2014-05-14T15:14:19-05:00 2013-06-30 450250958 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2012-07-01 470463911 AVERA ST ANTHONY'S HOSPITAL AVER 4023365132 300 N 2ND STREET ONEILL NE 687631569 RONALD CORK 4023365132 2014-05-14 1 KIM HUNWARDSEN CPA P00484560 6122536500 2014-05-14 2012 2015-11-30 17:44:51Z RONALD CORK 300 N 2ND STREET ONEILL NE 687631569 35406043 0 0928 X WWW.AVERA-STA.ORG X 1955 NE PROMOTION OF HEALTH 13 12 310 26 0 0 4866 660100 35518116 34476391 204504 264544 4680 5008 35732166 35406043 0 20000 0 0 16509883 16944510 0 0 0 17566232 17387762 34076115 34352272 1656051 1053771 39179797 38619867 14846454 13308231 24333343 25311636 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 29606809 20000 34476391 TO PROVIDE ACUTE PATIENT VISITS AND OUTPATIENT VISITS OF HEALTH CARE SERVICES. FOR THE YEAR ENDED JUNE 30, 2013, A TOTAL OF 2,781 PATIENT DAYS WERE RECORDED AND 276 NEWBORN PATIENT DAYS WERE RECORDED. CHARITY CARE IS ALSO PROVIDED BY THE FACILITY. FOR THE YEAR ENDED JUNE 30, 2013, THE FACILITY PROVIDED $584,987 IN CHARITY CARE, CALCULATED BY MULTIPLYING THE RATIO OF COST TO GROSS CHARGES FOR THE HOSPITAL BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CHARITY CARE TO ITS PATIENTS.THE HOSPITAL ALSO PROVIDES COMMUNITY BENEFIT HEALTH ACTIVITIES AT LESS THAN OR AT NO COST TO SUPPORT THOSE IN THE AREA SERVED. 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 YEARS ENDED JUNE 30, 2013 AND 2012, SPECIFIC ACTIVITIES INCLUDED SENIOR RESOURCE PROGRAMS FOR BILLING ASSISTANCE; MEETING FACILITIES; PROGRAMS FOR PATIENTS AND FAMILIES SUFFERING FROM CANCER, DIABETES, BREATHING DISORDERS, MENTAL ILLNESS, AND OTHERS; ASSISTANCE TO HEALTH EDUCATORS; EMERGENCY HEALTHCARE PROVIDERS; WELLNESS PROGRAMS; REDUCED PRICED SPORTS MEDICINE SERVICES; AND OVERNIGHT HOUSING FOR FAMILIES OF HOSPITALIZED PATIENTS. 29606809 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 12 0 1 310 1 0 0 0 0 0 0 0 0 0 0 X 13 12 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X MICHAEL GARMAN 4023365132 300 N 2ND STREET ONEILL NE 687631569 JIM RABE 1.00 0.00 X X 0 0 0 ED NORTH 1.00 0.00 X X 0 0 0 LISA LIND 1.00 0.00 X X 0 0 0 DR RICHARD FITCH 1.00 0.00 X 0 0 0 RANDY HUPP 1.00 0.00 X 0 0 0 JACK HURLEY 1.00 0.00 X 0 0 0 DIAN EDWARDS 1.00 0.00 X 0 0 0 DEB KELLY 1.00 0.00 X 0 0 0 SISTER SHARON ANN HAAS OSB 1.00 0.00 X 0 0 0 SISTER JANET SCHUMACHER PBVM 1.00 0.00 X 0 0 0 SISTER MARY JAEGER PBVM 1.00 10.00 X 0 0 0 PETER LUENINGHOENER MD 1.00 0.00 X 0 0 0 RONALD CORK 50.00 0.00 X X 0 212800 12871 MICHAEL GARMAN 40.00 0.00 X 142187 0 24662 EDWIN N COOK 40.00 0.00 X 540113 0 34002 MARK H MEYER 40.00 0.00 X 502704 0 11726 DEAN L BENSON 40.00 0.00 X 137432 0 19262 CAMERON EVERITT 40.00 0.00 X 162009 0 22766 ANTHONY AKAINDA 40.00 0.00 X 355186 0 30774 1839631 212800 156063 11 0 1 0 SACRED HEART HEALTH SERVICES 501 SUMMIT ST YANKTON SD 57078 PHYSICIAN/MGMT SERVICES 3746571 NORTH CENTRAL ANESTHESIA PO BOX 359 ONEILL NE 68763 ANESTHESIA SERVICES 1051780 DOCS WHO CARE 1337 S FOUNTAIN DR OLATHE KS 66061 ER STAFFING 407385 AVERA HEALTH 3900 W AVERA DRIVE SUITE 300 SIOUX FALLS SD 57108 E-SERVICES 224544 AVERA MCKENNAN 