2019-05-14T15:29:38-05:00 2018-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2017-07-01 460226738 St Benedict Health Center STBE 6059283311 401 West Glynn Drive Parkston SD 57366 Jim Breckenridge CFO Avera Health 6059283311 2019-05-10 1 Kim Hunwardsen CPA P00484560 6122536500 2019-05-13 8.39.233.75 2019-05-10 15:20:37 CD P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC EFC25E59FA7409AE560978A003AFB9E955B778C6 2017 2019-02-21 02:37:17Z Avera St Benedict Health Center Rita Blasius 401 West Glynn Drive Parkston SD 57366 26165100 0 0928 X www.avera.org/st-benedict X 1965 SD Promotion of health 11 8 253 188 0 0 160421 74311 23564399 25047117 1384362 1000186 48520 43486 25157702 26165100 127734 58615 0 0 13676089 13911189 0 0 0 7912498 8132825 21716321 22102629 3441381 4062471 41382178 45051661 2896374 1999430 38485804 43052231 X Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values. 0 0 19818984 58615 25064643 Avera St. Benedict Health Center's (Avera St. Benedict) mission is to provide healthcare services to Parkston, Tripp and Lake Andes, South Dakota residents and residents of the surrounding area. Avera St. Benedict is a 501(c)(3) organization affiliated with Avera Health. Avera St. Benedict consists of a 25-bed critical access hospital, a 49-bed nursing home, a 27-bed assisted living center and three rural health clinics. Services offered by Avera St. Benedict include primary care, general surgery, cardiac rehab, behavioral health, laboratory, imaging, telemedicine, speech therapy, physical therapy and occupational therapy. Avera St. Benedict provides acute care and long-term healthcare services, of which there were 644 patient discharges, 24,324 outpatient visits, 1,247 swing-bed days, 99 newborn patient days, 25,489 nursing home resident days and 19,856 clinic visits. Following is a breakdown of these statistics by facility:Avera St. Benedict Hospital644 Acute patient discharges24,324 Outpatient visits1,247 Swing-bed patient days99 Newborn patient days19,856 Clinic visitsAvera Bormann Manor25,489 Nursing home resident daysAvera St. Benedict maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $148,808.Avera St. Benedict also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera St. Benedict upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network of persons and institutions. Avera St. Benedict engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed. 19818984 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 42 0 1 253 1 0 0 0 0 0 0 0 0 0 0 X 11 8 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X Jamie Schaefer 6053223992 3900 W Avera Dr Ste 300 Sioux Falls SD 57108 Dan Neugebauer Chair 2.00 0.30 X X 0 0 0 Melissa Stork Vice Chair 2.00 0.00 X X 0 0 0 Dave Neugebauer Secretary 2.00 0.00 X X 0 0 0 Barb Weidenbach Board Member 2.00 0.00 X 0 0 0 Pat Reiner Board Member 2.00 0.00 X 0 0 0 Dorothy Marie Fink Board Member 2.00 0.00 X 0 0 0 Antoinette VanderPol MD Board Member/Chief of Staff 40.00 0.00 X 359879 0 24169 Sr Patricia Prunty Board Member 2.00 0.00 X 0 0 0 Sr Patricia Ann Toscano Board Member 2.00 0.00 X 0 0 0 Patricia Leischner Board Member 2.00 0.00 X 0 0 0 Rita Blasius President/CEO 40.00 0.50 X X 184577 0 18518 Jim Breckenridge CFO Avera Health 0.10 39.90 X 0 887406 34116 Jason Wickersham MD Family Medicine/OB 40.00 0.00 X 347046 0 37003 Ken Travnicek CRNA Nurse Anesthesiology 40.00 0.00 X 228010 0 34908 Richard W Honke II MD Family Medicine Physician 40.00 0.00 X 389402 0 36716 Larissa Sanger MD Family Medicine Physician 40.00 0.00 X 240112 0 38461 Beth Schroeder PA-C Family Medicine PA 40.00 0.00 X 193269 0 40060 Gale Walker Former President/CEO 40.00 0.00 X 101853 0 10678 2044148 887406 274629 10 1 1 0 Avera Queen of Peace 525 North Foster Street Mitchell SD 57301 ITS, administrative & management fees 1906058 Puetz Corporation PO Box 968 Mitchell SD 57301 Construction 1021852 Avera Health 3900 W Avera Dr Sioux Falls SD 57108 Quality, PMA, Credentialing, Other Servi 220712 Cassling Diagnostic Imaging Inc 13808 F St Omaha NE 681371102 Maintenance Contract and Repairs 159249 Avera McKennan PO Box 5045 Sioux Falls SD 57117 Outreach services 144801 5 28650 45661 74311 Net Patient & Resident Service Re 622110 23449707 23449707 Pharmacy Revenue 900099 781456 781456 Daycare Revenue 624410 112713 112713 703241 703241 25047117 40675 40675 25960 0 25960 25960 25960 959511 0 959511 959511 959511 AR Interest Income 900099 17526 17526 17526 26165100 25064643 0 1026146 X 58615 58615 581875 371980 209895 49120 49120 10312577 9839924 472653 432876 414068 18808 1853068 1747655 105413 681673 640103 41570 78909 78909 22367 22367 