2025-11-11T10:10:37-06:00 2024-12-31 410746749 CLIFTONLARSONALLEN LLP 121 WEST BRIDGE STREET OWATONNA MN 55060 990 2024-01-01 456013474 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PEMB 7012658461 301 MOUNTAIN STREET EAST CAVALIER ND 58220 LISA LETEXIER CEO 7012658461 2025-11-10 1 1 JUSTIN HARTERT P02236744 5074467100 2025-11-10 2024 2025-03-06 01:10:19Z LISA LETEXIER 301 MOUNTAIN STREET EAST CAVALIER ND 58220 23478668 0 X WWW.CAVALIERHOSPITAL.COM X 1976 ND TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE FOR THOSE WE SERVE. 10 9 206 13 0 0 271830 1001405 20951579 22120606 138514 139451 60185 217206 21422108 23478668 0 0 0 0 9939799 10713123 0 0 92229 10591815 10993676 20531614 21706799 890494 1771869 22126648 27290598 2825858 6217939 19300790 21072659 X THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE TO THOSE WE SERVE IN CAVALIER AND THE SURROUNDING COMMUNITIES. THE VISION THAT GUIDES PEMBINA COUNTY MEMORIAL HOSPITAL AND WEDGEWOOD MANOR IS TO DEVELOP A FAMILY CENTERED INTEGRATED HEALTHCARE ORGANIZATION WHICH PROVIDES SERVICES THAT MEET THE NEEDS OF THE REGION, THEREBY MAKING US THEIR PROVIDER OF CHOICE. 0 0 19779178 0 22120606 PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20 BED ACUTE CARE HOSPITAL, 38 BED NURSING HOME, A RURAL HEALTH CLINIC, AND 20 UNIT CONGREGATE HOUSING COMPLEX LOCATED IN CAVALIER, ND. THE FACILITY PROVIDES QUALITY MEDICAL AND LONG-TERM CARE TO THE RESIDENTS OF THE SURROUNDING AREA, REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES RECEIVED. A 24 HOUR EMERGENCY ROOM IS AVAILABLE FOR PATIENTS WHO NEED IMMEDIATE TREATMENT, AND TREATMENT IS PROVIDED TO ALL INDIVIDUALS WHO PRESENT, REGARDLESS OF THEIR ABILITY TO PAY. THE ASSOCIATION ALSO SUPPLIES FREE OR REDUCED SERVICES TO PATIENTS WHO MEET ESTABLISHED CRITERIA OUTLINED IN THE FACILITY'S CHARITY CARE POLICY AND PROVIDES HEALTH EDUCATION AND OTHER SERVICES TO THE COMMUNITY. 19779178 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 33 0 1 206 1 0 0 0 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X TAYLOR BROWN 7012656281 301 MOUNTAIN ST E CAVALIER ND 58220 SUSAN THOMPSON MEDICAL STAFF PRESIDENT 40.00 0.00 X X 218414 0 37140 LISA LETEXIER CEO 40.00 0.00 X 212022 0 16784 LAURA ERMER PHYSCIANS ASSISTANT 40.00 0.00 X 186734 0 9233 KIM FORD NURSE PRACTITIONER 40.00 0.00 X 179514 0 11629 JENNA CARPENTER NURSE PRACTITIONER 40.00 0.00 X 179520 0 9479 JANAE HEUCHERT PHARMACIST 40.00 0.00 X 129796 0 51958 MICHAEL BITTLES MD 40.00 0.00 X 183333 0 0 PATTI JOHNSON NURSING HOME ADMINISTRATOR 40.00 0.00 X 127591 0 30359 KATIE WERNER CFO 40.00 0.00 X 98201 0 45932 DUANNE DERAAS PRESIDENT 0.80 0.20 X X 0 0 0 TOM VAUGHN VICE PRESIDENT 0.80 0.20 X X 0 0 0 GEORGE WRIGHT SECRETARY/TREASURER 0.80 0.20 X X 0 0 0 GRETTA BEARD DIRECTOR 0.80 0.20 X 0 0 0 LARAE HORGAN DIRECTOR 0.80 0.20 X 0 0 0 GORDON JOHNSON DIRECTOR (THROUGH JUNE 2024) 0.80 0.20 X 0 0 0 DREW OLAFSON DIRECTOR 0.80 0.20 X 0 0 0 DARIN OTTO DIRECTOR 0.80 0.20 X 0 0 0 NICOLE SAFRANSKI DIRECTOR 0.80 0.20 X 0 0 0 JEREMY STONE DIRECTOR 0.80 0.20 X 0 0 0 1515125 0 212514 13 0 1 0 TRIAD TRAVEL NURSING AGENCY 112 N UNIVERSITY DR STE 320 FARGO ND 58102 NURSING AGENCY 892142 PARK RIVER CLINIC PO