2012-03-30T11:25:15-05:00 2011-05-31 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2010-06-01 460391067 PRAIRIE LAKES HEALTH CARE SYSTEM INC PRAI 6058827000 PO BOX 1210 WATERTOWN SD 57201 JILL FULLER 6058827000 2012-03-30 1 6123764500 2010 2016-02-24 21:20:13Z JILL FULLER PO BOX 1210 WATERTOWN SD 57201 102317335 0 X WWW.PRAIRIELAKES.COM X 1986 SD HEALTH CARE SERVICES 14 14 535 14 992580 -140232 183025 129359 72101819 77489811 4813465 3309449 1163648 1077973 78261957 82006592 353799 143596 0 0 33186900 33571146 0 0 0 34447459 38983847 67988158 72698589 10273799 9308003 154135009 169631399 35566965 34640935 118568044 134990464 PRAIRIE LAKES HEALTH CARE SYSTEM THROUGH THE EFFORTS OF ITS DEDICATED EMPLOYEES AND PHYSICIANS, PROVIDES HIGH QUALITY, AFFORDABLE AND COMPASSIONATE HEALTHCARE SERVICES FOR THE PEOPLE IN THE REGION. 0 0 62958599 143596 77489811 HEALTHCARE PROGRAMS, GENERAL/OTHER - ACUTE CARE, INPATIENT AND OUTPATIENT MEDICAL CARE IS PROVIDED TO THE COMMUNITY REGARDLESS OF ABILITY TO PAY, IN SUPPORT OF THE FACILITY'S HEALTH CARE MISSION. IN FISCAL YEAR 2011, THERE WERE 3,396 ADMISSIONS AND 82,088 OUTPATIENTS. 62958599 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 58 0 535 1 1 1 0 0 0 0 0 0 0 0 0 X 14 14 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 1 1 1 0 X X ADAM PAUL 6058827000 PO BOX 1210 WATERTOWN SD 57201 JOHN CALVIN 1.00 X 0 0 0 ROGER CARTER MD 1.00 X 0 0 0 VINCE FOLEY 1.00 X 0 0 0 CATHERINE GERRISH MD 1.00 X 0 0 0 BERNIE HANSON MD 1.00 X 0 0 0 MONTE HOPPER 1.00 X X 0 0 0 MARK ROBY 1.00 X 0 0 0 DOUG SHARP 1.00 X X 0 0 0 LUANN STRAIT 1.00 X X 0 0 0 LISSA TURBAK 1.00 X 0 0 0 DUSTIN FLATTEN 1.00 X X 0 0 0 GEOFF HEIG 1.00 X 0 0 0 GERALD RIEBER MD 1.00 X 0 0 0 JIM REDLINGER 1.00 X 0 0 0 JILL FULLER 40.00 X 365799 0 48449 MICHAEL ANDERSON 40.00 X 311692 0 33392 NATHAN LAKE 40.00 X 146941 0 3569 TRACI RABINE 40.00 X 135575 0 24465 MICHELE TURBAK 40.00 X 149241 0 20781 EVELIO GARCIA MD 40.00 X 1174658 0 45850 IVALDO LUNARDI MD 40.00 X 596014 0 47850 SALEM MAALIKI MD 40.00 X 955028 0 23850 SAIRAV SHAH MD 40.00 X 761847 0 0 JEFFREY BRINDLE MD 40.00 X 480692 0 36258 4645730 0 235649 22 0 1 0 EMERGENCY PRACTICE ASSOCIATES PO BOX 1260 WATERLOO IA 50704 ER MD COVERAGE 1367235 HGA PO BOX 86 MINNEAPOLIS MN 55486 CONSULTING 430934 CALIBER CREATIVE 1308 E CEDAR ST BRANDON SD 57005 ADVERTISING/PROMOTION 333507 PDS INC 4152 30TH AVE S STE 103 FARGO ND 58104 SLEEP STUDIES 329600 DR RAM S PANKAJ 3 CASCADE COURT EAST BURR RIDGE IL 60521 ORTHOPEDIC IOCUM COVERAGE 245318 9 120000 9359 129359 PROGRAM SERVICE REV 621400 76631032 76631032 RETAIL PHARMACY 900000 646214 646214 LAB SERVICE 