2022-05-16T15:18:09-05:00 2021-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2020-07-01 410853163 Avera Tyler AVER 5072475521 240 Willow Street Tyler MN 56178 Julie Lautt CFO Avera Health 5072475521 2022-05-12 1 Julie Lautt 999009999 Kim Hunwardsen CPA P00484560 6122536500 2022-05-12 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z Debbie Streier 240 Willow Street Tyler MN 56178 14114571 0 X See Schedule O X 1918 MN Promotion of health 15 11 126 20 0 0 926499 685619 11139147 12996924 57067 420664 1723 11364 12124436 14114571 22069 15832 0 0 6338505 6700328 0 0 0 4877799 5576474 11238373 12292634 886063 1821937 13515698 11048987 7374053 1826499 6141645 9222488 X Avera Health is a ministry rooted in the gospel. Our mission is to make a postive impact in the lives and health of persons and communities by providing quality services guided by Christian values. 0 0 10700729 15832 13008288 Avera Tyler's mission is to provide healthcare services to Tyler, Minnesota residents and residents of the surrounding counties including Lincoln, Pipestone and Lyon. Avera Tyler is a 501(c)(3) organization affiliated with Avera Health and controlled by Avera Marshall. Avera Tyler consists of a 21-bed hospital, a Rural Health Clinic and a 30-bed nursing home in Tyler, Minnesota; a Rural Health Clinic in Lake Benton, Minnesota; and a Rural Health Clinic in Ivanhoe, Minnesota until November 1, 2020. The program services offered include primary care, general surgery, infusion, radiology, nuclear medicine, ultrasound, chemotherapy, cardiac rehab, speech therapy, physical therapy and occupational therapy. Avera Tyler provides acute care and long-term healthcare services. Following is a breakdown of these statistics by facility:Avera Tyler Hospital82 Acute patient discharges37 Swing Bed patient discharges30 Long Term Care patient discharges7,656 Outpatient visits279 Swing-bed patient days7,919 Clinic visitsSunrise Manor10,750 Long-term resident daysAvera Tyler 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 $9,640.Avera Tyler 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 Tyler 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 Tyler 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. 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. 10700729 1 1 0 1 0 0 0 0 1 0 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 0 0 0 0 0 0 0 1 0 0 0 1 20 0 1 126 1 0 0 0 0 0 0 0 0 0 0 0 0 X 15 11 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 MN X Jamie Schaefer 6053223992 3900 W Avera Dr Ste 300 Sioux Falls SD 57108 X Curtis Louwagie MD Director/Ophthalmologist 1.50 40.00 X 0 784018 51440 Mary Maertens - Left 82020 President/CEO Avera Marshall 2.00 40.00 X X 0 464521 44796 Stephen Crim Director 1.50 11.50 X 0 42043 0 Doug Olsem Chair 1.50 1.50 X X 0 0 0 George Jorgensen Vice Chair 1.50 3.50 X X 0 0 0 Sr Roxanne Seifert Director 1.50 3.50 X 0 0 0 Sr Jodie Zimmerman Director 1.50 1.50 X 0 0 0 Quentin Fixen Director 1.50 1.50 X 0 0 0 Laurie Johansen Director 1.50 1.50 X 0 0 0 Joyce Strootman Director 1.50 1.50 X 0 0 0 Todd Bock Director 1.50 1.50 X 0 0 0 Amanda Sieling Director 1.50 1.50 X 0 0 0 Debbie Streier - Joined 22021 President/CEO Avera Marshall 2.00 43.00 X X 0 226926 31668 Mark Eakes MD Director 1.50 42.00 X 0 430852 46124 Greg Goepferich Director 1.50 1.50 X 0 0 0 LaVonne Koenen Director 1.50 3.50 X 0 0 0 Julie Lautt CFO Avera Health; Sec/Treas 0.10 41.30 X 0 903545 36378 Jim Breckenridge Former CFO Avera Health; Sec/Treas 0.00 0.00 X 0 329248 15667 Sharon Williams Former VP Finance 0.00 40.00 X 0 183173 35974 Allen AndersonAdministrator Former Officer 40.00 0.00 X 0 169792 28440 0 3534118 290487 0 1 1 0 Avera Marshall 300 South Bruce St Marshall MN 56258 Physicians and Shared Services 989652 Big Stone Therapies Inc 500 Cross St Big Stone City MN 57216 Therapy Services 707894 Avera McKennan 1325 S Cliff Ave Sioux Falls SD 57105 Lab, radiology and other 177768 Avera Health 3900 W Avera Dr Sioux Falls SD 57108 Shared Services 133916 4 14231 668238 3150 685619 Patient Service Revenue 622110 12640722 12640722 Pharmacy Revenue 900099 332369 332369 23833 23833 12996924 1796 1796 418868 0 418868 418868 418868 A/R Interest Income 900099 11364 11364 11364 14114571 13008288 0 420664 X 15832 15832 5314679 5145228 169451 265568 254284 11284 757486 732056 25430 362595 351337 11258 5250 5250 140 140 3148210 2099295 1048915 2113 2028 85 127216 77668 49548 71982 19611 52371 210244 144206 66038 15589 15243 346 16921 16076 845 134 134 267988 240492 27496 19326 19326 Medical Supplies 1062095 1061125 970 Bad Debt 46134 46134 Equipment Lease/Rental 36129 35619 510 547003 419785 127218 12292634 10700729 1591905 0 536093 1305173 1229003 1332458 264311 234626 41599 54062 8267595 6901472 1264043 1366123 10092463 6270760 88186 485785 13515698 11048987 733946 930394 3264371 266321 3276 102830 74655 3272906 551853 7374053 1826499 X 5535003 8504255 606642 718233 6141645 9222488 13515698 11048987 X 1821937 1169975 88931 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 140 140 0 Part II-B, Line 1: Avera Tyler paid dues to organizations which have a portion of the dues attributed to lobbying activities. 0 1 X 157440 157440 2013233 1502038 511195 6011719 5341183 670536 85203 58251 26952 1366123 Avera Pooled Investments 5507789 F Investment in Avera Health Foundation 762971 F 6270760 Third Party Payor Settlements 310308 Right of Use Operating Lease Obligations 62056 Deferred Payroll Taxes 179489 551853 X Part IV, Line 2b: The Organization holds funds on behalf of its residents. 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 12766 12766 0.00100 1537421 1263793 273628 0.02230 1550187 1263793 286394 0.02330 21759 7165 14594 0.00120 3458153 1511920 1946233 0.15890 168591 168591 0.01380 3648503 1519085 2129418 0.17390 5198690 2782878 2415812 0.19720 1 233238 2392667 2368978 23689 X 1 1 1 1 Avera Tyler 240 Willow St Tyler MN 56178 See Part V Section C 371548 X X X X 2 rural health clinics Avera Tyler 1 0 0 1 X X X X X X X X X 18 1 0 1 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 Part V Section C X see Part V Section C X see Part V Section C X X X X X X X 1 X 0 X X X X X 1 X 0 0 Avera Tyler Part V, Section B, Line 5: The Avera Tyler Community Health Needs Assessment (CHNA) was conducted in collaboration and partnership with community members, community organizations, stakeholders from local public health and internal stakeholders. These partners assisted in the development and analysis of assessment information through a series of data collection processes and a community forum. In addition, Avera Tyler partnered with Southwest Health and Human Services (SWHHS) to provide a more comprehensive look into the social determinants of health and wellness in the communities we serve. Avera Tyler Part V, Section B, Line 6b: Southwest Health and Human Services Avera Tyler Part V, Section B, Line 11: The community health needs assessment was completed in 2018. The three priorities identified were Mental Health, Obesity/Diabetes and Tobacco and e-cigarette use and exposure. Avera Tyler will take steps to address the identified needs.Mental Health * Increase the proportion of adults and children with mental health disorders who receive treatment. Improve behavioral health (BH) access and quality care. Increase appropriate use of screening and prevention services. * Increase awareness and reduce stigma around mental health issues and assist in disbursing local resource materials. Increase involvement with National Alliance on Mental Illness of Minnesota (NAMI).* Tap into depression resources * Provide employees with a depression screening tool * Provide and enhance utilization of employee assistance program (EAP) resources * Provide better adherence to medical care for those with behavioral health (BH) conditions measured by percentage of patients receiving BH screening and percentage of patients discharged with a BH referral. * Continue to operate mental health services, including inpatient and outpatient psychiatric programs. Partner with mental health providers to offer education on stress management to our patients and the community. * Further integrate mental health services into Primary Care. Monitor and improve collaborative opportunities between medical and behavioral health care. * Position Avera Marshall Behavioral Health as a Center of Excellence for the practice of Dialectical Behavior Therapy (DBT) as a champion for the Zero Suicide initiativeFY2021 Update: Avera Tyler did not address all identified goals in the 2019 CHNA due to the ongoing Covid pandemic. Virtual meetings and visits slowly increased. The relationship with Western Mental Health continued through FY21 with a representative from Western Mental Health providing weekly services in the Avera Tyler clinic.Obesity/Diabetes* Continue to collaborate with partner agencies to assist community members in obtaining needed nutritional information. * Explore potentialities in developing healthy eating and exercise programs to be promoted via affected communities' chambers of commerce and religious organizations. * Promote Obesity screening and counseling * Promote Healthy diet and physical activity * Provide hospital classes with Nutrition Services and Dieticians to cook healthier * Provide Weight loss Programs * Provide Wellness Coaches * Facility will provide meeting support * Continue working on strategies related to overall BMI improvement * Continue Education and screenings at health fairs and educational events* Distribute information on community resources such as free meals and food pantries * Support community support groups by providing meeting space, speakers, and educational topics FY2021 Update: With the ongoing Covid pandemic, Avera Tyler did not meet all their goals identified in the CHNA. Unfortunately, most activities in this area were in-person meetings and those were slow to resume. Plans are to resume when it is safe to gather.Tobacco and e-cigarette use and exposure* Emphasize communication and education on the health risks associated with tobacco and e-cigarette use (vaping) and exposure. * Initiate, promote and enforce smoking/vaping free policies on healthcare facilities grounds and promote asking partnering suppliers and onsite vendors to do the same.