2018-08-15T12:47:59-05:00 2017-09-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2016-10-01 460255944 MOBRIDGE REGIONAL HOSPITAL MOBR 6058453692 1401 10TH AVE W MOBRIDGE SD 57601 JOHN AYOUB CEO 6058453692 2018-08-14 1 LAURIE HANSON P00851848 6053391999 2018-08-14 2016 2022-09-23 18:48:47Z JOHN AYOUB 1401 10TH AVE W MOBRIDGE SD 57601 23864881 0 X WWW.MOBRIDGEHOSPITAL.ORG X 1959 SD PROVIDING HEALTHCARE TO PEOPLE THROUGHOUT THE REGION. 12 10 207 200 0 0 207513 211528 22591596 23495918 25335 62146 97289 95289 22921733 23864881 0 0 0 0 11222837 11759009 0 0 0 9944825 9658822 21167662 21417831 1754071 2447050 24952161 26787293 9010772 8398854 15941389 18388439 THE MISSION OF MOBRIDGE REGIONAL HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE SERVICES IN A COMPASSIONATE AND PROFESSIONAL MANNER FOR PEOPLE THROUGHOUT THE REGION. 0 0 19456432 23591207 MOBRIDGE REGIONAL HOSPITAL (MRH), A 25-BED CRITICAL ACCESS HOSPITAL, 16 BED ASSISTED LIVING CENTER, 8 BED SENIOR HOUSING CENTER, AND MEDICAL CLINICS, PROVIDES HEALTHCARE SERVICES TO PERSONS THROUGHOUT THE REGION. DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2017, THE HOSPITAL PROVIDED CARE TO THE NORTH CENTRAL REGION OF SOUTH DAKOTA, AND THE SOUTH CENTRAL REGION OF NORTH DAKOTA. THE HOSPITAL HAD: 1,840 PATIENT DAYS 1,705 ACUTE CARE DAYS 970 SWING BED CARE DAYS 4,048 EMERGENCY ROOM VISITS19,392 RURAL HEALTH CLINIC VISITS 5,964 ASSISTED LIVING DAYS (PRAIRIE SUNSET VILLAGE) 19456432 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 13 0 1 207 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X X RENAE TISDALL 6058458164 PO BOX 580 MOBRIDGE SD 57601 BILL BACHMEIER CHAIRMAN 1.00 0.00 X X 0 0 0 DELPHINE STEUCK VICE CHAIR 1.00 0.00 X X 0 0 0 HEIDI ROSHAU TREASURER 1.00 0.00 X X 0 0 0 DR TOM SWANSON SECRETARY 1.00 0.00 X X 0 0 0 JAKE KRAFT DIRECTOR 1.00 0.00 X 0 0 0 WALLY SCHOTT DIRECTOR 1.00 0.00 X 0 0 0 DR LEONARD LINDE DIRECTOR 1.00 0.30 X 0 0 0 BARB GROSS DIRECTOR 1.00 0.00 X 0 0 0 LAURIE BAUER DIRECTOR 1.00 0.00 X 0 0 0 LORI HIEL DIRECTOR 1.00 0.00 X 0 0 0 DR TRAVIS HENDERSON INTERNAL MEDICINE/DIRECTOR 40.00 0.00 X 296600 0 30703 DR ROBERT MARCIANO FAMILY MD/DIRECTOR 40.00 0.00 X 341678 0 22900 JOHN AYOUB CEO(BEGAN JAN. 2017) 40.00 0.00 X 0 0 0 RENAE TISDALL CFO 40.00 0.00 X 93074 0 22362 DR BELA CSAKI SURGEON 40.00 0.00 X 360558 0 16601 DR JOSH HENDERSON INTERNAL MEDICINE 40.00 0.00 X 253599 0 28237 DEBBIE SMITH CRNA 40.00 0.00 X 222017 0 16513 DR COLETTE DUCHENEAUX FAMILY MEDICINE 40.00 0.00 X 338672 0 30945 DR REGG HAGGE FAMILY MEDICINE 40.00 0.00 X 294388 0 25225 2200586 0 193486 14 0 1 0 CHI ST ALEXIUS HEALTH 900 EAST BROADWAY BISMARCK ND 58501 IT SERVICES, CEO SALARY, SUPPLIES, ETC 216695 NORTHERN PLAINS LAB PO BOX 2036 BISMARCK ND 58502 OUTSOURCE LABORATORY SERVICES 184699 2 211528 211528 PATIENT SERVICE REVENUE 623110 22468445 22468445 ASSISTED LIVING REVENUE 623110 425713 425713 ELECTRONIC HEALTH RECORDS 900099 354830 354830 CHANGE IN FOUNDATION INTEREST 900099 144059 144059 ANCILLARY CHARGES 900099 102871 102871 23495918 62146 62146 95289 0 95289 95289 95289 23864881 23591207 0 62146 865395 747126 118269 8459521 7852486 607035 289667 266490 23177 1555706 1445628 110078 588720 539554 49166 277287 277287 5239 5239 50267 50267 750924 750924 82604 7183 75421 718584 617940 100644 101739 576 101163 336652 331874 4778 37627 37627 64244 59161 5083 290649 290649 1716883 1716883 199034 162877 36157 MEDICAL SUPPLIES 2342161 2342161 BAD DEBT 1452179 1452179 EQUIPMENT AND MAINTENAN 1068301 1042555 25746 DUES AND SUBSCRIPTIONS 46836 15258 31578 117612 67950 49662 21417831 19456432 1961399 0 7424911 8582877 2633616 3119753 145657 251697 352984 358227 69664 142294 31558776 20867938 11651323 10690838 6000 1256000 1583924 1739131 1084082 646476 24952161 26787293 1341261 1402242 443537 88707 3090000 2710000 3783076 3527964 352898 669941 9010772 8398854 X 15109563 17451592 831826 936847 15941389 18388439 24952161 26787293 2447050 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 95575 95575 15900908 8696920 7203988 14738626 11712704 3025922 823667 458314 365353 10690838 INTEREST IN MOBRIDGE REGIONAL HEALTHCARE FOUNDATION 824304 F ASSETS LIMITED AS TO USE 914827 F 1739131 PREMIUM ON BONDS PAYABLE 6299 DEFERRED COMPENSATION PLAN PAYABLE 459135 UNAMORTIZED DEBT ISSUANCE COST -47494 PSV DEPOSITS 10001 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 242000 669941 X 22284281 -1380333 -1380333 23664614 200267 200267 23864881 19942252 0 19942252 1475579 1475579 21417831 PART X, LINE 2: THE ORGANIZATION IS A SOUTH DAKOTA 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 ORGANIZATION IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE HOSPITAL IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE. THE ORGANIZATION HAS DETERMINED IT IS NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAS NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. THE ORGANIZATION 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 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. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT RECLASSIFIED AS EXPENSE -1,452,179. NET ASSETS RELEASED FROM RESTRICTION 95,246. EXPENSE NETTED TO REVENUE ON AUDIT -23,400. PART XI, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN FOUNDATION 144,059. RESTRICTED GRANTS AND CONTRIBUTIONS 56,208. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT RECLASSIFIED AS EXPENSE 1,452,179. EXPENSE NETTED TO REVENUE ON AUDIT 23,400. 1 1 X 1 X 1 X 1 1 1 0 0 141000 141000 0.00710 3276672 2742235 534437 0.02680 3417672 2742235 675437 0.03390 4537588 1398977 3138611 0.15720 4537588 1398977 3138611 0.15720 7955260 4141212 3814048 0.19110 0 1452179 198949 5244713 5269044 -24331 X 1 1 1 1 MOBRIDGE REGIONAL HOSPITAL 1401 10TH AVENUE W MOBRIDGE SD 57601 WWW.MOBRIDGEHOSPITAL.ORG 48404 X X X X MOBRIDGE REGIONAL HOSPITAL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE 7D X X 1 15 1 SEE PART V, LINE 10A NARRATIVE. 0 1 X 100.000000000000 300.000000000000 X X X X X 1 1 X X X 1 X SEE PART V, LINE 16I NARRATIVE X SEE PART V, LINE 16I NARRATIVE X X X X X X X 1 X 0 X X X X X 1 X 0 0 MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 5: THE FACILITY OBTAINED DATA FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT THROUGH FOCUS GROUPS, SURVEYS AND PERSONAL INTERVIEWS INVOLVING COMMUNITY LEADERS, COMMUNITY HEALTHCARE PROVIDERS, COORDINATING AGENCIES, COMMUNITY MEMBERS AND THE UNDERSERVED POPULATION. MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 7D: THE CHNA REPORT IS AVAILABLE AT HTTP://WWW.MOBRIDGEHOSPITAL.ORG/ABOUT-US/COMMUNITY-ASSESSMENT-REPORT-990/MOBRIDGE REGIONAL HOSPITAL:PART V, SECTION B, LINE 10ATHE HOSPITAL'S IMPLEMENTATION STRATEGY IS POSTED ON THE WEBSITE AT HTTP://WWW.MOBRIDGEHOSPITAL.ORG/ABOUT-US/COMMUNITY-ASSESSMENT-REPORT-990/. THE IMPLEMENTATION STRATEGY BEGINS ON PAGE 5 OF THE CHNA. MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 11: PURSUANT TO THE IMPLEMENTATION STRATEGY ADOPTED BY MOBRIDGE REGIONAL HOSPITAL, THE FOLLOWING ACTIONS PLANS HAVE BEEN DEVELOPED. MENTAL HEALTH CARE - THE HOSPITAL WILL IDENTIFY OPPORTUNITIES TO OFFER ADDITIONAL MENTAL HEALTH SERVICES, BOTH IN PERSON AND ELECTRONICALLY. MRH WILL ALSO CONTINUE TO DEVELOP RELATIONSHIPS WITH MENTAL HEALTH PROFESSIONALS IN THE AREA. AS OF JULY, 2018 AN EMPLOYMENT AGREEMENT HAS BEEN OBTAINED WITH A DOCTOR OF NURSE PRACTITIONER WITH AN EMPHASIS IN PSYCHOLOGY FOR SERVICES TO BEGIN IN SEPTEMBER, 2018.URGENT CARE - MRH WILL EVALUATE THE BENEFITS AND COSTS OF ADDITIONAL URGENT CARE OPTIONS. DURING THE FY17, ADDITIONAL ADVANCED PRACTICE PROVIDER STAFF WAS RETAINED TO PROVIDE ADDITIONAL WALK IN CLINIC SERVICES OR EMERGENCY CARE SERVICES AS NEEDED.CANCER TREATMENT CENTER - MRH WILL CONTINUE TO DEVELOP RELATIONSHIPS WITH ONCOLOGISTS IN ORDER TO ENHANCE CANCER CARE OPTIONS IN THE COMMUNITY. OUTREACH SERVICES HAVE BEEN ESTABLISHED WITH AVERA HEALTH ONE DAY PER MONTH.KIDNEY DIALYSIS AND PEDIATRICS WILL NOT BE ADDRESSED. FINANCIAL FEASIBILITY STUDIES WERE COMPLETED. WE FOUND THE COST TO ADD KIDNEY DIALYSIS WAS FAR TOO GREAT AND WE ARE THEREFORE UNABLE TO PROVIDE THIS PARTICULAR SERVICE. THE COST TO RECRUIT AND RETAIN A PEDIATRICIAN WAS ALSO TOO GREAT. PEDIATRIC NEEDS WERE REFERRED TO BISMARCK, PIERRE, AND SIOUX FALLS. MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE USED AS A LAST RESORT. MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 16J: PART V, LINE 16A, FAP WEBSITE:HTTP://WWW.MOBRIDGEHOSPITAL.ORG/PATIENTS-AND-VISITORS/PAY-A-BILL/FINANCIAL-ASSISTANCE/PART V, LINE 16B, FAP APPLICATION WEBSITE:HTTP://WWW.MOBRIDGEHOSPITAL.ORG/PATIENTS-AND-VISITORS/PAY-A-BILL/FINANCIAL-ASSISTANCE/PART V, LINE 16C, PLAIN LANGUAGE SUMMARY WEBSITE:HTTP://WWW.MOBRIDGEHOSPITAL.ORG/PATIENTS-AND-VISITORS/PAY-A-BILL/FINANCIAL-ASSISTANCE/PART V, LINE 16J: A FINANCIAL ASSISTANCE NOTICE IS MADE PART OF THE BILLING INVOICE. A FINANCIAL ASSISTANCE NOTICE IS POSTED IN THE EMERGENCY ROOM, WAITING ROOMS, AND ADMISSIONS OFFICE, AND THE FULL POLICY IS MADE AVAILABLE UPON REQUEST AND ON THE WEBSITE. MOBRIDGE REGIONAL HOSPITAL PART V, SECTION B, LINE 20E: PROVIDED FINANCIAL ASSISTANCE INFORMATION WITH PATIENT DISCHARGE MATERIALS. MOBRIDGE REGIONAL HOSPITAL 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. 4 1 - PRAIRIE SUNSET VILLAGE 1320 W GRAND XING MOBRIDGE SD 57601 ASSISTED LIVING & SENIOR HOUSING 2 - MOBRIDGE MEDICAL CLINIC 1309 10TH AVE W MOBRIDGE SD 57601 PROVIDER BASED RURAL HEALTH CLINIC 3 - WEST RIVER HEALTH CLINIC 103 1ST AVENUE E MCLAUGHLIN SD 57642 PROVIDER BASED RURAL HEALTH CLINIC 4 - WEST DAKOTA HEALTH CLINIC 906 MAIN TIMBER LAKE SD 57656 PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO FPG, THE HOSPITAL USES AN ASSET TEST, REVIEWS MEDICAL INDIGENCY, AND CONSIDERS INSURANCE STATUS IN DETERMINING ELIGIBILITY FOR FINANCIAL ASSISTANCE. PRESUMPTIVE ELIGIBILITY MAY BE USED AS A LAST RESORT. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. LINE 7B WAS DETERMINED USING THE MEDICAID PS&R REPORT AND THE GENERAL LEDGER ACCOUNTING SYSTEM. LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 9/30/17. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES COSTS OF $4,236,298 ATTRIBUTABLE TO PHYSICIAN CLINICS. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $1,452,179 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART III, LINE 2: BAD DEBT EXPENSE ON PART III LINES 2 AND 3 IS BASED ON CHARGES. WHEN A PAYMENT IS RECEIVED OR A DISCOUNT GIVEN ON A BAD DEBT ACCOUNT IT OFFSETS THE CURRENT FISCAL YEAR BAD DEBT EXPENSE THROUGH A RECOVERY OF BAD DEBT ACCOUNT. PART III, LINE 3: THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON THE PERCENTAGE OF INDIVIDUALS LIVING BELOW THE POVERTY LEVEL IN 2016. THE 13.7% CAN REASONABLY BE CONSIDERED A COMMUNITY BENEFIT AS IT WOULD HAVE BEEN WRITTEN OFF TO CHARITY CARE. PART III, LINE 4: THE FOOTNOTE FOR BAD DEBT EXPENSE IS LOCATED 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 THE FISCAL YEAR ENDING 9/30/2017. 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: THE PATIENT ACCOUNT SPECIALIST AT THE MOBRIDGE REGIONAL HOSPITAL KEEPS ON FILE ALL GUARANTORS WHO HAVE QUALIFIED FOR FINANCIAL ASSISTANCE AND APPLIES THE FINANCIAL ASSISTANCE TO ALL ACCOUNTS WHEN THE GUARANTOR BALANCE BECOMES DUE. UPDATED FINANCIAL INFORMATION IS REQUESTED ANNUALLY FOR ANY CHANGES IN FINANCIAL ASSISTANCE THAT MAY APPLY. PART V, LINE 16A FINANCIAL ASSISTANCE POLICY, AND 16C PLAIN LANGUAGE SUMMARY DESCRIPTION OF FAILURETYPE OF FAILURE: 501(R)(4) - THE HOSPITAL DID NOT TO POST ITS 501R COMPLIANT FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY ON ITS WEBSITE IN A TIMELY MANNER. THE DOCUMENTS WERE AVAILABLE BY CONTACTING THE HOSPITAL AND WERE INCLUDED IN PATIENT BILLINGS AS REQUIRED.CAUSE OF THE FAILURE: THE HOSPITAL FACILITY EXPERIENCED TRANSITION IN ITS MARKETING DIRECTOR POSITION. THE MARKETING DIRECTOR IS RESPONSIBLE FOR POSTING DOCUMENTS TO THE WEBSITE.FACILITY OR FACILITIES WHERE THE FAILURE OCCURRED: THE FAILURE OCCURRED AT MOBRIDGE REGIONAL HOSPITAL.THE DATE(S) OF THE FAILURE AND ITS DISCOVERY: APRIL 2018THE NUMBER OF OCCURRENCES: UNKNOWNDESCRIPTION OF THE CORRECTION OF THE FAILUREMETHOD OF CORRECTION: THE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY WERE MADE AVAILABLE ON THE WEBSITE.DATE OF CORRECTION: FINANCIAL ASSISTANCE POLICY POSTED TO WEBSITE AUGUST 9, 2018. PLAIN LANGUAGE SUMMARY POSTED TO WEBSITE AUGUST 14, 2018.DESCRIPTION OF THE PRACTICES OR PROCEDURES PUT INTO PLACETHE FINANCIAL ASSISTANCE POLICY AND PLAIN LANGUAGE SUMMARY WERE POSTED ON THE WEBSITE AT HTTP://WWW.MOBRIDGEHOSPITAL.ORG/PATIENTS-AND-VISITORS/PAY-A-BILL/FINANCIAL-ASSISTANCE/. THE DOCUMENTS ARE ALSO AVAILABLE AT THE HOSPITAL. PART VI, LINE 2: MOBRIDGE REGIONAL HOSPITAL (MRH) IS COMMITTED TO PROVIDING HIGH QUALITY HEALTHCARE SERVICES TO ALL PEOPLE THROUGHOUT THE REGION. THE FACILITY PROVIDES FAMILY MEDICINE, INTERNAL MEDICINE, OB, ICU, ALS, AMBULANCE SERVICE, EMERGENCY CARE, AND SURGICAL SERVICES TO ALL PEOPLE WHO ARE IN NEED OF THOSE SERVICES. MRH CURRENTLY IS WORKING IN COLLABORATION WITH WALWORTH COUNTY AND THE STATE OF SOUTH DAKOTA TO PROVIDE COMMUNITY HEALTH