621500 212565 212565 77489811 371618 371618 728941 728941 728941 728941 23248574 20306636 4107 2941938 -4107 2937831 2937831 OTHER INCOME 900099 215231 215231 CAFETERIA REVENUE 722210 129844 129844 VENDING MACHINES 722210 2869 2869 1088 1088 349032 82006592 76631032 992580 4253621 143596 143596 532147 532147 27561330 24273280 3288050 449700 404434 45266 3050438 2682738 367700 1977531 1726902 250629 44787 44787 58685 58685 5098123 4191087 907036 401843 27774 374069 523534 499125 24409 941832 941832 489828 405809 84019 148090 57136 90954 1084716 1084716 4661280 4435763 225517 285769 285769 DRUGS 10305370 10305370 MEDICAL SUPPLIES 8037271 7802321 234950 PROVISION FOR BAD DEBTS 2508573 2508573 2010 BONDS REFUNDING LO 2046562 2046562 REPAIRS & MAINTENANCE 1584170 1583685 485 763414 540521 222893 72698589 62958599 9739990 0 1860 1558 6592938 6321488 7983065 6994797 63100 88633 391968 651081 1556922 1645996 373459 408091 103004653 48192865 53641128 54811788 78925172 93648690 2884822 3085144 676656 619820 1043919 1354313 154135009 169631399 11379661 12430100 22877103 20409894 1310201 1800941 35566965 34640935 X 115933222 132155320 2634822 2835144 118568044 134990464 154135009 169631399 X 9308003 7114417 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2341520 2341520 46003898 15054555 30949343 2540820 1262151 1278669 51681491 31876159 19805332 436924 436924 54811788 457(B) PAYABLE 1238274 LONG-TERM PTO 470767 ASBESTOS PAYABLE 91900 1800941 82006592 72698589 9308003 6914095 200322 7114417 16422420 78635202 0 78635202 3371390 3371390 82006592 70652027 0 70652027 2046562 2046562 72698589 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HEALTH SYSTEM FOLLOWS THE GUIDANCE IN THE ACCOUNTING STANDARDS REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE GUIDANCE CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE GUIDANCE FURTHER PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE APPLICATION OF THIS STANDARD HAS NO IMPACT ON THE HEALTH SYSTEM'S FINANCIAL STATEMENTS. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN TEMPORARILY RESTRICETED NET ASSETS 200,322. PART XII, LINE 4B - OTHER ADJUSTMENTS: OTHER INCOME 116,350. INVESTMENT INCOME 3,255,040. PART XIII, LINE 4B - OTHER ADJUSTMENTS: 2010 BOND REFINANCING LOSS 2,046,562. 1 1 X 1 X 1 X 1 1 1 0 1 0 212536 212536 0.00290 3020965 1080075 1940891 0.02670 3721786 1786158 1935628 0.02660 6955287 2866233 4089055 0.05620 3632012 4441632 -809620 0.00000 113500 113500 0.00160 3745512 4441632 -696120 0.00160 10700799 7307865 3392935 0.05780 30000 30000 0.00000 30000 30000 1 1421763 28951542 24099923 4851619 X 1 1 1 1 PRAIRIE LAKES HOSPITAL

