2013-11-12T14:59:48-06:00 2012-12-31 450250958 Eide Bailly LLP 200 East 10th Suite 500 Sioux Falls SD 571045126 990 2012-01-01 460278210 Coteau des Prairies Hospital COTE 6056987647 205 Orchard Drive Sisseton SD 572622398 Dan Ellis 6056987647 2013-11-12 1 Laurie Hanson P00851848 6053391999 2013-11-12 2012 2016-02-24 21:20:13Z Dan Ellis 205 Orchard Drive Sisseton SD 572622398 13225528 0 X www.cdphospital.com X 1967 SD Provision of healthcare services to the population of Sisseton, SD, and the surrounding area. 12 12 181 20 0 0 88340 88129 12586153 13095018 3989 8371 17309 18171 12695791 13209689 2000 0 0 0 6561613 7074864 0 0 0 5523717 5587819 12087330 12662683 608461 547006 7740033 9284464 1258793 2256218 6481240 7028246 Quality healthcare with a personal touch close to home. 0 0 10889085 13095018 Coteau des Prairies Hospital (CDPH) is a 25 bed acute care hospital and physician clinic. The hospital provides healthcare services for the care and treatment of any persons who are acutely ill or who otherwise require medical care and related services. Statistics for the period ended December 31, 2012, are as follows: acute patient days = 1,274, subacute patient days = 660, newborn days = 281, and emergency room visits = 5,270. 10889085 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 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 7 0 1 181 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X Larry Moen 6056984697 205 Orchard Drive Sisseton SD 572622398 Mary Carlson 2.00 X X 0 0 0 Faye Johnston 2.00 X X 0 0 0 Terry Jaspers 2.00 X X 0 0 0 DelRay German 2.00 X X 0 0 0 Debbie Wooley 1.00 X 0 0 0 Steven McCleerey 1.00 X 0 0 0 Erin Cameron 1.00 X 0 0 0 Cheryl Karst 1.00 X 0 0 0 Vivian Hove 1.00 X 0 0 0 Geri Opsal 1.00 X 0 0 0 Jay Hill 1.00 X 0 0 0 Kent Thoelke 1.00 X 0 0 0 Dan Ellis 40.00 X 124004 0 21294 Larry Moen 40.00 X 73224 0 12612 Dr Stanley Gallagher 40.00 X 584548 0 7023 Dr Judy Beumer 32.00 X 411950 0 26544 Dr David Staub 20.00 X 348039 0 9540 Dr Linda Peterson 24.00 X 166578 0 6359 Bradley Gallagher 40.00 X 104447 0 6125 1812790 0 89497 6 0 1 0 Charles Pryzmus 1004 5th Avenue North Wheaton MN 56296 Anesthesia Services 166760 1 87512 617 88129 Patient Service Revenue 622110 13037756 13037756 Misc Revenue 900099 35095 35095 Cafeteria Revenue 900099 22167 22167 13095018 3816 3816 18171 0 18171 18171 18171 20394 15839 4555 4555 4555 13209689 13095018 0 26542 221491 221491 5600341 5095133 505208 116798 103254 13544 394549 348933 45616 741685 651822 89863 17281 17281 39600 39600 918784 797551 121233 46957 46957 362300 270806 91494 380664 380664 167860 144906 22954 35333 29141 6192 141168 122573 18595 379581 379581 110363 110363 Medical Supplies 1949927 1949927 Bad Debt 499992 499992 Equipment Rental and Ma 452335 450607 1728 License and Permits 39122 37986 1136 46552 6873 39679 12662683 10889085 1773598 0 1311738 2107360 3633857 2965623 187288 244437 119729 97814 9781531 5912301 2487421 3869230 7740033 9284464 1258793 1021347 1234871 1258793 2256218 X 6481240 7028246 6481240 7028246 7740033 9284464 547006 0 X 0 1 X 0 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13556 13556 3663885 2524485 1139400 4397488 3283067 1114421 1706602 104749 1601853 3869230 X 12709697 0 12709697 499992 499992 13209689 12162691 0 12162691 499992 499992 12662683 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 4b - Other Adjustments: Provision for Bad Debts 499,992. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts 499,992. 1 1 X 1 X 1 X 175.000000000000 1 1 0 0 50200 50200 0.00400 1243681 1213362 30319 0.00240 1293881 1213362 80519 0.00640 10783 6479 4304 0.00030 1250 1250 0.00010 2861341 1481024 1380317 0.10900 1060 1060 0.00010 2874434 1487503 1386931 0.10950 4168315 2700865 1467450 0.11590 0 499992 249996 2981225 2951708 29517 X 1 0 1 1 Coteau des Prairies Hospital & Clinic

