2014-05-07T14:01:14-05:00 2013-06-30 420714325 MCGLADREY LLP 801 NICOLLET MALL SUITE 1100 MINNEAPOLIS MN 55402 990 2012-07-01 411924645 CENTRACARE HEALTH SYSTEM - LONG PRAIRIE CENT 3207322141 20 SE NINTH STREET LONG PRAIRIE MN 56347 CRAIG BROMAN 3207322141 2014-05-05 1 TODD A JACKSON P00092672 6123324300 2012 2015-11-30 17:44:51Z CENTRACARE HEALTH - LONG PRAIRIE DR TERENCE PLADSON 20 SE NINTH STREET LONG PRAIRIE MN 56347 26008072 0 X WWW.CENTRACARE.COM X 1999 MN CENTRACARE HEALTH SYSTEM WORKS TO IMPROVE THE HEALTH OF EVERY PATIENT EVERY DAY. 5 0 285 200 0 0 33537 13191 23370646 24088775 375418 449291 292479 1456815 24072080 26008072 536745 50365 0 0 14844682 15476487 0 0 0 8781926 8573673 24163353 24100525 -91273 1907547 19395442 20945664 5168512 5416061 14226930 15529603 TO PROVIDE QUALITY HEALTHCARE WITH COMPASSION, DIGNITY, INTEGRITY, AND RESPECT SHOWN TO ALL CUSTOMERS AND EMPLOYEES. 0 0 16767913 50365 25498150 CCH - LONG PRAIRIE IS A 25 BED CRITICAL ACCESS HOSPITAL, CLINIC AND 70 BED LONG TERM CARE FACILITY LOCATED IN THE MIDDLE OF TODD COUNTY PROVIDING ACUTE CARE, DIAGNOSTIC, NURSING HOME AND CLINIC SERVICES. THE CCH - LONG PRAIRIE IS PART OF A LARGER INTEGRATED HEALTH CARE DELIVERY SYSTEM KNOWN AS CENTRACARE HEALTH, A SYSTEM RECOGNIZED FOR BEING A LEADER IN PROVIDING HIGH-QUALITY, COMPREHENSIVE CARE THROUGHOUT THE REGION. CCH - LONG PRAIRIE PROVIDES ACUTE CARE SERVICES IN AREAS OF MEDICAL, SURGICAL AND OBSTETRICS ALONG WITH OTHER SERVICES OF EMERGENCY, IMAGING, LABORATORY, REHABILITATION, AND CHEMOTHERAPY. THIS HAS GENERATED CURRENT YEAR GROSS REVENUES OF $28,157,146 WITH EXPENSES OF $12,461,629. THERE WERE 620 INPATIENT VISITS, 2,451 INPATIENT DAYS WITH 17,973 OUTPATIENT VISITS. THE NURSING HOME GENERATED CURRENT YEAR GROSS REVENUES OF $3,990,119 AND EXPENSES OF $5,363,325. THERE WERE 22,782 RESIDENT DAYS. THE CLINIC SERVICES OF GENERAL SURGERY, NEUROLOGY, OBSTETRICS/GYNECOLOGY, ONCOLOGY, ORTHOPEDICS, AND UROLOGY GENERATED CURRENT YEAR GROSS REVENUES OF $5,391,497 AND EXPENSES OF $5,553,260. THERE WERE 13,400 CLINIC VISITS. 16767913 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 0 0 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 34 0 1 285 1 0 0 0 0 0 0 0 0 0 0 X 5 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 0 MN X LARRY KNUTSON 3207327240 20 SOUTHEAST NINTH STREET LONG PRAIRIE MN 56347 TERENCE R PLADSON MD 1.00 53.00 X X 0 1182844 200797 JAMES R DAVIS 1.00 41.00 X X 0 425311 37405 DAVID TILSTRA MD 1.00 43.00 X X 0 371398 56195 PAUL R HARRIS 2.00 44.00 X X 0 393819 76122 GREGORY R KLUGHERZ 1.00 45.00 X X 0 605116 96478 ALLEN HORN MD 1.00 42.00 X 0 562765 37058 DANIEL J SWENSON 40.00 0.50 X 0 233616 47352 ERIC M LOHN 9.00 31.50 X 0 203554 24538 JAMES M BERGMANN 40.00 X 162279 0 25816 THOMAS J HOCK 40.00 X 153570 0 35316 CHRISTOPHER A HAGEN 40.00 X 134010 0 23450 