2012-11-09T11:50:58-06:00 2011-12-31 450250958 EIDE BAILLY LLP 200 EAST 10TH SUITE 500 SIOUX FALLS SD 571045126 990 2011-01-01 460278210 COTEAU DES PRAIRIES HOSPITAL COTE 6056987647 205 ORCHARD DRIVE SISSETON SD 572622398 DAN ELLIS 6056987647 2012-11-09 1 LAURIE HANSON P00851848 6053391999 2012-11-09 2011 2016-02-24 21:20:13Z DAN ELLIS 205 ORCHARD DRIVE SISSETON SD 572622398 13170791 0 X WWW.CDPHOSPITAL.COM X 1967 SD PROVISION OF HEALTHCARE SERVICES TO THE POPULATION OF SISSETON, SD, AND THE SURROUNDING AREA. 12 12 176 20 0 0 0 88340 1030016 12586153 1116 3989 2000 17309 1033132 12695791 0 2000 0 0 391877 6561613 0 0 0 467545 5523717 859422 12087330 173710 608461 6405548 7740033 532769 1258793 5872779 6481240 QUALITY HEALTHCARE WITH A PERSONAL TOUCH CLOSE TO HOME. 0 0 10528281 2000 12586153 COTEAU DES PRAIRIES HOSPITAL (CDPH) IS A 25 BED ACUTE CARE HOSPITAL AND PHYSICIAN CLINIC. THE HOSPITAL PROVIDES HEALTHCARE SERVICES FOR THE CARE AND TREATMENT OF ANY PERSONS WHO ARE ACUTELY ILL OR WHO OTHERWISE REQUIRE MEDICAL CARE AND RELATED SERVICES. STATISTICS FOR THE PERIOD ENDED DECEMBER 31, 2011, ARE AS FOLLOWS: ACUTE PATIENT DAYS = 1,303, SUBACUTE PATIENT DAYS = 913, NEWBORN DAYS = 323, AND EMERGENCY ROOM VISITS = 4,479. 10528281 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 9 0 1 176 1 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 1 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 1 0 X LARRY MOEN 6056984697 205 ORCHARD DRIVE SISSETON SD 572622398 MARY CARLSON 2.00 X X 0 0 0 FAYE JOHNSTON 2.00 X X 0 0 0 DELRAY GERMAN 1.00 X X 0 0 0 TERRY JASPERS 2.00 X X 0 0 0 DEBBIE WOOLEY 1.00 X 0 0 0 STEVEN MCCLEEREY 1.00 X 0 0 0 ERIN CAMERON 1.00 X 0 0 0 CLAYTON HALVERSON THRU JAN 2011 1.00 X 0 0 0 CHERYL KARST 1.00 X 0 0 0 VIVIAN HOVE 1.00 X 0 0 0 TOM WAGNER THRU JULY 2011 1.00 X 0 0 0 GERI OPSAL 1.00 X 0 0 0 JAY HILL 1.00 X 0 0 0 KENT THOELKE 1.00 X 0 0 0 DAN ELLIS 40.00 X 121014 0 15623 LARRY MOEN 40.00 X 71642 0 8087 DR STANLEY GALLAGHER 40.00 X 460411 0 6981 DR JUDY BEUMER 32.00 X 317961 0 6995 DR DAVID STAUB 20.00 X 257294 0 6337 DR LINDA PETERSON 24.00 X 153696 0 6291 DR JAMES MCCABE 32.00 X 222229 0 10033 1604247 0 60347 6 0 1 0 CHARLES PRYZMUS 1004 5TH AVENUE NORTH WHEATON MN 56296 ANESTHESIA SERVICES 176133 1 45340 43000 88340 PATIENT SERVICE REV 622110 12500643 12500643 MISC REV 900099 62397 62397 CAFETERIA REV 900099 23113 23113 12586153 3989 3989 17309 0 17309 17309 17309 475000 475000 0 0 12695791 12586153 0 21298 2000 2000 216367 216367 5178988 4745817 433171 115247 101820 13427 415194 361460 53734 635817 561741 74076 90 90 38350 38350 725168 692357 32811 33726 33726 473749 358650 115099 343639 343639 141270 141270 30982 25339 5643 126620 108678 17942 411680 411680 143886 143886 MEDICAL SUPPLIES 1904184 1904184 BAD DEBT 678284 678284 EQUIP RENTAL & MAINT 430813 419392 11421 LICENSE AND PERMIT 15836 12399 3437 25440 3210 22230 12087330 10528281 1559049 0 864525 1311738 2569868 3633857 143717 187288 88601 119729 8073319 5585898 2738837 2487421 6405548 7740033 525693 1258793 7076 532769 1258793 X 5872779 6481240 5872779 6481240 6405548 7740033 608461 0 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13556 13556 3712170 2468290 1243880 4126400 3016974 1109426 221193 100634 120559 2487421 12695791 12087330 608461 608461 12695791 0 12695791 0 12695791 12087330 0 12087330 0 12087330 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. 1 1 X 1 X 1 X 175.000000000000 1 1 0 0 53569 53569 0.00470 1253402 1239257 14145 0.00120 1306971 1239257 67714 0.00590 412 412 0.00000 1000 1000 0.00010 2552921 1344425 1208496 0.10590 2000 2000 0.00020 2556333 1344425 1211908 0.10620 3863304 2583682 1279622 0.11210 0 678284 339142 2856841 2809950 46891 X 1 0 1 1 COTEAU DES PRAIRIES HOSPITAL & CLINIC

