2016-02-15T00:00:00-06:00 2015-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2014-07-01 460226283 Wagner Community Memorial Hospital WAGN 6053843611 513 Third Street SW Wagner SD 573800280 Bryan Slaba CEO 6053843611 2016-02-16 1 Laurie Hanson P00851848 6053391999 2016-02-15 2014 2016-08-17 19:52:53Z Bryan Slaba 513 Third Street SW Wagner SD 573800280 8658861 0 X www.avera.org/wagnerhospital/ X 1947 SD To provide healthcare services. 9 8 82 12 0 0 38477 13375 8710299 8137710 62330 488974 18652 18802 8829758 8658861 0 6040 0 0 3543908 3900348 0 0 0 5121490 4339505 8665398 8245893 164360 412968 11636632 11136888 6397863 5574959 5238769 5561929 X Wagner Community Memorial Hospital's mission is to provide care and treatment of the sick; provide care and support of the aged, disabled, and indigent; and to provide for those in need of hospitalization regardless of race, color, creed, or ability to pay. 0 1 7100176 6040 8156512 WCMH is a 20 bed critical access hospital equipped with extensive advanced services, including areas for Medical/Surgical, Pediatric, Intensive/Coronary Care, and Swing Bed/Long Term Care. The clinic is adjacent to the hospital making it convenient to see hospital patients, and share laboratory services and other diagnostic equipment. Outreach services include OB/GYN, Pediatrics, Orthopedic Surgery, General Surgery, Urology, Podiatry, ENT & Audiology. The people of the community truly believe in having access to care and support their local medical providers. The facility serves as the inpatient unit for the local Indian Health Services clinic and works collaboratively with the IHS physicians and leaders to care for the Native American population. WCMH experienced 497 Inpatient days, 224 Swing Bed days, 1941 Emergency Department visits, and 2516 clinic visits. 7100176 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 27 0 1 82 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X Lisa Weisser 6053843611 513 3rd Street SW Wagner SD 573800280 David Kotab Board President 0.50 X X 0 0 0 Bill Frei Board Vice President 0.50 X X 0 0 0 Elden Ridgeway Board Secretary (left Sept 2014) 0.50 X X 0 0 0 Chad Peters Board Secretary (begin Sept 2014) 0.50 X X 0 0 0 Jean Pirner Board Treasurer 0.50 X X 0 0 0 Merle Bartunek Director 0.50 X 0 0 0 Ann Freier-Metzger Director 0.50 X 0 0 0 Dorothy Holzbauer Director (left Sept 2014) 0.50 X 0 0 0 Dave Andrews Director (left Sept 2014) 0.50 X 0 0 0 Mitch Breen Director (begin Sept 2014) 0.50 X 0 0 0 Jan Coleman Director (begin Sept 2014) 0.50 X 0 0 0 Steve Cotton Director (begin Sept 2014) 0.50 X 0 0 0 Bryan Slaba CEO/Administrator 40.00 X 133131 0 13034 Dr Abdul S Qazi Family Practice 40.00 X 334810 0 12857 467941 0 25891 2 0 1 1 Avera Sacred Heart Hospital 501 S Summit Street Yankton SD 57078 Management, IT & Bio Med Services 552701 Coast to Coast Health Care Inc 5195 Hampstead Village Center Suite New Albany OH 43054 Physician Labor 459033 Dr Jeffery Pinter 27952 323rd Avenue Winner SD 57580 Physician Labor 390375 Avera eCare 501 S Summit Street Yankton SD 57078 Electronic Emergency Services 135824 Sees Physical Therapy LLC 100 Evergreen St Avon SD 57330 Physical Therapy Services 121330 5 11860 1515 13375 Patient Service Fees 621110 7671610 7671610 Medicaid EMR Incentive 900009 254100 254100 Other Revenue 900099 176320 176320 Apartment Revenue 900009 28780 28780 Change in int- Avera H 900099 6900 6900 8137710 67952 67952 18802 0 18802 18802 18802 421022 0 421022 421022 421022 8658861 8156512 0 488974 X 6040 6040 161540 161540 55109 55109 3134568 2551438 583130 56412 46099 10313 283034 231290 51744 209685 171351 38334 100135 100135 40730 40730 1244484 1244484 28046 28046 336971 284479 52492 21601 16919 4682 149811 149811 26871 26727 144 31679 24393 7286 260730 260730 758971 758971 54854 54854 Medical Supplies 671063 671063 Repairs and Maintenance 342122 338564 3558 Bad Debt 185655 185655 85782 22199 63583 8245893 7100176 1145717 0 617123 685816 58554 13658 1634115 1768931 159119 196707 88806 59909 12102079 5666078 7074915 6436001 1985216 1957622 18784 18244 11636632 11136888 497976 562944 2500 6108 5890906 5005907 6481 0 6397863 5574959 X 5238769 5561929 5238769 5561929 11636632 11136888 412968 -89808 0 X 0 1 X 1 0 X 4247 4247 8804285 3405324 5398961 2973813 2188571 785242 319734 72183 247551 6436001 X 8383398 -89808 -185655 -275463 8658861 0 8658861 8060238 0 8060238 185655 185655 8245893 Part X, Line 2: The Hospital is organized as 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 Hospital 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 Hospital 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 Hospital 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 Hospital 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 -185,655. Part XII, Line 4b - Other Adjustments: Bad debt expense 185,655. 