2012-05-15T13:23:43-05:00 2011-06-30 EIDE BAILLY LLP 800 NICOLLET MALL STE 1300 MINNEAPOLIS MN 554027033 990 2010-07-01 460224604 AVERA QUEEN OF PEACE HOSPITAL AVER 6059952251 525 NORTH FOSTER STREET MITCHELL SD 57301 WILLIAM E FLETT 6059952251 2012-05-14 0 KIM HUNWARDSEN CPA 6122536500 2012-05-14 2010 2016-02-24 21:20:13Z AVERA QUEEN OF PEACE HEALTH SERVICE THOMAS A CLARK 525 NORTH FOSTER STREET MITCHELL SD 57301 86034601 0 0928 X WWW.AVERAQUEENOFPEACE.ORG X 1905 SD PROMOTION OF HEALTH 18 15 876 120 0 0 1511770 1259988 78383045 82985131 500668 1329553 -899 -82807 80394584 85491865 118268 163174 0 0 46365915 47230003 0 0 48942 30201254 32188106 76685437 79581283 3709147 5910582 95601707 105824301 32298853 32789972 63302854 73034329 X AVERA IS A HEALTH MINISTRY ROOTED IN THE GOSPEL. OUR MISSION IS TO MAKE A POSITIVE IMPACT IN THE LIVES AND HEALTH OF PERSONS AND COMMUNITIES BY PROVIDING QUALITY SERVICES GUIDED BY CHRISTIAN VALUES. 0 0 64112115 163174 82985131 AVERA QUEEN OF PEACE'S MISSION IS TO PROVIDE HEALTHCARE SERVICES TO MITCHELL, SD RESIDENTS AND SURROUNDING AREA. THEY PROVIDE ACUTE CARE AND LONG-TERM HEALTHCARE SERVICES, OF WHICH THERE WERE 8,985 ACUTE PATIENT DAYS, 2,626 SWING-BED PATIENT DAYS, 1,151 NURSERY PATIENT DAYS, AND 41,822 NURSING HOME RESIDENT DAYS. THE BREAKOUT OF THESE STATISTICS PER FACILITY IS AS FOLLOWS.AVERA QUEEN OF PEACE HOSPITAL8,420 ACUTE PATIENT DAYS1,940 SWING-BED PATIENT DAYS1,151 NEWBORN PATIENT DAYSAVERA BRADY HEALTH AND REHABILITATION29,804 LONG-TERM CARE RESIDENT DAYS9,300 ASSISTED LIVING DAYS2,718 INDEPENDENT LIVING DAYSAVERA WESKOTA MEMORIAL MEDICAL CENTER (CAH)394 ACUTE PATIENT DAYS461 SWING-BED PATIENT DAYSAVERA DE SMET MEMORIAL HOSPITAL (CAH)171 ACUTE PATIENT DAYS225 SWING-BED PATIENT DAYS AVERA QUEEN OF PEACE MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY AND EQUIVALENT SERVICE STATISTICS. THE AMOUNT OF CHARGES FOREGONE, BASED ON ESTABLISHED RATES, WERE $1,928,334.AVERA QUEEN OF PEACE ALSO PROVIDES COMMUNITY BENEFIT HEALTH ACTIVITIES AT LESS THAN OR AT NO COST TO SUPPORT THOSE IN THE AREA SERVICED. THESE ACTIVITIES INCLUDE COMMUNITY EDUCATION PROGRAMS; SPECIAL PROGRAMS FOR THE ELDERLY, HANDICAPPED, AND MEDICALLY UNDERSERVED; AND A VARIETY OF BROAD COMMUNITY SUPPORT ACTIVITIES. DURING THE YEAR ENDED JUNE 30, 2011, SPECIFIC ACTIVITIES INCLUDE MEALS DELIVERED TO RESIDENTIAL HOMES; MEETING FACILITIES; PROGRAMS FOR PATIENTS AND FAMILIES SUFFERING FROM CANCER, DIABETES, BREATHING DISORDERS, AND OTHERS; ASSISTANCE TO HEALTH EDUCATORS; EMERGENCY HEALTHCARE PROVIDERS; WELLNESS PROGRAMS; AND OVERNIGHT HOUSING FOR FAMILIES OF HOSPITALIZED PATIENTS.AS A MEMBER OF THE AVERA HEALTH NETWORK, AVERA QUEEN OF PEACE UPHOLDS THE VISION OF THE PRESENTATION AND BENEDICTINE SISTERS TO WORK THROUGH COLLABORATION TO PROVIDE A QUALITY, EFFECTIVE HEALTH MINISTRY AND TO IMPROVE THE HEALTH CARE OF INDIVIDUALS AND OUR COMMUNITIES THROUGH A REGIONALLY INTEGRATED NETWORK OF PERSONS AND INSTITUTIONS. AVERA QUEEN OF PEACE ENGAGES IN ACTIVITIES DESIGNED TO IMPROVE THE HEALTH OF INDIVIDUALS AND COMMUNITIES IN RESPONSE TO A CALLING TO HEAL THE SICK, THE ELDERLY, AND THE OPPRESSED. 