2018-05-14T07:14:35-05:00 2017-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2016-07-01 460224604 Avera Queen of Peace Hospital AVER 6059952251 525 North Foster Street Mitchell SD 57301 William E Flett Sec/Treas & VP of Finance 6059952251 2018-05-11 0 Kim Hunwardsen CPA P00484560 6122536500 2018-05-09 198.135.125.11 2018-05-11 08:47:35 CD P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC F6CCFCC9BA9C612BF295D4DB650AF8F15E682770 2016 2021-01-29 14:40:06Z Avera Queen of Peace Health Service Thomas A Clark 525 North Foster Street Mitchell SD 57301 116974435 0 0928 X www.averaqueenofpeace.org X 1905 SD Promotion of health 18 14 971 52 0 0 205641 1615911 106138833 109423369 917063 4084587 -200565 -75121 107060972 115048746 275247 783630 0 0 60184304 61070062 0 0 89400 46026583 48178487 106486134 110032179 574838 5016567 134504013 139884199 45662750 45757451 88841263 94126748 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 93008960 783630 109426556 Avera Queen of Peace's mission is to provide healthcare services to Mitchell, SD residents and the surrounding area. They provide acute care and long-term healthcare services, of which there were 7,364 acute patient days, 1,841 swing-bed patient days, 1,117 nursery patient days, 29,086 nursing home resident days, 8,623 assisted living resident days, and 2,181 independent living days. The breakout of these statistics per facility is as follows.Avera Queen of Peace Hospital6,966 Acute patient days1,262 Swing-bed patient days1,117 Newborn patient daysAvera Brady Health and Rehabilitation29,086 Long-term care resident days8,623 Assisted living days2,181 Independent living daysAvera Weskota Memorial Medical Center (CAH)310 Acute patient days419 Swing-bed patient daysAvera De Smet Memorial Hospital (CAH)88 Acute patient days160 Swing-bed patient days Avera Queen of Peace maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $3,559,398.Avera Queen of Peace also provides community benefit health activities at less than or at no cost to support those in the area serviced. These activities include community education programs; special programs for the elderly, handicapped, and medically underserved; and a variety of broad community support activities. During the year ended June 30, 2017, specific activities include meals delivered to residential homes; meeting facilities; programs for patients and families suffering from cancer, diabetes, breathing disorders, and others; assistance to health educators; and emergency healthcare providers.As a member of the Avera Health network, Avera Queen of Peace upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide a quality, effective health ministry and to improve the health care of individuals and our communities through a regionally integrated network of persons and institutions. Avera Queen of Peace 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. 93008960 1 1 0 1 0 0 0 0 1 1 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 134 0 1 971 1 0 0 0 0 0 0 0 0 0 0 X 18 14 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 0 X William E Flett 6059952251 525 North Foster Mitchell SD 57301 Diane Sandhoff Chairperson 2.50 0.00 X X 0 0 0 Jean Koehler Vice Chair 2.50 0.00 X X 0 0 0 Jason Bradley Board Member 2.50 0.00 X 0 0 0 Julie Brookbank Board Member 2.50 0.00 X 0 0 0 Quinten Burg Board Member 2.50 0.00 X 0 0 0 Sister Kathleen Crowley Board Member 2.50 4.00 X 0 0 0 Sister Bonita Gacnik Board Member 2.50 0.00 X 0 0 0 Ryan Huber Board Member 2.50 0.00 X 0 0 0 Brian Kampmann MD Board Member (as of Feb 2017) 40.00 0.00 X 899320 0 46188 Sharry Knock Board Member 2.50 0.00 X 0 0 0 Michael Krause DO Board Member 5.00 0.00 X 38254 0 0 David Olson Board Member 2.50 0.00 X 0 0 0 Sister Joan Reichelt Board Member 2.50 3.30 X 0 0 0 Hillary Rockwell MD Board Member/Physician 40.00 0.00 X 405387 0 45188 Jennifer Tegethoff MDBoard Member/Physician (thru Jan 2017) 40.00 0.00 X 333540 0 46336 Jay Tolsma Board Member 2.50 0.00 X 0 0 0 Jerry Thomsen Board Member 2.50 0.00 X 0 0 0 Gopal Vyas Board Member 2.50 0.00 X 0 0 0 Thomas Clark President & CEO 40.00 0.00 X X 0 449089 44239 William E Flett Sec/Treas & VP of Finance 40.00 0.00 X 187002 0 41210 Chris Krouse DO Orthopedics, Sports Medicine 40.00 0.00 X 1157819 0 44590 Anwarul Haq MD Hematology and Oncology 40.00 0.00 X 663349 0 21249 Kathleen Naegele DO Hematology and Oncology 40.00 0.00 X 623577 0 44379 Xenofon Papadopoulos MD Urology 40.00 0.00 X 596071 0 44166 Dileep Bhat MD Urology 40.00 0.00 X 559947 0 32491 5464266 449089 410036 58 0 1 0 Avera Health 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 Shared Services 11032780 Journey Group Companies 800 South 7th Ave Sioux Falls SD 57104 Construction Services 4922709 Jalal U Akbar 2405 Brisbane Ln Plano TX 75075 Hospitalist Services 689846 Horizon Health Care Inc PO Box 99 Howard SD 57349 Medical Locum Services 265043 ABM Healthcare Support Serices Inc 22622 Harper Ave St Clair Shores