1 1 X 1 X 1 X 1 1 1 0 1 1 396 317100 317100 0.03930 2654 1772888 1342625 430263 0.05340 3050 2089988 1342625 747363 0.09270 7 109 6563 485 6078 0.00080 2 5 8082 400 7682 0.00100 2 101 1828181 344614 1483567 0.18410 2 1134 6400 6400 0.00080 13 1349 1849226 345499 1503727 0.18670 13 4399 3939214 1688124 2251090 0.27940 1 14160 14160 0.00180 1 33040 33040 0.00410 2 3 175 175 0.00000 2 407 2500 2500 6 410 49875 2500 47375 0.00590 0 185655 0 2604119 2615129 -11010 X 1 1 1 1 Wagner Community Memorial Hospital PO Box 280 Wagner SD 57380 www.avera.org/wagnerhospital/ 10571 X X X X Wagner Community Memorial Hospital 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X www.avera.org/wagnerhospital/about-us/ X 1 12 1 www.avera.org/wagnerhospital/about-us/ 0 0 1 X 150.000000000000 400.000000000000 X X X 1 1 X X X 1 X www.avera.org/wagnerhospital X X X X 1 X 0 X X X 1 X 0 0 Wagner Community Memorial Hospital Part V, Section B, Line 5: A variety of organizations were consulted in conducting the most recent needs assessment. The organizations included Indian Health Services, Lake Andes Healthcare Center, Wagner Good Samaritan Center, Charles Mix County Health Nurses, Yankton Sioux Tribe, SD Department of Health, and Avera Sacred Heart Hospital. Wagner Community Memorial Hospital Part V, Section B, Line 11: Pursuant to the implementation strategy adopted by Wagner Community Memorial Hospital, drug enforcement, response time of police emergency calls, availability of employment opportunities, responsiveness of public officials and the justice system, opportunity for small businesses in the community, access to affordable housing, and access to transportation will not be addressed as these needs are not the direct focus of the facility and are better handled through other resources. During the current year, the facility was not able to directly address the issue of drug and alcohol abuse prevention. Wagner Community Memorial Hospital Avera is the lead organization for the Southern Charles Mix County Healthcare Collaborative. It is expected that the recent increased awareness of methamphetamine will be used to drive the collaborative to address the escalating problem. Currently the collaborative is searching for any programs to emulate that have successfully addressed drug and alcohol abuse with specific emphasis on methamphetamines. Additionally, the facility continues to work toward accessibility and affordability of healthcare services through the adoption of a plan to "home grow" the provider base. In 2011, the administration, with board acknowledgement, embarked on a recruitment and retention program for certified advanced practitioners. As a result of this plan, the facility has agreed to support financially and programmatically three RNs employed by the facility who have accepted the challenge of becoming Advanced Practice Providers (APPs). The RNs have agreed to return to the hospital and establish a practice for a minimum of three years following degree and licensure. The first of the Family Nurse Practioner-Certified started practice on 07/07/14. The second and third will start practice in Febuary and March of 2016 respectively. Wagner Community Memorial Hospital Part V, Section B, Line 16i: The reference to the policy and its location is sent with all statements. The full policy is posted on the hospital facility's website. Part V, Section B, Line 16 Financial Assistance Policy Website Availability Wagner Community Memorial Hospital Part V, Section B, line 16a website: www.avera.org/wagnerhospital Part I, Line 3c: In addition to utilizing FPG to determine eligibility for financial assistance, the hospital uses the factors as marked on Part V, line 13. Part I, Line 6a: Wagner Community Memorial Hospital is included in the community benefit report that is submitted to Avera Health by Avera Sacred Heart. 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. Lines 7e, 7f and 7i were obtained utilizing the actual general ledger system. Line 7b was calculated based on the allocation of expenses per payer mix percentages. Line 7g was obtained from the Medicare cost report. Part I, Ln 7 Col(f): Bad debt expense of $185,655 was subtracted from total operating expense. Part II, Community Building Activities: Part II Line 7 includes:1-Participation on a board to look at housing rehabilitation for low income and elderly community members.2-Participation in community economic groups, including Wagner Area Growth (WAG), Rotary, and Chamber of Commerce.6-Participation in the Wagner Area Health and Wellness Consortium and Wagner VA Stand Down. 8-Hosted an eigth grade career fair for the region schools; held healthcare career events; and worked with Charles Mix County schools through the Health Occupations for Today and Tomorrow (HOTT) program. Part III, Line 2: Bad debt recoveries and discounts applied during the collection process are rare, but when they do occur they are posted against the bad debt account. Part III, Line 3: Under our financial assistance policy, presumptive charity care is given to those who are believed to qualify based on facts and circumstances known to the organization. Amounts that qualify as presumptive charity care are not recorded to bad debt. As such, the hospital does not believe any amount recorded as bad debt would qualify as charity care. Part III, Line 4: The footnote to the organization's financial statements that describes bad debt expense is on pages 5 and 6 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 6/30/2015.The entire shortfall should be treated as a community benefit. The shortfall is the direct result of sequestration enactments put in place by the federal government. Part III, Line 9b: The