2012-08-14T15:41:14-05:00 2011-09-30 EIDE BAILLY LLP 200 EAST 10TH STREET PO BOX 5125 SIOUX FALLS SD 571175125 990 2010-10-01 460255944 MOBRIDGE REGIONAL HOSPITAL MOBR 6058453692 PO BOX 580 MOBRIDGE SD 57601 ANGELIA SVIHOVEC 6058453692 2012-08-14 1 LAURIE HANSON 6053391999 2012-08-14 2010 2016-02-24 21:20:13Z ANGELIA SVIHOVEC PO BOX 580 MOBRIDGE SD 57601 16276441 0 X WWW.MOBRIDGEHOSPITAL.ORG X 1959 SD PROVIDING HEALTHCARE TO PEOPLE THROUGHOUT THE REGION. 12 10 180 150 0 0 1066313 190133 14215894 14204803 77629 57910 85058 86418 15444894 14539264 0 0 0 0 7344583 7780487 0 0 0 6282650 6481946 13627233 14262433 1817661 276831 17134975 16958515 7236331 6783040 9898644 10175475 THE MISSION OF MOBRIDGE REGIONAL HOSPITAL IS TO PROVIDE HIGH QUALITY HEALTHCARE SERVICES IN A COMPASSIONATE AND PROFESSIONAL MANNER FOR PEOPLE THROUGHOUT THE REGION. 0 0 12842187 14204803 MOBRIDGE REGIONAL HOSPITAL (MRH) PROVIDES HEALTHCARE SERVICES TO PERSONS THROUGHOUT THE REGION. DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2011, THE HOSPITAL HAD: 1,620 PATIENT DAYS 916 ACUTE CARE DAYS29,283 OUTPATIENT VISITS 5,502 ASSISTED LIVING DAYS (PRAIRIE SUNSET VILLAGE) 12842187 1 1 0 0 0 0 0 0 0 1 0 0 0 1 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 0 1 24 0 1 180 1 0 0 0 0 0 0 0 0 0 0 X 12 10 0 1 0 0 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X RENAE TISDALL 6058458164 PO BOX 580 MOBRIDGE SD 57601 DENNIS SCHNABEL 1.00 X X 0 0 0 DELPHINE STEUCK 1.00 X X 0 0 0 BILL BACHMEIER 1.00 X X 0 0 0 HEIDI ROSHAU 1.00 X X 0 0 0 JAKE KRAFT 1.00 X 0 0 0 WALLY SCHOTT 1.00 X 0 0 0 DONALD PAULSON 1.00 X 0 0 0 DR LEONARD LINDE 1.00 X 0 0 0 DR TRAVIS HENDERSON 40.00 X X 218515 0 24005 DR ROBERT MARCIANO 40.00 X X 270542 0 18069 BARB GROSS 1.00 X 0 0 0 DR TOM SWANSON 1.00 X 0 0 0 DOUG SCOTT THRU JAN 2011 1.00 X 0 0 0 BENJAMIN STOICK THRU JAN 2011 1.00 X 0 0 0 ANGELIA SVIHOVEC 40.00 X 139562 0 20416 RENAE TISDALL 40.00 X 68692 0 23163 DR BELA CSAKI 40.00 X 271065 0 18069 DR COLETTE DUCHENEAUX 40.00 X 316154 0 17443 DR KENRIC MALMBERG 40.00 X 187204 0 15293 DR JOSH HENDERSON 40.00 X 188606 0 14201 DEBBIE SMITH 40.00 X 191482 0 18090 1851822 0 168749 8 0 1 1 NORTH STAR CONSTRUCTION PO BOX 726 SPEARFISH ND 57783 INDEPENDENT CONTRACTOR TO BUILD MCLAUGHL 309855 ST ALEXIUS MEDICAL CENTER 900 EAST BROADWAY BISMARCK ND 58506 IT SERVICES, CEO SALARY, SUPPLIES, ETC 216920 MONDAK IMAGING SERVICES 11 SOUTH 7TH ST 241 MILES CITY MT 59301 MRI SERVICES 179893 NORTHERN PLAINS LAB PO BOX 2036 BISMARCK ND 58502 OUTSOURCE LABORATORY SERVICES 143943 4 169724 20409 190133 PATIENT SERVICE REV 622110 13655505 13655505 ASSISTED LIVING REV 623110 478297 478297 ANCILLARY CHARGES 900099 90965 90965 CHNG IN INT-MOBRIDGE H 900099 -19964 -19964 14204803 57910 57910 86418 86418 86418 86418 1737177 1737177 0 0 14539264 14204803 0 144328 806206 549648 256558 6309354 5692421 616933 223831 198718 25113 441096 389088 52008 46561 46561 8023 8023 43571 43571 451695 451534 161 75021 5550 69471 229390 62963 166427 47629 21973 25656 303084 299474 3610 36327 36327 60577 48066 12511 259916 259916 1058883 1058883 999833 999833 MEDICAL SUPPLIES 1451462 1451462 BAD DEBT 818573 818573 REPAIRS AND MAINTENANCE 397571 350920 46651 MINOR EQUIPMENT 103211 103211 DUES & SUBSCRIPTIONS 62422 21323 41099 28197 22304 5893 14262433 12842187 1420246 0 5476524 5402123 2207030 2212552 467670 492187 57774 119033 19364845 11891095 7672185 7473750 546198 556364 707594 702506 17134975 16958515 1755202 1586309 19000 19000 5050000 4755000 298103 279795 114026 142936 7236331 6783040 X 9284551 9682213 614093 493262 9898644 10175475 17134975 16958515 276831 0 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 95575 95575 10527105 6155038 4372067 8367172 5461960 2905212 374993 274097 100896 7473750 PREMIUM ON BONDS PAYABLE 13614 DEFERRED COMPENSATION PLAN PAYABLE 129322 142936 14539264 14262433 276831 0 276831 14539264 0 14539264 0 14539264 14262433 0 14262433 0 14262433 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE ORGANIZATION 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 ORGANIZATION 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 1 X 1 1 1 0 1 1 101902 101902 0.00760 1679131 1738470 -59339 0.00000 1781033 1738470 42563 0.00760 785477 388537 396940 0.02950 785477 388537 396940 0.02950 2566510 2127007 439503 0.03710 0 403036 342580 4758262 4693789 64473 X 1 0 1 1 MOBRIDGE REGIONAL HOSPITAL

