2011-05-13T11:18:19-05:00 2010-06-30 Eide Bailly LLP 5601 Green Valley Drive Suite 700 Minneapolis MN 554371145 990 2009-07-01 470463911 Avera St Anthony's Hospital STAN 4023365132 300 N 2nd Street ONeill NE 687631569 Ronald Cork 4023365132 2011-05-11 1 Kim Hunwardsen 9529446166 2011-05-11 2009 2016-02-24 21:20:13Z Ronald Cork 300 N 2nd Street ONeill NE 687631569 29052211 0 0928 X www.avera-sta.org X 1955 NE Promotion of health 13 12 255 40 0 0 222087 676123 25147289 28192582 140825 169378 5565 4750 25515766 29042833 35000 35000 0 11817651 13276849 0 0 12526375 13286003 24379026 26597852 1136740 2444981 20784081 25909611 2725518 5229383 18058563 20680228 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 23270384 35000 28192582 To provide acute patient visits and outpatient visits of health care services. For the year ended June 30, 2010, a total of 3,459 patient days were recorded and 275 newborn patient days were recorded. Charity care is also provided by the facility. For the year ended June 30, 2010, the facility provided $802,279 in charity care, based on charges foregone.The Hospital also provides community benefit health activities at less than or at no cost to support those in the area served. 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 years ended June 30, 2010 and 2009, specific activities included senior resource programs for billing assistance; meeting facilities; programs for patients and families suffering from cancer, diabetes, breathing disorders, mental illness, and others; assistance to health educators; emergency healthcare providers; wellness programs; reduced priced sports medicine services; and overnight housing for families of hospitalized patients. 23270384 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 10 0 1 255 1 0 0 0 0 0 0 0 0 0 13 12 0 1 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 X Michael Garman 4023365132 300 N 2nd Street ONeill NE 687631569 Dian Edwards 1.00 X X 0 0 0 Jim Rabe 1.00 X X 0 0 0 Lisa Lind 1.00 X X 0 0 0 Dr Richard Fitch 1.00 X 0 0 0 Rod Schellpeper 1.00 X 0 0 0 Jack Hurley 1.00 X 0 0 0 Ed North 1.00 X 0 0 0 Deb Kelly 1.00 X 0 0 0 Sister Sharon Ann Haas OSB 1.00 X 0 0 0 Sister Janet Schumacher PBVM 1.00 X 0 0 0 Sister Joan Reichelt PBVM 1.00 X 0 0 0 Matthew Winkelbauer MD 1.00 X 0 0 0 Ronald Cork 50.00 X X 0 167534 10109 Michael Garman 40.00 X 122761 0 25483 Edwin N Cook 40.00 X 324418 0 8404 Dean Benson 40.00 X 119792 0 22392 Bart Eastwood 40.00 X 487730 0 56787 Cameron Everitt 40.00 X 146307 0 26784 Anthony Akainda 40.00 X 329675 0 61949 1530683 167534 211908 7 0 1 0 North Central Anesthesia Services PO Box 741 ONeill NE 68763 Anesthesia Service 1529962 Sacred Heart Health Services 501 Summit St Yankton SD 57078 Management Fee/IT 1153091 Doc's Who Care 1309 S Fountain Drive Olathe KS 66061 Weekend Physician Coverage 329462 3 660897 8904 6322 676123 Patient Service Revenu 622110 27099746 27099746 Clinic Revenue 621110 567850 567850 Other Revenue 900099 305393 305393 Change in Fdtn Interes 900099 219593 219593 28192582 69957 69957 4750 4750 4750 4750 59088 49711 9378 59088 40333 99421 99421 29042833 28192582 0 174128 35000 35000 158416 158416 10464463 9596631 867832 312808 256451 56357 1624781 1423365 201416 716381 622347 94034 708848 708848 450 450 49813 49813 1341978 1176959 165019 42005 42005 736806 87823 648983 37082 37082 329164 329164 65709 48027 17682 206799 121597 85202 24444 24444 1142162 1142162 186427 186427 Medical Supplies 6221536 6221536 Bad Debts 1181794 1181794 Equipment Lease and Ren 799502 739811 59691 Miscellaneous 128544 33953 94591 Dues and Subscriptions 82940 42893 40047 26597852 23270384 3327468 0 3649130 3960791 3611698 3541890 11500 129500 930712 964032 54735 155144 23661965 14014371 7068428 9647594 1178706 5128059 6087415 50000 211819 312539 20784081 25909611 1411400 1889906 1314118 1689477 0 1650000 2725518 5229383 X 17901012 20529728 7051 0 150500 150500 18058563 20680228 20784081 25909611 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 150500 150500 150500 150500 1.00000 0 1 1 59191 665832 725023 220512 10334975 6554105 4001382 9171193 7181985 1989208 3210262 278281 2931981 9647594 Assets Limited to Use - Avera Pooled Investments 3963072 F Investment in Foundation 1861294 F Investment in Collaborative Arrangement 263049 C 6087415 Estimated Third-Party Payor Settlements 1650000 1650000 29042833 26597852 2444981 176684 176684 2621665 28565421 176684 176684 28388737 654096 654096 29042833 26597852 0 26597852 0 26597852 Part V, Line 4: Description of Intended Use of Endowment Funds: The Hospital's endowment consists of a portion of their interest in the net assets of Avera St. Anthony's Hospital Foundation. The Avera St. Anthony's Hospital Foundation includes endowment funds which have been established for a variety of purposes. 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. Part X: Description of Uncertain Tax Positions Under FIN 48: The Hospital has implemented the provision of FASB Accounting Standards Codification Topic ASC 740-10 (formerly Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes). The Hospital undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities, as defined by ASC 740-10. The implementation of this standard has had no impact on the financial statements. For the years ended June 30, 2010 and 2009, the unrecognized tax benefit accrual was zero. Part XII, Line 4b - Other Adjustments: Contributions Recorded in Fund Balance on Financial Statements: 654096. 1 1 X 1 X 1 X 1 1 0 1 1 525493 525493 0.01980 2071546 1547341 524205 0.01970 2597039 1547341 1049698 0.03950 1861 1861 0.00010 988 988 0.00000 2849 2849 0.00010 2599888 1547341 1052547 0.03960 0 774075 0 11952000 11828985 123015 X 0 Avera St Anthony's Hospital (ASAH)