2597262 1600640 996622 3089 1231 1858 1299573 1150456 149117 127827 3659 124168 301373 293873 7500 79126 71976 7150 20827 17222 3605 27948 27948 1358380 1358380 151424 151424 Medical Supplies 1628460 1628460 Bad Debt Provision 276318 276318 Sales Tax and Licenses 40279 40279 119663 75653 44010 22102629 19818984 2283645 0 4662226 4259520 2852318 2715697 302972 288198 86065 74400 26356159 12671030 14513680 13685129 387918 18408838 23688550 168161 340167 41382178 45051661 1804431 1999430 1031943 60000 0 2896374 1999430 X 37976607 42404483 453254 591681 55943 56067 38485804 43052231 41382178 45051661 X 4062471 322542 181414 X X 0 1 X 1 0 X 1 2128 31327 31032 2423 0 65370 124 2741 68235 52199 9508 3663 65370 52694 -495 52199 54947 -2253 52694 50632 4315 54947 0.82170 0.17830 0 1 1 97483 97483 16791363 6670982 10120381 8939417 5815971 3123446 527896 184077 343819 13685129 Assets Limited to Use - Avera Pooled Investments 23688550 F 23688550 X Part IV, Line 1b: Funds are held on behalf of the residents. Part V, Line 4: The Organization's endowment consists of a portion of their interest in the net assets of Avera Health Foundation. The Avera Health Foundation includes endowment funds which have been established for a variety of purposes. As required by generally accepted accounting principles, net assets associated with endowment funds, including funds designated by the Board of Directors to function as endowments (if any), are classified and reported based on the existence or absence of donor-imposed restrictions. The organization's permanently restricted endowment funds are donor restricted. The organization currently does not have any board designated endowment funds. Part X, Line 2: Avera Health and most of its sponsored organizations are considered nonprofit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Internal Revenue Code. These organizations are required to file a Return of Organization Exempt from Income Tax (Form 990) with the Internal Revenue Service (IRS). Avera Health and certain sponsored organizations also file an Exempt Organization Business Income Tax Return (Form 990T) with the IRS to report their unrelated business taxable income. Avera Health and its sponsored organizations believe that they have 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 consolidated financial statements. The Organization 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. The federal Form 990T filings and taxable subsidiary returns for consolidated subsidiaries are no longer subject to federal tax examinations by tax authorities for years before 2015. Certain consolidated entities are subject to federal income taxes. Deferred income tax assets and liabilities are recognized for the differences between the financial and income tax reporting basis of assets and liabilities based on enacted tax rates and laws. Deferred tax assets and liabilities are not material as of June 30, 2018 and 2017. The Organization paid an immaterial amount of federal and state income taxes for the years ended June 30, 2018 and 2017. 1 1 X 1 X 1 X 1 1 0 0 117858 117858 0.00540 952592 949344 3248 0.00010 327633 55716 271917 0.01250 1398083 1005060 393023 0.01800 7 3631 235541 37968 197573 0.00910 6 2856 125565 125565 0.00580 1 114 4180308 2870904 1309404 0.06000 1 3467 20988 20988 0.00100 15 10068 4562402 2908872 1653530 0.07590 15 10068 5960485 3913932 2046553 0.09390 1 20 138030 112713 25317 0.00120 1 20 138030 112713 25317 0.00120 1 276318 0 6697081 6738482 -41401 X 1 1 1 1 Avera St Benedict Health Center 401 West Glynn Drive Parkston SD 57366 www.avera.org/st-benedict 50749 X X X X 3 provider based clinics St Benedict Hospital Inc 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X See Part V, Section C X 1 15 1 See Part V, Section C 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X See Part V, Section C X See Part V, Section C X See Part V, Section C X X X X X X X 1 X 0 X X X X X 1 X 0 0 St. Benedict Hospital Inc. Part V, Section B, Line 5: A variety of individuals and groups of people were involved in the CHNA process from November 2015 through April 2016. Qualitative data was obtained from focus groups with the Parkston Commercial Club, Hutchinson County Ministerial Association, and a small group of Medicare Enrollees over the age of 65. The Parkston Commercial Club is a group of businesses in the Parkston area that meet monthly to support the community in a variety of ways, including fundraising for local events and family centered entertainment. Commercial club members are generally involved in many different activities in the community of Parkston, the local school district, and