2018-05-14T06:42:45-05:00 2017-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2016-07-01 420796764 Sioux Center Health SIOU 7127221271 1101 9th St SE Sioux Center IA 51250 Jackson Schuiteman CFO 7127221271 2018-05-11 1 Laurie Hanson P00851848 6053391999 2018-05-11 2016 2022-09-23 18:48:47Z Kayleen Lee 1101 9th St SE Sioux Center IA 51250 40617903 0 X www.siouxcenterhealth.org X 1951 IA To provide medical care for all ages. 41 38 565 144 0 0 32448 128505 37921778 40270011 78714 36930 153839 153130 38186779 40588576 21744 42500 0 0 19925030 21353259 0 0 65900 18853356 19270323 38800130 40666082 -613351 -77506 77862177 78325823 40981401 41522553 36880776 36803270 X Bring hope, health and healing to life. 1 0 35510191 42500 40346987 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, 2017, patient days were 1,448, swing-bed days were 520, and newborn days were 362.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 $268,000 for the year ended June 30, 2017, 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. 35510191 1 1 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 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 33 0 1 565 0 0 0 0 0 0 0 0 0 0 0 X 41 38 1 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 X Jackson Schuiteman 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 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 Terry Boote 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 Mayra Castelan Director 1.00 X 0 0 0 Lisa Christians 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 Roger Fedders Director 1.00 X 0 0 0 Randy Feenstra Director 1.00 X 0 0 0 Dan Hibma 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 Jennifer Jansen Director 1.00 X 0 0 0 Lauren Kaemingk 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 Scott Peterson Director 1.00 X 0 0 0 Rich Rikkers Director 1.00 X 0 0 0 Stan Speer Director 1.00 X 0 0 0 Doug Van Meeteren Director 1.00 X 0 0 0 Con Van Roekel 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 Dennis Wright 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 Josh Bowar Director 1.00 X 0 0 0 Cory Gotto Director 1.00 X 0 0 0 Stacy Koele Director 1.00 X 0 0 0 Kayleen Lee CEO 40.00 X 226423 0 28270 Jackson Schuiteman CFO 40.00 X 98602 0 20111 Dr Julie A McKay MD Diagnostic radiology 24.00 X 342394 0 67756 Dr Jamie J Vitamvas Family Medicine/OB 40.00 X 338106 0 39261 Dr Scott A Rens MD Family Medicine/OB 40.00 X 402511 0 74165 Dr Lorianne S Andersen MD Family Medicine/OB 40.00 X 294148 0 46067 Dr Jason R Koelewyn MD Family Medicine/OB 40.00 X 323900 0 54701 2026084 0 330331 13 0 1 1 Avera McKennan 1325 S Cliff Avenue Sioux Falls SD 571175045 Management fees & other services 1738184 Schelling Construction 44 14th St NW Sioux Center IA 51250 construction contractor 448167 Jon Clegg 1226 Turnberry Avenue Le Mars IA 51031 Anesthesia 336660 Northwest Iowa Diagnostics 714 Lincoln St Ne Le Mars IA 51031 Ultrasound Readings 201165 Thomas Posch 234 Marina Dell Ave Yankton SD 57078 Radiology Readings 114967 5 51529 76976 128505 Patient Service Revenue 622110 35605328 35605328 Assisted and Independent Living 623990 1892274 1892274 Daycare Revenue 624410 1166518 1166518 Change in Int: Avera Fdtn 900099 389482 389482 Investment in affiliates 900099 20938 20938 1195471 1195471 40270011 36930 36930 128603 0 128603 128603 128603 53854 29327 24527 24527 40588576 40270011 0 190060 12500 12500 30000 30000 389435 389435 223303 223303 16616823 15135949 1446994 33880 634674 600965 32249 1460 2308201 2117782 184980 5439 1180823 1040136 138240 2447 1495100 1495100 81223 81223 3736688 3492323 244365 201439 184789 16650 940905 530753 408191 1961 676501 676501 68868 65015 3853 195787 129911 62107 3769 1334873 1334873 4318848 4318848 410111 83724 326387 Medical Supplies 4232224 4232224 Bad Debt 663185 663185 Food 626832 608630 17908 294 Taxes 164917 164917 122822 48652 74170 40666082 35510191 5089991 65900 6801085 8730581 1401754 987498 3922728 4883502 64320 396972 451172 357634 391625 75520276 23830991 55250081 51689285 7802847 9024922 500907 446931 1428169 1655987 77862177 78325823 2806889 4111708 59927 10925000 10472500 99620 93620 25381796 24708738 1708169 2135987 40981401 41522553 X 35985420 35814975 667416 756675 227940 231620 36880776 36803270 77862177 78325823 -77506 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 324809 31223 356032 328776 -3967 324809 210511 118265 328776 187178 23333 210511 174398 12780 187178 0.65060 0.34940 1 0 630000 2219111 2849111 56315080 13636308 42678772 15124855 9469589 5655266 1231230 725094 506136 51689285 Investment in Northwest Iowa Diagnostics 40584 F Interest in Avera Health Foundation 2812713 F Investment in Avera Home Medical of Sioux Center LLC 121131 F Other investment 6050494 F 9024922 Deferred Compensation 1655987 Estimated third-party payor settlements 480000 2135987 X 39832452 -663185 -663185 40495637 92939 92939 40588576 40002897 0 40002897 663185 663185 40666082 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 -663,185. Part XI, Line 4b - Other Adjustments: Change in net assets of Avera Health Foundation 92,939. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 663,185. 1 1 X 1 X 1 X 1 1 0 1 1 217 208000 208000 0.00520 4297144 3623989 673155 0.01680 217 4505144 3623989 881155 0.02200 6 1836 12516 360 12156 0.00030 1 2 14554 14554 0.00040 3 14532 7953831 6437275 1516556 0.03790 1 22119 22119 0.00060 11 16370 8003020 6437635 1565385 0.03920 11 16587 12508164 10061624 2446540 0.06120 1 1419 1419 0.00000 1 347 1654468 1171518 482950 0.01210 2 347 1655887 1171518 484369 0.01210 0 663185 17906 9157101 9270320 -113219 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 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 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: The Summary of Health Needs identified in the implementation strategy of our CHNA include: Obesity, Mental Health Services, Translation and Interpretation, Community Education and Support Groups and Recreation. With limited financial and human resources, Sioux Center Health has not directly focused on the identified needs of Community Education and Support and Recreation. Through several partnerships in Sioux County, various Health Improvement Planning groups have been established and are creating action plans to address these needs.The following prioritized needs have been more directly addressed within Sioux Center Health:-Obesity: Sioux Center Health Physician, Dr. Scott Rens, received his certification as an American Board of Obesity Medicine Diplomate which distinguishes him as having specialized knowledge in the practice of obesity medicine. He is developing weight management programming and seeing patients to address these concerns. Sioux Center Health Dietician provided a program on weight management to identify the behaviors behind eating habits. Sioux Center Health continued partnerships with the Sioux Center Trials Council, Siouxperman Triathlon Committee, Health Sioux Center community group and other recreational offerings and events to remain an active voice for wellness in our community.-Mental Health: Sioux Center Health continued to provide 24/7 social worker coverage and also utilizes virtual telemedicine work through Avera eCare for Behavioral Health. Mental Health training for staff is ongoing to identify signs and treatment options.-Translation: Sioux Center Health created a Diversity Advisory Committee which focuses on the needs of translation and interpretation services offered to our patients and community. This team has been working on action plans to create more opportunities for staff to assist with interpretation within the clinic and also ensuring a culturally diverse mindset on communication, marketing and services. 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 before discharge. The charity care and other financial assistance options are discussed with OB patients during their "mommy and me" visit. Sioux Center Health Part V, Section B, Line 24: The policy does not cover elective procedures and they have confirmed no FAP patients had elective procedures. 7 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 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 ID 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 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 and Medicaid on line 7b were converted to cost based on an overall cost-to-charge ratio addressing all patient segments. Lines 7e, 7f, and 7i: Costs are reported based on data from the general ledger accounting system. The general ledger accounting system addresses all patient segments (inpatient, outpatient, emergency room, private insurance, Medicaid, Medicare, uninsured, and self-pay). The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $663,185. 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 2.7% 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 6/30/17. 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 V, Line 16i Financial Assistance Policy Description of failureType of failure: 501(r)(4) - The hospital is required to translate the financial assistance policy, plain language summary and financial assistance policy application into Spanish as more than the lesser of 1,000 individuals or 5% of the community served by the hospital speaks Spanish as a primary language. The hospital did not translate the financial assistance policy into Spanish. Cause of the failure: The hospital facility was not aware of the requirement to translate the full financial assistance policy into Spanish. The facility has staff available who are able to translate the policy to assist limited English proficiency (LEP) patients with questions related to the financial assistance policy.Facility or facilities where the failure