2014-02-15T09:05:43-06:00 2013-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2012-07-01 460226283 Wagner Community Memorial Hospital WAGN 6053843611 513 Third Street SW Wagner SD 573800280 Bryan Slaba 6053843611 2014-02-17 1 Laurie Hanson P00851848 6053391999 2014-02-17 2012 2015-11-30 17:44:51Z Bryan Slaba 513 Third Street SW Wagner SD 573800280 8727279 0 X www.avera.org/wagnerhospital/ X 1947 SD To provide healthcare services. 9 8 95 9 0 0 95684 574210 8280711 8111150 25939 27567 14552 14352 8416886 8727279 0 800 0 0 4023085 3878988 0 0 0 4568007 4812630 8591092 8692418 -174206 34861 11738938 11363536 7111938 6544695 4627000 4818841 X Wagner Community Memorial Hospital's mission is to provide care and treatment of the sick; provide care and support of the aged, disabled, and indigent; and to provide for those in need of hospitalization regardless of race, color, creed, or ability to pay. 0 0 7529960 8125502 WCMH is a 20 bed critical access hospital equipped with extensive advanced services, including areas for Medical/Surgical, Pediatric, Intensive/Coronary Care, and Swing Bed/Long Term Care. The clinic is adjacent to the hospital making it convenient to see hospital patients, and share laboratory services and other diagnostic equipment. Outreach services include OB/GYN, Pediatrics, Orthopedic Surgery, General Surgery, Urology, Podiatry, ENT & Audiology. The people of the community truly believe in having access to care and support their local medical providers. The facility serves as the inpatient unit for the local Indian Health Services clinic and works collaboratively with the IHS physicians and leaders to care for the Native American population. WCMH experienced 763 Inpatient days, 467 Swing Bed days, 2093 Emergency Department visits, and 2069 clinic visits. 7529960 1 0 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 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 34 0 1 95 1 0 0 0 0 0 0 0 0 0 0 X 9 8 0 1 1 0 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 X Lisa Weisser 6053843611 513 3rd Street SW Wagner SD 573800280 Ken Thaler 0.50 X X 0 0 0 David Kotab 0.50 X X 0 0 0 Elden Ridgeway 0.50 X X 0 0 0 Jean Pirner 0.50 X X 0 0 0 Merle Bartunek 0.50 X X 0 0 0 Dorothy Holzbauer 0.50 X 0 0 0 Ann Freier-Metzger 0.50 X 0 0 0 Bill Frie 0.50 X 0 0 0 Dave Andrews 0.50 X 0 0 0 Bryan Slaba 40.00 X 121577 0 6307 Dr Uzma Mian 40.00 X 341595 0 20134 Dr Abdul S Qazi 40.00 X 333556 0 11487 796728 0 37928 3 0 1 1 Avera Sacred Heart Hospital 501 S Summit Street Yankton SD 57078 Management, IT & Bio Med Services 548215 Cardinal Health Pharmacy 1603 N C Ave Sioux Falls SD 57104 Drugs 447471 Dr Jeffery Pinter 27952 323rd Avenue Winner SD 57580 Physician Labor 318140 Coast to Coast Health Care Inc 5195 Hampstead Village Center Suite New Albany OH 43054 Physician Labor 179352 Avera eCare 501 S Summit Street Yankton SD 57078 Electronic Emergency Services 138846 6 572939 1271 574210 Patient Service Fees 621110 7913235 7913235 Apartment Revenue 900099 116304 116304 Other Revenue 900099 81308 81308 Patient Interest Reven 900099 303 303 8111150 25467 25467 14352 0 14352 14352 14352 2100 0 2100 2100 2100 8727279 8125502 0 27567 X 800 800 132665 132665 53332 53332 3168004 2629478 538526 67096 55879 11217 264247 220072 44175 193644 161272 32372 103581 103581 24322 24322 50525 50525 1039158 1017605 21553 15648 15648 320755 251600 69155 67139 17455 49684 177073 177073 24528 24468 60 27095 19196 7899 281835 281824 11 821731 821731 47725 47725 Medical Supplies 893818 893818 Bad Debt 426867 426867 Repairs and Maintenance 410188 405861 4327 80642 23904 56738 8692418 7529960 1162458 0 413554 1434659 15360 6415 2077129 1495634 69645 187554 163372 118126 102132 13267098 5578606 8437909 7688492 399797 453508 19864 19324 11738938 11363536 769122 393773 8277 6336520 6135414 6296 7231 7111938 6544695 X 4626244 4818841 756 0 4627000 4818841 11738938 11363536 X 34861 18945 138035 X 0 1 X 0 1 1 X 4247 4247 9752882 3581107 6171775 3298953 1945827 1353126 211016 51672 159344 7688492 Tenant Security Deposits 7231 7231 X 8458148 18945 -288076 -269131 8727279 0 8727279 8265551 0 8265551 426867 426867 8692418 Description of Uncertain Tax Positions Under FIN 48: Part X, Line 2: 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: Change in interest in net assets of Avera Health Foundation 138,791. Bad Debt Expense -426,867. Part XII, Line 4b - Other Adjustments: Bad debt expense 426,867. 1 1 X 1 X 1 X 1 1 1 0 1 1 137 83800 83800 0.01010 2060 1534509 1138858 395651 0.04790 565816 461122 104694 0.01270 2197 2184125 1599980 584145 0.07070 10 814 12368 1015 11353 0.00140 2 3 6905 500 6405 0.00080 2 2512473 917359 1595114 0.19300 2 254 9248 9248 0.00110 16 1071 2540994 918874 1622120 0.19630 16 3268 4725119 2518854 2206265 0.26700 1 14750 14750 0.00180 1 7374 7374 0.00090 2 705 705 0.00010 3 391 5887 3000 2887 0.00030 7 391 28716 3000 25716 0.00310 0 426867 384180 3055626 3025373 30253 X 1 1 1 1 Wagner Community Memorial Hospital