300 N 2nd Street ONeill NE 68763

X X X X Part I, Line 3c: Charity care and discounted care utilizes a combination of income, assets, and expenses to determine what percentage of charity care they would qualify for. Part I, 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 an overall cost to charge ratio. Other benefits are actual expenses recorded in the general ledger. Part I, Line 7f: The amount of bad debt expense removed from the denominator of the calculation was $1,181,794. Part III, Line 4: Bad debt expense was converted to cost using an overall cost to charge ratio.The organization did not estimate the amount of bad debt expense attributable to patients eligible under the organization's charity care policy as the organization works hard at encouraging people to apply and makes adjustments to bad debt expense based on recommendations of the collection agency or reviews bad debt for those who qualify under charity care. 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.Notes from Financial Statement: The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's best estimate of amount 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 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. Part V: The organization also has the following types of facilities other than those required to be licensed as healthcare facilities in the state of Nebraska:1 home health1 sleep lab1 family practice clinic - Joint Venture Part VI, Line 2: Avera St. Anthony's Hospital conducts an annual strategic planning meeting that includes a cross section of community members. Our Hospital Board of Directors, Hospital Finance Committee, Foundation Board of Directors, COmmunity Medical Staff, and Hospital Department Directors meet to assess community input from the local nursing facility, assisted living, local public health office. Our Hospital and Foundation Boards and Finance Committee are made up of a majority of community members. This group drafts an annual strategic plan of goals, objectives, and strategies that are continuously updated to address the needs of the community. Additionally, input from the local ministerial association, law enforcement, chamber of commerce, elementary and secondary public and parochial schools, and the local community college are assessed and incorporated into the plan. Part VI, Line 3: Patients are informed of the financial assistance/charity care policy through brochures and posted policies at the registration desks of the hospital and emergency department. Avera St. Anthony's has staff in central registration that identify if a patient has the financial means to pay for services or insurance to cover these services. Public assistance is also pursued if deemed appropriate. If patients are identified as candidates for charity care they are directed to our financial services representative and the application process is inititated for charity care. Patient financial services can assist with determining what benefits the patient may qualify for and assists with helping them apply for any benefits. If there is no option for an outside assistance program, the patient is informed and encouraged to complete the application that utilizes a combination of income, assets, and expenses to determine what percentage of charity care they would qualify for. Additionally patients are advised of our financial assistance package when they receive our statements and if they are telephoned for payment arrangements. Part VI, Line 4: Avera St. Anthony's Hospital is located in O'Neill, NE the county seat of Holt County. We serve a large radius to include patients from Brown, Rock, Boyd, Keya Paha, Wheeler, Knox, Garfield, and Antelope counties. In 2009, the population for Holt County was estimated to be 10,011. Approximately 21% of the population is age 65 or older. The average per capita income is 20,914 and approximately 10.3% of the population is below the federal poverty level. The nearest hospital in the area is approximately 18 miles from Avera St. Anthony. Part VI, Line 5: N/A Part VI, Line 6: The organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care. The hospital operates an emergency room that is available to all, regardless of ability to pay. Part VI, Line 7: The communities in which Avera operates all have unique health and community benefit needs and in keeping with the Catholic Healthcare Association Guidelines each hospital strives to meet its community's identified needs. The Avera Central Office advocates for all on community benefit related matters of state, regional, and national importance. 