MI 48080 Environmental Services Mgmt 197375 17 1250000 174598 191313 1615911 Net Patient & Resident Services 622110 106632671 106632671 Cafeteria 900099 433400 433400 Interest in Avera Health Fnd 900099 248294 248294 Meaningful Use Revenue 900099 102055 102055 2006949 2006949 109423369 111637 111637 384948 463256 -78308 -78308 -78308 5038569 396814 1073674 388759 3964895 8055 3972950 3972950 Operating Interest 900099 3187 3187 3187 115048746 109426556 0 4006279 X 783630 783630 2126602 1917058 209544 46114502 41509696 4543289 61517 3021322 2727416 289855 4051 6945154 6263194 672830 9130 2862482 2577665 281096 3721 197187 197187 13102 13102 16741 16741 12467613 4302516 8165097 31677 21548 10129 7128183 5552888 1567464 7831 318678 212110 106568 2017909 1430149 587760 285862 236444 47080 2338 105661 63374 42277 10 1307354 1307354 5166401 5166401 996524 992103 4421 Medical Supplies 12982874 12982874 Bad Debt Expense 3162903 3162903 Repairs and Maintenance 1511228 1460765 50463 Taxes and Licenses 11683 11683 456907 310448 145657 802 110032179 93008960 16933819 89400 4287747 2772161 13693222 12309834 198392 1492565 1542276 1036171 1038197 126230815 66850685 60447306 59380130 983099 48671997 59813173 1975001 1211114 1540710 1496395 376195 122527 134504013 139884199 8329087 9753712 46979 34962737 34444913 4557 6426 2319390 1552400 45662750 45757451 X 86065086 91168813 1970452 2146910 805725 811025 88841263 94126748 134504013 139884199 X 5016567 396910 -127992 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 16741 16741 0 Part II-B, Line 1: Avera Queen of Peace Hospital paid dues to organizations which have a portion of the dues attributed to lobbying activities. 0 1 X 2715895 256959 252847 463879 13114 2748708 2859724 304703 241350 676074 13808 2715895 2681098 326197 95588 222117 21042 2859724 1065019 1990675 117527 473098 19025 2681098 1040814 24205 1065019 0.27560 0.16490 0.55950 0 1 1 834324 2890511 3724835 74485616 34911901 39573715 40792297 30425715 10366582 7228067 1513069 5714998 59380130 Interest in Avera Health Foundation 2938663 F Interest in net assets of Mabee Trust 807615 F Assets Limited to use - Avera Pooled Investments 56066895 F 59813173 Derivative liability 1552400 1552400 X Part IV, Line 2b: The Organization holds funds in trust on behalf of its residents. Part V, Line 4: The organization's endowments consist of a portion of their interest in the net assets of Avera Health Foundation and their beneficial interest in the Mabee Trust. Avera Health Foundation includes endowment funds which have been established for a variety of purposes. The endowment fund assets included in the Organization's beneficial interest in the Mabee Trust have been established to purchase equipment and furnishings for the Organization. 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 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 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 for consolidated subsidiaries are no longer subject to federal tax examinations by tax authorities for years before 2014. 1 1 X 1 X 1 X 1 1 1 0 1 1 1595 1174150 1174150 0.01100 7714 8220328 5039004 3181324 0.02980 9309 9394478 5039004 4355474 0.04080 8 4190 4190 0.00000 2 46700 46700 0.00040 2 209263 209263 0.00200 12 942075 942075 0.00880 24 1202228 1202228 0.01120 24 9309 10596706 5039004 5557702 0.05200 16251 16251 0.00020 1 5500 5500 0.00010 1 21751 21751 0.00030 1 3162903 0 37054258 45316282 -8262024 X 1 1 3 1 Avera Queen of Peace Hospital 525 North Foster Street Mitchell SD 57301 www.averaqueenofpeace.org 10552 X X X 8 Provider Based Clinics 2 Avera Weskota Memorial Medical Center 609 1st Street NE Wessington Springs SD 57382 www.avera.org/weskota 48209 X X X 3 Avera De Smet Memorial Hospital 306 Prairie Avenue SW De Smet SD 57231 www.avera.org/de-smet 50726 X X X Avera Queen of Peace Hospital 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X http://www.avera.org/queen-of-peace 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 https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X X X X X X X 1 X 0 X X X X X 1 X 0 1 Avera Weskota Memorial Medical Center 2 0 0 1 X X X X X X X X X 15 1 0 0 1 X www.avera.org/weskota/ 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 https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X X X X X X X 1 X 0 X X X X X 1 X 0 1 Avera De Smet Memorial Hospital 3 0 0 1 X X X X X X X X X 15 1 0 0 1 X www.avera.org/de-smet/ 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 https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X https://www.avera.org/patients-visitors/charity-patient-assistance-programs X X X X X X X 1 X 0 X X X X X 1 X 0 1 Avera Queen of Peace Hospital Part V, Section B, Line 5: The Administrative Fellow, in collaboration with local organizations and individuals, obtained primary data pertaining to the primary service area from 97 individual surveys, 14 key informant individuals, four focus groups, and 10 sector policy