2015-05-14T15:11:24-05:00 2014-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2013-07-01 460230199 AVERA ST MARY'S AVER 6052243130 801 EAST SIOUX AVENUE PIERRE SD 57501 BOB SUTTON CEO 6052243130 2015-05-12 1 KIM HUNWARDSEN CPA P00484560 6122536500 2015-05-12 2013 2016-03-07 17:11:31Z BOB SUTTON 801 EAST SIOUX AVENUE PIERRE SD 57501 72742645 0 0928 X WWW.AVERA.ORG/ST-MARYS-PIERRE X 1951 SD PROMOTION OF HEALTH 13 9 544 282 16841 15091 0 49360 51887350 72424426 1113330 125926 137810 131023 53138490 72730735 2468 65179 0 0 22132338 41724516 0 0 0 27559580 33838755 49694386 75628450 3444104 -2897715 60526872 68595878 20078675 29265165 40448197 39330713 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 67338875 65179 72424426 AVERA ST. MARY'S IS LISTED IN THE OFFICIAL CATHOLIC DIRECTORY. IT IS A TAX EXEMPT 501(C)(3) ORGANIZATION OPERATED AS A MINISTRY OF THE CATHOLIC CHURCH. EFFECTIVE JANUARY 1, 2013, AVERA ST. MARY'S BECAME AFFILIATED WITH AVERA HEALTH.THE HOSPITAL SERVES ALL PERSONS IN THE COMMUNITY ON A NON-DISCRIMINATORY BASIS. AVERA ST. MARY'S OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. AVERA ST. MARY'S HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. THE GOVERNING BODY IS COMPRISED OF PRIMARILY INDEPENDENT INDIVIDUALS, REPRESENTATIVE OF THE COMMUNITY AS A WHOLE. AVERA ST. MARY'S PROVIDES EDUCATION AND TRAINING OPPORTUNITIES TO HEALTHCARE STUDENTS ENROLLED IN THE LOCAL COLLEGE CAPITAL UNIVERSITY CENTER. AVERA ST. MARY'S PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE AND/OR OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. 67338875 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 0 1 0 0 0 0 0 0 1 0 1 1 1 0 1 0 0 0 1 0 0 1 1 0 0 0 0 0 1 1 0 0 0 1 X 2 0 1 544 1 1 1 0 0 0 0 0 0 0 0 0 X 13 9 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 0 X TOM WAGNER 6052243127 801 EAST SIOUX AVENUE PIERRE SD 57501 WILLIAM VAN CAMP CHAIR 2.00 1.00 X X 0 0 0 COLLEEN LAMB VICE CHAIR 2.00 1.00 X X 0 0 0 TERRY FITZKE SECRETARY/TREASURER 2.00 1.00 X X 0 0 0 SISTER MARY JAEGER BOARD MEMBER 2.00 8.00 X 0 0 0 JOE VILLA BOARD MEMBER 2.00 40.00 X 0 249301 7881 MIKEL HOLLAND MD BOARD MEMBER 2.00 40.00 X 0 301787 14287 OWEN GARNOS BOARD MEMBER 2.00 1.00 X 0 0 0 PEGGY WILLIAMS BOARD MEMBER 2.00 1.00 X 0 0 0 SISTER SANDRA MEEK BOARD MEMBER 2.00 1.00 X 0 0 0 SISTER KATHLEEN CROWLEY BOARD MEMBER 2.00 8.50 X 0 0 0 RICHARD MOLSEED BOARD MEMBER 2.00 40.00 X 0 351594 32153 BOB SUTTON BOARD MEMBER 2.00 50.00 X 0 213469 18024 JANET CRONIN BOARD MEMBER 2.00 1.00 X 0 0 0 ROCHELLE REIDER PRESIDENT & CEO (JULY-AUG) 50.00 0.00 X 0 190753 36030 PAUL EBMEIER PRESIDENT & CEO (AS OF AUG 2013) 50.00 0.00 X 0 161904 9306 TOM WAGNER CFO 50.00 0.00 X 151102 0 20713 DEBBIE BRAKKE VP QA/RISK MANAGEMENT 50.00 0.00 X 114452 0 20438 ELLEN LEE VP ADMINISTRATION 50.00 0.00 X 107836 0 21525 PAUL MARSO VP HUMAN RESOURCES 50.00 0.00 X 65363 0 10970 BARB HESPEN VP NURSING 50.00 0.00 X 49221 0 4464 KARL RICHARDS CLINICAL ADMINISTRATOR AMG 0.00 