2014-11-14T13:10:00-06:00 2013-12-31 450250958 Eide Bailly LLP 200 East 10th Suite 500 Sioux Falls SD 571045126 990 2013-01-01 460278210 Coteau des Prairies Hospital COTE 6056987647 205 Orchard Drive Sisseton SD 572622398 Dan Ellis CEO 6056987647 2014-11-14 1 Laurie Hanson P00851848 6053391999 2014-11-14 2013 2015-11-30 17:44:51Z Dan Ellis 205 Orchard Drive Sisseton SD 572622398 14051898 0 X www.cdphospital.com X 1967 SD Provision of healthcare services to the population of Sisseton, SD, and the surrounding area. 12 12 178 20 0 0 88129 754301 13095018 13266451 8371 -10668 18171 22327 13209689 14032411 0 2375 0 0 7074864 7374778 0 0 0 5587819 6075450 12662683 13452603 547006 579808 9284464 16804269 2256218 9196215 7028246 7608054 X Quality Care with a Personal Touch, Close to Home. 0 0 11694472 2375 13266451 Coteau des Prairies Hospital (CDPH) is a 25 bed acute care hospital and physician clinics located in Sisseton, South Dakota and the surrounding area. The Hospital provides health care services to patients who meet certain criteria under its Charity Care Policy without charge or at amounts less then established rates. Since the Hospital does not pursue collection of these amounts, they are not reported as patient service revenue. The estimated cost of providing these services was $67,400 for the year ended December 31, 2013, 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.Statistics for the period ended December 31, 2013, are as follows: acute patient days = 1,391, subacute patient days = 331, newborn days = 334, and emergency room visits = 4,816. 11694472 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 22 0 1 178 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X Larry Moen 6056984697 205 Orchard Drive Sisseton SD 572622398 Mary Carlson President 2.00 X X 0 0 0 Faye Johnston Vice President 2.00 X X 0 0 0 Terry Jaspers Treasurer 2.00 X X 0 0 0 Kent Thoelke Secretary 2.00 X X 0 0 0 Debbie Wooley Member 1.00 X 0 0 0 Steven McCleerey Member 1.00 X 0 0 0 Erin Cameron Member 1.00 X 0 0 0 Cheryl Karst Member 1.00 X 0 0 0 Vivian Hove Member 1.00 X 0 0 0 Geraldine Opsal Member 1.00 X 0 0 0 Jay Hill Member 1.00 X 0 0 0 Vern Donnell Member 1.00 X 0 0 0 Dan Ellis CEO 40.00 X 129540 0 20657 Larry Moen CFO 40.00 X 75522 0 11039 Stanley Gallagher DO Osteopathy 40.00 X 617231 0 7649 Judy Beumer MD OB GYN 32.00 X 381950 0 25136 David Staub MD Family Practice 20.00 X 411063 0 7649 Linda Peterson MD FACOG Family Practice 24.00 X 167292 0 6917 Bradley Gallagher PA-C Family Practice 40.00 X 115136 0 4833 1897734 0 83880 6 0 1 0 Charles Pryzmus 1004 5th Avenue North Wheaton MN 56296 Anesthesia Services 152162 1 175084 579217 754301 Patient service revenue 622110 13226368 13226368 Cafeteria revenue 722514 20623 20623 Supporting revenue 900099 19460 19460 13266451 5816 5816 22327 0 22327 22327 22327 3003 19487 -16484 -16484 -16484 14032411 13266451 0 11659 2375 2375 234034 234034 5888375 5361487 526888 114684 107230 7454 671537 610044 61493 466148 410154 55994 31730 31730 51990 51990 1249387 1108315 141072 43046 4965 38081 571354 444066 127288 342652 342652 175522 175522 156927 140045 16882 32453 24038 8415 55651 55651 452319 452319 140090 31654 108436 Medical Supplies 2244632 2244632 Bad Debt 409163 409163 Food 70945 70945 License and Permits 43243 38838 4405 4346 3029 1317 13452603 11694472 1758131 0 2107360 3009247 2965623 2803316 244437 248707 97814 89318 15513612 5556431 3869230 9957181 80500 0 616000 9284464 16804269 1021347 942937 163256 1234871 7381155 0 708867 2256218 9196215 X 7028246 7608054 7028246 7608054 9284464 16804269 579808 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13556 13556 10169498 2413646 7755852 4784045 3033921 1750124 546513 108864 437649 9957181 Construction accounts payable 708867 708867 X 13160434 -409163 -409163 13569597 462814 462814 14032411 13043440 0 13043440 409163 409163 13452603 Part X, Line 2: The Hospital is organized as a South Dakota nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Hospital is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Hospital has determined it is not subject to unrelated business income tax and has not filed an Exempt Organization Business Income Tax Return (Form 990T) with the IRS. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and as such, does not have any uncertain tax positions that are material to the financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts included in revenue for financial statements -409,163. Part XI, Line 4b - Other Adjustments: Contributions for long-lived assets included in revenue for Form 990 462,814. Part XII, Line 4b - Other Adjustments: Provision for bad debts included in revenue for financial statements 409,163. 1 1 X 1 X 1 X 175.000000000000 1 1 0 0 67400 67400 0.00520 2698328 2076385 621943 0.04770 2765728 2076385 689343 0.05290 6084 3432 2652 0.00020 2032438 865748 1166690 0.08940 1100 1100 0.00010 2039622 869180 1170442 0.08970 4805350 2945565 1859785 0.14260 0 409163 204582 3363684 3437276 -73592 X 1 1 1 1 Coteau des Prairies Hospital & Clinic 205 Orchard Drive Sisseton SD 57262 www.cdphospital.com 60020 X X X X 1 provider based rural health clinic Coteau des Prairies Hospital & Clinic 1 1 X X X X X X X X X 13 1 0 1 X www.cdphospital.com X X X X X X X X 0 0 1 1 150.000000000000 1 175.000000000000 1 X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 Coteau des Prairies Hospital & Clinic Part V, Section B, Line 3: The Hospital conducted community surveys online and in person, and an internal stake holder survey. There were also community and elite interviews with SWO, HIS, community leaders of service areas and emergency medical personnel, community members, and medical practitioners. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 6i: Coteau des Prairies Hospital has adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to the Hospital's website at www.cdphospital.com. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 7: The following needs will not be addressed due to other organizations in the community addressing.1. Teen pregnancy/unsafe sex: Several key constituent groups within the community have established programs that address these issues.2. Affordable health care: Affordable health care is a national issue - one much larger than can be adequately addressed by a small, critical access hospital.3. Economic development/affordable housing: Activities are underway in the community that adequately address the need expressed by the community members throughout this assessment.A separate OB wing is in the process of completion at the end of 2013. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 14g: A summary of the charity care policy is posted in the Hospital's main entrance/admission areas, the main entrance/admission areas for each of the clinics, and in the emergency rooms and waiting rooms. CDPH provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients as part of the intake process, when applicable. In addition, CDPH personnel discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, when applicable. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 18e: Prior to initiating any collection actions listed in Schedule H, Part V, Line 17, patients were made aware of the financial assistance policy through signage in admissions and phone calls by Hospital staff prior to being sent to collection. Patient accounts were not sent to collection until patients were offered the financial assistance policy. 3 Browns Valley Clinic 106 4th Street South Browns Valley MN 56219 Family Practice Clinic Rosholt Clinic 116 West Main Street Rosholt SD 57260 Family Practice Clinic Herman Clinic 204 5th St East Herman MN 56248 Family Practice Clinic Part I, Line 3c: CDPH offers free care to patients with a family income not to exceed 150% of Federal Poverty Guidelines. In addition to the FPG test, for free and discounted care, CDPH also looks at the patient's asset values as well as their uninsured or underinsured insurance coverage status. For discounted care, CDPH patients will qualify with a family income not to exceed 175% of FPG. 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. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services, line 7e and cash and in-kind donations, line 7i were compiled using actual costs and recorded in CBISA software. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): Bad debt expense of $409,163 was subtracted from total operating expense. Part II, Community Building Activities: None Part III, Line 2: Bad debt write-offs are recorded using gross charges. When a payment is received or a discount is given on a bad debt account it offsets the current fiscal year bad debt expense. Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: Bad debt expense attributable to charity care is estimated based on income levels and ethnicity in this area. More than 50% of CDPH charges are generated by the Native American population. Statistics show the average household income of Native American families in Roberts County is two-thirds of that of other ethnic groups. Virtually all Native Americans qualify for charity care, thus the organization estimates approximately 50% of bad debt is attributable to persons who would qualify for charity care. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 6 of the attached audited financial statements. Part III, Line 8: The Hospital provides services to Medicare patients knowing there could be a shortfall because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit.Total revenue received from Medicare (including DSH and IME) is the gross reimbursement plus settlement (including LSA). Both the total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicaid and Medicare Services. Part III, Line 9b: For patients who qualify for charity care and are cooperating in good faith to resolve their discounted hospital bills, Coteau des Prairies Hospital and Clinic may offer extended payment plans. The Hospital will not send unpaid bills to outside collection agencies and will cease all collection actions such as wage garnishments, liens on primary residences, or other legal actions. The Hospital will first make reasonable efforts to determine whether the patient is eligible for charity care under the financial assistance policy. Part VI, Line 2: The priority of CDPH is to promote the health of Sisseton and also the surrounding rural communities. During 2012, the Hospital began its efforts to conduct a community health needs