205 ORCHARD DRIVE SISSETON SD 57262

X X X X COTEAU DES PRAIRIES HOSPITAL & CLINIC 1 1 1 150.000000000000 1 175.000000000000 1 X X X X X 1 1 X X 1 0 1 X 1 1 3 BROWNS VALLEY CLINIC

106 4TH STREET SOUTH BROWNS VALLEY MN 56219

FAMILY PRACTICE CLINIC ROSHOLT CLINIC

116 WEST MAIN STREET ROSHOLT SD 57260

FAMILY PRACTICE CLINIC COTEAU DES PRAIRIES CLINIC

205 ORCHARD DRIVE SISSETON SD 57262

RURAL HEALTH CLINIC PART I, LINE 3C: CDPH OFFERS FREE CARE TO PATIENTS WITH A FAMILY INCOME NOT TO EXCEED 150% OF FEDERAL POVERTY GUIDELINES. IN ADDITION TO THE FPG TEST, FOR FREE AND DISCOUNTED CARE, CDPH ALSO LOOKS AT THE PATIENT'S ASSET VALUES AS WELL AS THEIR UNINSURED OR UNDERINSURED INSURANCE COVERAGE STATUS. FOR DISCOUNTED CARE, CDPH PATIENTS WILL QUALIFY WITH A FAMILY INCOME NOT TO EXCEED 175% OF FPG. PART I, LINE 7: LINE 7A WAS DETERMINED BY MULTIPLYING THE RATIO OF COST TO GROSS CHARGES FOR THE HOSPITAL BY THE GROSS UNCOMPENSATED CHARGES ASSOCIATED WITH PROVIDING CHARITY CARE TO ITS PATIENTS. LINE 7B WAS DETERMINED USING THE RATIO OF PATIENT CARE COSTS TO CHARGES CALCULATED IN IRS WORKSHEET 2. LINE 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 EXPENSES OF THE RURAL HEALTH CLINIC TOTAL $2,366,722. PART I, L7 COL(F): BAD DEBT EXPENSE OF $678,284 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART II: NONE PART III, LINE 4: A) WHEN A PAYMENT IS RECEIVED OR A DISCOUNT IS GIVEN ON A BAD DEBT ACCOUNT IT OFFSETS THE CURRENT FISCAL YEAR BAD DEBT EXPENSE. B) BAD DEBT EXPENSE ATTRIBUTABLE TO CHARITY CARE IS ESTIMATED BASED ON INCOME LEVELS AND ETHNICITY IN THIS AREA. MORE THAT 50% OF CDPH CHARGES ARE GENERATED BY THE NATIVE AMERICAN POPULATION. STATISTICS SHOW THE AVERAGE HOUSEHOLD INCOME OF NATIVE AMERICAN FAMILIES IN ROBERTS COUNTY IS TWO-THIRDS OF THAT OF OTHER ETHNIC GROUPS. VIRTUALLY ALL NATIVE AMERICANS QUALIFY FOR CHARITY CARE, THUS THE ORGANIZATION ESTIMATES APPROXIMATELY 50% OF BAD DEBT IS ATTRIBUTABLE TO PERSONS WHO WOULD QUALIFY FOR CHARITY CARE. C) 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. PART III, LINE 8: MEDICARE ALLOWABLE COST OF CARE WAS CALCULATED FROM THE MEDICARE COST REPORT FOR THE PERIOD ENDING 12/31/2011. THE MEDICARE COST REPORT WAS FILED IN ACCORDANCE WITH THE AUDITED FINANCIAL STATEMENTS. COTEAU DES PRAIRIES HOSPITAL & CLINIC PART V, SECTION B, LINE 13G: A SUMMARY OF THE POLICY WAS POSTED IN THE HOSPITAL FACILITY EMERGENCY ROOMS OR WAITING ROOMS AND IN THE ADMISSIONS OFFICES. COTEAU DES PRAIRIES HOSPITAL & CLINIC PART V, SECTION B, LINE 19D: ALL PATIENTS ARE CHARGED GROSS CHARGES INITIALLY. AS OF YEAR END, A POLICY HAD NOT BEEN APPROVED BY MANAGEMENT. HOWEVER, MANAGEMENT HAS ADOPTED AND APPROVED THE PROSPECTIVE METHOD TO DETERMINE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. COTEAU DES PRAIRIES HOSPITAL & CLINIC PART V, SECTION B, LINE 20: ALL PATIENTS ARE CHARGED