50.00 X 0 86013 17584 KAREN GALLAGHER EXECUTIVE DIRECTOR MISSION 50.00 0.00 X 109873 0 7187 MARK SCHMIDT EXECUTIVE DIRECTOR LONG TERM CARE 20.00 30.00 X 127098 0 23785 CHRISTOPHER OLSON CNA 40.00 0.00 X 213946 0 22002 DAWN ZASTOUPIL CNA 40.00 0.00 X 187527 0 24163 KEVIN ROARK CNA 40.00 0.00 X 184467 0 22132 BRAD SAATHOFF STAFF PHARMACIST 40.00 0.00 X 147322 0 10001 SANDRA JACOBSON DIRECTOR PHARMACY 40.00 0.00 X 143532 0 20337 1601739 1554821 342982 11 0 1 0 AVERA CENTRAL SERVICES 3900 WEST AVERA DRIVE SIOUX FALLS SD 571085721 SHARED SERVICES 3131942 AVERA HEALTH 3900 WEST AVERA DRIVE SIOUX FALLS SD 57108 SHARED SERVICES 901546 NXC IMAGING 2118 4TH AVE S MINNEAPOLIS MN 554042642 HOSPITAL SERVICES 255177 AVERA MCKENNAN 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 571175045 LAB SERVICES 176610 AVERA ECARE 3900 WEST AVERA DRIVE STE 301 SIOUX FALLS SD 571085721 HOSPITAL SERVICES 147716 9 49360 49360 PATIENT SERVICE REVENUE 621110 71120854 71120854 MEANINGFUL USE PAYMENTS 900099 961539 961539 MISCELLANEOUS REVENUE 900099 433990 417149 16841 CAFETERIA REVENUE 900099 30119 30119 CHANGE IN INTEREST IN FOUNDATION 900099 -122076 -122076 72424426 37869 37869 99706 0 99706 99706 99706 88057 0 88057 88057 88057 43227 49360 11910 31317 31317 72730735 72407585 16841 256949 X 65179 65179 825257 825257 60870 60870 32650235 30073189 2577046 1697471 1540496 156975 4451470 4081904 369566 2039213 1837331 201882 980 980 8867645 6340366 2527279 185496 185496 2284068 2158444 125624 1406529 1317918 88611 172896 102700 70196 186301 186301 873645 873645 3948119 3881001 67118 414771 407720 7051 MEDICAL SUPPLIES 8470411 8470411 BAD DEBT EXPENSE 4999407 4999407 REPAIRS AND MAINTENANCE 1593261 693068 900193 RENTALS AND LEASES 286910 286910 148316 148316 75628450 67338875 8289575 0 13656128 4637375 12502781 8442387 210608 243920 216861 270391 1334490 1992358 233253 828494 84013265 55073276 17410042 28939989 14962709 22292915 215916 680869 0 51264 60526872 68595878 6348536 6698992 217873 9953635 9641011 12707289 3776504 0 20078675 29265165 X 40448197 37237076 1780637 313000 40448197 39330713 60526872 68595878 X -2897715 2037680 -80810 -176639 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 1762 1762 0 PART II-B, LINE 1: AVERA ST. MARY'S PAID DUES TO ORGANIZATIONS WHICH HAVE A PORTION OF THE DUES ATTRIBUTED TO LOBBYING ACTIVITIES. 2701075 2701075 37512883 21378434 16134449 42434300 32507007 9927293 1365007 1187835 177172 28939989 ASSETS LIMITED AS TO USE - AVERA POOLED INVESTMENT FUND 22072890 F INVESTMENTS IN AFFILIATED ORGANIZATIONS 220025 C 22292915 X 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 2011. EMERALD GREEN 92587 49360 43227 8046 3864 92587 49360 43227 8046 3864 11910 31317 1 1 X 1 X 1 X 1 1 1 0 1 1 23472 496036 496036 0.00700 3214 8442615 6868707 1573908 0.02230 26686 8938651 6868707 2069944 0.02930 17858 17858 0.00030 1583610 1583610 0.02240 102795 102795 0.00150 1704263 1704263 0.02420 26686 10642914 6868707 3774207 0.05350 1 4999407 