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 E-EMERGENCY & E-PHARMACY 171763 15 281750 378350 660100 PATIENT SERVICE REVENUE 622110 29044368 29044368 CLINIC REVENUE 621110 4916317 4916317 OTHER REVENUE 900099 440482 440482 CHANGE IN FDTN INTEREST 900099 75224 75224 34476391 34598 34598 5008 0 5008 5008 5008 187232 42714 0 0 187232 42714 229946 229946 35406043 34476391 0 269552 X 20000 20000 161849 161849 13056104 11749494 1306610 370199 322972 47227 2477247 2039934 437313 879111 751269 127842 996006 996006 18237 18237 48001 48001 5541944 5326114 215830 75657 75657 1182394 286762 895632 90036 90036 455865 455865 239637 205437 34200 137692 70016 67676 527284 527284 2383525 2383525 249190 249190 MEDICAL SUPPLIES 4074541 4074541 BAD DEBTS 562984 562984 EQUIPMENT LEASE AND REN 546767 499874 46893 DUES AND SUBSCRIPTIONS 94065 41449 52616 163937 40099 123838 34352272 29606809 4745463 0 3056732 4759800 4633693 4073117 1069524 1072849 68608 71965 40666348 19529889 22590151 21136459 1206616 1223926 5593815 5634115 103324 31652 226571 172809 630763 443175 39179797 38619867 2333059 2262689 350000 0 11516845 11045542 646550 0 14846454 13308231 X 24182843 25161136 150500 150500 24333343 25311636 39179797 38619867 X 1053771 197522 -273000 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 150500 150500 150500 150500 150500 150500 150500 150500 150500 150500 1.00000 0 1 1 770022 770022 25615788 9745233 15870555 13121812 9344085 3777727 1158726 440571 718155 21136459 ASSETS LIMITED TO USE - AVERA POOLED INVESTMENTS 4899256 F INVESTMENT IN FOUNDATION 734859 F 5634115 X 34416131 197522 -835984 -638462 35054593 351450 351450 35406043 33789288 0 33789288 562984 562984 34352272 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE HOSPITAL'S ENDOWMENT CONSISTS OF A PORTION OF THEIR INTEREST IN THE NET ASSETS OF AVERA ST. ANTHONY'S HOSPITAL FOUNDATION. THE AVERA ST. ANTHONY'S HOSPITAL FOUNDATION INCLUDES ENDOWMENT FUNDS WHICH HAVE BEEN ESTABLISHED FOR A VARIETY OF PURPOSES. 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. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPITAL IS ORGANIZED AS A NEBRASKA 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 AND 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: PROVISION FOR BAD DEBTS INCLUDED IN REVENUE ON FINANCIAL STATEMENTS -562,984. LOSS ON RETIREMENT OF LOAN -273,000. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS INCLUDED IN FUND BALANCE ON FINANCIAL STATEMENTS 351,450. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS INCLUDED IN REVENUE ON FINANCIAL STATEMENTS 562,984. 1 1 X 1 X 1 X 1 1 0 1 1 1946 585000 585000 0.01730 4769 2411490 2096884 314606 0.00930 6715 2996490 2096884 899606 0.02660 8 3039 216188 73525 142663 0.00420 1 200761 200761 0.00590 3 199763 199763 0.00590 1 852 852 0.00000 13 3039 617564 73525 544039 0.01600 13 9754 3614054 2170409 1443645 0.04260 1 9329 119960 72173 47787 0.00140 1 109048 109048 0.00320 2 9329 229008 72173 156835 0.00460 1 562984 0 16664903 16977546 -312643 X 1 1 1 1 AVERA ST ANTHONY'S HOSPITAL

300 N 2ND STREET ONEILL NE 68763

