2020-03-26T15:16:33-05:00 2019-06-30 450250958 Eide Bailly LLP 200 E 10th St Ste 500 Sioux Falls SD 571046375 990 2018-07-01 420796764 Sioux Center Health SIOU 7127221271 1101 9th St SE Sioux Center IA 51250 Cory Nelson CEO 7127221271 2020-03-25 1 Laurie Hanson P00851848 6053391999 2020-03-25 67.130.171.59 2020-03-25 13:24:27 CD P C5ADF3E96DC5FD5E5884512D59AB882B10EDFEC1 8529E270CED9BF05DA3D232CE7794E4FD1825D85 2018 2020-09-23 17:36:50Z Cory Nelson 1101 9th St SE Sioux Center IA 51250 44768281 0 X www.siouxcenterhealth.org X 1951 IA To provide medical care for all ages. 40 39 590 66 0 0 37782 24691 40703133 44397819 35760 148269 47771 57368 40824446 44628147 35452 38750 0 0 21785910 24497605 0 0 58211 20184789 20404582 42006151 44940937 -1181705 -312790 76047825 74988976 39680570 37625147 36367255 37363829 X Bring hope, health and healing to life. 1 0 39331934 38750 44397819 Sioux Center Health operates a 19-bed acute-care hospital, a 69-bed nursing care facility, a medical clinic, specialty physician clinics, two independent assisted living facilities, and a daycare center located in Sioux Center, Iowa. During the fiscal year ending June 30, 2019, patient days were 1,321, swing-bed days were 552, and newborn days were 388.The Center also provides a wide variety of medically-related activities at less than, or at no cost to residents of communities throughout northwest Iowa. These activities include general community education programs and sponsorship of support groups for victims of chronic disease and their families. Other activities designed to measure or enhance the general health status of residents of the community include: classes related to CPR, diabetes, cardiac rehabilitation and childbirth; participation in health fairs at industrial and community sites throughout the area; cost free screenings to alert people with high blood pressure; providing use of meeting facilities at no charge to cancer, Alzheimer's, diabetes, weight maintenance, "senior and hospice support groups; programs for children; providing speakers for various events and education groups; and representation in community education programs.The Health Center provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Since the Health Center does not pursue collection of amounts determined to qualify as charity care, they are not reported as patient service revenue. The estimated cost of providing these services was $243,000 for the year ended June 30, 2019, calculated by multiplying the ratio of cost to gross charges for the Health Center by the gross uncompensated charges associated with providing charity care to its patients. 39331934 1 0 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 36 0 1 590 1 0 0 0 0 0 0 0 0 0 0 0 0 X 40 39 1 0 0 0 0 1 0 1 1 0 0 0 1 1 1 1 1 1 0 0 X Kari Timmer 7127228158 1101 9th St SE Sioux Center IA 51250 Brian Van Engen President Until 12/2018/Director 1.00 X X 0 0 0 Tim Byl VP/President From 01/2019 1.00 X X 0 0 0 Doug Van Meeteren Vice President From 01/2019 1.00 X X 0 0 0 Marj Wagner Secretary Until 12/2018/Director 1.00 X X 0 0 0 Kyle Hiemstra Director/Secretary From 01/2019 1.00 X X 0 0 0 Jeffrey Timmer Treasurer 1.00 X X 0 0 0 Nathan Bakker Director 1.00 X 0 0 0 Terry Boote Director 1.00 X 0 0 0 Lisa Christians Director 1.00 X 0 0 0 Lynne Hagen Director 1.00 X 0 0 0 Neil Van Schouwen Director 1.00 X 0 0 0 Curt Hohman Director 1.00 X 0 0 0 M Yvonne Rayborn MD Director 1.00 X 0 0 0 Vernon Beernink Director 1.00 X 0 0 0 Janet Boone Director 1.00 X 0 0 0 Delbert Broek Director 1.00 X 0 0 0 Leslie Brommer Director 1.00 X 0 0 0 Bob Bruxvoort Director 1.00 X 0 0 0 Paul Clousing Director 1.00 X 0 0 0 Brenda Dokter Director 1.00 X 0 0 0 Bruce Dooyema Director 1.00 X 0 0 0 David Eekhoff Director 1.00 X 0 0 0 Cory Gotto Director 1.00 X 0 0 0 Dan Hibma Director 1.00 X 0 0 0 Jennifer Jansen Director 1.00 X 0 0 0 Lauren Kaemingk Director 1.00 X 0 0 0 Rick Kattenberg Director 1.00 X 0 0 0 Jody Kock Director 1.00 X 0 0 0 Stacy Koele Director 1.00 X 0 0 0 John Koerselman Director 1.00 X 0 0 0 Ardith Lein Director 1.00 X 0 0 0 Dorinda Oostenink Director 1.00 X 0 0 0 Scott Peterson Director 1.00 X 0 0 0 Stan Speer Director 1.00 X 0 0 0 Dale Vander Berg Director 1.00 X 0 0 0 Betty Vermeer Director 1.00 X 0 0 0 Lyle Vermeer Director 1.00 X 0 0 0 Scott Wynja Director 1.00 X 0 0 0 Verdean Wynja