64112115 1 1 0 1 0 0 0 1 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 141 0 1 876 1 0 0 0 0 0 0 0 0 0 0 X 18 15 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X WILL FLETT 6059952251 525 NORTH FOSTER MITCHELL SD 57301 X ROGER MUSICK 2.50 X X 0 0 0 LORI ESSIG 2.50 X X 0 0 0 LOREN NOESS 2.50 X 0 0 0 CHARLES BERGELEEN 2.50 X 0 0 0 SISTER KATHLEEN CROWLEY 2.50 X 0 0 0 MARK REYNEN DO 2.50 X 0 0 0 SISTER BONITA GACNIK 2.50 X 0 0 0 DAVID OLSON 2.50 X 0 0 0 JACQUELYN JOHNSON 2.50 X 0 0 0 ELMER BIETZ 2.50 X 0 0 0 SISTER LYNN MARIE WELBIG 2.50 X 0 0 0 ROBERT SNORTUM MD 2.50 X 339217 0 34357 JERRY THOMSEN 2.50 X 0 0 0 RODNEY COMBS 2.50 X 0 0 0 TERRY TORGERSON 2.50 X 0 0 0 MICHAEL KRAUSE DO 2.50 X 40000 0 0 PATRICIA MALTERS MD 2.50 X 0 0 0 GREG VAN WALD 2.50 X 0 0 0 TOM RASMUSSON 40.00 X X 0 463190 30824 PATRICK J CLARK 40.00 X 225074 0 18975 JEROME HOWE MD 40.00 X 615152 0 26826 CHRISTOPHER KROUSE MD 40.00 X 1105344 0 27683 MICHAEL HALEY MD 40.00 X 689338 0 32688 DENNIS LELAND MD 40.00 X 728767 0 28682 BRIAN KAMPMANN MD 40.00 X 631724 0 28682 4374616 463190 228717 41 0 1 0 AVERA HEALTH 3900 W AVERA DRIVE SUITE 300 SIOUX FALLS SD 57108 SHARED SERVICES 3575868 AEGIS THERAPIES INC PO BOX 8103 FORT SMITH AR 72902 PHYSICAL AND OCCUPATIONAL THERAPY 245173 TREVOR A MEANEY 948 KIPPES COVE MITCHELL SD 57301 MIO SERVICES 148289 PHYSICIANS LABORATORY 1000E 21ST ST SUITE 4100 SIOUX FALLS SD 57117 PATHOLOGISTS 133771 HEARING PLUS 417 N MAIN 105 MITCHELL SD 57301 SPEECH THERAPY 107134 8 100654 1159334 1259988 NET PATIENT & RESIDENT 623000 80739311 80739311 OTHER REVENUE 900099 1280492 1280492 CAFETERIA 900099 451854 451854 INTEREST IN AVERA HEAL 900099 414265 414265 COMMUNITY WELLNESS 900099 99209 99209 82985131 71911 71911 459929 542736 -82807 -82807 -82807 1252075 5567 1252075 5567 1257642 1257642 85491865 82985131 0 1246746 163174 163174 627718 422698 205020 36586030 29705425 6852449 28156 2090566 1698604 390269 1693 5653693 4580089 1069051 4553 2271996 1839862 430316 1818 1430 1430 5997559 2561555 3436004 388236 35309 346447 6480 14178447 12259482 1913107 5858 172676 172676 1844286 1228747 615539 209103 137700 71019 384 104337 29290 75047 771815 771815 4048638 4048638 715535 715535 BAD DEBT EXPENSE 2384264 2384264 EQUIPMENT LEASE AND REN 140317 138381 1936 GRANT PROGRAM EXPENDITU 95111 95111 SALES TAX AND LICENSES 48364 42014 6350 1087988 1081746 6242 79581283 64112115 15420226 48942 3760652 3286441 7766 639 11822556 11706690 146041 108959 439315 332077 1429864 1222612 374967 653214 85847172 47550668 38824976 38296504 992846 7237868 36308275 41750866 1494449 1228431 95601707 105824301 5787890 6928998 458487 128877 22388204 22262117 561013 544037 3103259 2925943 