0 12836410 12271909 564501 X 1 1 1 1 AVERA ST MARY'S 801 EAST SIOUX AVENUE PIERRE SD 57501 WWW.AVERA.ORG/ST-MARYS-PIERRE/ 10566 X X X PROVIDER BASED CLINIC AVERA ST MARY'S 1 1 X X X X X X X X X 12 1 0 1 X WWW.AVERA.ORG/ST-MARYS-PIERRE/ X X X X X X 0 0 1 1 150.000000000000 1 400.000000000000 1 X X X X X X 1 1 X X X 1 0 X X X X 1 X 0 1 AVERA ST. MARY'S PART V, SECTION B, LINE 3: AVERA ST. MARY'S GATHERED INFORMATION REGARDING THE NEEDS OF THE COMMUNITY THROUGH A THREE-PRONGED PROCESS, INCLUDING SURVEYING THE COMMUNITY AS A WHOLE AT A LARGE COMMINITY EVENT, INTERVIEWING COMMUNITY LEADERS, AND HOLDING FOCUS GROUPS. AVERA ST. MARY'S INCLUDED THE FOLLOWING GROUPS IN THEIR INFORMATION GATHERING: HEALTH LEADERS WITH IN-DEPTH KNOWLEDGE OF THE LOCAL HEALTH CARE ENVIRONMENT, GOVERNMENT, BUSINESS, RETIRED, SOUTH DAKOTA STATE DEPARTMENTS OF HEALTH AND SOCIAL SERVICES, URBAN INDIAN HEALTH, AND RURAL HEALTH CLINICS. AVERA ST. MARY'S PART V, SECTION B, LINE 6I: THE IMPLEMENTATION STRATEGY IS AVAILABLE AT THE FOLLOWING WEBSITE: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/ AVERA ST. MARY'S PART V, SECTION B, LINE 7: ISSUES THAT WERE MENTIONED IN THE ASSESSMENT AND NO ACTION TAKEN ARE: SHORT TERM SHELTER FACILITY FOR THOSE OF LIMITED MEANS, DIVERSE CULTURAL NEEDS, DETOX FACILITIES AND PROGRAMS, BARRIERS (HOURS, AFFORDABILITY, AND AVAILABILITY). THE SHELTER AND DETOX HAVE BEEN STUDIED BY VARIOUS GROUPS IN THE PAST AND THE END RESULT HAS BEEN LACK OF SUSTAINABLE FINANCING. UNTIL THERE IS A SUSTAINABLE PLAN, WE ARE UNABLE TO ADDRESS THIS IN THE NEXT FEW YEARS. HOWEVER, BY FURTHER DEVELOPING MENTAL HEATH, WE BELIEVE THAT BOTH OF THESE NEEDS WILL BE FURTHER DEVELOPED IN THE PLANNING AND ACTION PROCESSES. CULTURAL NEEDS IS MUCH MORE THAN JUST ONE NEED AND SIMPLE SOLUTION. WE ARE PLANNING THAT THE KEY NEEDS WE ARE ADDRESSING WILL INCLUDE INPUT AND PARTICIPATION BY AND WITH THE NATIVE AMERICAN COMMUNITY. AVERA ST. MARY'S PART V, SECTION B, LINE 14G: 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 ST. MARY'S PART V, SECTION B, LINE 22: 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. 2 AVERA PARKWOOD INDEPENDENT LIVING FACILI 400 PARKWOOD DRIVE PIERRE SD 57501 INDEPENDENT LIVING MARYHOUSE 400 PARKWOOD DRIVE PIERRE SD 57501 LONG TERM CARE PART I, LINE 3C: A COMBINATION OF INCOME AND ASSETS TEST IS UTILIZED TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. POINTS ARE ASSIGNED BASED ON INCOME AS A PERCENTAGE OF FPG AND NET ASSETS OWNED WITH POINTS DEDUCTED FOR ONGOING MEDICAL EXPENSES SUCH AS DRUGS. PATIENTS WITH THE FEWEST POINTS RECEIVE THE LARGEST DISCOUNT. 