Director 1.00 X 0 0 0 Josh Bowar Director 1.00 X 0 0 0 Gretchen Zomermaand Director Until 06/2019 1.00 X 0 0 0 Mary Beimers Director Until 10/2018 1.00 X 0 0 0 Kayleen Lee CEO Until 03/2018 40.00 X 266869 0 40954 Cory Nelson CEO From 09/2018 40.00 X 51099 0 6182 Jackson Schuiteman CFO Until 09/2018 40.00 X 96081 0 16683 Kari Timmer CFO From 09/2018 40.00 X 11538 0 0 Dr Julie A McKay MD Diagnostic radiology 24.00 X 290651 0 30250 Dr Jamie J Vitamvas Family Medicine/OB 40.00 X 332467 0 33877 Dr Scott A Rens MD Family Medicine/OB 40.00 X 407372 0 28460 Dr Nicholas Mouw General Surgeon 40.00 X 392093 0 24829 Dr Jason R Koelewyn MD Family Medicine/OB 40.00 X 324053 0 29592 2172223 0 210827 22 0 1 1 Avera McKennan 1325 S Cliff Avenue Sioux Falls SD 571175045 Management fees & other services 2501218 Schelling Construction 44 14th St NW Sioux Center IA 51250 construction contractor 448167 Jon Clegg 1226 Turnberry Avenue Le Mars IA 51031 Anesthesia 336660 Northwest Iowa Diagnostics 714 Lincoln St Ne Le Mars IA 51031 Ultrasound Readings 201165 Thomas Posch 234 Marina Dell Ave Yankton SD 57078 Radiology Readings 114967 5 24691 24691 Patient Service Revenue 622110 38665796 38665796 Assisted and Independent Living 623990 2257352 2257352 Pharmacy Revenue 900099 1655550 1655550 Daycare Revenue 624410 1213048 1213048 Investment in Affiliates 900099 97221 97221 508852 508852 44397819 220757 220757 36479 0 36479 36479 36479 35059 107547 -72488 -72488 -72488 53476 32587 20889 20889 44628147 44397819 0 205637 X 12500 12500 26250 26250 584584 584584 208482 208482 18842764 17582488 1220832 39444 699650 646718 52877 55 2858748 2639505 219243 1303377 1190680 112509 188 86060 86060 5331694 3798027 1533667 212620 211490 1130 1298883 1034213 251209 13461 697825 693665 4160 88185 74103 14082 193254 147687 42429 3138 1134977 905308 229669 4092780 3549153 543627 427844 106684 321160 Medical Supplies 5072034 5072034 Bad Debt 713438 713438 Food 691236 658829 31612 795 Taxes 166129 166129 197623 106041 91582 44940937 39331934 5550792 58211 4928794 4516664 733660 300222 4330417 5058474 500305 597273 409239 479563 75723751 29866844 48246513 45856907 10614670 9590108 3980693 5673285 453474 731057 99758 1850060 2085665 76047825 74988976 4388973 4426062 9322662 7815406 109120 113220 23859755 22739794 2000060 2530665 39680570 37625147 X 35255764 36214588 874371 902071 237120 247170 36367255 37363829 76047825 74988976 X -312790 1309364 X 0 1 X 1 0 X 0 0 385500 24315 162645 247170 356032 29468 385500 324809 31223 356032 328776 -3967 324809 210511 118265 328776 0.00000 1.00000 0.00000 1 0 630000 2229111 2859111 56858901 18754103 38104798 807468 384803 422665 15198271 10727938 4470333 45856907 Investment in Northwest Iowa Diagnostics 29791 F Interest in Avera Health Foundation 5477233 F Investment in Avera Home Medical of Sioux Center LLC 166261 F 5673285 Deferred Compensation 2085665 Estimated third-party payor settlements 445000 2530665 X 45186323 558176 558176 44628147 0 44628147 44227499 0 44227499 713438 713438 44940937 Part V, Line 4: The Health Center's endowment consists of a portion of their interest in the net assets of the Avera Health Foundation. The Avera Health Foundation includes endowment funds which have been established for a variety of purposes. The Center does not have a formal policy or agreement with the Foundation covering the distribution of endowment fund earnings. The Center expects the Foundation to allow its endowment to grow consistent with the Center's objective to maintain the purchasing power of the endowment assets in order to provide additional real growth through new gifts and investment return. However, there is no current intention of using the permanently endowed funds. Part X, Line 2: The Health Center is an Iowa 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 Health Center is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Health Center is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Health Center files an Exempt Organization Business Income Tax Return (Form 990T) with the IRS to report its unrelated business taxable income. The Health Center 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 Health Center 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 -713,438. Change in net assets of Avera Health Foundation 1,271,614. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 713,438. 1 1 X 1 X 1 X 1 1 1 0 1 1 231 243000 243000 0.00550 5115791 3696974 1418817 0.03210 231 5358791 3696974 1661817 0.03760 7 2288 28525 5278 23247 0.00050 1 2 13861 13861 0.00030 3 10549 8307806 7049958 1257848 0.02840 1 33915 33915 0.00080 12 12839 8384107 7055236 1328871 0.03000 12 13070 13742898 10752210 2990688 0.06760 1 1012 1012 0.00000 1 347 1588723 1218048 370675 0.00840 2 347 1589735 1218048 371687 0.00840 0 713438 71344 9229502 9448798 -219296 X 1 1 1 1 Sioux Center Health 1101 9th St SE Sioux Center IA 51250 www.siouxcenterhealth.org 840080H X X X X Sioux Center Health 1 0 0 1 X X X X X X X X X 18 1 1 1 1 X See Line 10a X See Line 7d X X 1 18 1 http://siouxcenterhealth.org/patient-rights/ 0 1 X 100.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X http://www.siouxcenterhealth.org/financial-assistance/ X http://www.siouxcenterhealth.org/financial-assistance/ X http://www.siouxcenterhealth.org/financial-assistance/ X X X X X X X 1 X 0 X X X X 1 X 0 0 Sioux Center Health Part V, Section B, Line 5: Sioux Center Health, along with Community Health Partners, gathered quantitative and qualitative data to determine the best suitable health initiatives that will make a lasting impact for our communities. The data gathered includes demographic (population, race, sex, age and household) information as well as in-depth assessments from community stakeholders through focus group interviews. In order to avoid duplication of effort, the four critical access hospitals in Sioux County worked collaboratively with Community Health Partners to complete this community health needs assessment with a process that began in October of 2018. Sioux Center Health Part V, Section B, Line 6a: Hegg Memorial Health System Orange City Area Health System Hawarden Regional Healthcare Sioux Center Health Part V, Section B, Line 6b: Community Health Partners of Sioux County, the local public health agency for Sioux County. Sioux Center Health Part V, Section B, Line 7d: www.avera.org/about/community-health-needs-assessments/ Sioux Center Health Part V, Section B, Line 11: A Community Health Needs Assessment was completed in 2019 and while Sioux County has numerous positive attributes and scores well in the county health rankings for Iowa, there are several well defined areas of prioritized need that the hospital plans to address based on our findings from the community health needs assessment. The following prioritized health needs were identified and as the most significant needs for our community: Obesity, Mental Health, Translation and Interpretation, and Senior Adult Services. Sioux Center Health is addressing these needs by:Obesity: Through continued collaboration with Community Health Partners, Sioux Center Health is part of the National Diabetes Prevention Program (DPP). The DPP is a year-long weight management program aimed at those who are pre-diabetic or are at high risk of developing diabetes sometime during their life. The county has 12 trained program instructors, with 3 of them being Sioux Center Health staff. Partnerships with the Sioux Center Trails Council, Siouxperman committee and the Harvest Half Committee, along with various other community recreational offerings and facilities in Sioux Center will continue with Sioux Center Health remaining an active voice on behalf of our patients and community members where physical activity and healthy eating are concerned. Additionally, Sioux Center Health has partnered with our local Federally Qualified Health Center (FQHC), Promise Community Health, to provide a Healthy Hero's Family Fun 1k Walk and 5k run for our community members. This event focuses on being active through exercising and offers a health fair to provide education on various topics. Sioux Center Health will provide a Kids Cooking Camp "Eat the Rainbow" for kids 6-9 years old to learn age-appropriate cooking skills and how to prepare simple healthy recipes and learn the importance of eating the rainbow. Mental Health: Sioux Center Health will provide 24/7 social worker coverage as a resource for those patients needing mental health services. Along with this, Sioux Center Health will continue to use Avera eCARE Behavioral Health, which has 24 hour behavioral assessments through the use of a video camera. This service provides us with knowledge of