2013-07-15T08:48:59-05:00 2012-09-30 450250958 EIDE BAILLY LLP 3999 PENNSYLVANIA AVE SUITE 100 DUBUQUE IA 52002 990 2011-10-01 450227391 PRESENTATION MEDICAL CENTER PRES 7014773161 213 2ND AVENUE NE ROLLA ND 583670759 MARK KERR 7014773161 2013-07-16 1 CARMEN KRANTZ P00031958 5635561790 2013-07-16 2011 2016-02-24 21:20:13Z MARK KERR 213 2ND AVENUE NE ROLLA ND 583670759 9294852 0 0928 X WWW.PMC-ROLLA.COM X 1939 ND ACUTE CARE HOSPITAL THAT IS A MAJOR MEDICAL PROVIDER FOR ROLETTE COUNTY 10 9 117 35 0 0 813582 180809 7888048 8945934 38017 115701 7636 -729 8747283 9241715 0 0 0 0 3860413 3982747 0 0 0 4039769 4789988 7900182 8772735 847101 468980 4343552 4086346 2309117 1562021 2034435 2524325 X PRESENTATION MEDICAL CENTER IN UNION WITH THE SISTERS OF MARY OF THE PRESENTATION, IS A CATHOLIC HEALTHCARE ORGANIZATION. THROUGH THE POWER AND EXAMPLE OF JESUS CHRIST AND HIS GOSPEL VALUES, WE ARE COMMITTED TO JOYFULLY PROVIDE WHOLISTIC CARE AND HEALING WITH INTEGRITY, COMPASSION AND RESPECT TO ALL WE SERVE. 0 0 7438580 8945934 PRESENTATION MEDICAL CENTER (PMC) IS A 25-BED NOT-FOR-PROFIT, CRITICAL ACCESS HOSPITAL (CAH) LOCATED IN ROLLA, ROLETTE COUNTY, ND. AS A CRITICAL ACCESS HOSPITAL, OUR ORGANIZATION IS, BY DEFINITION, A COMMUNITY BENEFIT. PMC IS A CRITICAL INFRASTRUCTURE TO OUR COMMUNITY AND IS A MAJOR MEDICAL PROVIDER FOR ROLETTE COUNTY, PROVIDING INPATIENT, OUTPATIENT AND SURGICAL SERVICES. IN ADDITION, PMC IS A KEY PROVIDER OF EMERGENCY CARE WITH OVER 6,300 ER VISITS FOR FISCAL YEAR ENDING 2012. SERVICES IN THE AREAS OF CLINIC, LAB, RADIOLOGY, RESPIRATORY THERAPY, PHYSICAL THERAPY, CARDIAC REHAB, AND OUTREACH SPECIALTY PHYSICIAN SERVICES, ARE ALSO PROVIDED.PRESENTATION MEDICAL CENTER HAD 225 ACUTE PATIENT DAYS, 680 SWING-BED DAYS AND 2,099 EXTENDED SWING-BED DAYS.THE MEDICAL CENTER PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ESTABLISHED RATES. BECAUSE THE MEDICAL CENTER DOES NOT PURSUE COLLECTION OF AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS REVENUE. THE AMOUNTS OF CHARGES FOREGONE WERE $106,089 FOR THE YEAR ENDED SEPTEMBER 30, 2012. THE ESTIMATED COSTS OF THE CHARGES FOREGONE, BASED UPON AN OVERALL COST-TO-CHARGE RATIO CALCULATION, FOR THE YEAR ENDED SEPTEMBER 30, 2012 WERE APPROXIMATELY $94,000.IN ADDITION, THE MEDICAL CENTER PROVIDES SERVICES TO OTHER MEDICALLY INDIGENT PATIENTS UNDER CERTAIN GOVERNMENT REIMBURSED PUBLIC AID PROGRAMS. SUCH PROGRAMS PAY PROVIDERS AMOUNTS WHICH ARE LESS THAN ESTABLISHED CHARGES FOR THE SERVICES PROVIDED TO THE RECIPIENTS, AND FOR SOME SERVICES THE PAYMENTS ARE LESS THAN THE COST OF RENDERING THE SERVICES PROVIDED. THE MEDICAL CENTER ALSO COMMITS SIGNIFICANT TIME AND RESOURCES TO ENDEAVORS AND CRITICAL SERVICES WHICH MEET OTHERWISE UNFULFILLED COMMUNITY NEEDS. MANY OF THESE ACTIVITIES ARE SPONSORED WITH THE KNOWLEDGE THAT THEY WILL NOT BE SELF-SUPPORTING OR FINANCIALLY VIABLE. 