SERVICES, INCLUDING FAMILY PLANNING SERVICES, ADULT HEALTH, AND CHILD IMMUNIZATIONS. MRH'S MANAGEMENT STRIVES TO LISTEN TO THE COMMUNITY NEEDS. IF NEW HEALTHCARE NEEDS ARISE, ADMINISTRATION WILL COMPLETE AN ANALYSIS OF COST/BENEFIT FOR THE NEW SERVICE TO BE OFFERED. MRH'S ADMINISTRATION BELIEVES IN BEING OUT IN THE PUBLIC AT EVENTS TO ANSWER QUESTIONS THAT MAY SURFACE ABOUT THE FACILITY. PART VI, LINE 3: MRH POSTS ITS FINANCIAL ASSISTANCE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION IN THE ADMISSIONS AREAS AND CLINIC AREAS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT. THE FACILITY PROVIDES A COPY OF THE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS WITH DISCHARGE MATERIALS. THE PATIENTS ACCOUNT MANAGER DISCUSSES WITH THE PATIENT THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS, AND ASSISTS THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHERE APPLICABLE. PART VI, LINE 4: MRH IS LOCATED IN A SMALL RURAL COMMUNITY IN WALWORTH COUNTY, SOUTH DAKOTA, KNOWN AS MOBRIDGE. WALWORTH COUNTY HAS A POPULATION OF 5,443 PEOPLE RACIALLY COMPRISED OF MAINLY CAUCASIAN (82.4%) AND NATIVE AMERICANS/ALASKAN NATIVE (13.6%). THE COMMUNITY BORDERS THE STANDING ROCK RESERVATION AND THE CHEYENNE RIVER RESERVATION WHICH ACCOUNTS FOR THE LARGER NATIVE AMERICAN POPULATION AND RELATIONS WITH INDIAN HEALTH SERVICES. THE MEDIAN HOUSEHOLD INCOME OF MOBRIDGE IS $41,358, AND THE MEDIAN FAMILY INCOME IS $52,316. ROUGHLY 11.5% OF THE POPULATION IS BELOW THE POVERTY LINE. THE FACILITY OWNS AND OPERATES CLINICS IN MOBRIDGE, MCLAUGHLIN AND TIMBER LAKE. THE FACILITY SERVES PATIENTS FROM A SIX COUNTY AREA (WALWORTH, ZIEBACH, CORSON, DEWEY, CAMPBELL AND POTTER) AND IS APPROXIMATELY ONE HUNDRED MILES FROM ANOTHER HOSPITAL WITH A HIGHER LEVEL OF CARE OFFERED. ZIEBACH COUNTY IS THE 6TH POOREST COUNTY IN AMERICA, AND 46% OF PEOPLE LIVING IN THIS COUNTY ARE UNDER FEDERAL POVERTY GUIDELINES. PART VI, LINE 5: THE MOBRIDGE REGIONAL HOSPITAL IS COMMITTED TO THE PATIENTS WE SERVE, REGARDLESS OF RACE, COLOR, RELIGION, SEX, DISABILITY, OR ABILITY TO PAY. THE ORGANIZATION'S FINANCIAL ASSISTANCE ADJUSTMENTS HAVE CONTINUED TO TREND UP OVER THE PAST FEW YEARS, AND WE CONTINUE TO FOCUS BUDGET EFFORTS TO CONTINUE THIS TREND. MRH IS 100 MILES FROM ANOTHER HEALTHCARE FACILITY WITH A HIGHER LEVEL OF CARE AND PARTICIPATES IN THE NORTH DAKOTA AND SOUTH DAKOTA TRAUMA SYSTEMS WITH LEVEL III AND LEVEL IV CERTIFICATIONS, RESPECTIVELY. MRH CONTINUES A BROAD LEVEL OF BOARD INVOLVEMENT FOR CORSON, DEWEY, AND WALWORTH COUNTIES TO MONITOR COMMUNITY NEEDS IN THOSE AREAS. MRH CONTINUES TO BE A POPULAR PLACE FOR MEDICAL