2020-02-07T06:48:01-06:00 2019-06-30 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2018-07-01 460226283 WAGNER COMMUNITY MEMORIAL HOSPITAL WAGN 6053843611 513 THIRD STREET SW WAGNER SD 573800280 BRYAN SLABA CEO 6053843611 2020-02-06 1 LAURIE HANSON P00851848 6053391999 2020-02-06 67.130.171.59 2020-02-06 13:08:27 CS P C5ADF3E96DC5FD5E5884512D59AB882B10EDFEC1 8529E270CED9BF05DA3D232CE7794E4FD1825D85 2018 2020-09-22 18:59:49Z BRYAN SLABA 513 THIRD STREET SW WAGNER SD 573800280 10555413 0 X WWW.AVERA.ORG/WAGNERHOSPITAL/ X 1947 SD TO PROVIDE HEALTHCARE SERVICES. 8 7 85 9 0 0 13200 21370 9471249 10358404 170905 156737 18052 18902 9673406 10555413 7002 7464 0 0 4495752 5124190 0 0 0 4667103 4927270 9169857 10058924 503549 496489 11769791 12488638 5232294 5423465 6537497 7065173 X WAGNER COMMUNITY MEMORIAL HOSPITAL'S MISSION IS TO PROVIDE CARE AND TREATMENT OF THE SICK; PROVIDE CARE AND SUPPORT OF THE AGED, DISABLED, AND INDIGENT; AND TO PROVIDE FOR THOSE IN NEED OF HOSPITALIZATION REGARDLESS OF RACE, COLOR, CREED, OR ABILITY TO PAY. 0 0 8645620 7464 10358404 WCMH IS A 20 BED CRITICAL ACCESS HOSPITAL EQUIPPED WITH EXTENSIVE ADVANCED SERVICES, INCLUDING AREAS FOR MEDICAL/SURGICAL, PEDIATRIC, INTENSIVE/CORONARY CARE, AND SWING BED/LONG TERM CARE. THE CLINIC IS ADJACENT TO THE HOSPITAL MAKING IT CONVENIENT TO SEE HOSPITAL PATIENTS, AND SHARE LABORATORY SERVICES AND OTHER DIAGNOSTIC EQUIPMENT. OUTREACH SERVICES INCLUDE OB/GYN, PEDIATRICS, ORTHOPEDIC SURGERY, GENERAL SURGERY, UROLOGY, PODIATRY, ENT & AUDIOLOGY. THE PEOPLE OF THE COMMUNITY TRULY BELIEVE IN HAVING ACCESS TO CARE AND SUPPORT THEIR LOCAL MEDICAL PROVIDERS. THE FACILITY SERVES AS THE INPATIENT UNIT FOR THE LOCAL INDIAN HEALTH SERVICES CLINIC AND WORKS COLLABORATIVELY WITH THE IHS PHYSICIANS AND LEADERS TO CARE FOR THE NATIVE AMERICAN POPULATION. WCMH EXPERIENCED 363 INPATIENT DAYS, 522 SWING BED DAYS, 2,063 EMERGENCY DEPARTMENT VISITS, AND 3,101 CLINIC VISITS. 8645620 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 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 0 0 0 0 1 24 0 1 85 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 7 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X X LISA WEISSER 6053843611 513 3RD STREET SW WAGNER SD 573800280 X DAVID KOTAB BOARD PRESIDENT 0.50 X X 0 0 0 BILL FREI BOARD VICE PRESIDENT 0.50 X X 0 0 0 CHAD PETERS BOARD SECRETARY/TREASURER 0.50 X X 0 0 0 MITCHEL BREEN DIRECTOR 0.50 X 0 0 0 JANICE COLEMAN DIRECTOR (UNTIL MAR 2019) 0.50 X 0 0 0 STEVEN COTTON DIRECTOR 0.50 X 0 0 0 ANN FREIER-METZGER DIRECTOR 0.50 X 0 0 0 KAREN SOULEK DIRECTOR 0.50 X 0 0 0 RACHEL WOODS DIRECTOR 0.50 X 0 0 0 BRYAN SLABA CEO/ADMINISTRATOR 40.00 X 180997 0 18401 JESSICA VANDERHAM NURSE PRACTITIONER 40.00 