GROSS CHARGES INITIALLY. AS OF YEAR END, A POLICY HAD NOT BEEN APPROVED BY MANAGEMENT. HOWEVER, MANAGEMENT HAS ADOPTED AND APPROVED THE PROSPECTIVE METHOD TO DETERMINE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. COTEAU DES PRAIRIES HOSPITAL & CLINIC PART V, SECTION B, LINE 21: ALL PATIENTS ARE CHARGED GROSS CHARGES INITIALLY. AS OF YEAR END, A POLICY HAD NOT BEEN APPROVED BY MANAGEMENT. HOWEVER, MANAGEMENT HAS ADOPTED AND APPROVED THE PROSPECTIVE METHOD TO DETERMINE MAXIMUM AMOUNTS THAT CAN BE CHARGED TO FAP-ELIGIBLE INDIVIDUALS. PART V, SECTION B, LINE 14: THE HOSPITAL IS IN THE PROCESS OF UPDATING POLICIES AND PROCEDURES TO MEET THE PROVISIONS OF THE NEW 501(R). THEY WILL BE USING THE PROPOSED REGULATIONS AS A GUIDELINE FOR MAKING CHANGES TO CURRENT POLICIES. PART VI, LINE 2: THE PRIORITY OF CDPH IS TO PROMOTE THE HEALTH OF SISSETON AND ALSO THE SURROUNDING RURAL COMMUNITIES. THROUGH OUTREACH TO OUR COMMUNITY, INCLUDING OUR 2 OUTREACH CLINICS, THE HOME HEALTH DEPARTMENT, AND THROUGH WORKING WITH LOCAL, STATE AND FEDERAL DEPARTMENTS, CDPH DETERMINES THE HEALTH CARE NEEDS OF THE COMMUNITY, AND WORKS TO ENSURE THE SERVICES AND EVENTS PROVIDED TO THE COMMUNITY ARE BENEFICIAL AND IN ACCORDANCE WITH THE COMMUNITY'S HEALTH CARE NEEDS. PART VI, LINE 3: CDPH UTILIZES MULTIPLE METHODS FOR PATIENT EDUCATION OF FINANCIAL ASSISTANCE. A SUMMARY OF THE CHARITY CARE POLICY IS POSTED IN THE HOSPITAL'S MAIN ENTRANCE/ADMISSION AREAS AND ALSO IN THE MAIN ENTRANCE/ADMISSION AREAS FOR EACH OF THE CLINICS. CDPH PROVIDES A COPY OF THE POLICY, OR A SUMMARY THEREOF, AND FINANCIAL ASSISTANCE CONTACT INFORMATION TO PATIENTS AS PART OF THE INTAKE PROCESS, WHEN APPLICABLE. IN ADDITION, CDPH PERSONNEL DISCUSS WITH THE PATIENT THE AVAILABILITY OF VARIOUS GOVERNMENT BENEFITS, SUCH AS MEDICAID OR STATE PROGRAMS, AND ASSIST THE PATIENT WITH QUALIFICATION FOR SUCH PROGRAMS, WHEN APPLICABLE. PART VI, LINE 4: CDP HOSPITAL IS LOCATED IN SISSETON, A RURAL COMMUNITY IN THE NORTHEAST CORNER OF SOUTH DAKOTA WITH THE NEXT CLOSEST HEALTHCARE FACILITY BEING APPROXIMATELY 50 MILES AWAY. CDPH SERVES VARIOUS ETHNIC GROUPS. AN INDIAN HEALTH SERVICES (IHS) CLINIC IS LOCATED WITHIN 1 MILE OF THE HOSPITAL. CDPH SERVES AS THE MAIN EMERGENCY ROOM FOR THE IHS PATIENTS DURING OFFICE HOURS AND AFTER HOURS. ROBERTS COUNTY HAS AN ESTIMATED POPULATION OF 10,286 IN 2011 - OF THAT POPULATION 17.1% ARE 65 YEARS OR OLDER; 28.6% ARE 18 YEARS AND YOUNGER; 34.6% ARE OF NATIVE AMERICAN HERITAGE. ROBERTS COUNTY'S TOTAL POPULATION INCLUDES THE FOLLOWING STATISTICS: 14% HAVE ATTENDED 9TH THRU 12TH GRADE WITHOUT A DIPLOMA; AVERAGE HOUSEHOLD INCOME OF $37,708 OR LESS, USING 2.62 PERSONS PER HOUSEHOLD; AND 20.0% HOLD POVERTY STATUS FOR FAMILIES WITH CHILDREN UNDER 18 YEARS. LIVING IN A SMALL RURAL COMMUNITY THE MEAN TRAVEL TIME TO WORK IN MINUTES IS AN AVERAGE OF 17.6 MINUTES. PART VI, LINE 5: CDPH IS A SOLE COMMUNITY PROVIDER WITH AN 11 MEMBER VOLUNTEER BOARD OF DIRECTORS WHO ALL RESIDE IN THE PRIMARY SERVICE AREA. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED INDIVIDUALS AS THEY ARE REQUESTED. IF CDPH WERE TO HAVE SURPLUS FUNDS, THE FUNDS WOULD BE APPLIED TO PATIENT CARE IMPROVEMENTS AND ALSO TO REDUCE THE NEED FOR RATE INCREASES FOR THE PATIENTS. THE EMERGENCY ROOM IS STAFFED 24 HOURS A DAY, 7 DAYS A WEEK AND PATIENTS ARE WELCOMED REGARDLESS OF RACE OR THE ABILITY TO PAY FOR THE SERVICES. CDPH PARTICIPATES IN ALL GOVERNMENT-SPONSORED HEALTH PROGRAMS INCLUDING MEDICARE, MEDICAID, INDIAN HEALTH SERVICES, AND VETERAN AFFAIRS BENEFITS. THE HOSPITAL AND CLINICS WELCOME STUDENTS FOR TRAINING AND COLLEGE ROTATIONS IN VARIOUS HEALTHCARE PROFESSIONS. PART VI, LINE 6: N/A X X X 0 0 0 1 0 0 0 0 0 DR STANLEY GALLAGHER 460411 0 0 0 0 0 0 0 6981 0 467392 0 0 0 DR JUDY BEUMER 317961 0 0 0 0 0 0 0 6995 0 324956 0 0 0 DR DAVID STAUB 257294 0 0 0 0 0 0 0 6337 0 263631 0 0 0 DR LINDA PETERSON 153696 0 0 0 0 0 0 0 6291 0 159987 0 0 0 DR JAMES MCCABE 222229 0 0 0 0 0 0 0 10033 0 232262 0 0 0 PART I, LINE 5 PHYSICIANS ARE PAID 38% OF THEIR RESPECTIVE PROVIDER/CPT CODE REVENUE. FORM 990, PART VI, SECTION A, LINE 4 THE BY-LAWS WERE AMENDED TO STATE THAT THE ANNUAL MEETING WILL BE HELD FOLLOWING THE REGULAR SCHEDULED APRIL MEETING (PREVIOUSLY WAS TO BE HELD WITHIN 90 DAYS OF YEAR-END). FORM 990, PART VI, SECTION A, LINE 8B NO COMMITTEES WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 THE DIRECTOR OF FINANCE REVIEWS THE 990 IN DETAIL. AFTER HIS REVIEW, THE 990 IS PROVIDED TO EACH BOARD MEMBER. THE DIRECTOR OF FINANCE 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 BY THE CONFLICT OF INTEREST POLICY. THE DETERMINATION OF WHETHER A CONFLICT EXISTS IS MADE AT THE BOARD OF DIRECTORS LEVEL, AS IS THE REVIEW OF ACTUAL CONFLICTS. ANY PERSON DETERMINED TO HAVE A CONFLICT WILL HAVE AN OPPORTUNITY TO EXPLAIN THE SITUATION, AND HE/SHE WILL BE REQUIRED TO REFRAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION FOR THE CEO IS DETERMINED THROUGH INDIVIDUAL NEGOTIATIONS WITH THE EXECUTIVE COMMITTEE AND THE CEO. THE EXECUTIVE COMMITTEE USES SALARY SURVEYS TO DETERMINE WHAT CONSTITUTES REASONABLE COMPENSATION. NEGOTIATIONS WITH THE EXECUTIVE COMMITTEE INCLUDE A PERFORMANCE EVALUATION. AN EVALUATION IS DONE ANNUALLY BY THE EXECUTIVE COMMITTEE, AND APPROVED BY THE BOARD OF DIRECTORS. COMPENSATION OF CDPH'S OFFICERS IS DETERMINED THROUGH DISCUSSIONS BETWEEN THE EXECUTIVE COMMITTEE AND THE CEO. THE EXECUTIVE COMMITTEE USES SALARY SURVEYS TO DETERMINE WHAT CONSTITUTES REASONABLE COMPENSATION. DISCUSSIONS WITH THE EXECUTIVE COMMITTEE INCLUDE A PERFORMANCE EVALUATION. AN EVALUATION IS DONE ANNUALLY BY THE EXECUTIVE COMMITTEE, AND APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST.