2022-05-16T15:18:08-05:00 2021-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2020-07-01 460224604 Avera Queen of Peace AVER 6059952251 525 North Foster Street Mitchell SD 57301 Julie Lautt CFO Avera Health 6059952251 2022-05-12 0 Julie Lautt 999009999 Kim Hunwardsen CPA P00484560 6122536500 2022-05-12 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Avera Queen of Peace Health Service Douglas Ekeren 525 North Foster Street Mitchell SD 57301 154415978 0 0928 X See Schedule O X 1905 SD Promotion of health 17 14 855 26 123907 0 9703103 7715446 106371720 120596238 1409273 4184931 670387 1381367 118154483 133877982 26125 14848 0 0 64450306 65328474 0 0 13127 51500214 55328253 115976645 120671575 2177838 13206407 166237397 173794004 69080323 50831034 97157074 122962970 X Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values. 0 0 103745478 14848 120669457 Avera Queen of Peace's mission is to provide healthcare services to Mitchell, South Dakota residents and residents of the surrounding area. Avera Queen of Peace is a 501(c)(3) organization affiliated with Avera Health. Avera Queen of Peace consists of 42 acute beds, 8 ICU beds and a 84-bed nursing home in Mitchell, SD, a 16-bed critical access hospital in Wessington Springs, SD, a 6-bed critical access hospital in De Smet, SD and 12 physician clinics. The physician clinics include primary care, ob/gyn, pediatrics, orthopedics, general surgery, internal medicine, radiation, radiology, oncology, dermatology, therapy, ophthalmology and optometry. They provide acute care and long-term healthcare services. Following is a breakdown of these statistics by facility:Avera Queen of Peace Hospital1,635 Acute patient discharges462 Newborn patient discharges88 Swing Bed patient discharges104,867 Outpatient visits779 Swing-bed patient days886 Newborn patient days40,203 Clinic visitsAvera Brady Health and Rehabilitation80 Long Term Care patient discharges25,752 Long-term care resident daysAvera Westkota Memorial Medical Center (CAH)73 Acute patient discharges29 Swing Bed discharges4,083 Outpatient visits312 Swing-bed patient daysAvera De Smet Memorial Hospital (CAH)75 Acute patient discharges18 Swing Bed patient discharges12,400 Outpatient visits111 Swing-bed patient days3,088 Clinic visitsAvera Queen of Peace maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $2,183,802.Avera Queen of Peace also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera Queen of Peace upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network of persons and institutions. Avera Queen of Peace engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed.During the COVID pandemic over the last two years, Avera Health and its affiliated entities have stewarded significant funding toward community benefit, from our own resources and from state and federal assistance and relief funds. When the first cases were identified in 2020, we created a 24/7 hotline people could call to inquire about testing, treatment, and later vaccination. This hotline minimized the burden of clinics and helped protect patients and the public by keeping patients from presenting to healthcare facilities in person. Along with the hotline, Avera launched an innovative and specialized program for caring for COVID patients at home, including daily checkins, virtual visits (if needed) and at-home oxygen therapy. Throughout the pandemic this program has supported patients and kept hospitals from becoming overwhelmed.Additionally we launched public awareness campaigns for masking and vaccination that included earned media, paid advertising and digital presence. We set up testing sites and events, including a mass testing event for workers at the local protein plant. The state delegated vaccination efforts to South Dakota's health systems, and our state was recognized nationally for our "shots in arms" efficiency. Avera led efforts to prioritize those at highest risk, including not only elderly and infirm but homeless, congregate living residents and protein plant workers which included a high percentage of immigrants. We participated in national research for COVID therapies including convalescent plasma, monoclonal antibodies and antiviral medications. We worked with local and state officials to inform the public at regular press conferences and expanded bed capacity by reallocating resources across all hospitals in our system. Avera partnered with other health facilities and systems to ensure capacity for the sickest patients, and those in need of ICU care and ventilators. Avera also launched efforts to support and retain health care workforce, including such things as paying health insurance premiums, providing support payments, $2 across-the-board pay increases, increased on-call pay and shift differentials, and more. 103745478 1 1 0 1 0 0 0 0 1 1 1 1 0 0 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 0 0 0 1 110 0 1 855 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 17 14 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 0 X X Jamie Schaefer 6053223992 3900 W Avera Dr Ste 300 Sioux Falls SD 57108 Hillary Rockwell MD Board Member/Physician 40.00 0.00 X 419046 0 52040 Ryan Huber Chairperson 2.50 0.00 X X 0 0 0 Jay Tolsma Vice Chair 2.50 0.00 X X 0 0 0 Sister Kathleen Bierne Board Member 1.50 1.00 X 0 0 0 Sister Erin Colgan OSB Board Member 2.50 0.00 X 0 0 0 Jason Bradley Board Member 2.50 0.00 X 0 0 0 Julie Brookbank Board Member 2.50 0.00 X 0 0 0 Quinten Burg Board Member 3.50 0.00 X 0 0 0 Brad Zomer Board Member 2.50 0.00 X 0 0 0 Michael Krause DO Board Member 3.50 0.00 X 0 0 0 Ryan Thompson Board Member 2.50 0.00 X 0 0 0 Jean Koehler Board Member 2.50 0.00 X 0 0 0 Gopal Vyas Board Member 2.50 0.00 X 0 0 0 Mark Hunhoff Board Member 2.50 0.00 X 0 0 0 Tracey Larson Board Member 4.50 0.00 X 0 0 0 Amy Novak Board Member 5.50 0.00 X 0 0 0 Douglas Ekeren Interim Regional President/CEO 5.00 42.00 X X 0 626756 40677 Julie Lautt CFO Avera Health; Sec/Treas 0.10 41.30 X 0 903545 36378 Rochelle Reider VP Patient Services 40.00 0.00 X 200098 0 34975 Brian Kampmann Orthopedics, Sports Medicine 40.00 0.00 X 1308174 0 52800 Chris Krouse DO Orthopedics, Sports Medicine 40.00 0.00 X 1339020 0 45524 Kelly Smith Diagnostic Radiology 40.00 0.00 X 642012 0 53300 Jessica Claussen Opthalmology 40.00 0.00 X 615989 0 53614 Dennis Leland General Surgery 40.00 0.00 X 665190 0 40426 Thomas Clark Former Regional President/CEO 0.00 40.00 X 0 587865 45092 Jim Breckenridge Former CFO Avera Health; Sec/Treas 0.00 0.00 X 0 329248 15667 5189529 2447414 470493 88 1 1 0 Avera Health 3900 W Avera Dr Sioux Falls SD 57108 Shared Services and eCare Services 13554543 Avera McKennan 1325 S Cliff Ave Sioux Falls SD 57117 Medical Professionals, Interpreter, Prin 3476787 Sioux Falls Construction Co 4500 W 58th St Sioux Falls SD 571186370 Construction Services 935360 Medical Information Technology Inc 1 Meditech Cir Westwood MA 02090 Information Technology Services 786166 Restorix Health Inc 445 Hamilton Ave White Plains NY 10601 Wound Care Services 713486 13 279996 7416197 19253 7715446 Net Patient & Resident Services 622110 110209647 110209647 Retail Pharmacy 900099 906330 782423 123907 Cafeteria 900099 271753 271753 9208508 9208508 120596238 19148 19148 1564051 379810 1184241 1184241 1184241 24323969 20151565 6621 4172404 -6621 4165783 4165783 Operating Interest 900099 197126 197126 197126 133877982 120669457 123907 5369172 X 14848 14848 698436 464792 233644 73413 73413 50166801 48764535 1402266 3799360 3692661 106699 7454429 7240526 213903 3136035 3039623 96412 1933 1933 11984 11984 21935215 10240826 11690687 3702 9105 1442 7613 50 1028768 605234 417085 6449 1462849 605361 857488 1789261 1487465 301263 533 235638 228397 7241 119081 113768 5313 1121339 962334 159005 5297878 4613992 683696 190 494059 262857 231202 Medical Supplies 20602161 20578517 22479 1165 Equipment Lease/Rental 36604 35655 949 1182378 719232 462108 1038 120671575 103745478 16912970 13127 147462 96512 0 10433 17278694 15048599 1599259 1788336 441828 522510 121169152 71498497 52208367 49670655 88745882 100227015 226522 280330 1473683 1400988 4115700 4748626 166237397 173794004 8442743 9748937 8540944 972148 33008277 32503413 43869 49190 19044490 7557346 69080323 50831034 X 93943696 119201188 3213378 3761782 97157074 122962970 166237397 173794004 X 13206407 11382583 1216906 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 11984 11984 0 Part II-B, Line 1: Avera Queen of Peace Hospital paid dues to organizations which have a portion of the dues attributed to lobbying activities. 0 1 X 742586 125 36549 1609 2738 774913 726701 3630 17348 5093 742586 708556 356 25945 8156 726701 2748708 424 37389 2077965 708556 2715895 256959 252847 463879 13114 2748708 0.01320 0.98680 0.00000 0 1 1 473669 2822681 3296350 1827230 71732963 40196312 33363881 5483721 1481497 4002224 35198041 26981059 8216982 3630847 2839629 791218 49670655 Interest in Avera Health Foundation 3663527 F Interest in net assets of Mabee Trust 881354 F Avera Pooled Investments 95682134 F 100227015 Derivative Liability 968737 Deferred Payroll Taxes 1918072 Right of Use Operating Lease Obligation 1464780 Other Liabilities 62904 Estimated Third-Party Payor Settlements 3142853 7557346 X Part IV, Line 2b: The Organization holds funds in trust on behalf of its residents. Part V, Line 4: The organization's endowments consist of a portion of their interest in the net assets of Avera Health Foundation and their beneficial interest in the Mabee Trust. Avera Health Foundation includes endowment funds which have been established for a variety of purposes. The endowment fund assets included in the Organization's beneficial interest in the Mabee Trust have been established to purchase equipment and furnishings for the Organization. As required by generally accepted accounting principles, net assets associated with endowment funds, including funds designated by the Board of Directors to function as endowments (if any), are classified and reported based on the existence or absence of donor-imposed restrictions. The Organization's permanently restricted endowment funds are donor restricted. The Organization currently does not have any board-designated endowment funds. Part X, Line 2: Avera Health and its sponsored organizations believe that they have 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. 1 1 X 1 X 1 X 1 1 1 0 0 594962 594962 0.00490 8201733 5683653 2518080 0.02090 171447 99902 71545 0.00060 8968142 5783555 3184587 0.02640 362 362 0.00000 25240 25240 0.00020 233130 233130 0.00190 170879 170879 0.00140 429611 429611 0.00350 9397753 5783555 3614198 0.02990 3944 3944 0.00000 2193 2193 0.00000 1360 1360 0.00000 340 340 0.00000 680 680 0.00000 8517 8517 0.00000 1 5746298 0 31722635 39962318 -8239683 X 1 1 3 1 Avera Queen of Peace Hospital 525 North Foster Street Mitchell SD 57301 See Part V Section C 10552 X X X 4 Provider Based Clinics 2 Avera Weskota Memorial Medical Center 609 1st Street NE Wessington Springs SD 57382 See Part V Section C 48209 X X X 3 Avera De Smet Memorial Hospital 306 Prairie Avenue SW De Smet SD 57231 See Part V Section C 50726 X X X 1 Provider Based Clinic Avera Queen of Peace Hospital 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X See Part V Section C X See Part V Section C X 1 18 1 See Part V Section C 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X See Section V Part C X See Section V Part C X See Section V Part C X X X X X X X 1 X 0 X X X X X 1 X 0 0 Avera Weskota Memorial Medical Center 2 0 0 1 X X X X X X X X X 18 1 0 0 1 X See Part V Section C X See Part V Section C X 1 18 1 See Part V Section C 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X See Section V Part C X See Section V Part C X See Section V Part C X X X X X X X 1 X 0 X X X X X 1 X 0 0 Avera De Smet Memorial Hospital 3 0 0 1 X X X X X X X X X 18 1 0 0 1 X See Part V Section C X See Part V Section C X 1 18 1 See Part V Section C 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X See Section V Part C X See Section V Part C X See Section V Part C X X X X X X X 1 X 0 X X X X X 1 X 0 0 Avera Queen of Peace Hospital Part V, Section B, Line 3j: Avera Queen of Peace Hospital hired inHealth Strategies to conduct the focus group and analyze the results. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources and improvements. Those providing community input were chosen for their familiarity with the needs of medically underserved, low-income and minority populations as they serve with these populations through their activities. The following organizations were represented in the process: Mitchell Area Development Corporation Cornerstones Career Learning Center Mitchell Area Food Pantry Mitchell High School/Second Chance High School Mitchell Middle School Mitchell Ministerial Association Mitchell Department of Public Safety Mitchell Fire & Emergency Management Services (EMS) Hanson County Sheriff's Office Davison County Welfare Office Davison County Sheriff's Office SDDOH County Health Nurse - Davison County SDDOH County Health Nurse - Hanson County Avera Weskota Memorial Medical Center Part V, Section B, Line 5: Avera Weskota Hospital hired inHealth Strategies to conduct the focus group and analyze the results. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources and improvements. Those providing community input were chosen for their familiarity with the needs of medically underserved, low-income and minority populations as they serve with these populations through their activities. The following organizations were represented in the process: Wessington Springs Senior Nutrition Program Wessington Springs Food Pantry City of Wessington Springs Jerauld County Auditor Jerauld County Sheriff Jerauld County Commissioner South Dakota Department of Health and Human Services - Jerauld County and Sanborn County Wessington Springs School District Avera De Smet Memorial Hospital Part V, Section B, Line 5: Avera De Smet Hospital hired inHealth Strategies to conduct the focus group and analyze the results. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources and improvements. Those providing community input were chosen for their familiarity with the needs of medically underserved, low-income and minority populations as they serve with these populations through their activities. The following organizations were represented in the process: Inter-Lakes Community Action Partnership (ICAP) - Kingsbury County Eastern South Dakota SHINE (seniors over 60 services) Kingsbury County Sheriff's Department City of De Smet Kingsbury Court House - South Dakota Department of Social Services De Smet United Methodist Church American Lutheran Church, De Smet - Community Health Nurse De Smet School District Avera Queen of Peace Hospital Part V, Section B, Line 11: The community health needs assessment was completed in 2018. The community health priority areas identified were: Behavioral Health and Substance abuse, Transportation, and Affordable housing. The following actions and programs were included in the implementation strategy to address the community health priorities.BEHAVIORAL HEALTH AND SUBSTANCE ABUSEBehavioral health was identified as an area of need that Avera Queen of Peace is addressing. Access to services, early intervention, and education are critical to achieving positive outcomes for individuals and communities. The hospital has developed the following goals to address this need. -Increase psychology appointments; increase appointments with LCSW-Increase PHQ-9 screening follow-up appointments in ambulatory settings-Decrease average score on PHQ-9 screenings in in-patient settings-Decrease behavioral health crisis ED visits -Increase the number of Avera eBehavioral encountersFY 2021 Update: Avera Queen of Peace hired a new Psychologist in July 2019. The number of appointments continues to increase. Over the past two years, the number of appointments has increased more than 127%. Avera Queen of Peace continues to offer behavior health services through telehealth services.TRANSPORTATIONAnother need continuing to rise to the top of the community health needs is the need for affordable and reliable on-demand transportation. The need exists within city limits and between towns and cities for all citizens as the need to get to and from school, work, and medical appointments. Avera Queen of Peace has developed the following goals to address this need.-Create resource list/algorithm on transportation options for all relevant staff-Evaluate number of rides paid for by the AQOP Foundation-Evaluate the number of conversations AMG-Care Coordination is having with patients about transportation needs-Increase the number of those enrolled in mail-order pharmacyFY 2021 Update: Avera Queen of Peace continues to evaluate the number of rides paid for by the AQOP Foundation. Although Covid-19 limited transportation services, Avera Queen of Peace was able to provide 106 rides for patients. Avera Queen of Peace continues to enroll patients in and fill scripts through the mail-order pharmacy.AFFORDABLE HOUSINGGood health is dependent upon adequate housing, providing dwellers a sense of privacy, security, stability, and control. A minimum of 12 of every 100 households in the county is at risk for health issues such as infectious disease and poor childhood development due to the severe cost burden of housing. Avera Queen of Peace had started a project with the City of Mitchell for the construction of affordable housing on land that Avera Queen of Peace donated. FY 2021 Update: Due to Covid-19, this project was put on hold. Avera Queen of Peace Hospital does not currently have the resources to address the issues related to affordable housing. However, the 21.7 acre parcel of land donated to the City of Mitchell is still available for an affordable housing development. Avera Queen of Peace Hospital will continue to actively participate in community organizations that address housing issues. Avera Weskota Memorial Medical Center Part V, Section B, Line 11: The community health needs assessment was completed in 2018. The community health priority areas identified were: Further Community Health Education and Remove barriers to primary care access. The following actions and programs were included in the implementation strategy to address the community health priorities.FURTHER COMMUNITY HEALTH EDUCATION-Increase awareness of the national "Stop the Bleed" campaignFY 2021 Update: Due to Covid-19, in-school program was suspended.-Increase collaboration with Horizon Healthcare on community health educationFY 2021 Update: Avera Weskota Memorial Medical Center worked closely with Horizon on our community Covid-19 vaccine and education efforts.-Increase educational posts on FacebookFY 2021 Update: There were 54 educational posts to the Avera Weskota Memorial Medical Center Facebook page.REMOVE BARRIERS TO PRIMARY CARE ACCESS-Increase access to primary care services through hiring of additional primary care providerFY 2021 Update: Horizon hired a full-time physician in FY2020 and hired a second full-time physician in FY2021. While the physicians are not Avera Weskota employees, the hospital fully supported the hire and actively worked to ensure the physicians feel welcomed and oriented into the hospital and community.Many of these activities are continuations of activities the hospital has been conducting related to the prior community health needs assessment. Though the following health need/priority will not be addressed due to resource constraints, the hospital will continue to actively participate in numerous community organizations focused on community needs and improvements: -Economic stress Avera De Smet Memorial Hospital Part V, Section B, Line 11: The community health needs assessment was completed in 2018. The following actions and programs were included in the implementation strategy to address the community health priorities. REMOVE BARRIERS TO SKILLED HOME HEALTH CARE ACCESS-Increase Avera@Home Home Health patientsFY 2021 Update: During Covid-19, Avera DeSmet Memorial Hospital has continued to increase Home Health and hospice admissions. To date, 98 patients have been admitted to Home Health/Hospice in Kingsbury County.-Increase the number of Avera@Home Home Health patients using lab servicesFY 2021 Update: During Covid-19, Avera DeSmet Memorial Hospital was able to maintain a consistent number of patients as well as lab services for Home Health. To date, 23 Home Health patients have used the lab services.-Provide education and marketing materials for patientsFY 2021 Update: Marketing and education materials continue to be distributed to patients in both print and digital forms. Avera continued with significant marketing response to the Covid-19 pandemic.