2021-07-30T10:06:30-05:00 2020-12-31 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2020-01-01 460219795 COMMUNITY MEMORIAL HOSPITAL INC COMM 6057752621 PO BOX 319 BURKE SD 575230319 MISTIE DREY CEO 6057752621 2021-07-28 1 MISTIE DREY 999009999 LAURIE HANSON CPA P00851848 6053391999 2021-07-28 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z MISTIE DREY PO BOX 319 BURKE SD 575230319 7911331 0 X WWW.BURKEHOSPITAL.COM X 1945 SD PROVIDE MEDICAL SERVICES 9 8 66 10 0 0 85013 1246794 6210290 6513155 103420 60943 66748 84387 6465471 7905279 52210 8220 0 0 2740199 2898084 0 0 0 3050790 3413077 5843199 6319381 622272 1585898 12725029 16470278 5403081 7559422 7321948 8910856 X EXCELLENCE IN THE PROVISION OF HEALTH CARE AND RELATED SERVICES, GOVERNED AS A NOT-FOR-PROFIT COMMUNITY ORGANIZATION, SERVING THE NEEDS OF OUR PEOPLE WITH SUPERIOR QUALITY AND VALUE. 0 0 4892382 8220 6513155 COMMUNITY MEMORIAL HOSPITAL, INC., A 16-BED ACUTE CARE HOSPITAL, PROMOTES HEALTH OF THE COMMUNITY BY PROVIDING A VARIETY OF HEALTH CARE SERVICES. DURING 2020, COMMUNITY MEMORIAL HOSPITAL HAD 3,386 CLINIC VISITS IN BURKE AND 443 CLINIC VISITS IN BONESTEEL. THE HOSPITAL HAD 176 ADMISSIONS, 318 PATIENT DAYS, AND 948 SWINGBED DAYS.COMMUNITY MEMORIAL HOSPITAL HAS TAKEN STEPS TO ENHANCE PREVENTIVE CARE ON A YEARLY BASIS FOR PEOPLE OF ALL AGES THROUGH THE DEVELOPMENT OF SPECIALTY CLINICS TO ENSURE THAT THOSE WHO COME HERE FOR PREVENTIVE CARE RECEIVE THE SCREENINGS AND RECOMMENDATIONS APPROPRIATE TO THEIR PERSONAL AND FAMILY HISTORY. IN 2020, COVID INTERFERED WITH MANY OF THE SPECIALTY CLINICS AS PATIENTS WERE ENCOURAGED TO STAY HOME DURING THE PANDEMIC. THE FACILITY WORKED HARD TO FIND WAYS OF CONTINUING SUCH SERVICES IN A SAFE MANNER, INCLUDING HOSTING TWO DRIVE THRU FLU CLINICS AND A SOCIAL DISTANCING HEALTH FAIR WITH FREE LAB DRAWS. THE FACILITY ORGANIZED A GET YOUR PINK ON WALK THAT RECOGNIZED LOCAL BREAST CANCER SURVIVORS WHILE PROVIDING IMPORTANT INFORMATION ON ANNUAL MAMMOGRAMS. THE FACILITY ALSO PRODUCED A VIDEO FOR BREAST CANCER AWARENESS THAT RECEIVED OVER 10,000 VIEWS.COMMUNITY MEMORIAL HOSPITAL IS A PARTICIPATING SITE OFFERING COMPENSATION & PENSION EXAMS FOR VETERANS. BECOMING A PARTICIPATING SITE HAS BEEN A BENEFIT TO VETERANS IN OUR COMMUNITY AND SURROUNDING COMMUNITIES AS WE ARE ONE OF THE VERY FEW RURAL SITES OFFERING SUCH EXAMS. THE HOSPITAL SAW APPROXIMATELY 20 VETERANS IN 2020 AND HAS SEEN VETERANS FROM VARIOUS PARTS OF THE STATE. 