the surrounding area. The Hutchinson County Ministerial Association members are clergy from many different congregations, some of which run food and clothing banks for individuals in need. The Ministerial Association meets monthly to work together to address many community and individual needs that are also social determinants of health. Formal individual interviews were conducted with two county health nurses and a Hutterite Colony Outreach Nurse. County health nurses are the only form of public health in Hutchinson County. An electronic survey was completed by 88 community members that are involved in many different aspects of the community at large. St. Benedict Hospital Inc. Part V, Section B, Line 11: Access to CareTo improve access to care, Avera St. Benedict (ASB) has worked to educate the public on services available at Avera St. Benedict Health Center. This included continuous updates to Avera St. Benedict's website and social media page to improve access to care by letting the public have additional avenues to learn about services provided locally. ASB strives to maintain access to care locally by working with specialty providers/specialty outreach services. This saves community members time and dollars associated with saved travel. Avera St. Benedict currently maintains 14 onsite specialties.To address potential language barriers, all Avera St. Benedict employees were trained on how to access translation services and tools to improve communication with individuals that are non-English speaking. One of Avera St. Benedict's physicians is bilingual. This ensures the same quality care to individuals regardless of languages spoken.Avera St. Benedict increased access to care for individuals with transportation needs by dedicating a Registered Nurse at .8 FTE and an advanced practice provider at .1 FTE to provide primary care services as needed at local Hutterite Colonies and for the Amish. An RN is dedicated on an as needed basis for the Visiting Nurse program to provide in home services to the homebound elderly.Behavioral HealthAvera St. Benedict staffs a behavioral health specialist 32 hours per week to address behavioral health needs. The service area of Avera St. Benedict has access to quality behavioral health services with generally same day appointment availability. Avera St. Benedict works with Our Home, Inc. to provide no charge telepsychiatry access for the youth in need of these services. Avera St. Benedict also works with Avera University Psychiatry Associates to use psychiatry residents for telepsychiatry access for adult patients in need of psychiatry services. This decreased travel costs for patients and increased access to psychiatry for kids and adults with significant mental health needs. Avera St. Benedict provides a counselor at no cost, as needed, for first responder critical incident debriefing to be held at the location of choice of the first responders. Retention and resiliency of volunteer first responders in the community has been a positive impact.To decrease stigma surrounding behavioral health, Avera St. Benedict provided many free community education programs on behavioral health topics, including grief, diabetes management, substance abuse, depression, etc. Preventative Medicine and WellnessAvera St. Benedict provided Healthy Choice curriculum to approximately 75 fourth graders at Parkston and Andes Central School Districts in 2016 and 2017. Avera St. Benedict hosted an annual "Pretty in Pink" (Women's Health Day) to help educate approximately 100 females annually on recommended wellness and cancer prevention screenings.Avera St. Benedict hosted a free diabetes support group monthly from 2016-2017. Avera St. Benedict then transitioned to a free "Better Choices, Better Health" curriculum that focused on one of three topic areas: all chronic diseases; diabetes; and opioids. Four staff members are trained in the evidenced based "Better Choices, Better Health" curriculum. Collaboration with local businesses results in Avera St. Benedict doing worksite wellness screenings or providing other wellness services to 7 worksites in total. Avera St. Benedict provided multiple community education programs/activities that focused on preventative medicine and/or physical activity. In addition to this, a community member did a yoga class at Avera St. Benedict for a year and half that was open to the public. The Wellness Center added "fitness on demand", which is over 1000 virtual classes available 24/7. These programs/activities promoted a culture of wellness and physical activity for all ages in the community. Annual Wellness Visits were