available beds and makes calls to behavioral health facilities to assist in finding placement, should a patient need further treatment. Sioux Center Health will continue to build behavioral health programming within our medical clinics. Our Licensed Master Social Workers in combination with our Board Certified Psychiatric-Mental Health Nurse Practitioner will work with individuals and families to meet their life-long goals and achieve their emotional well-being. We offer medically managed treatment plans for all ages: children, adolescents and adults. Sioux Center Health will also utilize the mental health resources in Sioux City for those adolescent patients who are requiring inpatient care for mental health needs and detox/treatment. Sioux Center Health has established relationships with local/area mental health agencies and will continue to utilize their services where appropriate. Ongoing staff training in recognizing signs and/or treatment of mental health concerns will be provided.Translation and Interpretation: Sioux Center Health will create a Cultural Diversity Team to address translation/interpretation needs. Throughout this process, the team will be engaging not only our staff, but our Board of Directors as well. Sioux Center Health will provide education to the community and healthcare staff for increased knowledge and certification for Healthcare Interpretation. SCCH will continue to participate in the county-wide group of interpreters to identify needs throughout our community. Staff will be tested for their language knowledge and wear a "Habla Espaol" identification badge once approved. Sioux Center Health will provide a Certified Healthcare Interpreter (CHI) to assist non-English speaking patients through their healthcare journey. Collaboration with other local/area agencies who also serve those of ethnic minorities will be done in effort to provide the best care for our patients no matter what their health needs are.Senior Adult Services: Sioux Center Health will work with the building committee, staff and board of directors to identify the needs within our growing community. Plans will be developed to increase the number of beds available on the senior living campus and also identify any additional services needed on campus. Memory care services continue to be a needed service within our community and plans are being developed to create a memory care unit for assisted living residents needing this level of care. Sioux Center Health Part V, Section B, Line 13b: Sioux Center Health provides free care based on meeting presumptive eligibility requirements listed in the policy. Sioux Center Health Part V, Section B, Line 16j: Self pay patients are given a self-pay packet that explains financial assistance. A statement is sent out to all patients indicating financial assistance is available upon request. The charity care and other financial assistance options are discussed with inpatients if requested. Sioux Center Health Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital has confirmed no FAP eligible patients had elective procedures. 9 1 - Sioux Center Medical Clinic 1101 9th St SE Sioux Center IA 51250 Physician clinic 2 - Hull Medical Clinic 807 Main Hull IA 51239 Physician clinic and physical therapy 3 - Royal Meadows 1400 7th Ave SE Sioux Center IA 51250 Nursing facility 4 - Chears Home Health & Hospice 1400 7th Ave SE Sioux Center IA 51250 Home health and hospice 5 - Crown Pointe 1400 7th Ave SE Sioux Center IA 51250 Independent and assisted living 6 - Franken Manor 527 S Main Ave Sioux Center IA 51250 Independent and assisted living 7 - SCH Occupational Health Center 38 19th St SW Sioux Center IA 51250 Occupational health 8 - Early Childhood Center 1400 7th Ave SE Sioux Center IA 51250 Community daycare 9 - Hawarden Medical Clinic 1122 Ave L Hawarden Hawarden IA 51023 Physician clinic Part I, Line 3c: Sioux Center Health (SCH) provides free care based on meeting presumptive eligibility requirements listed in the policy. Federal Poverty Guidelines and financial asset-liabilities are used to determine eligibility for discounted care.Additional factors used to determine financial assistance eligibility include Asset level, medical indigency, and underinsurance status.Part I, Line 6b:The community benefit report is maintained at Sioux Center Health and mailed to community members. Part I, Line 7: Charity care expense on line 7a and Medicaid on line 7b were converted to cost based on an overall cost-to-charge ratio addressing all patient segments. Lines 7e, 7f, and 7i: Costs are reported based on data from the general ledger accounting system. The general ledger accounting system addresses all patient segments (inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, and self-pay). The cost for subsidized health services reported on line 7g was determined using the facility's cost accounting system. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $713,438. Part II, Community Building Activities: Sioux Center Health provides benefits to the community through the Hospital's membership in the local Chamber of Commerce and the recruitment of qualified professional staff. Daycare availability and affordability continues to be an issue in Sioux Center. Sioux Center health provides benefit to the community by offering quality daycare to 347 children. Part III, Line 2: All discounts and payments including contractual allowances, uninsured discounts, and charity care adjustments are applied to a patient's account before the account is written off to bad debt. Bad debt recoveries are applied to bad debt expense in the current year.Bad debt expense on line 2 is reported at charges as presented on the financial statement. Part III, Line 3: The estimated amount of bad debt expense attributable to patients that could have been eligible for charity care is based on estimated calculations from our collection agency. The agency estimated 10% of the total amount in collections could be charity care. Part III, Line 4: The footnote that describes bad debt expense is on pages 9 and 10 of the attached audited financial statements. Part III, Line 8: Medicare allowable cost of care was calculated from the Medicare cost report for fiscal year ending 6/30/19. 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. The Medicare cost report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: Sioux Center Health provides free care based on meeting presumptive eligibility requirements listed in the financial assistance policy. The Hospital does not pursue collection efforts to patients in the process of applying for assistance or persons meeting the presumptive eligibility requirements. Any personal portion due follows normal collection procedures. Sioux Center Health provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. The Hospital does not pursue collections of amounts determined to qualify as charity care. Part VI, Line 2: Sioux Center Health has a broad based Board of Directors providing community feedback on a quarterly basis. An open public meeting is conducted annually to listen to issues of the community and share information regarding services and programs. The Hospital analyzes statistical data through IHA and Iowa Public Health to determine disease related needs, services and market share. The Hospital works closely with Community Health Partners to identify and address community health related needs. Additionally, the Hospital conducted a community health needs assessment during the year ended 6/30/19 in compliance with 501(r). Part VI, Line 3: Patients are made aware of financial assistance programs (English and Spanish) in a variety of ways:1. Self-pay patients are given a self-pay packet that explains financial assistance, payment plans, and the Hospital's 10% lump sum payment options. The self-pay packet includes a Medicaid application. 2. A statement is sent out to all patients indicating financial assistance is available upon request.3. The financial assistance application is available on the Hospital website in English and Spanish versions.4. The financial assistance application is available at the registration and ER desk in English and Spanish versions.5. Included in SCH Facebook posts to increase awareness.Additionally, the financial assistance policy is available upon request and on the Sioux Center Health website. Part VI, Line 4: Sioux Center Health serves the local Sioux Center community and the surrounding area of Sioux County, IA. Sioux County is primarily rural and located in northwest Iowa. The US Census Bureau estimated the county's population at just over 34,500 as of July 1, 2018. The county is also home to three other critical access hospitals and Sioux Center also has a Federally Qualified Health Center (FQHC). Nearly 90% of Sioux Center Health's discharges come from Sioux County. According to 2013-2017 American Community Survey profiles, Sioux Center had a population of just over 7,500 with median family income of $73,185. 