2014-08-14T16:04:39-05:00 2013-09-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2012-10-01 460255944 Mobridge Regional Hospital MOBR 6058453692 1401 10th Ave W Mobridge SD 57601 Angelia Svihovec 6058453692 2014-08-14 1 Laurie Hanson P00851848 6053391999 2014-08-14 2012 2015-11-30 17:44:51Z Angelia Svihovec 1401 10th Ave W Mobridge SD 57601 19286102 0 X www.mobridgehospital.org X 1959 SD Providing healthcare to people throughout the region. 12 10 183 200 0 0 919867 1406967 15865149 16222019 48647 51632 88669 79290 16922332 17759908 0 0 0 0 8818289 9396702 0 0 0 6862465 7417830 15680754 16814532 1241578 945376 17807982 20379024 6390929 8016595 11417053 12362429 The mission of Mobridge Regional Hospital is to provide high quality healthcare services in a compassionate and professional manner for people throughout the region. 0 0 15030610 16222019 Mobridge Regional Hospital (MRH) provides healthcare services to persons throughout the region. During the fiscal year ended September 30, 2013, the hospital had: 1,949 Patient Days 1,621 Acute Care Days21,983 Outpatient Visits 5,407 Assisted Living Days (Prairie Sunset Village) 15030610 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 21 0 1 183 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X Renae Tisdall 6058458164 PO Box 580 Mobridge SD 57601 Dennis Schnabel 1.00 X X 0 0 0 Delphine Steuck 1.00 X X 0 0 0 Bill Bachmeier 1.00 X X 0 0 0 Heidi Roshau 1.00 X X 0 0 0 Jake Kraft 1.00 X 0 0 0 Wally Schott 1.00 X 0 0 0 Donald Paulson 1.00 X 0 0 0 Dr Leonard Linde 1.00 X 0 0 0 Barb Gross 1.00 X 0 0 0 Dr Tom Swanson 1.00 X 0 0 0 Dr Travis Henderson 40.00 X 240604 0 27282 Dr Robert Marciano 40.00 X 290415 0 20211 Angelia Svihovec 40.00 X 0 0 0 Renae Tisdall 40.00 X 74845 0 25483 Dr Bela Csaki 40.00 X 298809 0 20718 Dr Colette Reule 40.00 X 267561 0 24746 Dr Kenric Malmberg 40.00 X 234092 0 24129 Debbie Smith 40.00 X 194520 0 16517 Dr Josh Henderson 40.00 X 204031 0 21753 1804877 0 180839 10 0 1 0 CPI Group 7400 E Orchard Rd 270 Greenwood Village CO 80111 Architect Services 286044 St Alexius Medical Center 900 East Broadway Bismarck ND 58506 IT services, CEO salary, supplies, etc 211993 Johnson Controls PO Box 730068 Dallas TX 75373 Construction 179395 Mondak Imaging Services 11 South 7th St 241 Miles City MT 59301 MRI services 134589 Northern Plains Lab PO Box 2036 Bismarck ND 58502 Outsource laboratory services 119442 5 1038582 368385 1406967 Patient Service Revenue 623110 15490348 15490348 Assisted Living Revenue 623110 475628 475628 Ancillary Charges 900099 141822 141822 Chng in Fdtn Int 900099 114221 114221 16222019 51632 51632 79290 0 79290 79290 79290 1526194 1526194 0 17759908 16222019 0 130922 665924 563347 102577 7010459 6334765 675694 235405 213003 22402 995399 995399 489515 434824 54691 204336 204336 5203 5203 35307 35307 564125 564125 80547 5274 75273 225286 97392 127894 78363 11847 66516 263261 259346 3915 40441 40441 55943 54047 1896 238388 35 238353 1431028 1431028 155494 66542 88952 MEDICAL SUPPLIES 1814288 1814288 BAD DEBT 1210404 1210404 EQUIPMENT AND MAINTENAN 898299 872426 25873 DUES AND SUBSCRIPTIONS 60065 19076 40989 57052 43001 14051 16814532 15030610 1783922 0 4831323 3183801 2644276 4895950 30296 30054 492886 514594 140917 183699 24465233 14424053 8308619 10041180 658277 835513 701388 694233 17807982 20379024 1391633 1665770 19000 1524527 4450000 4130000 327784 431990 202512 264308 6390929 8016595 X 10812795 11683291 604258 679138 11417053 12362429 17807982 20379024 945376 0 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 95575 95575 10598081 6843062 3755019 11607346 7288842 4318504 2164231 292149 1872082 10041180 Premium on Bonds Payable 11176 Deferred Compensation Plan Payable 253132 264308 X 16549504 -1210404 -1210404 17759908 0 17759908 15604128 0 15604128 1210404 1210404 16814532 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: The Organization is a South Dakota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Organization is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Organization has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Organization believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Organization would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Bad Debt Reclassified as Expense -1,210,404. Part XII, Line 4b - Other Adjustments: Bad Debt Reclassified as Expense 1,210,404. 1 1 X 0 1 X 1 1 0 0 48000 48000 0.00310 2273369 2194661 78708 0.00500 2321369 2194661 126708 0.00810 3169389 1626911 1542478 0.09890 3169389 1626911 1542478 0.09890 5490758 3821572 1669186 0.10700 0 1210404 907803 5063131 5041041 22090 X 1 1 1 1 Mobridge Regional Hospital