occurred: The failure occurred in the hospital facility. The date(s) of the failure and its discovery: March 1, 2018The number of occurrences: UnknownDescription of the correction of the failureMethod of correction: The financial assistance policy was translated into Spanish. The documents were made available at each facility and on the website.Date of correction: May 14, 2018Description of the practices or procedures put into placeThe financial assistance policy was translated into Spanish and posted on the website at http://www.siouxcenterhealth.org/financial-assistance/. The translated documents are also available at the hospital facility. In addition, Sioux Center Health continues to provide translation services to assist LEP patients with questions they may have regarding financial assistance. 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 charity care and other financial assistance options are discussed with inpatients before discharge.4. The charity care and other financial assistance options are discussed with OB patients during their initial prenatal visits and the "mommy and me" visit.5. The financial assistance application is available on the Hospital website.6. The financial assistance application is available and the registration and ER desk.7. 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 is located in northwest Iowa. As of 2010, the county's population was just over 33,700. The county is also home to three other critical access hospitals. Nearly 90% of Sioux Center Health's discharges come from Sioux County. According to 2009-2013 American Community Survey profiles, Sioux Center had a population of just over 7,000 with median family income of $59,214. 6.5% of the families in Sioux Center were below the poverty level. The 2010 census shows a Hispanic population record of 13.1% 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 42 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 cancer research via Relay for Life activities, to 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. 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 12500 Scholarships 1 Scholarships 27 30000 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 0 1 0 0 0 0 0 0 0 Kayleen Lee CEO 221388 0 0 0 5035 0 4588 0 24832 0 255843 0 0 0 Dr Julie A McKay MD Diagnostic radiology 192322 0 148867 0 1205 0 48922 0 19318 0 410634 0 0 0 Dr Jamie J Vitamvas Family Medicine/OB 230492 0 49223 0 58391 0 20015 0 19730 0 377851 0 0 0 Dr Scott A Rens MD Family Medicine/OB 397817 0 3961 0 733 0 54033 0 20615 0 477159 0 0 0 Dr Lorianne S Andersen MD Family Medicine/OB 245612 0 30294 0 18242 0 26446 0 20105 0 340699 0 0 0 Dr Jason R Koelewyn MD Family Medicine/OB 253009 0 51181 0 19710 0 35676 0 19508 0 379084 0 0 0 Part I, Line 4b Sioux Center Health provides a nonqualified deferred compensation plan for its physicians. The following individual had amounts deferred into the account as reported in column C on Schedule J: Dr. Jamie J. Vitamvas $17,215 Form 990, Part VII, Section A, Line 5 & Form 990, Schedule J, Part II: Kayleen Lee, CEO, is compensated by 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 444784AR3 2012-10-18 10000000 Hospital Replacement 0 0 0 A 2662500 4000000 4000000 2005 0 0 1 1 B 865000 10055050 689063 623609 200000 8487328 2013 0 0 1 1 A 0 0 0 0 0 0 1 B 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 B 0 1 0 0 0 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 II line 3 2012 bond total proceeds of issue included $55,050 of interest earned on reserves. Dr Jamie Vitamvas Physician Recruitment Loan X 250000 64320 0 1 1 64320 Irene Schuiteman Family member of Jackson Schuiteman, CFO 55736 Compensation as an employee 0 Jerry Zomermaand Family member of Gretchen Zomermaand, Director 121219 Compensation as an employee 0 Tammy Byl Family member of Tim Byl, Vice President of the Board 19013 Compensation as an employee 0 Kim Bosma Family member of Cory Gotto, Director 27335 Compensation as employee 0 Form 990, Part III, line 2 New Specialty Clinics: Pediatric Cardiology (Eric Towe, MD) and Psychiatry-consultative (Grace LaFollette, APRN) 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 Brian Van Engen, Board President, and Stan Speer, Director, have a business relationship. Jennifer Jansen, Director, and Lauren Kaemingk, Director, have a business 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 CFO reviews the 990 in detail. After his review and prior to filing the return with the IRS, the 990 is emailed to board members of the organization. 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. Northwest Iowa Diagnostics 714 Lincoln St NE Le Mars IA 51031 820559254 Diagnostic radiology IA Sioux Center Community Hospital & Health Related 7915 57900 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 28407 161380 0 0 0.50000 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 1 0 0