0-1 POINTS RECEIVE 100% DISCOUNT ON BILLS WHILE REMAINING DISCOUNTS RANGE FROM 10-90% DEPENDING ON POINT TOTALS AND DOLLAR AMOUNT OF CHARGES. PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS POSTED ON OUR WEB SITE AT WWW.AVERA.ORG/ST-MARYS-PIERRE. PART I, LINE 7: CHARITY CARE AND UNREIMBURSED MEDICAID WAS CONVERTED TO COST USING THE OVERALL COST TO CHARGE RATIO IN IRS WORKSHEET 2. THE AMOUNTS ON LINES 7E AND 7I REPRESENT EXPENSES REPORTED IN THE GENERAL LEDGER. LINE 7G IS FROM THE COST REPORT. PART I, LN 7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $4,999,407. PART III, LINE 2: BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. BAD DEBT IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION. PART III, LINE 3: AVERA ST. MARY'S DOES NOT BELIEVE THAT ANY PORTION OF BAD DEBT EXPENSE COULD REASONABLY BE ATTRIBUTED TO PATIENTS WHO 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: NOTE 1 ON PAGES 9 AND 10 OF THE FINANCIAL STATEMENTS DESCRIBES BAD DEBT EXPENSE. 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. 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 A REASONABLE TIME PERIOD, THE ORGANIZATION OR ITS AGENT SHALL NOT SEND, NOR INDICATE 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 PATIENT WAS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS. AVERA ST. MARY'S DOES NOT REPORT ANY DATA TO ANY OF THE CREDIT AGENCIES, HOWEVER, THE COLLECTION AGENCIES AVERA ST. MARY'S UTILIZES MAY REPORT TO THE CREDIT AGENCIES. ANY EXTENDED PAYMENT PLANS OFFERED BY THE HOSPITAL, OR THE HOSPITAL'S REPRESENTATIVE, IN SETTLING THE OUTSTANDING BILLS OF PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SHALL BE INTEREST-FREE SO LONG AS THE REPAYMENT SCHEDULE IS MET. PART VI, LINE 2: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS A THREE-PRONGED PROCESS TO GATHER STAKEHOLDER INFORMATION ON COMMUNITY PERCEPTIONS OF THE HEALTH OF CENTRAL SOUTH DAKOTA WHICH INCLUDED A SURVEY AT A LARGE FARM/HOME SHOW IN FEBRUARY, 2013, INTERVIEWS WITH IDENTIFIED COMMUNITY LEADERS, AND SEVERAL FOCUS GROUPS.THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR AVERA ST. MARY'S WAS COMPLETED AND POSTED TO THEIR WEBSITE BY JUNE 30, 2013. PART VI, LINE 3: AVERA ST. MARY'S POSTS ITS CHARITY CARE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION IN ADMISSIONS AREAS, EMERGENCY ROOMS, AND OTHER AREAS OF THE ORGANIZATION'S FACILITIES IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT; (2) PROVIDES A COPY OF THE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS AS PART OF THE INTAKE PROCESS; (3) PROVIDES A COPY OF THE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS WITH DISCHARGE MATERIALS; (4) INCLUDES THE POLICY, OR A SUMMARY THEREOF, ALONG WITH FINANCIAL ASSISTANCE CONTACT INFORMATION, IN PATIENT BILLS; AND/OR (5) 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: AVERA ST. MARY'S IS AN ACUTE CARE HOSPITAL SERVING A RURAL COMMUNITY AREA OF CENTRAL SOUTH DAKOTA WHICH CONSISTS OF THE FOLLOWING PRIMARY COUNTIES: HUGHES, SULLY, DEWEY AND STANLEY COUNTY. PART VI, LINE 5: THE HOSPITAL SERVES ALL PERSONS IN THE COMMUNITY ON A NON-DISCRIMINATORY BASIS. AVERA ST. MARY'S OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. AVERA ST. MARY'S HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS IN THE AREA. THE GOVERNING BODY IS COMPRISED OF PRIMARILY INDEPENDENT INDIVIDUALS, REPRESENTATIVE