4892382 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 40 0 1 66 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X X TAMI LYON 6057752621 PO BOX 319 BURKE SD 575230319 X X THOMAS GLOVER CHAIRMAN 2.00 X X 0 0 0 MICHAEL KARBO VICE CHAIRMAN 1.00 X X 0 0 0 KAREN MARTIN SECRETARY 1.00 X X 0 0 0 JASON MOSTERD DIRECTOR (BEG JULY 2020) 1.00 X 0 0 0 RICHARD DOBESH DIRECTOR (UNTIL JUNE 2020) 1.00 X 0 0 0 BECKY JONES DIRECTOR 1.00 X 0 0 0 CLAYTON STEELE DIRECTOR 1.00 X 0 0 0 SUE CHYTKA DIRECTOR 1.00 X 0 0 0 RACHELLE NORBERG DIRECTOR 1.00 X 0 0 0 DOUG SPITZENBERGER DIRECTOR 1.00 X 0 0 0 MISTIE DREY CEO 40.00 X 0 0 0 DEB LEIBEL CNP 40.00 X 102521 0 14142 AMY JURACEK CNP 40.00 X 107491 0 15078 210012 0 29220 2 0 0 0 SANFORD HEALTH PO BOX 5074 SIOUX FALLS SD 571175074 MANAGEMENT FEES, CEO WAGES, IT SUPPORT 531371 WINNER PHYSICAL THERAPY 825 E 8TH ST 204 WINNER SD 57580 PT COVERAGE FOR IN HOUSE PATIENTS 312991 SANFORD CLINIC 1305 W 18TH ST SIOUX FALLS SD 57105 MD WAGES 267361 BURKE COMMUNITY PHARMACY PO BOX 358 BURKE SD 57523 PHARMACIST SERVICES 255145 4 986227 260567 1246794 PATIENT SERVICE REVENU 621110 4703551 4703551 CLINIC REVENUE 621498 896693 896693 PHARMACY REVENUE 446110 783424 783424 129487 129487 6513155 61972 61972 89410 5023 84387 84387 84387 1029 -1029 -1029 -1029 7905279 6513155 0 145330 X 5000 5000 3220 3220 134895 134895 2251182 1829089 422093 57109 51432 5677 287685 199901 87784 167213 136803 30410 218447 218447 22794 22794 43200 43200 1162646 1089351 73295 17986 2675 15311 76240 12850 63390 128121 128121 68404 51235 17169 2878 1791 1087 5885 2541 3344 113390 84929 28461 491533 368159 123374 39856 39856 MEDICAL SUPPLIES 891271 880871 10400 EQUIPMENT & MAINTENANCE 87089 22219 64870 LICENSES, DUES & SUBSCR 24990 5421 19569 EMPLOYEE RECRUITMENT 10000 10000 8347 8347 6319381 4892382 1426999 0 3801646 7044249 208457 212057 743026 668528 157500 217500 114688 114900 56971 85422 8654226 2079250 6808077 6574976 513750 557234 20215 21284 300699 974128 12725029 16470278 403069 483172 2255886 113584 162155 4886428 4658209 5403081 7559422 X 7316200 8855108 5748 55748 7321948 8910856 12725029 16470278 1585898 3010 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 44228 44228 5716530 868773 4847757 2497621 1109897 1387724 395847 100580 295267 6574976 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 733164 RESERVE FUND 240964 974128 X 7908289 3010 3010 7905279 0 7905279 6319381 0 6319381 0 6319381 PART IV, LINE 2B: THE FUNDS BEING HELD ARE FROM COMMUNITY DONORS AND ARE TO BE USED TO REBUILD THE CITY OF BURKE AS A RESULT OF THE TORNADO THAT WENT THROUGH THE CITY IN AUGUST 2019. PART X, LINE 2: THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENTS. THE HOSPITAL 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 150.000000000000 1 1 0 0 30000 30000 0.00470 363270 309101 54169 0.00860 393270 309101 84169 0.01330 21731 1641 20090 0.00320 1377258 796766 580492 0.09190 1398989 798407 600582 0.09510 1792259 1107508 684751 0.10840 1 138592 784 3079912 3067327 12585 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL INC PO BOX 319 BURKE SD 57523 