2011-08-26T11:27:58-05:00 2010-11-30 Eide Bailly LLP 200 East 10th Suite 500 Sioux Falls SD 571045126 990 2009-12-01 460278210 Coteau des Prairies Hospital COTE 6056987647 205 Orchard Drive Sisseton SD 572622398 Dan Ellis 6056987647 2011-08-26 1 Laurie Hanson 6053391999 2011-08-24 2009 2016-02-24 21:20:13Z Dan Ellis 205 Orchard Drive Sisseton SD 572622398 9814625 0 X www.cdphospital.com X 1967 SD Provision of healthcare services to the population of Sisseton, SD, and the surrounding area. 11 11 161 20 0 0 87860 54755 8622820 9722970 32183 20289 24008 16611 8766871 9814625 0 0 4788305 5434302 0 0 3878124 4605536 8666429 10039838 100442 -225213 6545198 6275376 620916 576307 5924282 5699069 Quality healthcare with a personal touch close to home. 1 0 8944143 9722970 Coteau des Prairies Hospital (CDPH) provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than its established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as patient service revenue. 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. CDPH performed 58 PSA screenings and 10 diabetic screenings to patients at a much reduced cost to the patients. Acute patient days = 1,029, subacute patient days = 502, newborn days = 222, and emergency room visits = 3,872. 8944143 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 15 0 161 1 0 0 0 0 0 0 0 11 11 0 0 1 0 0 0 0 1 1 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 Tom Brewster 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 Carol Ann Hosmer 1.00 X 0 0 0 Debbie Wooley 1.00 X 0 0 0 Steven McCleerey 1.00 X 0 0 0 Vern Donnell 1.00 X 0 0 0 Erin Cameron 1.00 X 0 0 0 Clayton Halverson 1.00 X 0 0 0 Cheryl Karst 1.00 X 0 0 0 Vivian Hove 1.00 X 0 0 0 Tom Wagner 1.00 X 0 0 0 Dan Ellis 40.00 X 0 0 0 Shelley Marmon 40.00 X 70476 0 286 Larry Moen 40.00 X 51349 0 1577 Dr Judy Beumer 32.00 X 320928 0 651 Dr David Staub 20.00 X 260740 0 5074 Dr David Kleinberg 16.00 X 265637 0 925 Dr Linda Peterson 24.00 X 120331 0 5902 1089461 0 14415 4 0 1 0 Charles Pryzmus 1004 5th Avenue North Wheaton MN 56296 Anesthesia Services 106024 1 17255 37500 54755 Program Service Rev. 622110 9692741 9692741 Cafeteria Rev. 900099 22038 22038 Misc Rev. 900099 8191 8191 9722970 20289 20289 16611 16611 16611 16611 9814625 9722970 0 36900 297306 297306 4068752 3817472 251280 101254 96896 4358 303337 295517 7820 663653 585159 78494 13343 13343 32797 32797 450824 438011 12813 32409 32409 132483 8989 123494 288163 80751 207412 121522 121522 15103 15103 79871 59392 20479 413299 413299 141823 141823 Medical Supplies 1982781 1982781 Bad Debt 506524 506524 Equip. Rental and Maint 368294 367886 408 License and Permit 5952 4952 1000 Sales Tax 4434 1750 2684 15914 6316 9598 10039838 8944143 1095695 0 1476393 841429 1958247 2330271 207913 208786 121626 122286 7924386 5151782 2781019 2772604 6545198 6275376 617916 569231 3000 7076 620916 576307 X 5924282 5699069 5924282 5699069 6545198 6275376 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 13556 13556 3698326 2358804 1339522 4007597 2696879 1310718 204907 96099 108808 2772604 9814625 10039838 -225213 0 -225213 10847756 1033131 1033131 9814625 0 9814625 10899259 859421 859421 10039838 0 10039838 Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital is organized as a nonprofit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Hospital has implemented Accounting Standards Codification 740, Income Taxes, (ASC 740). The Hospital undergoes an annual analysis of their various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities, as defined by ASC 740. For the thirteen month period ended December 31, 2010 and the year ended November 30, 2009, the unrecognized tax liability accrual was zero. The Hospital is no longer subject to federal tax examination by tax authorities for years before 2007. The Hospital will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense if incurred. Part XII, Line 2d - Other Adjustments: Less December 2010 Revenue : 1033131. Part XIII, Line 2d - Other Adjustments: Less December 2010 Expenses: 859421. Coteau des Prairies Hospital received audited financial statements for a 13 month period beginning 12/1/2009 and ending 12/31/2010 to reflect a change in year end. For tax return presentation, the twelve month period, 12/1/2009 thru 11/30/2010, was broken out and presented on the 2009 Form 990. In addition, a short year 2010 Form 990 will be filed for December 2010 to accurately present the 2010 information. The Part X statement above, is from the audited finacial statement report for the thirteen month period ended 12/31/2010. 1 1 X 1 X 1 X 175.000000000000 1 1 1 0 0 27061 0 27061 0.00280 1927603 1899257 28346 0.00300 877864 627192 250672 0.02630 2832528 2526449 306079 0.03210 12 451 1490 1490 0.00020 3190 3190 0.00030 3 1965541 1658418 307123 0.03220 1500 1500 0.00020 15 451 1971721 1658418 313303 0.03290 15 451 4804249 4184867 619382 0.06500 0 264806 135703 2744162 2740308 3854 X 1 0 Coteau des Prairies Hospital & Clinic

205 Orchard Drive Sisseton SD 57262