and procedure checklists. Key informant and sector checklists were conducted with Davison County Health Department and Regional Health Department management as well as community members and organizations within the community representing a broad range of interests, including medically underserved, low income, and diverse populations. The public health departments provide services to individuals living in poverty and vulnerable populations. Of the persons seen at the regional health departments, 34% are of American Indian ethnicity; 17% alone for Davison County. Invitations to participate in focus groups were sent to community organizations and advertisements were placed in various local newspapers throughout the region. Avera Weskota Memorial Medical Center Part V, Section B, Line 5: Avera Weskota Memorial Hospital gathered both primary and secondary data for the assessment. Primary data from three focus groups and written responses from individual surveys was collected and summarized by a Community Development Specialist from Planning & Development District II of Yankton, SD. Individuals representing a wide range of interests participated in the focus groups held at the Wessington Springs Community Club, the Wessington Springs Area Senior Citizens Center, and the Jerauld County Court House. Key community informants including the community health nurse were consulted and participated in committees that helped to prioritize the needs of the community. Avera De Smet Memorial Hospital Part V, Section B, Line 5: Avera De Smet Memorial Hospital partnered with the City of De Smet, De Smet Development Corporation, De Smet Chamber of Commerce, De Smet Event and Wellness Center and the School districts for De Smet, Iroquois, and Arlington to collect primary data from individual surveys and individual key informant interviews. Data was then evaluated and prioritized by a steering committee. Avera Queen of Peace Hospital Part V, Section B, Line 11: A. Behavioral Health ServicesBehavioral health has been identified an area of need that Avera Queen of Peace is addressing. Access to services, early intervention, and education are critical to achieving improved long-term outcomes for individuals and communities. The hospital has developed the following goals to address this need.1. Improve mental health and prevent crisis situations within our communities. 2. Improve recovery rates and reduce public health crisis related to alcohol and substance use disorders.3. Improve behavioral health and substance use disorders screening, wellness, and awareness through education and self-management programs. Progress toward these goals has included: * Suicide prevention/screening education for area Primary Care providers, their staff, and Emergency Management Services staff (23 attendees). Training provided by Helpline Center (South Dakota). * Avera Queen of Peace provided leadership expertise for the Mitchell Chamber Community Health and Wellness Fair. Wellness fair co-chairs were hospital employees-director of education and community health coordinator. The wellness fair was open to the public free of charge, and 400 persons attended. Vendors and programs that address behavioral health awareness and substance use disorders were invited and participated in the fair. * AQOP staff collaborated with local experts to provide suicide prevention screenings (2 screenings), and panel discussion, "Meth Changes Everything" (20 attendees) during Mitchell Chamber Community Health and Wellness Fair. * Avera Queen of Peace Community Health Coordinator became certified lay leader for Better Choices, Better Health programming. B. Access to CareAccess to primary and mental healthcare services was identified as a priority of the community. Our goal is to improve access to primary care and mental health care services. Although great efforts have been made, much of the area is still designated a Primary Care Healthcare Professional Shortage Area and most of the area remains designated as a Medically Underserved Area/Population. Increasing access to primary care, specialties, and care coordination teams contributes to improved health outcomes. Access to services, early intervention, education, and support are critical to achieve improved long-term outcome for individuals and communities. Avera Queen of Peace continues to actively recruit family practice and internal medicine physicians. Fiscal year 2017 physician recruitments included an internal medicine physician, pediatrician, and dermatologist. C. Prevention, Wellness, Screening and EducationOngoing education related to how physical and mental health issues impact overall health of an individual and learning to manage chronic disease conditions was identified to be a priority of the community. As the focus on community and population health increases, it becomes more critical to invest resources and create partnerships related to prevention, wellness, screenings and education. The hospital's education programs, participation in health fairs, and support group programs are intended to address community education and support. Personalized chronic disease management education and support are also essential to improve the overall health of individuals and communities. Partnerships and collaborations with health agencies, providers, and community organizations are essential to increase breadth and depth of prevention, wellness, screening, and education knowledge. The hospital has developed the following goals to address this need.1. Build a culture of health through collaborative prevention, wellness, screening and education. 