7438580 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 4 0 1 117 1 0 0 0 0 0 0 0 0 0 0 X 10 9 1 1 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 X PAULA WILKIE 7014773161 213 2ND AVENUE NE ROLLA ND 583670759 X NATHAN NEAMEYER 0.50 X X 0 0 0 DOUG KRETSCHMAR 0.50 X X 0 0 0 MICHAEL PFEIFER 40.00 X X 0 262362 34296 SR MARGARET ROSE PFEIFER 0.50 X 0 0 0 SR MARLYSS DIONNE 0.50 X 0 0 0 SR DOROTHY BUNCE 0.50 X 0 0 0 PAUL GRANN 0.50 X 0 0 0 SHEILA TROTTIER 0.50 X 0 0 0 JOHN HARDY 0.50 X 0 0 0 JANE SIVERTSON 0.50 X 0 0 0 MARK KERR 0.50 X 0 0 0 PAULA WILKIE 40.00 X 0 94469 30358 0 356831 64654 0 0 1 0 AMN HEALTHCARE PO BOX 281939 ATLANTA GA 303841939 LOCUM NURSING SERVICES 581095 SISTERS OF MARY OF THE PRESENTATION HEAL 1202 PAGE DR SW FARGO ND 58106 MANAGEMENT SERVICES 387871 ONWARD PO BOX 27421 NEW YORK NY 10087 LOCUM NURSING SERVICES 260709 PENNY WILKIE MD 2640 E DIVIDE AVENUE BISMARCK ND 58501 ER PHYSICIAN SERVICES 236200 ROY CORDY MD 914 3RD AVENUE S UNIT FARGO ND 58103 ER PHYSICIAN SERVICES 229225 7 22503 158306 180809 PATIENT SERVICE REVENU 622110 8244780 8244780 EHR INCENTIVE 900099 524422 524422 OUTSIDE LAUNDRY REVENU 812300 113315 113315 SUPPORTING REVENUE 900099 63417 63417 8945934 6224 6224 10668 11397 -729 -729 -729 151217 41740 109477 109477 109477 9241715 8945934 0 114972 3439553 2955313 484240 76485 66348 10137 228241 228647 -406 238468 203854 34614 423042 423042 2663 2663 39531 39531 2468582 2259545 209037 16395 16395 396864 304100 92764 250926 248184 2742 42901 30703 12198 33985 33985 364411 364411 45494 45494 MEDICAL SUPPLIES 415493 415493 BAD DEBT EXPENSE 282503 282503 7198 7198 8772735 7438580 1334155 0 19593 485660 1376409 1414889 160203 161394 30029 47073 9382636 8156392 1467571 1226244 221012 372086 30000 30000 1735 1037000 349000 4343552 4086346 1142823 880050 77764 745519 604207 420775 2309117 1562021 X 2034435 2524325 2034435 2524325 4343552 4086346 X 468980 20910 X X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 49958 49958 54533 3778085 3725089 107529 5480239 4411482 1068757 19821 19821 0 1226244 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 349000 349000 9241715 8772735 468980 27492 -6582 20910 489890 9250175 27492 27492 9222683 19032 19032 9241715 8772735 0 8772735 0 8772735 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE MEDICAL CENTER IS ORGANIZED AS A NORTH 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 MEDICAL CENTER IS ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. IN ADDITION, THE MEDICAL CENTER IS SUBJECT TO INCOME TAX ON NET INCOME THAT IS DERIVED FROM BUSINESS ACTIVITIES THAT ARE UNRELATED TO ITS EXEMPT PURPOSE, IF APPLICABLE. THE MEDICAL CENTER 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 MEDICAL CENTER 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: EQUITY TRANSFER TO SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION -6,582. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 19,032. 1 1 X 1 X 1 X 1 1 1 0 1 1 97884 97884 0.01150 97884 97884 0.01150 5 6792 51099 7700 43399 0.00510 1 14 14500 10010 4490 0.00050 379861 341124 38737 0.00460 4 14582 14582 0.00170 10 6806 460042 358834 101208 0.01190 10 6806 557926 358834 199092 0.02340 1 12 180 180 0.00000 3 324 11837 11837 0.00140 3 204 1700 1700 0.00020 7 540 13717 13717 0.00160 0 282503 141252 3433236 3399243 33993 X 1 1 1 1 PRESENTATION MEDICAL CENTER

213 2ND AVENUE NE ROLLA ND 583670759

