Community Benefit Insight - Tax-exempt hospital

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Pembina County Memorial Hospital Association

Pembina County Memorial Hospital

301 Mountain St East
Cavalier, ND 58220

Bed count	20	Medicare provider number	351319	Member of the Council of Teaching Hospitals	NO	Children's hospital	NO

EIN: 456013474

Display data for year:

Community Benefit Spending- 2021
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)

5.66%

Spending by Community Benefit Category- 2021
(as % of total functional expenses)

* = CBI denoted preventative categories

Community Benefit Spending Compared to Functional Expenses, 2010-2021

Additional data

Community Benefit Expenditures: 2021

All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Amount spent in the following IRS community benefit categories:

Financial Assistance at cost as % of operating expenses	$ 40,638 0.20 %
Medicaid as % of operating expenses	$ 0 0 %
Costs of other means-tested government programs as % of operating expenses	$ 0 0 %
Health professions education as % of operating expenses	$ 5,000 0.02 %
Subsidized health services as % of operating expenses	$ 1,082,955 5.22 %
Research as % of operating expenses	$ 0 0 %
Community health improvement services and community benefit operations* as % of operating expenses Note: these two community benefit categories are reported together on the Schedule H, part I, line 7e.	$ 45,900 0.22 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 0 0 %
Community building* as % of operating expenses	$ 700 0.00 %

* = CBI denoted preventative categories

Community building activities details:

Did tax-exempt hospital report community building activities?	YES
Number of activities or programs (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Persons served (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Community building expense as % of operating expenses	$ 700 0.00 %
Physical improvements and housing as % of community building expenses	$ 0 0 %
Economic development as % of community building expenses	$ 0 0 %
Community support as % of community building expenses	$ 0 0 %
Environmental improvements as % of community building expenses	$ 0 0 %
Leadership development and training for community members as % of community building expenses	$ 0 0 %
Coalition building as % of community building expenses	$ 700 100 %
Community health improvement advocacy as % of community building expenses	$ 0 0 %
Workforce development as % of community building expenses	$ 0 0 %
Other as % of community building expenses	$ 0 0 %
Direct offsetting revenue	$ 0
Physical improvements and housing	$ 0
Economic development	$ 0
Community support	$ 0
Environmental improvements	$ 0
Leadership development and training for community members	$ 0
Coalition building	$ 0
Community health improvement advocacy	$ 0
Workforce development	$ 0
Other	$ 0

Other Useful Tax-exempt Hospital Information: 2021

In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.

Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt as % of operating expenses	$ 279,800 1.35 %
Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program?	NO

Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2021 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.

Does the organization have a written financial assistance (charity care) policy?	YES
Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients?	YES
Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy as % of operating expenses	$ 21,265 7.60 %

Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.

Community Health Needs Assessment Activities: 2021

The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.

Did the tax-exempt hospital report that they had conducted a CHNA?	YES
Did the CHNA define the community served by the tax-exempt hospital?	YES
Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital?	YES
Did the tax-exempt hospital make the CHNA widely available (i.e. post online)?	YES
Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA?	YES

Supplemental Information: 2021

This section presents qualitative information submitted by the hospital, verbatim from the 990H record.

Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.

4A (Expenses $ 18856677 including grants of $ 0) (Revenue $ 20811684)
PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS A 20 BED ACUTE CARE HOSPITAL, 40 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.

Facility Information

Schedule H (Form 990) Section C. Supplemental Information for Part V, Section B.

PEMBINA COUNTY MEMORIAL HOSPITAL
PART V, SECTION B, LINE 5: AS PART OF THE ASSESSMENT'S OVERALL COLLABORATIVE PROCESS, THE CENTER FOR RURAL HEALTH SPEARHEADED EFFORTS TO COLLECT DATA FOR THE ASSESMENT IN A VARIETY OF WAYS, INCLUDING BUT NOT LIMITED TO: 1. GATHERING FEEDBACK FROM THE COMMUNITY, RESIDENTS OF THE AREA WERE GIVEN THE OPPORTUNITY TO PARTICIPATE IN A SURVEY. SIXTY-EIGHT PCMH SERVICE AREA RESIDENTS COMPLETED THE SURVEY. 2. ADDITIONAL INFORMATION WAS COLLECTED THROUGH 11 KEY INFORMANT INTERVIEWS WITH COMMUNITY MEMBERS.THE INPUT FROM THE RESIDENTS, WHO PRIMARILY RESIDE IN PEMBINA COUNTY, REPRESENTED THE BROAD INTERESTS OF THECOMMUNITIES IN THE SERVICE AREA. TOGETHER WITH SECONDARY DATA GATHERED FROM A WIDE RANGE OF SOURCES, THESURVEY PRESENTS A SNAPSHOT OF THE HEALTH NEEDS AND CONCERNS IN THE COMMUNITY. DUE TO THE COVID PANDEMIC INTERVIEWS WERE CONDUCTED VIRTUALLY.