1401 10th Avenue W Mobridge SD 57601

www.mobridgehospital.org X X X X Mobridge Regional Hospital 1 1 X X X X X X 12 1 0 1 X X X X X X 0 0 1 0 1 300.000000000000 1 X X X X 1 1 X X X X X 1 0 X X X X 1 X 1 1 4 Prairie Sunset Village

1320 W Grand Xing Mobridge SD 57601

Assisted Living & Senior Housing Mobridge Medical Clinic

1309 10th Ave W Mobridge SD 57601

Provider Based Rural Health Clinic West River Health Clinic

103 1st Avenue E McLaughlin SD 57642

Provider Based Rural Health Clinic West Dakota Health Clinic

906 Main Timber Lake SD 57656

Provider Based Rural Health Clinic Part I, Line 3c: MRH offers financial assistance discounts of up to 85% based on FPG. Please refer to Part V, Line 12 for other factors used in determining financial assistance eligibility. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Line 7b was determined using the Medicaid PS&R report and the general ledger accounting system. Line 7g was determined using the Medicare cost report for fiscal year ending 9/30/13. Part I, L7 Col(f): Bad debt expense of $1,210,404 was subtracted from total operating expense. Part III, Line 4: a) Bad debt expense on Part III Lines 2 and 3 is based on charges. When a payment is received or a discount given on a bad debt account it offsets the current fiscal year bad debt expense through a recovery of bad debt account. b) Bad debt expense attributable to financial assistance is estimated based on income levels. A large portion of MRH charges are generated by those below the poverty level. Statistics prove that most of the mentioned patients qualify for financial assistance. After review, MRH estimates approximately 75% of bad debt at cost is attributable to persons who would qualify for financial assistance. c) The footnote for bad debt expense is located on page 7 of the attached audited financial statements. Part III, Line 8: Medicare Allowable Cost of Care was calculated from the Medicare Cost Report for fiscal year ending 9/30/13. Part III, Line 9b: The patient account specialist at the Mobridge Regional Hospital keeps on file all guarantors who have qualified for financial assistance and applies the financial assistance to all accounts when the guarantor balance becomes due. Updated financial information is requested annually for any changes in financial assistance that may apply. Mobridge Regional Hospital Part V, Section B, Line 3: The facility obtained data for the community health needs assessment through focus groups, surveys and personal interviews involving community leaders, community healthcare providers, coordinating agencies, community members and the underserved population. Mobridge Regional Hospital Part V, Section B, Line 5c: The Organization's CHNA can be accessed at: www.mobridgehospital.org/community-outreach/Part V, Section B, Line 6:The Organization's Implementation Strategy can be accessed at www.mobridgehospital.org/community-outreach/. Mobridge Regional Hospital Part V, Section B, Line 6i: Financial feasibility studies for identified needs were completed by St. Alexius Medical Center. Mobridge Regional Hospital Part V, Section B, Line 7: Pursuant to the implementation strategy adopted by Mobridge Regional Hospital, providing cancer care and kidney dialysis will not be addressed. Because of Mobridge's size, the ability to recruit and retain physicians to provide cancer care and highly specialized care is nearly impossible. Financial feasibility studies were completed for needs identified. We found the cost to add kidney dialysis was far too great and we are therefore unable to provide this particular service. Additionally, the community had a concern regarding travel for the treatment of cancer. The Organization has and continues to meet the need of helping patients with travel expenses by supporting the local cancer foundation. Mobridge Regional Hospital Part V, Section B, Line 10: MRH offers financial assistance discounts of up to 85% based on FPG. Mobridge Regional Hospital Part V, Section B, Line 14g: A financial assistance notice is made part of the billing invoice. A financial assistance notice is posted in the emergency room, waiting rooms, and admissions office, and the full policy is made available upon request. Mobridge Regional Hospital Part V, Section B, Line 18e: Provided financial assistance information with patient discharge materials. Mobridge Regional Hospital Part V, Section B, Line 20d: The maximum amount charged to a patient under the financial assistance policy for emergency and medically necessary care is 50% of the gross charges. This is based on the