BOX 380 CAVALIER ND 58220 CONTRACT PHYSICIAN 622070 ALTRU HEALTH SYSTEM PO BOX 13780 GRAND FORKS ND 58208 EMR MANAGEMENT SERVICES 317507 DMS HEALTH TECHNOLOGIES PO BOX 670747 DALLAS TX 75267 DIAGNOSTIC IMAGING SERVICES 313551 MIDWEST RADIOLOGY PO BOX 2923 INDIANAPOLIS IN 46206 PROFESSIONAL RADIOLOGY SERVICES 217554 8 27536 973869 1001405 NET PATIENT REVENUE 621110 19800071 19800071 340B REVENUE 456110 2198573 2198573 ANCILLARY REVENUES 621110 121962 121962 22120606 139451 139451 12722 0 12722 12722 12722 OTHER INCOME 900099 204484 204484 204484 23478668 22120606 0 356657 X 786443 786443 8135356 7802420 272372 60564 212061 204875 5383 1803 958639 943705 6526 8408 620624 548586 67209 4829 985 985 80190 80190 2459 2459 5055902 4905558 147702 2642 53092 10525 41047 1520 153374 148741 4553 80 363591 287940 75651 27156 27156 816355 816355 161277 31971 124688 4618 MEDICAL SUPPLIES 3313866 3313866 PROVISION FOR BAD DEBT 448029 448029 EQUIPMENT RENTAL & REPA 181163 170666 10497 FOOD EXPENSE 177759 35238 137431 5090 158478 83547 72256 2675 21706799 19779178 1835392 92229 10358 10370 6970236 9745974 3049472 2898232 209387 271884 228963 278521 31267464 18067639 9920476 13199825 1169092 788254 568664 97538 22126648 27290598 2230515 1118800 10001 312733 13310 13310 219778 4334121 231777 195693 120477 243282 2825858 6217939 X 19300790 21072659 19300790 21072659 22126648 27290598 1771869 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2459 2459 0 PART II-B, LINE 1, LOBBYING ACTIVITIES: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION PAYS ANNUAL DUES TO THE NORTH DAKOTA LONG-TERM CARE ASSOCIATION. A PORTION OF THOSE DUES ARE USED BY THE ASSOCIATION TO CONDUCT LOBBYING ON BEHALF OF ALL MEMBER HOSPITALS. 1 6196 3930 4879 5247 1 X 160304 160304 10383415 7544460 2838955 1168399 730650 437749 12075853 9792529 2283324 7479493 7479493 13199825 RIGHT-OF-USE LEASE LIABILITIES 100973 DUE TO/FROM MEDICARE 142309 243282 X 22965620 0 22965620 513048 513048 23478668 21193751 0 21193751 513048 513048 21706799 PART IV, LINE 1B: A SMALL AUXILIARY OPERATES UNDER THE HOSPITAL'S EIN. PART IV, LINE 2B: THE ASSOCIATION HOLDS FUNDS UNDER AN AGENCY RELATIONSHIP FOR THE RESIDENTS OF WEDGEWOOD MANOR AND COUNTRY ESTATES. THE FUNDS ARE SHOWN AS CASH AND A CORRESPONDING LIABILITY IN ACCOUNTS PAYABLE IN THE ACCOMPANYING BALANCE SHEETS. FUNDS HELD AS OF DECEMBER 31, 2024 AND 2023 TOTALED $13,310. PART X, LINE 2: THE ASSOCIATION IS CLASSIFIED BY THE INTERNAL REVENUE SERVICE AS A TAX-EXEMPT ORGANIZATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS SUBJECTED TO FEDERAL INCOME TAX ONLY ON NET UNRELATED BUSINESS INCOME. THE ASSOCIATION FOLLOWS GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE ASSOCIATION FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE APPLICATION OF THIS STANDARD HAS NO EFFECT ON THE FINANCIAL STATEMENTS. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 448,029. CHARITY CARE 65,019. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 448,029. CHARITY CARE 65,019. 