2020-11-05T13:53:20-06:00 2019-12-31 450250958 EIDE BAILLY LLP 200 E 10TH ST STE 500 SIOUX FALLS SD 571046375 990 2019-01-01 460219795 COMMUNITY MEMORIAL HOSPITAL INC COMM 6057752621 PO BOX 319 BURKE SD 575230319 MISTIE SACHTJEN CEO 6057752621 2020-10-30 1 LAURIE HANSON P00851848 6053391999 2020-10-30 184.83.199.194 2020-10-30 09:47:06 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 50CCFF325394DF76E401CCE6D67578A0FB45D135 2019 2021-01-29 14:40:06Z MISTIE SACHTJEN PO BOX 319 BURKE SD 575230319 6673046 0 X WWW.BURKEHOSPITAL.COM X 1945 SD PROVIDE MEDICAL SERVICES 9 7 64 10 0 0 177535 85013 5564118 6210290 148226 103420 61752 66748 5951631 6465471 5420 52210 0 0 2616139 2740199 0 0 0 2443921 3050790 5065480 5843199 886151 622272 11923868 12725029 5238293 5403081 6685575 7321948 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 4524448 52210 6210290 COMMUNITY MEMORIAL HOSPITAL, INC., A 16-BED ACUTE CARE HOSPITAL, PROMOTES HEALTH OF THE COMMUNITY BY PROVIDING A VARIETY OF HEALTH CARE SERVICES. DURING 2019, COMMUNITY MEMORIAL HOSPITAL HAD 4,073 CLINIC VISITS IN BURKE AND 551 CLINIC VISITS IN BONESTEEL. THE HOSPITAL HAD 127 ADMISSIONS, 341 PATIENT DAYS, AND 1,334 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. JUST A FEW OF THE SPECIALTY CLINICS PROVIDED ARE A WOMEN'S HEALTH CLINIC, VASCULAR SCREENING CLINIC, FLU CLINIC, AND A SKIN CLINIC. FREE CHOLESTEROL SCREENINGS ARE OFFERED TWICE PER YEAR. COMMUNITY MEMORIAL HOSPITAL TAKES GREAT PRIDE IN THE CARE PROVIDED TO THE COMMUNITY IT SERVES.COMMUNITY MEMORIAL HOSPITAL BECAME 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 BEGAN OFFERING THESE SERVICES MID-YEAR SEEING APPROXIMATELY 30 VETERANS DURING THAT TIME AND HAVE SEEN VETERANS FROM VARIOUS PARTS OF THE STATE. 4524448 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 19 0 1 64 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 7 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 DEB LEIBEL CNP 40.00 X 114430 0 9168 THOMAS GLOVER CHAIRMAN 2.00 X X 0 0 0 MICHAEL KARBO VICE CHAIRMAN 1.00 X X 0 0 0 KAREN MARTIN SECRETARY/TREASURER 1.00 X X 0 0 0 AJ STEFFEN DIRECTOR (UNTIL MAR 2019) 1.00 X 0 0 0 RICHARD DOBESH DIRECTOR 1.00 X 0 0 0 BECKY JONES DIRECTOR 1.00 X 0 0 0 CLAYTON STEELE DIRECTOR 1.00 X 0 0 0 KATE WITT DIRECTOR (UNTIL MAR 2019) 1.00 X 0 0 0 SUE CHYTKA DIRECTOR 1.00 X 0 0 0 MISTIE SACHTJEN CEO 40.00 X 0 0 0 RACHELLE NORBERG DIRECTOR (BEG APR 2019) 1.00 X 0 0 0 DOUG SPITZENBERGER DIRECTOR (BEG APR 2019) 1.00 X 0 0 0 114430 0 9168 1 0 0 0 SANFORD HEALTH PO BOX 5074 SIOUX FALLS SD 571175074 MANAGEMENT FEES, CEO WAGES, IT SUPPORT 462463 PUETZ CORPORATION 800 N KIMBALL ST MITCHELL SD 57301 CONSTRUCTION 342770 WINNER PHYSICAL THERAPY 825 E 8TH ST 204 WINNER SD 57580 PT COVERAGE FOR IN HOUSE PATIENTS 278000 SANFORD CLINIC 1305 W 18TH ST SIOUX FALLS SD 57105 MD WAGES 