1401 10TH AVENUE W MOBRIDGE SD 57601

X X X X NA 1 4 PRAIRIE SUNSET VILLAGE

1320 W GRAND XING MOBRIDGE SD 57601

ASSISTED LIVING & SENIOR HOUSING MOBRIDGE MEDICAL CLINIC

1309 10TH AVE W MOBRIDGE SD 57601

PROVIDER BASED MEDICAL CLINIC WEST RIVER HEALTH CLINIC

103 1ST AVENUE E MCLAUGHLIN SD 57642

PROVIDER BASED RURAL HEALTH CLINIC WEST DAKOTA HEALTH CLINIC

906 MAIN TIMBER LAKE SD 57656

PROVIDER BASED RURAL HEALTH CLINIC PART I, LINE 3C: IN ADDITION TO USING FPG GUIDELINES, MRH UTILIZES AN ASSET TEST FOR FREE OR DISCOUNTED CARE ALONG WITH CONSIDERATION OF THE AMOUNT OF THE PATIENT'S BILL. PART I, LINE 6A: MRH'S COMMUNITY BENEFIT INFORMATION IS INCLUDED IN THE HOSPITAL'S ANNUAL REPORT, WHICH IS MAILED OUT TO MEMBERS AND IS AVAILABLE IN THE LOBBY AT THE HOSPITAL AND CLINICS. PART I, LINE 7: LINE 7A WAS DETERMINED USING THE RATIO OF PATIENT CARE COSTS TO CHARGES CALCULATED IN IRS WORKSHEET 2. LINE 7B WAS DETERMINED USING THE MEDICAID PS&R REPORT AND THE GENERAL LEDGER ACCOUNTING SYSTEM. LINE 7G WAS DETERMINED USING THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 9/30/11. PART I, L7 COL(F): BAD DEBT EXPENSE OF $818,573 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART III, LINE 4: A) THE COST TO CHARGE RATIO WAS CALCULATED USING IRS WORKSHEET 2 FOR THE FISCAL YEAR ENDING 9/30/2011.B) WHEN A PAYMENT IS RECEIVED OR A DISCOUNT GIVEN ON A BAD DEBT ACCOUNT IT OFFSETS THE CURRENT FISCAL YEAR BAD DEBT EXPENSE THROUGH A RECOVERY OF BAD DEBT ACCOUNT. C) BAD DEBT EXPENSE ATTRIBUTABLE TO CHARITY CARE IS ESTIMATED BASED ON INCOME LEVELS. A LARGE PORTION OF MRH CHARGES ARE GENERATED BY THE NATIVE AMERICAN POPULATION AND THOSE BELOW THE POVERTY LEVEL. STATISTICS PROVE THAT MOST OF THE MENTIONED PATIENTS QUALIFY FOR CHARITY CARE. AFTER REVIEW, MRH ESTIMATES APPROXIMATELY 85% OF BAD DEBT AT COST IS ATTRIBUTABLE TO PERSONS WHO WOULD QUALIFY FOR CHARITY CARE. D) FOOTNOTE FROM FINANCIAL STATEMENT: THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS, RESIDENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT AND RESIDENT RECEIVABLES BY PAYOR CLASS AND USES AGING OF INDIVIDUAL ACCOUNTS TO ESTIMATE AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND RESIDENTS 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 OF CHARITY CARE IS APPROPRIATE. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR FISCAL YEAR ENDING 9/30/11. PART VI, LINE 2: MOBRIDGE REGIONAL HOSPITAL (MRH) IS COMMITTED TO PROVIDING HIGH QUALITY HEALTHCARE SERVICES TO ALL PEOPLE THROUGHOUT THE REGION. THE FACILITY PROVIDES FAMILY MEDICINE, INTERNAL MEDICINE, OB, ICU, ALS, AMBULANCE SERVICE, EMERGENCY CARE, AND SURGICAL SERVICES TO ALL PEOPLE WHO ARE IN NEED OF THOSE SERVICES. MRH CURRENTLY IS WORKING IN COLLABORATION WITH WALWORTH COUNTY AND THE STATE OF SOUTH DAKOTA TO PROVIDE COMMUNITY HEALTH SERVICES, INCLUDING FAMILY PLANNING SERVICES, ADULT HEALTH, AND CHILD IMMUNIZATIONS. MRH'S MANAGEMENT STRIVES TO LISTEN TO THE COMMUNITY NEEDS. IF NEW HEALTHCARE NEEDS ARISE, ADMINISTRATION WILL COMPLETE AN ANALYSIS OF COST/BENEFIT FOR THE NEW SERVICE TO BE OFFERED. MRH'S ADMINISTRATION BELIEVES IN BEING OUT IN THE PUBLIC AT EVENTS TO ANSWER QUESTIONS THAT MAY SURFACE ABOUT THE FACILITY. PART VI, LINE 3: MRH POSTS ITS CHARITY CARE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION IN THE ADMISSIONS AREAS AND CLINIC AREAS IN WHICH ELIGIBLE PATIENTS ARE LIKELY TO BE PRESENT. THE FACILITY PROVIDES A COPY OF THE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS WITH DISCHARGE MATERIALS. THE PATIENTS ACCOUNT MANAGER DISCUSSES WITH THE PATIENT THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS, AND ASSISTS THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHERE APPLICABLE.MRH'S CHARITY CARE PROGRAM IS AVAILABLE TO BOTH NEW AND ESTABLISHED PATIENTS. THE CHARITY CARE POLICY COVERS ALL MEDICALLY NECESSARY SERVICES PROVIDED BY THE INSTITUTION THAT ARE ORDERED BY PHYSICIANS.MRH'S CHARITY CARE PROGRAM IS AVAILABLE TO ALL PATIENTS WHO INDICATE AN INABILITY TO PAY AND MEET THE CRITERIA AS ESTABLISHED BY THE HOSPITAL FOR ALL OR A PORTION OF THEIR OUTSTANDING HOSPITAL BILL. PART VI, LINE 4: MRH IS LOCATED IN A SMALL RURAL COMMUNITY IN WALWORTH COUNTY, SOUTH DAKOTA, KNOWN AS MOBRIDGE. ACCORDING TO THE 2010 CENSUS, MOBRIDGE HAS A POPULATION OF 3,465 PEOPLE RACIALLY COMPRISED OF MAINLY CAUCASIAN (75.67%) AND NATIVE AMERICANS (20.46%). THE COMMUNITY BORDERS THE STANDING ROCK RESERVATION AND THE CHEYENNE RIVER RESERVATION WHICH ACCOUNTS FOR THE LARGER NATIVE AMERICAN POPULATION AND RELATIONS WITH INDIAN HEALTH SERVICES. THE MEDIAN HOUSEHOLD INCOME OF MOBRIDGE IS $37,417, AND THE MEDIAN FAMILY INCOME IS $52,316. ROUGHLY 17.6% OF THE POPULATION IS BELOW THE POVERTY LINE. THE FACILITY OWNS AND OPERATES CLINICS IN MOBRIDGE, MCLAUGHLIN AND TIMBER LAKE. THE FACILITY SERVES PATIENTS FROM A SIX COUNTY AREA (WALWORTH, ZIEBACH, CORSON, DEWEY, CAMPBELL AND POTTER) AND IS APPROXIMATELY ONE HUNDRED MILES FROM ANOTHER HOSPITAL WITH A