2025-07-24T14:18:52-05:00 2025-03-31 450250958 Eide Bailly LLP 4585 Coleman St Ste 200 Bismarck ND 58503 990 2024-04-01 450226419 Good Samaritan Hospital Association GOOD 7017765261 2975 Hwy 2 E Rugby ND 583687801 Melissa Shepard CFO 7017765261 2025-07-24 1 1 Lisa Chaffee CPA P00193453 7012551091 2025-07-24 2024 2025-03-06 01:10:19Z X Heart of America Medical Center Erik Christenson 2975 Hwy 2 E Rugby ND 583687801 36636821 0 X www.hamc.com X 1905 ND Provide quality medical care based on the needs and demographics of north central North Dakota. 9 9 344 28 0 0 1725570 3696066 31217303 32471108 437575 156320 65120 53040 33445568 36376534 0 0 0 0 18634921 18957118 0 0 0 12685255 16399234 31320176 35356352 2125392 1020182 71154311 87485667 40090165 59065303 31064146 28420364 X To deliver compassionate care by advancing the physical and spiritual well-being of the communities we serve through smart medicine and exceptional service. 0 0 31382368 32471108 Good Samaritan Hospital Association (GSHA) is a nonprofit healthcare organization owned by 20 local churches representing all Christian denominations in the area. Each year, these churches elect a board of trustees at an annual meeting, and this board serves as the legal governing body responsible for the Association. GSHA is dedicated to providing comprehensive healthcare services to the community of Rugby, ND, and its surrounding areas.GSHA operates a 25-bed licensed acute/swing bed critical access hospital, three rural health clinics (located in Rugby, Dunseith, and Maddock), a surgery department, a provider-based surgical clinic and (Continued on Schedule O)pain clinic, 18 skilled nursing home beds, 60 basic care beds, and 37 assisted living apartments. Additionally, we offer a robust hospital-based hospice program, serving the community with compassionate end-of-life care.In response to the current economic challenges and the lingering effects of COVID-19, we have seen an increase in the need for charity care. To address this, GSHA provided an estimated $322,000 in charity care services for the year ending March 31, 2024 (calculated by multiplying the ratio of costs to gross charges for the Organization by the gross uncompensated charges associated with providing charity care to its patients). Our CEO has actively engaged the community through numerous health updates on the radio, educating the public about new initiatives and changes from CMS.GSHA offered a variety of community-focused programs and services to improve health outcomes, promote wellness, and support underserved populations. These programs included:-Free or reduced-fee flu shot clinics-Diabetic education and chronic care management programs-Participation in health fairs and community events-Health education outreach, including radio updates from the CEO, school presentations, senior meal support through Meals on Wheels, and public forums-Volunteer ambulance services and EMT training courses-Free blood pressure screenings and wellness/physical therapy programs-Meeting space for local groups and churches-CPR and first aid training for the communityGSHA also maintains strong partnerships with CNA, LPN, and RN training programs, supporting clinical rotations, internships, and career pathways for future healthcare professionals through a regional healthcare education consortium. Our Diabetes Education program offers various nutrition classes focused on maintaining and controlling diabetes. Through our 340b program, patients can request free test strips from our DME department, ensuring they have the necessary supplies for effective diabetes management. Furthermore, we host a monthly diabetes support group to assist patients and their families in managing the condition through shared experiences and expert advice.The Ambulance Service is operated by GSHA after the community was unable to sustain it as a volunteer service. We staff the ambulance 24/7, respond to all 911 calls in our area, and provide community services such as home blood draws for those unable to make it to the hospital. The operation of the ambulance service is subsidized through a mill levy and a state grant. 