X X X X PROVIDER BASED CLINICS - 1 RHC & 4 PHYSICIAN CLINICS ST ANTHONY'S HOSPITAL 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X 0 0 1 1 150.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X 1 0 X X X X X 1 X 0 1 PART I, LINE 3C: TO DETERMINE ELIGIBILITY FOR CHARITY CARE, AVERA ST. ANTHONY'S HOSPITAL HAS DEVELOPED A TEST WHICH UTILIZES A COMBINATION OF HOUSEHOLD INCOME, HOUSEHOLD ASSETS, AND ALSO CONSIDERS UNPAID PAST AND ONGOING MEDICAL EXPENSES. CHARITY DISCOUNT MAY RANGE FROM 10 - 100% DEPENDING ON SCORE. PART I, LINE 6A: WE HAVE A COMMUNITY BENEFIT REPORT SPECIFIC TO OUR HOSPITAL AVAILABLE ON OUR WEBSITE OR ON REQUEST AS WELL AS 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 WAS CONVERTED TO COST BASED ON AN OVERALL COST-TO-CHARGE RATIO ADDRESSING ALL PATIENT SEGMENTS. UNREIMBURSED MEDICAID AND SUBSIDIZED HEALTH SERVICES WERE CONVERTED TO COST USING THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. OTHER BENEFITS ARE ACTUAL EXPENSES RECORDED IN THE GENERAL LEDGER. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM THE DENOMINATOR OF THE CALCULATION WAS $562,984. PART II: LIFELINE IS A SECURE PERSONAL MEDICAL ALERT EMERGENCY RESPONSE SERVICE FOR THE ELDERLY AND DISABLED. THIS SERVICE ASSISTS THESE INDIVIDUALS TO LIVE WITH GREATER INDEPENDENCE BY LIVING ALONE BUT STILL HAVING ACCESS TO MEDICAL HELP. VAN TRANSPORTATION IS PROVIDED TO INDIVIDUALS THAT ARE UNABLE TO DRIVE. WITH NO PUBLIC TRANSPORTATION IN OUR AREA THE VAN TRANSPORTATION HELPS BUS CHILDREN TO SCHOOL AND TAKES THE ELDERLY SHOPPING AND TO HEALTH CARE APPOINTMENTS. THE VAN EVEN OFFERS TRANSPORTATION TO LARGER CITIES ABOUT 200 MILES AWAY WITH ADVANCE NOTICE FOR SPECIALTY MEDICAL SERVICES. PART III, LINE 4: BAD DEBT EXPENSE IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION. THE ORGANIZATION DID NOT ESTIMATE THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY AS THE ORGANIZATION WORKS HARD AT ENCOURAGING PEOPLE TO APPLY AND MAKES ADJUSTMENTS TO BAD DEBT EXPENSE BASED ON RECOMMENDATIONS OF THE COLLECTION AGENCY OR REVIEWS BAD DEBT FOR THOSE WHO QUALIFY UNDER CHARITY CARE. 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.THE FOOTNOTE TO THE ORGANIZATION'S FINANCIAL STATEMENTS CAN BE FOUND ON PAGE 5 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 CMS. ST. ANTHONY'S FOLLOWS THE CHA GUIDELINES IN REPORTING COMMUNITY BENEFITS AND THEREFORE ANY MEDICARE SHORTFALL 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 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. ANTHONY'S HOSPITAL DOES NOT REPORT ANY DATA TO ANY OF THE CREDIT AGENCIES, HOWEVER, THE COLLECTION AGENCIES AVERA ST. ANTHONY'S HOSPITAL 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. ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 3: OUR HOSPITAL WORKED WITH THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT AND 10 OTHER HOSPITALS IN THE HEALTH DEPARTMENT'S DISTRICT. THIS COLLABORATIVE APPROACH ALLOWED FOR ADDITIONAL RESOURCES AND THE SUPPORT AND EXPERTISE OF A STATE PUBLIC HEALTH AGENCY. ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 4: CNCS, OSMOND GENERAL HOSPITALANTELOPE MEMORIAL HOSPITALBROWN COUNTY HOSPITALNIOBRARA VALLEY HOSPITALTILDEN COMMUNITY HOSPITALWEST HOLT MEMORIAL HOSPITALCHERRY COUNTY HOSPITALAVERA CREIGHTON HOSPITALOSMOND GENERAL HOSPITALROCK COUNTY HOSPITAL ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 5C: THE CHNA IS AVAILABLE AT THE FOLLOWING LINK: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/. ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 6I: THE ORGANIZATION'S IMPLEMENTATION STRATEGY MAY BE FOUND ON THEIR WEBSITE AT: HTTP://WWW.AVERA.ORG/EXPERIENCE/SHARED/COMMUNITY-NEEDS-HEALTH-ASSESSMENTS/. ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 7: THE FOLLOWING NEEDS WERE IDENTIFIED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT AS NEEDS IN SURROUNDING AREAS, HOWEVER THEY WERE NOT IDENTIFIED IN THE PRIMARY MARKET AREA OF THE HOSPITAL; THEREFORE, THEY WILL NOT BE ADDRESSED: WORKSITE WELLNESS INCENTIVES; VACCINATION AGAINST SEASONAL INFLUENZA AND PNEUMOCOCCAL DISEASE; ANNUAL DENTAL REFERRALS; YOUTH MENTAL HEALTH PROGRAMS ADDRESSING BULLYING, SUICIDE ATTEMPTS, AND DOMESTIC/DATING VIOLENCE AWARENESS AND PREVENTION; SKIN CANCER/SUN SAFETY; COLORECTAL CANCER SCREENING; AND FOOD BORNE ILLNESSES. ST. ANTHONY'S HOSPITAL 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 ON THE BILLING STATEMENT. IN ADDITION, THE FINANCIAL ASSISTANCE POLICY IS DISCUSSED WITH THE PATIENT UPON ADMISSION TO THE FACILITY. ST. ANTHONY'S HOSPITAL PART V, SECTION B, LINE 18E: IF A PATIENT IS SELF PAY AND HAS A LARGE BALANCE A THIRD PARTY AGENCY, THE MIDLAND GROUP, IS USED TO HELP THEM APPLY FOR MEDICAID. IF THEY ARE NOT ELIGIBLE FOR MEDICAID A COMPLETED CHARITY APPLICATION IS PROCESSED. ST. ANTHONY'S HOSPITAL 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. PART VI, LINE 2: AVERA ST. ANTHONY'S HOSPITAL CONDUCTS AN ANNUAL STRATEGIC PLANNING MEETING THAT INCLUDES A CROSS SECTION OF COMMUNITY MEMBERS. OUR HOSPITAL BOARD OF DIRECTORS, HOSPITAL FINANCE COMMITTEE, FOUNDATION BOARD OF DIRECTORS, COMMUNITY MEDICAL STAFF, AND HOSPITAL DEPARTMENT DIRECTORS MEET TO ASSESS COMMUNITY INPUT FROM THE LOCAL NURSING FACILITY, ASSISTED LIVING, AND LOCAL PUBLIC HEALTH OFFICE. OUR HOSPITAL AND FOUNDATION BOARDS AND FINANCE COMMITTEE ARE MADE UP OF A MAJORITY OF COMMUNITY MEMBERS. THIS GROUP DRAFTS AN ANNUAL STRATEGIC PLAN OF GOALS, OBJECTIVES, AND STRATEGIES THAT ARE CONTINUOUSLY UPDATED TO ADDRESS THE NEEDS OF THE COMMUNITY. ADDITIONALLY, INPUT FROM THE LOCAL MINISTERIAL ASSOCIATION, LAW ENFORCEMENT, CHAMBER OF COMMERCE, ELEMENTARY AND SECONDARY PUBLIC AND PAROCHIAL SCHOOLS, AND THE LOCAL COMMUNITY COLLEGE ARE ASSESSED AND INCORPORATED INTO THE PLAN. WE ARE ALSO CURRENTLY WORKING WITH OUR LOCAL HEALTH DEPARTMENT TO ASSESS ADDITIONAL COMMUNITY NEEDS. PART VI, LINE 3: PATIENTS ARE INFORMED OF THE FINANCIAL ASSISTANCE/CHARITY CARE POLICY THROUGH BROCHURES AND POSTED POLICIES AT THE REGISTRATION DESKS OF THE HOSPITAL AND EMERGENCY DEPARTMENT. AVERA ST. ANTHONY'S HAS STAFF IN CENTRAL REGISTRATION THAT IDENTIFY IF A PATIENT HAS THE FINANCIAL MEANS TO PAY FOR SERVICES OR INSURANCE TO COVER THESE SERVICES. PUBLIC ASSISTANCE IS ALSO PURSUED IF DEEMED APPROPRIATE. IF PATIENTS ARE IDENTIFIED AS CANDIDATES FOR CHARITY CARE THEY ARE DIRECTED TO OUR