PO Box 280 Wagner SD 57380

www.avera.org/wagnerhospital/ X X X X Wagner Community Memorial Hospital 1 1 X X X X X X X X X 12 1 0 1 X X X X 0 0 1 1 100.000000000000 1 400.000000000000 1 X X X 1 1 X X X X 1 0 X X X 1 X 0 0 2 Community Villa

208 Grant Avenue SE Wagner SD 57380

Subsidized Elderly/Disabled Independent Westside Estates

315 Birch Avenue SW Wagner SD 57380

Subsidized Elderly/Disabled Independent Part I, Line 3c: In addition to utilizing FPG to determine eligibility for financial assistance, the hospital uses the factors as marked on Part V, line 12. Part I, Line 6a: Wagner Community Memorial Hospital is included in the community benefit report that is submitted to Avera Health by Avera Sacred Heart. It is available through the website and requested mailing, and is filed with the Catholic Health Association. 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. Lines 7e, 7f and 7i were obtained utilizing the actual general ledger system. Lines 7b and 7c were calculated based on the allocation of expenses per payer mix percentages. Line 7g was obtained from the Medicare cost report. Part I, L7 Col(f): Bad debt expense of $426,867 was subtracted from total operating expense. Part II: Part II Line 7 includes:1-Participation on a board to look at housing rehabilitation for low income and elderly community members.2-Participation in community economic groups, including Wagner Area Growth (WAG), Rotary, and Chamber of Commerce.6-Participation in the Wagner Area Health and Wellness Consortium and Wagner VA Stand Down. 8-Hosted an eigth grade career fair for the region schools; held healthcare career events; and worked with Charles Mix County schools through the Health Occupations for Today and Tomorrow (HOTT) program. Part III, Line 4: a) Bad debt recoveries and discounts applied during the collection process are rare, but when they do occur they are posted against the bad debt account.b) WCMH estimated the amount on line 3 of $384,180 by taking bad debt expense at cost multiplied by 90%. Of the accounts sent to collection, only 5% are collected. The primary area served by WCMH has a Native American population of 42%. 67% of all bad debt are related to Native Americans, all of whom would qualify under the financial assistance policy. It is estimated that a minimum of an additional 23% of patients would qualify under the financial assistance policy based on the overall poverty level of the area served.c) The footnote to the organization's financial statements that describes bad debt expense is 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 the fiscal year ending 6/30/2013. Part III, Line 9b: The collection practices as set forth in the policy requires that if a patient qualifies for charity care, no bill will be sent. Instead, a letter indicating that the patient's bill has been completely forgiven will be sent. When sending a bill to any patient, the organization shall include on the bill a statement that indicates that if the patient meets certain income requirements the patient may be eligible for a government-sponsored program or for financial assistance from the organization for help in paying for the services that were provided, and a statement that provides the patient with an organization contact resource from which the patient may obtain information about the organization's financial assistance policy for low-income uninsured patients and how to apply for such assistance for the payment of services that were provided.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 intimate 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 paitent was eligible under the organization's financial assistance policy for low-income uninsured patients. WCMH does not report any data to any of the credit agencies, however, the collection agencies WCMH utilizes may report to the credit agencies. Wagner Community Memorial Hospital Part V, Section B, Line 3: A variety of organizations were consulted in conducting the most recent needs assessment. The organizations included Indian Health Services, Lake Andes Healthcare Center, Wagner Good Samaritan Center, Charles Mix County Health Nurses, Yankton Sioux Tribe, SD Department of Health, and Avera Sacred Heart Hospital. Wagner Community Memorial Hospital Part V, Section B, Line 5c: The community health needs assessment is available upon request and on our website at http://www.avera.org/wagnerhospital/about-us/. Wagner Community Memorial Hospital Part V, Section B, Line 6i: The community health needs implementation strategy begins on page 32 of the community health needs assessment. Please