X X X X 1 PROVIDER BASED CLINIC PRESENTATION MEDICAL CENTER 1 0 1 1 200.000000000000 1 200.000000000000 1 X X X X 1 1 X X 1 0 1 X 0 0 PART I, LINE 3C: PRESENTATION MEDICAL CENTER ALSO EVALUATES A PATIENT'S FAMILY SIZE, ASSETS, AND DEMOGRAPHICS TO DETERMINE ELIGIBILITY FOR ADDITIONAL FREE OR DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PART I, LINE 6A: PRESENTATION MEDICAL CENTER'S COMMUNITY BENEFIT REPORT CAN BE FOUND ON ITS WEBSITE AT PMC-ROLL.COM. PART I, LINE 7: CHARITY CARE EXPENSE WAS CONVERTED TO COST ON LINE 7A BASED ON THE COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2. INPATIENT AND OUTPATIENT HOSPITAL SERVICES PROVIDED TO MEDICAID PROGRAM BENEFICIARIES ARE PRIMARILY PAID ON A COST-RELATED BASIS, THEREFORE THERE IS NO COMMUNITY BENEFIT RELATED TO MEDICAID ON LINE 7B. COMMUNITY HEALTH IMPROVEMENT SERVICES, HEALTH PROFESSIONS EDUCATION, AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS, LINES 7E, 7F, AND 7I, ARE REPORTED BASED ON ACTUAL EXPENSES RECORDED IN THE ORGANIZATION'S GENERAL LEDGER. THE COST FOR SUBSIDIZED HEALTH SERVICES REPORTED ON LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. PART I, L7 COL(F): THE AMOUNT OF BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES TO DETERMINE THE PERCENTAGE WAS $282,503. PART II: CASE MANAGEMENT SERVICES WERE PROVIDED TO PATIENTS, THEIR FAMILY MEMBERS, AND COMMUNITY MEMBERS. THOSE INDIVIDUALS REQUIRING SUBSTANCE ABUSE REFERRALS AND ASSISTANCE REQUIRE INTENSIVE SERVICES. DUE TO THE SIGNIFICANT NUMBER OF SOCIAL ISSUES IN ROLETTE COUNTY, CASE MANAGEMENT SERVICES ARE PROVIDED TO CONNECT PATIENTS WITH THE SERVICES THAT THEY NEED TO REGAIN/MAINTAIN THEIR HEALTH STATUS. EVERY EFFORT IS MADE TO ASSIST PATIENTS IN OBTAINING THE SERVICES THAT THEY REQUIRE TO MAINTAIN GOOD HEALTH AND A QUALITY LIFESTYLE.TRANSPORTATION SERVICES WERE PROVIDED TO PATIENTS WHO NEEDED RIDES HOME FOLLOWING HOSPITALIZATION AND FOR APPOINTMENTS FOR SPECIALIZED CARE. THESE ARE PATIENTS WHO DO NOT HAVE FAMILY OR FRIENDS WHO ARE WILLING OR ABLE TO TRANSPORT THEM FOR THESE APPOINTMENTS. BY ASSISTING WITH TRANSPORTATION, PATIENTS ARE ABLE TO RECEIVE SPECIALTY CONSULTATION SERVICES THAT ALLOW THEM TO ENHANCE THE QUALITY OF THEIR LIFE.THE SOCIAL SERVICE DEPARTMENT PROVIDED INFORMATION, ASSISTANCE, AND REFERRALS TO COMMUNITY MEMBERS SEEKING SUCH SERVICES, PARTICULARLY DURING TIMES OF MEDICAL CRISIS.THE AREA PUBLIC SCHOOLS PARTICIPATED IN THIRD GRADE TOURS. THE SCHOOLS ARE ALSO OFFERED THE OPPORTUNITY TO PARTICIPATE IN TOURS AT THE REQUEST OF THEIR TEACHERS. PMC PARTICIPATED IN THE JOB SHADOWING PROGRAMS WITH THE LOCAL SCHOOL. THE TOURS AND JOB SHADOW PROGRAM ARE INTENDED TO GET YOUNG STUDENTS INTERESTED IN THE FIELD OF HEALTH CARE AND THEREFORE INCREASE ACCESS TO HEALTH CARE SERVICES IN THE COMMUNITY IN THE FUTURE. PART III, LINE 4: BAD DEBT EXPENSE IS THE WRITE-OFF OF A PATIENT'S ACCOUNT FOR SERVICES PROVIDED BY THE HOSPITAL AFTER ALL PAYMENTS, DISCOUNTS, AND CONTRACTUAL ALLOWANCES HAVE BEEN APPLIED. ACCOUNTS THAT QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE OR CHARITY CARE ARE NOT WRITTEN OFF TO BAD DEBT. PAYMENTS RECEIVED ON ACCOUNTS PREVIOUSLY WRITTEN OFF TO BAD DEBT REDUCES BAD DEBT EXPENSE. THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN ESTIMATE OF APPLICATIONS DENIED DUE TO LACK OF INFORMATION. PRESENTATION MEDICAL CENTER ESTIMATES THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENT'S UNDER THE CHARITY CARE POLICY BECAUSE THE ORGANIZATION KNOWS THAT SOME ACCOUNTS ARE WRITTEN OFF TO BAD DEBT THAT MAY HAVE BEEN CHARITY CARE IF THE PATIENT HAD COMPLETED THE PAPER WORK.FOOTNOTE TO FINANCIAL STATEMENTS:THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. PART