32298853 32789972 X 61096999 70490116 1412272 1748895 793583 795318 63302854 73034329 95601707 105824301 X 5910582 3820893 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 1 11839 0 0 0 11839 0 0 1 793583 131273 924856 1032880 -239297 793583 1028163 4717 1032880 0.14000 0.86000 0 1 1 1109295 1164024 2273319 50179690 24777545 25402145 31684898 21643535 10041363 1709265 1129588 579677 38296504 INVESTMENT IN AFFILIATED ORGANIZATIONS 262853 C INTEREST IN AVERA HEALTH FOUNDATION 2295037 F INTEREST IN NET ASSETS OF MABEE TRUST 809145 F ASSETS LIMITED TO USE - AVERA POOLED INVESTMENTS 38383831 F 41750866 DERIVATIVE LIABILITY 1845240 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 783966 CAPITAL LEASE OBLIGATIONS 296737 2925943 85491865 79581283 5910582 3755885 65008 3820893 9731475 88349916 3755885 224999 3980884 84369032 1122833 1122833 85491865 79581283 0 79581283 0 79581283 PART IV, LINE 2B: THE ORGANIZATION HOLDS FUNDS IN TRUST ON BEHALF OF ITS RESIDENTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION'S ENDOWMENTS CONSIST OF A PORTION OF THEIR INTEREST IN THE NET ASSETS OF AVERA HEALTH FOUNDATION AND THEIR BENEFICIAL INTEREST IN THE MABEE TRUST. AVERA HEALTH FOUNDATION INCLUDES ENDOWMENT FUNDS WHICH HAVE BEEN ESTABLISHED FOR A VARIETY OF PURPOSES. THE ENDOWMENT FUND ASSETS INCLUDED IN THE ORGANIZATION'S BENEFICIAL INTEREST IN THE MABEE TRUST HAVE BEEN ESTABLISHED TO PURCHASE EQUIPMENT AND FURNISHINGS FOR THE ORGANIZATION. AS REQUIRED BY GENERALLY ACCEPTED ACCOUNTING PRINCIPLES, NET ASSETS ASSOCIATED WITH ENDOWMENT FUNDS, INCLUDING FUNDS DESIGNATED BY THE BOARD OF DIRECTORS TO FUNCTION AS ENDOWMENTS (IF ANY), ARE CLASSIFIED AND REPORTED BASED ON THE EXISTENCE OR ABSENCE OF DONOR-IMPOSED RESTRICTIONS. THE ORGANIZATION'S PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE DONOR RESTRICTED. THE ORGANIZATION CURRENTLY DOES NOT HAVE ANY BOARD-DESIGNATED ENDOWMENT FUNDS. 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. PART XI, LINE 8 - OTHER ADJUSTMENTS: CAPITAL CONTRIBUTIONS, NET -129,511. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 308,019. LOSS ON REFINANCING -22,511. CHANGE IN ACCOUNTING PRINCIPLE -90,989. PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 308,019. LOSS ON REFINANCING -22,511. RECLASSIFICATION OF ACCUMULATED LOSSES ON INTEREST RATE SWAP -60,509. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANTS AND CONTRIBUTIONS RECORDED IN FUND BALANCE FOR FINANCIAL STATEMENTS 748,069. CHANGE IN INTEREST IN AVERA FOUNDATION RECORDED IN FUND BALANCE FOR F/S 255,146. CHANGE IN INTEREST IN MABEE TRUST RECORDED IN FUND BALANCE FOR F/S 119,618. 1 1 X 1 X 1 X 1 1 0 1 1 237 822544 822544 0.01070 7091 7425354 5373132 2052222 0.02660 7328 8247898 5373132 2874766 0.03730 36 71654 52495 475 52020 0.00070 1 4 6043 6043 0.00010 48 45370 152915 152915 0.00200 85 117028 211453 475 210978 0.00280 85 124356 8459351 5373607 3085744 0.04010 1 500 2737 2737 0.00000 1 350 3508 3508 0.00000 1 518 56192 56192 0.00070 1 244 1902 1902 0.00000 4 1612 64339 64339 0.00070 1 979933 24750473 33664494 -8914021 X 1 1 3 1 AVERA QUEEN OF PEACE HOSPITAL