272486 BURKE BUILDING CENTER 1307 MAIN ST BURKE SD 57523 GENERAL CONTRACTOR 196298 5 47220 16951 20842 85013 PATIENT SERVICE REVENU 621110 4365592 4365592 CLINIC REVENUE 621498 1064872 1064872 PHARMACY REVENUE 446110 662566 662566 117260 117260 6210290 97263 97263 78864 8672 70192 70192 70192 197062 190905 6157 6157 6157 4554 47220 7998 -3444 -3444 6465471 6210290 0 170168 X 48725 48725 3485 3485 437549 437549 1856807 1471815 384992 52027 45479 6548 231613 167479 64134 162203 132863 29340 201950 201950 19787 19787 1113992 988856 125136 20506 2614 17892 95847 14355 81492 124120 124120 84292 63134 21158 6219 4497 1722 9870 7036 2834 112828 84507 28321 462521 346424 116097 34118 34118 MEDICAL SUPPLIES 697449 676827 20622 EQUIPMENT & MAINTENANCE 36043 17221 18822 LICENSES, DUES & SUBSCR 22642 11582 11060 8606 8606 5843199 4524448 1318751 0 3098014 3801646 256857 208457 570038 743026 217500 157500 123651 114688 35083 56971 8415347 1607270 6585442 6808077 676376 513750 18037 20215 342870 300699 11923868 12725029 718638 403069 113584 4519655 4886428 5238293 5403081 X 6485461 7316200 200114 5748 6685575 7321948 11923868 12725029 622272 14101 0 X 0 1 X 1 0 X 0 1 X 44228 44228 5635078 396793 5238285 2328634 1109897 1218737 407407 100580 306827 6808077 X 6487570 14101 7998 22099 6465471 0 6465471 5851197 7998 7998 5843199 0 5843199 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 7,998. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 7,998. 2019 GALA 51774 47220 4554 190 4598 3210 51774 47220 4554 190 4598 3210 7998 -3444 1 1 X 1 X 1 X 150.000000000000 1 1 0 0 30000 30000 0.00510 299056 286101 12955 0.00220 329056 286101 42955 0.00730 20574 2462 18112 0.00310 1326049 893335 432714 0.07410 1346623 895797 450826 0.07720 1675679 1181898 493781 0.08450 1 2800202 2820290 -20088 X 1 1 1 1 COMMUNITY MEMORIAL HOSPITAL INC PO BOX 319 BURKE SD 57523 WWW.BURKEHOSPITAL.COM 10530 X X X 2 PROVIDER BASED 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: PHYSICAL HEALTH. 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 CENTER TO COVER THE COSTS OF VARIOUS EXERCISE CLASSES ALLOWING THE CLASSES TO BE OFFERED AT NO COST TO THE PUBLIC. YOGA CLASSES WERE ADDED IN 2019 AT FITNESS ON MAIN LOCATED IN BURKE. IN 2019, WE EXPANDED TO INCLUDE POST 36 FITNESS IN BONESTEEL ALLOWING CLASSES TO BE OFFERED AT NO COST TO THE PUBLIC IN THEIR COMMUNITY AS WELL. WE WILL CONTINUE TO ASSIST IN IMPROVING UPON THE SERVICES OFFERED. WE ALSO WORKED TOGETHER HOSTING THE ANNUAL COMMUNITY WEIGHT LOSS CHALLENGE. WE CONTINUE TO OFFER A VARIETY OF LAB TESTS FREE OR AT A DISCOUNTED RATE DURING OUR COMMUNITY HEALTH FAIRS HELD TWICE EACH YEAR. THE HOSPITAL ALSO IMPLEMENTED 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. PRIORITY 2: 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 A FULL TIME COUNSELING SERVICE ON