31382368 1 1 0 1 0 0 0 0 1 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 0 1 38 0 1 344 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X Melissa Shepard 7017765261 2975 Hwy 2 E Rugby ND 583687801 Wayne Trottier President 1.00 0.00 X X 0 0 0 Michael Graner Vice Chair 1.00 0.00 X X 0 0 0 Craig Zachmeier Trustee 1.00 0.00 X 0 0 0 Kolin Johnson Trustee 1.00 0.00 X 0 0 0 Kim Bott Trustee 1.00 0.00 X 0 0 0 Tanner Johnson Trustee 1.00 1.00 X 0 0 0 Will Griffin Trustee 1.00 0.00 X 0 0 0 Travis Maddock Trustee 1.00 0.00 X 0 0 0 Lisa Thorp Trustee 1.00 0.00 X 0 0 0 Erik Christenson Secretary - CEO 59.00 1.00 X 176857 0 49870 Melissa Shepard Treasurer - CFO 59.00 1.00 X 139470 0 19980 Dustin Hager COO & Provider 40.00 0.00 X 211059 0 47170 Ronald Skipper MD ER Provider 40.00 0.00 X 391460 0 52009 Cammy Kelsch FNP-C ER Provider 65.00 0.00 X 274968 0 50880 Josalynne Hoff Rue MD Physician 40.00 0.00 X 310958 0 51887 Chelsey Wyatt CRNA 40.00 0.00 X 309461 0 46778 Bobbi Burchinal Family NP 66.50 0.00 X 232328 0 51400 2046561 0 369974 18 0 1 0 Envision Co-operative 2819 Hwy 2 W Rugby ND 58368 Fuel & service new building 181251 Eide Bailly LLP PO Box 2545 Fargo ND 58108 Audit and Professional Services 176032 Jerry Turner 15739 W Hwy 2770 Stone Lake WI 54876 Project Manager 149876 Rural Surgical Solutions PLLC PO Box 393 Velva ND 58790 Surgeon contracted 102500 4 1489672 1663785 542609 3696066 Patient Service Revenue 621400 29330017 29330017 Pharmacy Revenue 456110 2270662 2270662 Daycare Services 812900 259623 259623 Cafeteria Revenue 722514 249345 249345 361461 361461 32471108 416607 416607 53040 0 53040 53040 53040 260287 -260287 -260287 -260287 36376534 32471108 0 209360 X 649247 198223 451024 231228 231228 14305020 12798260 1506760 488278 436891 51387 2235235 1998230 237005 1048110 916019 132091 71404 71404 12147 12147 3559937 2990605 569332 37219 37219 359986 198069 161917 32181 32181 1376220 1262093 114127 78967 62181 16786 120022 58561 61461 1536978 1536978 3211558 3102409 109149 343996 343996 Medical Supplies 4523864 4523864 Repairs & Maintenance 508307 496860 11447 Food 401994 401994 Dues and Subscriptions 49682 2089 47593 174772 167814 6958 35356352 31382368 3973984 0 8398455 11039707 3164270 3417191 201683 257436 334709 124523 73255340 11285326 45707932 61970014 1695356 2043662 177248 219956 11474658 8413178 71154311 87485667 7847988 3150432 250000 17269 17701 31289626 55138056 935282 509114 40090165 59065303 X 25774368 27887131 5289778 533233 31064146 28420364 71154311 87485667 X 1020182 8513 -3672477 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 1496 0 0 0 1496 0 Part II-B, Line 1: GSHA engages in lobbying through its membership dues to the American Hospital Association (AHA), the North Dakota Hospital Association (NDHA), and the North Dakota Long Term Care Association (NDLTCA). These organizations advocate for their members by supporting legislation that aligns with their collective interests. They strive to ensure that laws and regulations are fair and equitable, enabling healthcare facilities to provide affordable, high-quality care, especially in rural areas. 1 89711 45846 29914 105643 1 X 417447 417447 59774291 6262732 53511559 13012522 5022594 7989928 51080 51080 61970014 Beneficial Interest in Assets Held by Others 1252364 Insurance Receivable 500000 Employee Retention Credit Receivable 5707922 Operating Lease 20592 Third Party Settlements 932300 8413178 Insurance Payable 500000 Related Party 248 Operating Lease Liability 8866 509114 X 32682656 8513 -3656545 -3648032 36330688 45846 45846 36376534 35326438 0 35326438 29914 29914 35356352 Part IV, Line 1b: The Auxiliary, managed by volunteers under the Good Samaritan Hospital Association, is dedicated to supporting patients and residents. This volunteer organization maintains the funds, which are allocated for various activities, including the operation of a gift shop. A governing Board oversees the distribution of these funds to ensure they are used effectively. Part IV, Line 2b: The Organization acts as custodian for the funds of the nursing facility residents and Haaland Estates residents. The residents utilize these funds for recipient liability, hair care, or other expenses as they are needed. Part X, Line 2: The Organization believes that 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. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Change in interest in net assets of Foundation -3,656,545. Part XI, Line 4b - Other Adjustments: Auxillary Revenue 45,846. Part XII, Line 4b - Other Adjustments: Auxillary Expenses 29,914. 