JACOBSON MEMORIAL HOSPITAL CARE CENTER: Form 990, tax year 2016
View the entire original 990 at ProPublica ↗
- Organization
- JACOBSON MEMORIAL HOSPITAL CARE CENTER (EIN 45-0222079)
- Tax period
- 2016-07-01 to 2017-06-30
- Filed
- 2018-05-14
- IRS object ID
- 201841349349305484
- Schema version
- 2016v3.0
- 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 D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2018-05-14T13:17:08-05:00 | ReturnTs |
| Tax Period End | 2017-06-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1Txt |
| City | FARGO | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 581082545 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2016-07-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450222079 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | JACO | BusinessNameControlTxt |
| Phone | 7015842792 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Theo Stoller | PersonNm |
| Person Title | CEO/Administrator | PersonTitleTxt |
| Phone | 7015842792 | PhoneNum |
| Signature | 2018-05-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | LISA CHAFFEE CPA | PreparerPersonNm |
| PTIN | P00193453 | PTIN |
| Phone | 7012398500 | PhoneNum |
| Preparation | 2018-05-10 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2016 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Theo Stoller | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $7,755,195 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.jacobsonhospital.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1949 | FormationYr |
| Legal Domicile State | ND | LegalDomicileStateCd |
| Activity Or Mission | To provide quality healthcare to advance the health of patients and communities we serve. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 9 | VotingMembersIndependentCnt |
| Total Employee | 99 | TotalEmployeeCnt |
| Total Volunteers | 100 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $537,557 | PYContributionsGrantsAmt |
| CY Contributions Grants | $156,928 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $6,720,323 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $7,595,552 | CYProgramServiceRevenueAmt |
| PY Investment Income | $1,195 | PYInvestmentIncomeAmt |
| CY Investment Income | $1,015 | CYInvestmentIncomeAmt |
| PY Other Revenue | $1,200 | PYOtherRevenueAmt |
| CY Other Revenue | $1,700 | CYOtherRevenueAmt |
| PY Total Revenue | $7,260,275 | PYTotalRevenueAmt |
| CY Total Revenue | $7,755,195 | 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 | $2,977,290 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $2,994,678 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $3,943,594 | PYOtherExpensesAmt |
| CY Other Expenses | $4,487,501 | CYOtherExpensesAmt |
| PY Total Expenses | $6,920,884 | PYTotalExpensesAmt |
| CY Total Expenses | $7,482,179 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $339,391 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $273,016 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $4,876,116 | TotalAssetsBOYAmt |
| Total Assets EOY | $5,417,812 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $2,169,123 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $2,438,330 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $2,706,993 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $2,979,482 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | To advance the health of patients and communities we serve through a culture of leadership, continuous improvement and accountability. Jacobson Memorial Hospital Care Center (JMHCC) understands the relationship that exists between body, mind and the human spirit. We believe that respect, integrity, quality, commitment and accountability are the foundation by which a healthcare provider should practice in accordance with respect of this relationship. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $6,493,960 | ExpenseAmt |
| Revenue | $7,595,552 | RevenueAmt |
| Desc | Jacobson Memorial Hospital Care Center (JMHCC) is a 30 bed non-profit hospital organization in Elgin, North Dakota. The Board of Directors is made up of community members from the surrounding areas served by JMHCC. JMHCC's primary activity is to provide health care to Grant County. It provides acute care services, ER, swing bed, and clinical services. JMHCC also provides a wide range of outpatient services such as physical, speech and occupational therapy and cardiac rehab. JMHCC provides non-emergency services through clinics in the communities of Elgin and Glen Ullin, in addition to the emergency services it provides in Elgin. | Desc |
| Total Program Service Expenses | $6,493,960 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | 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 | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | 0 | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | 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 | 0 | TaxExemptBondsInd |
| 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 |
| IRP Document | 20 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 99 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| 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 | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 9 | 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 | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Scott Ostenson | PersonNm |
| Phone | 7015847236 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (14 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|
| Leslie Niederman | |||||||
| Chairperson | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Kim Oien | |||||||
| Vice Chairperson | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Marcy Koepplin | |||||||