lowest discount under the charity care policy of 50%. The Financial Assistance Policy is being updated to comply with Section 501(r). This will be completed at least by September 30, 2014. Mobridge Regional Hospital Part V, Section B, Line 21: The hospital provides a reduction to gross charges under the following conditions: patients indicate they have family income of no more than 300% of FPG, are uninsured or underinsured, and complete the required paperwork to be eligible for financial assistance.The hospital has not determined the amount generally billed under the various proposed methods of calculation. Therefore, it is possible a patient under the financial assistance policy could have paid more than the amount generally billed. The Financial Assistance Policy is being updated to comply with Section 501(r). This will be completed at least by September 30, 2014. Mobridge Regional Hospital Part V, Section B, Line 22: The financial assistance policy covers medically necessary services only. Therefore, the hospital may have charged FAP-eligible individuals an amount equal to gross charges for nonmedically necessary services. Part VI, Line 2: Mobridge Regional Hospital (MRH) is committed to providing high quality healthcare services to all people throughout the region. The facility provides family medicine, internal medicine, OB, ICU, ALS, ambulance service, emergency care, and surgical services to all people who are in need of those services. MRH currently is working in collaboration with Walworth County and the State of South Dakota to provide Community Health Services, including family planning services, adult health, and child immunizations. MRH's management strives to listen to the community needs. If new healthcare needs arise, administration will complete an analysis of cost/benefit for the new service to be offered. MRH's administration believes in being out in the public at events to answer questions that may surface about the facility. During the year ended 9/30/13 the community health needs assessment was completed. Please see Schedule H Part V for more information. Part VI, Line 3: MRH posts its financial assistance policy, or a summary thereof, and financial assistance contact information in the admissions areas and clinic areas in which eligible patients are likely to be present. The facility provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients with discharge materials. The Patients Account Manager discusses with the patient the availability of various government benefits, such as Medicaid or state programs, and assists the patient with qualification for such programs, where applicable.MRH's financial assistance program is available to both new and established patients. The financial assistance policy covers all medically necessary services provided by the institution that are ordered by physicians.MRH's financial assistance program is available to all patients who indicate an inability to pay and meet the criteria as established by the hospital for all or a portion of their outstanding hospital bill. Part VI, Line 4: MRH is located in a small rural community in Walworth County, South Dakota, known as Mobridge. According to the 2010 Census, Mobridge has a population of 3,465 people racially comprised of mainly Caucasian (75.67%) and Native Americans (20.46%). The community borders the Standing Rock Reservation and the Cheyenne River Reservation which accounts for the larger Native American population and relations with Indian Health Services. The median household income of Mobridge is $37,417, and the median family income is $52,316. Roughly 17.6% of the population is below the poverty line. The facility owns and operates clinics in Mobridge, McLaughlin and Timber Lake. The facility serves patients from a six county area (Walworth, Ziebach, Corson, Dewey, Campbell and Potter) and is approximately one hundred miles from another hospital with a higher level of care offered. According to the 2010 Census, Ziebach county is the poorest county in America, and 62% of people living in this county are under federal poverty guidelines. Corson County ranked 9th of the poorest counties in America. The poverty level in Mobridge is 59.1% greater than the South Dakota average and 75.5% greater than the National average. The median earnings for males is 50.3% greater than the median earnings for females in Mobridge. Part VI, Line 5: The Mobridge Regional Hospital is committed to the patients we serve, regardless of race, color, religion, sex, disability, or ability to pay. The organization's financial assistance