GOOD SAMARITAN HOSPITAL ASSOCIATION: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- GOOD SAMARITAN HOSPITAL ASSOCIATION (EIN 45-0226419)
- Tax period
- 2009-04-01 to 2010-03-31
- Filed
- 2011-02-09
- IRS object ID
- 201120409349300302
- Schema version
- 2009v1.7
- 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 K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-02-09T08:17:58-06:00 | Timestamp |
| Tax Period End Date | 2010-03-31 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4310 17TH AVE S PO BOX 2545 | AddressLine1 |
| City | FARGO | City |
| State | ND | State |
| ZIP Code | 581082545 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-04-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 450226419 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GOOD SAMARITAN HOSPITAL ASSOCIATION | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | GOOD | NameControl |
| Phone | 7017765261 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Jeffrey Lingerfelt | Name |
| Title | CEO | Title |
| Phone | 7017765261 | Phone |
| Date Signed | 2011-02-08 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | LISA CHAFFEE CPA | Name |
| Phone | 7012398500 | Phone |
| Date Prepared | 2011-02-08 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
Doing Business As DoingBusinessAs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Heart of America Medical Center | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Jeffrey Lingerfelt | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 SOUTH MAIN AVE | AddressLine1 |
| City | RUGBY | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 18095590 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| Web Site | www.hamc.com | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1905 | YearFormation |
| State Legal Domicile | ND | StateLegalDomicile |
| Activity Or Mission Description | Provide quality medical care based on the needs and demographics of north central North Dakota. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 10 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 7 | NbrIndependentVotingMembers |
| Total Nbr Employees | 389 | TotalNbrEmployees |
| Total Nbr Volunteers | 150 | TotalNbrVolunteers |
| Total Gross UBI | 255337 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 15801 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 184112 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 170946 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 16705524 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 17652183 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 83918 | InvestmentIncomePriorYear |
| Investment Income Current Year | 191700 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 694 | OtherRevenuePriorYear |
| Other Revenue Current Year | 26498 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 16974248 | TotalRevenuePriorYear |
| Total Revenue Current Year | 18041327 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 1569 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 692 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 10080627 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 10465811 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 35064 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 7218101 | OtherExpensePriorYear |
| Other Expenses Current Year | 7786544 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 17300297 | TotalExpensesPriorYear |
| Total Expenses Current Year | 18253047 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | -326049 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | -211720 | RevenuesLessExpensesCY |
| Total Assets BOY | 12678996 | TotalAssetsBOY |
| Total Assets EOY | 12828201 | TotalAssetsEOY |
| Total Liabilities BOY | 4129799 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 3832549 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 8549197 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 8995652 | NetAssetsOrFundBalancesEOY |
| Mission Description | To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 15862746 | Expense |
| Grants | 692 | Grants |
| Revenue | 17400298 | Revenue |
| Description | Good Samaritan Hospital Association is a not-for-profit health care organization, owned by over thirty area churches representing all of 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. Our Mission is, "To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service." Good samaritan hospital association's (GSHA) primary focus is healthcare within and around the community of Rugby, ND. GSHA has 25 licensed acute/swing beds as a critical access hospital, 80 medicare skilled nursing home beds, 68 basic care beds, and 37 assistant 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 $215,848 gross charges forgone during the year ending 3/31/10.-Smoking ceasation sessions-Cancer education program-Lifeline-Public healthcare educational and informational notices-Free testing and information during health shows & community events-Ambulance volunteers-Provides EMT course 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 & churches.-CPR training-Wellness programs-Sponsor LPN/RN school program through consortium of facilities & colleges | Description |
| Total Program Service Expense | 15862746 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 1 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| Independent Audit Financial Stmt | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 1 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 58 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 389 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 1 | UnrelatedBusinessIncome |