FINANCIAL SERVICES REPRESENTATIVE AND THE APPLICATION PROCESS IS INITITATED FOR CHARITY CARE. PATIENT FINANCIAL SERVICES CAN ASSIST WITH DETERMINING WHAT BENEFITS THE PATIENT MAY QUALIFY FOR AND ASSISTS WITH HELPING THEM APPLY FOR ANY BENEFITS. IF THERE IS NO OPTION FOR AN OUTSIDE ASSISTANCE PROGRAM, THE PATIENT IS INFORMED AND ENCOURAGED TO COMPLETE THE APPLICATION THAT UTILIZES A COMBINATION OF INCOME, ASSETS, AND EXPENSES TO DETERMINE WHAT PERCENTAGE OF CHARITY CARE THEY WOULD QUALIFY FOR. PART VI, LINE 4: AVERA ST. ANTHONY'S HOSPITAL IS LOCATED IN O'NEILL, NEBRASKA, THE COUNTY SEAT OF HOLT COUNTY. WE SERVE A LARGE RADIUS TO INCLUDE PATIENTS FROM BROWN, ROCK, BOYD, KEYA PAHA, WHEELER, KNOX, GARFIELD, AND ANTELOPE COUNTIES. IN 2010, THE POPULATION FOR HOLT COUNTY WAS ESTIMATED TO BE 10,435. APPROXIMATELY 20.5% OF THE POPULATION IS AGE 65 OR OLDER. THE AVERAGE PER CAPITA INCOME IS $22,498 AND APPROXIMATELY 7.8% OF THE POPULATION IS BELOW THE FEDERAL POVERTY LEVEL. THE NEAREST HOSPITAL IN THE AREA IS APPROXIMATELY 18 MILES FROM AVERA ST. ANTHONY. PART VI, LINE 5: THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF VOLUNTEER MEMBERS WHO RESIDE IN THE COMMUNITY. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE REINVESTED IN FACILITIES TO IMPROVE PATIENT CARE. THE HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS AVAILABLE TO ALL, REGARDLESS OF ABILITY TO PAY. 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 CORPORATE STAFF OF AVERA HEALTH ADVOCATES FOR ALL MEMBERS REGARDING COMMUNITY BENEFIT RELATED MATTERS OF STATE, REGIONAL, AND NATIONAL IMPORTANCE. 1 NORTHEAST COMMUNITY COLLEGE FOUNDATION 801 E BENJAMIN AVE PO BOX 469 NORFOLK NE 687020469 510145185 501(C)(3) 20000 HELP WITH EXPANSION OF O'NEILL, NEBRASKA CAMPUS 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION PROVIDED SUPPORT FOR A BUILDING PROJECT. THIS PROJECT WILL BE MONITORED TO COMPLETION. 0 0 0 0 0 0 0 0 0 RONALD CORK 0 207751 0 0 0 5049 0 10371 0 2500 0 225671 0 0 MICHAEL GARMAN 140329 0 0 0 1858 0 5813 0 18849 0 166849 0 0 0 EDWIN N COOK 532106 0 0 0 8007 0 10609 0 23392 0 574114 0 0 0 MARK H MEYER 495586 0 0 0 7118 0 10555 0 1170 0 514429 0 0 0 DEAN L BENSON 137162 0 0 0 270 0 5487 0 13775 0 156694 0 0 0 CAMERON EVERITT 161712 0 0 0 297 0 6549 0 16218 0 184776 0 0 0 ANTHONY AKAINDA 353368 0 0 0 1818 0 10338 0 20436 0 385960 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I, LINE 3: THE PRESIDENT & CEO'S COMPENSATION IS PAID BY A RELATED ORGANIZATION, SACRED HEART HEALTH SERVICES. AVERA ST. ANTHONY'S HOSPITAL RELIED ON THE RELATED ORGANIZATION FOR DETERMINING THE COMPENSATION FOR THE PRESIDENT & CEO USING THE METHODS DESCRIBED IN PART I, LINE 3. 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 ST. ANTHONY'S HOSPITAL DOES NOT HAVE A COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CEO AND CFO. AFTER INITIAL REVIEWS, A DRAFT IS PROVIDED TO THE FINANCE COMMITTEE FOR FINAL REVIEW. THE RETURN IS PROVIDED TO THE BOARD 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. COMPENSATION OF THE CEO IS DETERMINED BY AVERA SACRED HEART HOSPITAL, A RELATED EXEMPT ORGANIZATION. THE BOARD OF DIRECTORS REVIEWS THE MANAGEMENT AGREEMENT WITH AVERA SACRED HEART HOSPITAL AND DISCUSSES AND APPROVES THE AGREEMENT. NEGOTIATIONS ARE DONE AS NEEDED. FOR THE CFO, A SALARY REVIEW IS DONE BY A COMMITTEE BASED ON HOSPITAL ASSOCIATION SURVEYS, INCLUDING HOSPITAL SIZE. THERE IS ALSO A RELATIONSHIP BETWEEN THE CEO'S SALARY AND THE CFO'S SALARY, IN THAT A PERCENTAGE OF THE INCREASE FOR THE CFO IS BASED ON CEO'S SALARY BASE. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE GENERAL PUBLIC. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER IRS INSTRUCTIONS AND THEREFORE AVAILABLE TO THE GENERAL PUBLIC. OTHER FEES FORM 990, PART IX, LINE 11G REPAIRS AND MAINTENANCE: PROGRAM SERVICE EXPENSES 978,606. MANAGEMENT AND GENERAL EXPENSES 107,493. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,086,099. MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,016,124. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,016,124. MISCELLANEOUS FEES: PROGRAM SERVICE EXPENSES 2,331,384. MANAGEMENT AND GENERAL EXPENSES 108,337. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,439,721. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: LOSS ON RETIREMENT OF LOAN -273,000. FORM 990, PART XII, LINE 2C: THE AUDIT COMMITTEE OF AVERA HEALTH, PARENT ORGANIZATION, SELECTS THE AUDITOR AND REVIEWS THE AUDITED FINANCIAL STATEMENTS FOR AVERA ST. ANTHONY'S HOSPITAL. 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ANTHONY'S HOSPITAL NE 501(C)(3) LINE 11A, I AVERA ST ANTHONY'S HOSPITAL 1 AVERA HOME MEDICAL EQUIPMENT LLC 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 460488198 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A MRIS LLC 1325 S CLIFF AVE PO BOX 5045 SIOUX FALLS SD 57117 470874983 HEALTH CARE SERVICES INCLUDING AIRCRAFT SD N/A HOME MEDICAL EQUIPMENT OF PIERRE LLC 329 E DAKOTA PIERRE SD 57501 460444002 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF FLOYD VALLEY HOSPITAL LLC 714 E LINCOLN ST NE LEMARS IA 51031 820582350 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF ESTHERVILLE LLC PO BOX 5045 SIOUX FALLS SD 57117 201686097 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 MARSHALL LLC 1104 EAST COLLEGE DRIVE MARSHALL MN 56258 205271924 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A AVERA HOME MEDICAL EQUIPMENT OF SPENCER HOSPITAL LLC 2400 S MINNESOTA AVENUE 102 SIOUX FALLS SD 57117 800619999 MEDICAL SERVICES - HOME MEDICAL EQUIPMENT SD N/A Q&M PROPERTIES LLC 525 NORTH FOSTER MITCHELL SD 57301 730652049 MEDICAL CLINIC BUILDING 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 10720 SIKES PLACE SUITE 300 CHARLOTTE NC 28277 562143771 HEALTHCARE SERVICES NC N/A ACCOUNTS MANAGEMENT INC 5132 S CLIFF AVENUE SUITE 101 SIOUX FALLS SD 57108 460373021 COLLECTION SERVICES SD N/A C 0 AVERA HEALTH PLANS INC 3900 WEST AVERA DRIVE SUITE 101 SIOUX FALLS SD 57105 460451539 HEALTH FINANCING AND HEALTH PLAN ADMIN SD N/A C 0 AVERA PROPERTY INSURANCE INC 610 W 23RD STREET YANKTON SD 57078 460463155 PROPERTY INSURANCE SD N/A C 0 VALLEY HEALTH SERVICES 501 SUMMIT STREET YANKTON SD 57078 460357149 RENTAL REAL ESTATE SD N/A C 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 1 1 0 0