2. Engage and empower individuals to actively manage their chronic disease through education and support. Progress toward these goals has included: * Implementation of A1C Champions Program (education and awareness event attended by 18 individuals.) * Many pre-diabetic patients have the ability to prevent diabetes but may need pre-diabetic education. In fiscal year 2017 the Foundation began offering financial assistance for pre-diabetic patients to attend preventative education sessions when the patient is uninsured or the session is not a covered benefit. * Diabetic supply assistance to patients who cannot afford supplies (8 patients). * Avera Queen of Peace provided $3000 for diabetic test strips for patients of Rural Electronic Gestational Diabetes Program (eGDM). * Several educational events provided free of charge to community members (service clubs, senior citizens, and others). Some of the topics covered: Girls' adolescent health, Boys' adolescent health, how to communicate with one's physician, spiritual/emotional health, colorectal cancer, caregiver support and self-care, heat exposure/stroke, healthy vision, anxiety and stress management, healthy holiday eating, fall prevention. * Free blood pressure clinics and education. Average number of monthly attendees (83). Avera Weskota Memorial Medical Center Part V, Section B, Line 11: The Health Education Team consists of representatives from Avera Weskota Memorial Hospital, Horizon Health Care, Weskota Manor Avera, and the South Dakota Department of Health, Jerauld County Office of Child and Family Services. The team's purpose is to provide health education to the community in the Wessington Springs area. The Health Education Team coordinates community education programs and health screenings at several events throughout the year. The three needs that will be addressed are: 1 Prevention/Wellness Care2 Community Education Regarding Mental Health Issues - Alcohol, Drug Use and Depression 3 Perceived Lack of Healthcare ServicesPrevention/Wellness Care: Goal # 1 - Provide and promote prevention and wellness education and screening opportunities to community members locally.Objective #1 - Provide and promote improvements in long term health as a result of physical activity by increasing access, education and event opportunities locally.Objective #2 - Provide and promote improvements in long term health as a result of good nutrition through prevention and wellness education and awareness opportunities locally.Objective #3 - Provide and promote overall health prevention and wellness education and awareness opportunities locally.Goal #1 Status Update: We participate in our local health fair, provide speakers for community events and organization an annual walk/run event on the 4th of July. We submit articles on a variety of topics to increase the education on health and wellness to our community and staff. Community Education Regarding Mental Health Issues- Alcohol, Drug Use, and DepressionGoal #1 - Provide and promote community education and individual services to increase awareness and understanding of behavioral health and substance use disorders.Objective # 1 - Provide and promote opportunities that increase education and awareness of depression.Objective #2 - Provide and promote screening and treatment options locally.Goal #1 Update: We provided a speaker on the topic of depression to a local community group.Perceived Lack of Healthcare ServicesGoal #1 - Improve the perceived lack of healthcare services through communication, education, and community events.Objective #1 - Increase utilization of local health care services through awareness, education, and communication. Objective #2 - Increase awareness of services through communication and community events.Goal #1 Status Update: We have developed a Facebook page. We regularly submit educational articles to the local newspaper. We create awareness of our services through social media, health fair, newspaper articles, and our fun run/walk event on the 4th of July. CHNA Needs Not Addressed:Though Avera Weskota Memorial Hospital is a leader in identifying the needs of the community, some needs fall outside the span of control of the hospital. Unmet needs identified by the 2016 Community Health Needs Assessment will