WWW.BURKEHOSPITAL.COM 10530 X X X 2 RURAL HEALTH CLINICS COMMUNITY MEMORIAL HOSPITAL INC 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X SEE 7D BELOW X SEE 7D BELOW X 1 19 1 SEE 7D ABOVE 0 1 X 100.000000000000 150.000000000000 X X X X X 1 1 X X X X X 1 X SEE PART V, LINE 16J NARRATIVE X SEE PART V, LINE 16J NARRATIVE X SEE PART V, LINE 16J NARR X X X X X X 1 X 0 X X X X 1 X 0 0 COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 5: COMMUNITY MEMORIAL HOSPITAL (CMH) SURVEYED SEVERAL CROSS SECTIONS OF THE COMMUNITY INCLUDING THE CITY COUNCIL, STAFF OF BURKE SCHOOL DISTRICT, BURKE COMMUNITY CLUB, GREGORY COUNTY EMPLOYEES, CMH BOARD OF DIRECTORS, CMH EMPLOYEES AND FIRST FIDELITY BANK EMPLOYEES. IN ADDITION A SURVEY WEBSITE WAS PUBLISHED IN THE LOCAL NEWSPAPER FOR OTHER INTERESTED PARTIES TO COMPLETE. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 7D: PART V, LINE 7A:HTTPS://WWW.BURKEHOSPITAL.COM/COMMUNITY-HEALTH-NEEDS-ASSESSMENTPART V, LINE 7B:HTTPS://WWW.SANFORDHEALTH.ORG/ABOUT/COMMUNITY-HEALTH-NEEDS-ASSESSMENT COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 11: THE HOSPITAL TAKES PRIDE IN ADDRESSING THE NEEDS IDENTIFIED FROM THE COMMUNITY HEALTH NEEDS ASSESSMENT AND CONTINUES TO MAKE IT A FOCUS EVERY YEAR. OUR COMMUNITY IS A HUGE PART OF OUR SUCCESS AND AS A FACILITY WE WANT TO GIVE BACK AS MUCH AS POSSIBLE. ADMINISTRATION AND STAFF ARE VERY ACTIVE IN THE COMMUNITY AND FOCUS ON MAKING IMPROVEMENTS WITHIN THE COMMUNITY.PRIORITY 1: MENTAL HEALTH. MENTAL HEALTH EFFECTS PEOPLE OF ALL AGES AND IS A SERIOUS HEALTH PROBLEM THAT CAN BE DIFFICULT TO ADDRESS. AS A FACILITY, WE WORKED HARD TO IMPROVE OUR ACCESS TO MENTAL HEALTH SERVICES AND WERE ABLE TO SECURE TWO FULL TIME COUNSELING SERVICES ON OUR CAMPUS. DUE TO HEALTH ISSUES, ONE SERVICE HAD TO DISSOLVE. THE CURRENT SERVICE IS THRIVING WITH PLANS OF EXPANSION DUE TO THE HIGH NEED OF SERVICES IN THE AREA. IN THE CLINIC SETTING, PROVIDERS AND NURSING STAFF FOCUS ON OUR PHQ 9 SCORES AND IDENTIFYING PATIENTS WITH DEPRESSION. WE ALSO HAVE A HEALTH COACH THROUGH ONE OF OUR CLINIC NURSING STAFF TO ASSIST IN A PERCENTAGE OF PATIENTS MEETING QUALITY MEASURES. AS A FACILITY WE ALSO CONTINUE TO FOCUS ON PAIN MANAGEMENT AND MONITORING OUR OPIOID PRESCRIBING. THERE HAS BEEN A SIGNIFICANT DECREASE IN PATIENTS BEING PRESCRIBED OPIOIDS. WE CONTINUE TO EDUCATE THE PUBLIC ON OUR MED DROP BOX AND TAKE BACK PROGRAM. THE AVAILABILITY OF DRUG TAKE-BACK RECEPTACLES IS KEY IN REDUCING THE AVENUE OF DIVERSION CREATED BY UNUSED, UNWANTED AND EXPIRED DRUGS IN AN INDIVIDUAL'S MEDICINE CABINET. THE NATIONAL SURVEY ON DRUG USE AND HEALTH RELEASED IN SEPTEMBER 2016 BY SAMHSA (SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION) STATES THAT 53.7% OF PEOPLE AGED 12 OR OLDER OBTAINED THE PRESCRIPTION PAIN RELIEVERS