1 1 X 1 X 1 X 1 1 0 0 322000 322000 0.00910 4033057 3857465 175592 0.00500 4355057 3857465 497592 0.01410 34480 34480 0.00100 6422104 4310622 2111482 0.05970 6456584 4310622 2145962 0.06070 10811641 8168087 2643554 0.07480 1 826005 206501 9221849 9288322 -66473 X 1 1 1 1 Heart of America Medical Center 2975 Hwy 2 E Rugby ND 583687801 www.hamc.com 5046 X X X X 3 Provider based clinics Heart of America Medical Center 1 0 0 1 X X X X X X X X X 24 1 0 1 1 X https://www.hamc.com/CHNA/ X See Part V, Page 8 X 1 24 1 https://www.hamc.com/CHNA/ 0 1 X 200.000000000000 300.000000000000 1 1 X X X X X 1 X https://www.hamc.com/patient-forms#CCP X https://www.hamc.com/patient-forms#CCP X https://www.hamc.com/patient-forms#CCP X X X X X X 1 X 0 X X X X 1 X 0 0 Heart of America Medical Center Part V, Section B, Line 5: In conducting its most recent Community Health Needs Assessment (CHNA), the hospital facility, Heart of America Medical Center, ensured input was gathered from individuals and organizations that represent the broad interests of the community it serves. The CHNA was completed with the assistance of the Center for Rural Health at the University of North Dakota (CRH), utilizing a comprehensive approach that included interviews, community focus groups, and surveys to collect both qualitative and quantitative data.The CHNA process actively involved:-Local and regional public health entities, including participation from public health professionals with knowledge of the health needs of the community.-Individuals representing medically underserved, low-income, and minority populations, as well as organizations serving or advocating for those populations.-Community members across multiple counties, ensuring geographic and demographic diversity.The service area covered in the CHNA included Pierce, Rolette, Benson, McHenry, Bottineau, Towner, Wells, and Sheridan counties, encompassing both rural and frontier populations.This inclusive process ensured that community health priorities were informed by those most impacted and those with direct knowledge of local needs and challenges. Additionally, community input and feedback helped shape the hospital's implementation strategy to address the identified needs effectively. Heart of America Medical Center Part V, Section B, Line 6b: Lake Region District Health Unit & UND Center for Rural Health Heart of America Medical Center Part V, Section B, Line 11: In our most recent Community Health Needs Assessment (CHNA), the following key community health and wellbeing needs were identified:1. The ability to retain primary care providers (MDs, DOs, NPs, and PAs)2. Attracting and retaining young families to the community3. Availability of resources to help elderly residents remain in their homes4. Availability of vision care services5. Lack of affordable housingOur organization has determined that we will not directly address the following two needs:-Availability of vision care: Vision services are not reimbursed under hospital-based billing structures and are outside the hospital's scope of direct care. However, we have supported efforts to recruit optometrists and ophthalmologists to the region through professional networking and community relationship-building.-Affordable housing: While affordable housing is a significant barrier to workforce recruitment and retention, it is outside the scope of our facility's operational capabilities, as we are not a property development entity. That said, we continue to engage with local stakeholders and advocate for housing solutions by raising awareness of how the housing shortage impacts healthcare staffing and long-term community stability.A new CHNA was completed during the current tax year. Due to the timing of completion, implementation planning is underway and full execution will begin in the next fiscal cycle. However, the following actions were taken to continue addressing the needs identified in the prior CHNA:1. Retention of Primary Care Providers:The facility has successfully recruited and onboarded multiple Advanced Practice Providers (NPs and PAs) to expand access to primary care. We have also contracted with surgical providers, including general surgeons and CRNAs, who offer essential pain management services to meet the needs of our patient population.2. Attracting and Retaining Young Families:The opening of our new hospital facility, with its modern design and enhanced clinical capabilities, has played a key role in attracting new staff and young professionals to the area. We continue to promote a positive