STUDENTS TO COMPLETE CLINICAL ROTATIONS, AND WE CONTINUE TO OFFER A WIDE VARIETY OF CERTIFICATION CLASSES TO NURSES AND THE MEMBERS OF THE COMMUNITY INCLUDING EMT-B, PALS, ACLS, TNCC, ALSO, NALS, EMT-I, AND CPR. MRH HAS DEVELOPED A WORKSITE WELLNESS PROGRAM WITHIN THE ORGANIZATION AND HAS GOALS TO WORK WITH OTHER BUSINESSES IN THE COMMUNITY TO PROMOTE OVERALL HEALTHY LIFESTYLES.MRH PROVIDES VARIOUS HEALTH SCREENINGS AVAILABLE TO THE COMMUNITY AND SURROUNDING COMMUNITIES THROUGHOUT THE YEAR. THE HEALTH SCREENINGS INCLUDE FREE CHOLESTEROL CHECKS, BMI, BLOOD PRESSURE AND WAIST/HIP RATIOS. THESE PREVENTATIVE HEALTH SCREENINGS PROMOTE THE GENERAL HEALTH OF THE COMMUNITY.THE HOSPITAL HAS A BOARD OF DIRECTORS COMPRISED OF VOLUNTEERS WHO RESIDE IN THE SERVICE AREA. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE AREA. ALL QUALIFIED PHYSICIANS WHO SHOW AN INTEREST MUST GO THROUGH A CREDENTIAL REVIEW AND BOARD APPROVAL. SURPLUS FUNDS, IF AVAILABLE, ARE REINVESTED IN THE FACILITIES TO IMPROVE PATIENT CARE. X X 0 0 0 0 0 0 0 1 0 DR TRAVIS HENDERSON INTERNAL MEDICINE/DIRECTOR 231435 0 59716 0 5449 0 10600 0 20103 0 327303 0 0 0 DR ROBERT MARCIANO FAMILY MD/DIRECTOR 248271 0 88195 0 5212 0 10600 0 12300 0 364578 0 0 0 DR BELA CSAKI SURGEON 351516 0 0 0 9042 0 10600 0 6001 0 377159 0 0 0 DR JOSH HENDERSON INTERNAL MEDICINE 198660 0 49224 0 5715 0 9924 0 18313 0 281836 0 0 0 DEBBIE SMITH CRNA 220653 0 0 0 1364 0 8898 0 7615 0 238530 0 0 0 DR COLETTE DUCHENEAUX FAMILY MEDICINE 188852 0 144985 0 4835 0 10600 0 20345 0 369617 0 0 0 DR REGG HAGGE FAMILY MEDICINE 190043 0 63747 0 40598 0 4403 0 20822 0 319613 0 0 0 PART I, LINE 3 THE CEO IS COMPENSATED THROUGH A MANAGEMENT AGREEMENT WITH ST. ALEXIUS MEDICAL CENTER IN BISMARCK, ND. THE BOARD OF DIRECTORS OF MOBRIDGE REGIONAL HOSPITAL REVIEWS THE MANAGEMENT AGREEMENT AND MAKES A DETERMINATION AS TO WHETHER THE COMPENSATION FOR THE CEO'S SERVICES IS REASONABLE. PART I, LINE 7 THE PHYSICIANS ARE PAID BASED ON RELATIVE VALUE UNIT BASED PRODUCTION. A CITY OF MOBRIDGE SOUTH DAKOTA 466000320 607429BA4 2007-05-08 5773898 REFINANCE BONDS ISSUED 1997 USED FOR CONSTRUCTION; PURCHASE CT, CLINIC & EMR 0 0 0 A 3045000 5773898 265908 88005 1000000 4416499 2008 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 0 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: CITY OF MOBRIDGE, SOUTH DAKOTA DATE THE REBATE COMPUTATION WAS PERFORMED: 08/15/2017 FORM 990, PART VI, SECTION A, LINE 3 MRH CURRENTLY HAS A MANAGEMENT AGREEMENT WITH ST. ALEXIUS MEDICAL CENTER IN BISMARCK, ND. THE AGREEMENT PROVIDES THE CEO AND INFORMATION TECHNOLOGY SUPPORT AT A COST TO