be addressed by recommended community organizations. These unmet needs include: * Assisted Living: Assisted living was identified as a need in the community for the 2013 and 2016 CHNA. In 2013, this issue was referred to Weskota Manor Avera. Developing assisted living is in the nursing home's long range strategic plan, but it is not financially feasible at this time. The health care community, hospital advisory board, and nursing home governing board will be educated regarding this plan. Avera Weskota Memorial Hospital will refer the identified need to Weskota Manor Avera for consideration in their long range strategic planning.In-home services are available to assist tenants in the independent living apartments. Services include: skilled home health and hospice services, hot meal programs, bus transit services and homemaker programs. * Recruitment of Healthcare Workers: Recruitment of healthcare staff was also identified as a concern. Low unemployment rate as well as a shortage of healthcare and home maker program applicants is a problem across the state. The facility will continue to apply creative ideas to recruitment and will not pursue this as a community health needs priority. Avera Weskota Memorial Hospital and the other healthcare facilities will continue to work with this issue. The hospital is using the South Dakota Retention Bonus as an incentive to recruit and retain professional staff, in addition to loan forgiveness and bonuses. This incentive has helped recruit and retain some, but not all, staff. Avera Weskota is participating in a Margaret A. Cargill Foundation Grant with Dakota Wesleyan University to educate and prepare Certified Nursing Assistants (CNA) and nurses in rural communities. In addition, the hospital will participate with University of South Dakota and United States Department of Agriculture (USDA) project, a project whereby student education is delivered via telemedicine to rural students at the facility. Avera De Smet Memorial Hospital Part V, Section B, Line 11: The five priorities are more medical doctors locally, affordable housing, high cancer rates, need for mental health, and senior transport and activities. Avera De Smet Memorial Hospital leadership three year implementation plans will focus on the following prioritized needs: * More Medical Doctors locally (Access to Care)* High Cancer Rates (Wellness and Prevention Education and Screening)* Mental Health (Behavioral Health)Access to Care Goal #1 - Provide the residents of Kingsbury County better access to care locally.Objective #1 - Recruit more local medical doctors to our area.Objective # 2 - Recruit more medical doctors to our area for outreach services.Objective #3 - Recruit more providers to be credentialed to provide eCare Telemedicine services in our area.Objective #4 - Improve home health services in our service area.Status Update: We have been involved in a group at the system level to address the needs and improve access to the needs of home health patients in our region. Objective #1 was removed due to the current stable medical staff. Wellness, Prevention Education, and ScreeningGoal #1 - Provide and promote prevention and wellness education and screening opportunities to community members locally. Objective #1 - Provide and promote cancer prevention and wellness education and screening opportunities locally.Objective #2 - Provide and promote chronic disease management prevention and wellness education locally.Objective #3 - Promote overall health education and awareness by supporting and participating in community events.Status Update: The system has developed educational topics that meet the objectives. The topics are sent to our local newspaper on a least a quarterly basis. The information is modified to be specific to our location and services.Behavioral Health Goal # 1 - Address the need for mental health services through satellite clinics or telemedicine.Objective #1 - Provide mental health screenings with primary care providers.Objective #2 - Increase the number of options and supports for patients seeking behavioral health services.Objective #3 - Increase community awareness and education of local services provided to community members.Status Update: A mental health screening has been incorporated into the medical record.The following unmet needs that will not be addressed include affordable housing, senior transportation, and activities. These needs will be addressed by other organizations withing the community. Avera Queen of Peace Hospital 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. Avera Weskota Memorial Medical Center 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. Avera De Smet Memorial Hospital 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. Avera Queen of Peace Hospital 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. Avera Weskota Memorial Medical Center 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. Avera De Smet