* Continue current and expand hospital prevention classes* Facility will provide Tobacco Cessation Programs and meeting support* Employees will participate in community education to promote the prevention of smokingFY2021 Update: Similar with the other two goals from the CHNA, the pandemic has posed some barriers to meeting our goals. Most specific is the inability to meet due to safety. Additionally, staff time is stretched thin as they care for patients during high activity and staff shortages.The following health needs/priorities will not be directly addressed by Avera Tyler due to capability to address by other community organizations:* Cardiovascular disease* Asthma* CancerMany of these activities are continuations of activities the hospital has been conducting related to the prior community health needs assessment. Avera Tyler 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 Tyler 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 on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera Tyler 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 Tyler 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. Part V, Section B, Lines 7a, 7b and 10a: avera.org/about/community-health-needs-assessments/#tyler Part V, Section B, Lines 16a, 16b, and 16c: avera.org/patients-visitors/charity-patient-assistance-programs/financial-assistance-forms/ Part V, Section A website address: avera.org/locations/profile/avera-tyler-hospital 1 1 - Avera Sunrise Manor 240 Willow St Tyler MN 56178 Skilled nursing facility 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 was converted to cost using an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid was calculated using the costing methods to prepare the cost report. Subsidized health services were calculated based on a combination of the Medicare cost report and actual expenses recorded to the general ledger. Community health improvement services, health professions education, and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger. Part I, Line 7g: Rural health clinic costs are included in subsidized health services. Revenues of $1,064,733 and costs of $2,474,127 were included for a net community benefit of $1,409,394. Part I, Line 7, Column (f): The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 46,134. Part III, Line 2: The amount on line 2 represents implicit price concessions and bad debts. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents. Bad debt reflects amounts that will not be paid by patients based on an adverse change in the patient's ability to pay. Part III, Line 4: The footnote to the Organization's financial statements that describes implicit price concession and bad debt is located in the audited financial statement report on pages 17 and 18. Part III, Line 8: Avera Tyler 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 programs 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: In addition to the CHNA, Avera Tyler identifies the needs of the community by providing topical and seasonal lectures within the community, performing outreach to other organizations (i.e. the high school), utilizing patient surveys, attending community events and stakeholder events to determine specific needs, and by having the professional medical staff determine needs based on their daily interactions with the community. 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 Tyler is a 21-bed critical access hospital in Tyler, Minnesota. The primary service area is defined as Lincoln County, Minnesota, including the communities of Arco, Hendricks, Ivanhoe, Lake Benton and Tyler. Ivanhoe is the county seat. According to the U.S. Census Bureau Quick Facts 2019 data, the estimated population of Lincoln County as of July 1, 2019 is 5,639 and is predominately white at 97.4%. It is estimated that 25.1% of the population is 65 years and over. The median household income is $53,077 with an 10.1% poverty rate. Uninsured individuals under age 65 is estimated at 6.3%. Part VI, Line 5: The organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care. Charity care is available for those with a diminished ability to pay. As a result of the mission statement, Avera