III, LINE 8: TOTAL REVENUE RECEIVED FROM MEDICARE IS THE GROSS REIMBURSEMENT PLUS SETTLEMENT. BOTH 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: PRESENTATION MEDICAL CENTER BELIEVES IT HAS AN OBLIGATION TO MAKE EVERY EFFORT POSSIBLE TO COLLECT FOR SERVICES RENDERED FROM ALL PATIENTS WHO HAVE THE ABILITY TO PAY THEIR ACCOUNT. THERE ARE NO COLLECTION EFFORTS FOR PATIENTS WHO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE, INDIGENT PATIENTS, OR PATIENTS THAT HAVE SET UP PAYMENT ARRANGEMENTS. IF A PORTION OF AN ACCOUNT IS WRITTEN OFF TO CHARITY CARE, ANY PERSONAL PORTION DUE FOLLOWS THE SAME COLLECTION PROCEDURES AS OTHER ACCOUNTS. FOR PATIENTS WHO ARE INDIGENT, PRESENTATION MEDICAL CENTER HAS A CHARITY CARE PROVISION WITH THE APPROPRIATE APPLICATION PROCESS. FOR SELF PAY PATIENTS, PRESENTATION MEDICAL CENTER OFFERS A PROMPT PAYMENT DISCOUNT OF 25% FOR PAYMENT IN FULL WITHIN 30 DAYS FROM THE DATE OF THEIR FIRST STATEMENT. PRESENTATION MEDICAL CENTER PART V, SECTION B, LINE 11H: PRESENTATION MEDICAL CENTER ALSO EVALUATES A PATIENT'S FAMILY SIZE, ASSETS, AND DEMOGRAPHICS TO DETERMINE ELIGIBILITY FOR ADDITIONAL FREE OR DISCOUNTED CARE TO LOW INCOME INDIVIDUALS. PRESENTATION MEDICAL CENTER PART V, SECTION B, LINE 13G: A BROCHURE IS PROVIDED TO EVERY PATIENT WHEN THEY REGISTER OUTLINING OUR PAYMENT EXPECTATIONS AND EXPLAINING OUR COMMUNITY CARING PROGRAM. AN APPLICATION FOR THE COMMUNITY CARING PROGRAM IS INCLUDED WITH THE FIRST STATEMENT OF EVERY PRIVATE PAY PATIENT. THIS YEAR, WE ADDED THE APPLICATION TO OUR WEBSITE. NOTIFICATION ABOUT CHARITY CARE IS AVAILABLE IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND OTHER PUBLIC AREAS WITHIN THE HOSPITAL. INFORMATION IS ALSO INCLUDED IN PATIENT BILLS AND PATIENT INFORMATION PACKETS. AT REGISTRATION, PATIENTS ARE GIVEN THE PAYMENT POLICY AND COMMUNITY CARING PROGRAM HANDOUT. THIS HANDOUT EXPLAINS PATIENT RESPONSIBILITIES, INSURANCE BILLING GUIDELINES, FINANCING AND PAYMENT OPTIONS, AND THE COMMUNITY CARING GUIDELINES. PRESENTATION MEDICAL CENTER PART V, SECTION B, LINE 19D: PRESENTATION MEDICAL CENTER'S FINANCIAL ASSISTANCE POLICY PROVIDES FREE CARE OR DISCOUNTED CARE TO ELIGIBLE RECIPIENTS. DURING THE CURRENT YEAR ALL FAP ELIGIBLE INDIVIDUALS WERE PROVIDED FREE CARE BASED ON THEIR NEEDS. THEREFORE, FAP ELIGIBLE INDIVIDUALS DID NOT PAY ANYTHING FOR SERVICES. PART VI, LINE 2: PRESENTATION MEDICAL CENTER STRIVES TO PROVIDE BASIC HEALTHCARE SERVICES TO ITS COMMUNITIES. WE HAVE WORKED WITH THE PUBLIC HEALTH FOR ROLETTE COUNTY, ROLETTE COUNTY POLICE DEPARTMENT, ROLLA COMMUNITY AMBULANCE, ROLETTE COUNTY SOCIAL SERVICES AND OTHER COMMUNITY DEPARTMENTS TO PROVIDE BASIC CARE TO THE MEMBERS OF OUR COMMUNITY. WORKING WITH THESE INDIVIDUALS ALLOWS US TO PROVIDE DIFFERENT SERVICES TO OUR COMMUNITY AND TO MAKE SURE THAT ONE OF THESE ENTITIES IS ABLE TO PROVIDE CARE AND OR COVER FOR ONE ANOTHER.OUR COMMUNITY HEALTH NEEDS ASSESSMENT WILL BE COMPLETED BY THE END OF FISCAL YEAR 2013 AND POSTED TO OUR WEBSITE TO MEET THE REQUIREMENTS OF 501(R). PART VI, LINE 3: PRESENTATION MEDICAL CENTER IS COMMITTED TO PROVIDING CARE TO PERSONS WHO ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR GOVERNMENT PROGRAMS, OR OTHERWISE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE. OUR COMMUNITY CARING PROGRAM WAS ESTABLISHED IN 2005. WE HAVE