OUR CAMPUS. WE HAVE HOPES OF EXPANDING SERVICES MORE IN THE NEXT YEAR. IN THE CLINIC SETTING, PROVIDERS AND NURSING STAFF FOCUSED ON OUR PHQ 9 SCORES AND IDENTIFYING PATIENTS WITH DEPRESSION. WE ALSO BEGAN IMPLEMENTATION OF A HEALTH COACH THROUGH ONE OF OUR CLINIC NURSING STAFF TO ASSIST IN THE PERCENTAGE OF PATIENTS MEETING QUALITY MEASURES.IN 2019, WE PUT A LOT OF FOCUS ON PAIN MANAGEMENT AND MONITORING OUR OPIOID PRESCRIBING AS A FACILITY. BY IMPLEMENTING NEW POLICIES AND ENFORCING GUIDELINES ESTABLISHED IN PATIENT AGREEMENTS, THE FACILITY WAS ABLE TO SUBSTANTIALLY DECREASE THE NUMBER OF PATIENTS BEING PRESCRIBED OPIOIDS. A PRESCRIPTION MED DROP BOX WAS ALSO ADDED IN THE CLINIC. 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. WITH THIS DATA, IT IS A GREAT ADDITION TO THE FACILITY. COMMUNITY MEMORIAL HOSPITAL IS THE ONLY FACILITY IN THE COUNTY THAT HAS A MED DROP BOX. 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 $782,679 AND COSTS OF $948,995 WERE INCLUDED ON LINE 7G FOR A NET COMMUNITY SHORTFALL OF $166,316. PART III, LINE 4: FOOTNOTE FROM FINANCIAL STATEMENTS: PLEASE SEE NOTE 1, FINANCIAL STATEMENT, PATIENT RECEIVABLES ON PAGES 8-9. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 12/31/2019. 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, 7% WAS FROM TITLE 19, 9% FROM COMMERCIAL INSURANCE, AND 17% 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. 1 BURKE FIRE DEPARTMENT PO BOX 240 BURKE SD 57523 460385539 10931 TORNADO ASSISTANCE BURKE AMBULANCE SERVICE PO BOX 61 BURKE SD 57523 271595556 10931 TORNADO ASSISTANCE LONG TERM RECOVERY GROUP PO BOX 319 BURKE SD 57523 460219795 21863 TORNADO ASSISTANCE 2 1 PART I, LINE 2: FUNDS FROM THE GALA WERE DONATED TO ORGANIZATIONS INVOLVED IN SUPPORTING THE PEOPLE OF BURKE AFTER THE TORNADO HIT THE TOWN. DEBRA LEIBEL FAMILY MEMBER OF TOM GLOVER, BOARD CHAIRMAN 129351 WAGES AND BENEFITS 0 KIMBERLY SHEPPERD FAMILY MEMBER OF AJ STEFFEN, BOARD DIRECTOR 68935 WAGES AND BENEFITS 0 ANDREA STEFFEN FAMILY MEMBER OF AJ STEFFEN, BOARD DIRECTOR 48062 WAGES AND BENEFITS 0 AMY JURACEK FAMILY MEMBER OF KATE WITT, BOARD DIRECTOR 111983 WAGES AND BENEFITS 0 AMANDA STEFFEN FAMILY MEMBER OF AJ STEFFEN, BOARD DIRECTOR 35576 WAGES AND BENEFITS 0 PATRICIA JONES FAMILY MEMBER OF REBECCA JONES, BOARD DIRECTOR 43642 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 SACHTJEN WERE $130,488 AND $17,918 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 2019. 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 SACHTJEN (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 988,471. MANAGEMENT AND GENERAL EXPENSES 44,807. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,033,278. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 385. MANAGEMENT AND GENERAL EXPENSES 80,329. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 80,714.