| Form990-T Filed | 1 | Form990-TFiled |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Nbr Voting Governing Body Members | 10 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 7 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 0 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 0 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 1 | MembersOrStockholders |
| Election Of Board Members | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 1 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 0 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 1 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Bonnie Kuehnemund | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 7017765261 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 S Main Avenue | AddressLine1 |
| City | Rugby | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| Wes Black | |||||||
| Board Chairman | 1.70 | X | X | 0 | 0 | 0 | |
| Jon Nelson | |||||||
| Board Vice Chairman | 1.10 | X | X | 0 | 0 | 0 | |
| Mark Schaan | |||||||
| Trustee | 1.10 | X | 0 | 0 | 0 | ||
| Metta Schell | |||||||
| Trustee (Through 10/09) | 0.80 | X | 0 | 0 | 0 | ||
| Arlyss Bergrud | |||||||
| Trustee | 0.80 | X | 0 | 0 | 0 | ||
| Craig Johnson | |||||||
| Trustee (Through 9/09) | 1.10 | X | 0 | 0 | 0 | ||
| Richard Anderson | |||||||
| Trustee | 0.90 | X | 0 | 0 | 0 | ||
| John McClintockJr | |||||||
| Trustee | 0.80 | X | 0 | 0 | 0 | ||
| Tom Moller Jr | |||||||
| Trustee | 0.80 | X | 0 | 0 | 0 | ||
| Brett McAtee | |||||||
| Trustee | 0.80 | X | 0 | 0 | 0 | ||
| Stacie Schmitt | |||||||
| Trustee | 0.80 | X | 0 | 0 | 0 | ||
| Curt Ekren | |||||||
| Trustee | 1.10 | X | 0 | 0 | 0 | ||
| Jerry Jurena | |||||||
| Sec/CEO (Through 11/09) | 40.00 | X | 106579 | 0 | 13215 | ||
| Bonnie Kuehnemund | |||||||
| Comptroller/Treasurer | 40.00 | X | 81562 | 0 | 15114 | ||
| Jeffrey Lingerfelt | |||||||
| Sec/CEO (Starting 11/09) | 40.00 | X | 24652 | 0 | 1039 | ||
| Susanne Levene | |||||||
| Surgeon | 40.00 | 280180 | 0 | 8930 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 492973 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 38298 | TotalOtherCompensation |
| Number Individuals GT100 K | 2 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| American Staffing Services | |||||
| 2233 University Ave W 301 | St Paul | MN | 55114 | Contract Nursing Services | 394734 |
| Diversified Med Resource | |||||
| 1104 Walnut Street E | Devils Lake | ND | 58301 | ER Physician Services | 357240 |
| Dakota Travel Nurse Inc | |||||
| 3015 Memorial Hwy | Mandan | ND | 58554 | Contract Nursing Services | 244293 |
| Wipfli LLP | |||||
| PO BOX 3160 | Milwaukee | WI | 53201 | Consultant Services | 198462 |
| DMS Imaging | |||||
| PO Box 86 | Minneapolis | MN | 55486 | Nuclear Imaging Services | 192832 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 9 | NumberOfContractorsGT100K |
| Related Organizations | 30417 | RelatedOrganizations |
| Government Grants | 39129 | GovernmentGrants |
| All Other Contributions | 101400 | AllOtherContributions |
| Total Contributions | 170946 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (4 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | Unrelated Business RevenueUnrelatedBusinessRevenue |
|---|---|---|---|---|
| Patient service revenu | 900099 | 16735183 | 16735183 | |
| Mgmt services | 541610 | 172654 | 172654 | |
| Golden Heart Ambulance | 541200 | 79747 | 79747 | |
| Gift shop revenue | 453220 | 29218 | 29218 |
Total Oth Program Service Revenue TotalOthProgramServiceRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 635381 | TotalRevenueColumn |
| Related Or Exempt Function Income | 635381 | RelatedOrExemptFunctionIncome |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 17652183 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 41196 | TotalRevenueColumn |
| Exclusion | $41,196 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 62953 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 43406 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 19547 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 19547 | TotalRevenueColumn |
| Unrelated Business Revenue | 2936 | UnrelatedBusinessRevenue |
| Exclusion | $16,611 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 148497 | Securities |
| Other | 4731 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | 2724 | Other |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 148497 | Securities |
| Other | 2007 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 150504 | TotalRevenueColumn |
| Exclusion | $150,504 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 14417 | GrossIncomeFundraisingEvents |
| Fundraising Direct Expenses | 7982 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 6435 | TotalRevenueColumn |
| Exclusion | $6,435 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Gaming | 667 | GrossIncomeGaming |
| Gaming Direct Expenses | 151 | GamingDirectExpenses |
Net Income From Gaming NetIncomeFromGaming
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 516 | TotalRevenueColumn |
| Related Or Exempt Function Income | 516 | RelatedOrExemptFunctionIncome |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 18041327 | TotalRevenueColumn |
| Related Or Exempt Function Income | 17400298 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 255337 | UnrelatedBusinessRevenue |
| Exclusion | $214,746 | ExclusionAmount |
Grants To Domestic Orgs GrantsToDomesticOrgs
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 692 | Total |
| Program Services | 692 | ProgramServices |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 250329 | Total |