THEY MOST RECENTLY MISUSED FROM A FRIEND OR RELATIVE. COMMUNITY MEMORIAL HOSPITAL IS STILL THE ONLY FACILITY IN THE COUNTY THAT HAS A MED DROP BOX.PRIORITY 2: HEALTHCARE AND WELLNESS. AS A HEALTH CARE FACILITY, WE CONTINUE TO BE COMMITTED TO PROMOTING A HEALTHY LIFESTYLE. WE ENCOURAGE OUR PATIENTS AND COMMUNITY MEMBERS TO BE MORE ACTIVE. WE CONTINUE TO COLLABORATE WITH OUR LOCAL FITNESS CENTERS, FITNESS ON MAIN IN BURKE AND POST 36 FITNESS IN BONESTEEL, TO COVER THE COSTS OF VARIOUS EXERCISE CLASSES, ALLOWING THE CLASSES TO BE OFFERED AT NO COST TO THE PUBLIC. ALLOWING CLASSES TO BE OFFERED AT NO COST INCREASES ATTENDANCE AND ELIMINATES FINANCIAL DETERRENCE. WE WILL CONTINUE TO ASSIST IN IMPROVING UPON THE SERVICES OFFERED. WE CONTINUE TO OFFER A VARIETY OF LAB TESTS FREE OR AT A DISCOUNTED RATE DURING OUR COMMUNITY HEALTH FAIRS HELD TWICE EACH YEAR. IN 2020, IT WAS LIMITED TO ONE TIME DUE TO COVID. THE HOSPITAL PROVIDES A QUARTERLY NEWSLETTER TO KEEP COMMUNITY MEMBERS UP TO DATE ON SERVICES BEING OFFERED IN ADDITION TO EDUCATIONAL INFORMATION FROM PROVIDERS. HEALTH AWARENESS EDUCATION WAS POSTED ON THE FACILITY WEBPAGE REGULARLY AND A HEART HEALTH LUNCH AND LEARN WAS HELD FREE TO THE PUBLIC. THE FACILITY PUT A FOCUS ON BREAST CANCER AWARENESS MONTH IN 2020 HOSTING A GET YOUR PINK ON WALK THAT RECOGNIZED LOCAL SURVIVORS AS WELL AS PROMOTING ANNUAL MAMMOGRAMS. THE HOSPITAL PRODUCED A VIDEO CENTERED AROUND THE IMPORTANCE OF GETTING REGULAR MAMMOGRAMS AND THE VIDEO RECEIVED A LOT OF ATTENTION WITH OVER 10,000 VIEWS.SEVERAL THINGS THAT WERE PLANNED IN 2020, WERE CANCELLED DUE TO COVID FOR PATIENT SAFETY AND FOLLOWING THE CDC GUIDELINES AROUND SOCIAL DISTANCING. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 13H: PATIENTS WHOSE FAMILY INCOME EXCEEDS 150% OF THE FPL MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASE-BY-CASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE; HOWEVER, THE DISCOUNTED RATES SHALL NOT BE GREATER THAN THE AMOUNTS GENERALLY BILLED TO COMMERCIALLY INSURED PATIENTS. A DETERMINATION BASED ON PRESUMPTIVE ELIGIBILITY MAY BE MADE IF ALL OTHER AVENUES HAVE BEEN EXHAUSTED. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 15E: THE PHONE NUMBER FOR COMMUNITY MEMORIAL HOSPITAL IS LISTED ON THE APPLICATION. THE CMH EMPLOYEE ANSWERING THE PHONE WILL DIRECT THE PATIENT TO SOMEONE WHO CAN HELP WITH THE APPLICATION. CMH ALSO OFFERS INFORMATION REGARDING OTHER ORGANIZATION OR GOVERNMENT AGENCIES WHICH OFFER ASSISTANCE. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 16J: PART V, LINE 16A, 16B, & 16C:THE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATION ARE POSTED TO THE WEBSITE AT HTTPS://WWW.BURKEHOSPITAL.COM/FINANCIAL-ASSISTANCE.PART V, LINE 16J: FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY AND APPLICATION ARE AVAILABLE IN THE ER AND NEAR THE ADMISSION DESK. A SIGN IS POSTED IN THE ADMISSIONS AREA TO INFORM PATIENTS THAT FINANCIAL ASSISTANCE IS AVAILABLE. THE HOSPITAL PROVIDES A COPY OF THE POLICY, SUMMARY AND APPLICATION TO PATIENTS WHO MAY QUALIFY UNDER THE FINANCIAL ASSISTANCE POLICY. THE FA POLICY, SUMMARY AND APPLICATION ARE ALSO LOCATED AT THE COUNTY WELFARE OFFICE. LESS THAN FIVE PERCENT OF THE POPULATION, AND FEWER THAN 1,000 INDIVIDUALS IN THE SERVICE AREA SPEAK A LANGUAGE OTHER THAN ENGLISH AS THEIR PRIMARY LANGUAGE. HOWEVER, A TRANSLATION SERVICE IS AVAILABLE IF NEEDED. COMMUNITY MEMORIAL HOSPITAL, INC PART V, SECTION B, LINE 24: THE HOSPITAL FACILITY MAY HAVE CHARGED FAP ELIGIBLE INDIVIDUALS AN AMOUNT EQUAL TO GROSS CHARGES FOR SERVICES THAT ARE NOT COVERED UNDER THE FINANCIAL ASSISTANCE POLICY. PART I, LINE 3C: INDIVIDUALS WILL NOT BE DENIED CHARITY CARE BASED ON RACE, CREED, SEX, NATIONAL ORIGIN, DISABILITY, AGE OR ABILITY TO PAY. BUSINESS OFFICE STAFF TRY TO IDENTIFY ELIGIBLE INDIVIDUALS AT THE TIME OF ADMISSION, HOWEVER INDIVIDUALS CAN BECOME ELIGIBLE FOR CHARITY CARE AT ANY POINT DURING OR AFTER THEIR MEDICAL ENCOUNTER. ONCE AN INDIVIDUAL IS IDENTIFIED AS A POTENTIAL CHARITY CARE RECIPIENT, COMMUNITY MEMORIAL HOSPITAL UTILIZES BOTH AN INCOME AND AN ASSET TEST TO EVALUATE ELIGIBILITY FOR CHARITY CARE. THE HOSPITAL REVIEWS A SCHEDULE OF THE PATIENT'S CURRENT INCOME AND EXPENSES AND ASSET LEVELS TO DETERMINE IF THE PATIENT CAN REASONABLY BE EXPECTED TO MAKE PAYMENT OF MEDICAL EXPENSES. A DETERMINATION BASED ON PRESUMPTIVE ELIGIBILITY MAY BE MADE IF 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. LINE 7E WAS OBTAINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINES 7B AND 7G WAS OBTAINED FROM THE MEDICAID AND MEDICARE COST REPORTS, RESPECTIVELY.RURAL HEALTH CLINIC NET REVENUES OF $682,509 AND COSTS OF $987,491 WERE INCLUDED ON LINE 7G FOR A NET COMMUNITY SHORTFALL OF $304,984. PART III, LINE 2: THE AMOUNT ON LINE 2 REPRESENTS IMPLICIT PRICE CONCESSIONS. THE ORGANIZATION DETERMINES ITS ESTIMATE OF IMPLICIT PRICE CONCESSION BASED ON ITS HISTORICAL COLLECTION EXPERIENCE WITH THIS CLASS OF PATIENTS. PART III, LINE 3: THE ORGANIZATION BELIEVES A SMALL AMOUNT OF THE IMPLICIT PRICE CONCESSIONS AMOUNT MAY BE ATTRIBUTABLE TO CHARITY CARE. A PERCENTAGE OF CHARITY CARE TO NET PATIENT REVENUE WAS USED TO DETERMINE THE AMOUNT OF IMPLICIT PRICE CONCESSION THAT MAY HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE. PART III, LINE 4: FOOTNOTE FROM FINANCIAL STATEMENTS: PLEASE SEE NOTE 1, FINANCIAL STATEMENT, PATIENT SERVICE REVENUE ON PAGES 11-12. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 12/31/2020. MEDICAL SERVICES ARE PROVIDED TO PATIENTS WITH MEDICARE COVERAGE REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED. PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE VITALLY NEEDED BY OUR COMMUNITY. PART III, LINE 9B: ONCE A DECISION HAS BEEN MADE GRANTING FINANCIAL ASSISTANCE AND THE PATIENT/GUARANTOR HAS BEEN NOTIFIED, CMH WILL NO LONGER ATTEMPT TO COLLECT THE DISCOUNTED AMOUNT. IF, DURING THE COLLECTION PROCESS, IT IS DETERMINED THAT SOMEONE MAY QUALIFY FOR FINANCIAL ASSISTANCE, THE COLLECTION PROCESS STOPS AND THE FINANCIAL ASSISTANCE APPLICATION PROCESS BEGINS. COLLECTION IS HALTED UNTIL THE FINANCIAL ASSISTANCE APPLICATION IS REVIEWED AND QUALIFICATION IS DETERMINED. APPROVED FINANCIAL ASSISTANCE REQUESTS WILL BE WRITTEN OFF WITHIN TEN DAYS FROM THE DATE APPROVED. THE DECISION TO WRITE OFF THE ACCOUNT IS PERMANENT. PART VI, LINE 2: COMMUNITY MEMORIAL HOSPITAL CONDUCTED A FORMAL COMMUNITY NEEDS ANALYSIS DURING 2019. IN ADDITION TO CONDUCTING THE NEEDS ASSESSMENT EVERY THREE YEARS, ADMINISTRATION MEETS WITH PROVIDERS AND CLINIC MANAGERS MONTHLY AND WITH THE MEDICAL STAFF GROUP BI-MONTHLY. DURING THESE MEETINGS, TOPICS FROM PATIENT INTERACTIONS ARE DISCUSSED TO IDENTIFY ANY COMMUNITY HEALTH NEEDS. PART VI, LINE 3: INDIVIDUALS ARE MADE AWARE OF FINANCIAL ASSISTANCE THROUGH POSTING OF THE POLICY AND APPLICATION IN THE ER, CLINIC, AND ADMISSIONS OFFICE. STAFF IN THE ADMISSIONS OFFICE PROVIDE INFORMATION TO INDIVIDUALS WHO MAY QUALIFY FOR MEDICARE, MEDICAID, OR OTHER FINANCIAL ASSISTANCE.THE FINANCIAL ASSISTANCE POLICY AND APPLICATION ARE ALSO AVAILABLE ON THE FACILITY WEBSITE. PART VI, LINE 4: COMMUNITY MEMORIAL HOSPITAL SERVES SEVERAL COMMUNITIES IN SOUTH CENTRAL SOUTH DAKOTA AND NORTH CENTRAL NEBRASKA. WE SERVE A RURAL POPULATION THAT IS VERY HOMOGENEOUS IN COMPOSITION. THE AREAS SERVED ARE PRIMARILY FARMING/RANCHING AND RETIREMENT COMMUNITIES. WE HAVE A VERY LOW PERCENTAGE OF UNINSURED RESIDENTS IN OUR AREA. WE ARE LOCATED IN A FEDERAL HEALTH PROFESSIONAL SHORTAGE AREA. 67% OF THE ORGANIZATION'S REVENUE WAS FROM SERVING THE MEDICARE POPULATION, 6% WAS FROM TITLE 19, 19% FROM COMMERCIAL INSURANCE, AND 8% FROM OTHER PAYERS AND SELF-PAY. PART VI, LINE 5: THE GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION. FAMILY MEMBERS OF SOME OF THE MEMBERS OF THE GOVERNING BODY ARE EMPLOYED BY THE ORGANIZATION DUE TO THE SMALL POPULATION OF THE COMMUNITY. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY. SURPLUS FUNDS, IF ANY, ARE REINVESTED FOR FACILITY AND EQUIPMENT UPGRADES, AND IMPROVING TECHNICAL SKILLS OF EMPLOYEES. COMMUNITY MEMORIAL HOSPITAL PROVIDES THE FOLLOWING TYPES OF COMMUNITY EDUCATION:A HEALTH FAIR IS PROVIDED SEMI-ANNUALLY FOR THE COMMUNITY WITH MANY DIFFERENT ASPECTS OF HEALTH CARE REPRESENTED. BLOOD DRAWS, BLOOD PRESSURES, GLUCOSE TESTING, AND DIFFERENT SCREENING TESTS ARE JUST A FEW OF THE SERVICES OFFERED BY THE