-Provide Avera@Home access to community resource informationFY 2021 Update: Access to all community resources were provided to Avera @Home. Additionally, a Primary Care physician was hired to help care for the growing number of referrals and to help with health education in the community.Many of these activities are continuations of activities the hospital has been conducting related to the prior community health needs assessment. Though the following health needs/priorities will not be addressed due to resource constraints, the hospital recognizes its shared responsibility with the community and is actively participating in at least two community groups that have been formed to address these issues. -Lack of public transportation-Lack of affordable housing Avera Queen of Peace Hospital Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide. Avera Weskota Memorial Medical Center Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide. Avera De Smet Memorial Hospital Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide. Avera Queen of Peace Hospital Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera Weskota Memorial Medical Center Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera De Smet Memorial Hospital Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera Queen of Peace Hospital Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility. Avera Weskota Memorial Medical Center Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility. Avera De Smet Memorial Hospital Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility. Avera Queen of Peace Hospital Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy. Avera Weskota Memorial Medical Center Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy. Avera De Smet Memorial Hospital Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy. Avera Queen of Peace Hospital Part V, Section B, Line 7a, 7b and 10c: avera.org/about/community-health-needs-assessments/#queen Avera Weskota Memorial Medical Center Part V, Section B, Ln 7a, 7b, and 10a: avera.org/about/community-health-needs-assessments/#weskota Avera De Smet Memorial Hospital Part V, Section B, Line 7a, 7b and 10a: avera.org/about/community-health-needs-assessments/#de-smet Part V, Section B, Lines 16a-16c The FAP, FAP Application, and plain language summary are available for all facilities at:avera.org/patients-visitors/charity-patient-assistance-programs/financial-assistance-forms/ Schedule H Part V, Section A organization's website: The website for Avera Queen of Peace Hospital is:avera.org/locations/queen-of-peace/The website for Avera Weskota Memorial Medical Center is:avera.org/locations/profile/avera-weskota-memorial-hospital/The website for Avera De Smet Memorial Hospital is:avera.org/locations/profile/avera-de-smet-memorial-hospital/ 5 1 - Avera Brady Health and Rehab 500 S Ohman St Mitchell SD 57301 Nursing Home 2 - Avera Brady Assisted Living 1414 W Cedar Ave Mitchell SD 57301 Assisted Living 3 - Avera Medical Group De Smet 801 3rd St SW De Smet SD 57231 Clinic 4 - Avera Medical Group Mitchell 1900 Grassland Drive Mitchell SD 57301 7 Clinics-OBGYN, Surgery, Peds, Internal Med, Family Med, Derm, Urology 5 - Avera Medical Group Optometry 1200 East 6th Ave Mitchell SD 57301 Clinic Part I, Line 3c: The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted. 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. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Costs of other means-tested government programs, line 7c, and subsidized health services, line 7g, were obtained from EPSi analytical reports. Community health improvement services, line 7e, Health professions education, line 7f, and cash and in-kind donations, line 7i were compiled using actual costs recorded in the CBISA software. Part II, Community Building Activities: Avera Queen of Peace Hospital provided donations to various organizations to support activities as listed on Part II. Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents. Part III, Line 4: The footnote to the Organization's financial statements that describes implicit price concession is located in the audited financial statement report on pages 17 and 18. Part III, Line 8: Avera Queen of Peace provides services to patients under the Medicare program knowing they may not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, in years the costs associated with services provided under the Medicare program are not completely covered, the Medicare shortfall is considered a community benefit. 