see line 5c for the website address. Wagner Community Memorial Hospital Part V, Section B, Line 7: Pursuant to the implementation strategy adopted by Wagner Community Memorial Hospital, drug enforcement, response time of police emergency calls, availability of employment opportunities, responsiveness of public officials and the justice system, opportunity for small businesses in the community, access to affordable housing, and access to transportation will not be addressed as these needs are not the direct focus of the facility and are better handled through other resources.During the current year, the facility was not able to directly address the issue of drug and alcohol abuse prevention. Wagner Community Memorial Hospital Avera is the lead organization for the Southern Charles Mix County Healthcare Collaborative. It's expected that the recent increased awareness of methamphetamine will be used to drive the collaborative to address the escalating problem. Currently the collaborative is searching for any programs to emulate that have successfully addressed drug and alcohol abuse with specific emphasis on methamphetamines. Additionally, the facility continues to work toward accessibility and affordability of healthcare services through the adoption of a plan to "home grow" the provider base. In 2011, the administration, with board acknowledgement, embarked on a recruitment and retention program for certified advanced practitioners. As a result of this plan, the facility has agreed to support financially and programmatically three RNs employed by the facility who have accepted the challenge of becoming mid-level providers. The RNs have agreed to return to the hospital and establish a practice for a minimum of three years following degree and licensure. The facility also intends to continue working with health care and community leaders in Southern Charles Mix County to improve the community through the Wagner Area Health and Wellness Consortium whose mission "is to combine resources of each entity to maximize the health and wellness opportunities for Wagner and surrounding communities." The consortium emphasizes youth education and activities to promote improved health and wellness now and in the future. Wagner Community Memorial Hospital Part V, Section B, Line 14g: The reference to the policy and its location is sent with all statements. Part VI, Line 2: In addition to preparing a community health needs assessment during the fiscal year ended June 30, 2013, WCMH determines patient needs through constant communication with patients, primary and specialty providers, and state and federal governmental health agencies. WCMH strives to consistently investigate, analyze, and determine the greatest needs of our community. Part VI, Line 3: WCMH has a written charity care policy. First reference to the policy is given to the patient upon admission. A second reference is attached to the third request for payment along with contact information. If neither notice is acted upon and the account continues to be unpaid a patient advocate will try to contact the patient if we have reasonable assupmtion that they may qualify for financial assistance. If the patient expresses interest in financial assistance, the patient advocate determines if any other opportunities are available for the patient. If the only option available is WCMH's charity care, the proper documentation is completed. The amount of reduction a patient may receive is based on a sliding scale point system. Part VI, Line 4: Wagner is a rural community located in southern Charles Mix County of South Dakota which has many health disparities with unmet needs. If one looks at the county as a whole, the average individual income is $17,403 with the median family income at $29,444. Inhabitants below the poverty level total 21.5%. County education demographics include 72.3% of residents having a high school degree and 14.2% holding a Bachelor's Degree in comparison to the national average of 80.4% and 24.4%. According to the US Census Bureau Fact Finder most recent data, 46.8% of residents in the county are of American Indian descent as compared to the national average of 0.9%. All of Charles Mix County is considered medically underserved by HRSA and the SD Department of Health. The service area is also considered a health professional shortage area with few providers and many miles in between these rural communities. Wagner provides the only local hospital facility since Indian Health Services (IHS) closed their facility in 1992. In 2008, the IHS emergency room closed putting a burden on the Wagner facility until a new clinic was built by the Wagner Hospital. There are only a few rural health clinics available in addition to the IHS clinic and the newly built VA