| Secretary | 1.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Claire Hauge | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Gene Zimmerman | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Ann Hertz | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Joel Klein | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Marcy Haase | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Ron Bartz | |||||||
| Director | 1.00 | Yes (X) | $0 | $0 | $0 | ||
| Theo Stoller | |||||||
| CEO/Administrator | 40.00 | Yes (X) | $140,065 | $0 | $0 | ||
| Scott Ostenson | |||||||
| CFO | 40.00 | Yes (X) | $60,029 | $0 | $4,148 | ||
| Linda Duppong | |||||||
| PA | 32.00 | $107,532 | $0 | $18,388 | Yes (X) | ||
| Carey Rivinius | |||||||
| NP | 32.00 | $136,477 | $0 | $20,933 | Yes (X) | ||
| Arthur Renner | |||||||
| PA | 32.00 | $115,870 | $0 | $11,804 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $559,973 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $55,273 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 4 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | Yes (1) | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Ainsworth-Benning | |||||
| 345 Industrial Drive | Spearfish | SD | 57783 | Construction | $693,715 |
| Dakota Travel Nurse | |||||
| 1200 Collins Ave | Mandan | ND | 58554 | Traveling Nurses | $474,606 |
| Titan Nurse Staffing | |||||
| 2110 S 169th Plaza | Omaha | NE | 68130 | Traveling Nurses | $254,420 |
| ARL Inc | |||||
| 206 5th St NW | Elgin | ND | 58533 | Medical Director/Physician | $225,693 |
| St Alexius | |||||
| 900 E Broadway | Bismarck | ND | 58506 | Management Services | $221,631 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 6 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $126,928 | RelatedOrganizationsAmt |
| Government Grants | $7,510 | GovernmentGrantsAmt |
| All Other Contributions | $22,490 | AllOtherContributionsAmt |
| Total Contributions | $156,928 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| Net Patient Revenue | 623000 | $7,017,403 | $7,017,403 |
| Other Revenue | 900099 | $578,149 | $578,149 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $7,595,552 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,015 | TotalRevenueColumnAmt |
| Exclusion | $1,015 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $1,700 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $0 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $1,700 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $1,700 | TotalRevenueColumnAmt |
| Exclusion | $1,700 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $7,755,195 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $7,595,552 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $2,715 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $212,649 | TotalAmt |
| Management And General | $212,649 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $60,669 | TotalAmt |
| Program Services | $60,669 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,144,991 | TotalAmt |
| Program Services | $2,022,869 | ProgramServicesAmt |
| Management And General | $122,122 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $21,150 | TotalAmt |
| Program Services | $19,657 | ProgramServicesAmt |
| Management And General | $1,493 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $373,956 | TotalAmt |
| Program Services | $338,237 | ProgramServicesAmt |
| Management And General | $35,719 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $181,263 | TotalAmt |
| Program Services | $167,206 | ProgramServicesAmt |
| Management And General | $14,057 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $19,156 | TotalAmt |
| Management And General | $19,156 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,320,518 | TotalAmt |
| Program Services | $1,978,853 | ProgramServicesAmt |
| Management And General | $341,665 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $23,347 | TotalAmt |
| Management And General | $23,347 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $193,795 | TotalAmt |
| Program Services | $144,130 | ProgramServicesAmt |
| Management And General | $49,665 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $26,403 | TotalAmt |
| Management And General | $26,403 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $202,663 | TotalAmt |
| Program Services | $190,543 | ProgramServicesAmt |
| Management And General | $12,120 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $24,521 | TotalAmt |
| Program Services | $18,902 | ProgramServicesAmt |
| Management And General | $5,619 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $18,493 | TotalAmt |
| Program Services | $13,781 | ProgramServicesAmt |
| Management And General | $4,712 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $51,442 | TotalAmt |
| Program Services | $51,442 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $600,940 | TotalAmt |
| Program Services | $600,940 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $54,778 | TotalAmt |
| Management And General | $54,778 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical Supplies | $565,985 | $565,985 | |
| Bad Debt | $194,604 | $194,604 | |
| Food | $76,876 | $76,876 | |
| Dues and Subscriptions | $56,281 | $37,427 | $18,854 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $57,699 | TotalAmt |
| Program Services | $11,839 | ProgramServicesAmt |
| Management And General | $45,860 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $7,482,179 | TotalAmt |
| Program Services | $6,493,960 | ProgramServicesAmt |
| Management And General | $988,219 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $594,410 | BOYAmt |
| EOY | $1,278,313 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,175,621 | BOYAmt |