1 1 X 1 X 1 X 0 0 1 1 51393 0 51393 0.00240 3144792 3674722 0 0.00000 0 0 3196185 3674722 51393 0.00240 134696 0 134696 0.00620 20544 0 20544 0.00090 7049689 6737380 312309 0.01440 0 0 1045 0 1045 0.00000 7205974 6737380 468594 0.02150 10402159 10412102 519987 0.02390 700 700 0.00000 700 700 0.00000 1 448029 34050 6290120 6396958 -106838 X 1 1 1 1 PEMBINA COUNTY MEMORIAL HOSPITAL 301 MOUNTAIN STREET EAST CAVALIER ND 58220 WWW.CAVALIERHOSPITAL.COM 5009 X X X X PEMBINA COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 23 1 0 1 1 X SEE PART V, SECTION B, LINE 7D X X 1 23 1 SEE PART V, SECTION B, LINE 7D 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X HTTP://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: IN 2023, PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION TOOK A PROACTIVE APPROACH TO IDENTIFYING THE NEEDS OF OUR COMMUNITY BY PARTICIPATING IN A COMMUNITY HEALTH NEEDS ASSESSMENT IN COLLABORATION WITH PEMBINA COUNTY PUBLIC HEALTH. THE ASSESSMENT WAS FACILITATED BY THE CENTER FOR RURAL HEALTH (UND SCHOOL OF MEDICINE & HEALTH SCIENCES).THIRTEEN COMMUNITY MEMBERS REPRESENTED SEVENTEEN COMMUNITIES SERVED BY PCMHA INCLUDING REPRESENTATIVES OF THE HEALTH COMMUNITY, BUSINESS COMMUNITY, POLITICAL BODIES, LAW ENFORCEMENT, FAITH COMMUNITY, AND AGRICULTURE COMMUNITIES. MEMBERS WERE INTRODUCED TO THE NEEDS ASSESSMENT PROCESS, REVIEWED BASIC DEMOGRAPHIC INFORMAATION AND SERVED AS A FOCUS GROUP. SURVEYS WERE DISTRIBUTED TO THE COMMUNITY AT LARGE TO COLLECT QUALITATIVE DATA INCLUDING INFORMATION RELATED TO COMMUNITY-PERCEIVED HEALTH NEEDS. SIXTY COMMUNITY MEMBERS COMPLETED THE SURVEY IN THE COMMUNITIES THROUGHOUT THE COUNTIES IN THE PCMHA SERVICE AREA. INTERVIEWS WERE ALSO CONDUCTED. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN COLLABORATION WITH PEMBINA COUNTY PUBLIC HEALTH AND WAS FACILITATED BY THE CENTER FOR RURAL HEALTH. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THE ORGANIZATION'S COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT HTTPS://WWW.CAVALIERHOSPITAL.COM/HOW-TO-HELP/RESOURCES.HTML. PEMBINA COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: AN IMPLEMENTATION PLAN HAS BEEN DEVELOPED BASED ON COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) PROCESS CONDUCTED IN 2023. THE CHNA WAS CONDUCTED IN COLLABORATION WITH PEMBINA COUNTY PUBLIC HEALTH TO DETERMINE THE MOST PRESSING HEALTH NEEDS OF PEMBINA COUNTY.THE TOP NEEDS IDENTIFIED IN THE CHNA PROCESS INCLUDES:-ALCOHOL USE AND ABUSE YOUTH AND ADULT-AVAILABILITY OF MENTAL HEALTH SERVICES-AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES-AVAILABILITY OF VISION CARE-BULLYING/CYBERBULLYING-COST OF LONG-TERM/ NURSING HOME CARE-DEPRESSION/ ANXIETY YOUNG AND ADULT-HAVING ENOUGH AFFORDABLE HOUSING-SMOKING AND TOBACCO USE (SECOND-HAND SMOKE- YOUTH)THROUGHOUT 2024, THE PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) HAS CONTINUED TO ADDRESS AND SUPPORT THE FOLLOWING COMMUNITY NEEDS:PRIORITY AREA: AVAILABILITY OF MENTAL HEALTH SERVICES:GOAL: INCREASE ACCESSIBILITY TO BEHAVIORAL HEALTH SERVICES2024 CONTRIBUTIONS:1. CONTINUE TO OFFER ONE FULL-TIME AND FLEX-TIME BEHAVIORAL HEALTH FAMILY NURSE PRACTITIONER TO SEE PATIENTS BOTH IN-PERSON AND VIRTUALLY. IN ADDITION, WE OFFER A MENTAL HEALTH LICENSED CLINICAL SOCIAL WORKER IN THE CLINIC THAT SEES PATIENTS BOTH VIRTUALLY AND IN-PERSON.2. ENCOURAGE ATTENDANCE AND CONTINUE