facility. Many clinics provide only primary care services and are often staffed by Physician Assistants. If more specialized care is needed, patients must travel to either Yankton, South Dakota, which is about 115 miles round trip or they drive the 280 round trip miles to Sioux Falls, which is the area's tertiary care hub with all types of specialty care available. In addition to the shortage of quality health care services, residents of Southern Charles Mix County also suffer from many chronic health conditions. The percent of the population over 65 years of age is almost double the national average in more than half of the county. The disability status of the county's inhabitants is consistent with, if not higher than, the national average of 21.3% in a majority of the communities. Gaps exist among socioeconomic groups in the rate of diabetes and its associated complications in South Dakota as well as throughout the United States. Certain racial and ethnic communities including American Indians, as well as economically disadvantaged or older people, suffer disproportionately compared to other populations. Diabetes prevalence for adults located in Central SD surpasses South Dakota and U.S. percentages. Part VI, Line 5: WCMH is a community hospital with an open board selected from associates, all of whom are community members and can not be WCMH employees. All providers who wish to obtain privileges at WCMH are encouraged and welcome to use the appointment/reappointment privileging application process. In 2010, WCMH lead the establishment of the Southern Charles Mix County Healthcare Consortium (SCMCHC). The mission of the consortium is to determine the greatest needs of the area maximizing resources of the eight member facilities and agencies to address the determined needs. SCMCHC has applied for a USDA-RD planning grant to accomplish this task which includes the completion of an independent needs assessment. WCMH uses surplus funds to fund building improvements to enhance services to its patients.WCMH provides Community Health Improvement Services which include: Community CPR classes, sponsorship to the Dakota Smiles Mobile Dental Program, Blood Pressure screenings at area events, assisting with community disasters and award scholarships to the local high school graduates. Fourteen different healthcare career fairs were sponsored and presented by WCMH throughout southern Charles Mix County. Part VI, Line 6: WCMH is a managed facility of Avera Health. Avera Health and the Hospital work cooperatively to enhance healthcare throughout the community served by the Hospital. As a managed facility, WCMH is able to participate in Avera e-CARE services. These services include Avera e-ICU, e-Emergency, e-Pharmacy and e-Consult. These services allow rural patients to be cared for at their local hospitals, provide rural hospitals access to immediate specialty care and support, and help reduce health care costs and travel.WCMH also has access to "back office" support services, such as legal consultation, quality benchmarking, coding, computer services, contract negotiations, administrative consultation, group purchasing, human resource assistance and many other services. Avera Health is able to provide these services to WCMH at a cost below that which the Hospital could otherwise achieve. In turn, local caregivers are able to devote more resources to patient and resident care. Avera Health and WCMH dedicate resources to endeavors that make a positive difference to improve the health of the communities they serve. These activities include leadership development and training for community members, economic development, physical improvements in the community, contributions to nonprofit community organizations, nonprofit event sponsorships, donated medical supplies, community health education and support groups, health screenings, flu-shot clinics, community health education and various other activities. X X X 0 0 0 0 0 0 0 0 0 Bryan Slaba 121059 0 0 0 518 0 5137 0 1170 0 127884 0 0 0 Dr Uzma Mian 341595 0 0 0 0 0 4472 0 15662 0 361729 0 0 0 Dr Abdul S Qazi 333556 0 0 0 0 0 2095 0 9392 0 345043 0 0 0 Supplemental Information Part III Form 990, Part VII, Section A, Line 5 & Form 990, Schedule J, Part II: Bryan Slaba, CEO/Administrator, is paid by Avera Sacred Heart Hospital, 501 Summit Street, Yankton, SD 57078. 