OF THE COMMUNITY AS A WHOLE. AVERA ST. MARY'S PROVIDES EDUCATION AND TRAINING OPPORTUNITIES TO HEALTHCARE STUDENTS ENROLLED IN THE LOCAL COLLEGE CAPITAL UNIVERSITY CENTER. AVERA ST. MARY'S PARTICIPATES IN MEDICAID, MEDICARE, CHAMPUS, TRICARE AND/OR OTHER GOVERNMENT SPONSORED HEALTH CARE PROGRAMS. PART VI, LINE 6: THE COMMUNITIES IN WHICH AVERA OPERATES ALL HAVE UNIQUE HEALTH AND COMMUNITY BENEFIT NEEDS AND IN KEEPING WITH THE CATHOLIC HEALTHCARE ASSOCIATION GUIDELINES EACH HOSPITAL STRIVES TO MEET ITS COMMUNITY'S IDENTIFIED NEEDS. THE AVERA CENTRAL OFFICE ADVOCATES FOR ALL ON COMMUNITY BENEFIT RELATED MATTERS OF STATE, REGIONAL AND NATION IMPORTANCE. 1 CAPITAL AREA UNITED WAY OF PIERRE 1801 E WELLS STE 2 PIERRE SD 57501 460403398 501(C)(3) 10000 CORPORATE CONTRIBUTION PIERRE SCHOOL DISTRICT 211 S POPLAR PIERRE SD 57501 466001892 STATE OF SD 6600 ATHLETIC SPONSOR 2 0 PART I, LINE 2: DURING THE REQUEST FOR DONATION - GROUPS ARE INTERVIEWED AS TO THE DEMONSTRATED USE IN THE PAST AND HOW DONATIONS AFFECT THEIR FUTURE PROGRAMS. 0 0 0 0 0 0 0 0 0 JOE VILLA BOARD MEMBER 0 245741 0 0 0 3560 0 0 0 8193 0 257494 0 0 MIKEL HOLLAND MD BOARD MEMBER 0 300492 0 0 0 1295 0 5100 0 9936 0 316823 0 0 RICHARD MOLSEED BOARD MEMBER 0 300318 0 0 0 51276 0 13475 0 19340 0 384409 0 0 BOB SUTTON BOARD MEMBER 0 199523 0 0 0 13946 0 0 0 18439 0 231908 0 0 ROCHELLE REIDER PRESIDENT & CEO (JULY-AUG) 0 189330 0 435 0 988 0 15367 0 21066 0 227186 0 0 PAUL EBMEIER PRESIDENT & CEO (AS OF AUG 2013) 0 161904 0 0 0 0 0 4578 0 4916 0 171398 0 0 TOM WAGNER CFO 149822 0 0 0 1280 0 3024 0 18438 0 172564 0 0 0 MARK SCHMIDT EXECUTIVE DIRECTOR LONG TERM CARE 126726 0 0 0 372 0 2587 0 21947 0 151632 0 0 0 CHRISTOPHER OLSON CNA 213347 0 0 0 599 0 3089 0 19662 0 236697 0 0 0 DAWN ZASTOUPIL CNA 187252 0 0 0 275 0 3750 0 21162 0 212439 0 0 0 KEVIN ROARK CNA 184200 0 0 0 267 0 3017 0 19864 0 207348 0 0 0 BRAD SAATHOFF STAFF PHARMACIST 147160 0 0 0 162 0 2870 0 7434 0 157626 0 0 0 SANDRA JACOBSON DIRECTOR PHARMACY 141686 0 0 0 1846 0 2479 0 18606 0 164617 0 0 0 SCHEDULE J, PART I, LINE 3: THE PRESIDENT & CEO'S COMPENSATION IS PAID BY A RELATED ORGANIZATION, AVERA HEALTH. AVERA ST. MARY'S RELIED ON THE RELATED ORGANIZATION FOR DETERMINING THE COMPENSATION FOR THE PRESIDENT & CEO USING THE METHODS DESCRIBED IN PART I, LINE 3. DR RILEY LAMB FAMILY RELATIONSHIP WITH BOARD MEMBER RELOCATION/SIGN ON BONUS X 295944 243920 0 1 1 243920 DEBORAH HOLLAND FAMILY MEMBER OF BOARD MEMBER 60870 EMPLOYEE COMPENSATION 0 FORM 990, PART V, LINE 1A: INDEPENDENT CONTRACTORS REPORTED RELATE TO SERVICES RECEIVED BY AVERA ST. MARY'S, HOWEVER A RELATED ORGANIZATION FILES APPLICABLE FORM 1099S ON BEHALF OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 2 SISTER KATHLEEN CROWLEY, SISTER MARY JAEGER, JOE VILLA, MIKEL HOLLAND, RICHARD MOLSEED, BOB SUTTON, ROCHELLE REIDER, AND PAUL EBMEIER HAVE BUSINESS RELATIONSHIPS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS AVERA HEALTH, A NONPROFIT CORPORATION