TO SUPPORT LOCAL LED SUPPORT GROUPS. SEEK OPPORTUNITIES TO EXPAND SUCH GROUPS.3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES.4. HOST AN 8-WEEK GRIEF COURSE PUT ON BY OUR GRIEF AND PASTORAL COUNCIL. THE COURSE WAS FREE TO COMMUNITY ATTENDEES.5. CONTINUE TO OFFER BOTH MEDICAL AND MENTAL HEALTH SERVICES BY TELEMEDICINE.PRIORITY AREA: ALCOHOL USE & ABUSE, DEPRESSION/ANXIETY YOUNG AND ADULT:GOAL: INCREASE ACCESSIBILITY TO TREATMENT FOR DEPRESSION AND ANXIETY AND PROMOTE DANGERS OF ALCOHOL USE BY OUR YOUTH AND ADULTS.2024 CONTRIBUTIONS:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MEDICAL HEALTH PROVIDERS SERVICES AT CLINICARE IN PERSON AND TELETHERAPY AND SEEK ANY VIABLE OPPORTUNITIES TO EXPAND SERVICES AS AVAILABLE.2. SUPPORT YOUTH AND ADULT ALCOHOL-FREE ACTIVITIES AND EDUCATION WITHIN OUR COMMUNITIES. ESPECIALLY ENCOURAGING ANY SCHOOL-LED AFTER PROM ACTIVITIES.3. CONTINUE TO PROVIDE SPACE FOR SUPPORT GROUPS TO MEET AT PEMBINA COUNTY MEMORIAL HOSPITAL.4. WE PARTICIPATE IN LANTERNS BY THE LAKE. WE PROVIDE STAFF THAT SPEAK ON THE DANGERS OF DRUG AND ALCOHOL USE, AND WE ALSO PROVIDE EDUCATIONAL MATERIALS FOR TABLES.PRIORITY AREA: AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES:GOAL: INCREASE ACCESS AND AWARENESS OF RESOURCES, SERVICES, AND PROGRAMS TO ALLOW ELDERLY TO STAY IN THEIR HOMES LONGER.2024 CONTRIBUTIONS:1. CONTINUE TO SUPPORT AND PROMOTE THE BONE BUILDERS CLASS THAT IS OFFERED WEEKLY TO THIS POPULATION.2. CONTINUE TO SUPPORT AND PROMOTE ACCESS TO THE PRESCRIPTION ASSISTANCE PROGRAM AND OTHER MEDICATION PROGRAMS.3. CONTINUE TO WORK WITH PEMBINA COUNTY HEALTH COALITION TO PROVIDE AND DISTRIBUTE A RESOURCE GUIDE FOR PEMBINA COUNTY OF SERVICES OFFERED.4. COLLABORATE WITH NDSU, PEMBINA COUNTY MEALS AND TRANSPORTATION, SOCIAL SERVICES AND OFFERING SERVICES TO PROGRAMS SUCH AS QSP AND SENIOR MEALS.5. IN ADDITION, WE ALSO OFFER FREE COUNSELING DURING MEDICARE ENROLLMENT PERIOD.PRIORITY AREA: SMOKING AND TOBACCO USE:GOAL: INCREASE ACCESSIBILITY TO TREATMENT FOR QUITTING SMOKING AND USING TOBACCO.2024 CONTRIBUTIONS:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MEDICAL HEALTH PROVIDERS SERVICES AT CLINICARE AND SEEK ANY VIABLE OPPORTUNITIES TO EXPAND SERVICES AS AVAILABLE. CURRENTLY WE HAVE THREE STAFF TRAINED TO HELP PATIENTS WITH THIS.2. SUPPORT YOUTH AND ADULT TOBACCO FREE ACTIVITIES AND EDUCATION WITHIN OUR COMMUNITIES.3. CONTINUE TO OFFER AND PROMOTE SUPPORTIVE MEDICATIONS AND EDUCATION ON RISKS OF SMOKING, VAPING AND TOBACCO USE. 4. WE PARTICIPATE IN THE TEEN MAZE, WHICH SUPPORTS AND EDUCATES ALL CHILDREN IN OUR SERVICE AREA.OTHER NEEDS IDENTIFIED IN THE CHNA, BUT NOT ADDRESSED IN THIS IMPLEMENTATION PLAN:1. AVAILABILITY OF VISION CARE - PCMHA WOULD BE AN ACTIVE PARTICIPANT IN COMMUNITY EFFORTS TO HELP IN THIS SERVICE BUT HAVE EXHAUSTED SOLO EFFORTS THAT WERE CURRENTLY AVAILABLE.2. BULLYING/CYBERBULLYING - PCMHA WILL PROMOTE EDUCATION AND EFFORTS TOWARDS THIS ISSUE AND WILL CONTINUE TO SUPPORT EFFORTS MADE ON THIS ISSUE. WE OFFER EAP SERVICES TO BOTH EMPLOYEES AND FAMILIES.3. COST OF LONG-TERM/NURSING HOME CARE - PCMHA PROVIDES ONGOING FEEDBACK TO GOVERNMENT POLICYMAKERS AT THE STATE AND FEDERAL LEVEL AS THESE RATES ARE CALCULATED BY THEM FOR ALL INSTITUTIONS. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES OCCUR ON A REGULAR BASIS. HOSPITAL AND NURSING HOME SOCIAL WORK DESIGNEES ARE AVAILABLE TO ASSIST INDIVIDUALS WHO LACK HEALTH INSURANCE THROUGH PROGRAMS OFFERED AND OUR FINANCIAL ASSISTANCE PROGRAM. WE HAVE STAFF TRAINED TO HELP FILL OUT PAPERWORK FOR NORTH DAKOTA MEDICAID.4. HAVING ENOUGH AFFORDABLE HOUSING - PCMHA IS PARTICIPATING WITH COMMUNITY LED EFFORTS TO DEVELOP MORE AFFORDABLE HOUSING WITHIN ITS SERVICE AREA. PCMHA IS A STEERING COMMITTEE PARTICIPANT IN A REGIONAL HOUSING STUDY. 3 1 - CLINICARE 301 MOUNTAIN STREET EAST CAVALIER ND 58220 RURAL HEALTH CLINIC 2 - WEDGEWOOD MANOR 804 MAIN STREET WEST CAVALIER ND 58220 SKILLED NURSING HOME 3 - COUNTRY ESTATES 107 BJORNSON DRIVE CAVALIER ND 58220 CONGREGATE HOUSING PART I, LINE 3C: IN ADDITION TO LOOKING AT THE FEDERAL POVERTY GUIDELINES, OTHER FACTORS, SUCH AS THE PATIENT'S FINANCIAL STATUS AND/OR ABILITY TO PAY ARE CONSIDERED. PART I, LINE 7: THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7A AND 7B WERE CALCULATED USING THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS FORM 990 INSTRUCTIONS. THE COMMUNITY BENEFIT AMOUNTS REPORTED ON LINES 7E-7I WERE THE DIRECT COSTS TO THE HOSPITAL. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED ON LINE 7G INCLUDE THE FOLLOWING DEPARTMENTS OF THE HOSPITAL THAT HAVE A COST TO CHARGE RATIO GREATER THAN 1 AS IDENTIFIED ON THE MEDICARE COST REPORT. THESE INCLUDE ADULTS AND PEDIATRICS, SKILLED NURSING FACILITY, AND EMERGENCY ROOM. PART II, COMMUNITY BUILDING ACTIVITIES: PCMH PARTICIPATES IN THE COMMUNITY HEALTH NEEDS ASSESSMENT EVERY 3 YEARS AND USE THIS TOOL TO FOCUS ON NEEDS IDENTIFIED BY THE COMMUNITIES WE SERVE. IN RESPONSE TO THE NEEDS IDENTIFIED, WE PROVIDE VARIOUS EDUCATION AND SHARE VALUABLE KNOWLEDGE FROM OUR PROVIDERS WITH THE COMMUNITY THRU OUTREACH PROGRAMS. IN ADDITION, WE MAKE SURE WE ESTABLISH PARTNERSHIPS WITH OTHER HEALTH FOCUSED GROUPS SUCH AS PEMBINA COUNTY PUBLIC HEALTH TO COLLABORATE AND EFFECTIVELY SHARE OUR MISSION TO DELIVER QUALITY HEALTH SERVICES. PART III, LINE 2: IN CALCULATING BAD DEBT EXPENSE, THE ORGANIZATION ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE PROVISION FOR BAD DEBTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES A PROVISION FOR BAD DEBTS, IF NECESSARY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS, THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE. PART III, LINE 3: 7.6% OF THE INDIVIDUALS IN PEMBINA COUNTY FALL BELOW THE FEDERAL POVERTY LEVELS ACCORDING TO THE 2023 CENSUS DATA. CARE IS GIVEN TO INDIVIDUALS REGARDLESS OF THEIR ABILITY TO PAY AND IF THE INDIVIDUAL'S FAMILY SIZE AND INCOME ARE BELOW THE FEDERAL POVERTY GUIDELINES THEN THEY WOULD BE ELIGIBLE FOR 100% CHARITY CARE ALLOWANCE. THEREFORE THE ORGANIZATION ESTIMATES THAT 7.6% OF THE BAD DEBT EXPENSE IS ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THIS IS A COMMUNITY BENEFIT AND A REASONABLE ESTIMATE BASED ON THE DEMOGRAPHICS OF THE AREA THE ORGANIZATION SERVES. PART III, LINE 4: SEE THE "PATIENT RECEIVABLES AND ALLOWANCE FOR CREDIT LOSSES NOTE 1 ON PAGE 8 OF THE ATTACHED FINANCIAL STATEMENTS FOR