| Management And General | 250329 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 8472150 | Total |
| Program Services | 7449543 | ProgramServices |
| Management And General | 993483 | ManagementAndGeneral |
| Fundraising | 29124 | Fundraising |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 143679 | Total |
| Program Services | 126337 | ProgramServices |
| Management And General | 16848 | ManagementAndGeneral |
| Fundraising | 494 | Fundraising |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 967981 | Total |
| Program Services | 850796 | ProgramServices |
| Management And General | 113857 | ManagementAndGeneral |
| Fundraising | 3328 | Fundraising |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 631672 | Total |
| Program Services | 540681 | ProgramServices |
| Management And General | 88878 | ManagementAndGeneral |
| Fundraising | 2113 | Fundraising |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 185982 | Total |
| Management And General | 185982 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 40450 | Total |
| Management And General | 40450 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2535900 | Total |
| Program Services | 2503992 | ProgramServices |
| Management And General | 31908 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 45648 | Total |
| Program Services | 1054 | ProgramServices |
| Management And General | 44594 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2433123 | Total |
| Program Services | 2133761 | ProgramServices |
| Management And General | 299357 | ManagementAndGeneral |
| Fundraising | 5 | Fundraising |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 176148 | Total |
| Management And General | 176148 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 486772 | Total |
| Program Services | 477000 | ProgramServices |
| Management And General | 9772 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 171924 | Total |
| Program Services | 125170 | ProgramServices |
| Management And General | 46754 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5074 | Total |
| Program Services | 5074 | ProgramServices |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 73615 | Total |
| Program Services | 73615 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1045488 | Total |
| Program Services | 1045488 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 143692 | Total |
| Program Services | 143692 | ProgramServices |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Bad debt | 383561 | 383561 | |
| Recruitment | 46262 | 46262 | |
| Sales and Use Taxes | 10044 | 1669 | 8375 |
| Franchise | 621 | 621 | |
| UBIT Taxes | -208 | -208 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2448 | Total |
| Management And General | 2448 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 18253047 | Total |
| Program Services | 15862746 | ProgramServices |
| Management And General | 2355237 | ManagementAndGeneral |
| Fundraising | 35064 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 790856 | BOY |
| EOY | 688575 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2612436 | BOY |
| EOY | 2333927 | EOY |
Other Notes Loans Receivable Net OtherNotesLoansReceivableNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 501189 | BOY |
| EOY | 422414 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 179314 | BOY |
| EOY | 161348 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 50793 | BOY |
| EOY | 66170 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 20815647 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 16571108 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4894994 | BOY |
| EOY | 4244539 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 3332031 | BOY |
| EOY | 4269421 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 244383 | BOY |
| EOY | 319807 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 73000 | BOY |
| EOY | 322000 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12678996 | BOY |
| EOY | 12828201 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1661174 | BOY |
| EOY | 1587671 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 914131 | BOY |
| EOY | 558771 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 963435 | BOY |
| EOY | 999539 | EOY |
Unsecured Notes Loans Payable UnsecuredNotesLoansPayable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 570000 | BOY |
| EOY | 686568 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 21059 | BOY |
| EOY | 0 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4129799 | BOY |
| EOY | 3832549 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8304814 | BOY |
| EOY | 8675845 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 244383 | BOY |
| EOY | 319807 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8549197 | BOY |
| EOY | 8995652 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12678996 | BOY |
| EOY | 12828201 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| 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) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Agent Trustee Etc | 1 | AgentTrusteeEtc |
| Beginning Balance | 91548 | BeginningBalance |
| Additions During Year | 52794 | AdditionsDuringYear |
| Distributions During Year | 51532 | DistributionsDuringYear |
| Ending Balance | 92810 | EndingBalance |
| Included On FS | 0 | IncludedOnFS |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 137447 | OtherCostOrOtherBasis |
| Book Value | 137447 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 13005425 | OtherCostOrOtherBasis |
| Depreciation | 10117105 | Depreciation |