SEEN A CONTINUAL INCREASE EVERY YEAR IN CHARITY CARE AS WE TRY TO GET PATIENTS INVOLVED IN THE PROGRAM BEFORE THEIR ACCOUNTS ARE SENT TO COLLECTIONS. A BROCHURE IS PROVIDED TO EVERY PATIENT WHEN THEY REGISTER OUTLINING OUR PAYMENT EXPECTATIONS AND EXPLAINING OUR COMMUNITY CARING PROGRAM. AN APPLICATION FOR THE COMMUNITY CARING PROGRAM IS INCLUDED WITH THE FIRST STATEMENT OF EVERY PRIVATE PAY PATIENT. THIS YEAR, WE ADDED THE APPLICATION TO OUR WEBSITE. NOTIFICATION ABOUT CHARITY CARE IS AVAILABLE IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, THE BUSINESS OFFICE, AND OTHER PUBLIC AREAS WITHIN THE HOSPITAL. INFORMATION IS ALSO INCLUDED IN PATIENT BILLS AND PATIENT INFORMATION PACKETS. AT REGISTRATION, PATIENTS ARE GIVEN THE PAYMENT POLICY AND COMMUNITY CARING PROGRAM HANDOUT. THIS HANDOUT EXPLAINS PATIENT RESPONSIBILITIES, INSURANCE BILLING GUIDELINES, FINANCING AND PAYMENT OPTIONS, AND THE COMMUNITY CARING GUIDELINES. PART VI, LINE 4: PRESENTATION MEDICAL CENTER (PMC) IS A 25-BED NOT-FOR-PROFIT, CRITICAL ACCESS HOSPITAL (CAH) LOCATED IN ROLLA, ROLETTE COUNTY, ND. ROLLA, ND IS LOCATED IN NORTH CENTRAL NORTH DAKOTA, NEXT TO THE CANADIAN BORDER. PRESENTATION MEDICAL CENTER IS LOCATED APPROXIMATELY 40 MILES FROM BOTTINEAU, 120 MILES NORTHEAST OF MINOT, 170 MILES NORTHWEST OF GRAND FORKS, 205 MILES NORTHEAST OF BISMARCK, AND 240 MILES NORTHWEST OF FARGO. THE NEAREST CITY WITH A POPULATION > 50,000 IS BISMARCK, ND.PMC IS HIGHLY DEPENDENT UPON GOVERNMENT PAYORS AND IS A MEDICAID DISPROPORTIONATE SHARE HOSPITAL. IN THE FISCAL YEAR ENDING 09/30/2012, MEDICAID WAS THE PAYOR FOR 14.7% OF INPATIENTS AND 46.8% OF OUTPATIENTS, WHILE MEDICARE WAS THE PAYOR FOR 73.3% OF INPATIENTS AND 20.8% OF TOTAL OUTPATIENTS. BY VIRTUE OF WHERE WE ARE LOCATED AND THE SERVICES THAT WE PROVIDE, WE ARE A BENEFIT TO OUR COMMUNITY.THE SERVICE AREA OF PMC INCLUDES ROLETTE AND PART OF TOWNER COUNTIES. ROLETTE COUNTY HAS A TOTAL POPULATION OF 14,206 WITH 75% OF THE POPULATION BEING NATIVE AMERICAN. WITH THIS CENSUS, 2.08% OF NORTH DAKOTA'S POPULATION LIVES IN ROLETTE COUNTY. THE PER CAPITA INCOME FOR ROLETTE COUNTY IS $13,632 COMPARED WITH NORTH DAKOTA'S PER CAPITA INCOME OF $25,803 WITH 31.8% OF THE COUNTY LIVING BELOW THE POVERTY GUIDELINES. (SOURCE: U.S. CENSUS BUREAU).THE CLOSEST HEALTHCARE FACILITY IS 7 MILES AWAY LOCATED IN BELCOURT, ND, WHICH IS AN INDIAN HEALTHCARE FACILITY. ALL OTHER HOSPITALS ARE LOCATED 40 PLUS MILES FROM PRESENTATION MEDICAL CENTER. PRESENTATION MEDICAL CENTER'S TERTIARY FACILITY IS LOCATED OVER 120 MILES AWAY IN MINOT, ND. IT IS IN THE BEST INTEREST OF THE COMMUNITY TO BE ABLE TO OFFER BASIC HEALTHCARE NEEDS DUE TO THE DISTANCE THAT THE PATIENT MUST TRAVEL. PART VI, LINE 5: PRESENTATION MEDICAL CENTER WORKS TO ADDRESS THE BASIC HEALTHCARE NEEDS IN ROLETTE COUNTY AND THE SURROUNDING COMMUNITIES. THE HOSPITAL IS A MAJOR MEDICAL PROVIDER FOR THE COUNTY PROVIDING INPATIENT, OUTPATIENT, AND SURGICAL SERVICES. IN ADDITION, PRESENTATION MEDICAL CENTER IS A KEY PROVIDER OF EMERGENCY CARE. THE EMERGENCY ROOM IS OPEN 24 HOURS AND IS AVAILABLE REGARDLESS OF A PERSONS ABILITY TO PAY.PRESENTATION MEDICAL CENTER EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE USED FOR EQUIPMENT UPGRADES AND FACILITY IMPROVEMENTS. A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY RESIDES