401 9TH AVE NW WATERTOWN SD 57201

X X X NA 1 3 SISSETON SATELLITE DIALYSIS

5 EAST CHESTNUT SISSETON SD 57262

DIALYSIS UNIT BROOKINGS SATELLITE DIALYSIS

300 22ND AVENUE BROOKINGS SD 57006

DIALYSIS UNIT ORTONVILLE SATELLITE DIALYSIS

450 EASTVOLD AVENUE ORTONVILLE MN 56278

DIALYSIS UNIT PART I, LINE 7: THE COSTS ARE CALCULATED USING A COST TO CHARGE RATIO. $2,508,573 IN BAD DEBT EXPENSE WAS ELIMINATED WHEN CALCULATING PART I, LINE 7. PART II: THE ORGANIZATION SUPPORTS COMMUNITY BUILDING ACTIVITIES THROUGH ITS CASH DONATION TO FOCUS WATERTOWN, AN ECONOMIC DEVELOPMENT COMPANY THAT ATTRACTS NEW BUSINESSES TO WATERTOWN. PART III, LINE 4: BAD DEBT IS DETERMINED BY THE PERCENTAGE OF PRIVATE PAY ACCOUNTS THAT ARE HISTORICALLY WRITTEN OFF TO BAD DEBT. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE PERTAINING TO BAD DEBT EXPENSE. PART III, LINE 8: MEDICARE AMOUNTS WERE DERIVED FROM THE 2011 MEDICARE COST REPORT AND ASHORTFALL WAS NOT CALCULATED. PART III, LINE 9B: FINANCIAL ASSISTANCE/CHARITY CARE FORM IS SENT TO THE PATIENT FOR COMPLETION. UPON RECEIPT BY THE FACILITY, THE FORM AND GUIDELINES ARE REVIEWED AND THE PATIENT IS NOTIFIED OF THE QUALIFICATION FOR FINANCIAL ASSISTANCE/CHARITY CARE. THE PATIENT'S ACCOUNT(S) ARE THEN WRITTEN OFF. PART VI, LINE 2: THE FACILITY CONDUCTS NEEDS ASSESSMENT SURVEYS IN THE COMMUNITY AND SURROUNDING AREA TO DETERMINE WHAT HEALTH CARE SERVICES NEED TO BE ADDRESSED. PART VI, LINE 3: PRIVATE PAY INPATIENTS SPEAK WITH A SOCIAL WORKER TO DETERMINE IF THEY HAVE A NEED FOR FINANCIAL ASSISTANCE. THE SOCIAL WORKER WILL GIVE THEM A NUMBER OF AVAILABLE OPTIONS FOR ASSISTANCE. AFTER A PATIENT HAS RECEIVED STATEMENTS WITH THE PORTION THAT THEY ARE RESPONSIBLE FOR THEY ARE CONTACTED TO SEE IF THEY ARE IN NEED OF FINANCIAL ASSISTANCE. AT THAT TIME THEY ARE INFORMED OF ALL OPTIONS AVAILABLE TO THEM. PART VI, LINE 4: PRAIRIE LAKES HEALTH CARE SYSTEM'S PRIMARY SERVICE AREA COVERS 3 COUNTIES IN SOUTH DAKOTA WITH A POPULATION OF APPROXIMATELY 36,000. IT'S SECONDARY SERVICE AREA COVERS 4 COUNTIES IN SOUTH DAKOTA AND 3 COUNTIES IN MINNESOTA WITH A POPULATION OF 54,000. PART VI, LINE 6: THE ORGANIZATION OFFERS FREE HEALTH SEMINARS FREE TO COMMUNITY MEMBERS COVERING A VARIETY OF HEALTH TOPICS IN AN EFFORT TO EDUCATE PEOPLE ABOUT LEADING HEALTHY LIVES. COMMUNITY FORUMS ARE HELD TO UPDATE ATTENDEES ABOUT NEW EVENTS AND TECHNOLOGY AT THE FACILITY. THE ORGANIZATION WORKS WITH THE TECHNICAL INSTITUTE AND TWO STATE UNIVERSITIES TO HELP TRAIN MEDICAL STUDENTS. THE ORGANIZATION IS DEDICATED TO IMPLEMENTING AND MAINTAINING THE MOST CURRENT TECHNOLOGY IN PROVIDING CARE. PART VI, LINE 7: N/A 0 WATERTOWN AREA UNITED WAY PO BOX 283 WATERTOWN SD 57201 460359557 501(C)(3) 30000 GENERAL DONATION PRAIRIE LAKES HEALTH CARE FOUNDATION 401 9TH AVE NW WATERTOWN SD 57201 460350240 501(C)(3) 21262 BASH FUNDRAISING EVENT BOYS AND GIRLS CLUB OF WATERTOWN 1000 3RD AVE NE WATERTOWN SD 57201 460311845 501(C)(3) 7500 GENERAL DONATION SANFORD CLINIC 901 4TH ST NW WATERTOWN SD 57201 460447693 501(C)(3) 10000 GENERAL DONATION WATERTOWN SCHOOL DISTRICT PO BOX 730 WATERTOWN SD 57201 466001273 5000 GENERAL DONATION HUMAN SERVICE AGENCY PO BOX 1030 WATERTOWN SD 57201 460275247 501(C)(3) 6000 GENERAL DONATION FOCUS WATERTOWN PO BOX 332 WATERTOWN SD 57201 470813269 501(C)(6) 30000 ASSIST IN BRINGING BUSINESSES TO WATERTOWN 5 2 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE GRANTS ARE APPROVED BY ADMINISTRATION AND GIVEN AS UNRESTRICTED DONATIONS. THYE ARE NOT MONITORED ONCE GIVEN. X X X X X 0 0 0 0 0 0 