implemented in the clinics for Medicare beneficiaries, resulting in 30% of Medicare ACO beneficiaries per year receiving one of these visits. This has shown improved preventative screening rates and immunizations for the Medicare population in the community. No cost blood pressure checks are available in all ASB locations. Community education lectures on immunizations took place for the following: HPV vaccination, influenza, and shingles. Colony outreach nurse and primary care providers went to 9 colonies and completed a Q & A panel about HPV vaccination and how this helps prevent cancers. ASB provided nursing staff once per month to help patients with clinical foot care to prevent foot care issues from worsening.Environment and SafetyAvera St. Benedict certified or educated over 150 community/agricultural workers in CPR, which improves the likelihood of positive health outcomes from a cardiac event or farm accident. In addition, over 150 farm youth and youth involved in babysitting completed basic first aid training to improve the likelihood of positive health outcomes from injury. Chronic Disease, Obesity, and Related Health ConcernsAvera St. Benedict serves as a training site location for students in health care professions. ASB is an active training site for students in the FARM program, RHEPS Program, medical residents, other medical students, physician assistant students, nurse practitioner students, nursing students, behavioral health students, medical assistant students, health care administration students, etc.Avera St. Benedict provided training to students from July 2016-January 2019. This has helped increase the pipeline for health professions to assist with long term health care professional recruitment and retention, including having many of these students come back to Avera St. Benedict for careers. ASB supports the Parkston HOSA Chapter by providing healthcare advice, health care career education, and helping with fundraising efforts. ASB provides a physician to sit on the HOSA Advisory Board. Students get real life experience and exposure to health professions careers. By being involved in HOSA, it allows rural health to maintain viability and relevance.Avera St. Benedict provides meeting space for internal and external chronic disease self-management support groups to use rooms on the health center campus at no cost for meetings. Examples of this include weekly Weight Watchers and Alcoholics Anonymous. This access to self-management groups correlates to improved health outcomes. St. Benedict Hospital Inc. Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide. St. Benedict Hospital Inc. Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the Hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. St. Benedict Hospital Inc. Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility. St. Benedict Hospital Inc. 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. Schedule H Part V, Section C, Lines 7a and 10a: Community Health Needs Assessment and Implementation Strategy websitehttps://www.avera.org/about/community-health-needs-assessments/ Schedule H Part V, Section C, Lines 16a, 16b and 16c: https://www.avera.org/patients-visitors/charity-patient-assistance-programs/financial-assistance-forms/ 2 1 - Avera Bormann Manor 501 North 4th Street Parkston SD 57366 Nursing Home 2 - Avera St Benedict Assisted Living 400 W Fir Parkston SD 57366 Assisted Living Part I, Line 3c: The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted. Part I, Line 7: Charity care expense, line 7a, was converted to cost based on an overall cost-to-charge ratio addressing all patient segments. Community health improvement services, line 7e, health professions education, line 7f, and cash and in-kind contributions, line 7i are reported based on actual expenses recorded in the Organization's general ledger. The cost for subsidized health services, line 7g, was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): Bad debt expense of $276,318 is included on Form 990, Part IX, line 25, column (A) but excluded for purposes of calculating this percentage. Part II, Community Building Activities: Avera St. Benedict Health Center (ASBHC) operates a community daycare providing a safe environment for the children and it operates at a loss. Lower income families are provided a safe and affordable place for their children. While not all the families are lower income, the organization sees this as a community need as there is no other facility in the area and the community as a whole would struggle to find daycare for their children. Despite operating at a loss, the Board of Directors