IN ROLLA, ND AND NONE ARE EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION. THE GOVERNING BODY DOES NOT HAVE ANY FAMILY RELATIONSHIPS WITH EACH OTHER.IN ADDITION TO OUR VERY EXISTENCE, PMC BELIEVES THAT THERE ARE ADDITIONAL AREAS THAT HIGHLIGHT OUR BENEFIT TO THE COMMUNITY. BY BEING WHAT AND WHO WE ARE, WE STRIVE TO BE A GOOD COMMUNITY CITIZEN AND AN ASSET TO THE COMMUNITIES THAT WE SERVE. PMC ROUTINELY PROVIDES A VARIETY OF SERVICES THAT ADDRESS NEEDS WITHIN THE COMMUNITY.PMC PROVIDED AN ANNUAL HEALTHY COMMUNITY DAY THAT OFFERS EDUCATIONAL MATERIAL AND HEALTH SCREENINGS, INCLUDING LABORATORY SCREENINGS THAT PROVIDE INFORMATION ABOUT AN INDIVIDUALS' GENERAL HEALTH CONDITION. THESE SERVICES ARE OFFERED TO ALL COMMUNITY RESIDENTS.PMC PROVIDES INFORMATION ABOUT HEALTH ISSUES AND TOPICS OF INTEREST TO THE COMMUNITY IN OUR PRESENTATIONS NEWS LETTER. PHYSICAL THERAPY STUDENTS ALSO HAD THE OPPORTUNITY TO OBTAIN CLINICAL EXPERIENCE AT PMC.PMC WORKED WITH THE ROLLA OFFICE OF THE NORTH DAKOTA JOB SERVICES TO PROVIDE CERTIFIED NURSE AIDE TRAINING CLASSES. THE CERTIFIED NURSE AIDE STUDENTS ALSO RECEIVE THEIR CLINICAL TRAINING AT PMC.BLOOD DRIVES ARE SPONSORED FOUR TIMES PER YEAR. UNITED BLOOD SERVICES USES THE INSERVICE ROOM AS A COLLECTION SITE AND THE LAB AND ADMISSION STAFF MEMBERS ARE RESPONSIBLE FOR RECRUITING AND COORDINATING DONORS.STAFF SUPPORT AND OFFICE SPACE IS PROVIDED TO THE RURAL MENTAL HEALTH CONSORTIUM. THIS ALLOWS MENTAL HEALTH SERVICES TO BE AVAILABLE IN THE COMMUNITY ON A WEEKLY BASIS.MEALS ARE ALSO PROVIDED FOR CAREGIVERS AND LODGING IS OFFERED FOR FAMILY MEMBERS WHO CHOOSE TO REMAIN IN THE HOSPITAL WITH THEIR LOVED ONE.SPORT INJURY EVALUATION AND SCREENINGS ARE PROVIDED TO AREA HIGH SCHOOL STUDENTS AND STAFF MEMBERS FROM PHYSICAL THERAPY PROVIDE SUPPORT AT LOCAL ATHLETIC EVENTS.MEETING ROOM SPACE IS PROVIDED FOR WEIGHT WATCHERS, SUPPORT GROUPS, PARAMEDIC EDUCATION, MINISTERIAL ASSOCIATION, HEARING AID TESTING, 4-H MEETINGS AND ANY OTHER GROUPS NEEDING MEETING SPACE. PART VI, LINE 6: WE ARE AN AFFILIATE OF THE SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION. PRESENTATION MEDICAL CENTER OPERATES IN ACCORDANCE WITH THE MISSION, VISION, AND VALUES OF THE SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION. OUR ANNUAL BUDGETING PROCESS INCLUDES AN ASSESSMENT OF HOW OUR BUDGET DEMONSTRATES A COMMITMENT TO THE VALUES OF THE SYSTEM AND THE SYSTEM WORKS TO ENSURE WE ARE ALWAYS MINDFUL OF OUR DUTY TO CARE FOR THE POOR AND THOSE IN NEED. PRESENTATION MEDICAL CENTER HAS A STRATEGIC PLAN DEVELOPED FROM THEMES SET FORTH BY THE HEALTH SYSTEM FOR ALL AFFILIATES. 0 0 0 0 0 0 0 0 0 MICHAEL PFEIFER 0 222355 0 25419 0 14588 0 26833 0 9544 0 298739 0 0 SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 3: PRESENTATION MEDICAL CENTER DOES NOT PAY COMPENSATION TO THE CEO. THIS INDIVIDUAL IS COMPENSATED BY SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION, A RELATED ORGANIZATION, FOR SERVICES AT THE HOSPITAL. SISTERS OF MARY OF THE PRESENTATION USE ONE OR MORE OF THE METHODS ON PART I, QUESTION 3 TO DETERMINE COMPENSATION. SUPPLEMENTAL INFORMATION PART III PART I, QUESTION 7: THE BONUS AMOUNT FOR MICHAEL PFEIFER, CEO, AND PAULA WILKIE, CFO, IS DETERMINED BY SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION, A RELATED ORGANIZATION. SUPPLEMENTAL