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 Centers for Medicare and Medicaid Services. Part III, Line 9b: If the patient qualifies for the organization's financial assistance policy for low-income, uninsured patients and is cooperating with the organization with regard to efforts to settle an outstanding bill within current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven. Part VI, Line 2: Health care needs are assessed through various methods. Given Mitchell is a regional center/hub and the sixth largest city in South Dakota, Avera Queen of Peace is integrally involved with community organizations, universities/colleges, schools, state programs and local governments. The next largest hospital offering the same level of services is 72 miles from Mitchell and most of the towns within our region have a population of less than 2,000. By working with all in our region, we are able to determine health needs and provide programs and solutions where possible. In addition to activities reported in the Community Health Needs Assessment, Avera Queen of Peace, Avera Weskota and Avera De Smet collaborate with a community health committees within their respective community to assess and promote health related matters. Part VI, Line 3: Uninsured patients who hold an inpatient status are counseled by a Patient Advocate to screen them for coverage eligibility and to assist in payer source enrollment. Those that are not eligible are provided a charity care application along with instructions on how to fill out the application. All patients receive statements that indicate who to contact should they need financial assistance. In addition, all patients receive a summary of financial assistance upon registration, as well as in their final statement. Should a patient contact Patient Financial Services and indicate inability to pay, they are transferred to a financial counselor to assist them with the financial assistance application process. Also, inpatient and same day surgery patients receive a brochure in their admissions packet. Pre-collection letters also include information regarding the financial assistance and uninsured programs. Part VI, Line 4: Avera Queen of Peace is a 50-bed hospital in Mitchell, South Dakota. The primary service area is defined as Davison County, South Dakota. Mitchell is the county seat of Davison County. According to the U.S. Census Bureau Quick Facts 2019 data, the estimated population of Davison County as of July 1, 2019 is 19,775 and is predominately white at 92.9%. It is estimated that 19.1% of the population is 65 years and over. The median household income is $50,570 with an 11.7% poverty rate. Uninsured individuals under age 65 is estimated at 9.8%. Part VI, Line 5: Avera Queen of Peace is a State Certified Level #4 Community Trauma Center and operates an emergency department staffed 24 hours per day with board certified physicians. Emergency care is provided on an open door basis regardless of ability to pay. Avera Queen of Peace leases two critical access hospitals which provide a broad range of inpatient, outpatient services and 24 hour emergency rooms in two very rural communities.Similar to the hospitals in the Avera Queen of Peace region, the clinics are operated on an open door basis and care is provided regardless of ability to pay.Medical staff privileges are extended to all licensed and qualified applicants. The Avera Queen of Peace Board of Directors is principally comprised of community members from the primary and secondary services areas. Members come from a variety of backgrounds including banking, education, agriculture, healthcare and private industry. Part VI, Line 6: Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance. 0 0 0 0 0 0 0 0 0 Chris Krouse DO Orthopedics, Sports Medicine 1182532 0 149723 0 6765 0 14250 0 31274 0 1384544 0 0 0 Brian Kampmann Orthopedics, Sports Medicine 1124742 0 179032 0 4400 0 14250 0 38550 0 1360974 0 0 0 Julie Lautt CFO Avera Health; Sec/Treas 0 842009 0 55127 0 6409 0 14250 0 22128 0 939923 0 0 Dennis Leland General Surgery 578741 0 76781 0 9668 0 14250 0 26176 0 705616 0 0 0 Kelly Smith Diagnostic Radiology 466551 0 152108 0 23353 0 14250 0 39050 0 695312 0 0 0 Jessica Claussen Opthalmology 555855 0 10312 0 49822 0 14250 0 39364 0 669603 0 0 0 Douglas Ekeren Interim Regional President/CEO 0 587258 0 28842 0 10656 0 14250 0 26426 0 667432 0 0 Thomas Clark Former Regional President/CEO 0 547808 0 26164 0 13893 0 14250 0 30842 0 632957 0 0 Hillary Rockwell MD Board Member/Physician 395267 0 21453 0 2326 0 14250 0 37790 0 471086 0 0 0 Jim Breckenridge Former CFO Avera Health; Sec/Treas 0 299918 0 0 0 29330 0 7704 0 7964 0 344916 0 0 Rochelle Reider VP Patient Services 197060 0 270 0 2768 0 10215 0 24760 0 235073 0 0 0 Schedule J, Part I, Line 3: The President/CEO is compensated by Avera Health. Avera Queen of Peace relied on the related organization for determining the compensation for the President/CEO using the methods described in Part I, Line 3. Rhonda Zomer Family member of board member 73413 Compensation 0 Form 990, Item J The organization's website is: avera.org/locations/queen-of-peace/ Form 990, Part VI, Section A, line 2 Jim Breckenridge, Julie Lautt, Doug Ekeren and Thomas Clark have a business relationship. Form 990, Part VI, Section A, line 6 The sole member of the organization is Avera Health, a nonprofit corporation organized and existing under the laws of the state of South Dakota and exempt under 501(c)(3) of the Internal Revenue Code of 1986, as amended. Form 990, Part VI, Section A, line 7a Avera Health, as the sole member, has the power to appoint and remove, with or without cause, members of the Board of Directors. Form 990, Part VI, Section A, line 7b Avera Health, as the sole member, has the following rights as the Member. 