X 132710 0 29873 LINDSEY NEDVED NURSE PRACTITIONER 40.00 X 122278 0 31342 JORDAN WEBER PHYSICIANS ASSISTANT 40.00 X 127717 0 11925 563702 0 91541 4 0 1 1 AVERA SACRED HEART HOSPITAL 501 S SUMMIT STREET YANKTON SD 57078 MANAGEMENT, IT, SALARIES 730452 AVERA HEALTH 3900 W AVERA DR STE 301 SIOUX FALLS SD 57108 MAINTENANCE, CREDENTIALING, TELEMEDICINE 485172 JEFFREY D PINTER MD 27952 323RD AVENUE WINNER SD 57580 PHYSICIAN ER COVERAGE 482970 PHILIP KILMER MD 11332 AVERY RD PALM BEACH GARDENS FL 33410 PHYSICIAN ER COVERAGE 164400 SEES PHYSICAL THERAPY 100 EVERGREEN ST AVON SD 57315 PHYSICAL THERAPY 155005 5 19685 1685 21370 PATIENT SERVICE FEES 621110 10141213 10141213 PHARMACY REVENUE 900099 172342 172342 44849 44849 10358404 7955 7955 18902 0 18902 18902 18902 148782 0 148782 148782 148782 10555413 10358404 0 175639 X 7464 7464 214538 214538 31665 31665 4072114 3623641 448473 85018 73685 11333 431207 373727 57480 289648 251038 38610 2413 2413 50750 50750 1634939 1339219 295720 26123 26123 362286 299087 63199 57463 19807 37656 151738 151738 54113 47412 6701 37323 26600 10723 217050 217050 525126 488288 36838 52704 52704 MEDICAL SUPPLIES 884457 884390 67 BAD DEBT 519005 519005 REPAIRS AND MAINTENANCE 252474 249519 2955 99306 42285 57021 10058924 8645620 1413304 0 435799 670458 1776391 1406171 127494 144223 81313 69445 12482057 7590477 5214196 4891580 3709349 4937738 73208 75585 352041 293438 11769791 12488638 423196 650519 4809098 4679546 0 93400 5232294 5423465 X 6537497 7065173 6537497 7065173 11769791 12488638 496489 31187 0 X 0 1 X 1 0 X 4247 4247 8821483 4747145 4074338 3314075 2655539 658536 342252 187793 154459 4891580 ASSETS LIMITED AS TO USE - AVERA POOLED INVESTMENTS 4937738 F 4937738 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 93400 93400 X 10067595 31187 -519005 -487818 10555413 0 10555413 9539919 0 9539919 519005 519005 10058924 PART X, LINE 2: THE HOSPITAL IS ORGANIZED AS A SOUTH DAKOTA NONPROFIT CORPORATION AND HAS BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE HOSPITAL HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -519,005. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 519,005. 1 1 X 1 X 1 X 1 1 1 0 0 251900 251900 0.02500 1475102 1343636 131466 0.01310 1727002 1343636 383366 0.03810 10 940 19154 19154 0.00190 2 4 3155 3155 0.00030 1 783 2478249 1106342 1371907 0.13640 2 1596 4456 4456 0.00040 15 3323 2505014 1106342 1398672 0.13900 15 3323 4232016 2449978 1782038 0.17710 1 28 1522 1522 0.00020 2 449 908 908 0.00010 3 477 2430 2430 0.00030 0 519005 150511 3433525 3447011 -13486 X 1 1 1 1 WAGNER COMMUNITY MEMORIAL HOSPITAL PO BOX 280 WAGNER SD 57380 WWW.AVERA.ORG/WAGNERHOSPITAL/ 10571 X X X X WAGNER COMMUNITY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X