2019-05-14T09:34:37-05:00 2018-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2017-07-01 420796764 Sioux Center Health SIOU 7127221271 1101 9th St SE Sioux Center IA 51250 Cory Nelson CEO 7127221271 2019-05-09 1 Laurie Hanson P00851848 6053391999 2019-05-09 199.247.43.75 2019-05-09 14:52:15 CD P B6FFF6638DA5C0693B1D4E59656EC3970D617C9D 401A7809F2AA56B1FE621E55666FA95C3E42E950 2017 2019-02-21 02:37:17Z Cory Nelson 1101 9th St SE Sioux Center IA 51250 40942704 0 X www.siouxcenterhealth.org X 1951 IA To provide medical care for all ages. 42 39 573 106 0 0 128505 37782 40270011 40703133 36930 35760 153130 47771 40588576 40824446 42500 35452 0 0 21353259 21785910 0 0 55973 19270323 20184789 40666082 42006151 -77506 -1181705 78325823 76047825 41522553 39680570 36803270 36367255 X Bring hope, health and healing to life. 0 0 36143477 35452 41239348 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, 2018, patient days were 1,437, swing-bed days were 500, and newborn days were 342.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 $155,000 for the year ended June 30, 2018, 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. 36143477 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 38 0 1 573 1 0 0 0 0 0 0 0 0 0 0 X 42 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 VanEngen President 1.00 X X 0 0 0 Tim Byl Vice President 1.00 X X 0 0 0 Marj Wagner Secretary 1.00 X X 0 0 0 Jeffrey Timmer Treasurer 1.00 X X 0 0 0 Josh Bowar 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 Kyle Hiemstra 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 Doug Van Meeteren Director 1.00 X 0 0 0 Nathan Bakker Director 1.00 X 0 0 0 Vernon Beernink Director 1.00 X 0 0 0 Mary Beimers 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 Neil Van Schouwen 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 Gretchen Zomermaand Director 1.00 X 0 0 0 Kayleen Lee CEO 40.00 X 249551 0 39798 Jackson Schuiteman CFO 40.00 X 104176 0 22177 Dr Julie A McKay MD Diagnostic radiology 24.00 X 309891 0 23034 Dr Jamie J Vitamvas Family Medicine/OB 40.00 X 415133 0 27107 Dr Scott A Rens MD Family Medicine/OB 40.00 X 387003 0 24427 Dr Nicholas Mouw General Surgeon 40.00 X 373325 0 22841 Dr Jason R Koelewyn MD Family Medicine/OB 40.00 X 373406 0 23912 2212485 0 183296 16 0 1 1 Avera McKennan 1325 S Cliff Avenue Sioux Falls SD 571175045 Management fees & other services 1809832 Jon Clegg 1226 Turnberry Avenue Le Mars IA 51031 Anesthesia 391898 Northwest Iowa Diagnostics 714 Lincoln St Ne Le Mars IA 51031 Ultrasound Readings 181860 Thomas Posch 234 Marina Dell Ave Yankton SD 57078 Radiology Readings 123801 Sightpath Medical LLC PO Box 204253 Dallas TX 75320 cataract services 103038 5 37782 37782 Patient Service Revenue 622110 35478678 35478678 Assisted and Independent Living 623990 2038961 2038961 Daycare Revenue 624410 1121824 1121824 Investment in Affiliates 900099 42097 42097 2021573 2021573 40703133 124110 124110 35923 0 35923 35923 35923 88350 -88350 -88350 -88350 41756 29908 11848 11848 40824446 40703133 0 83531 12500 12500 22952 22952 451506 451506 228116 228116 16786947 15475272 1277107 34568 642003 613273 28552 178 2479001 2229084 248120 1797 1198337 1062835 134813 689 2254811 2254811 104158 104158 4119700 3807833 311867 176733 203 172914 3616 974114 604428 355976 13710 716518 713251 3267 62426 58089 4337 176148 123050 52215 883 1260546 1260546 4074069 4074069 405280 101110 304170 Medical Supplies 4468213 4468213 Food 632419 616840 15047 532 Bad Debt 460213 460213 Taxes 164359 164359 135082 47241 87841 42006151 36143477 5806701 55973 8730580 4928794 987498 733660 4819182 4330417 64320 451172 500305 391625 409239 76099507 27852994 51689285 48246513 6212209 10614670 2974428 3980693 349537 453474 1655987 1850060 78325823 76047825 4111708 4388973 10472500 9322662 93620 109120 24708738 23859755 2135987 2000060 41522553 39680570 X 35814975 35255764 756675 874371 231620 237120 36803270 36367255 78325823 76047825 X -1181705 745690 X 0 1 X 1 0 X 0 0 356032 29468 385500 324809 31223 356032 328776 -3967 324809 210511 118265 328776 187178 23333 210511 0.61510 0.38490 1 0 630000 2219111 2849111 56721506 16491136 40230370 15735477 11038062 4697415 793413 323796 469617 48246513 Investment in Northwest Iowa Diagnostics 33572 F Interest in Avera Health Foundation 3795813 F Investment in Avera Home Medical of Sioux Center LLC 151308 F 3980693 Deferred Compensation 1850060 Estimated third-party payor settlements 150000 2000060 X 40986727 162281 162281 40824446 0 40824446 41545938 0 41545938 460213 460213 42006151 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 -460,213. Change in net assets of Avera Health Foundation 622,494. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 460,213. 1 1 X 1 X 1 X 1 1 0 1 1 1 169 155000 155000 0.00370 1 4818149 3415583 1402566 0.03380 2 169 4973149 3415583 1557566 0.03750 7 1769 19061 5288 13773 0.00030 1 14528 14528 0.00030 4 14414 8400909 6772682 1628227 0.03920 1 40429 40429 0.00100 13 16183 8474927 6777970 1696957 0.04080 15 16352 13448076 10193553 3254523 0.07830 1 1417 1417 0.00000 1 347 1681195 1121824 559371 0.01350 2 347 1682612 1121824 560788 0.01350 0 460213 35436 9528736 9686333 -157597 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 15 1 1 1 1 X See Line 10a X See Line 7d X X 1 15 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. Stakeholders representing the county participated in county-wide focus groups between January and March 2015. Four county level focus groups were conducted ranging from 2 - 15 participants and lasting approximately 1 hour each. 3 of the focus groups were comprised of a cross section of providers who serve a variety of roles throughout the county including school nurses, social service providers, mental health providers, and public health providers. The fourth group was the Latina Health Coalition of Sioux County, which includes residents of several local communities, including Sioux Center, who represent the Hispanic/Latino community. Stakeholders provided information and perspective about the health needs specific to the county and in some cases relevant to particular communities within Sioux County. In addition to these county level groups, each participating hospital identified stakeholders and convened local focus groups. In Sioux Center, Sioux Center Health staff identified stakeholders that represented parents of young children, adults age 60+, and healthcare system representatives and mailed invitations to potential participants and used reminder phone calls. Groups met at Sioux Center Health or a community meeting room. 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: Each of the health needs identified through the research are important for the overall health of the community. However due to limited human and financial resources, Sioux Center Health will not have a strategic focus on the following identified needs as part of the implementation plan: community education and recreation. There are several partnerships throughout the county that have been established through health improvement planning that have been further identifying these needs and working on improvements. The following prioritized needs are included in our current implementation strategy:-Obesity. Sioux Center Health, through collaboration with Community Health Partners has received two grants with an obesity management focus and has been offering group programming to address this area. Sioux Center Health also has a physician who has become board certified in bariatric medicine and we are developing specific programming with this focus for our community. SCH continued partnerships with the Sioux Center Trails Council, Healthy Sioux Center community group and other recreational offerings and facilities to remain an active voice for patients and community members.-Mental Health Services: Sioux Center Health is providing 24/7 social worker coverage. In addition, SCH will also use eCare (24 hour behavioral assessments through use of video camera) and Care Match (list of all open beds in Iowa for inpatient care). Ongoing staff training in recognizing signs and/or treatment of mental health concerns will also be provided.