organizational culture and professional development opportunities to support retention.3. Supporting Elderly Residents to Remain in Their Homes:We continue to collaborate with community partners such as public health, home health, and senior services organizations such as Senior Meals on Wheels to ensure elderly individuals have access to in-home support and resources. Our care coordination and discharge planning teams actively refer patients to appropriate services that enable aging in place. Heart of America Medical Center Part V, Section B, Line 15e: As part of the application process the patient will provide name, demographic information, occupation, employer, spouses demographic information, dependent information, and insurance information. Documentation that may be required to assist with processing of application to include pay stubs, itemized income and expenses, verification from welfare agency, verification from unemployment or workers compensation, or income tax returns as supporting documentation. Part V, Line 7b: Other Website:https://ruralhealth.und.edu/projects/community-health-needs-assessment/reports 4 1 - Heart of America Nursing Facility 2975 Hwy 2 E Rugby ND 58368 Long-term Skilled Care Nursing Facility 2 - Heart of America Hospice 1025 3rd Ave SE Rugby ND 58368 Hospice care 3 - Haaland Estates Basic Care 1025 3rd Ave SE Rugby ND 58368 Basic Care Nursing Facility 4 - Haaland Estates Assisted Living 1025 3rd Ave SE Rugby ND 58368 Assisted Living Facility Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Community Health Improvement Services, line 7e, reflects actual expenses recorded to the general ledger. Medicaid, line 7b, and Subsidized health services, line 7g, were calculated based on information from the Cost Report. Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concession based on its historical collection experience with this class of patients. Part III, Line 3: The Organization estimated the implicit price concessions attributable to patients who likely would qualify for financial assistance by applying the percentage of financial assistance applications sent out but not received back or not completed. Part III, Line 4: The footnote to the Organization's financial statements related to implicit price concessions can be found on page 14-15 of the attached audited financial statements. Part III, Line 8: Hospital services reimbursed on a fee schedule are not included in the Medicare calculation per the 990 instructions. Had this been reported the Hospital would have had a greater loss from Medicare services of $726,813.$358,891 - Medicare fee schedule revenue(1,085,705) - Medicare estimated costs of care relating to payments (726,813) - Net (shortage)Medicare allowable costs were obtained from the Medicare Cost Report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.Good Samaritan Hospital Association is a critical access hospital and is reporting a Medicare shortfall due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit. Part III, Line 9b: Our accounts are worked effectively and thoroughly with self-pay statements printed monthly once insurances have met their obligations. The goal is to obtain payment in full, establish acceptable payment arrangements, and 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 third party collection company also offers charity care during collection calls. The statements explain who to call for a charity care application. Our charity program is income based and patients have 120 days to submit a financial assistance application, and uses 200% of the Federal poverty guidelines. If they qualify, the bill is written off 100% to charity care. Once approved they qualify for assistance for 6 months before and 6 months after of the approval date. After 120 days in collections, the account is written to bad debt. At least 30 days before we take extraordinary collection action we send notification. Up to 240 days we accept applications and stop collection actions and reverse the collection effort. Part VI, Line 2: Heart of America Medical Center (HAMC) and its associated facilities proudly serve a close-knit community where healthcare providers personally know their patients. GSHA board members, who reside in these communities, are tasked with bringing back community concerns to ensure that the needs of the community are prioritized. We also greatly value the insights and feedback provided by