2012-05-14T12:14:50-05:00 2011-06-30 EIDE BAILLY LLP 200 EAST 10TH STREET PO BOX 5125 SIOUX FALLS SD 571175125 990 2010-07-01 460226283 WAGNER COMMUNITY MEMORIAL HOSPITAL WAGN 6053843611 513 THIRD STREET SW WAGNER SD 573800280 BRYAN SLABA 6053843611 2012-05-07 1 LAURIE HANSON 6053391999 2012-05-07 2010 2016-02-24 21:20:13Z BRYAN SLABA 513 THIRD STREET SW WAGNER SD 573800280 7865930 0 X N/A X 1947 SD TO PROVIDE HEALTHCARE SERVICES. 9 9 84 9 0 0 930609 454381 6901908 7342022 30440 55025 14652 14502 7877609 7865930 2688 2133 0 0 3336694 3535003 0 0 0 3971601 4361941 7310983 7899077 566626 -33147 8125154 10546961 4100156 5866459 4024998 4680502 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 6712073 2133 7342022 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 1,004 INPATIENT DAYS, 458 SWING BED DAYS, 2,003 EMERGENCY DEPARTMENT VISITS, 1,501 URGENT CARE VISITS AND 1,350 CLINIC VISITS. 6712073 1 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 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 27 0 1 84 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 DAVE ANDREWS 0.50 X 0 0 0 BILL FREI 0.50 X 0 0 0 BRYAN SLABA 40.00 X 106307 0 21509 ROBERT HUBLEY 40.00 X 208144 0 24477 AHMED DESSOUKI 40.00 X 216183 0 17468 530634 0 63454 3 0 1 1 AVERA SACRED HEART HOSPITAL 501 S SUMMIT STREET YANKTON SD 57078 MANAGEMENT AND IT SERVICES 406400 AVERA SACRED HEART RURAL HEALTH 501 S SUMMIT STREET YANKTON SD 57078 CONTRACT PHYSICIAN LABOR 215624 DR JEFFERY PINTER 27952 323RD AVENUE WINNER SD 57580 PHYSICIAN ER COVERAGE 215540 ARCHITECTURE INC 415 S MAIN AVE SIOUX FALLS SD 57101 ARCHITECTURE SERVICES 145737 DR GARY A BUBAK 29778 398TH AVENUE WAGNER SD 57380 PHYSICIAN ER COVERAGE 108975 5 450849 3532 454381 MNGMNT & IT SERVICES 622110 7206715 7206715 APARTMENT REVENUE 900099 102121 102121 OTHER REVENUE 900099 33119 33119 PATIENT INT REVENUE 900009 67 67 7342022 39005 39005 14502 14502 14502 14502 16020 16020 16020 16020 7865930 7342022 0 69527 2133 2133 124894 124894 139070 139070 2784246 2431636 352610 48012 40491 7521 252563 212999 39564 186218 157047 29171 3130 3130 33675 33675 562799 418222 144577 48296 48296 1510929 1430839 80090 38322 2100 36222 116530 116530 16174 15592 582 51629 16573 35056 117026 117026 552170 552170 46985 46985 BAD DEBT 649645 649645 REPAIRS AND MAINTENANCE 310194 305188 5006 ACS FEES 130816 12000 118816 TAXES AND LICENSES 33498 33498 DUES AND SUBSCRIPTIONS 20977 10134 10843 119146 2195 116951 7899077 6712073 1187004 0 1267479 719839 8201 0 1377552 1480843 70226 104278 66638 77627 11796365 4366903 4472726 7429462 841404 714508 20928 20404 8125154 10546961 630979 1220937 37000 3432177 4639501 0 6021 4100156 5866459 X 3671277 4679746 353721 756 4024998 4680502 8125154 10546961 X -33147 688651 X 0 1 0 X 1 1 X 4247 4247 5734754 2830892 2903862 2781330 1503869 1277461 3276034 32142 3243892 7429462 INTEREST IN POOLED INVESTMENT FUND 711249 F INTEREST IN NET ASSETS OF AVERA HEALTH FOUNDATION 3259 F 714508 TENANT SECURITY DEPOSITS 6021 6021 7865930 7899077 -33147 74891 613760 688651 655504 8554581 74891 613760 688651 7865930 0 7865930 7899077 0 7899077 0 7899077 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 613,760. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF AVERA HEALTH FOUNDATION 613,760. 1 1 X 1 X 1 X 1 1 1 0 1 1 245 81376 20920 60456 0.00830 4437 1475002 1123909 351093 0.04840 595912 571844 24068 0.00330 4682 2152290 1716673 435617 0.06000 10 1793 13420 13420 0.00190 3 72 4020 4020 0.00060 4 2007603 504528 1503075 0.20730 3 2177 3528 3528 0.00050 20 4042 2028571 504528 1524043 0.21030 20 8724 4180861 2221201 1959660 0.27030 3 56 102417 102121 296 0.00000 2 35 1720 1720 0.00020 101498 101498 0.01400 3 417 1677 1677 0.00020 8 508 207312 102121 105191 0.01440 0 357692 324612 2436275 2412154 24121 X 1 1 1 1 WAGNER COMMUNITY MEMORIAL HOSPITAL