is committed to providing the service to the community. ASBHC provides transportation to the residents of Avera Bormann Manor. The transportation includes physician visits and getting medication and supplies. Without this service these individuals would be at risk of not getting to their appointments or obtaining the supplies they need.Employees of ASBHC serve a food pantry called the Love Feast in Mitchell, SD. This group of employees works an evening meal for those in need. Proper nutrition for these individuals in essential for health and without this service many would go hungry or not get a balanced meal, in turn affecting their health and wellness. Part III, Line 2: Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year. Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted. Part III, Line 4: The footnote to the Organization's financial statements that describes bad debt expense can be found on page 10 of the attached audited financial statements. Part III, Line 8: Any Medicare shortfall for St. Benedict Hospital is excluded from the community benefit report. Patients with Medicare coverage are accepted regardless of whether or not a surplus or deficit is realized from providing the services. This means providing Medicare services promotes access to healthcare services which is a key advantage for our community and therefore any shortfall is considered a community benefit.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 Centers for Medicare and Medicaid Services. Part III, Line 9b: 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 current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven. Part VI, Line 2: Community needs are evaluated and assessed on an on-going basis in several ways. ASBHC has completed formal "needs assessments" several times over the course of the past several years. This has been accomplished with input from focus groups, surveys, short and long range planning by the Health Center Board, demographic and health care data analysis, regular meetings with the provider staff, and collaboration with the local school and churches, as well as local law enforcement. Part VI, Line 3: Patients are informed of the financial assistance/charity care policy through brochures at the registration desks of the Hospital and Clinics. ASBHC has staff in Central Registration that identify if a patient is able to pay for services through insurance or otherwise. If they identify on the front end that the patient needs assistance, the patient is connected to a representative in Patient Financial Services who can assist with determining what benefits the patient may qualify for and help them apply for any benefits. If there is no option for an outside assistance program, the patient is informed and encouraged to complete the application that utilizes a combination of income, assets, and expenses to determine what percentage of charity care they would qualify for. Part VI, Line 4: Avera St. Benedict Health Center (ASB) is located in Parkston, S.D and also has health services available in the surrounding communities of Tripp, and Lake Andes, SD. Tripp is about 12 miles south of Parkston, in Hutchinson County, SD and Lake Andes is about 45 miles southwest of Parkston in Charles Mix County, SD. Also included in the community is an adolescent psychiatric residential treatment facility that has an ongoing census of up to 40 adolescents who have been either emotionally or physically abused or have been ordered by the courts to reside at this residential treatment center.Parkston is located in Hutchinson County, S.D., in the south central part of the state. Agriculture is the primary economic driver in the county. Avera St. Benedict's primary service area is defined as Hutchinson County. About 60 percent of inpatient discharges and 65 percent of Emergency Room visits were from Hutchinson County. According to the U.S. Census Bureau's 2017 data, the population of Hutchinson County was just over 7,300 people and is predominately White/Caucasian (97%). About 24 percent of the population is over the age of 65. County Health Rankings statistics assesses the unemployment rate of 2.4 percent compared with the state of South Dakota's 2.8 percent unemployment (2018.) County Health Rankings states that the median household income of Hutchinson County is $51,800, which is about $3,100 less than the state's average. Uninsured adults are at 13 percent and uninsured children at 8 percent in the county (2018). The CDC (2014) rates 11.5-14.4 percent of Hutchinson County residents living in poverty. The Centers for Disease Control rates high school graduation rates in