| EOY | $892,938 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $91,315 | BOYAmt |
| EOY | $92,648 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,608 | BOYAmt |
| EOY | $43,038 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $8,860,937 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $5,938,867 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,811,440 | BOYAmt |
| EOY | $2,922,070 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $133,722 | BOYAmt |
| EOY | $138,805 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $60,000 | BOYAmt |
| EOY | $50,000 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,876,116 | BOYAmt |
| EOY | $5,417,812 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $717,985 | BOYAmt |
| EOY | $664,082 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $226,734 | BOYAmt |
| EOY | $113,367 | EOYAmt |
Escrow Account Liability EscrowAccountLiabilityGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $655 | BOYAmt |
| EOY | $655 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,223,749 | BOYAmt |
| EOY | $1,660,226 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,169,123 | BOYAmt |
| EOY | $2,438,330 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,706,993 | BOYAmt |
| EOY | $2,979,482 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,706,993 | BOYAmt |
| EOY | $2,979,482 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,876,116 | BOYAmt |
| EOY | $5,417,812 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | $273,016 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | -$527 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $0 | 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
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
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 | $13,294 | OtherCostOrOtherBasisAmt |
| Book Value | $13,294 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,796,345 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,381,241 | DepreciationAmt |
| Book Value | $1,415,104 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $3,380,166 | OtherCostOrOtherBasisAmt |
| Depreciation | $2,298,891 | DepreciationAmt |
| Book Value | $1,081,275 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $671,132 | OtherCostOrOtherBasisAmt |
| Depreciation | $258,735 | DepreciationAmt |
| Book Value | $412,397 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $2,922,070 | TotalBookValueLandBuildingsAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $7,560,064 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | -$527 | NetUnrealizedGainsInvstAmt |
| Other Revenue | -$194,604 | OtherRevenueAmt |
| Revenue Not Reported | -$195,131 | RevenueNotReportedAmt |
| Revenue Subtotal | $7,755,195 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $7,755,195 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $7,287,575 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $7,287,575 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $194,604 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $194,604 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $7,482,179 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (4 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part IV, Line 2b: | The Hospital acts as custodian for the funds of the swing bed patients. These funds are included in cash and cash equivalents and accounts payable in the consolidated financial statements. Patient trust funds totaled $655 at June 30, 2017 and 2016. |
| Part X, Line 2: | Jacobson Memorial Hospital Care Center (JMHCC) is organized as a North Dakota nonprofit organization and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). JMHCC is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, JMHCC is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. JMHCC has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. JMHCC believes it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. JMHCC would recognize future accrued interest and penalties related to unrecognized tax liabilities in income tax expense if such interest and penalties are incurred. |
| Part XI, Line 2d - Other Adjustments: | Provision for Bad Debts included in Revenue in the Financial Statements -194,604. |
| Part XII, Line 4b - Other Adjustments: | Provision for Bad Debts included in Revenue in the Financial Statements 194,604. |
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 |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent200 D | Yes (X) | Percent200DInd |
| Free Care Medically Indigent | 0 | 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 | $20,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $20,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00270 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $282,292 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $229,700 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $52,592 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00720 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $302,292 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $229,700 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $72,592 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00990 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,487,424 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,370,582 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $116,842 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01600 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,487,424 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,370,582 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $116,842 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01600 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $1,789,716 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $1,600,282 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $189,434 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.02590 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $194,604 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $27,245 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $2,370,241 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $2,387,557 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$17,316 | 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 | Jacobson Memorial Hospital Care Center | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 E St N | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58553 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.jacobsonhospital.org | WebsiteAddressTxt |