0 Marcia Podzimek Family relationship with Dorothy Holzbauer, board member 53332 Employee Compensation 0 Form 990, Part VI, Section A, line 3 Services provided by the CEO are through a management agreement with Avera Sacred Heart Health Services in Yankton, South Dakota. Form 990, Part VI, Section A, line 4 The bylaws were updated to eliminate committees and change the quorum for members from 21 to 5. Form 990, Part VI, Section A, line 6 There is only one class of member. Any individual, partnership, corporation or association having legal entity, who has contributed $25 or more to the Corporation with request of membership at the time of donation, shall be a member thereof and each member shall have one vote at all meetings of the members of the corporation. Membership of any individual who shall become deceased shall revert by request to that individual's next of kin or according to his will. Any member who has contributed $50 or more shall have the right to transfer such membership to his or her spouse. Said transfer to be approved by the Board of Directors. The basis for membership is on non-refundable contributions. Form 990, Part VI, Section A, line 7a Only one class of member exists. At the annual meeting, members approve the minutes of the last annual meeting, elect board members of the Wagner Community Memorial Hospital, and vote on other business that may be properly brought before the members. Form 990, Part VI, Section A, line 7b The Board of Directors may adopt amendments at any regular or special meeting of the Board and the same shall be effective until the next regular or special meeting of the members, at which time, the same will be ratified or rejected, and, if ratified, the same shall be binding as incorporated by-laws of the corporation. Form 990, Part VI, Section A, line 8b Wagner Community Memorial Hospital does not have committees. Form 990, Part VI, Section B, line 11 The CEO will review the 990. After the form 990 has been reviewed, it will be forwarded to the members of the Governing Body for their review. It will be presented at a board meeting, and filed subsequent to that. Form 990, Part VI, Section B, line 12c Directors and Management Officials are required to complete annual conflict of interest questionnaires which are monitored and tracked. The questionnaires are reviewed by the Board for any possible conflicts with any noted conflicts being brought to management's attention. Inquiries of conflicts are also reviewed at the monthly Board meetings. After a conflict is deemed to exist, the Board determines the level of participation of the potential conflicting member. Form 990, Part VI, Section B, line 15a Avera Sacred Heart Health Services and Wagner Community Memorial Hospital Compensation Committee use comparability data to determine appropriate compensation of the CEO based on experience and performance. The compensation amount is approved annually by the Board of Directors. Form 990, Part VI, Section C, line 19 Documents are made available upon request. Other Fees Form 990, Part IX, line 11g Anesthesia Purchase Other: Program service expenses 56,460. Management and general expenses 0. Fundraising expenses 0. Total expenses 56,460. Emergency Unit Medical Locum Fees: Program service expenses 660,868. Management and general expenses 0. Fundraising expenses 0. Total expenses 660,868. Laboratory Purchase Other: Program service expenses 1,388. Management and general expenses 0. Fundraising expenses 0. Total expenses 1,388. Radiology Purchase Other: Program service expenses 8,497. Management and general expenses 0. Fundraising expenses 0. Total expenses 8,497. Pharmacy Purchase Other: Program service expenses 92,551. Management and general expenses 0. Fundraising expenses 0. Total expenses 92,551. Physical Therapy Purchase Other: Program service expenses 144,395. Management and general expenses 0. Fundraising expenses 0. Total expenses 144,395. Occup Therapy Purchase Other: Program service expenses 41,706. Management and general expenses 0. Fundraising expenses 0. Total expenses 41,706. Speech Therapy Purchase Other: Program service expenses 5,580. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,580. Nutrition Svcs Purchase Other: Program service expenses 4,183. Management and general expenses 0. Fundraising expenses 0. Total expenses 4,183. Social Services Purchase Other: Program service expenses 597. Management and general expenses 0. Fundraising expenses 0. Total expenses 597. Community Villa Purchase Other: Program service expenses 540. Management and general expenses 0. Fundraising expenses 0. Total expenses 540. Westside Estates Purchase Other: Program service expenses 840. Management and general expenses 0. Fundraising expenses 0. Total expenses 840. Info Technology Consulting Fees: Program service expenses 0. Management and general expenses 10,724. Fundraising expenses 0. Total expenses 10,724. Administration Consulting Fees: Program service expenses 0. Management and general expenses 10,829. Fundraising expenses 0. Total expenses 10,829. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Change in interest in net assets of Avera Health Foundation 138,791. Change in temporary restricted net assets -756.