the HAMC Auxiliary Board, as well as the dedicated efforts of dozens of volunteers who collectively contribute thousands of hours to our hospital and long-term care facilities. Part VI, Line 3: Good Samaritan Hospital Association, operating as Heart of America Medical Center, is dedicated to providing medical care regardless of a patient's financial situation. We offer comprehensive information about federal, state, and local payment assistance programs before services are rendered, or in emergency situations, as soon as it is appropriate.Our HAMC Community (Charity) Care program is available for inpatient and outpatient hospital services, clinic services, and swing bed care. Social work staff are on hand to provide patients with information about this program, which is also accessible on our website along with details about our Prompt Payment Discount program.Staff members who handle self-pay bills actively encourage patients to apply for Community Care, and our third-party collection company supports this effort by advising patients experiencing financial hardships to seek assistance through Community Care. Part VI, Line 4: Good Samaritan Hospital Association, operating as Heart of America Medical Center (HAMC), serves a largely rural population centered in Rugby, North Dakota, and spanning a 50-mile radius. The primary geographic service area includes Pierce County and portions of Rolette, Benson, McHenry, Bottineau, Towner, Wells, and Sheridan counties in north-central North Dakota. This area is designated as medically underserved and faces challenges common to rural communities, including geographic isolation, workforce shortages, and limited access to specialty care.The total population served is estimated at over 13,000 residents, based on the 2025 Community Health Needs Assessment (CHNA). Pierce County, where HAMC is located, has experienced a population decline of approximately 2.4% between 2020 and 2023, with 23.9% of residents aged 65 and older, reflecting a growing elderly population with increased healthcare needs. The median household income in Pierce County is significantly below the state average, and approximately 11.6% of residents live below the poverty line. Racially, the population is predominantly White/Caucasian, though the service area also includes members of Native American communities, particularly in Rolette County.The population served by HAMC includes a high percentage of elderly individuals, working families, and lower-income residents. Major employers in the region include Heart of America Medical Center, Rugby Public Schools, and Rugby Manufacturing. The facility is the largest employer in the county, with around 300 staff, and plays a vital role not only in healthcare delivery but also in supporting the regional economy.The region's rural characteristics and socio-economic profile require a broad, community-focused approach to healthcare, and HAMC remains committed to addressing these needs through compassionate, patient-centered services. Part VI, Line 5: Good Samaritan Hospital Association (GSHA) is supported by 14 member churches spread throughout our service area and represent a diverse range of people. The GSHA board of directors, who live in our primary service area and are engaged in various professions and activities, are elected by these member churches. This board serves as the legal governing body of the non-profit organization and is responsible for ensuring that GSHA fulfills its mission to provide comprehensive, compassionate healthcare services to the community. Through the Heart of America Johnson Clinics, Heart of America Medical Center serves Rugby, Dunseith, and Maddock, ND, ensuring our patients receive healthcare services close to home. We offer specialty services in ophthalmology, podiatry, audiology, and mental health through partnerships with specialty clinics and providers. Additionally, we provide a shared OB service with Trinity, allowing patients to see their primary care provider for up to 30 weeks.Our state-of-the-art cancer treatment center features a chemotherapy suite, and we recently added life-saving 3D mammography equipment to our radiology department. Heart of America Hospice delivers personalized, holistic end-of-life care and services to local hospice patients and their families within a 60-mile radius of Rugby.Without GSHA, our community would lack essential services such as a hospital, 