205 Orchard Drive Sisseton SD 57262

X X X X Coteau des Prairies Hospital & Clinic 1 0 1 1 150.000000000000 1 175.000000000000 1 X X X X X 1 1 X X 1 0 X 1 X 0 0 4 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 Coteau Des Prairies Clinic

205 Orchard Drive Sisseton SD 57262

Rural Health 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. Line 7b was determined using the ratio of patient care costs to charges calculated in IRS Worksheet 2. Line 7e, 7f, and 7i were obtained utilizing the actual general ledger system. Line 7g was obtained from the Medicare cost report. Part I, L7 Col(f): Bad debt expense of $499,992 was subtracted from total operating expense. Part II: None Part III, Line 4: a) 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. b) Bad debt expense attributable to charity care is estimated based on income levels and ethnicity in this area. More that 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. c) Footnote from Financial Statement: Patient receivables are uncollateralized patient and third-party payor obligations. Unpaid patient receivables do not have any interest assessed.Payments of patient receivables are allocated to the specific claims identified on the remittance advice or, if unspecified, are applied to the earliest unpaid claim.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. The Hospital's process for calculating the allowance for doubtful accounts for self-pay patients has not significantly changed from December 31, 2011 to December 31, 2012. The Hospital does not maintain a material allowance for doubtful accounts from third-party payors, nor did it have significant write offs from third-party payors. The Hospital has not significantly changed its charity care or uninsured discount policies during fiscal years 2012 or 2011. Part III, Line 8: Medicare allowable cost of care was calculated from the Medicare cost report for the period ending 12/31/2012. The Medicare cost report was filed in accordance with the audited financial statements. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 14g: A summary of the policy was posted in the hospital facility emergency rooms or waiting rooms and in the admissions offices. Coteau des Prairies Hospital & Clinic Part V, Section B, Line 18e: Prior to initiating any collection actions listed above, patients are made aware of the financial assistance policy through signage in admissions, and phone calls by hospital staff prior to being sent to collection. Patients accounts are not sent to collection until patients have been offered 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 is in the process of finalizing its implementation strategy and anticipates making the community health needs assessment and implementation strategy widely available by December 31, 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 estimated population in Sisseton, SD in 2012 was 2,470. Approximately 47.04% of the Sisseton area people are white, 47.81% are Native American, 0.08% are Black, 0.4% are Asian, 0.80% claim Hispanic, and 4.66% claim "Other".The estimated population in Roberts County, SD in 2012 was 10,303. Approximately 60.4% of Roberts County area people are white, 35.9% are native American, 0.2% are Black, 0.3% are Asian, and 1.6% claim Hispanic, and 1.6% claim "Other". 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 Dr Stanley Gallagher 584548 0 0 0 0 0 0 0 7023 0 591571 0 0 0 Dr Judy Beumer 411950 0 0 0 0 0 9800 0 16744 0 438494 0 0 0 Dr David Staub 348039 0 0 0 0 0 0 0 9540 0 357579 0 0 0 Dr Linda Peterson 166578 0 0 0 0 0 0 0 6359 0 172937 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 7450000 122280 1234871 6092849 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 8b No committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The Director of Finance reviews the 990 in detail prior to filing the return. Form 990, Part VI, Section B, line 12c All board members and officers are covered by the Conflict of Interest Policy. 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.