525 NORTH FOSTER STREET MITCHELL SD 57301

X X X 3 PROVIDER BASED CLINICS 2 AVERA WESKOTA MEMORIAL MEDICAL CENTER

609 1ST STREET NE WESSINGTON SPRINGS SD 57382

X X X 3 AVERA DE SMET MEMORIAL HOSPITAL

306 PRAIRIE AVENUE SW DE SMET SD 57231

X X X NOT REQUIRED 1 2 AVERA BRADY ASSISTED LIVING

1414 W CEDAR AVE MITCHELL SD 57301

ASSISTED LIVING AVERA BRADY HEALTH AND REHAB

500 S OHMAN ST MITCHELL SD 57301

NURSING HOME PART I, LINE 3C: TO DETERMINE ELIGIBILITY FOR CHARITY CARE, AVERA QUEEN OF PEACE HOSPITAL HAS DEVELOPED A TEST WHICH UTILIZES A COMBINATION OF HOUSEHOLD INCOME, HOUSEHOLD ASSETS, AND ALSO CONSIDERS UNPAID PAST AND ONGOING MEDICAL EXPENSES. CHARITY DISCOUNT MAY RANGE FROM 0 - 100% DEPENDING ON SCORE. PART I, LINE 6A: PART 1, LINE 6A: OUR COMMUNITY BENEFIT REPORT IS CONTAINED IN A REPORT PREPARED BY AVERA HEALTH, A RELATED ORGANIZATION. IT IS AVAILABLE THROUGH THE WEBSITE AND REQUESTED MAILING, AND IS FILED WITH THE CATHOLIC HEALTH ASSOCIATION. PART I, LINE 7: CHARITY CARE AND UNREIMBURSED MEDICAID WAS CONVERTED TO COST USING THE COST TO CHARGE RATIO IN IRS WORKSHEET 2. THE AMOUNTS ON LINES 7E-I REPRESENT EXPENSES REPORTED IN THE GENERAL LEDGER. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDES COSTS OF $1,336,019 RELATED TO RURAL HEALTH CLINICS. PART I, L7 COL(F): AQOP BAD DEBT EXPENSE OF $2,484,698 IS INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A) BUT EXCLUDED FOR PURPOSES OF CALCULATING THIS PERCENTAGE. PART II: AVERA QUEEN OF PEACE SUPPORTS NUMEROUS ECONOMIC DEVELOPMENT ORGANIZATIONS WITH PARTICIPATION AT MEETINGS AND DONATIONS THROUGHOUT ITS SERVICE AREA. ADDITIONALLY, AVERA QUEEN OF PEACE WORKS WITH DAKOTA WESLEYAN UNIVERSITY, THE MITCHELL TECHNICAL INSTITUTE, AND LOCAL HIGH SCHOOLS TO ADDRESS HEALTHCARE WORKER SHORTAGES IN THE COMMUNITIES OF ITS SERVICE AREA. PART III, LINE 4: BAD DEBT WAS CONVERTED TO COST USING THE COST TO CHARGE RATIO DERIVED FROM IRS WORKSHEET 2. BAD DEBT EXPENSE IS REPORTED NET OF DISCOUNTS AND CONTRACTUAL ALLOWANCES. A PAYMENT ON AN ACCOUNT PREVIOUSLY WRITTEN OFF REDUCES BAD DEBT EXPENSE IN THE CURRENT YEAR. NOTE FROM FINANCIAL STATEMENT:PATIENT AND RESIDENT RECEIVABLES ARE UNCOLLATERALIZED PATIENT, RESIDENT AND THIRD-PARTY PAYOR OBLIGATIONS. PAYMENTS OF PATIENT AND RESIDENT RECEIVABLES ARE ALLOCATED TO THE SPECIFIC CLAIMS IDENTIFIED ON THE REMITTANCE ADVICE OR, IF UNSPECIFIED, ARE APPLIED TO THE EARLIEST UNPAID CLAIM.THE CARRYING AMOUNT OF PATIENT AND RESIDENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S 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 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 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 AS CHARITY CARE IS APPROPRIATE. PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. AVERA