Memorial Hospital 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. Avera Queen of Peace Hospital 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. A plain language summary is offered to all uninsured patients at the time of registration. Avera Weskota Memorial Medical Center 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. A plain language summary is offered to all uninsured patients at the time of registration. Avera De Smet Memorial Hospital 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. A plain language summary is offered to all uninsured patients at the time of registration. Avera Queen of Peace Hospital Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Avera Weskota Memorial Medical Center Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Avera De Smet Memorial Hospital Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Part V, Section B, Line 10a: Implementation Strategy The most recently adopted implementation strategy for each of the facilities has been posted to the following website:http://www.avera.org/app/files/public/67531/2016-chna-implementationplan-queen-of-peace.pdf 2 1 - Avera Brady Health and Rehab 500 S Ohman St Mitchell SD 57301 Nursing Home 2 - Avera Brady Assisted Living 1414 W Cedar Ave Mitchell SD 57301 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 6a: Our community benefit report is contained in a report prepared by Avera Health, a related organization. It is available through the website and requested mailing, and is filed with the Catholic Health Association. 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. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services, line 7e, health professions education, line 7f, and cash and in-kind donations, line 7i were compiled using actual costs recorded in the CBISA software. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): Avera Queen of Peace bad debt expense of $3,162,903 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 Queen of Peace supports numerous economic development organizations with participation at meetings and donations throughout its service area. Additionally, Avera Queen of Peace works with Dakota Wesleyan University, the Mitchell Technical Institute, and local high schools to address healthcare worker shortages in the communities of its service area. Avera Queen of Peace also partners with the Mitchell Senior Meals program to ensure access to nutritious meals for the elderly. Part III, Line 2: The bad debt expense is only the uncollected portion of the patient account. Any discounts would be treated as a reduction in revenue. All forms of payment, including self-pay, insurance, contractual allowances, and discounts reduce the patient's account prior to the account being classified as bad debt. A payment received on an account previously written off as bad debt reduces bad debt expense. Bad debt expense reported on line 2 is at charges as reported on the financial statements. Part III, Line 3: Avera Queen of Peace does not believe that any portion of bad debt expense could reasonably be attributed to patients who may qualify for financial assistance since evaluations are completed to determine those amounts due and will be reclassified from bad debt expense to charity care within 30 days following the evaluation of the amount. Part III, Line 4: The footnote to the Organization's financial statements that describes bad debt expenses is located in Footnote 1 on page 10 of the attached audited financial statements. Part III, Line 8: Medicare allowable costs of care are based on 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. Avera Queen of Peace follows the CHA guidelines in reporting community benefits and therefore any Medicare shortfall (as calculated including our non-cost report entities) is excluded from our community benefit report. However, Medicare is the Organization's largest payer and patients with Medicare coverage are accepted regardless of whether or not a surplus or deficit is realized from providing the services. This basis therefore means providing Medicare services promotes access to healthcare services which is a key advantage for our community. 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: Health care needs are assessed through various methods. Given Mitchell is a regional center/hub and the sixth largest city in South Dakota, Avera Queen of Peace is integrally involved with community organizations, universities/colleges, schools, state programs and local governments. The next largest hospital offering the same level of services is 72 miles from Mitchell and most of the towns within our region have a population of less than 2,000. By working with all in our region, we are able to determine health needs and provide programs and solutions where possible. In addition to activities reported in the Community Health Needs Assessment, Avera Queen of Peace, Avera Weskota and Avera De Smet collaborate with