| Book Value | 2888320 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 6870888 | OtherCostOrOtherBasis |
| Depreciation | 6007376 | Depreciation |
| Book Value | 863512 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 801887 | OtherCostOrOtherBasis |
| Depreciation | 446627 | Depreciation |
| Book Value | 355260 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 4244539 | TotalOfBookValueLandBuildings |
| Total Revenue | 18041327 | TotalRevenue |
| Total Expenses | 18253047 | TotalExpenses |
| Excess Or Deficit For Year | -211720 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 587221 | NetUnrealizedGLOnInvestments |
| Other | $70,954 | OtherAmount |
| Total Adjustments | 658175 | TotalAdjustments |
| Excess Or Deficit Per FS | 446455 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 18635491 | TotRevenueEtcAuditedFinclStmt |
| Net Unrealized Gains Investments | 587221 | NetUnrealizedGainsInvestments |
| Other Revenues | 8198 | OtherRevenues |
| Revenue Not Rptd F990 | 595419 | RevenueNotRptdF990 |
| Revenue Subtotal | 18040072 | RevenueSubtotal |
| Other Revenues Not Included | 1255 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 1255 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 18041327 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 18264460 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 43406 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 43406 | ExpensesNotRptdF990 |
| Expenses Subtotal | 18221054 | ExpensesSubtotal |
| Other Expenses Not Included | 31993 | OtherExpensesNotIncluded |
| Expenses Not Rptd On Fin Stmt | 31993 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 18253047 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (7 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| Part IV, Line 1b: | Good Samaritan Hospital Association has an auxiliary that it operates. Good Samaritan does not report the auxiliary's net assets on its financial statements. | |
| Part X: | The Association undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities. The Association has not identified any liability as a result of this analysis. | Description of Uncertain Tax Positions Under FIN 48: |
| Part XI, Line 8 - Other Adjustments: | Increase in investment in net assets of Foundation: 75424. Change in Auxiliary net assets: -1262. Prior period adjustment to Auxiliary Net assets: -3208. | |
| Part XII, Line 2d - Other Adjustments: | Interdepartmental Donation: 8198. | |
| Part XII, Line 4b - Other Adjustments: | Rental expenses: -43406. Auxiliary Revenues: 44661. | |
| Part XIII, Line 2d - Other Adjustments: | Rental expenses: 43406. | |
| Part XIII, Line 4b - Other Adjustments: | Auxiliary expenses: 31993. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent200 | X | Pcent200 |
| FPG Reference Discounted Care | 0 | FPGReferenceDiscountedCare |
| Free Disc Care Medically Indigent | 0 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 0 | AnnualCommunityBenefitReport |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 150692 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 150692 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00840 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 594606 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 335604 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 259002 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01450 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 745298 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 335604 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 409694 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02290 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 11852 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2640 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 9212 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00050 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 300 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 300 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00000 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 601128 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 275435 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 325693 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01820 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2435 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 2435 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 615715 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 278075 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 337640 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01880 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1361013 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 613679 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 747334 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04170 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $267,779 | BadDebtExpenseAmount |
| Amount Attributable To | 56501 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4737650 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 4851993 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | -114343 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
Form990 Schedule H Part V Form990ScheduleHPartV (2 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Licensed HospitalLicensedHospital | General Medical And SurgicalGeneralMedicalAndSurgical | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours | OtherOther |
|---|---|---|---|---|---|---|---|---|
| Heart of America Medical Center | ||||||||
| 800 South Main Ave | Rugby | ND | 58368 | X | X | X | X | Longterm care |
| Haaland Estates | ||||||||
| 1025 3rd Ave SE | Rugby | ND | 58368 | Basic care/asstd lvg | ||||
Form990 Schedule H Part VI Form990ScheduleHPartVI
| Field | Value | IRS element (for citing) |
|---|---|---|
| Income Based Criteria | Part I, Line 3c: The organization does not provide discounted care. If a person qualifies for the charity care program the care is completely free; the discount is either 100% or 0%. At this time there is no sliding fee scale which provides for a discounted care percentage between 0 and 100. | IncomeBasedCriteria |
| Costing Method Used | Part I, Line 7: The following methods were used to determine the costs reported:Row a: The organization used Worksheet 2 to determine the cost.Row b: Worksheet 2 was used to bring gross hospital Medicaid pateint revenues (per the internal finacial records) to cost. Net revenues was calculated by using internal records of gross charges less estimated discounts.Row e: Costs were tracked by staff throughout the year for the various activities. Revenues are actual revenues received for the particular activity.Row f: Cost is based on the actual cost of a scholarship which was awarded to a local high school student planning on pursuing a college degree in healthcare.Row g: The cost to charge ratio from the Medicare cost report was used primarily for determining the cost of providing these services along with the estimated offsetting revenues.Row i: In-kind contributions were estimated costs of our facilities and equipment used by community groups throughout the year. Costs are estimated using square footage and costing from the Medicare cost report as a general basis.Part I, Line 7f: The amount of bad debt expense removed from the denominator is $383,561. | CostingMethodUsed |
| Subsidized Health Services Expln | Part I, Line 7g: Part I, Line 7g includes $188,263 of costs from a surgical clinic. | SubsidizedHealthServicesExpln |
| Percent Of Total Expense Expln | Part I, Line 7f: | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: Financial Statement Bad Debt Expense Footnote:The carrying amount of patient and resident receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients, residents, and third-party payors. Management reviews patient and resident receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients or residents due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision.Bad debt expense was converted to cost using the ratio of patient care cost to charges calculated using Worksheet 2.The Heart of America Medical Center submits claims to any insurance or third party payors first prior to billing self pay. Currently we use a valuation allowance calculation of 35% of self pay accounts 0-90 days and 85% of self pay accounts over 90 days as an estimate of our bad debt expense within our accounts receivables. As accounts are determined to actually be bad debts, they are referred to a collection agency and written off as bad debt. Eligibility for our Charity Care program is determined based on each individual's financial capability. Patients are eligible for Charity Care based on their income using 200% of the published poverty guidelines. Medical indigence, such as homeless, no income, or qualifying for other aid (Medicaid, WIC, food stamps, etc) is considered as presumptive charity care.In estimating the amount of our bad debt expense attributable to patients eligible under our charity care policy we took 2008 and 2009 US Census Bureau population and poverty level statistics for the area in which we serve; primarily a five county area. From those statistics we determined approximately 21.1% of our market population are at the poverty level based on the FPG. Even though our charity care guidelines are based on 200% of the FPG, we chose to be conservative and used the estimated 21.1% at the poverty level and applied it to our bad debt expense. Our bad debt consists of those unable to pay, but also those who just are unwilling to pay. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: The ($114,343) medicare shortfall, is the result of the healthcare services provided to our patients which are being reimbursed by Medicare on a fee for service reimbursement such as labs, professional services, and some physical therapy, occupational therapy, or speech, or to our Medicare skilled LTC residents. The shortfall is all related to patients or residents who are covered by Medicare and therefore are elderly which is considered to be a charitable class. We provide the service to promote quality healthcare to our elderly who would have trouble going elsewhere to receive the services, even though there is a shortfall in the Medicare overall payment. We believe 100% of the $114,343 is a community benefit.Medicare revenue and allowable costs were obtained from the 2009 Medicare Cost Report. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: Accounts are worked effectively and thoroughly with self pay statements printed monthly once insurance's 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 200% of the federal poverty levels. 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. | DebtCollectionPolicy |