MARK A CHRISTIANSEN 40.00 X 126418 0 14175 CHRISTINE M OLSON 40.00 X 126186 0 21413 702463 3978423 696115 10 0 1 0 CENTRACARE CLINIC 1200 6TH AVENUE NORTH ST CLOUD MN 56303 PHYSICIAN SERVICES 1380539 CENTRAL MINNESOTA DIAGNOSTIC INC 150 TENTH ST NW PO BOX 158 MILACA MN 56353 MOBILE MRI & CT SERVICES 354019 WEST CENTRAL ANESTESIA 10382 AUGUSTA DRIVE SAUK CENTRE MN 56378 CRNA SERVICES 234635 3 13191 13191 PATIENT AND RESIDENT SERVICE REVE 900099 24088775 24088775 24088775 442087 442087 47440 0 47440 47440 47440 7204 0 7204 7204 7204 QUALITY & TECH INITIATIVES 900099 869810 869810 SUPPLIES/DRUGS/FOOD SALES 900099 253149 253149 286416 286416 1409375 26008072 25498150 0 496731 50365 50365 11081085 8282801 2798284 567779 418327 149452 3127160 2287751 839409 700463 510717 189746 54259 2397 51862 79557 79557 1776585 1477963 298622 48624 48624 256742 141413 115329 369977 73618 296359 650257 348411 301846 35799 22794 13005 88612 55652 32960 147186 405 146781 117059 117059 761892 761892 144599 44046 100553 MEDICAL SUPPLIES 1842770 1805724 37046 BAD DEBT 694271 694271 MEDICAID SURCHARGE 531386 22515 508871 MINOR EQUIPMENT 405844 297652 108192 568254 231091 337163 24100525 16767913 7332612 0 1788867 3281076 3347382 3527708 312449 300224 173785 168171 15623920 7993626 7468332 7630294 5554750 5255135 632363 496856 117514 286200 19395442 20945664 1916671 2497266 17021 15559 6724 2535244 2461890 692852 441346 5168512 5416061 X 14203003 15502347 23927 27256 14226930 15529603 19395442 20945664 X 1907547 127626 -732500 X 0 1 X 1 0 X 0 1 X 312427 312427 8781533 3649797 5131736 279639 135636 144003 6250321 4208193 2042128 7630294 ASSETS INTERNALLY DESIGNATED FOR CAPITAL ACQUISITIONS 5255135 F 5255135 THIRD PARTY PAYOR SETTLEMENTS 205000 ASSET RETIREMENT OBLIGATION 107939 CAPITAL LEASES 128407 441346 PART IV, LINE 2B: RESIDENT TRUST FUNDS ARE HELD BY THE ORGANIZATION ON BEHALF OF THE RESIDENTS IN A SEPARATE BANK ACCOUNT. 1 1 1 X 175.000000000000 1 X 1 1 1 0 1 1 303115 303115 0.01300 3518570 2273928 1244642 0.05320 3821685 2273928 1547757 0.06620 1516581 1516581 0.06480 326 326 0.00000 1516907 1516907 0.06480 5338592 2273928 3064664 0.13100 1 694271 5745031 5784361 -39330 X 1 1 1 1 LONG PRAIRIE

20 NINTH STRET SOUTHEAST LONG PRAIRIE MN 56347

X X X X RURAL HEALTH CLINIC, NURSING HOME CENTRACARE HEALTH - LONG PRAIRIE 1 1 X X X X X X X X X X 1 1 1 X X X 1 0 1 1 175.000000000000 1 250.000000000000 1 X 1 1 X X X X X X 1 X X 1 X X X X X X 1 X 0 0 1 LONG PRAIRIE CARE CENTER

20 NINTH STREET SE LONG PRAIRIE MN 56347