7.0% of the families in Sioux Center were below the poverty level. The 2017 census shows a Hispanic population record of 13.10% in Sioux Center, and this number does not take into account undocumented aliens. Part VI, Line 5: The governing board is comprised of 40 volunteer members that reside in the community and primary service area. The Hospital is focused on its mission and serving people regardless of their ability to pay. The Hospital participates in mission projects throughout the year yielding support for various causes from local missions thatprovide after school activities, counseling, or domestic abuse services. This support comes in the form of paid staff volunteering their time, Hospital sponsored fundraisers, and direct financial support from the Hospital and its employees. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are used to make improvements in patient care, medical education, and research.Sioux Center Health has a strong mission to bring hope, health and healing to life. We offer services for our patients, residents and family to support the mind, body and spirit. The Hospital operates an emergency room and is available to anyone, regardless of their ability to pay. The Hospital supports continuing education and training of all the healthcare professionals and assists in providing both internal and external opportunities. Sioux Center Health supports the communities it serves by being an active participant in the community. The hospital offers opportunities to volunteer for community events, has staff that participate in governance through chambers, businesses and churches. Also, the staff participate in various advisory groups supporting all ranges of ages and educational levels. The hospital supports advocacy activities focused on improved public health from organization walks, educational seminars and information shared with the public through various communication means. Part VI, Line 6: The Hospital 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, the Hospital is able to participate in Avera eCARE services. These services include Avera eICU, eEmergency, ePharmacy and eConsult. 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.The Hospital 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 the Hospital 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. Avera Health and the Hospital 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. 1 Northwest Iowa Community College Foundation 603 W Park Street Sheldon IA 51201 421275893 501(c)3 10000 scholarships 1 Scholarship 23 26250 Part I, Line 2: SCH provides the money for scholarships directly to Northwest Iowa Community College Foundation (NICCF). NICCF determines and processes the scholarship funding. Applications and supporting materials are received directly from the applicant. The health instructors at Northwest Iowa Community College make the selection of who receives the money from the group of eligible applicants. Regarding scholarships reported in Part III, the Sioux Center Health Foundation, which is part of Sioux Center Health, receives the scholarship applications. The applications are reviewed for completeness and eligibility criteria. Applicants that are employees or dependents of employees of Sioux Center Health are automatically approved. If there are no employees or dependents within the applicant pool, the application packets are edited for anonymity and given to SCH personnel for review and selection. Scholarship checks are written jointly to the college and student. Refunds are to be returned to SCH should the student not attend college as planned. X X X 1 1 0 0 0 0 0 0 0 Kayleen Lee CEO Until 03/2018 23353 0 195895 0 47621 0 13750 0 28392 0 309011 0 0 0 Dr Julie A McKay MD Diagnostic radiology 190069 0 99500 0 1082 0 2800 0 27907 0 321358 0 0 0 Dr Jamie J Vitamvas Family Medicine/OB 244490 0 32497 0 55480 0 2800 0 31534 0 366801 0 6030 0 Dr Scott A Rens MD Family Medicine/OB 395847 0 9965 0 1560 0 2800 0 26117 0 436289 0 0 0 Dr Nicholas Mouw General Surgeon 341452 