SEE LINE 7D NARRATIVE X X 1 18 1 SEE LINE 7D NARRATIVE 0 1 X 150.000000000000 400.000000000000 X X X 1 1 X X X X 1 X SEE 16J NARRATIVE X SEE 16J NARRATIVE X SEE 16J NARRATIVE X X X X X X X 1 X 0 X X X X 1 X 0 0 WAGNER COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE WAGNER COMMUNITY MEMORIAL HOSPITAL-AVERA REPRESENTATIVES REACHED OUT TO LOCAL COMMUNITY MEMBERS AND LEADERS TO DEVELOP A COMMUNITY FOCUS GROUP USED IN CONDUCTING THE MOST RECENT NEEDS ASSESSMENT. THE ORGANIZATIONS INCLUDED THE AMERICAN INDIAN POPULATION AND A FOCUS GROUP CONSISTING OF REPRESENTATIVES FROM WAGNER GOOD SAMARITAN SOCIETY, WAGNER/LAKE ANDES EMERGENCY MEDICAL SERVICES, WAGNER COMMUNITY MEMORIAL HOSPITAL-AVERA BOARD MEMBERS, WAGNER INDIAN HEALTH SERVICES, YANKTON SIOUX TRIBE, WAGNER POLICE DEPARTMENT AND SDSU EXTENSION. WAGNER COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: THE CHNA REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE AT HTTPS://WWW.AVERA.ORG/LOCATIONS/WAGNER-COMMUNITY-MEMORIAL-HOSPITAL-AVERA/ WAGNER COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: PURSUANT TO THE IMPLEMENTATION STRATEGY ADOPTED BY WAGNER COMMUNITY MEMORIAL HOSPITAL, MENTAL HEALTH SERVICES, SUBSTANCE ABUSE, DIABETES, OBESITY AND VIOLENCE WERE IDENTIFIED AS COMMUNITY NEEDS. IN RESPONSE TO THE IDENTIFIED NEEDS, THE FACILITY ACCOMPLISHES THE FOLLOWING ACTIVITIES ANNUALLY:1. MENTAL HEALTH SERVICES: WCMH HAS CONTRACTED WITH AVERA MEDICAL GROUP TO PROVIDE BEHAVIORAL HEALTH CLINICS FOR BOTH MEDICAL AND THERAPY NEEDS. CURRENTLY THE MEDICAL PROVIDER IS IN THE CLINIC ONCE A MONTH AND THE THERAPY CLINIC IS AVAILABLE TWICE A MONTH. ADDITIONAL DAYS WILL BE ADDED TO BOTH PROVIDERS AS THEIR SCHEDULES ALLOW.2. SUBSTANCE ABUSE: WCMH PRESENTED SUBSTANCE ABUSE RESOURCES AT NURSE AND PROVIDER MEETINGS BI-ANNUALLY. INCREASED UTILIZATION OF TELEMEDICINE SERVICES THROUGH EADDICTION, ETRIAGE ETC. HAS RESULTED IN IMPROVING REFERRAL TIME FOR OUTPATIENT SUBSTANCE ABUSE EVALUATIONS. 3. DIABETES: WCMH PROVIDES DIABETIC EDUCATION BY PROVIDING DIABETIC INFORMATIONAL PACKETS FOR CURRENT AND FUTURE DIABETIC AND PRE-DIABETIC PATIENTS. BY INCREASING PATIENTS' KNOWLEDGE OF DIABETES, IMPROVEMENTS CAN BE MADE TO THEIR QUALITY OF LIFE. WCMH PROVIDERS WILL REFER PATIENTS WHO QUALIFY FOR IHS BENEFITS TO THE IHS DIABETIC EDUCATION PROGRAM. A WCMH DIETICIAN WILL BE USED AS A RESOURCE. WCMH NURSES WILL INFORM PATIENTS THAT GLUCOSE METERS ARE AVAILABLE IN TOWN AT JAMES DRUG FOR PURCHASE OR AT IHS, TO THOSE WHO QUALIFY FOR BENEFITS. 