2012-05-11T07:35:20-05:00 2011-06-30 EIDE BAILLY LLP 200 EAST 10TH STREET PO BOX 5125 SIOUX FALLS SD 571175125 990 2010-07-01 460225414 St Michael's Hospital Inc STMI 6055893341 410 West 16th Avenue Tyndall SD 570662318 Carol Deurmier 6055893341 2012-05-03 1 Laurie Hanson 6053391999 2012-05-03 2010 2016-02-24 21:20:13Z Carol Deurmier 410 West 16th Avenue Tyndall SD 570662318 8256492 0 0928 X www.avera.org/ash/stmichaels X 1966 SD To provide healthcare services. 7 7 96 56 381391 0 156561 26224 7443576 8156936 370105 69866 0 -6095 7970242 8246931 0 0 0 0 3410831 3746458 0 0 0 3766192 4121466 7177023 7867924 793219 379007 7235523 8194262 1474464 1729418 5761059 6464844 X It is the mission of St. Michael's Hospital to provide readily accessible health care to the people of Bon Homme County and the surrounding areas. In keeping with the heritage of the Catholic Church, St. Michael's will aim to promote the physical, mental, social and spiritual health of all its patients and residents. The health care centers will continue to offer quality services based on community needs and fiscal solvency. 0 0 6954696 8156936 St. Michael's Hospital, Inc. (SMH) operates a 25-bed critical access hospital with provider based rural health clinics located in Tyndall and in Avon. Laboratory and radiology personnel are also available as needed 24-hours a day, 7-days a week. During the fiscal year ending June 30, 2011, patient days were 344 and swing-bed days were 3,240. 6954696 1 0 0 0 0 0 0 0 1 1 1 0 0 0 1 1 0 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 0 0 0 0 0 1 16 0 1 96 1 1 1 0 0 0 0 0 0 0 0 0 X 7 7 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X Lisa Ronke 6055893341 410 W 16th Ave Tyndall SD 570662318 Dr James Torsney 1.00 X X 0 0 0 Russell Bechtold 1.00 X X 0 0 0 Jim Stoebner 1.00 X X 0 0 0 Marlene Zieser-Blackburn 1.00 X X 0 0 0 Father Gerald Thury 1.00 X 0 0 0 Sister Paulette Larsen 1.00 X 0 0 0 Marty Koch 1.00 X 0 0 0 Don Irish 1.00 X 0 0 0 Carol Deurmier 50.00 X 112518 0 22117 Lisa Ronke 40.00 X 35084 0 14530 Dr Melvin Wallinga 40.00 X 156072 0 19341 Dr Jill Kruse 40.00 X 155822 0 16422 459496 0 72410 3 0 1 1 Avera Sacred Heart Hospital 501 Summit Yankton SD 57078 Management, Speech, Occupational Therapy 549158 1 26224 26224 Patient Service Fees 621110 5867105 5867105 Retail Pharmacy 446110 2245441 1864050 381391 Miscellaneous 900099 44390 44390 8156936 69866 69866 3466 9561 -6095 -6095 -6095 8246931 7775545 381391 63771 192466 192466 2977678 2705651 272027 104235 94915 9320 252177 229484 22693 219902 196829 23073 29100 29100 20097 13190 6907 7972 1385 6587 52111 15291 36820 125942 125942 302044 291876 10168 16347 10592 5755 1308 1308 49057 49057 373464 373464 73539 73539 Supplies 2799552 2760977 38575 ACS Fees 95815 95815 Bad Debt 59583 59583 Equipment Lease and Ren 39346 30067 9279 Dues and Subscriptions 26998 14370 12628 49191 33117 16074 7867924 6954696 913229 0 1665228 1465504 774920 762484 26172 26172 320123 409483 33404 32121 7825297 4455996 2940507 3369301 348079 841735 1099711 1262940 27379 24522 7235523 8194262 546462 878481 1798 237 926204 850700 1474464 1729418 X 5729819 6433186 11862 12020 19378 19638 5761059 6464844 7235523 8194262 X 379007 324778 X 0 1 0 X 0 X 19378 260 19638 19138 240 19378 18878 260 19138 0.00000 1.00000 0.00000 0 0 62249 28819 91068 3519356 1738946 1780410 4114346 2664315 1450031 100527 52735 47792 3369301 Interest in Avera Pooled Investment Funds 1262940 F 1262940 8246931 7867924 379007 173475 151303 324778 703785 8420406 173475 173475 8246931 0 8246931 7867924 0 7867924 0 7867924 Description of Intended Use of Endowment Funds: Part V, Line 4: The intended use of the organization's endowment funds is to provide for capital needs that may arise. 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. The Hospital's federal Form 990 filings are no longer subject to federal tax examinations by tax authorities for years before 2008. Part XI, Line 8 - Other Adjustments: Net assets released from restrictions 150,885. Increase in temporarily restricted net assets 158. Increase in permanently restricted net assets 260. 1 1 X 1 X 1 X 100.000000000000 1 1 0 1 1 29190 29190 0.00370 172089 163769 8320 0.00110 201279 163769 37510 0.00480 118862 9345 109517 0.01400 18880 18880 0.00240 1324631 851425 473206 0.06060 10950 10950 0.00140 1473323 860770 612553 0.07840 1674602 1024539 650063 0.08320 557 557 0.00010 1040 1040 0.00010 2067 2067 0.00030 3664 3664 0.00050 0 45539 19662 2775487 2748006 27481 X 1 1 1 1 St Michael's Hospital Inc