24-hour emergency room, rural health clinics, surgical clinic, skilled nursing care facility, basic care facility, assisted living facility, and a wellness/fitness center. We operate many of these programs at a loss, yet we continue to provide them to meet the needs of the people in our communities and service area.Providers applying to HAMC are granted privileges in our community once approved by the board of directors, as recommended by the medical staff during board meetings.To plan for our organization's future and ensure our community is prepared for ongoing changes in the healthcare model, we are committed to improving patient care facilities and upgrading medical equipment.As discussed above, GSHA offers comprehensive cancer treatments to our patients and communities, allowing them to stay closer to home during times of vulnerability. GSHA also operates a fully staffed ambulance department, addressing the community's need for emergency medical transport. Despite not being a cost-reimbursed service due to the proximity of other ambulance services in neighboring rural areas, our ambulance department fills a critical gap, responding to the communities need via ambulance runs and emergency (911) calls and conducting transfers to tertiary facilities annually.To recruit and retain staff, GSHA participates in an education reimbursement program, which also attracts new families to Rugby. Additionally, GSHA provides a daycare fringe benefit, enabling parents to return to the workforce or remain employed after starting families, with the convenience of onsite daycare services.While being a community-minded organization has led to some financial inefficiencies, our commitment to serving the community remains steadfast. As the largest employer in the community and region, GSHA feels the pressure to offer extensive services and support, striving to meet and exceed community needs. Part VI, Line 6: GSHA operates independently as a Critical Access Hospital. Despite not being part of an affiliated healthcare system, we maintain robust partnerships through rural health network agreements with Trinity Medical Center in Minot and Med Center One in Bismarck, N.D. These agreements are designed to enhance our patients' continuity of care by establishing efficient referral processes and facilitating easy transfers between facilities. They also promote effective communication among healthcare providers.Additionally, GSHA is affiliated with Altru's in Grand Forks and utilizes the Epic Electronic Health Record (EHR) system. We are actively participating in the BCBS ACO and a Medicare ACO, ensuring that our patients receive optimal and coordinated care. X X X X 0 0 0 0 0 0 0 0 0 Ronald Skipper MD ER Provider 391460 0 0 0 0 0 15428 0 39417 0 446305 0 0 0 Josalynne Hoff Rue MD Physician 306700 0 4258 0 0 0 11509 0 43224 0 365691 0 0 0 Chelsey Wyatt CRNA 309461 0 0 0 0 0 11508 0 37924 0 358893 0 0 0 Cammy Kelsch FNP-C ER Provider 274860 0 108 0 0 0 11313 0 42257 0 328538 0 0 0 Bobbi Burchinal Family NP 232328 0 0 0 0 0 9341 0 44601 0 286270 0 0 0 Dustin Hager COO & Provider 206626 0 4258 0 175 0 5235 0 43629 0 259923 0 0 0 Erik Christenson Secretary - CEO 176695 0 162 0 0 0 6376 0 43972 0 227205 0 0 0 Melissa Shepard Treasurer - CFO 139470 0 0 0 0 0 5482 0 14975 0 159927 0 0 0 Sarah Christenson Family member of CEO 82949 Compensation 0 Lauren McClintock Family member of CEO 72662 Compensation 0 Scott Brossart Family member of CEO 75617 Compensation 0 Form 990, Part VI, Section A, line 1a The Executive Committee consists of all the Board of Trustees residing in the Rugby community plus the Chairman of the Board of Trustees. The Executive Committee shall have the power to transact all regular business of the hospital during the interim between meetings of the Board of Trustees and it shall refer to all matters of major importance to the Board. Form 990, Part VI, Section A, line 6 Membership in the corporation shall consist of such Lutheran congregations which are now members of this Association and such other congregations as shall from time to time apply for membership herein. The Congregational members of the Organization shall be represented by the following 4 specific designations: -4 From Rugby/Balta/Orrin -1 From Towner/Willow City -1 from Rolette/Wolford/Dunseith -1 from Leeds/Maddock The Board of Trustees shall also have at least one physician representative and, in its