| State License | 5014 | 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 |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Care 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 | 16 | 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 | See Part V, Section C | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 16 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | www.jacobsonhospital.org/About-Us.html | StrategyWebsiteURLTxt |
| 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 | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 200.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Residency Criteria | Yes (X) | ResidencyCriteriaInd |
| Other Criteria | Yes (X) | OtherCriteriaInd |
| 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 |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | www.jacobsonhospital.org/Patients-Visitors.html | 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 |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicaid Medcr Prvt | Yes (X) | LookBackMedicaidMedcrPrvtInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | Yes (1) | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 5: To gather feedback from the community, residents of the county and local health care professionals were given the chance to participate in a survey. Approximately 100 community members and health care professionals took the survey. Additional information was collected through a Community Group comprised of community members and through key informant interviews with community leaders. Fifteen residents participated as a Community Group member, key informant interviewee, or both. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 11: Access to Exercise and wellness activities: JMHCC is actively working with the school to open a fitness center that would be available to the public. We also hold a 5k every year while also helping sponsor and promote other area 5k's and other walks. We offer health fairs targeting preventative care issues. Youth alcohol use and abuse: Jacobson Memorial Hospital does not intend to address this need directly, but has plans to work with Custer Health and the local Sherriff to get education out to the community. Attracting and retaining young families: Jacobson Memorial Hospital does not intend to address this need directly, but will continue to recruit as best we can for open positions. We recently conducted an economic impact study to show how JMHCC supports the community, and we continue to offer above average pay and benefits to employees to entice them to stay. Availability of specialists: We continue to work with larger health systems to bring in specialists for our patients needs. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 13h: Family size is also a factor in determining amounts charged to patients under the financial assistance policy. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 16j: An ad is in the local newspaper once per year. |
| Jacobson Memorial Hospital Care Center | Part V, Section B, Line 24: All individuals eligible under the hospital financial assistance policy are provided a discount for emergency and other medically necessary care. FAP-eligible patients without insurance may be charged gross charges on elective procedures. |
| Part V, Section B, Line 7a: | http://www.jacobsonhospital.org/About-Us.html |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 2 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - Elgin Community Clinic | ||||
| 603 E St N | Elgin | ND | 58553 | Rural Health Clinic |
| 2 - Glen Ullin Family Medical Clinic | ||||
| 602 E Ash Ave | Glen Ullin | ND | 58631 | Rural Health Clinic |
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Part I, Line 3c: | The organization does offer free care under their charity care policy for people at 100% of the federal poverty guidelines, and they offer discounted care starting at 200% of the Federal Poverty Guidelines. Family size is also a factor in determining discounted care. |
| Part I, Line 7: | Charity care expense was converted to cost on line 7a based on an overallcost-to-charge ratio addressing all patient segments. The cost for Medicaid, line 7b, and subsidized health services, line 7g, were determined using the Cost Report. |
| Part I, Ln 7 Col(f): | The amount of bad debt expense removed from the denominator is $194,604. |
| Part III, Line 2: | Bad debt expense is reported as charges shown on the financial statements. |
| Part III, Line 3: | Approximately 14% of the individuals in Grant county are below the Federal Poverty Guidelines and so we estimate that approimately 14% of the total bad debt expense is attributable to patients eligible for charity care. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on page 8 of the attached audited financial statements. |