NURSING HOME PART I, LINE 7: THE ORGANIZATIONS TOTAL EXPENSES WERE REDUCED BY THEIR NON-OPERATING REVENUE, MEDICAID SURCHARGE AND MN CARE TAX, AND THEIR COMMUNITY BENEFIT EXPENSE. THE NET TOTAL EXPENSES WERE THEN DIVIDED BY GROSS CHARGES TO DETERMINE THE COST TO CHARGE RATIO. PART III, LINE 4: THE FOLLOWING IS FROM THE "ACCOUNTS RECEIVABLE" PARAGRAPH INCLUDED IN NOTE 2 OF THE ORGANIZATION'S AUDITED FINANCIALS."PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF EXPECTED NET COLLECTIONS, CONSIDERING HISTORICAL NET COLLECTION, BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTH CARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUECY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE ANY MODIFICATIONS TO THE PROVISION FOR UNCOLLECTIBLE ACCOUNTS TO ESTABLISH AN APPROPRIATE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS. AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE, CENTRACARE FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITH COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICITONS ON COLLECTION EFFORTS AS DETERMINED BY CENTRACARE." PART III, LINE 8: THE 2013 MEDICARE COST REPORT WAS USED TO DETERMINE ALLOWABLE COSTS. PART III, LINE 9B: THE COLLECTION POLICIES AT CENTRACARE HEALTH - LONG PRAIRIE REQUIRE COLLECTION STAFF TO OFFER CHARITY TO PATIENTS WHO INDICATE THAT PAYMENT MAY BE AN ISSUE. IF A PATIENT DOES QUALIFY FOR FULL CHARITY, ALL OTHER COLLECTION EFFORTS MUST CEASE. IF A PATIENT QUALIFIES FOR PARTIAL CHARITY, COLLECTION EFFORTS WILL CONTINUE ON THE BALANCE OF THE ACCOUNT. THESE PROVISIONS APPLY TO BOTH HOSPITAL EMPLOYED COLLECTION STAFF AND COLLECTION AGENCY STAFF. NO PATIENTS, WHETHER THEY QUALIFY FOR CHARITY OR NOT, ARE REPROTED TO CREDIT RATING AGENCIES. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 1J: CCHS CHNA PROCESS ALSO CONSIDERED SECONDARY DATA FROM THE DARTMOUTH ATLAS, ROBERT WOOD JOHNSON, MINNESOTA DEPARTMENT OF HEALTH, US CENSUS BUREAU, MINNESOTA HOSPITAL ASSOCIATION, ST. CLOUD AREA UNITED WAY, CATHOLIC CHARITIES OF THE DIOCESE OF ST. CLOUD, MINNESOTA SENIOR FEDERATION, PUBLIC HEALTH DEPARTMENTS FROM APPROPRIATE COUNTIES AND ADDITIONAL FEDERAL AND STATE ENTITIES.THE CHNA WAS INFORMED BY A COLLABORATIVE AND ONGOING COMMUNITY HEALTH SURVEY JOINTLY FUNDED AND MANAGED WITH A NUMBER OF AREA COUNTIES WHO WERE JOINTLY CONDUCTING COMMUNITY SURVEYS TO INFORM THEIR COMMUNITY HEALTH ASSESSMENTS IN SUPPORT OF DEVELOPMENT OF THEIR COMMUNITY HEALTH IMPROVEMENT PLANS.LACK OF CURRENT PUBLIC HEALTH DATA WAS A SIGNIFICANT INFORMATION GAP IN THE CHNA AS THE SURVEY COULD NOT BE COMPLETED IN TIME TO INCLUDE ITS DATA IN THE CCH CHNA. CCH HAS COMMITTED TO A CONTINUING EFFORT WITH PUBLIC HEALTH OFFICIALS TO JOINTLY DEVELOP PRIORITIES WITH THE COUNTIES AS A PART OF ITS ACTION PLANS. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 3: DATA WAS OBTAINED FROM LOCAL COUNTY PUBLIC HEALTH DEPARTMENTS, INCLUDING THEIR MOST RECENT HEALTH ASSESSMENTS AND COMMUNITY REPORTS. IN ADDITION, HEALTH-RELATED INFORMATION WAS COLLECTED FROM AREA NONPROFIT ORGANIZATIONS THAT REGULARLY CONDUCT ASSESSMENTS AND EVALUATIONS OF THE SERVICES THEY PROVIDE AND THEIR TARGETED DEMOGRAPHICS. USEFUL MATERIAL WAS GATHERED FROM THE LOCAL UNITED WAY, CATHOLIC CHARITIES, THE CENTRAL MINNESOTA COUNCIL ON AGING, AND THE TRI-COUNTY ACTION PROGRAM (TRI-CAP). THESE ORGANIZATIONS SUPPORT A BROAD RANGE OF CONSTITUENTS WITH DIVERSE HEALTH-RELATED NEEDS; THEY REPRESENT DEMOGRAPHICS THAT ARE STATISTICALLY MORE LIKELY TO ENCOUNTER HEALTH-RELATED BARRIERS. CCH ALSO CONDUCTED A SERIES OF FOCUS GROUPS THAT INFORMED ITS CHNA. SPECIFICALLY, THE FOCUS GROUPS REPRESENTED POPULATIONS OF COLOR, RECENT IMMIGRANT POPULATIONS, CULTURAL MINORITIES, THOSE WHO WERE AUDIBLY CHALLENGED AND OTHERS WHO WERE DEEMED TO BE UNDER-REPRESENTED OR UNDER-SERVED. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 4: CCH CONDUCTED ITS CHNA JOINTLY WITH ALL OF ITS 501 C 3 HOSPITALS AS OF THE BEGINNING OF ITS FISCAL 2013. THOSE FACILITIES INCLUDED ST. CLOUD HOSPITAL, CENTRACARE HEALTH MELROSE, CENTRACARE HEALTH LONG PRAIRIE AND CENTRACARE HEALTH SAUK CENTRE.EACH HOSPITAL PREPARED INDIVIDUAL ACTION PLANS TO THE CHNA BASED ON SPECIFIC INPUT FROM THOSE COMMUNITIES. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 5C: IN ADDITION TO MAKING ITS CHNA AVAILABLE TO THE PUBLIC ON ITS WEB SITE AND AT ITS BUSINESS OFFICE, CCH HAS SHARED COPIES OF THE CHNA WITH COUNTY PUBLIC HEALTH OFFICIALS AND, INTERNALLY, WITH INDIVIDUALS WORKING ON QUALITY IMPROVEMENT AND COMMUNITY HEALTH INITIATIVES.CCH HAS ALSO PUBLISHED CONTACT INFORMATION FOR ITS DIRECTOR OF COMMUNITY & GOVERNMENT RELATIONS TO RESPOND TO QUESTIONS OR CONCERNS ABOUT THE CHNA. THE DIRECTOR HAS ALSO PRESENTED RESULTS OF THE CHNA TO COMMUNITY GROUPS AND TO REPRESENTATIVES OF LOCAL FUNDING GROUPS. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 6I: THE NEEDS IDENTIFIED BY THE CHNA ARE CURRENTLY IN ORGANIZATIONAL WORK PLANS AND ARE UNDER IMPLEMENTATION. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 7: PER GUIDANCE FROM THE IRS, (CITE), THE CHNA FOR CCH ELECTED NOT TO DIRECTLY ADDRESS SEVERAL DETERMINANTS OF HEALTH THAT IT IDENTIFIED IN ITS PROCESS WHICH WERE NOT WITHIN THE ORGANIZATIONS CAPABILITIES OR CORE COMPETENCIES. EXAMPLES OF ISSUES NOT SPECIFICALLY ADDRESSED IN THE CHNA ACTION PLANS INCLUDE HIGH SCHOOL GRADUATION RATES, AFFORDABLE HOUSING OR SUPPORTED HOUSING. (CCH DID SUPPORT AN EFFORT OF THE CITY OF ST. CLOUD TO CONDUCT A HOUSING ASSESSMENT AS A RESULT OF THE CHNA PROCESS AND IS ALREADY THE LARGEST AREA PROVIDER OF SUPPORTED HOUSING DUE TO ITS EXTENSIVE CHEMICAL DEPENDENCY PROGRAMS AND SENIOR HOUSING PROGRAMS.) CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 14G: PATIENTS WHO ARE AT A SELF PAY STATUS RECEIVE CHARITY CARE INFORMATION EITHER VIA A TELEPHONE CALL OR A LETTER. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 16E: THE ORGANIZATION EMPLOYES THE USE OF COLLECTION AGENCIES TO COLLECT A PATIENT'S BALANCE. AFTER THOSE EFFORTS ARE EXHAUSTED, THE ORGANIZATION DOES UTILIZE LAWSUITS AS WELL. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 17E: THE ORGANIZATION CONTRACTS WITH SEVERAL COLLECTION AGENCIES TO ATTEMPT TO COLLECT PATIENT BALANCES. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 18E: OUR CREDIT COLLECTION AGENCIES ARE REQUIRED TO PROVIDE CHARITY INFORMATION AS PART OF THEIR COLLECTION PROCESS PRIOR TO ANY CONSIDERATION OF LEGAL ACTION AGAINST THE PATIENT. CENTRACARE HEALTH - LONG PRAIRIE PART V, SECTION B, LINE 20D: PER AGREEMENT WITH THE MINNESTOA ATTORNEY GENERAL, THE ORGANIZATION PROVIDES A DISCOUNT TO THE UNINSURED EQUAL TO THE AVERAGE DISCOUNT OF OUR LARGEST (BY VOLUME) NON-GOVERNMENTAL PAYOR. PART VI, LINE 2: THE ORGANIZATION'S STRATEGIC PLANNING ASSESS THE NEEDS OF THE COMMUNITY AND PATIENTS THROUGH PATIENT SATISFACTION SURVEYS, COMMENT CARDS, COMMUNITY ASSESSMENTS AND A DIVERSE OPERATING COMMITTEE THAT REPRESENTS THE COMMUNITY AND BRINGS TO THE TABLE ISSUES, CONCERNS, AND RECOMMENDATIONS FOR HEALTH CARE SERVICES. PART VI, LINE 3: INPATIENTS WHO ARE SELF PAY ARE IDENTIFIED, AND A REPRESENTATIVE OF LONG PRAIRIE'S BILLING DEPARTMENT EXPLAINS THE CHARITY CARE POLICY TO PATIENTS. THEY ALSO EXPLAIN THE SELF PAY DISCOUNT AND SCREENS THE PATIENT FOR ELIGIBILITY FOR ANY STATE OR FEDERAL PROGRAMS. THEY ALSO ASSIST THE PATIENT WITH ANY PAPERWORK REQUIRED TO APPLY FOR SUCH PROGRAMS. OUTPATIENTS WHO ARE SELF PAY RECEIVE AN AUTOMATIC SELF PAY DISCOUNT. IF THE PATIENT DOES NOT REMIT PAYMENT, COLLECTION STAFF ATTEMPT TO REACH THE PATIENT BY PHONE. PATIENTS ARE TOLD ABOUT THE CHARITY PROGRAM. FOR BOTH INPATIENTS AND OUTPATIENTS, ALL STATEMENTS CONTAIN A LETTER REGARDING THE AVAILABILITY OF CHARITY CARE. ALSO ALL PRECOLLECTION LETTERS HAVE THIS SAME LANGUAGE INDICATING THE AVAILABILITY AND PROCESS OF OBTAINING CHARITY CARE. PART VI, LINE 4: THE COMMUNITY OF LONG PRAIRIE AND THE SURROUNDING AREA CONSISTS OF APPROXIMATELY 25,000 PEOPLE. THE 2005 DEMOGRAPHIC INFORMATION INDICATES A SENIOR POPULATION (60 YEARS OR OLDER) OF 21% WHICH COMPARES TO 12.6% FOR THE ENTIRE STATE OF MINNESOTA. THE PER CAPITA INCOME OF THE RESIDENTS IN OUR AREA IS EXTREMELY DEPRESSED AT $20,696 COMPARED TO A STATE AVERAGE OF $33,322. AREA CONSISTS OF AGRICULTURE AND SOME INDUSTRY. PART VI, LINE 5: THE FACILITY HAS A COMMUNITY BASED OPERATING COMMITTEE THAT MEETS ON A MONTHLY BASIS TO REVIEW VARIOUS ASPECTS OF THE FACILITY AND PROVIDE INPUT ON THOSE ASPECTS FROM A COMMUNITY PERSPECTIVE. THE FACILITY PARTICIPATES IN THE COMMUNITY BLOOD DRIVES BY PROVIDING FOOD AND SUPPLIES FOR BOTH THE WORKERS AND BLOOD DONORS. THE FACILITY ALSO SPONSORS A HEALTH FAIR ON AN ANNUAL BASIS FOR THE LOCAL AND SURROUNDING COMMUNITIES. PART VI, LINE 6: THE ORGANIZATION IS PART OF CENTRACARE HEALTH SYSTEM (CCHS) WHICH PROVIDES A BROAD RANGE OF HEALTH CARE SERVICES TO