410 West 16th Avenue Tyndall SD 570660027

X X X X NA 1 3 St Michaels Hospital Inc

410 West 16th Avenue Tyndall SD 57066

Wellness Center Bon Homme Family Practice Clinic

130 Main Street Avon SD 57315

Family Practice Clinic Bon Homme Family Practice Clinic

410 West 16th Avenue Tyndall SD 57066

Family Practice Clinic Part I, Line 3c: In addition to the use of FPG to determine eligibility for free or discounted care, SMH also looks at the patient's assets, liabilities, outstanding medical debts and the overall debt to asset ratio for each situation. Being in a rural community with a small population, SMH may also use known information of a patient's hardships in making the final decision. Part I, Line 6a: SMH prepares a community benefit report that is submitted to Avera Health. The information is then made available to the public through Avera Health's community benefit report. Part I, Line 7: Line 7a was determined using the ratio of patient care costs to charges calculated in IRS Worksheet 2. Lines 7e, 7f, and 7i were obtained utilizing the actual general ledger system. Lines 7b and 7g were obtained from the Medicare cost report. Part I, Line 7g: The expenses of the rural health clinics total $804,282. Part I, L7 Col(f): Bad debt expense of $59,583 was subtracted from total operating expense. Part II: SMH is involved with the area Chamber of Commerce and Rotary Club. SMH works to enhance the quality of life and empower its patients, care-givers and community with the resources they need when they need them. SMH also provides healthcare career education to promote healthcare careers and rural health. Part III, Line 4: a) The cost to charge ratio was calculated on IRS Worksheet 2 for the fiscal year ending 6/30/2011.b) The amount on line 3 of $19,662 is 33% of total bad debt expense. The number is based on a detailed review of the accounts that are currently listed with Credit Collection Bureau and Accounts Management. Upon reviewing each account that is at CCB and AMI, it was found that about 33% of the outstanding balances may have been eligible under the facility's charity care policy. Since we are a small community, we were able to identify which accounts may have qualified for charity care because of low income or some known hardship to the household. Also for this review process, any families with prior applications for charity care were given consideration when reviewing the CCB and AMI accounts. c) Bad debt expense is made up of the actual accounts that are written off during the year as well as a change in the estimate for patient accounts that are still outstanding on the books and records of the facility. Bad debt recoveries are posted as a reduction to bad debt expense.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: SMH 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 does not pursue collections of amounts determined to qualify as charity care. Part VI, Line 2: The South Dakota Department of Health's Rural Health office conducted a Community Assessment for Bon Homme County with a special focus on the needs of the communities of Tyndall and Avon. SMH utilized this data in determining services needed.The Community Assessment compiled by the South Dakota Office of Rural Health for Bon Homme County identified a high health status indicator for diabetes mellitus (41.6 compared to 25.0 in the entire state of South Dakota and 24.4 in the United States). SMH has established a diabetes education program that has been awarded Education Recognition by the American Diabetes Association. This education is provided by an interdisciplinary team which includes a dietitian and nurses with specialized training. The program is available to all persons, and is designed to provide a benefit the community.The Medical Staff of SMH, in working with the activity directors and coaching staffs of our local schools, also identified a concern for safety for athletes who have suffered a concussion and the need for a consistent process to determine when it is safe for the child to resume participation. In response to that need, SMH now provides an Impact program to high school students who participate in athletic programs in Tyndall and in Avon. The Impact program is funded totally by SMH and is provided free of charge to the students. It provides a baseline which can be used to assist in the determination for safe return to play after a concussion occurs. Part VI, Line 3: The SMH staff assists patients who may be eligible for financial assistance by discussing the availability of various government benefits, such as Medicaid or state programs, and assisting the patient with qualification for such programs where applicable. The programs are discussed at the time of admission and by patient request. Posters highlighting various assistance options (i.e. All Women Count) are posted in the admission area. SMH staff also discusses the availability of its charity care policy with patients upon admission. Part VI, Line 4: SMH serves a rural population in Bon Homme County which includes the cities of Tyndall, Avon, Tabor, and Springfield. There is one other hospital in Bon Homme County located in Scotland.The 2010 census for Bon Homme County reported 7,070 people with 12.4% of the population at 100% poverty or below. 