| Part III, Line 8: | Medicare allowable costs were obtained from the 2016 Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.Even though Medicare was at a loss, the hospital still provided services to these patients. The elderly are an underserved population who experience issues with access to healthcare services. It is a community benefit to be able to treat them at the local hospital. |
| Part III, Line 9b: | Jacobson Memorial Hospital Care Center (JMHCC) has established a collections policy and procedure to facilitate effective and efficient collections for self-pay balances. When a patient submits an application for charity care, collection proceedings are stopped until a decision is made. If an application is determined to be incomplete, a letter is sent letting the patient know additional information is required. If we still do not receive the additional information in 30 days, the patient is sent a letter stating that their application for charity care has been declined and that collection proceedings could start again if payments are not made. When a complete application is received the finance committee meets, which includes the CEO, CFO, and two board members, and they determine if the patient qualifies for charity care and for how much of a discount. If it is determined that a patient is eligible for charity care they receive a letter stating so with a percentage that they qualified for and amount due. It is communicated that they are still expected to make payments. If a patient is sent to collections and later fills out a charity care application and is found to be eligible for a discount, we would pull the account back from collections and set up a payment plan with the patient. |
| Part VI, Line 2: | JMHCC obtained information about the needs of the community through a strategic planning committee made up of representatives from the service area including members of the board of directors, medical staff, hospital administration, hospital staff and community members. These individuals provide the hospital with insight on the issues facing the members of the community. JMHCC completed a community health needs assessment in the spring of 2017. The assessment was completed by the Center for Rural Health. |
| Part VI, Line 3: | Jacobson Memorial Hospital Care Center communicates information about the Charity Care Program to its patients and those living within its primary service area, identifies potential applicants and assists the patients that qualify for discounted services with the applicant process. Jacobson Memorial Hospital Care Center informs the general public within its primary service area of the availability of Charity Care through the following: includes the Charity Care policy in the Patient/Resident Payment Policy provided to all patients at the point of service or admission; posts the policy on community bulletin boards within the Jacobson Memorial Hospital Care Center facilities; posts the policy and information on the Jacobson Memorial Hospital Care Center website; releases general information at least annually in the legal newspaper located within Jacobson Memorial Hospital Care Center's primary service area; and other as deemed appropriate by the Administrator. |
| Part VI, Line 4: | According to data collected while preparing the Community Health Needs Assessment in the spring of 2017, approximately 27% of the population of Grant County is over age 65. The median household income in Grant County is significantly lower than for the rest of North Dakota - $31,852 compared to $46,050. Grant County had a population of 2,388 while the city of Elgin had a population of 642. There are no other hospitals that serve the community. In fact the next nearest hospital is roughly 80 miles away. |
| Part VI, Line 5: | Jacobson Memorial Hospital Care Center (JMHCC) has a Board of Directors made up of volunteers and members of the community. JMHCC does extend medical staff privileges to all qualified physicians serving in the community. Net increases in net assets are invested back into facilities and equipment in order to provide better patient care. In addition to our charity care policy, JMHCC provides many other services to meet the needs of those in Grant County which include:-provide office space so that we can continue to offer mental health services to the community on an outpatient basis.-participate in a number of community events every year including annual discounted lab services during hospital week.-participate in a Scrubs Camp sponsored by the Center for Rural Health and many other local health care organizations such as the New Leipzig ambulance and the local pharmacy, vision and dental practices.-operate a 24 hour emergency department that is available to anyone regardless of the ability to pay.-offer volunteer opportunities for capable area residents to come in and give our long term care residents and our swing-bed patients some activities to participate in. |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | 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 (2 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Theo Stoller | ||||||||||||||
| CEO/Administrator | $140,065 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $140,065 | $0 | $0 | $0 |
| Carey Rivinius | ||||||||||||||
| NP | $136,477 | $0 | $0 | $0 | $0 | $0 | $2,730 | $0 | $18,230 | $0 | $157,437 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | Form 990, Schedule J, Part I, Line 3: | FormAndLineReferenceDesc |