THE PATIENTS OF CENTRAL MINNESOTA. CCHS IS DEDICATED TO IMPROVING THE HEALTH OF PEOPLE LIVING AND WORKING IN THE COMMUNITIES IT SERVES. TO ACCOMPLISH ITS GOALS IT WORKS ACTIVELY WITH ITS AFFILIATE HEALTH CARE ORGANIZATIONS. CCHS CONTINUES TO FOCUS ON PROVIDING THE BEST CARE POSSIBLE AND IN REINVESTING INTO THE COMMUNITY. CCHS ALSO PROMOTES WELLNESS BY SPONSORING PROGRAMS AND EVENTS IN LOCAL COMMUNITIES THAT FOCUS ON HEALTHY EATING AND EXERCISE, AND BY CONDUCTING SCREENINGS FOR CONDITIONS SUCH AS HIGH BLOOD PRESSURE. REPORTS FILED WITH STATES PART VI, LINE 7 MN 0 CENTRACARE HEALTH FOUNDATION 1406 6TH AVENUE NORTH ST CLOUD MN 56303 411855173 501(C)(3) 50000 SUPPORT FOUNDATION PROGRAMS 1 0 1 0 0 0 0 1 0 0 TERENCE R PLADSON MD 0 836543 0 335293 0 11008 0 177733 0 23064 0 1383641 0 0 JAMES R DAVIS 0 285404 0 86006 0 53901 0 16180 0 21225 0 462716 0 0 DAVID TILSTRA MD 0 258062 0 77615 0 35721 0 32861 0 23334 0 427593 0 15972 PAUL R HARRIS 0 271402 0 73440 0 48977 0 39705 0 36417 0 469941 0 46361 GREGORY R KLUGHERZ 0 388446 0 120000 0 96670 0 77276 0 19202 0 701594 0 72702 ALLEN HORN MD 0 268622 0 145145 0 148998 0 18601 0 18457 0 599823 0 0 DANIEL J SWENSON 0 171115 0 45831 0 16670 0 22003 0 25349 0 280968 0 14863 ERIC M LOHN 0 161440 0 17969 0 24145 0 14681 0 9857 0 228092 0 0 JAMES M BERGMANN 153076 0 8382 0 821 0 12160 0 13656 0 188095 0 0 0 THOMAS J HOCK 145317 0 7840 0 413 0 11615 0 23701 0 188886 0 0 0 CHRISTOPHER A HAGEN 127986 0 5391 0 633 0 6829 0 16621 0 157460 0 0 0 PART I, LINE 3 THE COMPENSATION PAID TO THE PRESIDENT AND VICE-PRESIDENTS (NON-MEDICAL PROVIDERS) IS DETERMINED BY CENTRACARE HEALTH SYSTEM, A RELATED ORGANIZATION. CENTRACARE HEALTH SYSTEM USES THE FOLLOWING METHODS TO DETERMINE COMPENSATION: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - FORM 990 OF OTHER ORGANIZATIONS - WRITTEN EMPLOYMENT CONTRACT - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THE CORPORATIONS' EXECUTIVES ARE ELIGIBLE TO PARTICIPATE IN BENEFIT PLANS WHICH INCLUDE TAX DEFERRED NON-QUALIFIED INVESTMENT ACCOUNTS. THESE PLANS MAY PROVIDE, BUT ARE NOT CERTAIN TO PROVIDE, FOR PAYMENT OF TAX DEFERRED COMPENSATION TO THESE EXECUTIVES AT SOME TIME IN THE FUTURE. THE EXECUTIVE HAS NO LEGAL RIGHT TO THESE DOLLARS UNTIL, AND UNLESS, CERTAIN FUTURE EVENTS OCCUR. IN ACCORDANCE WITH THE INSTRUCTIONS TO FORM 990, THE AMOUNTS LISTED IN PART VII AND SCHEDULE J, PART II, COLUMN C, REFLECT TAX DEFERRED COMPENSATION. THIS COMPENSATION IS POTENTIALLY REPORTED TWICE ON FORM 990 - ONCE WHEN THE COMPENSATION IS DEFERRED OR ACCRUED AND AGAIN IF AND WHEN IT IS PAID TO THE EXECUTIVE. THE FOLLOWING INDIVIDUALS PARTICIPATED IN THE NON-QUALIFIED PLAN: TERENCE R PLADSON - PAID $0; ACCRUED $158,983 JAMES R DAVIS - PAID $0; ACCRUED $0 DANIEL J SWENSON - PAID $14,863; ACCRUED $11,755 PAUL R HARRIS - PAID $46,361; ACCRUED $29,333 