INFORMATION REGARDING THE ORGANIZATION'S BAD DEBT EXPENSE. PART III, LINE 8: ALL OF THE MEDICARE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT. THE ORGANIZATION TREATS INDIVIDUALS REGARDLESS OF ABILITY TO PAY. MOST OF THE MEDICARE SHORTFALL COMES FROM THE NURSING HOME. THE ELDERLY ARE AN UNDERSERVED POPULATION AND IT IS A COMMUNITY BENEFIT TO BE ABLE TO TREAT THEM AT THE LOCAL NURSING HOME.MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES. PART III, LINE 9B: IF AN INDIVIDUAL SUBMITS A FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL CEASE ALL COLLECTION EFFORTS UNTIL A DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY IS MADE.IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL SUBMITS A COMPLETE FINANCIAL ASSISTANCE APPLICATION, THE EXTRAORDINARY COLLECTION ACTION WILL BE SUSPENDED. SUSPENDING AN ACTION MEANS THAT NO FURTHER STEPS ARE TAKEN ON THAT EXTRAORDINARY COLLECTION ACTION AND NO NEW EXTRAORDINARY COLLECTION ACTIONS ARE INITIATED. THIS SUSPENSION MAY BE LIFTED WHEN HOSPITAL DETERMINES THE INDIVIDUAL'S ELIGIBILITY FOR FINANCIAL ASSISTANCE AND NOTIFIES THE INDIVIDUAL AS PRESCRIBED IN THE FINANCIAL ASSISTANCE POLICY. IF HOSPITAL OR ANOTHER AUTHORIZED PARTY HAS ALREADY BEGUN AN EXTRAORDINARY COLLECTION ACTION AGAINST AN INDIVIDUAL WHEN THAT INDIVIDUAL IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, HOSPITAL AND/OR THE OTHER AUTHORIZED PARTY WILL TAKE ALL REASONABLY AVAILABLE MEASURES TO REVERSE THE EXTRAORDINARY COLLECTION ACTION. IF AN INDIVIDUAL SUBMITS AN INCOMPLETE FINANCIAL ASSISTANCE APPLICATION, HOSPITAL SHALL TAKE THE FOLLOWING STEPS TO ENCOURAGE THEM TO COMPLETE THE APPLICATION.1. SUSPEND ANY EXTRAORDINARY COLLECTION ACTIONS TO OBTAIN PAYMENT FOR THE CARE. 2. PROVIDE A WRITTEN NOTICE TO THE RESPONSIBLE PARTY THAT INCLUDES THE FOLLOWING INFORMATION. A. THE ADDITIONAL INFORMATION AND/OR DOCUMENTATION THAT MUST BE SUBMITTED. B. THE PHYSICAL LOCATION AND PHONE NUMBER OF A HOSPITAL EMPLOYEE OR DEPARTMENT THAT CAN PROVIDE INFORMATION ABOUT THE FINANCIAL ASSISTANCE POLICY. C. THE PHYSICAL LOCATION AND PHONE NUMBER OF AN ORGANIZATION OR HOSPITAL EMPLOYEE/OFFICE/DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FINANCIAL ASSISTANCE APPLICATION PROCESS. 3. ALLOW A REASONABLE AMOUNT OF TIME FOR THE RESPONSIBLE PARTY TO SUBMIT A COMPLETE FINANCIAL ASSISTANCE APPLICATION. SUCH PERIOD OF TIME SHALL BE AT LEAST 30 DAYS FROM THE DATE THE WRITTEN NOTICE IS SENT TO THE RESPONSIBLE PARTY. IF THE RESPONSIBLE PARTY FAILS TO PROVIDE THE REQUESTED INFORMATION WITHIN THE STATED TIME, HOSPITAL MAY RENEW THE PREVIOUSLY INITIATED EXTRAORDINARY COLLECTION ACTIONS. IF AN INDIVIDUAL HAS MADE FULL OR PARTIAL PAYMENT, AND THE INDIVIDUAL IS SUBSEQUENTLY DETERMINED TO QUALIFY FOR FINANCIAL ASSISTANCE, ANY PAYMENTS IN EXCESS OF THEIR NEWLY CALCULATED REMAINING LIABILITY WILL BE REFUNDED TO THE PATIENT WITHIN 30 DAYS OF THE FINANCIAL ASSISTANCE ELIGIBILITY DETERMINATION. IF THE REFUNDABLE AMOUNT IS LESS THAN $1.00, IT WILL NOT BE REFUNDED. PART VI, LINE 2: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION ASSESSES THE COMMUNITY'S HEALTH NEEDS AS FOLLOWS:1. REPRESENTATION ON THE COUNTY WIDE EMERGENCY SERVICES BOARD. 