4. OBESITY: WCMH PARTICIPATES IN THE WAGNER AREA HEALTH AND WELLNESS CONSORTIUM, WHO'S OBJECTIVE IS TO COMBINE THE RESOURCES OF EACH ENTITY TO MAXIMIZE THE HEALTH AND WELLNESS OPPORTUNITIES FOR WAGNER AND THE SURROUNDING COMMUNITIES. THE CONSORTIUM EMPHASIZES YOUTH EDUCATION AND ACTIVITIES TO PROMOTE IMPROVED HEALTH AND WELLNESS NOW AND IN THE FUTURE. WCMH WILL CONTINUE TO EDUCATE THEIR PATIENTS ON A HEALTHY DIET BY COORDINATING WITH SDSU EXTENSION TO ESTABLISH HEALTHY COOKING AND EATING EDUCATION.5. VIOLENCE: WCMH SHARES THE COMMUNITY'S CONCERNS ON VIOLENCE. WCMH DOES TAKE PART IN ANNUAL COMPETENCY TRAINING WHICH INCLUDES A SECTION ON VIOLENCE AND HOW TO DEAL WITH PATIENTS PRESENTING THESE ISSUES. VIOLENCE CONCERNS HAVE BEEN SHARED WITH LAW ENFORCEMENT. WAGNER COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE USED AS A LAST RESORT. WAGNER COMMUNITY MEMORIAL HOSPITAL PART V, SECTION B, LINE 16J: PART V, LINE 16A, FAP WEBSITE:HTTPS://WWW.AVERA.ORG/LOCATIONS/WAGNER-COMMUNITY-MEMORIAL-HOSPITAL-AVERA/PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTPS://WWW.AVERA.ORG/LOCATIONS/WAGNER-COMMUNITY-MEMORIAL-HOSPITAL-AVERA/PART V, LINE 16C, FAP PLAIN LANGUAGE SUMMARY WEBSITE:HTTPS://WWW.AVERA.ORG/LOCATIONS/WAGNER-COMMUNITY-MEMORIAL-HOSPITAL-AVERA/PART V, LINE 16I: THE REFERENCE TO THE POLICY AND ITS LOCATION IS SENT WITH ALL STATEMENTS. WAGNER COMMUNITY 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. PART I, LINE 3C: THE HOSPITAL MAY USE PRESUMPTIVE ELIGIBILITY AS A LAST RESORT. 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. LINES 7E, 7F AND 7I WERE OBTAINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINE 7B WAS CALCULATED BASED ON THE ALLOCATION OF EXPENSES PER PAYER MIX PERCENTAGES. LINE 7G WAS OBTAINED FROM THE MEDICARE COST REPORT. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDED PROVIDER BASED CLINIC REVENUE OF $677,895 LESS EXPENSE OF $1,113,591, FOR A NET BENEFIT OF $435,696. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $519,005 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II, COMMUNITY BUILDING ACTIVITIES: PART II INCLUDES:WCMH HOSTED AN 8TH GRADE CAREER FAIR FOR REGION SCHOOLS. THE GOAL OF THE CAREER FAIR IS TO EXPOSE STUDENTS TO THE TECHNICAL SKILLS AND EDUCATION NEEDED TO BE SUCCESSFUL IN BUSINESS AND INDUSTRY.SOC - STRENGTHENING OUR COMMUNITY. SOC IS A PROJECT OF THE AWARE ADVISORY COMMITTEE THAT IS MADE UP OF A CROSS-SECTION OF COMMUNITY MEMBERS WHOSE GOAL IS TO BUILD RELATIONSHIPS AND CREATE CAPACITY TO BECOME A SELF-HEALING COMMUNITY WITH A FOCUS ON MENTAL HEALTH WELL-BEING. PART III, LINE 2: BAD DEBT RECOVERIES AND DISCOUNTS APPLIED DURING THE COLLECTION PROCESS ARE RARE, BUT WHEN THEY DO OCCUR THEY ARE POSTED AGAINST THE BAD DEBT ACCOUNT. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON THE PERCENTAGE OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN 2018. THEREFORE, 29% CAN REASONABLY BE CONSIDERED A COMMUNITY BENEFIT AS IT WOULD HAVE BEEN WRITTEN OFF TO CHARITY CARE. PART III, LINE 4: THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT EXPENSE IS ON PAGES 6 AND 7 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING 6/30/2019.MANY PATIENTS IN OUR SERVICE AREA QUALIFY FOR MEDICARE. THE FACILITY PROVIDES SERVICES TO THESE PATIENTS EVEN THOUGH MEDICARE REIMBURSEMENT IS NOT SUFFICIENT TO COVER THE COST OF PROVIDING THIS CARE. PROVIDING SERVICES TO THIS POPULATION PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH ARE NEEDED IN OUR COMMUNITY, THEREBY PROVIDING A BENEFIT TO OUR COMMUNITY.TOTAL REVENUE RECEIVED FROM MEDICARE AND THE MEDICARE ALLOWABLE COSTS ARE REPORTED FROM THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY THE CENTERS FOR MEDICAID AND MEDICARE SERVICES. PART III, LINE 9B: THE COLLECTION PRACTICES AS SET FORTH IN THE POLICY REQUIRES THAT IF A PATIENT QUALIFIES FOR CHARITY CARE, NO BILL WILL BE SENT. INSTEAD, A LETTER INDICATING THAT THE PATIENT'S BILL HAS BEEN COMPLETELY FORGIVEN WILL BE SENT. WHEN SENDING A BILL TO ANY PATIENT, THE ORGANIZATION SHALL INCLUDE ON THE BILL A STATEMENT THAT INDICATES THAT IF THE PATIENT MEETS CERTAIN INCOME REQUIREMENTS THE PATIENT MAY BE ELIGIBLE FOR A GOVERNMENT-SPONSORED PROGRAM OR FOR FINANCIAL ASSISTANCE FROM THE ORGANIZATION FOR HELP IN PAYING FOR THE SERVICES THAT WERE PROVIDED, AND A STATEMENT THAT PROVIDES THE PATIENT WITH AN ORGANIZATION CONTACT RESOURCE FROM WHICH THE PATIENT MAY OBTAIN INFORMATION ABOUT THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS AND HOW TO APPLY FOR SUCH ASSISTANCE FOR THE PAYMENT OF SERVICES THAT WERE PROVIDED.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 A REASONABLE TIME PERIOD, THE ORGANIZATION OR ITS AGENT SHALL NOT SEND, NOR INTIMATE THAT IT WILL SEND, THE UNPAID BILL TO ANY OUTSIDE COLLECTION AGENCY. AT SUCH TIME AS THE ORGANIZATION SENDS THE UNCOLLECTED ACCOUNT TO AN OUTSIDE COLLECTION AGENCY, THE AMOUNT REFERRED TO THE AGENCY SHALL REFLECT THE REDUCED-PAYMENT LEVEL FOR WHICH THE PAITENT WAS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS. WCMH DOES NOT REPORT ANY DATA TO ANY OF THE CREDIT AGENCIES, HOWEVER, THE COLLECTION AGENCIES WCMH UTILIZES MAY REPORT TO THE CREDIT AGENCIES. PART VI, LINE 2: IN ADDITION TO PREPARING A COMMUNITY HEALTH NEEDS ASSESSMENT DURING THE FISCAL YEAR ENDED JUNE 30, 2019, WCMH DETERMINES PATIENT NEEDS THROUGH CONSTANT COMMUNICATION WITH PATIENTS, PRIMARY AND SPECIALTY PROVIDERS, AND STATE AND FEDERAL GOVERNMENTAL HEALTH AGENCIES. WCMH STRIVES TO CONSISTENTLY INVESTIGATE, ANALYZE, AND DETERMINE THE GREATEST NEEDS OF OUR COMMUNITY. PART VI, LINE 3: AT EACH POINT OF ADMISSION, NOTICES ARE POSTED STATING WCMH OFFERS FINANCIAL ASSISTANCE WITH CONTACT INFORMATION. REFERENCE TO THE POLICY IS GIVEN TO THE PATIENT UPON ADMISSION AND AGAIN WITH THE NOTICE/STATEMENT FOR PAYMENT, INCLUDING CONTACT INFORMATION. IF THE PATIENT EXPRESSES INTEREST IN FINANCIAL ASSISTANCE, A PATIENT ADVOCATE WILL ASSIST IN COMPLETING THE PROPER APPLICATION. PART VI, LINE 4: WAGNER IS A RURAL COMMUNITY LOCATED IN SOUTHERN CHARLES MIX COUNTY OF SOUTH DAKOTA WHICH HAS MANY HEALTH DISPARITIES WITH UNMET NEEDS. IF ONE LOOKS AT SOUTHERN CHARLES MIX COUNTY, THE AVERAGE INDIVIDUAL INCOME IS $22,848.00 WITH THE MEDIAN FAMILY INCOME AT $29,228.00. COMPARED TO THE NATIONAL AVERAGE OF $32,397.00 AND $73,891.00. INHABITANTS BELOW THE POVERTY LEVEL TOTAL 29%. COUNTY EDUCATION DEMOGRAPHICS INCLUDE 87.3% OF RESIDENTS HAVING A HIGH SCHOOL DEGREE AND 17.2% HOLDING A BACHELOR'S DEGREE IN COMPARISON TO THE NATIONAL AVERAGE OF 90% AND 31.6%. ACCORDING TO THE US CENSUS BUREAU FACT FINDER MOST RECENT DATA, 31.9% OF RESIDENTS IN THE COUNTY ARE OF AMERICAN INDIAN DESCENT AS COMPARED TO THE NATIONAL AVERAGE OF .08%. ALL OF CHARLES MIX COUNTY IS CONSIDERED MEDICALLY UNDERSERVED BY THE HRSA OF THE SD DEPARTMENT OF HEALTH. THE SERVICE AREA IS ALSO CONSIDERED A HEALTH PROFESSIONAL SHORTAGE AREA WITH FEW PROVIDERS AND MANY MILES IN BETWEEN THESE RURAL COMMUNITIES. IN 2008, THE IHS EMERGENCY ROOM CLOSED PUTTING A BURDEN ON THE WAGNER FACILITY UNTIL A NEW CLINIC WAS BUILT BY THE WAGNER HOSPITAL. THERE ARE ONLY A FEW RURAL HEALTH CLINICS AVAILABLE IN ADDITION TO THE IHS CLINIC AND THE VA FACILITY. MANY CLINICS PROVIDE ONLY PRIMARY CARE SERVICES AND ARE OFTEN STAFFED BY PHYSICIAN ASSISTANTS. IN CASES WHERE MORE SPECIALIZED CARE IS NEEDED, PATIENTS HAVE THE OPTION TO TRAVEL TO YANKTON, SD WHICH IS A 108 MILE ROUND TRIP OR TRAVEL 222 MILES ROUND TRIP TO SIOUX FALLS, SD WHICH IS THE AREA'S TERTIARY CARE HUB FOR ALL TYPES OF SPECIALTY CARE. IN ADDITION TO THE SHORTAGE OF QUALITY HEALTH CARE SERVICES, RESIDENTS OF SOUTHERN CHARLES MIX COUNTY ALSO SUFFER FROM MANY CHRONIC HEALTH CONDITIONS. THE PERCENT OF THE POPULATION OVER 65 YEARS OF AGE IS ALMOST DOUBLE THE NATIONAL AVERAGE IN MORE THAN HALF OF THE COUNTY. THE DISABILITY STATUS OF THE COUNTY'S INHABITANTS IS CONSISTENT WITH THE NATIONAL AVERAGE OF 12.8%. GAPS EXIST AMONG SOCIOECONOMIC GROUPS IN THE RATE OF DIABETES AND ITS ASSOCIATED COMPLICATIONS IN SOUTH DAKOTA AS WELL AS THROUGHOUT THE UNITED STATES. CERTAIN RACIAL AND ETHNIC COMMUNITIES INCLUDING AMERICAN INDIANS, AS WELL AS ECONOMICALLY DISADVANTAGED OR OLDER PEOPLE, SUFFER DISPROPORTIONATELY COMPARED TO OTHER POPULATIONS. SOUTHERN CHARLES MIX COUNTY SERVICE AREA IS 46.5% AMERICAN INDIAN COMPARED TO THE STATE WHICH IS AT 8.7%. PART VI, LINE 5: WCMH PROVIDES COMMUNITY HEALTH IMPROVEMENT SERVICES WHICH INCLUDE: COMMUNITY CPR CLASSES; BLOOD PRESSURE SCREENINGS AT AREA EVENTS; AWARD SCHOLARSHIPS TO LOCAL HIGH SCHOOL GRADUATES; DAKOTA SENIOR MEAL DELIVERY FOR LOCAL ELDERLY IN OUR COMMUNITY; DONATION OF CASES OF BOTTLED WATER TO COMMUNITIES THAT WERE EFFECTED BY FLOODING THAT CONTAMINATED THEIR DRINKING WATER; BIKE DONATION TO THE LOCAL BOYS AND GIRLS CLUB TO PROMOTE EXERCISE AND HEALTHY LIVING IN YOUTH.AVERA HEALTH AND WCMH DEDICATE RESOURCES TO ENDEAVORS THAT MAKE A POSITIVE DIFFERENCE TO IMPROVE THE HEALTH OF THE COMMUNITIES THEY SERVE. THESE ACTIVITIES INCLUDE LEADERSHIP DEVELOPMENT AND TRAINING FOR COMMUNITY MEMBERS, ECONOMIC DEVELOPMENT, PHYSICAL IMPROVEMENTS IN THE COMMUNITY, CONTRIBUTIONS TO NONPROFIT COMMUNITY ORGANIZATIONS, NONPROFIT EVENT SPONSORSHIPS, DONATED MEDICAL SUPPLIES, COMMUNITY HEALTH EDUCATION AND SUPPORT GROUPS, HEALTH SCREENINGS, FLU-SHOT CLINICS, COMMUNITY HEALTH EDUCATION AND VARIOUS OTHER ACTIVITIES. PART VI, LINE 6: WCMH IS A MANAGED FACILITY OF AVERA HEALTH. AVERA HEALTH AND THE HOSPITAL WORK COOPERATIVELY TO ENHANCE HEALTHCARE THROUGHOUT THE COMMUNITY SERVED BY THE HOSPITAL. AS A MANAGED FACILITY, WCMH IS ABLE TO PARTICIPATE IN AVERA E-CARE SERVICES. THESE SERVICES INCLUDE AVERA E-EMERGENCY, E-PHARMACY, E-CONSULT, E-HOSPITALIST AND ESANE. THESE SERVICES ALLOW RURAL PATIENTS TO BE CARED FOR AT THEIR LOCAL HOSPITALS, PROVIDE RURAL HOSPITALS ACCESS TO IMMEDIATE SPECIALTY CARE AND SUPPORT, AND HELP REDUCE HEALTH CARE COSTS AND TRAVEL.WCMH ALSO HAS ACCESS TO "BACK OFFICE" SUPPORT SERVICES, SUCH AS LEGAL CONSULTATION, QUALITY BENCHMARKING, CODING, COMPUTER SERVICES, CONTRACT NEGOTIATIONS, ADMINISTRATIVE CONSULTATION, GROUP PURCHASING, HUMAN RESOURCE ASSISTANCE AND MANY OTHER SERVICES. AVERA HEALTH IS ABLE TO PROVIDE THESE SERVICES TO WCMH AT A COST BELOW THAT WHICH THE HOSPITAL COULD OTHERWISE ACHIEVE. IN TURN, LOCAL CAREGIVERS ARE ABLE TO DEVOTE MORE RESOURCES TO PATIENT AND RESIDENT CARE. X X X 0 0 0 0 0 0 0 0 0 BRYAN SLABA CEO/ADMINISTRATOR 179385 0 0 0 1612 0 9046 0 10012 0 200055 0 0 0 JESSICA VANDERHAM NURSE PRACTITIONER 132060 0 0 0 650 0 0 0 29908 0 162618 0 0 0 LINDSEY NEDVED NURSE PRACTITIONER 121628 0 0 0 650 0 3950 0 27427 0 153655 0 0 0 SCHEDULE J, PART II: BRYAN SLABA, CEO/ADMINISTRATOR, IS COMPENSATED THROUGH AN ARRANGEMENT WITH AVERA SACRED HEART HOSPITAL, 501 SUMMIT STREET, YANKTON, SD 57078. JESSICA PETERS FAMILY RELATIONSHIP WITH CHAD PETERS, BOARD MEMBER 31665 EMPLOYEE COMPENSATION 0 FORM 990, PART VI, SECTION A, LINE 2 DIRECTOR MITCHEL BREEN AND DAVID KOTAB HAVE A BUSNIESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THERE IS ONLY ONE CLASS OF MEMBER. ANY INDIVIDUAL, PARTNERSHIP, CORPORATION OR ASSOCIATION HAVING LEGAL ENTITY, WHO HAS CONTRIBUTED $25 