HEALTH FAIR. IN ADDITION, EDUCATION FOR ALL SCHOOL AGES IS PROVIDED DURING A WEEK OF ACTIVITIES AT THE HOSPITAL. ACTIVITIES INCLUDE: TOURS OF DIFFERENT DEPARTMENTS, HAND WASHING TECHNIQUES, POISON CONTROL EDUCATION, AND A TEDDY BEAR CLINIC WHICH ENTAILS A TRIP TO THE EMERGENCY DEPARTMENT WITH THE TEDDY BEAR BEING THE PATIENT AND THE STUDENT BEING THE PARENT DESCRIBING THE COMPLAINTS. COMMUNITY MEMORIAL HOSPITAL ALSO PROVIDES CPR TRAINING TO BOTH THE STAFF AND COMMUNITY MEMBERS. DISASTER PREPAREDNESS TRAINING IS PROVIDED TO THE LOCAL FIRE DEPARTMENT. ADVANCED CARDIAC LIFE SUPPORT (ACLS) CLASSES AND TRAUMA NURSE CURRICULUM COURSES (TNCC) ARE PROVIDED TO STAFF AS WELL AS NURSES FROM SURROUNDING COMMUNITIES. COMMUNITY MEMORIAL HOSPITAL SPONSORS DIFFERENT ACTIVITIES IN THE COMMUNITY AS WELL AS PARTICIPATES IN COMMUNITY PROJECTS, INCLUDING SCHOOL YEAR BOOK, AFTER PROM PARTY, PARADES AND OTHER COMMUNITY EVENTS. A GREAT DEAL OF PRIDE IS TAKEN IN THE COMMUNITY WITH THE COMMUNITY GIVING AS MUCH TO THE HOSPITAL AS THE HOSPITAL GIVES BACK TO THE COMMUNITY. DEBRA LEIBEL FAMILY MEMBER OF TOM GLOVER, BOARD CHAIRMAN 116662 WAGES AND BENEFITS 0 AMANDA STEFFEN FAMILY MEMBER OF MISTIE DREY, CEO 18233 WAGES AND BENEFITS 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL INCLUDE FIVE MEMBERS ALL OF WHOM SHALL BE MEMBERS OF THE BOARD OF DIRECTORS, AND SHALL INCLUDE THE CHAIR, THE VICE CHAIR, SECRETARY, AND THE ADMINISTRATOR. THE EXECUTIVE COMMITTEE SHALL HAVE THE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE INTERIM BETWEEN MEETINGS OF THE BOARD, PROVIDED THAT ANY ACTION TAKEN BY THE EXECUTIVE COMMITTEE SHALL NOT CONFLICT WITH THE ARTICLES OF INCORPORATION, THE BYLAWS OR THE POLICIES OR EXPRESSED WISHES OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 3 COMMUNITY MEMORIAL HOSPITAL HAS ENTERED INTO A MANAGEMENT AGREEMENT WITH SANFORD HEALTH NETWORK TO PROVIDE MANAGEMENT SERVICES FOR THE FACILITY. THE CEO OF COMMUNITY MEMORIAL HOSPITAL IS AN EMPLOYEE OF SANFORD HEALTH NETWORK. COMPENSATION AND BENEFITS FOR MISTIE DREY WERE $127,498 AND $34,313 RESPECTIVELY. DUTIES OF THE CEO INCLUDE: SUPPORTING FACILITY OPERATIONS AND ADMINSTRATION, RECOMMENDING BUDGETS AND MANAGING RESOURCES ACCORDINGLY, AND OVERSEEING DESIGN AND DELIVERY OF QUALITY PROGRAMS, PRODUCTS, AND SERVICES. FORM 990, PART VI, SECTION A, LINE 6 COMMUNITY MEMORIAL HOSPITAL HAS ONE CLASS OF GENERAL MEMBERSHIP. THE GENERAL MEMBERSHIP INCLUDES ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION WHO HAS CONTRIBUTED TO THE COMMUNITY MEMORIAL HOSPITAL BUILDING FUND OR CLINIC FUND AND WHO RESIDES IN THE FOUR-COUNTY AREA OF GREGORY AND TRIPP COUNTIES OF SOUTH DAKOTA AND KEYA PAHA AND BOYD COUNTIES IN NEBRASKA. THESE MEMBERSHIPS SHALL BE FOR THE LIFE OF THE CONTRIBUTOR AND ARE NOT TRANSFERABLE. IN