| Needs Assessment | Part VI, Line 2: Heart of America Medical Center serves a smaller community where providers know their patients and the GSHA Board of Directors live in and are members of the local and surrounding communities. For the year ending March 31, 2010 needs were assessed through informal means from discussions with physicians, board of directors, administration, employees, and by community members voicing concerns. A specific limited community survey was completed to determine the need for kidney dialysis. A community assessment is currently planned to be done in early 2011 to further assess health care needs of the communities we serve. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: Our charity care policy and application is provided to all admits to our hospital upon admissions. This includes assistance contact information. At the admission area there are brochures on Charity Care Program/Prompt Payment Discount which also addresses our charity care program. Also in processing the self pay bills, the patient is encouraged to complete our charity care application if applicable to assist in taking care of their bill. Our Social Service department is also very involved with assisting our patients and residents with governmental benefits primarily North Dakota Medicaid. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: Heart of America Medical Center (HAMC) is a rural Critical Access Hospital (CAH) in north central North Dakota with the closest tertiary facility 65 miles away to the west. The closest smaller hospital is 43 miles away. HAMC basically serves in whole or part the counties of Pierce, Benson, McHenry, Rolette, and Bottineau counties. Our primary service area is in a 45 miles radius with a target population of approximately 15,000 people. Pierce County alone had a population of 4,091 in 2008 according to the US Census Bureau with 98% white and 25% age 65 or older. Rugby has a population of approximately 2,900. Of our hospital's patients, approximately 60% are Medicare and 6% Medicaid. Within our market area approximately 21% of the population is below the Federal Poverty Guidelines. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: n/a | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: Good Samaritan Hospital Association (GSHA) is owned by 32 member churches located throughout our service area. The GSHA Board of Directors is voted in by the member churches and they are community members who reside in our primary service area-both Rugby and the surrounding satellite communities. They are not employees or contractors of GSHA, but serve in various occupations and involved in various community activities. GSHA extends medical staff privileges to all qualified physicians in the community and is continuously striving to bring in more providers in order to maintain providers to provide the care needed by our patients and promote health within our communities. When surplus funds are available they are used to purchase and upgrade equipment, and invested back into the facility and services we provide to maintain high quality patient care.We continually strive to meet the healthcare needs within our community and the surrounding areas. As of March 31, 2010 the family practice clinic in Rugby was a separate entity from GSHA; however, we have been working together to merge in order to better meet the healthcare needs of our communities. A merger did take place August 2010. This merger will strengthen our abilities to serve the communities by providing us with a better physician/midlevel recruitment platform and higher continuity of care. In striving to meet the needs of the communities we provide services including assistant living, basic care, skilled nursing, medical and surgical hospital services along with numerous outpatient services and therapies. We have lost money on some of these services such as cardiac rehab, our surgical clinic, and our hospice program but continue to maintain these services because of the need within the community. If we did not provide services such as these, the services would be unavailable in the community. Patients would have to go out of town to get the services which is not always possible, so some would not have access to these services if we did not provide them.Currently we are not involved much in community building activities. Being a small CAH facility with limited resources, our focus is more on health related programs and services needed within our community in which if we did not provide the service, it would not be available within the community. GSHA is not part of any affiliated health care system; however, as a CAH we do have Rural Health Network agreements with both Trinity Medical Center in Minot and MedCenter One in Bismarck in order to help and promote the availability of a range of high-quality care. They enhance the continuity of healthcare delivery among all levels of care needed by our patients by identifying and forming a process to facilitate patient referral and transfers between facilities and also enhance the communications between us. GSHA is also part of a consortium of smaller CAH facilities to share computer hardware. This has allowed us to expand our computer capabilities at a lower cost which provides the opportunity to better serve our patients and meet their healthcare needs. | OtherInformation |
| Affiliated Health Care System | Part VI, Line 7: n/a | AffiliatedHealthCareSystem |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Housing Allowance Or Residence | X | HousingAllowanceOrResidence |
| Written Policy Re T And E Expenses | 1 | WrittenPolicyReTAndEExpenses |
| Substantiation Required | 1 | SubstantiationRequired |
| Compensation Committee | X | CompensationCommittee |
| Independent Consultant | X | IndependentConsultant |
