2013-01-23T15:14:54-06:00 2012-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH STREET PO BOX 5125 SIOUX FALLS SD 571175125 990 2011-07-01 460226283 Wagner Community Memorial Hospital WAGN 6053843611 513 Third Street SW Wagner SD 573800280 Bryan Slaba 6053843611 2013-01-23 1 Laurie Hanson P00851848 6053391999 2013-01-23 2011 2016-02-25 16:41:14Z Bryan Slaba 513 Third Street SW Wagner SD 573800280 8416886 0 X N/A X 1947 SD To provide healthcare services. 9 9 104 9 0 0 454381 95684 7342022 8280711 55025 25939 14502 14552 7865930 8416886 2133 0 0 0 3535003 4023085 0 0 0 4361941 4568007 7899077 8591092 -33147 -174206 10546961 11738938 5866459 7111938 4680502 4627000 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 7438258 8295263 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 839 Inpatient days, 568 Swing Bed days, 1805 Emergency Department visits, 751 Urgent Care visits and 1594 clinic visits. 7438258 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 26 0 1 104 1 0 0 0 0 0 0 0 0 0 0 X 9 9 0 1 0 0 1 1 1 1 1 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 116385 0 6069 Robert Hubley til August 2011 40.00 X 162019 0 19694 Ahmed Dessouki til May 2011 40.00 X 116150 0 7524 Dr Uzma Mian 40.00 X 128355 0 4165 522909 0 37452 4 0 1 1 Avera Sacred Heart Hospital 501 S Summit Street Yankton SD 57078 Management and IT Services 296573 Dr Jeffery Pinter 27952 323rd Avenue Winner SD 57580 Physician Labor 247280 Linde Healthcare Staffing 3668 South Geyer Road St Louis MO 63127 Physician Labor 213446 Avera Sacred Heart Rural Health 501 S Summit Street Yankton SD 57078 Contract Physician Labor 151974 Dr Gary A Bubak 29778 398th Avenue Wagner SD 57380 Physician Labor 119625 6 91698 3986 95684 Patient Service Fees 621110 8110290 8110290 Apartment Revenue 900099 104340 104340 Other Revenue 900099 65873 65873 Patient Interest Reven 900099 208 208 8280711 25191 25191 14552 0 14552 14552 14552 748 0 748 748 748 8416886 8295263 0 25939 126430 126430 114626 114626 3260696 2761352 499344 47436 40218 7218 259422 219945 39477 214475 181838 32637 17733 17733 54800 54800 1045359 989449 55910 34992 34992 346305 287624 58681 51730 21354 30376 157164 157164 13365 13365 34278 31022 3256 186042 184902 1140 776029 776029 44697 44679 18 Medical Supplies 703207 703207 Bad Debt 522967 522967 Repairs and Maintenance 366173 360316 5857 ACS Fees 109344 109344 103822 28201 75621 8591092 7438258 1152834 0 719839 413554 15360 1480843 2077129 69645 104278 187554 77627 118126 13209997 4772088 7429462 8437909 714508 399797 20404 19864 10546961 11738938 1220937 769122 4639501 6336520 6021 6296 5866459 7111938 X 4679746 4626244 756 756 4680502 4627000 10546961 11738938 X -174206 120704 X 0 1 0 X 1 1 X 4247 4247 9752882 3162224 6590658 3248352 1573565 1674787 204516 36299 168217 8437909 Tenant Security Deposits 6296 6296 8416886 8591092 -174206 -38440 159144 120704 -53502 8014623 -38440 -363823 -402263 8416886 0 8416886 8068125 0 8068125 522967 522967 8591092 Description of Uncertain Tax Positions Under FIN 48: Part X: 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 8 - Other Adjustments: Change in interest in net assets of Avera Health Foundation 159,144. Part XII, Line 2d - Other Adjustments: Change in interest in net assets on Avera Health Foundation 159,144. Bad debt expense -522,967. Part XIII, Line 4b - Other Adjustments: Bad debt expense 522,967. 1 1 X 1 X 1 X 1 1 1 0 1 1 125400 125400 0.01550 1311638 919341 392297 0.04860 1437038 919341 517697 0.06410 10 1796 14766 200 14566 0.00180 5237 5237 0.00060 2008703 442201 1566502 0.19420 3188 3188 0.00040 10 1796 2031894 442401 1589493 0.19700 10 1796 3468932 1361742 2107190 0.26110 2 1389 1389 0.00020 34137 34137 0.00420 2 35526 35526 0.00440 0 522967 470670 3134944 3103904 31040 X 1 0 1 1 Wagner Community Memorial Hospital

PO Box 280 Wagner SD 57380

X X X X Wagner Community Memorial Hospital 1 1 1 100.000000000000 1 400.000000000000 1 X X X 1 1 X X X 1 0 1 X 1 1 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 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: Line is 7a calculated by multiplying the ratio of cost to gross charges by the gross uncompensated charges associated with providing charity. Lines 7e, 7f and 7i were obtained utilizing the actual general ledger system. Lines 7b and 7g were obtained from the Medicare cost report. Part I, Line 7g: The rural health clinic expense totalled $958,196 Part I, L7 Col(f): Bad debt expense of $522,967 was subtracted from total operating expense. Part II: Line 7 includes donations to support Boys & Girls club activities, as well as area schools' After Prom programs. Also, vascular screening tests were donated to the Wagner Chamber of Commerce. 