Tyler provides numerous services which do not produce a profit. Examples are ambulance services and a 24/7 fully staffed emergency department.Avera Tyler is very involved in the community. Avera Tyler's leadership team is encouraged to participate in civic and community organizations. The leadership team is involved in the Tyler Area Community Club which sponsors events in the community such as "Band Shell Bazaar" which occurs on Wednesday evenings in August. This includes music entertainment, games for kids and includes a farmers market. Annually Avera Tyler has a hospice benefit. The hospice benefit did not occur this year with pandemic restrictions; although, it is resuming again in calendar year 2022. The proceeds are used to care for hospice patients and their families. Avera Tyler is also involved in the annual community celebration Aebleskiver Days which includes a parade. A booth for Avera Tyler at the Lincoln County Fair provides water to annual fair attendees. Again, these activities did not occur during the pandemic but are resuming in calendar year 2022. Several support groups which include Caregivers Support Groups and Powerful Tools for Caregivers are sponsored at Avera Tyler. Avera Medical Group Tyler and Lake Benton providers provide many educational sessions for the Tyler community. Additionally health screens are provided free of charge by the Avera Medical Group staff. Most of these activities were halted during the pandemic, but some did provide virtual options. Avera Tyler uses financial opportunities to further the technology used at the hospital in order to better serve their patients.As noted above, many services that do not produce a profit were postponed during the Covid pandemic but are all resuming in calendar year 2022. 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 Julie Lautt CFO Avera Health; Sec/Treas 0 842009 0 55127 0 6409 0 14250 0 22128 0 939923 0 0 Curtis Louwagie MD Director/Ophthalmologist 0 706743 0 73026 0 4249 0 14250 0 37190 0 835458 0 0 Mary Maertens - Left 82020 President/CEO Avera Marshall 0 455688 0 960 0 7873 0 14250 0 30546 0 509317 0 0 Mark Eakes MD Director 0 334963 0 41366 0 54523 0 14250 0 31874 0 476976 0 0 Jim Breckenridge Former CFO Avera Health; Sec/Treas 0 299918 0 0 0 29330 0 7704 0 7964 0 344916 0 0 Debbie Streier - Joined 22021 President/CEO Avera Marshall 0 220366 0 285 0 6275 0 11286 0 20382 0 258594 0 0 Sharon Williams Former VP Finance 0 179432 0 1260 0 2481 0 9471 0 26503 0 219147 0 0 Allen AndersonAdministrator Former Officer 0 168736 0 0 0 1056 0 8663 0 19777 0 198232 0 0 Schedule J, Part I, Line 3: The President/CEO serves Avera Marshall, Avera Tyler, and Avera Granite Falls and was compensated by a related organization, Avera Health. Avera Tyler relied on the related organization for determining the compensation for the President/CEO using the methods described in Part I, Line 3. Form 990, Item J The organization's website is: avera.org/locations/profile/avera-tyler-hospital/ Form 990, Part VI, Section A, line 2 Jim Breckenridge, Julie Lautt, Mary Maertens Debbie Streier, Stephen Crim and Sharon Williams have a business relationship. Form 990, Part VI, Section A, line 6 The sole member of the Corporation is Avera Marshall, a nonprofit corporation organized and existing under the laws of the State of Minnesota and exempt under 501(c)(3) of the Internal Revenue Code of 1986, as amended. Form 990, Part VI, Section A, line 7a Avera Marshall 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 Marshall, the Member of Avera Tyler, has the exclusive right: (a) To approve the adoption, amendment or repeal of the statements of philosophy, mission and values of the Corporation. (b) To initiate the adoption, amendment or repeal of any provision of the Articles of Incorporation or Bylaws of the Corporation, and to give final approval of any such action with respect thereto. (c) To appoint and remove, with or without cause, the Board of Directors of the Corporation. (d) To appoint and/or remove, with or without cause, the President and Chief Executive Officer of the Corporation. (e) To approve operating/capital budgets and strategic plans of the Corporation (f) 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. (g) To approve acquisitions, sales and leases, according to policy which may be adopted from time to time by the Member. (h) To establish and maintain employee benefit programs. (i) To establish and maintain insurance programs. (j) To approve major community fund drives. (k) To approve the appointment of auditors. (l) To adopt policies designed to effectuate the reserved powers of the Member. (m) To initiate and give final approval to equity and asset transfers by and between the Member and the Corporation and any affiliates or subsidiaries of the Member. (n) To initiate