTION B, LINE 15A MEMBERS OF THE BOARD OF TRUSTEES REVIEW STATE-WIDE SALARY SURVEY INFORMATION AND OTHER FORM 990'S WHEN DETERMINING ANY WAGE CHANGES. THE CEO HAS AN ANNUAL EVALUATION COMPLETED EACH YEAR. THE CEO HAS THE OPPORTUNITY TO GIVE A PROPOSAL TO THE BOARD AT HIS EVALUATION. ANY CHANGE OR REVISION IS RECORDED IN THE BOARD MINUTES. AN ADDENDUM TO THE TERMS OF EMPLOYMENT IS SIGNED BY THE BOARD PRESIDENT AND CEO FOR THE PERSONNEL FILE. THE CEO APPROVES THE CFO COMPENSATION BASED UPON SURVEY DATA ON AN ANNUAL BASIS. THE RESULTS ARE DOCUMENTED IN THE CFO'S ANNUAL EVALUATION PAPERWORK. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G EMERGENCY ROOM PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,574,758. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,574,758. CLINIC MD PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 216,888. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 216,888. NURSING HOME PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 55,082. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 55,082. OTHER CONTRACTOR SERVICES: PROGRAM SERVICE EXPENSES 942,591. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 942,591. ADMINISTRATIVE PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 444,770. MANAGEMENT AND GENERAL EXPENSES 621,979. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,066,749. MCKENZIE COUNTY HEALTHCARE SYSTEMS PROPERTIES 516 N MAIN ST WATFORD CITY ND 58854 462905447 PROPERTY MANAGEMENT ND 2 681414 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 709 4TH AVE NE WATFORD CITY ND 58854 363431210 TO SUPPORT THE MCKENZIE COUNTY HEALTHCARE SYSTEMS ND 501(C)(3) LINE 7 MCKENZIE COUNTY HEALTHCARE SYSTEMS INC 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC C 2811256 ACTUAL THE BENEFIT FUND OF MCKENZIE COUNTY HEALTHCARE SYSTEMS INC E 117517 ACTUAL