adjustments have continued to trend up over the past few years, and we continue to focus budget efforts to continue this trend. MRH is 100 miles from another healthcare facility with a higher level of care and participates in the North Dakota and South Dakota trauma systems with level III and level IV certifications, respectively. MRH continues a broad level of board involvement for Corson, Dewey, and Walworth Counties to monitor community needs in those areas. MRH continues to be a popular place for medical students to complete clinical rotations, and we continue to offer a wide variety of certification classes to nurses and the members of the community including EMT-B, PALS, ACLS, TNCC, ALSO, NALS, EMT-I, and CPR. MRH has developed a worksite wellness program within the organization and has goals to work with other businesses in the community to promote overall healthy lifestyles.MRH provides various health screenings available to the community and surrounding communities throughout the year. The health screenings include free cholesterol checks, BMI, blood pressure and waist/hip ratios. These preventative health screenings promote the general health of the community.The hospital has a Board of Directors comprised of volunteers who reside in the service area. Medical staff privileges are extended to all qualified physicians in the area. All qualified physicians who show an interest must go through a credential review and board approval. Surplus funds, if available, are reinvested in the facilities to improve patient care. X X 0 0 0 0 0 0 0 1 0 Dr Travis Henderson 212791 0 22529 0 5284 0 9533 0 18146 0 268283 0 0 0 Dr Robert Marciano 229571 0 56276 0 4568 0 10000 0 10633 0 311048 0 0 0 Dr Bela Csaki 289384 0 0 0 9425 0 10000 0 11297 0 320106 0 0 0 Dr Colette Reule 215482 0 46426 0 5653 0 10000 0 15082 0 292643 0 0 0 Dr Kenric Malmberg 193068 0 35493 0 5531 0 9150 0 15321 0 258563 0 0 0 Debbie Smith 195004 0 0 0 -484 0 7932 0 8974 0 211426 0 0 0 Dr Josh Henderson 193035 0 5251 0 5745 0 7183 0 14906 0 226120 0 0 0 Part I, Line 7 The physicians are paid based on relative value unit based production. A City of Mobridge South Dakota 466000320 607429BA4 2007-05-08 5773898 Refinance bonds issued 1997 used for construction; purchase CT, Clinic & EMR 0 0 0 A 1625000 5773898 267790 88005 1000000 4416499 2008 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 1 0 0 0 0 0 Schedule K Part IV, Arbitrage, Line 2c Date Rebate Computation Performed Issuer Name: City of Mobridge, South Dakota Date the Rebate Computation was Performed: 07/13/2012 Form 990, Part VI, Section A, line 3 MRH currently has a management agreement with St. Alexius Medical Center in Bismarck, ND. The agreement provides the CEO, Angelia K. Svihovec, and information technology support at a cost to MRH. The original management agreement date was January 1, 2000. Angelia Svihovec, CEO, received W-2 compensation of $152,413 during the calendar year ended 12/31/12. Form 990, Part VI, Section A, line 6 There is only one class of member; all members have one vote (same voting rights). Form 990, Part VI, Section A, line 7a The nominating committee nominates candidates for election. The members vote on candidates at the annual meeting. Form 990, Part VI, Section A, line 8b There is no committee with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The CEO, CFO, and Finance Committee will review the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers the entire Board of Directors. If a conflict should arise, it would first go to the CEO for evaluation, then to the Board of Directors for final evaluation. The Board of Directors is responsible for making the final decision in determining if a conflict exists. If a conflict is found, the person(s) involved would be required to abstain from discussions and voting on the item causing the conflict. Form 990, Part VI, Section B, line 15 The Finance Committee determines and approves the physician contracts, including compensation. The CEO's salary is determined using a salary survey and discussions with the management company. The Finance Committee approves the salary of the CEO annually. The Board of Directors approves the Finance Committee minutes, which include discussions regarding the CEO's salary. Salaries for other Officers or members of management are determined by the CEO through the use of salary survey information from SDAHO and employee service and experience files. Salary increases were implemented on September 8th, 2013. Form 990, Part VI, Section C, line 19 Documents are made available upon request.