HIGHER LEVEL OF CARE OFFERED. ACCORDING TO THE 2010 CENSUS, ZIEBACH COUNTY IS THE POOREST COUNTY IN AMERICA, AND 62% OF PEOPLE LIVING IN THIS COUNTY ARE UNDER FEDERAL POVERTY GUIDELINES. CORSON COUNTY RANKED 9TH OF THE POOREST COUNTIES IN AMERICA. PART VI, LINE 6: THE MOBRIDGE REGIONAL HOSPITAL IS COMMITTED TO THE PATIENTS WE SERVE, REGARDLESS OF RACE, COLOR, RELIGION, SEX, DISABILITY, OR ABILITY TO PAY. THE ORGANIZATION'S CHARITY CARE WRITE-OFFS HAVE CONTINUED TO TREND UP OVER THE PAST FEW YEARS, AND WE CONTINUE TO FOCUS BUDGET EFFORTS TO CONTINUE THIS TREND. MRH IS 100 MILES FROM ANOTHER HEALTHCARE FACILITY WITH A HIGHER LEVEL OF CARE AND PARTICIPATES IN THE NORTH DAKOTA AND SOUTH DAKOTA TRAUMA SYSTEMS WITH LEVEL III AND LEVEL IV CERTIFICATIONS, RESPECTIVELY. MRH CONTINUES A BROAD LEVEL OF BOARD INVOLVEMENT FOR CORSON, DEWEY, AND WALWORTH COUNTIES TO MONITOR COMMUNITY NEEDS IN THOSE AREAS. MRH CONTINUES TO BE A POPULAR PLACE FOR MEDICAL STUDENTS TO COMPLETE CLINICAL ROTATIONS, AND WE CONTINUE TO OFFER A WIDE VARIETY OF CERTIFICATION CLASSES TO NURSES AND THE MEMBERS OF THE COMMUNITY INCLUDING EMT-B, PALS, ACLS, TNCC, ALSO, NALS, EMT-I, AND CPR. MRH ALSO HAS DEVELOPED A WORKSITE WELLNESS PROGRAM WITHIN THE ORGANIZATION AND HAS GOALS TO WORK WITH OTHER BUSINESSES IN THE COMMUNITY TO PROMOTE OVERALL HEALTHY LIFESTYLES.MRH ALSO PROVIDES VARIOUS HEALTH SCREENINGS AVAILABLE TO THE COMMUNITY AND SURROUNDING COMMUNITIES THROUGHOUT THE YEAR. THE HEALTH SCREENINGS INCLUDE FREE CHOLESTEROL CHECKS, BMI, BLOOD PRESSURE AND WAIST/HIP RATIOS. THESE PREVENTATIVE HEALTH SCREENINGS PROMOTE THE GENERAL HEALTH OF THE COMMUNITY.THE HOSPITAL HAS A BOARD OF DIRECTORS COMPRISED OF VOLUNTEERS WHO RESIDE IN THE SERVICE AREA. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS IN THE AREA. ALL QUALIFIED PHYSICIANS WHO SHOW AN INTEREST MUST GO THROUGH A CREDENTIAL REVIEW AND BOARD APPROVAL. SURPLUS FUNDS, IF AVAILABLE, ARE REINVESTED IN THE FACILITIES TO IMPROVE PATIENT CARE. X X 0 0 0 0 0 0 0 1 0 DR TRAVIS HENDERSON 192758 0 25622 0 135 0 8650 0 15355 0 242520 0 0 0 DR ROBERT MARCIANO 207160 0 62724 0 658 0 9800 0 8269 0 288611 0 0 0 ANGELIA SVIHOVEC 139144 0 0 0 418 0 5823 0 15636 0 161021 0 0 0 DR BELA CSAKI 265796 0 0 0 5269 0 9800 0 8269 0 289134 0 0 0 DR COLETTE DUCHENEAUX 208139 0 107821 0 194 0 9800 0 7643 0 333597 0 0 0 DR KENRIC MALMBERG 178943 0 0 0 8261 0 7023 0 8269 0 202496 0 0 0 DR JOSH HENDERSON 165609 0 0 0 22997 0 1846 0 12355 0 202807 0 0 0 DEBBIE