QUEEN OF PEACE FOLLOWS THE CHA GUIDELINES IN REPORTING COMMUNITY BENEFITS AND THEREFORE ANY MEDICARE SHORTFALL (AS CALCULATED INCLUDING OUR NON-COST REPORT ENTITIES) IS EXCLUDED FROM OUR COMMUNITY BENEFIT REPORT. HOWEVER, MEDICARE IS THE ORGANIZATION'S LARGEST PAYER AND PATIENTS WITH MEDICARE COVERAGE ARE ACCEPTED REGARDLESS OF WHETHER OR NOT A SURPLUS OR DEFICIT IS REALIZED FROM PROVIDING THE SERVICES. THIS BASIS THEREFORE MEANS PROVIDING MEDICARE SERVICES PROMOTES ACCESS TO HEALTHCARE SERVICES WHICH IS A KEY ADVANTAGE FOR OUR COMMUNITY. PART III, LINE 9B: IF THE PATIENT QUALIFIES FOR THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME, UNINSURED PATIENTS AND IS COOPERATING WITH THE ORGANIZATION WITH REGARD TO EFFORTS TO SETTLE AN OUTSTANDING BILL WITHIN A REASONABLE TIME PERIOD, THE ORGANIZATION OR IT'S AGENT SHALL NOT SEND, NOR INTIMATE THAT IT WILL SEND, THE UNPAID BILL TO ANY OUTSIDE AGENCY IF DOING SO MAY NEGATIVELY IMPACT A PATIENT'S CREDIT. AT SUCH TIME AS THE ORGANIZATION SENDS THE UNCOLLECTED ACCOUNT TO AN OUTSIDE COLLECTION AGENCY, THE AMOUNT REFERRED TO THE AGENCY SHALL REFLECT THE REDUCED-PAYMENT LEVEL FOR WHICH THE PATIENT WAS ELIGIBLE UNDER THE ORGANIZATION'S FINANCIAL ASSISTANCE POLICY FOR LOW-INCOME UNINSURED PATIENTS. ANY EXTENDED PAYMENT PLANS OFFERED BY A HOSPITAL IN SETTLING THE OUTSTANDING BILLS OF LOW INCOME, UNINSURED PATIENTS WHO QUALIFY FOR FINANCIAL ASSISTANCE SHALL BE INTEREST-FREE SO LONG AS THE REPAYMENT SCHEDULE IS MET. PART VI, LINE 2: COMMUNITY NEEDS ASSESSMENTS OCCUR AT VARIOUS LOCATIONS THROUGHOUT THE AVERA QUEEN OF PEACE REGION AND AVERA HEALTH SYSTEM. ANNUAL BOARD PLANNING SESSIONS TAKE PLACE AT ALL FACILITIES IN THE AVERA QUEEN OF PEACE REGION. BOARD MEMBERS AND OTHER COMMUNITY LEADERS REVIEW AND DISCUSS SUCCESSES, CHALLENGES, AND SERVICE GAPS IN THEIR COMMUNITIES. NEEDS ARE IDENTIFIED AND RESOURCES DIRECTED TO ADDRESS THESE NEEDS. PART VI, LINE 3: PRINTED NOTICES ARE POSTED IN VISIBLE LOCATIONS EXPERIENCING HIGH VOLUMES OF INPATIENT OR OUTPATIENT REGISTRATIONS SUCH AS THE ADMITTING OFFICE, THE BILLING/BUSINESS OFFICE, AND EMERGENCY DEPARTMENT AS WELL AS THE ORGANIZATION WEBSITE. PATIENTS ARE ALSO MADE AWARE OF POSSIBLE ELIGIBILITY ON THE ADMISSION AUTHORIZATION FORM AND PATIENT INFORMATION BOOKLETS IN ALL HOSPITAL PATIENT ROOMS. A BROCHURE ENTITLED: "MANAGING YOUR HEALTH CARE EXPENSES" IS PROVIDED TO ALL SELF-PAY PATIENTS. THE AQOP PATIENT ADVOCATE WORKS WITH UNINSURED/UNDERINSURED PATIENTS TO ENROLL THEM IN APPLICABLE SOCIAL SERVICE PROGRAMS AND/OR IDENTIFY CHARITY, COUNTY OR RISK POOL ELIGIBILITY. PART VI, LINE 4: THE PRIMARY SERVICE AREA OF AVERA QUEEN OF PEACE HOSPITAL CONSISTS OF THE COUNTIES OF DAVISON, AURORA, HANSON, AND SANBORN. THE 2010 CENSUS LISTED A TOTAL POPULATION OF 27,900 WITHIN THESE FOUR COUNTIES. AVERA QUEEN OF PEACE HAS A SECONDARY SERVICE AREA OF 18 VERY RURAL COUNTIES