2011-05-13T08:16:28-05:00 2010-06-30 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2009-07-01 460225414 St Michael's Hospital Inc STMI 6055893341 410 West 16th Avenue Tyndall SD 570662318 Carol Deurmier 6055893341 2011-05-09 1 Laurie Hanson 6053391999 2011-05-09 2009 2016-02-24 21:20:13Z X Carol Deurmier 410 West 16th Avenue Tyndall SD 570662318 7637152 0 0928 X www.avera.org/ash/stmichaels X 1966 SD To provide healthcare services. 7 7 100 30 382521 -8864 60788 156561 7374117 7443576 23256 37015 0 7458161 7637152 0 0 3388281 3410831 0 0 3737065 3766192 7125346 7177023 332815 460129 6859783 7235523 1637728 1474464 5222055 5761059 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. 1 0 5641930 6997148 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. 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 services. Approximately 1150 clients served. SMH provided financial and in kind donations for various community needs like H1N1 flu clinics, meeting rooms provided, 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. 636829 446428 SMH provides emergency services 24-hours a day, 7-days a week. In addition to nursing staff, a midlevel provider and/or physician is 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 6/30/2010, there were 629 patients who received emergency care at SMH. 48576 SMH has also made available eEmergency services via an arrangement with Avera McKennan Hospital 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 eEmergency services are provided at no cost to the patient. Approximately 50 patients benefited from the eEmergency services during the first year of availability. 6327335 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 18 0 1 100 1 1 1 0 0 0 0 0 0 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 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 Jim Stoebner 1.00 X 0 0 0 Don Irish 1.00 X 0 0 0 Carol Deurmier 50.00 X 105130 0 21068 Lisa Ronke 40.00 X 35393 0 13041 Dr Jill Kruse 40.00 X 150132 0 5407 Dr Melvin Wallinga 40.00 X 163585 0 18154 454240 0 57670 3 0 1 1 Avera Sacred Heart Hospital 501 Summit Yankton SD 57078 Management, Speech, Occupational Therapy 412365 1 66205 90356 156561 Patient Service Rev 622110 5617311 5617311 Retail Pharmacy Rev 446110 1753011 1370490 382521 Miscellaneous Rev 900099 73254 73254 7443576 36828 36828 187 187 187 187 7637152 7061055 382521 37015 48906 48906 2810658 2535280 275378 94132 84359 9773 243611 217805 25806 213524 187901 25623 28370 28370 14257 9514 4743 7806 755 7051 49725 14007 35718 83402 83402 106530 105404 1126 16252 9216 7036 9056 7533 1523 53088 53088 365422 365422 74408 74408 Supplies 2335012 2304295 30717 ACS Fee 218426 218426 Repairs and Maintenance 186755 172048 14707 Bad Debt Expense 85000 85000 Equipment Lease and Ren 47533 38710 8823 85150 62590 22560 7177023 6327335 849688 0 1449432 1665228 743310 774920 26172 26172 304621 320123 33553 33404 7025896 4085389 2929884 2940507 308287 348079 1034288 1099711 30236 27379 6859783 7235523 618624 546462 21426 1798 997678 926204 1637728 1474464 X 5191291 5729819 11626 11862 19138 19378 5222055 5761059 6859783 7235523 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 19138 240 19378 18878 260 19138 0.00000 1.00000 0.00000 0 0 68640 28819 97459 3505668 1610309 1895359 3322242 2427482 894760 100527 47598 52929 2940507 Interest in Avera Foundation 1099711 F 1099711 7637152 7177023 460129 78875 78875 539004 7716027 78875 78875 7637152 0 7637152 7177023 0 7177023 0 7177023 Part V, Line 4: Description of Intended Use of Endowment Funds: The intended use of the organization's endowment funds is to provide for capital needs that may arise. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital has adopted the provisions of FASB Accounting Standards Codification Topic 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes), on July 1, 2009. The implementation of this standard had no impact on the financial statements. As of both the date of adoption, and as of June 30, 2010, the unrecognized tax benefit accrual was zero. The Hospital will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. The Hospital is no longer subject to Federal tax examinations by tax authorities for years before 2007. 1 1 X 1 X 1 X 100.000000000000 1 1 0 1 1 7534 7534 0.00100 307032 286710 20322 0.00280 314566 286710 27856 0.00380 108487 31730 76757 0.01070 28408 1055 27353 0.00380 2 644082 318065 326017 0.04540 9475 9475 0.00130 2 790452 350850 439602 0.06120 2 1105018 637560 467458 0.06500 366 366 0.00010 370 370 0.00010 736 736 0.00020 0 70253 34240 2849109 2813981 35128 X 1 1 St Michael's Hospital Inc

410 West 16th Avenue Tyndall SD 570660027

X X X X Wellness Center Bon Homme Family Practice Clinic

410 West 16th Avenue Tyndall SD 57066

Family Practice Clinic Bon Homme Family Practice Clinic

130 Main Street Avon SD 57315

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 or other dilemas 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: Lines 7a and 7b were 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.Line 7g was obtained from the Medicare cost report. Part I, Line 7f: Bad debt expense of $85,000 was subtracted from total operating expense. Part III, Line 4: a) The cost to charge ratio was calculated on IRS Worksheet 2 for the fiscal year ending 6/30/2010.b) The amount on line 3 of $34,240 is 40% of total bad debt expense. The number is based on a detailed review of the accounts that are currently listed with Credit Collection Bureau. Upon reviewing each account that is at CCB, it was found that about 40% 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 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 6/30/2010. 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, Office of Rural Health 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 primary purpose of this program is to benefit the community and is available to everyone. 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 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 about 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 2004 census population of Bon Homme County was 7,085 people with 12.9% of the population at 100% poverty or less and 36.5% of the population at 200% poverty or less. 20.8% of Bon Homme County's population is age 65 or older (compared to 14.3% in the state of South Dakota). Part VI, Line 5: 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 provided healthcare career education to promote healthcare careers and rural health. Part VI, Line 6: The majority of the 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. Part VI, Line 7: N/A X X 0 0 0 1 0 0 0 0 0 Carol Deurmier 104024 0 287 0 819 0 4508 0 17215 0 126853 0 0 0 Dr Jill Kruse 150010 0 0 0 122 0 0 0 5407 0 155539 0 0 0 Dr Melvin Wallinga 163171 0 0 0 414 0 6837 0 11317 0 181739 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 III, line 2 New Program Services See detailed description for eEmergency at Form 990, Part III, Line 4b. 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 Directors does not utilize committees. 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.