| Explanation | Jacobson Memorial Hospital Care Center does not pay compensation to Theo Stoller, Administrator, directly. He is compensated by an unrelated organization, CHI St. Alexius Health. The Jacobson Memorial Hospital Board of Directors uses the processes described in Part I, Question 3 to determine appropriate compensation for Theo. Any increase in compensation is communicated to CHI St. Alexius Health. CHI St. Alexius Health sends Jacobson Memorial a monthly bill for his wages earned at Jacobson Memorial. | ExplanationTxt |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Crystal Stoller | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Family member of Officer Theo Stoller | RelationshipDescriptionTxt |
| Transaction | $60,669 | TransactionAmt |
| Transaction | Compensation | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| Form 990, Part VI, Section A, line 1 | The Executive Committee shall consist of the Board Chairperson, Vice Chairperson, and the Secretary. The Executive Committee shall have power to transact all regular business of the hospital during the period between the meetings of the governing board, subject to any prior limitations imposed by the governing board and with the understanding that all matters of major importance will be referred to the governing board. It shall be the further duty of the Executive Committee to examine the monthly financial reports. Minutes of the Executive Committee meetings shall be submitted to the Board, and its actions shall be subject to approval or disapproval at the next regular board meeting. The board president only votes if there is a tie. |
| Form 990, Part VI, Section A, line 6 | There is one class of members. Each member pays a one-time fee of $10 for membership. |
| Form 990, Part VI, Section A, line 7a | Each member receives one vote to elect a director to the Hospital Board. Elections take place at the scheduled annual meeting which is held during the last quarter in the calendar year. |
| Form 990, Part VI, Section A, line 7b | The by-laws of the corporation may be amended by affirmative vote of a two-thirds (2/3) majority of the members present at the annual meeting or any special meeting of the corporation, provided, that a notice of such proposed amendments shall have been published in the notice calling the meeting, or, the by-laws may be amended by a vote of three-fourths (3/4) of the Board of Directors members. |
| Form 990, Part VI, Section B, line 11b | Upon receipt of the draft Form 990, the Organization will provide a copy to the Executive Committee to approve to meet the filing deadline, followed by a copy to each board member to review at the next regular board meeting. |
| Form 990, Part VI, Section B, line 12c | Yearly, Officers, Directors and key employees are given the Organization's Conflict of Interest Policy and a Conflict of Interest Acknowledgement Statement in which they must sign. It is the duty of an interested person to disclose the existence of a potential conflict of interest. If any individual discloses a possible conflict, he/she shall leave the governing board or committee meeting while the determination of a conflict of interest is discussed and voted upon by the remaining board or committee members to determine if in fact a conflict of interest exists. If it is found that a conflict exists the conflicted individual is asked to leave the meeting. The remaining board or committee members shall exercise due diligence in determining whether JMHCC can obtain with reasonable efforts a more advantageous transaction or arrangement from a person or entity that would not give rise to a conflict of interest. If a more advantageous transaction or arrangement is not reasonably possible under circumstances not producing a conflict of interest, the Governing Board or committee shall determine by a majority vote of the disinterested directors whether the transaction or arrangement is in JMHCC's best interest, for its own benefit, and whether it is fair and reasonable. In conformity with the above determination it shall make its decision as to whether to enter into the transaction or arrangement. In this fiscal year each affected person signed the policy with no conflicts noted. |
| Form 990, Part VI, Section B, line 15a | The compensation of the Hospital Administrator is reviewed and approved by the independent Board of Directors. The Hospital obtains salary surveys from the Long Term Care Assoication and the North Dakota Hospital Association in deliberating the compensation amount. The compensation determination is presented and approved at a board meeting each year. |
| Form 990, Part VI, Section C, line 19 | The Organization's governing documents, conflict of interest policy, and financial statements are available to the public upon request. |
| Form 990, Part IX, line 11g | Contracted Services: Program service expenses 1,978,853. Management and general expenses 341,665. Fundraising expenses 0. Total expenses 2,320,518. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Foundation | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO Box 367 | AddressLine1Txt |
| City | Elgin | CityNm |
| State Abbreviation | ND | StateAbbreviationCd |
| ZIP | 58533 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 208145158 | EIN |
| Primary Activities | To support Jacobson Memorial Hospital | 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 | Jacobson Memorial Hospital Care Center | 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 | Yes (1) | 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 | 0 | 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 | 0 | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp
Other Organization Name OtherOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Jacobson Memorial Hospital Foundation | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionTypeTxt |
| Involved | $126,928 | InvolvedAmt |
| Method Of Amount Determination | Actual Amount | MethodOfAmountDeterminationTxt |