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 0 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Susanne Levene | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Base Compensation Filing Org | 280000 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 0 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 0 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 180 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 4900 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 0 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 4943 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 290023 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 0 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | Part I, Line 1a | ReturnReference |
| Explanation | Jeffrey Lingerfelt's apartment rent was paid as part of his moving package in the amount of $2,000. This amount was included as taxable compensation in his W-2. | Explanation |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | City of Rugby ND | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 456002152 | IssuerEIN |
| Date Issued | 2005-06-09 | DateIssued |
| Issue Price | 1800000 | IssuePrice |
| Description Of Purpose | Capital expenditures - purchase radiology equipment and computer equipment | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Proceeds | 1800000 | TotalProceeds |
| Issuance Costs From Proceeds | 10000 | IssuanceCostsFromProceeds |
| Capital Expenditures | 1790000 | CapitalExpenditures |
| Year Of Subst Completion | 2008 | YearOfSubstCompletion |
| Current Refunding | 0 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 1 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 0 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Bond Counsel Routinely Engaged | 0 | BondCounselRoutinelyEngaged |
| Prcntge Prvt Business Use By Others | 0.00000 | PrcntgePrvtBusinessUseByOthers |
| Percentage Of Prvt Business Re UBI | 0.00000 | PercentageOfPrvtBusinessReUBI |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUse |
| Post Issuance Compliance Procdrs | 1 | PostIssuanceComplianceProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8038 T Filed | 1 | Form8038TFiled |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Exception To Rebate | 0 | ExceptionToRebate |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (3 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| Julie Baustad | |||
| Family member of board member Richard Anderson | 91588 | Employment | 0 |
| Nancy Schneibel | |||
| Family member of board member Stacie Schmitt | 49752 | Employment | 0 |
| Jodi Schaan | |||
| Family member of board member Mark Schaan | 48363 | Employment | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (7 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section A, line 6 | The organization is owned by local churches, whose delegates vote at the annual meeting on election of 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 Good Samaritan Hospital Association can do so through vote at the annual meeting. |
| Form 990, Part VI, Section A, line 7a | The local churches are members. Each church has two delegates and these delegates vote in the board of directors at the annual meeting. |
| Form 990, Part VI, Section A, line 7b | Any changes in the Articles of Incorporation or Bylaws are subject to approval by the delegates. |
| Form 990, Part VI, Section B, line 11 | The CEO and CFO will review the Form 990 first. After CFO and CEO approval the 990 will be sent out electronically to the board members prior to it being filed. |
| Form 990, Part VI, Section B, line 12c | Each year Board Members and Officers sign a Conflict of Interest statement. Employees are also covered within the conflict of interest policy by which if they have any conflict of interest they are to sign the statement stipulating the conflict of interest. The CEO receives and reviews the responses regarding the annual disclosure in order to determine if a conflict exists. If there is an issue the board member abstains from voting on the issue. |
| Form 990, Part VI, Section B, line 15a | Comparative data is incorporated into the review process. Each board member completes their own evaluation form. The human resource committee reviews the responses and makes a recommendation to the full board. The full board makes the decision as to any changes in compensation. This is an annual review process which last took place during the summer of 2009. There are no other positions which the board approves the wages. The CEO approves the CFO wages. All employees have an annual review which is done by the department head or supervisor. Wages within the various positions are compared to the NDHA annual salary survey report at the time of the individual's annual review. |
| Form 990, Part VI, Section C, line 19 | Upon request |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 South Main Ave | AddressLine1 |
| City | Rugby | City |
| State | ND | State |
| ZIP Code | 583682118 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 363513553 | EIN |
| Primary Activities | Fundraising for Heart of America Medical Center | PrimaryActivities |
| Legal Domicile State | ND | LegalDomicileState |
| Exempt Code Section | 501(c)(3) | ExemptCodeSection |
| Public Charity Status | 7 | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | None | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 0 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 1 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 1 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 1 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 1 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Good Samaritan Health Services Foundation | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | Q | TransactionType |
| Amount Involved | 80374 | AmountInvolved |