assessment. Through this process, CDPH determined the health care needs of the community, and is working to ensure the services and events provided to the community are beneficial and in accordance with the community's health care needs. The Hospital finalized its CHNA and implementation strategy and made both documents widely available to the Public on December 04, 2013. Part VI, Line 3: CDPH utilizes multiple methods for patient education of financial assistance. A summary of the charity care policy is posted in the Hospital's main entrance/admission areas, the main entrance/admission areas for each of the clinics, and in the emergency rooms and waiting rooms. CDPH provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients as part of the intake process, when applicable. In addition, CDPH personnel discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, when applicable. Part VI, Line 4: CDP Hospital is located in Sisseton, a rural community in the northeast corner of South Dakota with the next closest healthcare facility being approximately 50 miles away. CDPH serves various ethnic groups. An Indian Health Services (IHS) clinic is located within 1 mile of the hospital. CDPH serves as the main emergency room for the IHS patients during office hours and after hours. The 2013 estimated population in Sisseton, SD was 2,470. Approximately 47% of the Sisseton area people are white, 47% are Native American, and 6% are two or more races.The estimated population in Roberts County, SD in 2013 was 10,149. Approximately 61% of Roberts County area people are white, 34% are native American, 3% are two or more races, and 1% claim Hispanic or Latino. Part VI, Line 5: CDPH is a sole community provider with a 12 member volunteer Board of Directors who all reside in the primary service area. Medical staff privileges are extended to all qualified individuals as they are requested. If CDPH were to have surplus funds, the funds would be applied to patient care improvements and also to reduce the need for rate increases for the patients. The emergency room is staffed 24 hours a day, 7 days a week and patients are welcomed regardless of race or the ability to pay for the services. CDPH participates in all government-sponsored health programs including Medicare, Medicaid, Indian Health Services, and Veteran Affairs benefits. The Hospital and clinics welcome students for training and college rotations in various healthcare professions. Part VI, Line 6: N/A X X X 0 0 0 1 0 0 0 0 0 Dan Ellis CEO 129540 0 0 0 0 0 4082 0 16765 0 150387 0 0 0 Stanley Gallagher DO Osteopathy 617231 0 0 0 0 0 0 0 7839 0 625070 0 0 0 Judy Beumer MD OB GYN 381950 0 0 0 0 0 10200 0 15139 0 407289 0 0 0 David Staub MD Family Practice 411063 0 0 0 0 0 0 0 7649 0 418712 0 0 0 Linda Peterson MD FACOG Family Practice 167292 0 0 0 0 0 0 0 7106 0 174398 0 0 0 Part I, Line 5 Physicians are paid 38% of their respective provider/CPT code revenue. A City of Sisseton South Dakota 466000460 2012-07-06 7450000 Fund hospital remodeling and building addition project 0 0 0 A 68845 7450000 211000 122280 6092849 1234871 0 0 0 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 A 1 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the President, Vice President, the Secretary, the Treasurer and one other member of the Board to be elected by the Board at the annual meeting. The Executive Committee has the power to transact all regular business of the hospital & clinic during the period between the meetings of the Board. Subject to any prior limitation imposed by the Board and with the understanding that all matters of major importance will be referred to the Board. Minutes of the Executive Committee meetings are available to the Board. Form 990, Part VI, Section B, line 11 The Board of Directors receives a copy of the Form 990 prior to filing. The Director of Finance reviews the 990 in detail. Form 990, Part VI, Section B, line 12c The conflict of interest policy is completed annually and covers officers and board members. The determination of whether a conflict exists is made at the Board of Directors level, as is the review of actual conflicts. Any person determined to have a conflict will have an opportunity to explain the situation, and he/she will be required to refrain from voting. Form 990, Part VI, Section B, line 15 Compensation for the CEO is determined through individual negotiations with the Executive Committee and the CEO. The Executive Committee uses salary surveys to determine what constitutes reasonable compensation. Negotiations with the Executive Committee include a performance evaluation. An evaluation is done annually by the Executive Committee, and approved by the Board of Directors. Compensation of CDPH's officers is determined through discussions between the Executive Committee and the CEO. The Executive Committee uses salary surveys to determine what constitutes reasonable compensation. Discussions with the Executive Committee include a performance evaluation. An evaluation is done annually by the Executive Committee, and approved by the Board of Directors. Form 990, Part VI, Section C, line 19 The governing documents, conflict of interest policy and financial statements are available upon request.