a community health committees within their respective community to assess and promote health related matters. Part VI, Line 3: A summary of the financial assistance policy is posted in the Hospital facility's emergency rooms, waiting rooms, and admissions office and is included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Part VI, Line 4: Avera Queen of Peace's service area includes Davison County and surrounding counties in South Dakota. In 2015, the population for Davison County was estimated to be 19,858. Approximately 17.7% of the population is age 65 or older. The average per capita income is $25,881 and approximately 13.4% of individuals are below the federal poverty level. The nearest like hospital in the area is approximately 72 miles from Avera Queen of Peace. Part VI, Line 5: Avera Queen of Peace is a State Certified Level #4 Community Trauma Center and operates an emergency department staffed 24 hours per day with board certified physicians. Emergency care is provided on an open door basis regardless of ability to pay. Avera Queen of Peace leases two critical access hospitals which provide a broad range of inpatient, outpatient services and 24 hour emergency rooms in two very rural communities.Avera Queen of Peace operated three rural health clinics during the year which provide primary care services in three rural communities.Similar to the hospitals in the Avera Queen of Peace region, the clinics are operated on an open door basis and care is provided regardless of ability to pay.Medical staff privileges are extended to all licensed and qualified applicants. The Avera Queen of Peace Board of Directors is principally comprised of community members from the primary and secondary services areas. Members come from a variety of backgrounds including banking, education, agriculture, healthcare and private industry. 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 Dakota Wesleyan University 1200 W University Ave Mitchell SD 57301 460224589 501(c)(3) 750000 Donation De Smet Community Foundation PO Box 42 De Smet SD 57231 461401425 501(c)(3) 25000 Donation 2 0 Part I, Line 2: The Organization only makes grants to other organizations which are tax-exempt under Section 501(c)(3). 1 0 0 0 0 0 0 0 0 Brian Kampmann MD Board Member (as of Feb 2017) 797616 0 98734 0 2970 0 20600 0 27184 0 947104 0 0 0 Hillary Rockwell MD Board Member/Physician 361169 0 14606 0 29612 0 20600 0 25565 0 451552 0 0 0 Jennifer Tegethoff MDBoard Member/Physician (thru Jan 2017) 289537 0 42435 0 1568 0 20600 0 26402 0 380542 0 0 0 Thomas Clark President & CEO 0 445623 0 0 0 3466 0 21200 0 23844 0 494133 0 0 William E Flett Sec/Treas & VP of Finance 174098 0 0 0 12904 0 15475 0 26468 0 228945 0 0 0 Chris Krouse DO Orthopedics, Sports Medicine 987599 0 165603 0 4617 0 20600 0 25586 0 1204005 0 0 0 Anwarul Haq MD Hematology and Oncology 315043 0 65000 0 283306 0 20600 0 1380 0 685329 0 0 0 Kathleen Naegele DO Hematology and Oncology 541666 0 15000 0 66911 0 20041 0 25592 0 669210 0 0 0 Xenofon Papadopoulos MD Urology 541833 0 15000 0 39238 0 18980 0 26440 0 641491 0 0 0 Dileep Bhat MD Urology 236716 0 65000 0 258231 0 20600 0 11891 0 592438 0 0 0 Part I, Line 3 The President/CEO's compensation is paid by a related organization, Avera Health. Avera Queen of Peace relied on the related organization for determining the compensation for the President/CEO using the methods described in Part I, Line 3. Part I, Line 4a The following individuals received severance payments: Anwarul Haq, MD $228,459 Dileep Bhat, MD $222,498 Kathleen Naegele DO Employed physician Recruitment X 251384 158546 0 1 1 Xenofon Papadopoulos MD Employed physician Recruitment X 101431 39846 0 1 1 198392 Form 990, Part VI, Section A, line 2 Sister Kathleen Crowley has a business relationship with Thomas Clark. 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 has the following rights as the Member. 1) To approve the adoption, amendment or repeal of the statements of philosophy, mission and values of Corporation; 2) To initiate the adoption, amendment or repeal of any provision of the Articles of Incorporation or Bylaws of Corporation, and to give final approval of any such action with respect thereto; 3) To approve and act upon the alienation of real property and precious artifacts under the canonical stewardship of the Sisters of the Presentation of the Blessed Virgin Mary of Aberdeen, South Dakota ("Presentation Sisters") or the Benedictine Sisters of Sacred Heart Monastery ("Benedictine Sisters"), pursuant to the policies established by the Member; 4) To approve any plan of merger, consolidation or dissolution of the Corporation, or the divestiture of a sponsored work or ministry associated with the Corporation; 5) To approve the creation of new sponsored works or ministries to be conducted by or under the authority of the Corporation; 6) To appoint and remove, with or without cause, the Board of Directors of the Corporation. 