SMITH 183596 0 0 0 7886 0 7475 0 10615 0 209572 0 0 0 PART I, LINE 7 THE PHYSICIANS ARE PAID BASED ON PRODUCTION. SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART II: ANGELIA SVIHOVEC'S COMPENSATION: THE CEO IS COMPENSATED FOR HER SERVICES THROUGH A MANAGEMENT AGREEMENT WITH ST. ALEXIUS MEDICAL CENTER IN BISMARCK, ND. CITY OF MOBRIDGE SOUTH DAKOTA 466000320 607429BA4 2007-05-08 5773898 REFINANCED EXISTING TAX-EXEMPT BONDS AND PURCHASE CT, CLINIC AND EMR. 0 0 0 5773898 269394 4416499 88005 1000000 2008 0 0 1 1 0 0 0 0 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 MRH CURRENTLY HAS A MANAGEMENT AGREEMENT WITH ST. ALEXIUS MEDICAL CENTER IN BISMARCK, ND. THE AGREEMENT PROVIDES THE CEO, ANGELIA K. SVIHOVEC, AND INFORMATION TECHNOLOGY SUPPORT AT A COST TO MRH. THE ORIGINAL MANAGEMENT AGREEMENT DATE WAS JANUARY 1, 2000. FORM 990, PART VI, SECTION A, LINE 6 THERE IS ONLY ONE CLASS OF MEMBER; ALL MEMBERS HAVE ONE VOTE (SAME VOTING RIGHTS). FORM 990, PART VI, SECTION A, LINE 7A THE NOMINATING COMMITTEE NOMINATES CANDIDATES FOR ELECTION. THE MEMBERS VOTE ON CANDIDATES AT THE ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO COMMITTEE WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE CEO, CFO, AND FINANCE COMMITTEE WILL REVIEW THE FORM 990 PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS THE ENTIRE BOARD OF DIRECTORS. IF A CONFLICT SHOULD ARISE, IT WOULD FIRST GO TO THE CEO FOR EVALUATION, THEN TO THE BOARD OF DIRECTORS FOR FINAL EVALUATION. THE BOARD OF DIRECTORS IS RESPONSIBLE FOR MAKING THE FINAL DECISION IN DETERMINING IF A CONFLICT EXISTS. IF A CONFLICT IS FOUND, THE PERSON(S) INVOLVED WOULD BE REQUIRED TO ABSTAIN FROM DISCUSSIONS AND VOTING ON THE ITEM CAUSING THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 THE FINANCE COMMITTEE DETERMINES AND APPROVES THE PHYSICIAN CONTRACTS, INCLUDING COMPENSATION. THE CEO'S SALARY IS DETERMINED USING A SALARY SURVEY AND DISCUSSIONS WITH THE MANAGEMENT COMPANY. THE FINANCE COMMITTEE APPROVES THE SALARY OF THE CEO ANNUALLY. THE BOARD OF DIRECTORS APPROVES THE FINANCE COMMITTEE MINUTES, WHICH INCLUDE DISCUSSIONS REGARDING THE CEO'S SALARY. SALARIES FOR OTHER OFFICERS OR KEY EMPLOYEES ARE DETERMINED BY THE CEO THROUGH THE USE OF SALARY SURVEY INFORMATION FROM SDAHO AND EMPLOYEE SERVICE AND EXPERIENCE FILES. SALARY INCREASES WERE IMPLEMENTED IN SEPTEMBER 2010, AND MOST RECENTLY IN DECEMBER 2011. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE MADE AVAILABLE UPON REQUEST.