GREGORY R KLUGHERZ - PAID $72,702; ACCRUED $64,777 ALLEN HORN, MD - PAID $0; ACCRUED $0 DAVID TILSTRA, MD - PAID $15,972; ACCRUED $12,515 PART I, LINE 6 THE ORGANIZATION PROVIDES INCENTIVE COMPENSATION TO DESIGNATED INDIVIDUALS BASED ON FOUR DISCRETE AREAS: A COMPARISON BETWEEN BUDGETED AND ACTUAL NET OPERATING INCOME FOR CENTRACARE CLINIC OR CENTRACARE HEALTH SYSTEM; ACHIEVEMENT OF IMPROVEMENT IN PATIENT SATISFACTION GOALS AS COMPARED TO NATIONAL AND BASELINE RANKINGS; ACHIEVEMENT OF IMPROVEMENT IN OVERALL EMPLOYMENT ENGAGEMENT SCORES; AND ACHIEVEMENT OF UP TO THREE INDIVIDUAL GOALS WHICH ARE TIED TO THE CENTRACARE SYSTEM'S STRATEGIC PLAN. THE INCENTIVE COMPENSATION PAID OUT IS NOT A PORTION OR PERCENTAGE OF ACTUAL NET EARNINGS OF ANY CENTRACARE HEALTH SYSTEM AFFILIATE, HOWEVER NET EARNINGS GOALS ARE REQUIRED TO BE MET BEFORE INCENTIVE COMPENSATION IS PAID. FORM 990, PART VI, SECTION A, LINE 6 CENTRACARE HEALTH SYSTEM, A MINNESOTA NONPROFIT ASSOCIATION, IS THE SOLE MEMBER OF CENTRACARE HEALTH SYSTEM - LONG PRAIRIE. FORM 990, PART VI, SECTION A, LINE 7A ALL BOARD MEMBERS ARE APPOINTED BY CENTRACARE HEALTH SYSTEM, THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING MATTERS ARE RESERVED FOR ACTION BY CENTRACARE HEALTH SYSTEM, THE SOLE MEMBER: 1. ADOPTION OR AMENDMENTS TO THE ARTICLES OF INCORPORATION OR BYLAWS. 2. APPOINTMENT OF DIRECTORS AND OFFICERS. 3. APPROVAL OF THE CORPORTAION'S ANNUAL OPERATING AND CAPITAL BUDGETS AND ANY DEBTS TO BE INCURRED. 4. APPROVAL OF ALL STRATEGIC PLANS. 5. DETERMINATION OF THE DISSOLUTION OF OR THE DISCONTINUATION OF THE BUSINESS OF THE CORPORATION. 6. APPROVAL OF ANY TRANSACTION WHICH MAY AFFECT THE CORPORATION'S STATUS AS AN ORGANIZATION EXEMPT FROM FEDERAL INCOME TAXATION. FORM 990, PART VI, SECTION B, LINE 11 ANNUALLY, AT THE BOARD OF DIRECTORS' MEETING, PRIOR TO FILING, THE FULL BOARD HAS AN OPPORTUNITY TO REVIEW THE FORM 990 WITH STAFF TO ASK QUESTIONS AND SEEK CLARIFICATIONS AND TO APPROVE THE FINAL DOCUMENT. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ARE REQUIRED TO REVIEW AND SIGN A CONFLICT OF INTEREST QUESTIONNAIRE TWICE A YEAR. ALL STAFF SIGN CONFLICTS OF INTEREST FORMS ON AN ANNUAL BASIS. THE QUESTIONNAIRES ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AS WELL AS THE CORPORATE COMPLIANCE GROUP (A COMPLIANCE COMMITTEE WHICH INCLUDES INTERNAL MEMBERS AND OUTSIDE COUNSEL) THE RESPONSES TO THE QUESTIONNAIRE ARE THEN REVIEWED WITH THE EXECUTIVE COMMITTE OF THE BOARD. THE CORPORATE COMPLIANCE OFFICER IS RESPONSIBLE FOR MONITORING CONFLICTS OF INTERESTS RELATED TO BOARD AND STAFF AND TO ALERT AFFECTED PARTIES WHEN A CONFLICT ARISES. WHEN AN ACTUAL CONFLICT ARISES, THE AFFECTED PARTY IS ASKED TO RECUSE HIM/HER SELF FROM THE DECISION MAKING PROCESS. THE CORPORATE COMPLIANCE OFFICER ATTENDS BOARD MEETINGS AND SPECIFIED BOARD COMMITTEE