7) To appoint and/or remove, with or without cause, the President and Chief Executive Officer of the Corporation. 8) To approve operating/capital budgets and strategic plans of the 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 Avera Queen of Peace Hospital does not have committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11b The return is reviewed initially by the CFO. The return is made available to the Board of Directors for review prior to filing. 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 15b The CEO 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. The compensation of the VP of Finance is determined by Human Resources based on a market analysis of comparable positions. The compensation is approved by the CEO. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not available to the general public. The Organization's financial statements are attached to the Form 990 per IRS instructions and therefore are available to the general public. Form 990, Part IX, line 11g Recruitment: Program service expenses 10,630. Management and general expenses 17,294. Fundraising expenses 0. Total expenses 27,924. Purchased Services: Program service expenses 3,392,738. Management and general expenses 783,971. Fundraising expenses 0. Total expenses 4,176,709. ACS Fees: Program service expenses 899,148. Management and general expenses 7,363,832. Fundraising expenses 0. Total expenses 8,262,980. Form 990, Part XI, line 9: Change in Fair Value of Interest Rate Swap 766,990. Equity Transfers -894,982. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the consolidated audited financial statements of Avera Health, which includes Avera Queen of Peace. Form 990, Part VI, Section B, Line 16b: There is no written policy or procedure since in the event of any such proposed transaction the board or a committee with delegated authority reviews all materials, valuations and operational aspects for any proposed transaction. Such transaction would be evaluated in accordance with the exempt status of the organization and its applicable purposes. Any transaction also would be approved by the board and the member. Form 990, Part X, Line 20: The issue price includes the filing Organization's share of the entire bond issue, which was issued to Avera Health on behalf of the Avera Obligated Group. The Avera Obligated Group consists of Avera Health, Avera McKennan, Avera St. Luke's, Avera Queen of Peace, Avera Marshall, Avera St. Mary's, and Avera Sacred Heart. In accordance with IRS instructions, information related to the tax exempt bond reporting is being reported on Avera Health's tax return (EIN 46-0422673). Integrated Therapy Services LLC 525 N Foster St Mitchell SD 57301 320450803 Physical, Occupational, and Speech Therapy SD 553975 0 Avera Queen of Peace 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 Avera Gettysburg 606 East Garfield Gettysburg SD 57442 460234354 Healthcare Services SD 501(c)(3) Line 3 Avera St Mary's 0 Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 68763 470463911 Healthcare Education 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 Fundraising IA 501(c)(3) Line 10 Avera Holy Family 0 Avera Marshall 300 S Bruce Street Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) Line 3 Avera Health 0 St Benedict Health Center 401 West Glynn Drive Parkston SD 57366 460226738 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 St Benedict Health Center Foundation 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 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 Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare Services SD 501(c)(3) Line 3 Avera Health 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 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 Street 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 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 Q & M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical clinic building SD Avera Queen of Peace Related 339449 0 1 0.50000 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 102 Sioux Falls SD 57117 800619999 medical services - home medical equipment 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 Accounts Management Inc 5132 S Cliff Ave Suite 101 Sioux Falls SD 57108 460373021 collection agency SD N/A C 0 Avera Property Insurance Inc 610 W 23rd St Ste 1 PO Box 38 Yankton SD 57078 460463155 insurance SD N/A C 0 Dr Donald & Marguerite Mabee Trust c/o First National Bank of South Da Mitchell SD 57301 466056202 investing SD Avera Queen of Peace Hospital T 15512 807615 1.00000 1 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 Inc 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 1 1 0 1 0 0 0 0 Avera Health C 1250000 General Ledger Schedule R, Part I, Identification of Disregarded Entities: Integrated Therapy Services, LLC merged into another entity. All information will be reported under the other entity's EIN as of January 1, 2017.