SURROUNDING THE PRIMARY SERVICE AREA. PART VI, LINE 6: AVERA QUEEN OF PEACE IS A VERIFIED LEVEL III TRAUMA CENTER AND OPERATES AN EMERGENCY DEPARTMENT STAFFED 24 HOURS PER DAY WITH BOARD CERTIFIED PHYSICIANS. EMERGENCY CARE IS PROVIDED ON AN OPEN DOOR BASIS REGARDLESS OF ABILITY TO PAY.AVERA QUEEN OF PEACE LEASES OR MANAGES THREE CRITICAL ACCESS HOSPITALS WHICH PROVIDE A BROAD RANGE OF INPATIENT, OUTPATIENT SERVICES AND 24 HOUR EMERGENCY ROOMS IN 3 VERY RURAL COMMUNITIES.AVERA QUEEN OF PEACE OWNS THREE RURAL HEALTH CLINICS WHICH PROVIDE PRIMARY CARE SERVICES IN THREE RURAL COMMUNITIES. SIMILAR TO THE HOSPITALS IN THE AQOP REGION, THESE CLINICS ARE OPERATED ON AN OPEN DOOR BASIS AND CARE IS PROVIDED REGARDLESS OF ABILITY TO PAY.MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL LICENSED AND QUALIFIED APPLICANTS. THE AVERA QUEEN OF PEACE BOARD OF DIRECTORS IS PRINCIPALLY COMPRISED OF COMMUNITY MEMBERS FROM THE PRIMARY AND SECONDARY SERVICES AREAS. MEMBERS COME FROM A VARIETY OF BACKGROUNDS INCLUDING BANKING, EDUCATION, AGRICULTURE, HEALTHCARE, AND PRIVATE INDUSTRY. PART VI, LINE 7: AVERA IS A SPONSORED MINISTRY OF THE BENEDICTINE AND PRESENTATION SISTERS. THE COMMUNITIES IN WHICH AVERA HEALTH OPERATES ALL HAVE UNIQUE HEALTH AND COMMUNITY BENEFITS NEEDS. IN KEEPING WITH CATHOLIC HEALTH ASSOCIATION GUIDELINES, EACH HOSPITAL STRIVES TO MEET ITS COMMUNITY'S IDENTIFIED NEEDS. THE CORPORATE STAFF OF AVERA HEALTH ADVOCATES FOR ALL MEMBERS REGARDING COMMUNITY BENEFIT RELATED MATTERS OF STATE, REGIONAL AND NATIONAL IMPORTANCE. 1 MITCHELL CHARITABLE FOUNDATION PO BOX 1366 MITCHELL SD 57301 460390971 501(C)(3) 5000 DONATION MITCHELL TECH INSTITUTE FOUNDATION 821 N CAPITAL MITCHELL SD 57301 460452950 501(C)(3) 45000 DONATION UNIVERSITY OF SOUTH DAKOTA 414 E CLARK ST VERMILLION SD 57069 466018891 501(C)(3) 24000 DONATION ABBOTT HOUSE INC 909 COURT MERRILL MITCHELL SD 57301 460229822 501(C)(3) 21793 PURCHASE PRICE EXERCISE EQUIPMENT DONATION MITCHELL AREA DEVELOPMENT CORPORATION 610 N MAIN ST MITCHELL SD 57301 460394983 501(C)(3) 10000 DONATION 5 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE ORGANIZATION ONLY MAKES GRANTS TO OTHER ORGANIZATIONS WHICH ARE TAX-EXEMPT UNDER SECTION 501(C)(3). 0 0 0 0 0 0 0 0 0 ROBERT SNORTUM MD 296330 0 38849 0 4038 0 13778 0 20579 0 373574 0 0 0 TOM RASMUSSON 0 449516 0 0 0 13674 0 12250 0 19998 0 495438 0 0 PATRICK J CLARK 182898 0 37158 0 5018 0 10616 0 8805 0 244495 0 0 0 JEROME HOWE MD 178624 0 393251 0 43277 0 11500 0 15806 0 642458 0 0 0 CHRISTOPHER KROUSE MD 875753 0 151147 0 78444 0 11500 0 17863 0 1134707 0 0 0 MICHAEL HALEY MD 190674 0 460315 0 38349 0 11500 0 21668 0 722506 0 0 0 DENNIS LELAND MD 194679 0 501017 0 33071 0 11500 0 17662 0 757929 0 0 0 BRIAN KAMPMANN MD 542949 0 36594 0 52181 0 11500 0 18442 0 661666 0 0 0 SUPPLEMENTAL INFORMATION PART III SCHEDULE J, PART I LINE 3: THE PRESIDENT/CEO'S COMPENSATION IS PAID BY A RELATED ORGANIZATION, AVERA HEALTH. AVERA QUEEN OF PEACE RELIED ON THE RELATED ORGANIZATION FOR DETERMINING THE COMPENSATION FOR THE PRESIDENT/CEO USING THE METHODS DESCRIBED IN PART I, LINE 3. CHRISTOPHER KROUSE RECRUITMENT X 340000 56022 0 1 1 BRIAN KAMPMANN RECRUITMENT X 136000 52937 0 1 1 108959 FORM 990, PART VI, SECTION A, LINE 2 SISTER KATHLEEN CROWLEY HAS A BUSINESS RELATIONSHIP WITH TOM RASMUSSON. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS AVERA HEALTH, A NONPROFIT CORPORATION ORGANIZED AND EXISTING UNDER THE LAWS OF THE STATE OF SOUTH DAKOTA AND EXEMPT UNDER 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. FORM 990, PART VI, SECTION A, LINE 7A AVERA HEALTH, AS THE SOLE MEMBER, HAS THE POWER TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, MEMBERS OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B AVERA HEALTH HAS THE FOLLOWING RIGHTS AS THE MEMBER. 1) TO APPROVE THE ADOPTION, AMENDMENT OR REPEAL OF THE STATEMENTS OF PHILOSOPHY, MISSION AND VALUES OF CORPORATION; 2) TO INITIATE THE ADOPTION, AMENDMENT OR REPEAL OF ANY PROVISION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF CORPORATION, AND TO GIVE FINAL APPROVAL OF ANY SUCH ACTION WITH RESPECT THERETO; 3) TO APPROVE AND ACT UPON THE ALIENATION OF REAL PROPERTY AND PRECIOUS ARTIFACTS UNDER THE CANONICAL STEWARDSHIP OF THE SISTERS OF THE PRESENTATION OF THE BLESSED VIRGIN MARY OF ABERDEEN, SOUTH DAKOTA ("PRESENTATION SISTERS") OR THE BENEDICTINE SISTERS OF SACRED HEART MONASTERY ("BENEDICTINE SISTERS"), PURSUANT TO THE POLICIES ESTABLISHED BY THE MEMBER; 4) TO APPROVE ANY PLAN OF MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION, OR THE DIVESTITURE OF A SPONSORED WORK OR MINISTRY ASSOCIATED WITH THE CORPORATION; 5) TO APPROVE THE CREATION OF NEW SPONSORED WORKS OR MINISTRIES TO BE CONDUCTED BY OR UNDER THE AUTHORITY OF THE CORPORATION; 6) TO APPOINT AND REMOVE, WITH OR WITHOUT CAUSE, THE BOARD OF DIRECTORS OF THE CORPORATION. 7) TO APPOINT AND/OR REMOVE, WITH OR WITHOUT CAUSE, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER OF THE CORPORATION. 8) TO APPROVE OPERATING/CAPITAL BUDGETS AND STRATEGIC PLANS OF THE CORPORATION. 9) TO APPROVE EXPENDITURES OUTSIDE OF OPERATING AND CAPITAL BUDGETS EXCEEDING DEFINED THRESHOLDS ACCORDING TO POLICY WHICH MAY BE ADOPTED FROM TIME TO TIME BY THE MEMBER. 10) TO APPROVE ACQUISITIONS, SALES AND LEASES, ACCORDING TO POLICY WHICH MAY BE ADOPTED FROM TIME TO TIME BY THE MEMBER. 11) TO ESTABLISH AND MAINTAIN EMPLOYEE BENEFIT PROGRAMS. 12) TO ESTABLISH AND MAINTAIN INSURANCE PROGRAMS. 13) TO APPROVE MAJOR COMMUNITY FUND DRIVES. 14) TO APPROVE THE APPOINTMENT OF AUDITORS. 