1) To approve the adoption, amendment or repeal of the statements of philosophy, mission and values of Corporation; 2) To initiate the adoption, amendment or repeal of any provision of the Articles of Incorporation or Bylaws of Corporation, and to give final approval of any such action with respect thereto; 3) To approve and act upon the alienation of real property and precious artifacts under the canonical stewardship of the Sisters of the Presentation of the Blessed Virgin Mary of Aberdeen, South Dakota ("Presentation Sisters") or the Benedictine Sisters of Sacred Heart Monastery ("Benedictine Sisters"), pursuant to the policies established by the Member; 4) To approve any plan of merger, consolidation or dissolution of the Corporation, or the divestiture of a sponsored work or ministry associated with the Corporation; 5) To approve the creation of new sponsored works or ministries to be conducted by or under the authority of the Corporation; 6) To appoint and remove, with or without cause, the Board of Directors of the Corporation. 7) To appoint and/or remove, with or without cause, the President and Chief Executive Officer of the Corporation. 8) To approve operating/capital budgets and strategic plans of the Corporation. 9) To approve expenditures outside of operating and capital budgets exceeding defined thresholds according to policy which may be adopted from time to time by the Member. 10) To approve acquisitions, sales and leases, according to policy which may be adopted from time to time by the Member. 11) To establish and maintain employee benefit programs. 12) To establish and maintain insurance programs. 13) To approve major community fund drives. 14) To approve the appointment of auditors. 15) To adopt policies designed to effectuate the reserved powers of the Member. Form 990, Part VI, Section A, line 8b Avera Queen of Peace Hospital does not have committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11b The Form 990 is reviewed by the Avera Health VP of Financial Reporting, Tax Manager, Facility CEO and Finance Committee (if applicable). After initial review the Form 990 is made available to the Board and other Operation Finance Leaders. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers board members, officers, and key employees. At each board meeting, a request is made for all board members to disclose any potential conflict of interest pertaining to any item listed on the agenda or pertaining to any potential item that could be discussed during the course of the meeting. The declaration of conflict of interest is recorded in the meeting minutes. The board makes a determination of whether there is a conflict of interest and if so, implements the procedure for evaluating the issue or transaction involved. The board member or officer with the conflict must refrain from voting. A statement of conflict of interest disclosure is made on an annual basis by officers and directors. The information is maintained in a database and a report is provided to the board. Form 990, Part VI, Section B, line 15b The CEO and CFO-Avera Health are compensated by Avera Health. Annually the Compensation Committee of Avera Health, which is comprised of six (6) System Members appointed by the Religious Orders, meets with an independent consultant regarding fair market value of officers and key employees. The Compensation Committee approves all salaries based on comparable data and documents the basis for their decision in meeting minutes. Depending on the individual's role with the organization, some officers and key employees are compensated by Avera Queen of Peace. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not available to the general public. The Organization's financial statements are attached to the Form 990 per IRS instructions and therefore are available to the general public. Form 990, Part IX, line 11g Purchased Services: Program service expenses 6,916,732. Management and general expenses 351,360. Fundraising expenses 3,702. Total expenses 7,271,794. Repairs and Maintenance: Program service expenses 1,784,496. Management and general expenses 33,983. Fundraising expenses 0. Total expenses 1,818,479. Medical Prof Fees: Program service expenses 1,539,598. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,539,598. Centralized Services: Program service expenses 0. Management and general expenses 11,305,344. Fundraising expenses 0. Total expenses 11,305,344. Form 990, Part XI, line 9: Change in Beneficial Interest in Mabee Trust 102,664. Other change in net assets held by Avera Health Foundation 706,421. Change in Fair Value of Interest Rate Swap 407,821. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the consolidated audited financial statements of Avera Health, which includes Avera Queen of Peace. Form 990, Part VI, Section B, Line 16b: There is no written policy or procedure since in the event of any such proposed transaction the board or a committee with delegated authority reviews all materials, valuations and operational aspects for any proposed transaction. Such transaction would be evaluated in accordance with the exempt status of the organization and its applicable purposes. Any transaction also would be approved by the board and the member. Form 990, Part X, Line 20: The issue price includes the filing Organization's share of the entire bond issue, which was issued to Avera Health on behalf of the Avera Obligated Group. The Avera Obligated Group consists of Avera Health, Avera McKennan, Avera St. Luke's, Avera Queen of Peace, Avera Marshall, Avera St. Mary's, Avera St. Anthony, Avera St.Benedict, Avera Holy Family, Avera Tyler, Avera Granite Falls, Avera Gettysburg, Avera at Home, and Avera Sacred Heart. In accordance with IRS instructions, information related to the tax exempt bond reporting is being reported on Avera Health's tax return (EIN 46-0422673). Avera Health 3900 West Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) Line 10 N/A 0 Avera Gettysburg 606 East Garfield Gettysburg SD 57442 460234354 Healthcare Services SD 501(c)(3) Line 3 Avera St Mary's 0 Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 68763 470463911 Healthcare Services NE 501(c)(3) Line 3 Avera Health 0 Avera Holy Family 826 North 8th Street Estherville IA 51334 420680370 Healthcare Services IA 501(c)(3) Line 3 Avera Health 0 Avera Holy Family Foundation 826 North 8th Street Estherville IA 51334 421317452 Support Health Related Services IA 501(c)(3) Line 10 Avera Holy Family 0 Avera Marshall 300 S Bruce Street Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) Line 3 Avera Health 0 St Benedict Health Center 401 West Glynn Drive Parkston SD 57366 460226738 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 St Benedict Health Center Foundation West Glynn Drive PO Box B Parkston SD 57366 460458725 Support Health Related Services SD 501(c)(3) Line 12a, I St Benedict Health Center 0 Avera McKennan 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 460224743 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera St Mary's 801 East Sioux Avenue Pierre SD 57501 460230199 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera at Home 5116 S Solberg Ave Sioux Falls SD 57108 460399291 Home Services SD 501(c)(3) Line 10 Avera Health 0 Lewis and Clark Health Education and Service Agency 1000 W 4th Street Suite 9 Yankton SD 57078 460337013 Healthcare Education SD 501(c)(3) Line 10 Sacred Heart Health Services 0 Avera St Luke's 305 South State Street Aberdeen SD 57401 460224598 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera Tyler 240 Willow Street Tyler MN 56178 410853163 Healthcare Services MN 501(c)(3) Line 3 Avera Marshall 0 Avera Health Plans Inc 3900 West Avera Drive Suite 101 Sioux Falls SD 57108 460451539 Health Financing and Health Plan Admin SD 501(c)(4) Avera Health 0 Avera Granite Falls 345 10th Ave Granite Falls MN 56241 843156881 Healthcare Services MN 501(c)(3) Line 3 Avera Marshall 0 Q & M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical clinic building SD N/A 0 1 Avera Home Medical Equipment of Floyd Valley Hospital LLC 714 Lincoln St NE Lemars IA 51031 820582350 Medical services - home medical equipment SD N/A 0 0 Avera Home Medical Equipment of Sioux Center LLC 38 19th ST SW Sioux Center IA 51250 753203100 medical services - home medical equipment SD N/A 0 0 Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Ave 102 Sioux Falls SD 57117 800619999 medical services - home medical equipment SD N/A 0 0 Surgical Associates Endoscopy Clinic LLC 310 S Pennsylvania St Aberdeen SD 57401 460461429 surgical associates SD N/A 0 0 Heart Hospital of South Dakota LLC 4500 W 69th Street Sioux Falls SD 57108 562143771 healthcare services SD N/A 0 0 Brookings Health System - Avera HME LLC 101 22nd Ave Suite 101 Brookings SD 57006 453204123 Medical Services - Home Medical Equipment SD N/A 0 0 National Rural ACO 4 LLC dba Prairie Hills Care Organization 7509 NW Tiffany Springs Parkway Kansas City MO 64153 371780735 Accountable Care Organization KS N/A 0 0 National Rural ACO 5 LLC dba Great Plains Care Organization 7509 NW Tiffany Springs Parkway Kansas City MO 64153 383958290 Accountable Care Organization KS N/A 0 0 Caravan Health ACO 41 LLC dba Prairie View Care Organization 7509 NW Tiffany Springs Parkway Kansas City MO 64153 821447782 Accountable Care Organization KS N/A 0 0 Accounts Management Inc 5132 S Cliff Ave Suite 101 Sioux Falls SD 57108 460373021 collection agency SD N/A C 0 Avera Property Insurance Inc 1000 West 4th Street Suite 1 Yankton SD 57078 460463155 insurance SD N/A C 0 Dr Donald & Marguerite Mabee Trust c/o First National Bank of South Da Mitchell SD 57301 466056202 investing SD Avera Queen of Peace Hospital T 102663 881354 1.00000 1 Valley Health Services 501 Summit Street Yankton SD 57078 460357149 rental real estate SD N/A C 0 Alucent Biomedical Inc 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 571175045 471818349 biotech research SD N/A C 0 South Dakota State Medical Holding Inc 5300 South Broadband Lane Sioux Falls SD 57108 460401087 insurance SD N/A C 0 DakotaCare Administrative Services Inc 5300 South Broadband Lane Sioux Falls SD 57108 460424322 insurance SD N/A C 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 Schedule R, Part III: Q & M Properties, LLC dissolved effective June 30, 2021. National Rural ACO 4 LLC liquidated effective December 31, 2020.