MEETINGS WHERE CONFLICT ISSUES MAY ARISE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION AND BENEFITS OF THE PRESIDENT IS SUBJECT TO FULL COMPENSATION AND BENEFITS COMPARABILITY STUDIES CONDUCTED BIENNIALLY BY ATHIRD PARTY INDEPENDENT COMPENSATION CONSULTANT. HOWEVER, THE COMPENSATION PORTION OF THE STUDY IS REVIEWED ANNUALLY BY THE CONSULTANTAND UPDATED FOR COMPENSATION COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVAL. THE MOST RECENT FULL REVIEW WAS DONE IN MAY 2012. THE THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT IS RETAINED BY ST. CLOUD HOSPITAL TO PERFORM THESE SERVICES. THE COMPENSATION AND BENEFITS OF THE VICE PRESIDENTS (NON-MEDICALPROVIDERS) ARE SUBJECT TO FULL COMPENSATION AND BENEFITS COMPARABILITY STUDIES CONDUCTED BIENNIALLY BY A THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT. HOWEVER, THE COMPENSATION PORTION OF THE STUDY IS REVIEWED ANNUALLY BY THE CONSULTANT AND UPDATED FOR COMPENSATION COMMITTEE AND BOARD OF DIRECTORS REVIEW AND APPROVAL. THE MOST RECENT FULL REVIEW WAS DONE IN MAY 2012. THE THIRD PARTY INDEPENDENT COMPENSATION CONSULTANT IS RETAINED BY ST. CLOUD HOSPITAL TO PERFORM THESE SERVICES. FORM 990, PART VI, SECTION C, LINE 19 THE HOSPITAL/CENTRACARE HEALTH SYSTEM DOES NOT GENERALLY MAKE ITS GOVERNING DOCUMENTS OR CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. THE HOSPITAL/CENTRACARE HEALTH SYSTEM DOES DO AN ANNUAL REPORT TO THE COMMUNITY IN WHICH FINANCIAL RESULTS ARE REPORTED TO AND DISCUSSED WITH THE PUBLIC. THIS REPORT IS AVAILABLE TO THE PUBLIC ON THE ORGANIZATION'S WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 9: NET EQUITY TRANSFERS TO AFFILIATED ORGANIZATIONS -856,000. OTHER CHANGES IN NET ASSETS 123,500. CENTRACARE HEALTH SYSTEM 1406 6TH AVE NORTH ST CLOUD MN 56303 411813221 HEALTH CARE MN 501(C)(3) 11 - TYPE 3 FI N/A 0 CENTRACARE HEALTH SYSTEM-MELROSE 11 NORTH 5TH AVENUE WEST MELROSE MN 56352 411865315 ACUTE & LT CARE MN 501(C)(3) LINE 3 CENTRACARE HEALTH SYSTEM 1 CENTRAL MINNESOTA EMERGENCY PHYSICIANS 1406 6TH AVE NORTH ST CLOUD MN 56303 411708142 EMERGENCY PHYS MN 501(C)(3) LINE 3 CENTRACARE HEALTH SYSTEM 0 CENTRACARE CLINIC 1200 6TH AVE NORTH ST CLOUD MN 56303 411806657 MULTI-SPECIALTY MN 501(C)(3) LINE 3 CENTRACARE HEALTH SYSTEM 0 CENTRACARE HEALTH FOUNDATION 1406 6TH AVE NORTH ST CLOUD MN 56303 411855173 FUNDRAISING MN 501(C)(3) LINE 7 CENTRACARE HEALTH SYSTEM 0 CENTRACARE HEALTH-SAUK CENTRE 425 ELM STREET NORTH SAUK CENTRE MN 56378 452438973 ACUTE CARE MN 501(C)(3) LINE 3 CENTRACARE HEALTH SYSTEM 1 ST CLOUD HOSPITAL 1406 6TH AVE NORTH ST CLOUD MN 56303 410695596 ACUTE & LONG TERM CARE MN 501(C)(3) LINE 3 CENTRACARE HEALTH SYSTEM 0 CENTRACARE PHARMACY SERVICES INC 1406 6TH AVE NORTH ST CLOUD MN 56303 411620618 RETAIL PHARMACY MN CENTRACARE HEALTH SYSTEM C 0 0 1 0 0 1 0 0 0 0 0 1 0 1 0 1 1 1 1 0