PO BOX 280 WAGNER SD 57380

X X X X NA 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 3C: 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: LINES 7A, 7B AND 7C WERE DETERMINED USING THE RATIO OF PATIENT CARE COSTS TO CHARGES CALCULATED USING WORKSHEET 2. LINES 7E, 7F AND 7I WERE OBTAINED UTILIZING THE ACTUAL GENERAL LEDGER SYSTEM. LINE 7G WAS OBTAINED FROM THE MEDICARE COST REPORT. PART I, LINE 7G: THE RURAL HEALTH CLINIC EXPENSE TOTALLED $1,057,233. PART I, L7 COL(F): BAD DEBT EXPENSE OF $649,645 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II: WCMH OWNS TWO ELDERLY AND DISABLED INDEPENDENT LIVING FACILITIES. THE FACILITIES ARE BOTH RENT SUBSIDIZED AND COMBINED HAVE A TOTAL OF 26 UNITS. WCMH WAS ALSO ABLE TO RECRUIT AND RETAIN A PA-C TO ASSIST WITH THE NEEDS OF THE AREA. PART III, LINE 4: A) THE COST-TO-CHARGE RATIO WAS CALCULATED USING WORKSHEET 2.B) 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.C) 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.D) FOOTNOTE FROM FINANCIAL STATEMENT: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST 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. MANAGEMENT ALSO REVIEWS ACCOUNTS TO DETERMINE IF CLASSIFICATION AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE FISCAL YEAR ENDING 6/30/2011. PART III, LINE 9B: ALL SERVICES PROVIDED AT THE WAGNER COMMUNITY MEMORIAL HOSPITAL & CLINIC ARE EXPECTED TO BE PAID IN FULL AFTER RECEIVING THE BILL OF SERVICES. MEDICARE, MEDICAID AND COMMERCIAL INSURANCE WILL BE SENT AT THE REQUEST OF THE PATIENT PROVIDED WE HAVE THE CORRECT INSURANCE INFORMATION. ANY CO-INSURANCE OR DEDUCTIBLES MUST BE PAID AT THE TIME OF SERVICES OR OTHER ARRANGEMENTS NEED TO BE MADE BEFORE DISCHARGE. - A STATEMENT WILL BE SENT OUT MONTHLY TO THE RESPONSIBLE PARTY ALLOWING THEM TO PAY IN FULL OR MAKE ARRANGEMENTS TO PAY IN FULL. ARRANGEMENTS MUST BE CONFIRMED IN WRITING.- AN INTEREST CHARGE OF 1% MONTHLY MAY BE CHARGED TO ALL SERVICES 90 DAYS OLD OR OLDER.- PATIENTS MAY RECEIVE A FINAL NOTICE IF NO PAYMENT AGREEMENT HAS BEEN MADE FOR SERVICES 90 DAYS OR OLDER.- PATIENTS MAY RECEIVE A FINAL NOTICE IF NO PAYMENT AGREEMENT HAS BEEN MADE AFTER THIRD PARTY PAYORS HAVE MADE PAYMENT.-FOLLOWING THE FINAL NOTICE, PATIENT ACCOUNTS MAY BE TURNED OVER TO SMALL CLAIMS COURT OR TO A COLLECTION AGENCY. THIS MAY RESULT IN ADDITIONAL FEES THAT WILL BE CHARGED TO THE ACCOUNT.-ALL ACCOUNT COLLECTIONS ARE TREATED THE SAME, AND THE POLICY DOES NOT OUTLINE ANY PROVISIONS FOR THE COLLECTION PRATICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. HOWEVER, A REVIEW MAY BE MADE EITHER AT THE REQUEST OF THE PATIENT OR HOSPITAL STAFF TO DETERMINE IF THE ACCOUNT MAY QUALIFY FOR CHARITY CARE. 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. 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 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 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 6: 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 7: 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 106015 0 0 0 292 0 4694 0 17494 0 128495 0 0 0 ROBERT HUBLEY 207771 0 0 0 373 0 3899 0 21257 0 233300 0 0 0 AHMED DESSOUKI 216183 0 0 0 0 0 0 0 17468 0 233651 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. VICKI THALER FAMILY RELATIONSHIP WITH KEN THALER, BOARD MEMBER. 44506 EMPLOYEE COMPENSATION 0 MARCIA PODZIMEK FAMILY RELATIONSHIP WITH DOROTHY HOLZBAUR, BOARD MEMBER. 45336 EMPLOYEE COMPENSATION 0 DEBORAH HUBLEY FAMILY RELATIONSHIP WITH ROBERT HUBLEY, HIGHEST COMPENSATED EMPLOYEE. 49228 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 SEVICES 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 KEY EMPLOYEES 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 GAINS ON INVESTMENTS: 74,891. CHANGE IN INTEREST IN NET ASSETS OF AVERA HEALTH FOUNDATION 613,760. TOTAL TO FORM 990, PART XI, LINE 5: 688,651.