0 18885 0 31756 0 2800 0 22486 0 417379 0 0 0 Dr Jason R Koelewyn MD Family Medicine/OB 277657 0 27801 0 18595 0 2800 0 27249 0 354102 0 0 0 Part I, Lines 4a-b Compensation for Kayleen Lee includes $195,895 of severance pay. Sioux Center Health provides a nonqualified deferred compensation plan for its physicians. The following individual had an amount included in reportable compensation, column B(iii) under a 457(f) plan: Dr. Nicholas Mouw $29,507 Schedule J, Part II: Kayleen Lee, CEO Until 03/2018 and Cory Nelson, CEO from 09/2018 are compensated through an arrangement with Avera McKennan, 800 E 21st Street, Sioux Falls, SD 57105. A City of Hull Iowa 426004780 2017-12-18 8300000 Hospital Facility Revenue Refunding Bond, Series 2017(2012 issue). 0 0 0 A 484594 8300000 156681 8143319 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 1 0 0 0 1 A 1 Irene Schuiteman Family member of Jackson Schuiteman, CFO 50527 Compensation as an employee 0 Jerry Zomermaand Family member of Gretchen Zomermaand, Director 123235 Compensation as an employee 0 Kim Bosma Family member of Cory Gotto, Board member 34720 Compensation as an employee 0 Form 990, Part III, line 2 Behavioral Health Services (clinic) Parkinson Wellness Class (therapy) Running Clinic (therapy) Dry Needling (therapy) Form 990, Part VI, Section A, line 1 The Executive Committee is composed of four officers: President, Vice President, Secretary, Treasurer, and seven board members. The Executive Committee shall have power to transact all regular business of the facility during the interim between the meetings of the Board of Directors, provided any action taken shall not conflict with the policies and expressed wishes of the Board of Directors and that it shall refer all matters of major importance to the Board of Directors. Form 990, Part VI, Section A, line 2 Board members Verdean Wynja and Scott Wynja have a family relationship. Form 990, Part VI, Section A, line 7a One member of the governing body is appointed by Avera McKennan. Form 990, Part VI, Section B, line 11b The 990 is emailed to the executive board members for review and any questions addressed prior to filing the return with the IRS. Form 990, Part VI, Section B, line 12c Officers, Directors and Trustees are required to complete 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. Conflicts are also reviewed at the Board level. After a conflict is deemed to exist, the individual(s) involved must abstain from the discussion and vote related to the issue. Form 990, Part VI, Section B, line 15a The CEO is employed through a management agreement with Avera McKennan but is considered a common law employee of Sioux Center Health. Avera McKennan annually reviews the compensation of the CEO, using comparability data and a performance rating system and meets with the Board of Directors of Sioux Center Health. Avera McKennan recommends a salary adjustment for the CEO. The Board of Directors is responsible for approval of the salary adjustment. The deliberation and decision is documented at Avera McKennan and in the board minutes. Compensation for the CFO is reviewed and approved annually by the CEO and Human Resources. Market data is used to determine an appropriate salary range. The review process and salary adjustment is documented in the personnel file. Form 990, Part VI, Section C, line 19 The documents are made available upon request. Form 990, Part IX, line 11g Professional Fees: Program service expenses 1,224. Management and general expenses 56,767. Fundraising expenses 0. Total expenses 57,991. Purchased services: Program service expenses 3,055,333. Management and general expenses 1,259,149. Fundraising expenses 0. Total expenses 4,314,482. Repairs and maintenance: Program service expenses 741,470. Management and general expenses 217,751. Fundraising expenses 0. Total expenses 959,221. Form 990, Part XI, line 9: Change in interest in net assets of Avera Health Foundation 1,309,364. Northwest Iowa Diagnostics 714 Lincoln St NE Le Mars IA 51031 820559254 Diagnostic radiology IA Sioux Center Community Hospital & Health Related -3782 29805 0 1 0.36990 Avera Home Medical Equipment of Sioux Center LLC 38 19th Street SW Sioux Center IA 51250 753203100 Home medical supplies SD N/A Related 85780 176659 0 0 0.50000 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 1 0 0