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 $324,612 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) Footnote from Financial Statement: Patient accounts receivable are reduced by an allowance for doubtful accounts. In evaluating the collectability of accounts receivable, the Hospital analyzes its past history and identifies trends for each of its major payor sources of revenue to estimate the appropriate allowance for doubtful accounts and provision for bad debts. Management regularly reviews data about these major payor sources of revenue in evaluating the sufficiency of the allowance for doubtful accounts. For receivables associated with services provided to patients who have third party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary, for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payor has not yet paid, or for payors who are known to be having financial difficulties that make the realization of amounts due unlikely.For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates, if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. Part III, Line 8: Medicare allowable cost of care was calculated from the medicare cost report for the fiscal year ending 6/30/2012. Wagner Community Memorial Hospital Part V, Section B, Line 19d: All patients are charged gross charges initially. As of year end, a policy had not been approved by management to determine the amounts generally billed discount under the Prospective or Look-back Method.The Hospital is in the process of updating policies and procedures to meet the provisions of the new 501(r). They will be using the proposed regulations as a guideline for making changes to current policies. Wagner Community Memorial Hospital Part V, Section B, Line 20: The Hospital is in the process of updating policies and procedures to meet the provisions of the new 501(r). They will be using the proposed regulations as a guideline for making changes to current policies. Wagner Community Memorial Hospital Part V, Section B, Line 21: The Hospital is in the process of updating policies and procedures to meet the provisions of the new 501(r). They will be using the proposed regulations as a guideline for making changes to current policies. Part VI, Line 2: 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 it is believed 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.The Hospital is in the process of updating policies and procedures to meet the provisions of the new 501(r). They will be using the proposed regulations as a guideline for making changes to current policies. 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 $35,808. Inhabitants below the poverty level total 24%. County education demographics include 80.7% of residents having a high school degree and 15.5% holding a Bachelor's Degree in comparison to the national average of 85% and 27.9%. According to the US Census Bureau Fact Finder most recent data, 31.7% of residents in the county are of American Indian descent, almost all members of the Yankton Sioux Tribe. All of Charles Mix County is considered medically underserved by HRSA and the SD Department of Health. The county 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. 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 mid-level providers. 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 19.3% 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. The American Indian population in Wagner and Lake Andes is between 40-53% as compared to the national average of 0.9%. American Indian population in the nearby towns of Marty and Ravinia are 97% and 66%, respectively. 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 115886 0 0 0 499 0 4888 0 1886 0 123159 0 0 0 Robert Hubley til August 2011 161775 0 0 0 244 0 7919 0 12245 0 182183 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. Dr. Robert Hubley, Physician, is paid by Avera Sacred Heart Hospital, 501 Summit Street, Yankton, SD 57078. Uzma Mian Comm needs loan X 100000 69645 0 1 1 69645 Vicki Thaler Family relationship with Ken Thaler, board member. 48251 Employee Compensation 0 Marcia Podzimek Family relationship with Dorothy Holzbaur, board member. 49948 Employee Compensation 0 Deborah Hubley Family relationship with Robert Hubley, highest compensated employee. 16428 Employee Compensation 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the President, as Chairman, and two other members of the Board of Directors appointed by the President. The Executive Committee will have power to transact all regular business of the hospital during the interim between the meetings of the Board of Directors provided any action taken does not conflict with the policies and expressed wishes of the Board of Directors, and that it shall refer all matters of major importance to the Board of Directors. 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 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 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -38,440. Change in interest in net assets of Avera Health Foundation 159,144. Total to Form 990, Part XI, Line 5: 120,704.