collection practices as set forth in the policy requires that if a patient qualifies for charity care, no bill will be sent. Instead, a letter indicating that the patient's bill has been completely forgiven will be sent. When sending a bill to any patient, the organization shall include on the bill a statement that indicates that if the patient meets certain income requirements the patient may be eligible for a government-sponsored program or for financial assistance from the organization for help in paying for the services that were provided, and a statement that provides the patient with an organization contact resource from which the patient may obtain information about the organization's financial assistance policy for low-income uninsured patients and how to apply for such assistance for the payment of services that were provided.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 a reasonable time period, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. At such time as the organization sends the uncollected account to an outside collection agency, the amount referred to the agency shall reflect the reduced-payment level for which the paitent was eligible under the organization's financial assistance policy for low-income uninsured patients. WCMH does not report any data to any of the credit agencies, however, the collection agencies WCMH utilizes may report to the credit agencies. Part VI, Line 2: In addition to preparing a community health needs assessment during the fiscal year ended June 30, 2013, WCMH determines patient needs through constant communication with patients, primary and specialty providers, and state and federal governmental health agencies. WCMH strives to consistently investigate, analyze, and determine the greatest needs of our community. Part VI, Line 3: WCMH has a written charity care policy. First reference to the policy is given to the patient upon admission. A second reference is attached to the third request for payment along with contact information. If neither notice is acted upon and the account continues to be unpaid a patient advocate will try to contact the patient if we have reasonable assumption that they may qualify for financial assistance. If the patient expresses interest in financial assistance, the patient advocate determines if any other opportunities are available for the patient. If the only option available is WCMH's charity care, the proper documentation is completed. The amount of reduction a patient may receive is based on a sliding scale point system. Part VI, Line 4: Wagner is a rural community located in southern Charles Mix County of South Dakota which has many health disparities with unmet needs. If one looks at the county as a whole, the average individual income is $17,403 with the median family income at $29,444. Inhabitants below the poverty level total 21.5%. County education demographics include 72.3% of residents having a high school degree and 14.2% holding a Bachelor's Degree in comparison to the national average of 80.4% and 24.4%. According to the US Census Bureau Fact Finder most recent data, 46.8% of residents in the county are of American Indian descent as compared to the national average of 0.9%. All of Charles Mix County is considered medically underserved by HRSA and the SD Department of Health. The service area is also considered a health professional shortage area with few providers and many miles in between these rural communities. Wagner provides the only local hospital facility since Indian Health Services (IHS) closed their facility in 1992. In 2008, the IHS emergency room closed putting a burden on the Wagner facility until a new clinic was built by the Wagner Hospital. There are only a few rural health clinics available in addition to the IHS clinic and the newly built VA facility. Many clinics provide only primary care services and are often staffed by Physician Assistants. If more specialized care is needed, patients must travel to either Yankton, South Dakota, which is about 115 miles round trip or they drive the 280 round trip miles to Sioux Falls, which is the area's tertiary care hub with all types of specialty care available. In addition to the shortage of quality health care services, residents of Southern Charles Mix County also suffer from many chronic health conditions. The percent of the population over 65 years of age is almost double the national average in more than half of the county. The disability status of the county's inhabitants is consistent with, if not higher than, the national average of 21.3% in a majority of the communities. Gaps exist among socioeconomic groups in the rate of diabetes and its associated complications in South Dakota as well as throughout the United States. Certain racial and ethnic communities including American Indians, as well as economically disadvantaged or older people, suffer disproportionately compared to other populations. Diabetes prevalence for adults located in Central SD surpasses South Dakota and U.S. percentages. Part VI, Line 5: WCMH provides Community Health Improvement Services which include: Community CPR classes, sponsorship to the Dakota Smiles Mobile Dental Program, Blood Pressure screenings at area events, assisting with community disasters and award scholarships to the local high school graduates. Fourteen different healthcare career fairs were sponsored and presented by WCMH throughout southern Charles Mix County. Part VI, Line 6: WCMH 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, WCMH is able to participate in Avera e-CARE services. These services include Avera e-ICU, e-Emergency, e-Pharmacy and e-Consult. 