ADDITION, ANY PATIENT OF THE HOSPITAL WHO HAS PAID THE HOSPITAL BILL IN FULL UPON DISCHARGE OR SHORTLY THEREAFTER AND WHO RESIDES IN THE PREVIOUSLY MENTIONED FOUR-COUNTY AREA SHALL BE A MEMBER OF THIS CORPORATION FOR THREE YEARS FROM THE DATE OF SAID PAYMENT IN FULL. ALSO, ALL MEMBERS OF THE LADIES AUXILIARY TO THE COMMUNITY MEMORIAL HOSPITAL, INC., OF BURKE, SOUTH DAKOTA, SHALL BE MEMBERS WITH FULL VOTING RIGHTS. PRESENT EMPLOYEES SHALL NOT BE CONSIDERED ELIGIBLE TO SERVE ON THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A GOVERNING BOARD MEMBERS ARE ELECTED BY THE MEMBERSHIP. FORM 990, PART VI, SECTION A, LINE 7B APPROVAL BY THE MEMBERS OF THE ORGANIZATION IS REQUIRED TO: ESTABLISH MISSION STATEMENT APPROVE THE SALE OF REAL PROPERTY ELECT OR REMOVE THE BOARD OF DIRECTORS APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION REVIEW THE ANNUAL REPORT AND FINANCIAL AUDIT ESTABLISH SERVICES TO MEET THE NEEDS OF THE COMMUNITY THE MEMBERS MAY DELEGATE THE ABOVE AUTHORITIES BY CONTRACT, AS THE MEMBERS DEEM NECESSARY AND APPROPRIATE. FORM 990, PART VI, SECTION A, LINE 8B THE EXECUTIVE COMMITTEE DID NOT MEET IN 2020. FORM 990, PART VI, SECTION B, LINE 11B THE CEO DOES A DETAILED REVIEW OF THE FORM 990. TWO BOARD MEMBERS ALSO PERFORM A DETAILED REVIEW OF THE 990. A COPY OF THE 990 IS DISTRIBUTED TO ALL BOARD MEMBERS PRIOR TO FILING OF THE FORM WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST DISCLOSURE IS REQUIRED TO BE COMPLETED BI-ANNUALLY AND RESPONSES ARE REVIEWED BY THE CEO. IF A CONFLICT IS DEEMED TO EXIST, THE MEMBER(S) INVOLVED IS REQUIRED TO ABSTAIN FROM DISCUSSION, DELIBERATION, AND VOTING ON THE MATTER CAUSING THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15A SANFORD HEALTH NETWORK REVIEWS AND DETERMINES THE CEO'S COMPENSATION ANNUALLY. COMPENSATION RANGES ARE DETERMINED USING STATE SALARY SURVEY RESULTS. THE PROCESS AND DECISION IS DOCUMENTED AND MAINTAINED INTERNALLY BY SANFORD'S VP OF ADMINISTRATION. THE BOARD OF DIRECTORS OF COMMUNITY MEMORIAL HOSPITAL, INC, APPROVES THE AMOUNT OF THE CEO'S COMPENSATION THROUGH THEIR ACCEPTANCE OF THE MANAGEMENT AGREEMENT. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE DISTRIBUTED AT THE ANNUAL MEMBERSHIP MEETING, AND OTHER ITEMS ARE PROVIDED UPON REQUEST. FORM 990, PART VII: MISTIE DREY (CEO) UNDER MANAGEMENT AGREEMENT WITH SANFORD HEALTH NETWORK ACTS AS BOTH THE TOP MANAGEMENT OFFICIAL AND THE TOP FINANCIAL OFFICIAL. FORM 990, PART IX, LINE 11G CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 1,087,393. MANAGEMENT AND GENERAL EXPENSES 34,877. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,122,270. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,958. MANAGEMENT AND GENERAL EXPENSES 38,418. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 40,376.