-Translation and Interpretation: Sioux Center Health has created a Diversity Advisory Council and established a Cultural Diversity business plan. The council will continue to identify gaps and solutions to better serve our growing diverse population. In addition, we employ two certified health care interpreters. 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. 8 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 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, but submitted to Avera and is included in their annual community benefit report. Part I, Line 7: Charity care expense on line 7a was converted to cost based on an overall cost-to-charge ratio addressing all patient segments. Medicaid on line 7b: Gross charges are compared to expenses calculated using the cost to charge ratio. This is netted against the net revenue to determine any benefit.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 $460,213. 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 7.7% of the total amount in collections could be charity care. Part III, Line 4: The footnote that describes bad debt expense is on pages 7 and 8 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 6/30/18. 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 6/30/16 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 2010 census shows a Hispanic population record of 13.8% in Sioux Center, and this number does not take into account undocumented aliens. Part VI, Line 5: Sioux Center Health has a strong community focused perspective. The governing board is comprised of 41 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 that provide 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 14 22952 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 health instructors 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 0 1 0 0 0 0 0 0 0 Kayleen Lee CEO 212860 0 17903 0 18788 0 12524 0 27618 0 289693 0 0 0 Dr Julie A McKay MD Diagnostic radiology 193048 0 115638 0 1205 0 2800 0 20702 0 333393 0 0 0 Dr Jamie J Vitamvas Family Medicine/OB 289361 0 7456 0 118316 0 2800 0 24775 0 442708 0 0 0 Dr Scott A Rens MD Family Medicine/OB 383290 0 2980 0 733 0 2800 0 22095 0 411898 0 0 0 Dr Nicholas Mouw General Surgeon 341446 0 0 0 31879 0 2800 0 20510 0 396635 0 0 0 Dr Jason R Koelewyn MD Family Medicine/OB 290128 0 63226 0 20052 0 2800 0 21580 0 397786 0 0 0 Part I, Line 4b 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. Jamie J. Vitamvas $6,030 Dr. Jason R. Koelewyn $18,000 Schedule J, Part II: Kayleen Lee, CEO, is compensated through an arrangement with Avera McKennan, 800 E 21st Street, Sioux Falls, SD 57105. A City of Sioux Center 426005218 2005-04-11 4000000 Acquisition, renovation, construction, equipping, & furnishing nursing home 0 0 0 B City of Hull Iowa 426004780 2017-12-18 8300000 Hospital Facility Revenue Refunding Bond, Series 2017(2012 issue). 0 0 0 A 2812500 4000000 4000000 2005 0 0 1 1 B 164838 8300000 156681 8143319 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 0 0 0 1 0 0 0 1 A 1 B 1 Schedule K, Part IV, Line 2C: 2005 Bond proceeds have all be spent. No further arbitrage calculations are required for the 2005 bond. Schedule K, Part IV, Line 2C: Arbitrage calcuation for 2012 bond was completed on 10/31/2017. Irene Schuiteman Family member of Jackson Schuiteman, CFO 51039 Compensation as an employee 0 Jerry Zomermaand Family member of Gretchen Zomermaand, Director 123124 Compensation as an employee 0 Tammy Byl Family member of Tim Byl, Vice President of the Board 20658 Compensation as an employee 0 Kim Bosma Family member of Cory Gotto, Board member 33295 Compensation as an employee 0 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 XI, line 9: Change in interest in net assets of Avera Health Foundation 745,690. Northwest Iowa Diagnostics 714 Lincoln St NE Le Mars IA 51031 820559254 Diagnostic radiology IA Sioux Center Community Hospital & Health Related 8269 57572 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 34272 165682 0 0 0.50000 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 1 0 0