INFORMATION PART III PART II: MICHAEL PFEIFER, CEO WAS COMPENSATED BY SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION, A RELATED ORGANIZATION, FOR SERVICES PROVIDED TO THE HOSPITAL. FORM 990, PART VI, SECTION A, LINE 2 MICHAEL PFEIFER, PAULA WILKIE AND SR. MARGARET ROSE PFEIFER HAVE BUSINESS RELATIONSHIPS WITH EACH OTHER. FORM 990, PART VI, SECTION A, LINE 3 SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION, A RELATED ORGANIZATION, FACILITATES THE MANAGEMENT AND OPERATIONS OF PRESENTATION MEDICAL CENTER. THE OFFICERS OF THE ORGANIZATION ARE DIRECTLY COMPENSATED BY SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS THE SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER IS ENTITLED TO VOTE IN THE ELECTION OF DIRECTORS AND TO CAST ONE VOTE FOR EACH DIRECTOR TO BE ELECTED. THE MEMBER IS ALSO ENTITLED TO ONE VOTE ON EVERY OTHER MATTER TO BE VOTED ON BY THE MEMBER. VOTES CAST ON BEHALF OF THE MEMBER ARE CAST BY THE CHIEF EXECUTIVE OFFICER OF SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE AUTHORITY TO ACT ON THE FOLLOWING MATTERS ARE EXCLUSIVELY VESTED IN THE MEMBER OF THE ORGANIZATION: 1. ANY CHANGE IN THE PHILOSOPHY, OBJECTIVES AND PURPOSES OF THE ORGANIZATION; 2. AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS; 3. THE ELECTION OR REMOVAL OF THE DIRECTORS; 4. MERGER OR CONSOLIDATION WITH ANY OTHER ORGANIZATION; 5. DISSOLUTION OF THE ORGANIZATION OR THE SALE, LEASE OR EXCHANGE OF ALL OR SUBSTANTIALLY ALL OF ITS PROPERTY OR ASSETS; 6. THE SALE, LEASE, TRANSFER OR ENCUMBRANCE OF ANY LAND, BUILDINGS OR OTHER ASSETS OWNED BY THE ORGANIZATION OR IN WHICH THE ORGANIZATION HAS OR WILL HAVE EQUITABLE OR LEGAL TITLE; 7. APPROVAL OF THE ANNUAL OPERATING AND CAPITAL BUDGETS; 8. APPOINTMENT OF THE CHIEF EXECUTIVE OFFICER. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION DOES NOT HAVE COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS DISTRIBUTED TO THE GOVERNING BODY BEFORE IT IS FILED. THE CEO AND CFO REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR MUST SUBMIT IN WRITING TO THE CHAIRPERSON OF THE BOARD AND THE CEO A LIST OF ALL BUSINESS OR OTHER ORGANIZATIONS OF WHICH THE INDIVIDUAL IS AN OFFICER, DIRECTOR, TRUSTEE, MEMBER, OWNER (EITHER AS A SOLE PROPRIETOR OR PARTNER), SHAREHOLDER WITH A 5% OR GREATER INTEREST IN ALL OUTSTANDING VOTING SHARES, EMPLOYEE OR AGENT, WITH WHICH THE ORGANIZATION HAS, OR MIGHT REASONABLY IN THE FUTURE ENTER INTO, A RELATIONSHIP OR A TRANSACTION IN WHICH THE DIRECTOR WOULD HAVE CONFLICTING INTERESTS. EACH WRITTEN STATEMENT IS RESUBMITTED WITH ANY NECESSARY CHANGES EACH YEAR. THE CHAIRPERSON OF THE BOARD REVIEWS THE STATEMENTS OF THE DIRECTORS AND THE VICE CHAIRPERSON OF THE BOARD REVIEWS THE STATEMENT FILED BY THE CHAIRPERSON. WHEN A CONFLICT ARISES THE AFFECTED DIRECTOR MAKES KNOWN THE POTENTIAL CONFLICT, WHETHER DISCLOSED BY WRITTEN STATEMENT OR NOT, AND AFTER ANSWERING ANY QUESTIONS, WILL WITHDRAW FROM THE MEETING FOR AS LONG AS THE MATTER CONTINUES UNDER DISCUSSION. SHOULD THE MATTER BE BROUGHT TO A VOTE, THE AFFECTED DIRECTOR WILL NOT VOTE ON IT. IN THE EVENT THE DIRECTOR DOES NOT WITHDRAW VOLUNTARILY, THE CHAIRPERSON OF THE BOARD AS AUTHORITY TO REQUIRE THE DIRECTOR TO REMOVE HIMSELF FROM THE ROOM DURING BOTH THE DISCUSSION AND VOTE ON THE MATTER. IN THE EVENT THE CONFLICT OF INTEREST