X X X Rural Health Clinic, Home Health Agency, Swing Bed 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 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, 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. In addition to FPG, CDPH also looks at the patient's asset values as well as their uninsured or underinsured insurance coverage status. Part I, Line 7: Lines 7a, 7b and 7c 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 7g: The expenses of the Rural Health Clinic total $1,733,870 which is comprised of payroll, benefits, professional fees, supplies, sales tax and advertising. Part I, Line 7f: Bad debt expense of $506,524 was subtracted from total operating expense. Part III, Line 4: a) The cost-to-charge ratio was calculated using Worksheet 2.b) When a payment is received or a discount is given on a bad debt account it offsets the current fiscal year bad debt expense. c) 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 at cost is attributable to persons who would qualify for charity care. 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. Part III, Line 8: Medicare allowable cost of care was calculated from the Medicare cost report for the period ending 12/31/2010. The Medicare Cost Report was filed in accordance with the audited financial statements, and represented a 13 month period. For tax return presentation, the twelve month period, 12/1/2009 thru 11/30/2010, was broken out and presented on the 2009 Form 990 Schedule H. Part III, Line 9b: Part VI, Line 2: The priority of CDPH is to promote the health of Sisseton and also the surrounding rural communities. CDPH held 11 events through the year which included blood pressure screening, blood glucose testing, annual PSA screening, diabetic screening, and also a complete heart screening. 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: Sisseton is 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 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. Sisseton has a population of 2,572 - of that population 38.9% are 62 years or older, and 43.2% are of Native American heritage. Sisseton's total population includes the following statistics: 24.9% have attended 9th thru 12th grade without a diploma; 24.2% have a household income of $14,999 or less; and 23.2% hold poverty status for families with children under 18 years. Part VI, Line 5: None Part VI, Line 6: 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 7: N/A X X X 0 0 0 1 0 0 0 0 0 Dr Judy Beumer 320928 0 0 0 0 0 0 0 651 0 321579 0 0 0 Dr David Staub 260740 0 0 0 0 0 0 0 5074 0 265814 0 0 0 Dr David Kleinberg 265637 0 0 0 0 0 0 0 925 0 266562 0 0 0 Dr Linda Peterson 120331 0 0 0 0 0 0 0 5902 0 126233 0 0 0 Part I, Line 5 Physicians are paid 38% of their respective provider/CPT code revenue. Form 990, Part III, line 2 New Program Services In December 2009, CDPH added a CT scanning unit onsite as a way to offer the service to patients 24 hours a day 7 days a week. CDPH purchased and reopened the Rosholt Clinic in August 2010 to supply healthcare to the northeast corner of Roberts County, South Dakota, along with rural North Dakota and rural Minnesota communities. Licensed Respiratory Therapy services were added at CDPH in December 2009 to better patient respiratory care. Form 990, Part VI, Section A, line 4 The Board of Directors of CDPH proposed and accepted changes to the organization's bylaws which became effective June 15, 2010. The changes include the following: a) The number of directors shall not be more than 12, but never less than required by law, and no person who is a credentialed medical professional or employee of CDPH or spouse of either. b) A majority of the directors shall constitute a quorum for the transaction of business. c) The Board of Directors shall hold an annual meeting no later than 90 days after the end of the fiscal year. d) The chairperson or President shall be elected for a term of 1 year. e) Addition and updates to the list of CEO/Administrator's authority and responsibilities which include: 1) Accepting general control of all ordering of goods and supplies as are needed to operate the hospital. However, there shall be a restriction of all capital and service contracts exceeding $5,000.00. 2) Regulating the hours and duties of the hospital employees and see to it that at all times there is competent help on duty which will meet the requirements of the State Department of Health. However, wage ranges, annual increases or new positions shall be approved by the Board. 3) Sign and deliver in the name of the Corporation any contracts or other instruments necessary in the ordinary course of business. f) The fiscal year of the corporation shall now follow the calendar and run January 1st through December 31st. g) All Board of Directors are required to sign the Conflict of Interest Policy and the Confidentiality Agreement. 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 are made at the Board of Directors level, as are 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 or key employees 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.