and give final approval to (i) any and all issuances of obligations under any existing or future master indentures binding the Corporation, any indebtedness (including, without limitation, capitalized leases) in excess of dollar thresholds as may be from time to time established by the Member, and (ii) any pledges of collateral for such indebtedness and any pledges of real estate as collateral for any indebtedness regardless of amount. (o) (i) Full and exclusive power to execute supplemental master indentures, including, without limitation, those authorizing the issuance of obligations or series of obligations, (ii) full and exclusive power to prepare, or authorize the preparation of, any and all documents, agreements, swap agreements, investment contracts, certificates and disclosure materials (including, without limitation, Official Statements and any supplements thereto) reasonably and ordinarily prepared in connection with the issuance of obligations thereunder, or related bonds associated therewith and to execute and deliver such items to the appropriate parties in connection therewith, and (iii) full and exclusive power to authorize the entrance of members to, or withdrawal of members from, any obligated group, subject to the other requirements of the applicable master indenture for such entrance or withdrawal. Form 990, Part VI, Section A, line 8b There are no 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 15 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. Form 990, Part VI, Section C, line 19 The organization's governing documents and conflict of interest policy are not made available to the general public. The Organization's financial statements are attached to the Form 990 per IRS instructions and therefore available to the general public. Form 990, Part VII: Debbie Streier worked 40 hours per week for Avera St Luke's through January 31, 2021 and 40 hours per week for Avera Marshall beginning February 1, 2021. Form 990, Part IX, line 11g Purchased Services: Program service expenses 1,784,508. Management and general expenses 22,034. Fundraising expenses 0. Total expenses 1,806,542. Medical Prof Fees: Program service expenses 2,168. Management and general expenses 0. Fundraising expenses 0. Total expenses 2,168. Repairs and Maintenance: Program service expenses 312,619. Management and general expenses 37,229. Fundraising expenses 0. Total expenses 349,848. Centralized Services: Program service expenses 0. Management and general expenses 989,652. Fundraising expenses 0. Total expenses 989,652. Form 990, Part XI, line 9: Other change in net assets held by Avera Health Foundation 88,931. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the consolidated audited financial statements for Avera Health, which includes Avera Tyler. Form 990, Part X, Line 20: Avera Tyler is part of the Avera Obligated Group which consists of Avera Health, Avera McKennan, Avera St. Luke's, Avera Queen of Peace, Avera Sacred Heart, Avera Marshall, Avera St. Mary's, Avera St. Anthony's, Avera St. Benedict, Avera Holy Family, Avera Tyler, Avera Granite Falls, Avera Gettysburg and Avera at Home. Avera Tyler was not allocated any share of the bond issue, and thus does not have an amount on line 20. Avera Health 3900 West Avera Drive Ste 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) Line 10 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 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 Avera Queen of Peace Hospital 525 North Foster Mitchell SD 57301 460224604 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 Gettysburg 606 East Garfield Gettysburg SD 57442 460234354 Healthcare services SD 501(c)(3) Line 3 Avera St Mary's 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 St Mary's 801 East Sioux Avenue Pierre SD 57501 460230199 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Avera Marshall 300 S Bruce Street Marshall MN 56258 410919153 Healthcare services MN 501(c)(3) Line 3 Avera Health 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 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 Q&M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical clinic building SD N/A 0 0 Surgical Associates Endoscopy Clinic LLC 310 S Penn Aberdeen SD 57401 460461429 Surgical associates SD N/A 0 0 Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Ave Sioux Falls SD 57117 800619999 Medical Services - home medical equipment 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 Healthcare Services 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 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 Company 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 1 0 0 0 0 0 1 1 0 1 1 1 1 1 1 1 Schedule R, Part III: Q&M Properties, LLC dissolved effective June 30, 2021. National Rural ACO 4 LLC liquidated effective December 31, 2020.