2. REPRESENTATION ON THE DOMESTIC VIOLENCE BOARD. 3. CONTINUED MEETINGS WITH PUBLIC HEALTH AND OTHER COMMUNITY REPRESENTATIVES REGARDING MENTAL HEALTH ISSUES. PART VI, LINE 3: NOTICES OF THE FAP ARE POSTED IN ALL WAITING AREAS, REGISTRATION AREAS, AND UPON DISCHARGE. WE PARTICIPATE IN THE HOSPITAL PRESUMPTIVE ELIGIBILITY (HPE) PROGRAM WHICH ALLOWS US TO ASSIST PATIENTS WITH IMMEDIATE ACCESS TO TEMPORARY ENROLLMENT IN MEDICAID WHILE APPLYING FOR PERMANENT COVERAGE. PART VI, LINE 4: PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS COMPRISED OF A 20-BED CRITICAL ACCESS HOSPITAL, 38-BED NURSING HOME (WEDGEWOOD MANOR), A 20-UNIT CONGREGATE HOUSING PROJECT (COUNTRY ESTATES), AND RURAL HEALTH CLINIC LOCATED IN CAVALIER, NORTH DAKOTA.OUR ORGANIZATION SERVES PEMBINA COUNTY AND THE SURROUNDING REGION (THE NORTH EAST CORNER OF NORTH DAKOTA). EXTRAPOLATED U.S. CENSUS DATA FOR 2023, BASED ON THE 2020 U.S. CENSUS, SHOWED A POPULATION OF 6,787 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $66,884. THE PER CAPITA INCOME FOR THE COUNTY WAS $41,314. 8.7% OF THE POPULATION IS BELOW THE POVERTY LINE. WE ARE CONSIDERED A RURAL AREA; AGRICULTURE IS OUR MAIN INDUSTRY. WE ARE THE ONLY HOSPITAL IN PEMBINA COUNTY; CAVALIER AND WALSH COUNTIES (NEIGHBORING COUNTIES) ALSO HAVE MEDICAL FACILITIES. PART VI, LINE 5: THE MISSION OF PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) IS TO PROVIDE A FAMILY CENTERED APPROACH TO THE DELIVERY OF HEALTH SERVICES AND TO PROMOTE A HEALTHY LIFESTYLE FOR THOSE WE SERVE. OUR KEY LEADERS AND VOLUNTEER BOARD MEMBERS ARE RESIDENTS WHO LIVE WITHIN THE AREAS WE SERVE. IN A RURAL SETTING, IT IS CRUCIAL TO BE INVOLVED IN THE HEALTH OF OUR COMMUNITY, SO PCMHA SUPPORTS AND PARTICIPATES IN INITIATIVES TO EDUCATE OUR COMMUNITY AT EVERY OPPORTUNITY. NOT ONLY DO WE PROMOTE HEALTHY LIFESTYLES AND EDUCATION ON TOPICS SUCH AS DIABETES, CARDIAC HEALTH, MENTAL/BEHAVIORAL HEALTH, AND BREASTFEEDING SUPPORT CLASSES WE ALSO PARTICIPATE IN SCRUBS CAMP TO EMPHASIZE THE IMPORTANCE OF VARIOUS HEALTHCARE PROFESSIONS TO OUR YOUTH TO ENCOURAGE AND PROMOTE INTEREST IN THE FIELDS OF MEDICINE. X X 0 0 0 0 0 0 0 0 0 SUSAN THOMPSON MEDICAL STAFF PRESIDENT 218414 0 0 0 0 0 1038 0 36102 0 255554 0 0 0 LISA LETEXIER CEO 212022 0 0 0 0 0 8650 0 8134 0 228806 0 0 0 LAURA ERMER PHYSCIANS ASSISTANT 186734 0 0 0 0 0 6922 0 2311 0 195967 0 0 0 KIM FORD NURSE PRACTITIONER 179514 0 0 0 0 0 0 0 11629 0 191143 0 0 0 JENNA CARPENTER NURSE PRACTITIONER 179520 0 0 0 0 0 7199 0 2280 0 188999 0 0 0 JANAE HEUCHERT PHARMACIST 129796 0 0 0 0 0 6160 0 45798 0 181754 0 0 0 MICHAEL BITTLES MD 183333 0 0 0 0 0 0 0 0 0 183333 0 0 0 PATTI JOHNSON NURSING HOME ADMINISTRATOR 127591 0 0 0 0 0 5411 0 24948 0 157950 0 0 0 PARK RIVER CLINIC PARK RIVER CLINIC IS OWNED BY DR. KULVINDER SUMRA, A FORMER BOARD MEMBER 622070 PAYMENT FOR DR. SUMRA'S PHYSICIAN SERVICES 0 FORM 990, PART VI, SECTION A, LINE 1A THE EXECUTIVE COMMITTEE IS MADE UP OF THE PRESIDENT, VICE PRESIDENT, AND SECRETARY/TREASURER. THIS COMMITTEE SHALL HAVE THE FOLLOWING DUTIES AND DELEGATED RESPONSIBILITIES, SUBJECT TO ANY PRIOR LIMITATIONS IMPOSED BY THE BOARD OF DIRECTORS: A) MEET AS NEEDED BETWEEN SCHEDULED BOARD MEETINGS