ORGANIZED AND EXISTING UNDER THE LAWS OF THE STATE OF SOUTH DAKOTA AND EXEMPT UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. FORM 990, PART VI, SECTION A, LINE 7A AVERA HEALTH, AS THE SOLE MEMBER HAS THE POWER TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B AVERA HEALTH, AS THE SOLE MEMBER, HAS THE FOLLOWING RIGHTS AS THE MEMBER: 1) 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 THERE ARE NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED BY THE CFO. THE CFO PRESENTS THE RETURN TO THE BOARD AT A BOARD MEETING OR AN ELECTRONIC COPY OF THE RETURN IS SENT TO EACH BOARD MEMBER BY EMAIL FOR THEIR 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 ORGANIZATION HAS A PHYSICIAN RELATIONS/EXECUTIVE COMPENSATION COMMITTEE TO REVIEW PHYSICIAN RELATED TRANSACTIONS AND COMPENSATION RELATED TO PHYSICIANS, OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION. THE COMMITTEE MEETS AS NEEDED WITH RESPECT TO PHYSICIAN COMPENSATION. WITH RESPECT TO LEADERSHIP POSITIONS WE CONTRACT WITH AN OUTSIDE CONSULTANT TO GATHER WAGE AND MARKET DATA. INFORMATION IS PROVIDED TO THE CONSULTANT FOR LEADERSHIP POSITIONS THAT REFLECTS THE LEADER'S AREA OF RESPONSIBILITIES INCLUDING THE POSITION TITLE AND EDUCATION REQUIREMENTS, REPORTING STRUCTURE, NUMBER OF FTE'S, TOTAL REVENUE AND EXPENSES AND YEARS OF EXPERIENCE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S CONFLICT OF INTEREST POLICY AND GOVERNING DOCUMENTS ARE NOT PUBLICLY AVAILABLE. FINANCIAL STATEMENTS ARE CONSOLIDATED IN THE AVERA HEALTH CONSOLIDATED FINANCIALS. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,787,616. MANAGEMENT AND GENERAL EXPENSES 712,547. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,500,163. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 1,876,507. MANAGEMENT AND GENERAL EXPENSES 747,978. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,624,485. OTHER FEES: PROGRAM SERVICE EXPENSES 2,676,243. MANAGEMENT AND GENERAL EXPENSES 1,066,754. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,742,997. FORM 990, PART XI, LINE 9: IMPAIRMENT LOSS -1,163,308. EQUITY TRANSFERS -1,227,493. TEMPORARILY AND PERMANENTLY RESTRICTED TRANSFER FROM ST. MARY'S FOUNDATION 2,215,713. OTHER CHANGES IN UNRESTRICTED NET ASSETS -1,551. FORM 990, PART VI, LINE 16: THERE IS NO WRITTEN POLICY OR PROCEDURE 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). FORM 990, PART XII, LINE 2C: DURING THE TAX YEAR, AVERA ST. MARY'S WAS AFFILIATED WITH CHI FROM JULY 1, 2012 THROUGH DECEMBER 31, 2012 AND AFFILIATED WITH AVERA HEALTH FROM JANUARY 1, 2013 THROUGH JUNE 30, 2013. THE FINANCIAL INFORMATION WAS INCLUDED IN THE CONSOLIDATED FINANIAL STATEMENTS FOR BOTH CHI AND AVERA HEALTH FOR THE RESPECTIVE PORTION OF THE YEAR. FOR THE PERIOD JANUARY 1 THROUGH JUNE 30, THE AUDIT COMMITTEE OF AVERA HEALTH, PARENT ORGANIZATION, SELECTED THE AUDITOR AND REVIEWED THE AUDITED FINANCIAL STATEMENTS FOR AVERA ST. MARY'S. 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