2012-05-01T08:49:05-05:00 2011-06-30 EIDE BAILLY LLP 200 EAST 10TH STREET PO BOX 5125 SIOUX FALLS SD 571175125 990 2010-07-01 460228038 MADISON COMMUNITY HOSPITAL MADI 6052566551 917 N WASHINGTON AVE MADISON SD 57042 TAMARA MILLER 6052566551 2012-04-26 1 LAURIE HANSON 6053391999 2012-04-26 2010 2016-02-24 21:20:13Z TAMARA MILLER 917 N WASHINGTON AVE MADISON SD 57042 12740989 0 X WWW.MADISONHOSPITAL.COM X 1955 SD PROVIDE HEALTH CARE SERVICES TO AREA RESIDENTS. 11 11 168 15 0 0 56283 134848 12500713 12537792 65615 62449 5500 5900 12628111 12740989 0 0 0 0 6574529 6665732 0 0 0 5284479 5577866 11859008 12243598 769103 497391 10200608 10822178 803441 950000 9397167 9872178 X MADISON COMMUNITY HOSPITAL SERVES AS A COMMUNITY HEALTH FOCAL POINT THROUGH THE PROVISION AND MAINTENANCE OF A PROGRESSIVE, EFFICIENT, AND WELL MANAGED HEALTHCARE INSTITUTION, COMMITTED TO QUALITY MEDICAL PRACTICE, AND HIGH ETHICAL STANDARDS.MADISON COMMUNITY HOSPITAL SERVES AS A COMMUNITY AND SERVICE AREA BASED PRIMARY CARE INSTITUTION WITH BASIC SECONDARY CARE SUPPORT SERVICES, AND FACILITIES PROVIDED TO MEET DEMONSTRATED NEEDS WHICH CAN BE MET WITHIN THE FINANCIAL AND RESOURCE CONSTRAINTS OF THE ORGANIZATION. 0 0 10717882 12423644 MADISON COMMUNITY HOSPITAL (HOSPITAL) IS A 25-BED ACUTE CARE HOSPITAL LOCATED IN MADISON, SOUTH DAKOTA. FOR THE YEAR ENDED JUNE 30, 2011: ACUTE PATIENT DAYS = 1,058; NEWBORN DAYS = 87; SKILLED DAYS = 1,357; AND INTERMEDIATE DAYS = 177.TO FULFILL ITS MISSION OF COMMUNITY SERVICE, THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FORGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY AND EQUIVALENT SERVICE STATISTICS. THE AMOUNTS FORGONE, BASED ON ESTABLISHED RATES, WERE $54,043.60 FOR THE YEAR ENDED JUNE 30, 2011. 10717882 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 26 0 1 168 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 0 0 X MRS TAMARA MILLER 6052566551 917 N WASHINGTON AVE MADISON SD 57042 BRAD WILKENS 1.00 X X 0 0 0 LOREN SCOTT 1.00 X X 0 0 0 LOIS NIEDERT 1.00 X X 0 0 0 CHRIS LEMAIR 1.00 X X 0 0 0 NORM JOHNSON 1.00 X 0 0 0 DAN BROWN 1.00 X 0 0 0 PEGGY CASANOVA 1.00 X 0 0 0 ROBIN SCHWEBACH 1.00 X 0 0 0 LELAND WHITE 1.00 X 0 0 0 JAN DAVIS 1.00 X 0 0 0 GREG HOLLISTER 1.00 X 0 0 0 TAMARA MILLER 40.00 X 134104 0 23588 ROBERT SUMMERER 40.00 X 507640 0 30294 DARREL SIMON 40.00 X 192584 0 21330 DARWIN EGEBERG 40.00 X 111593 0 10494 945921 0 85706 4 0 1 0 UNIVERSAL HOSPTIAL SERVICES 7505 S LOUISE AVE SIOUX FALLS SD 57108 BIO-MED CONTRACT 360165 INTERLAKES MEDICAL CENTER 903 N WASHINGTON AVE MADISON SD 57042 ER CALL COVERAGE 283533 SANFORD LABORATORIES PO BOX 5056 SIOUX FALLS SD 57117 REFERENCE LAB 186479 MEDICAL X-RAY CENTER 1417 S MINNESOTA AVE SIOUX FALLS SD 57105 OUTREACH MRI 132818 DMS IMAGING SDS 12-2208 PO BOX 86 MINNEAPOLIS MN 55486 OUTREACH NUC MED 115592 5 41755 93093 134848 PATIENT SERVICE REV 900099 12339996 12339996 MEALS 624210 86897 86897 MCMC REVENUE 621110 77748 77748 MISCELLANEOUS 900099 33151 33151 12537792 57449 57449 5900 5900 5900 5900 5000 5000 5000 5000 12740989 12423644 0 182497 158319 158319 5040009 4659475 380534 240972 223183 17789 797766 733289 64477 428666 385977 42689 58038 58038 99739 99739 788118 515212 272906 102886 102886 