OR MORE TO THE CORPORATION WITH REQUEST OF MEMBERSHIP AT THE TIME OF DONATION, SHALL BE A MEMBER THEREOF AND EACH MEMBER SHALL HAVE ONE VOTE AT ALL MEETINGS OF THE MEMBERS OF THE CORPORATION. MEMBERSHIP OF ANY INDIVIDUAL WHO SHALL BECOME DECEASED SHALL REVERT BY REQUEST TO THAT INDIVIDUAL'S NEXT OF KIN OR ACCORDING TO HIS WILL. ANY MEMBER WHO HAS CONTRIBUTED $50 OR MORE SHALL HAVE THE RIGHT TO TRANSFER SUCH MEMBERSHIP TO HIS OR HER SPOUSE. SAID TRANSFER TO BE APPROVED BY THE BOARD OF DIRECTORS. THE BASIS FOR MEMBERSHIP IS ON NON-REFUNDABLE CONTRIBUTIONS. FORM 990, PART VI, SECTION A, LINE 7A ONLY ONE CLASS OF MEMBER EXISTS. AT THE ANNUAL MEETING, MEMBERS APPROVE THE MINUTES OF THE LAST ANNUAL MEETING, ELECT BOARD MEMBERS OF THE WAGNER COMMUNITY MEMORIAL HOSPITAL, AND VOTE ON OTHER BUSINESS THAT MAY BE PROPERLY BROUGHT BEFORE THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS REQUIRE MEMBER APPROVAL. FORM 990, PART VI, SECTION A, LINE 8B WAGNER COMMUNITY MEMORIAL HOSPITAL DOES NOT HAVE COMMITTEES. FORM 990, PART VI, SECTION B, LINE 11B THE CEO WILL REVIEW THE 990. AFTER THE FORM 990 HAS BEEN REVIEWED, IT WILL BE FORWARDED TO THE MEMBERS OF THE GOVERNING BODY FOR THEIR REVIEW. FORM 990, PART VI, SECTION B, LINE 12C DIRECTORS AND MANAGEMENT OFFICIALS ARE REQUIRED TO COMPLETE ANNUAL CONFLICT OF INTEREST QUESTIONNAIRES WHICH ARE MONITORED AND TRACKED. THE QUESTIONNAIRES ARE REVIEWED BY THE BOARD FOR ANY POSSIBLE CONFLICTS WITH ANY NOTED CONFLICTS BEING BROUGHT TO MANAGEMENT'S ATTENTION. INQUIRIES OF CONFLICTS ARE ALSO REVIEWED AT THE MONTHLY BOARD MEETINGS. AFTER A CONFLICT IS DEEMED TO EXIST, THE BOARD DETERMINES THE LEVEL OF PARTICIPATION OF THE POTENTIAL CONFLICTING MEMBER. FORM 990, PART VI, SECTION B, LINE 15A AVERA SACRED HEART HEALTH SERVICES AND WAGNER COMMUNITY MEMORIAL HOSPITAL COMPENSATION COMMITTEE USE COMPARABILITY DATA TO DETERMINE APPROPRIATE COMPENSATION OF THE CEO BASED ON EXPERIENCE AND PERFORMANCE. THE COMPENSATION AMOUNT IS APPROVED ANNUALLY BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART VII IN ADDITION TO HIS ROLE AS CEO/ADMINISTRATOR, BRYAN SLABA HAS OVERSIGHT OF FINANCIAL OPERATIONS OF THE ENTITY. FORM 990, PART IX, LINE 11G CONTRACTED FEES: PROGRAM SERVICE EXPENSES 830,144. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 830,144. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 509,075. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 509,075. INFO TECHNOLOGY CONSULTING FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 160,800. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 160,800. ADMINISTRATION CONSULTING FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 134,920. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 134,920.