PEMBINA COUNTY MEMORIAL HOSPITAL
PART V, SECTION B, LINE 6B: PEMBINA COUNTY MEMORIAL HOSPITAL CONDUCTED THEIR CHNA WITH PEMBINA COUNTY PUBLIC 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: IN 2020, PCMHA DEVELOPED AN IMPLEMENTATION PLAN BASED ON THE RESULTS OF THE 2020 CHNA. THE TOP NEEDS IDENTIFIED IN THE CHNA PROCESS INCLUDED:- ALCOHOL USE AND ABUSE- YOUTH AND ADULTS- ATTRACTING AND RETAINING YOUNG FAMILIES- AVAILABILITY OF MENTAL HEALTH SERVICES- AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES- COST OF LONG-TERM/ NURSING HOME CARE- DEPRESSION/ ANXIETY- YOUTH AND ADULTS- DRUG USE AND ABUSE (INCLUDING PRESCRIPTION DRUG USE)- ADULTS- HAVING ENOUGH CHILD DAYCARE SERVICES- NOT ENOUGH AFFORDABLE HOUSINGTHE PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) BOARD OF DIRECTORS HAS DETERMINED THAT THE FOLLOWING HEALTH NEEDS IDENTIFIED IN THE CHNA SHOULD BE ADDRESSED THROUGH THE IMPLEMENTATION STRATEGY NOTED FOR EACH SUCH NEED:PRIORITY AREA: AVAILABILITY OF MENTAL HEALTH SERVICESGOAL: INCREASE ACCESSIBILITY TO BEHAVIORAL HEALTH SERVICESSTRATEGIES:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MENTAL HEALTH PROVIDER SERVICES AT CLINICARE AND SEEK ANY OPPORTUNITY TO EXPAND SERVICES.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. PRIORITY AREA: ALCOHOL USE AND ABUSE, DEPRESSION/ANXIETY- YOUTH AND ADULTGOAL: DECREASE THE USE OF ALCOHOL BY OUR YOUTH AND ADULTS AND PROVIDE ACCESS TO TREATMENT FOR DEPRESSION AND ANXIETY.STRATEGIES:1. CONTINUE TO SUPPORT AND PROMOTE THE CURRENT MENTAL HEALTH PROVIDER SERVICES AT CLINICARE AND SEEK ANY OPPORTUNITY TO EXPAND SERVICES.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. PRIORITY AREA: DRUG USE AND ABUSE (INCLUDING PRESCRIPTION DRUG USE) ADULTSGOAL: DECREASE THE USE AND MISUSE OF DRUGSPRIORITY AREA: AVAILABILITY OF RESOURCES TO HELP THE ELDERLY STAY IN THEIR HOMES STRATEGIES:1. PROMOTE THE PCBHC SUPPORTED PROGRAMS AND ALL FAITH BASED ORGANIZATIONS.2. RESEARCH THE VIABILITY OF EXPANDING THE PALLIATIVE CARE GROUP TO INCLUDE A GRIEF SUPPORT PROGRAM.3. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALITY VIA TELEMEDICINE.4. SUPPORT YOUTH AND ADULT ALCOHOL FREE ACTIVITIES AND EDUCATION WITHIN OUR COMMUNITIES.5. CONTINUE TO PROVIDE SPACE FOR SUPPORT GROUPS TO MEET AT PCMH.STRATEGIES:1. PROMOTE THE DESTRUCTION OF LEFT OVER OR UNUSED MEDICATIONS WITH DETERA OR DROP OFF BOXES LOCATED THROUGHOUT THE COMMUNITIES.2. PROMOTE THE SERVICES OFFERED BY MENTAL HEALTH PRACTITIONERS AT CLINICARE OR ALTRU SPECIALTY VIA TELEMEDICINE.3. CONTINUE TO COLLABORATE WITH PEMBINA COUNTY BEHAVIORAL HEALTH COALITION (PCBHC) TO BRING EDUCATION, CLASSES, SPEAKERS, PROGRAMS, AND AWARENESS TO OUR COMMUNITIES.4. COLLABORATE WITH HEALTH PROVIDERS TO BRING MAT (MEDICATION ASSISTED TREATMENT) TO PEMBINA COUNTY.GOAL: INCREASE ACCESS AND AWARENESS TO RESOURCES, SERVICES AND PROGRAMS TO ALLOW ELDERLY TO STAY IN THEIR HOMES LONGEROTHER NEEDS IDENTIFIED IN THE CHNA, BUT NOT ADDRESSED IN THIS IMPLEMENTATION PLAN:1. ATTRACTING AND RETAINING YOUNG FAMILIES - PCMHA CONTINUES TO BE AN ACTIVE PARTICIPANT IN COMMUNITY RECRUITMENT EFFORTS. SUPPORTING THE CAVLANDIC BIKE SHARE PROGRAM IN 2020 - PCMHA CONTINUES TO OFFER COMPETITIVE WAGES AND BENEFITS TO RECRUIT AND RETAIN FAMILIES. 2. COST OF LONG-TERM/NURSING HOME CARE - HOSPITAL SOCIAL WORK DESIGNEE IS AVAILABLE TO ASSIST INDIVIDUALS WHO LACK HEALTH INSURANCE THROUGH PROGRAMS OFFERED AND OUR FINANCIAL ASSISTANCE PROGRAM. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES OCCUR ON A REGULAR BASIS. ADMINISTRATION PROVIDES ONGOING FEEDBACK TO GOVERNMENT POLICY MAKERS AT THE STATE LEVEL REGARDING LONG TERM HEALTH CARE AND HEALTH INSURANCE COSTS3. HAVING ENOUGH CHILD DAYCARE SERVICES - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE CHILD DAYCARE SERVICES WITHIN ITS SERVICE AREA.4. NOT ENOUGH AFFORDABLE HOUSING - PCMHA WILL PARTICIPATE WITH ANY COMMUNITY LED EFFORTS TO DEVELOP MORE AFFORDABLE HOUSING WITHIN ITS SERVICE AREA.STRATEGIES:1. CONTINUE TO WORK WITH THE PEMBINA COUNTY HEALTH COALITION TO PROVIDE AND DISTRIBUTE A RESOURCE GUIDE FOR PEMBINA COUNTY OF SERVICES OFFERED.2. PROMOTE THE QSP PROGRAM AND OTHER SERVICES OFFERED THROUGH PEMBINA COUNTY SOCIAL SERVICES.3. MEDICAL PROVIDERS WILL PROMOTE THE SENIOR MEAL PROGRAM.4. CONTINUE TO COLLABORATE WITH NDSU PEMBINA COUNTY EXTENSION OFFICE WITH THE DIABETES PREVENTION AND STEPPING ON PROGRAMS.5. COLLABORATION AND REFERRALS TO COUNTY SOCIAL SERVICES AND HOUSING AUTHORITY.