MRH. THE ORIGINAL MANAGEMENT AGREEMENT DATE WAS JANUARY 1, 2000. ANGELIA SVIHOVEC, CEO, RECEIVED COMPENSATION OF $141,083 AND ESTIMATED BENEFITS OF $13,000 DURING THE PERIOD 1/1/16 THROUGH 9/30/16. ANGELIA SVIHOVEC LEFT MRH SEPTEMBER 2016. JOHN AYOUB, CEO, BEGAN WORKING AT MRH JANUARY 2017. MRH WAS WITHOUT A CEO OCTOBER - DECEMBER, 2016. THE CEO OVERSEES ALL DAILY OPERATIONAL ACTIVITIES AND REPORTS TO THE ORGANIZATION'S BOARD OF DIRECTORS. THE CEO WORKS VERY CLOSELY WITH ALL DEPARTMENT SUPERVISORS TO ENSURE THAT ALL AREAS OF THE HOSPITAL ARE RUNNING EFFICIENTLY AND SMOOTHLY. THE CEO IS RESPONSIBLE FOR PHYSICIAN CONTRACTING AND WORKS VERY CLOSELY WITH HUMAN RESOURCES FOR RECRUITMENT OF PROFESSIONAL MEDICAL STAFF. FORM 990, PART VI, SECTION A, LINE 6 THERE IS ONLY ONE CLASS OF MEMBER; ALL MEMBERS HAVE ONE VOTE (SAME VOTING RIGHTS). EACH PERSON WHO DONATES $100 OR MORE IS A MEMBER ENTITLED TO ONE VOTE. FORM 990, PART VI, SECTION A, LINE 7A THE NOMINATING COMMITTEE NOMINATES CANDIDATES FOR ELECTION. THE MEMBERS VOTE ON CANDIDATES AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO COMMITTEE WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11B THE CEO, CFO, AND BOARD OF DIRECTORS WILL REVIEW THE FORM 990 VIA ELECTRONIC TRANSMISSION PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS THE ENTIRE BOARD OF DIRECTORS. IF A CONFLICT SHOULD ARISE, IT WOULD FIRST GO TO THE CEO FOR EVALUATION, THEN TO THE BOARD OF DIRECTORS FOR FINAL EVALUATION. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR MAKING THE FINAL DECISION IN DETERMINING IF A CONFLICT EXISTS. IF A CONFLICT IS FOUND, THE PERSON(S) INVOLVED WOULD BE REQUIRED TO ABSTAIN FROM DISCUSSIONS AND VOTING ON THE ITEM CAUSING THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE FINANCE COMMITTEE DETERMINES AND APPROVES THE PHYSICIAN CONTRACTS, INCLUDING COMPENSATION. THE CEO'S SALARY IS DETERMINED USING A SALARY SURVEY AND DISCUSSIONS WITH THE MANAGEMENT COMPANY. THE FINANCE COMMITTEE APPROVES THE SALARY OF THE CEO ANNUALLY. THE BOARD OF DIRECTORS APPROVES THE FINANCE COMMITTEE MINUTES, WHICH INCLUDE DISCUSSIONS REGARDING THE CEO'S SALARY. SALARIES FOR OTHER OFFICERS OR MEMBERS OF MANAGEMENT ARE DETERMINED BY THE CEO THROUGH THE USE OF SALARY SURVEY INFORMATION FROM SDAHO AND EMPLOYEE SERVICE AND EXPERIENCE FILES. THIS PROCESS IS UNDERTAKEN ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST. MOBRIDGE REGIONAL HEALTHCARE FOUNDATION PO BOX 580 MOBRIDGE SD 57601 460416693 OUTREACH FOR MOBRIDGE REGIONAL HOSPITAL SD 501(C)(3) LINE 12C, III-FI MOBRIDGE REGIONAL HOSPITAL 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0