AFFECTS THE CHAIRPERSON, THE VICE CHAIRPERSON HAS AUTHORITY TO REQUIRE THE CHAIRPERSON REMOVE HIMSELF IN THE SAME MATTER. IF THE MATTER IS THE ITEM OF BUSINESS FOR WHICH A SPECIAL MEETING OF THE BOARD WAS CALLED, THE AFFECTED DIRECTOR WILL NOT BE COUNTED TO ESTABLISH A QUORUM, AND HE WILL NOT PARTICIPATE IN THE DELIBERATIONS OR VOTE ON IT. THE ORGANIZATION'S CEO AND CFO ARE BOTH COMPENSATED BY SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION, A RELATED ORGANIZATION. THE COMPENSATION PROCESS IS DETERMINED BY THE RELATED ORGANIZATION. THE SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION BOARD OF TRUSTEES DIRECTLY ENGAGES A NATIONALLY RECOGNIZED INDEPENDENT COMPENSATION CONSULTING FIRM TO REVIEW THE TOTAL COMPENSATION ARRANGEMENTS OF THE OFFICERS AND KEY EMPLOYEES. THE SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION BOARD OF TRUSTEES APPROVES ALL COMPENSATION BASED ON COMPARABLE DATA AND DOCUMENTS THEIR DECISION IN THE MEETING MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST. FORM 990, PART VII, SECTION A: SR. MARGARET ROSE PFEIFER, SR. MARLYSS DIONNE, AND SR. DOROTHY BUNCE DEVOTED TIME PROVIDING SERVICES TO SEVERAL OF THE RELATED ORGANIZATIONS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 27,492. EQUITY TRANSFER TO SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION -6,582. TOTAL TO FORM 990, PART XI, LINE 5: 20,910. FORM 990, PART XII, LINE 2C: THE GOVERNING BOARD OF SISTERS OF MARY OF THE PRESENTATION ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT FOR PRESENTATION MEDICAL CENTER. SISTERS OF MARY OF THE PRESENTATION HEALTH CORPORATION 1202 PAGE DRIVE SW FARGO ND 58103 450359620 FACILITATES MANAGEMENT AND OPERATIONS OF TEN RELATED FACILITIES ND 501(C)(3) LINE 11A, I SMP MARYVALE PROVINCIAL CENTER 0 ST ANDREW'S HOSPITAL FOUNDATION 316 OHMER STREET BOTTINEAU ND 58318 450413201 PROVIDE SUPPORT TO ST. ANDREW'S HOSPITAL ND 501(C)(3) LINE 11A, I SMP HEALTH CORPORATION 0 SMP PRAIRIELAND HOME HEALTH AGENCY 1102 PAGE DRIVE SW FARGO ND 581060007 450391192 HOME HEALTH AND SUPPORTIVE SERVICES ND 501(C)(3) LINE 9 SMP HEALTH CORPORATION 0 ST ANDREW'S HOSPITAL 316 OHMER STREET BOTTINEAU ND 58318 450226426 PROVISION OF HEALTH CARE SERVICES ND 501(C)(3) LINE 3 SMP HEALTH CORPORATION 0 ST ALOISIUS HOSPITAL 325 EAST BREWSTER STREET HARVEY ND 58341 450226729 PROVISION OF HEALTH CARE SERVICES ND 501(C)(3) LINE 3 SMP HEALTH CORPORATION 0 ST MARGARET'S HOSPITAL 600 EAST FIRST STREET SPRING VALLEY IL 61362 362167884 PROVISION OF HEALTH CARE SERVICES IL 501(C)(3) LINE 3 SMP HEALTH CORPORATION 0 SISTERS OF MARY OF THE PRESENTATION LONG TERM CARE 1202 PAGE DRIVE SW FARGO ND 581060007 752999939 PROVIDE EXTENDED CARE AND MEDICALLY RELATED SERVICES ND 501(C)(3) LINE 9 SMP HEALTH CORPORATION 0 ST MARGARET'S HOSPITAL FOUNDATION 600 EAST FIRST STREET SPRING VALLEY IL 61362 364042262 PROVIDE SUPPORT TO ST. MARGARET'S HOSPITAL IL 501(C)(3) LINE 11A, I SMP HEALTH CORPORATION 0 ST ANDREW'S BOTTINEAU CLINIC LLC 316 OHMER STREET BOTTINEAU ND 58318 450451306 PROVISION OF HEALTH CARE SERVICES ND N/A ROLETTE CLINIC INC PO BOX 759 ROLLA ND 58367 450308335 LEASING ND PRESENTATION MEDICAL CENTER C 10173 53 0.66670 SMP ENTERPRISES PO BOX 10007 FARGO ND 581060007 363486506 HOME HEALTH CARE SERVICES ND N/A C 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 0