the county at 87.6 percent and adults over 25 years of age with a Bachelor's degree or higher at 33.7 percent (2008-2012). The secondary service area, including portions of Douglas, Davison, Bon Homme, Hanson and Charles Mix Counties are demographically similar to Hutchinson County with rural, agricultural lifestyles. These four counties made up about 40 percent of inpatient discharges and 30 percent of Emergency Room visits. Charles Mix County is demographically different from the rest of the service area in that there is a 32 percent Native American population, lower rates of individuals 16 and older in the civilian labor force (61%), and higher rates of poverty (24%). Avera St. Benedict is the primary medical provider for 8 Hutterian Brethren Colonies in the primary and secondary service area, which includes about 550 individuals. Avera St. Benedict Health Center sees about 8,000 people a year for one or more services at the health center. Part VI, Line 5: The Organization's governing body is comprised of volunteer members who reside in the community. The Board of Directors meets monthly and has community representation that brings forward issues relative to challenges, needs and services within the community. The local ministerial group meets monthly at the Hospital and also identifies needs and gaps within the parishioners they serve. Medical staff privileges are extended to all qualified physicians in the community. The medical staff, including the physicians/mid-levels/department directors, has the opportunity to meet monthly and also discuss ways to meet the needs of the community they serve. Surplus funds are reinvested in facilities to improve patient care. The Hospital operates an emergency room that is available to all, regardless of ability to pay.ASBHC has a fitness center on campus that is available to help the community focus on wellness and prevention. This endeavor is subsidized by the facility to improve the health and well-being of the community as a whole. The chaplaincy mission services participate and spearhead many community projects including an angel tree at Christmas to address the needs of children in our service area. ASBHC also donates to the local food pantry and purchases, prepares, and serves a meal to the Love Feast in Mitchell, SD annually. The meal serves 300 plus people in need of nutrition. At that event, bags of groceries are provided to the families in need that are in attendance to take home. There are several other projects of this nature on a smaller scale at the local school system. ASBHC donates to community events such as American Cancer Society projects and sponsors health related educational programs to the community at large. Avera St. Benedict also provides medical, nursing, and other ancillary health professions the opportunity for hands on learning experiences through residencies, internships, clinical rotations and other shadowing and profession mentoring programs to help with students health care training needs. Part VI, Line 6: Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance. 1 Mount Marty College 1105 W 8th Street Yankton SD 57078 460283336 501(c)(3) 20000 Donation Mitchell School District 821 North Capital St Mitchell SD 57301 466001338 State of SD 5500 Regional transportation program Dakota Heartland Development Association 601 N Main St Mitchell SD 57301 352397643 501(c)(3) 7500 Sponsorship South Dakota Community Foundation PO Box 823 Parkston SD 57366 460398115 501(c)(3) 7000 Sponsorship St Benedict Health Center Foundation 401 West Glynn Drive Parkston SD 57366 460458725 501(c)(3) 5250 General Support 5 0 Part I, Line 2: The organization provides grants/contributions to other organizations which are tax-exempt under IRS Section 501(c)(3) and governmental divisions that benefit the community and region through programs and activities. X X 0 0 0 0 0 0 0 0 0 Antoinette VanderPol MD Board Member/Chief of Staff 311304 0 47200 0 1375 0 13500 0 10669 0 384048 0 0 0 Rita Blasius President/CEO 158059 0 2000 0 24518 0 8341 0 10178 0 203096 0 0 0 Jim Breckenridge CFO Avera Health 0 815781 0 0 0 71625 0 13500 0 20616 0 921522 0 0 Jason Wickersham MD Family Medicine/OB 282625 0 58500 0 5921 0 13500 0 23503 0 384049 0 0 0 Ken Travnicek CRNA Nurse Anesthesiology 205621 0 2350 0 20039 0 11208 0 23700 0 262918 0 0 0 Richard W Honke II MD Family Medicine Physician 317565 0 62588 0 9249 0 13500 0 23216 0 426118 0 0 0 Larissa Sanger MD Family Medicine Physician 218380 0 21000 0 732 0 12333 0 26128 0 278573 0 0 0 Beth Schroeder PA-C Family Medicine PA 153588 0 35560 0 4121 0 10049 0 30011 0 233329 0 0 0 Gale Walker