AND TAKE ACTION AS REQUIRED ON BEHALF OF THE BOARD WHEN IT IS NOT FEASIBLE TO BRING THE FULL BOARD TOGETHER IN TIME TO ADDRESS AN ISSUE. ALL SUCH ACTIONS SHALL BE REPORTED TO THE BOARD AT THE NEXT REGULARLY SCHEDULED BOARD MEETING. B) MEET ON AN ANNUAL BASIS AND RECOMMEND TO THE BOARD APPROPRIATE COMPENSATION FOR THE ADMINISTRATOR/CHIEF EXECUTIVE OFFICER (CEO). C) REVIEW AT LEAST ANNUALLY AND MAKE RECOMMENDATIONS TO THE BOARD CONCERNING ANY NECESSARY CHANGES TO THESE BYLAWS. D) EVALUATE THE PERFORMANCE OF THE BOARD ON AN ANNUAL BASIS. E) PERFORM SUCH OTHER DUTIES AND RESPONSIBILITIES AS MAY BE ASSIGNED BY THE BOARD OF DIRECTORS TO THE COMMITTEE FROM TIME TO TIME. FORM 990, PART VI, SECTION A, LINE 6 ANY COMMUNITY MEMBER OR EMPLOYEE MAY PURCHASE STOCK WHICH GIVES THEM A VOTING RIGHT AT THE ANNUAL MEETING. THE CORPORATION SHALL ALWAYS MEET THE IRS COMMUNITY BOARD REQUIREMENTS FOR EXEMPTION FROM INCOME TAXATION - THE COMMUNITY BOARD IS ONE IN WHICH INDEPENDENT PERSONS REPRESENTATIVE OF THE COMMUNITY COMPRISE A MAJORITY. NO EMPLOYEE OF THE CORPORATION, EXCEPT FOR MEMBERS MAINTAINING ACTIVE MEDICAL STAFF PRIVILEGES OF THE CORPORATION, SHALL BE ELIGIBLE FOR MEMBERSHIP ON THE BOARD BECAUSE OF THE PERCEIVED CONFLICT OF INTEREST. A MAJORITY OF THE BOARD SHALL CONSIST OF INDEPENDENT DIRECTORS. ONE (1) MEMBER OF THE BOARD SHALL BE AN EX-OFFICIO MEMBER APPOINTED BY ALTRU HEALTH SYSTEM FOR THE TERMS OF THE ALTRU/PCMHA AFFILIATION AGREEMENT. FORM 990, PART VI, SECTION A, LINE 7A ALL STOCKHOLDERS MAY VOTE AT THE ANNUAL MEETING WHEN BOARD MEMBERSHIP IS RENEWED AND NOMINATIONS ARE TAKEN. FORM 990, PART VI, SECTION B, LINE 11B A COMPLETE COPY OF THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS VIA EMAIL FOR THEIR REVIEW PRIOR TO MEETING APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C THE PROCESS OF DISCLOSING THE CONFLICT OF INTEREST IS GONE THROUGH ANNUALLY. EACH BOARD MEMBER COMPLETES A FORM AND DISCLOSES IF THEY HAVE A CONFLICT OF INTEREST. THE CEO AND BOARD PRESIDENT REVIEW THE DISCLOSURE FORMS AND IF A CONFLICT RAISES AN ISSUE, IT IS BROUGHT TO THE FULL BOARD FOR DISCUSSION ON FURTHER ACTION (IF NECESSARY), WHICH MAY RESULT IN A CONSULTATION WITH AN ATTORNEY. IF THE BOARD IS VOTING ON AN ISSUE WHERE THERE IS A CONFLICT OF INTEREST, THE PERSON WITH THE CONFLICT OF INTEREST IS ASKED TO ABSTAIN FROM THE VOTE. FORM 990, PART VI, SECTION B, LINE 15 THE CEO'S COMPENSATION IS REVIEWED ANNUALLY BY THE BOARD OF DIRECTORS. COMPARATIVE DATA IS GATHERED FROM THE ND HOSPITAL ASSOCIATION'S WAGE SURVEYS. A BLUE FORM IS GIVEN TO HR INDICATING ANY SALARY DECISIONS. THE CFO'S COMPENSATION IS REVIEWED ANNUALLY BY THE CEO. CHANGES TO THE CFO'S SALARY MAY BE BASED ON NORTH DAKOTA HOSPITAL ASSOCIATION SURVEYS OR OTHER INDUSTRY SURVEYS AND ALSO BUDGET APPROVAL BY THE BOARD OF DIRECTORS. FOR OTHERS, THE BOARD IS NOT INVOLVED IN THE FINAL COMPENSATION DECISION, BUT INSTEAD THE CEO AND CFO MAKE THE FINAL COMPENSATION DECISION. THE PROCESS DESCRIBED HERE WAS LAST COMPLETED IN 2024. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES: PROGRAM SERVICE EXPENSES 4,905,558. MANAGEMENT AND GENERAL EXPENSES 147,702. FUNDRAISING EXPENSES 2,642. TOTAL EXPENSES 5,055,902.