Supplemental Information

Schedule H (Form 990) Part VI

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, DIABETIC EDUCATION, SKILLED NURSING FACILITY, AND EMERGENCY ROOM.

PART II, COMMUNITY BUILDING ACTIVITIES:
PEMBINA COUNTY MEMORIAL HOSPITAL PARTICIPATES IN AND SUPPORTS THE AMERICAN CANCER SOCIETY RELAY FOR LIFE AND HAS A BOOTH/DISPLAY AT THE COUNTY FAIR FOR GENERAL HEALTH EDUCATION. THE HOSPITAL ALSO WORKS TO SUPPORT EMERGENCY PREPAREDNESS IN THE COMMUNITY. EFFORTS INCLUDE QUARTERLY MEETINGS WITH PUBLIC HEALTH, THE 911 COORDINATOR, AND AMBULANCE REPRESENTATIVES TO DISCUSS EMERGENCY PREPAREDNESS.

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 2020 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 AND RESIDENT RECEIVABLES NOTE ON PAGE 9 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:
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.

PART VI, LINE 4:
PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION IS COMPRISED OF A 20-BED CRITICAL ACCESS HOSPITAL, 40-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). THE US CENSUS FOR 2020 SHOWED A POPULATION OF 6,844 FOR PEMBINA COUNTY. THE MEDIAN INCOME FOR A HOUSEHOLD IN PEMBINA COUNTY WAS $60,910. THE PER CAPITA INCOME FOR THE COUNTY WAS $35,096. 8.0% 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:
PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION (PCMHA) SERVES THE NORTHEASTERN CORNER OF NORTH DAKOTA AND NORTHWESTERN PART OF MINNESOTA. IT IS OUR MISSION 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 COMMUNITY, SO PCMHA SUPPORTS AND PARTICIPATES IN INITIATIVES TO HELP MANAGE CHRONIC CONDITIONS SUCH AS DIABETES, PROVIDING HEALTH EDUCATION, AND PROMOTING THE IMPORTANCE OF ADDRESSING MENTAL AND BEHAVIORAL HEALTH NEEDS. IN REPSONSE TO COVID-19, PCMHA DIRECTED RESOURCES TO SUPPORT AND PROVIDE EDUCATION TO PATIENTS AND RESIDENTS AND THEIR FAMILIES TO HELP NAVIGATE THIS UNPRECEDENTED SITUATION. IT IS IMPERATIVE TO FURTHER OUR EXEMPT STATUS TO CONTINUE TO PROMOTE OUR SERVICES AND QUALITY OF CARE WITHIN OUR SERVICE AREA.

Operating expenses	$ 20,740,658
Total amount spent on community benefits as % of operating expenses	$ 1,174,493 5.66 %