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.WCMH 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 WCMH 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 WCMH 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. X X X 0 0 0 0 0 0 0 0 0 Bryan Slaba CEO/Administrator 132546 0 0 0 585 0 5822 0 7212 0 146165 0 0 0 Dr Abdul S Qazi Family Practice 334810 0 0 0 0 0 10126 0 2731 0 347667 0 0 0 Schedule J, Part II: Bryan Slaba, CEO/Administrator, is compensated through an arrangement with Avera Sacred Heart Hospital, 501 Summit Street, Yankton, SD 57078. Marcia Podzimek Family relationship with Dorothy Holzbauer, board member 55109 Employee Compensation 0 Form 990, Part III, line 3 During the year ended June 30, 2015, the Hospital transferred two apartment complexes, Community Villa and Westside Estates, to another nonprofit corporation in Wagner, South Dakota. Form 990, Part VI, Section A, line 6 There is only one class of member. Any individual, partnership, corporation or association having legal entity, who has contributed $25 or more to the Corporation with request of membership at the time of donation, shall be a member thereof and each member shall have one vote at all meetings of the members of the corporation. Membership of any individual who shall become deceased shall revert by request to that individual's next of kin or according to his will. Any member who has contributed $50 or more shall have the right to transfer such membership to his or her spouse. Said transfer to be approved by the Board of Directors. The basis for membership is on non-refundable contributions. Form 990, Part VI, Section A, line 7a Only one class of member exists. At the annual meeting, members approve the minutes of the last annual meeting, elect board members of the Wagner Community Memorial Hospital, and vote on other business that may be properly brought before the members. Form 990, Part VI, Section A, line 7b Amendments to the Articles of Incorporation and Bylaws require member approval. Form 990, Part VI, Section A, line 8b Wagner Community Memorial Hospital does not have committees. Form 990, Part VI, Section B, line 11 The CEO will review the 990. After the form 990 has been reviewed, it will be forwarded to the members of the Governing Body for their review. Form 990, Part VI, Section B, line 12c Directors and Management Officials are required to complete annual 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. Inquiries of conflicts are also reviewed at the monthly Board meetings. After a conflict is deemed to exist, the Board determines the level of participation of the potential conflicting member. Form 990, Part VI, Section B, line 15a Avera Sacred Heart Health Services and Wagner Community Memorial Hospital Compensation Committee use comparability data to determine appropriate compensation of the CEO based on experience and performance. The compensation amount is approved annually by the Board of Directors. Form 990, Part VI, Section C, line 19 Documents are made available upon request. Form 990, Part IX, line 11g Anesthesia Purchase Other : Program service expenses 37,680. Management and general expenses 0. Fundraising expenses 0. Total expenses 37,680. Emergency Unit Purchase Other : Program service expenses 53,783. Management and general expenses 0. Fundraising expenses 0. Total expenses 53,783. Laboratory Purchase Other : Program service expenses 806. Management and general expenses 0. Fundraising expenses 0. Total expenses 806. Radiology Purchase Other : Program service expenses 7,908. Management and general expenses 0. Fundraising expenses 0. Total expenses 7,908. Pharmacy Purchase Other : Program service expenses 95,010. Management and general expenses 0. Fundraising expenses 0. Total expenses 95,010. Physical Therapy Purchase Other : Program service expenses 135,009. Management and general expenses 0. Fundraising expenses 0. Total expenses 135,009. Occup Therapy Purchase Other : Program service expenses 35,784. Management and general expenses 0. Fundraising expenses 0. Total expenses 35,784. Speech Therapy Purchase Other : Program service expenses 11,970. Management and general expenses 0. Fundraising expenses 0. Total expenses 11,970. Nutrition Svcs Purchase Other : Program service expenses 1,801. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,801. Social Services Purchase Other : Program service expenses 489. Management and general expenses 0. Fundraising expenses 0. Total expenses 489. Community Villa Purchase Other : Program service expenses 1,170. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,170. Westside Estates Purchase Other : Program service expenses 1,760. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,760. Emergency Unit Contract Physician : Program service expenses 861,314. Management and general expenses 0. Fundraising expenses 0. Total expenses 861,314.