15) TO ADOPT POLICIES DESIGNED TO EFFECTUATE THE RESERVED POWERS OF THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE RETURN IS REVIEWED INITIALLY BY THE CFO. THE RETURN IS MADE AVAILABLE TO THE BOARD OF DIRECTORS FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY COVERS BOARD MEMBERS, OFFICERS, AND KEY EMPLOYEES. AT EACH BOARD MEETING, A REQUEST IS MADE FOR ALL BOARD MEMBERS TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST PERTAINING TO ANY ITEM LISTED ON THE AGENDA OR PERTAINING TO ANY POTENTIAL ITEM THAT COULD BE DISCUSSED DURING THE COURSE OF THE MEETING. THE DECLARATION OF CONFLICT OF INTEREST IS RECORDED IN THE MEETING MINUTES. THE BOARD MAKES A DETERMINATION OF WHETHER THERE IS A CONFLICT OF INTEREST AND IF SO, IMPLEMENTS THE PROCEDURE FOR EVALUATING THE ISSUE OR TRANSACTION INVOLVED. THE BOARD MEMBER OR OFFICER WITH THE CONFLICT MUST REFRAIN FROM VOTING. A STATEMENT OF CONFLICT OF INTEREST DISCLOSURE IS MADE ON AN ANNUAL BASIS BY OFFICERS AND DIRECTORS. THE INFORMATION IS MAINTAINED IN A DATABASE AND A REPORT IS PROVIDED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 15: THE CEO IS COMPENSATED BY AVERA HEALTH. ANNUALLY THE COMPENSATION COMMITTEE OF AVERA HEALTH, WHICH IS COMPRISED OF SIX (6) SYSTEM MEMBERS APPOINTED BY THE RELIGIOUS ORDERS, MEETS WITH AN INDEPENDENT CONSULTANT REGARDING FAIR MARKET VALUE OF OFFICERS AND KEY EMPLOYEES. THE COMPENSATION COMMITTEE APPROVES ALL SALARIES BASED ON COMPARABLE DATA AND DOCUMENTS THE BASIS FOR THEIR DECISION IN MEETING MINUTES. THE COMPENSATION OF THE SENIOR VP OF FINANCE IS DETERMINED BY HUMAN RESOURCES BASED ON A MARKET ANALYSIS OF COMPARABLE POSITIONS. THE COMPENSATION IS APPROVED BY THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE GENERAL PUBLIC. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE ATTACHED TO THE FORM 990 PER IRS INSTRUCTIONS AND THEREFORE ARE AVAILABLE TO THE GENERAL PUBLIC. FORM 990, PART VII: IN ADDITION TO THE HOURS SERVED AT AVERA QUEEN OF PEACE HOSPITAL, SISTER KATHLEEN CROWLEY ALSO SERVES 1 HOUR PER WEEK AT BOTH AVERA WORKERS' COMPENSATION TRUST AND AVERA HOLY FAMILY AND 5 HOURS PER WEEK AT AVERA HEALTH. SISTER LYNN MARIE WELBIG SERVES AN ADDITIONAL 2 HOURS PER WEEK AT SACRED HEART HEALTH SERVICES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 3,755,885. CAPITAL CONTRIBUTIONS, NET -129,511. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP 308,019. LOSS ON REFINANCING -22,511. CHANGE IN ACCOUNTING PRINCIPLE -90,989. TOTAL TO FORM 990, PART XI, LINE 5: 3,820,893. FORM 990, PART XII, LINE 2C: THE AUDIT COMMITTEE OF AVERA HEALTH, PARENT ORGANIZATION, SELECTS THE AUDITOR AND REVIEWS THE AUDITED FINANCIAL STATEMENTS FOR AVERA QUEEN OF PEACE. FORM 990, PART X, LINE 20: THE ISSUE PRICE INCLUDES THE FILING ORGANIZATION'S SHARE OF THE ENTIRE BOND ISSUE, WHICH WAS ISSUED TO AVERA HEALTH ON BEHALF OF THE AVERA OBLIGATED GROUP. THE AVERA OBLIGATED GROUP CONSISTS OF AVERA MCKENNAN, AVERA ST. LUKE'S, AVERA QUEEN OF PEACE, AND AVERA SACRED HEART. IN ACCORDANCE WITH IRS INSTRUCTIONS, INFORMATION RELATED TO THE TAX EXEMPT BOND REPORTING IS BEING REPORTED ON AVERA HEALTH'S TAX RETURN (EIN 46-0422673). 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