discretion, two members at large Trustees, one of whom shall have a background in legal or insurance and another who shall have a background in finance both of whom shall reside in the geographical region served by the Association. The physician representative shall be a non-voting representative appointed by the Board of Trustees. Form 990, Part VI, Section A, line 7a Each member church has up to three voting delegates at the annual meeting where the board of directors is elected to serve on the board. Form 990, Part VI, Section A, line 7b Amendments to the Articles of Incorporation must be voted on by a two-thirds majority vote of the members. Amendments to Bylaws must be voted on by a two-thirds majority vote of the Board of Trustees. Form 990, Part VI, Section B, line 11b The Board receives an electronic copy of the draft Form 990 prior to a board meeting to review. An overview of the 990 is provided as part of the financial summary for the Board during the actual board meeting to answer any questions they may have as well. A motion is made to approve the draft. Form 990, Part VI, Section B, line 12c Covered Persons: All employees, managers, medical staff, executive leadership, board members, volunteers, contractors, and others engaged in the work place. A conflict of Interest Statement must be signed by each board member and shall be dated no later than December 31st of each year. Determination of conflict: All employees and board members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Conflict review: Actual or potential board member conflicts of interest must be disclosed to the Corporate Compliance Committee (CCC). The CCC will handle reports or concerns of situations that may give rise to a conflict of interest with the assistance of legal counsel. The CCC will issue its decision to the Covered Persons in writing and will document and file its decision. Restrictions on those with a conflict: In self-dealing transactions the board member shall not participate in the board decision-making and shall make full disclosure of their interests. If the fairness of the transaction is questioned, the burden of establishing fairness falls upon the trustee involved and the board member must seek guidance and approval from the CCC prior to pursuing any business or personal activity that may constitute a conflict of interest. Form 990, Part VI, Section B, line 15 Comparative data is reviewed and incorporated into the review process such as looking at state wage survey data. For the CEO, each board member completes their own evaluation form. The human resource committee reviews the responses and makes a recommendation to the full board. The full board decides on any changes to CEO compensation. The review is done annually at time of anniversary date of contract. The board typically does not approve wages for other positions. The CEO approves the CFO wages. Comparative data is used throughout the facility and incorporated into the annual review of employee wages done by the department head or supervisor. Wages are compared to the NDHA annual salary survey report at the time of their annual review. Form 990, Part VI, Section C, line 19 These documents are available upon request. Financial statements are available for viewing by the public at all board meetings. Form 990, Part VI, Line 16b: The Organization is a 49% owner in a retail pharmacy located in the clinic building. The pharmacy bylaws requires an annual board meeting including representatives of the Hospital. The meeting evaluates the joint venture arrangement and assures the facility is not violating its tax exempt status. The pharmacy is organized and operating as a C-Corporation. Form 990, Part IX, line 11g Contracted Services: Program service expenses 2,907,511. Management and general expenses 159,367. Fundraising expenses 0. Total expenses 3,066,878. Other Fees: Program service expenses 83,094. Management and general expenses 409,965. Fundraising expenses 0. Total expenses 493,059. Form 990, Part XI, line 9: Change in interest in net assets of Foundation -3,656,545. Change in interest in net assets of Auxillary -15,932. Good Samaritan Health Services Foundation 2975 Hwy 2 E Rugby ND 583687801 363513553 Fundraising for Good Samaritan Hospital Association ND 501(c)(3) Line 7 Good Samaritan Hospital Association 1 0 0 1 0 1 0 0 0 0 0 0 0 1 1 1 1 1 1 1 Good Samaritan Health Services Foundation C 1489672 Accrual