Former President/CEO 74099 0 0 0 27754 0 4916 0 5763 0 112532 0 0 0 Denise Leischner Family member of Pat Leischner, Board Member 49120 Compensation and benefits as an employee 0 Form 990, Part VI, Section A, line 6 The sole member of the organization is Avera Health, a nonprofit corporation organized and existing under the laws of the state of South Dakota and exempt under 501(c)(3) of the Internal Revenue Code of 1986, as amended. Form 990, Part VI, Section A, line 7a Avera Health, as the sole member, has the power to appoint and remove, with or without cause, members of the Board of Directors. Form 990, Part VI, Section A, line 7b Avera Health, as the sole member, has the following rights as the Member. 1) Define the purpose, philosophy and mission of this Corporation. 2) Receive and approve budgets of this Corporation. 3) Review and approve audited financial reports of this Corporation. 4) Dissolve, merge or consolidate this Corporation. 5) Approve the selection and retention of the independent auditing firm. 6) Approve any action which would change the character of this Corporation. 7) Initiate and/or approve all amendments to the Articles of Incorporation and Bylaws of this Corporation. 8) Appoint and remove, with or without cause, the Directors, sanction vacancies and determine the number of Directors of this Corporation; 9) To approve expenditures outside of operating and capital budgets exceeding defined thresholds according to policy which may be adopted from time to time by the Member; 10) To approve acquisitions, sales and leases, according to policy which may be adopted from time to time by the Member; 11) To establish and maintain employee benefit programs; 12) To establish and maintain insurance programs; 13) To approve major community fund drives; 14) To approve the appointment of auditors; 15) To adopt policies designed to effectuate the reserved powers of the Member. Form 990, Part VI, Section A, line 8b St. Benedict Hospital does not have any committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11b The Form 990 is reviewed by the Avera Health VP of Financial Reporting, Tax Manager, Facility CEO and Finance Committee (if applicable). After initial review the Form 990 is made available to the Board and other Operation Finance Leaders. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers board members, officers and key employees. At each board meeting, a request is made for all board members to disclose any potential conflict of interest pertaining to any item listed on the agenda or pertaining to any potential item that could be discussed during the course of the meeting. The declaration of conflict of interest is recorded in the meeting minutes. The board makes a determination of whether there is a conflict of interest and if so, implements the procedure for evaluating the issue or transaction involved. The board member or officer with the conflict must refrain from voting. A statement of conflict of interest disclosure is made on an annual basis by officers and directors. The information is maintained in a database and a report is provided to the board. Form 990, Part VI, Section B, line 15a The President and CEO of Avera Queen of Peace, a related organization, initiates the annual review for the CEO. He sends out evaluation forms to the board of St. Benedict's. Comparative data from Avera Health System is used to develop a recommended compensation structure. The compensation for the CEO is approved by Avera St. Benedict's board. This is done on an annual basis, usually in January. The CFO-Avera Health is compensated by Avera Health. Annually the Compensation Committee of Avera Health, which is comprised of six (6) System Members appointed by the Religious Orders, meets with an independent consultant regarding fair market value of officers and key employees. The Compensation Committee approves all salaries based on comparable data and documents the basis for their decision in meeting minutes. Form 990, Part VI, Section C, line 19 The organization's governing documents and conflict of interest policy are not made available to the general public. The organization's financial statements are attached to the Form 990 per IRS instructions and therefore available to the general public. Form 990, Part IX, line 11g Purchased Services: Program service expenses 332,234. Management and general expenses 158,504. Fundraising expenses 0. Total expenses 490,738. Repairs and Maintenance: Program service expenses 501,693. Management and general expenses 20,260. Fundraising expenses 0. Total expenses 521,953. ACS Fees: Program service expenses 766,713. Management and general expenses 817,858. Fundraising expenses 0. Total expenses 1,584,571. Form 990, Part XI, line 9: Change in Interest in Avera Foundation 181,414. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the audited financial statements for Avera Health, which includes St. Benedict Health Center. Form 990, Part X, Line 20: St. Benedict Health Center is part of the Avera Obligated Group which consists of Avera Health, Avera McKennan, Avera St. Luke's, Avera Queen of Peace, Avera Sacred Heart, Avera Marshall, Avera St. Mary's, Avera St. Anthony's, Avera St. Benedict, Avera Holy Family, Avera Tyler, Avera Gettysburg and Avera at Home. St. Benedict Health Center was not allocated any share of the bond issue, and thus does not have an amount on line 20. Avera Health 3900 West Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) Line 10 N/A 0 St Benedict Health Center Foundation 401 West Glynn Drive PO Box B Parkston SD 57366 460458725 Support health related services SD 501(c)(3) Line 12a, I St Benedict Health Center 1 Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 68763 470463911 Healthcare services NE 501(c)(3) Line 3 Avera Health 0 Avera Holy Family 826 North 8th Street Estherville IA 51334 420680370 Healthcare services IA 501(c)(3) Line 3 Avera Health 0 Avera Holy Family Foundation 826 North 8th Street Estherville IA 51334 421317452 Support health related services IA 501(c)(3) Line 10 Avera Holy Family 0 Avera McKennan 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 460224743 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Avera Queen of Peace Hospital 525 North Foster Street Mitchell SD 57301 460224604 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Avera at Home 5116 S Solberg Ave Sioux Falls SD 57108 460399291 Home Services SD 501(c)(3) Line 10 Avera Health 0 Lewis and Clark Health Education and Service Agency 1000 W 4th ST Suite 9 Yankton SD 57078 460337013 Healthcare education SD 501(c)(3) Line 10 Sacred Heart Health Services 0 Avera St Luke's 305 South State Street Aberdeen SD 57401 460224598 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Avera Marshall 300 S Bruce ST Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) Line 3 Avera Health 0 Avera Gettysburg 606 East Garfield Gettysburg SD 57442 460234354 Healthcare services SD 501(c)(3) Line 3 Avera St Mary's 0 Avera St Mary's 801 East Sioux Avenue Pierre SD 57501 460230199 Healthcare services SD 501(c)(3) Line 3 Avera Health 0 Avera Tyler 240 Willow Street Tyler MN 56178 410853163 Healthcare services MN 501(c)(3) Line 3 Avera Marshall 0 Avera Health Plans Inc 3900 West Avera Drive Suite 101 Sioux Falls SD 57108 460451539 Health financing and health plan admin SD 501(c)(4) Avera Health 0 Avera Home Medical Equipment of Floyd Valley Hospital LLC 714 Lincoln ST NE Lemars IA 51031 820582350 Medical services - home medical equipment SD N/A Avera Home Medical Equipment of Sioux Center LLC 38 19th ST SW Sioux Center IA 51250 753203100 Medical services - home medical equipment SD N/A Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Ave Sioux Falls SD 57117 800619999 Medical Services - home medical equipment SD N/A Q&M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical Clinic Building SD N/A Surgical Associates Endoscopy Clinic LLC 310 S Pennsylvania St Aberdeen SD 57401 460461429 Surgical Associates SD N/A Heart Hospital of South Dakota LLC 4500 W 69th Street Sioux Falls SD 57108 562143771 Healthcare Services SD N/A Brookings Health System - Avera HME LLC 101 22nd Ave Suite 101 Brookings SD 57006 453204123 Medical Services - Home Medical Equipment SD N/A National Rural ACO 4 LLC dba Prairie Hills Care Organization 7509 NW Tiffany Springs Parkway Kansas City MO 64153 371780735 Accountable Care Organization KS N/A National Rural ACO 5 LLC dba Great Plains Care Organization 7509 NW Tiffany Springs Parkway Kansas City MO 64153 383958290 Accountable Care Organization KS N/A Accounts Management Inc 5132 S Cliff Avenue Suite 101 Sioux Falls SD 57108 460373021 Collection Agency SD N/A C 0 Avera Property Insurance Inc 510 W 23rd Street PO Box 38 Yankton SD 57078 460463155 Insurance SD N/A C 0 Valley Health Services 501 Summit Street Yankton SD 57078 460357149 Rental Real Estate SD N/A C 0 Alucent Medical Inc 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 571175045 471818349 Biotech Research SD N/A C 0 South Dakota State Medical Holding Company 2600 W 49th Street Sioux Falls SD 57105 460401087 Insurance SD N/A C 0 DakotaCare Administrative Services Inc 2600 W 49th Street Sioux Falls SD 57105 460424322 Insurance SD N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0