19.1% of Bon Homme County's population is age 65 or older (compared to 14.3% in the state of South Dakota). Part VI, Line 6: The majority of SMH's governing body is comprised of persons who reside in Bon Homme County who are neither employees nor contractors of the organization, nor family members thereof. The organization extends medical staff privileges to all qualified physicians in its community for some or all of its departments. SMH applies surplus funds to improvements in patient care and providing readily accessible health care to the people of Bon Homme County and the surrounding area.SMH provides a variety of community benefit health activities at no cost or less than cost. These activities include wellness programs, diabetes education, foot clinics, CPR classes, and blood pressure screenings. A variety of programs are provided at no charge for the children in our communities such as the Impact concussion program, flu shot clinics, and athletic screenings. SMH also provides athletic physicals for students at a discounted rate. SMH provides a nurse on an as needed basis for ambulance transfers at no cost to the local ambulance service. Approximately 1,889 clients were served during the fiscal year ended 6/30/2011. SMH provided financial and in kind donations for various community needs such as meeting room availability, medical staff coverage at local sporting events, supplies for local blood drive and health education, along with Health Profession education for nursing and physical therapy students.SMH provides emergency services 24-hours a day, 7-days a week. In addition to nursing staff, a midlevel provider and/or physician are in house or on call at all times to provide care to anyone presenting with an emergent condition, regardless of their ability to pay. For fiscal year ended 6/30/2011, there were 621 patients who received emergency care at SMH.SMH has also made available e-Emergency services through an arrangement with Avera Health whereby emergency physicians and other specialists are available via videoconferencing to assist the medical staff and nurses with patients presenting to the SMH emergency room. The e-Emergency services are provided at no cost to the patient. 30 patients benefited from the e-Emergency services during fiscal year ended 6/30/2011. Part VI, Line 7: SMH 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, SMH 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.SMH 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 SMH 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 SMH 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 0 0 0 1 0 0 0 0 0 Carol Deurmier 111630 0 0 0 888 0 5000 0 17796 0 135314 0 0 0 Dr Melvin Wallinga 155298 0 0 0 774 0 6560 0 12781 0 175413 0 0 0 Dr Jill Kruse 155678 0 0 0 144 0 6230 0 10192 0 172244 0 0 0 Part I, Line 5 Dr. Wallinga is paid based on production. Supplemental Information Part III Form 990, Part VII, Section A, Line 5 & Form 990, Schedule J, Part II: Carol Deurmier, CEO, is compensated by Avera Sacred Heart Hospital, 501 Summit, Yankton, SD 57078. Dr Jill Kruse Recruitment X 26172 26172 0 1 1 26172 Form 990, Part VI, Section A, line 3 St. Michael's Hospital has a Partners in Health management agreement with Avera Sacred Heart Hospital. Form 990, Part VI, Section A, line 8b The Board of Director committees are advisory in nature only and do not have authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The CEO and CFO review the 990. The 990 is then provided to each board member for their review prior to the actual filing of the 990. Form 990, Part VI, Section B, line 12c St. Michael's Hospital Conflict of Interest Policy covers any director/trustee, officer, member of a committee with Board-delegated powers, key employee who has a direct or indirect financial interest, CEO and CFO as well as their family members. SMH requires any director/trustee, Board committee member, officer and key employee to disclose the existence of a financial interest, other actual or possible conflict of interest and all material facts annually by completing a disclosure statement; and if a conflict of interest arises after the completion of the annual disclosure, at the time the new conflict arises. The Board of Directors makes the determination as to whether a conflict of interest exists. The Board of Directors addresses conflict of interests via a formalized procedure. This procedure may include a presentation by the interested person, but excludes the interested person from further discussion or voting on the transaction or arrangement that may constitute a conflict of interest. The Board of Directors also include a standing agenda item at the beginning of each meeting which requires the disclosure of potential conflict of interest for any items included on the agenda. Form 990, Part VI, Section B, line 15 Compensation for the CEO is determined by SMH's Board of Directors. This compensation process includes an annual performance review and comparability data. The CEO determines the compensation for other key employees including the CFO based on an annual performance appraisal and use of comparability data. Form 990, Part VI, Section C, line 19 The documents are not available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 173,475. Net assets released from restrictions 150,885. Increase in temporarily restricted net assets 158. Increase in permanently restricted net assets 260. Total to Form 990, Part XI, Line 5: 324,778.