0 0 0 JILL FULLER 309299 0 56500 0 0 0 19960 0 28489 0 414248 0 301657 0 MICHAEL ANDERSON 204000 0 100000 0 7692 0 14892 0 18500 0 345084 0 263937 0 EVELIO GARCIA MD 1124658 0 50000 0 0 0 7350 0 38500 0 1220508 0 1213963 0 IVALDO LUNARDI MD 546014 0 50000 0 0 0 7350 0 40500 0 643864 0 1137457 0 SALEM MAALIKI MD 955028 0 0 0 0 0 7350 0 16500 0 978878 0 927140 0 SAIRAV SHAH MD 711847 0 50000 0 0 0 0 0 0 0 761847 0 0 0 JEFFREY BRINDLE MD 462834 0 0 0 17858 0 7350 0 28908 0 516950 0 487004 0 SOUTH DAKOTA HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 460315509 83755VRN6 2010-12-08 21672812 CURRENT REFUNDING OF SERIES 1998 BONDS & ADVANCE REFUNDING OF SERIES 2002 0 0 0 2101397 25166290 3303 24731480 431508 1 1 1 1 0 0 0 0 1 0 0 0 0 0 0 SCHEDULE K, PART II, LINE 3 THE DIFFERENCE IN THE ISSUANCE PRICE INCLUDED IN PART I, LINE A, COLUMN E OF $21,672,812 IS DIFFERENT THAN THE TOTAL PROCEEDS OF ISSUANCE INCLUDED IN PART II, LINE 3 OF $25,166,290 IS THE TRUSTEE FUNDS UTILIZED DURING THE REFINANCING. EVELIO GARCIA MD SIGNING BONUS X 140000 42067 0 1 1 SALEM MAALIKI MD SIGNING BONUS X 75000 46566 0 1 1 88633 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPRISED OF THE OFFICERS OF THE ORGANIZATION. EXCEPT AS MAY BE LIMITED BY THE BOARD, THE EXECUTIVE COMMITTEE HAS AND EXERCISES THE AUTHORITY OF THE BOARD IN THE MANAGEMENT OF THE BUSINESS OF THE ORGANIZATION IN THE INTERVALS BETWEEN MEETINGS OF THE BOARD AND IS AT ALL TIMES SUBJECT TO THE CONTROL AND DIRECTION OF THE BOARD. THE EXECUTIVE COMMITTEE ALSO SERVES AS THE ORGANIZATION'S COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE COMMITTEE WILL REVIEW THE FORM 990 BEFORE IT IS FILED WITH THE IRS. THE FINANCE COMMITTE WILL DETERMINE IF IT IS NECESSARY FOR THE BOARD TO REVIEW THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C A CONFLICT OF INTEREST STATEMENT IS SIGNED BY ALL BOARD MEMBERS ON AN ANNUAL BASIS. THAT STATEMENT DISCLOSES ANY AREAS THAT MAY HAVE A POTENTIAL FOR CONFLICT OF INTEREST WITH THEMSELVES OR FAMILY MEMBERS. AT BOARD MEETINGS, THE MEMBERS WILL EXCUSE THEMSELVES FROM ANY DISCUSSION OR VOTING ON AN ISSUE WHERE A CONFLICT MAY EXIST. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION COMPARABILITY STUDIES ARE REVIEWED EACH YEAR FOR ALL POSITIONS. THE COMPENSATION STUDIES ARE CONDUCTED INTERNALLY BY THE HUMAN RESOURCES DEPARTMENT. THE HUMAN RESOURCES DEPARTMENT HAS ACCESS TO VARIOUS COMPENSATION SURVEYS WHICH THEY REVIEW IN ORDER TO DETERMINE IF THE HOSPITAL'S COMPENSATION IS REASONABLE COMPARED TO OTHER FACILITIES. THE LAST COMPENSATION STUDY WAS PERFORMED IN 2010. THE BOARD APPROVES SALARY OF THE CEO THROUGH ITS EXECUTIVE COMMITTEE SERVING AS THE COMPENSATION COMMITTEE. THE BOARD DELEGATES VICE PRESIDENT EXECUTIVE COMPENSATION APPROVAL TO CEO BASED ON THE ORGANIZATION'S COMPENSATION PHILOSOPHY IN CONJUNCTION WITH MARKET BENCHMARKS. THE EXECUTIVE COMMITTEE REVIEWS AND APPROVES THE SALARIES OF OTHER KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE AVAILABLE THROUGH FILINGS WITH BONDING AUTHORITY. THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 6,914,095. CHANGE IN TEMPORARILY RESTRICETED NET ASSETS 200,322. TOTAL TO FORM 990, PART XI, LINE 5: 7,114,417. PRAIRIE LAKES HOME CONNECTIONS INC 401 9TH AVE NW WATERTOWN SD 57201 460394984 HOMEMAKER & NURSING SERVICES SD 501(C)(3) 9 N/A 0 PRAIRIE LAKES FOUNDATION INC 401 9TH AVE NW WATERTOWN SD 57201 460350240 PROMOTES HEALTH EDUCATION AND GENERAL HEALTH AND WELL-BEING OF THE PUBLIC SD 501(C)(3) 7 N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0