1909698 1801729 107969 117706 117706 35958 35856 102 28644 21678 6966 597957 597957 150867 150867 OUTREACH 629715 629715 BAD DEBTS 608048 608048 MAINTENANCE AND REPAIRS 336995 336995 DUES AND SUBSCRIPTIONS 22666 22666 90831 51062 39769 12243598 10717882 1525716 0 3950686 4780679 1588380 1689834 1000 129540 140055 309007 352691 114019 111971 10924055 7302669 3682034 3621386 426942 124562 10200608 10822178 803441 950000 803441 950000 X 9336534 9792928 60633 79250 9397167 9872178 10200608 10822178 X 497391 -22380 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4663527 2696273 1967254 5968219 4443964 1524255 292309 162432 129877 3621386 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL AND CENTER BELIEVES THAT THEY HAVE 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 AND CLINIC 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. 1 1 X 1 X 130.000000000000 1 X 1 1 1 0 0 36092 36092 0.00310 617931 377340 240591 0.02070 654023 377340 276683 0.02380 4703 4703 0.00040 1312434 870202 442232 0.03800 1317137 870202 446935 0.03840 1971160 1247542 723618 0.06220 0 406073 84167 4945061 4896100 48961 X 1 0 1 1 MADISON COMMUNITY HOSPITAL

917 N WASHINGTON AVENUE MADISON SD 57042

X X X NA 1 PART I, LINE 7: LINES 7A AND 7B WERE DETERMINED USING THE RATIO OF PATIENT CARE COSTS TO CHARGES CALCULATED IN WORKSHEET 2. LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT. LINE 7E WAS DETERMINED USING THE GENERAL LEDGER. PART I, L7 COL(F): BAD DEBT EXPENSE OF $608,048 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. 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 POSTED IN A SEPARATE ACCOUNT ON THE GENERAL LEDGER. THIS ACCOUNT IS COMBINED WITH THE BAD DEBT EXPENSE ACCOUNT TO RESULT IN A NET BAD DEBT EXPENSE AMOUNT ON THE AUDITED FINANCIAL STATEMENT. THE BAD DEBT ALLOWANCE AND EXPENSE TAKES CONTRACTUAL ALLOWANCES INTO ACCOUNT.C) THE HOSPITAL APPLIED THE 2011 POVERTY LEVEL PERCENTAGE FOR ITS AREA TO THE TOTAL AMOUNT SENT TO COLLECTIONS DURING THE FISCAL YEAR ENDED JUNE 30, 2011 TO DETERMINE AN ESTIMATE OF ELIGIBLE CHARITY CARE REPORTED AS BAD DEBT. 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 VI, LINE 2: A DEMOGRAPHIC AND SERVICE LINE ANALYSIS WAS COMPLETED TO DETERMINE COMMUNITY HEALTHCARE NEEDS. IN ADDITION, A PREVIOUSLY COMPLETED COMMUNITY HEALTHCARE NEEDS ASSESSMENT FOR OUR COUNTY IS REFERRED TO FREQUENTLY FOR INFORMATION. PART VI, LINE 3: DISCHARGE PLANNING PERSONNEL IN THE BUSINESS OFFICE COUNSEL PATIENTS UPON ADMISSION AND THROUGH THE DISCHARGE PLANNING PROCESS ON MEDICAID, COUNTY WELFARE PROGRAMS, CHARITY CARE, ETC. FINANCIAL ASSISTANCE PROGRAMS ARE DETAILED EITHER IN PERSON OR THROUGH A BROCHURE THAT EXPLAINS THE HOSPITAL'S FINANCIAL ASSISTANCE AND PAYMENT REQUIREMENTS. COVERED VS NONCOVERED CHARGES ARE DISCUSSED WITH THE PATIENT. A PATIENT ASSESSMENT, INCLUDING A DISCUSSION ON FINANCIAL RESPONSIBILITIES, CONCERNS, AND GOVERNMENT PROGRAMS, IS COMPLETED ON EACH INPATIENT BY DISCHARGE PLANNING. PART VI, LINE 4: MADISON COMMUNITY HOSPITAL IS THE ONLY HOSPITAL IN THE SERVICE AREA. EIGHT PHYSICIANS AND THREE PHYSICIAN EXTENDERS PRACTICE IN THE COMMUNITY. THE SERVICE AREA FOR MCH INCLUDES 14 ZIP CODE COMMUNITIES THAT ARE WITHIN A 21-MILE RADIUS OF THE HOSPITAL. IT INCLUDES ALL OF LAKE COUNTY AND PORTIONS OF BROOKINGS, KINGSBURY, MINER, MOODY, MCCOOK AND MINNEHAHA COUNTIES. TOTAL SERVICE AREA POPULATION WAS CALCULATED AT 19,625 IN 2010. ESTIMATED MEDIAN HOUSEHOLD INCOME IN 2010: $45,606. PART VI, LINE 6: THE GOVERNING BODY OF MADISON COMMUNITY HOSPITAL IS COMPRISED OF COMMUNITY MEMBERS, NONE OF WHICH ARE EMPLOYEES OR CONTRACTORS OF THE HOSPITAL. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. SURPLUS FUNDS ARE USED TO IMPROVE PATIENT CARE AND FACILITIES. THE HOSPITAL OPERATES AN EMERGENCY ROOM WHICH IS AVAILABLE TO ALL REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL PARTICIPATES IN EDUCATION AND TRAINING OF HEALTHCARE PROFESSIONALS THROUGH RESIDENCIES AND INTERNSHIPS FOR NURSING STUDENTS, THERAPY STUDENTS, PHYSICIANS AND PHYSICIAN'S ASSISTANTS. THE HOSPITAL PARTICIPATES IN SEVERAL GOVERNMENT SPONSORED HEALTH PROGRAMS, INCLUDING BUT NOT LIMITED TO: MEDICARE, MEDICAID, VA, TRI-CARE, AND ALL-WOMEN-COUNT. THE HOSPITAL OFFERS VOLUNTEER OPPORTUNITIES TO MEMBERS OF THE COMMUNITY. X X 0 0 0 1 0 0 0 0 0 TAMARA MILLER 133800 0 0 0 304 0 6895 0 17624 0 158623 0 0 0 ROBERT SUMMERER 507336 0 0 0 304 0 12532 0 18693 0 538865 0 0 0 DARREL SIMON 192446 0 0 0 138 0 10120 0 11976 0 214680 0 0 0 PART I, LINE 5 ROBERT SUMMERER, DR., IS PAID BASED ON PRODUCTION. LAURA NIEDERT PARAMEDIC CLASSES X 1000 1000 0 1 1 1000 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL HAVE THE BOARD PRESIDENT AS ITS CHAIRMAN AND FOUR APPOINTED MEMBERS. THE EXECUTIVE COMMITTEE SHALL HAVE POWER TO TRANSACT ALL REGULAR BUSINESS OF THE FACILITY DURING THE INTERIM BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS, PROVIDED ANY ACTION TAKEN SHALL 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 B, LINE 11 THE ADMINISTRATOR AND DIRECTOR OF ACCOUNTING REVIEW THE 990 IN DETAIL. AFTER THEIR REVIEW, THE 990 IS PROVIDED TO EACH BOARD MEMBER. THE ADMINISTRATOR PRESENTS THE 990 TO THE BOARD OF DIRECTORS AT THE MEETING HELD PRIOR TO ITS FILING IF SO REQUESTED BY ANY BOARD MEMBER. WHETHER PRESENTED IN A BOARD MEETING OR NOT, THE 990 IS NOT FILED UNTIL EACH BOARD MEMBER HAS BEEN GIVEN A COPY OF IT AND GIVEN AMPLE TIME TO REVIEW IT. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS AND OFFICERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE BOARD WILL REVIEW ACTUAL CONFLICTS AND MAKE DETERMINATIONS WHETHER A CONFLICT EXISTS. THE RESTRICTIONS ARE IMPOSED ON A CASE BY CASE BASIS BASED ON THE BOARD'S DETERMINATION. FORM 990, PART VI, SECTION B, LINE 15A THE CEO'S COMPENSATION AND BENEFITS ARE REVIEWED ON AN ANNUAL BASIS IN EXECUTIVE SESSION AT THE BOARD OF TRUSTEE MEETING. THE BOARD OF TRUSTEES APPROVES THE SALARY AND BENEFITS COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THESE DOCUMENTS ARE NOT AVAILABLE TO THE GENERAL PUBLIC OTHER THAN AS INCLUDED ON THE WEBSITE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: LOSS FROM WHOLLY OWNED SUBSIDIARY -22,380. TOTAL TO FORM 990, PART XI, LINE 5: -22,380. MADISON COMMUNITY MEDICAL CENTER 917 N WASHINGTON AVENUE MADISON SD 57045 460398320 OFFICE RENTAL SD N/A C 117292 283329 1.00000 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 MADISON COMMUNITY MEDICAL CENTER P 77748 FMV