1 Northeast Community College Foundation 801 E Benjamin Avenue Norfolk NE 68702 510145185 501(c)(3) 25000 The $25,000 grant is to be used for the future Nursing College in Norfolk. O'Neill Community Foundation - Community Center Capital Campaign PO Box 543 ONeill NE 68763 470769903 501(c)(3) 10000 The $10,000 grant is for the future O'Neill Community Center. 2 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Grant fund compliance is monitored by the Chief Financial Officer annually at fiscal year end or sooner if dictated by the grantor. The recipient department director or administrator provides progress documentation through capital and operation budget requests and utilization. 0 0 0 0 0 0 0 0 0 Ronald Cork 0 165182 0 287 0 2065 0 7947 0 2162 0 177643 0 0 Edwin N Cook 324418 0 0 0 0 0 0 0 10358 0 334776 0 0 0 Bart Eastwood 487730 0 0 0 0 0 11000 0 48498 0 547228 0 0 0 Cameron Everitt 146307 0 0 0 0 0 6028 0 22022 0 174357 0 0 0 Anthony Akainda 329675 0 0 0 0 0 9800 0 55388 0 394863 0 0 0 Supplemental Information Part III Schedule J, Part I, Line 3: The President & CEO's compensation is paid by a related organization, Sacred Heart Health Services. Avera St. Anthony's Hospital relied on the related organization for determining the compensation for the President & CEO using the methods described in Part I, Line 3. Edwin N Cook DO Pre-employment Advance X 50000 11500 0 1 1 11500 Form 990, Part VI, Section A, line 3 The organization utilizes the management services of Avera Sacred Heart Hospital for day-to-day operations of the facility. The CEO of the facility is an employee of Avera Sacred Heart Hospital. 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 by the CEO and CFO prior to filing. The return is made available to the Board of Directors subsequent 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 Compensation of the CEO is determined by the management company Avera Sacred Heart Hospital. The board of directors reviews the management agreement with Avera Sacred Heart Hospital and discusses and approves the agreement. Negotiations are done as needed. For the CFO, a salary review is done by a committee based off hospital association surveys, including hospital size. There is also a relationship between the CEO's salary and the CFO's salary, in that a percentage of the increase for the CFO is based on CEO's salary base. Form 990, Part VI, Section C, line 19 The organization's governing documents, conflict of interest policy, and financial statements are not available to the general public. Avera Health 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of health SD 501(c)(3) 9 N/A Avera Health Foundation 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 460367530 Grant making SD 501(c)(3) 7 N/A Avera Holy Family 826 North 8th Street Estherville IA 51334 420680370 Healthcare services IA 501(c)(3) 3 N/A Avera Holy Family Foundation 826 North 8th Street Estherville IA 51334 421317452 Support of Holy Family Hospital and Home Health Agency IA 501(c)(3) 9 N/A St Benedict Hospital Inc 401 West Glynn Drive Parkston SD 57366 460226738 Healthcare services SD 501(c)(3) 3 N/A St Benedict Health Center Foundation 401 West Glynn Drive PO Box B Parkston SD 57366 460458725 Support health related services SD 501(c)(3) 11a N/A Avera McKennan 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 460224743 Healthcare services SD 501(c)(3) 3 N/A St Anthony's Hospital Foundation 2nd Adams Street ONeill NE 68763 470728707 Support to Hospital NE 501(c)(3) 11a N/A Avera Queen of Peace Hospital 525 North Foster Mitchell SD 57301 420224604 Healthcare services SD 501(c)(3) 3 N/A Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare services SD 501(c)(3) 3 N/A Sacred Heart Rural Health Clinics Inc 501 Summit Street Yankton SD 57078 460423930 Clinic services SD 501(c)(3) 3 N/A Health Management Services 501 Summit Street Yankton SD 57078 460399291 Adult daycare and homemaking services SD 501(c)(3) 9 N/A Lewis and Clark Health Ed and Serv Agency 1000 W 4th Street Suite 9 Yankton SD 57078 460337013 Healthcare education SD 501(c)(3) 9 N/A Benedictine Health Foundation 1017 West Fifth Street Yankton SD 57078 410370373 Support for organizations providing health care services SD 501(c)(3) 11b N/A Avera St Luke's 305 South State Street Aberdeen SD 57401 460224598 Healthcare services SD 501(c)(3) 3 N/A Avera Marshall 300 S Bruce St Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) 3 N/A Avera Marshall Foundation 300 S Bruce St Marshall MN 56258 411784801 Fundraising MN 501(c)(3) 9 N/A Avera Home Medical Equipment LLC 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 460488198 Medical services - home medical equipment SD N/A Midwest Regional Imaging 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 470874983 Health care - medical imaging SD N/A Mersco Medical of Pierre LLC 329 E Dakota Pierre SD 57501 460444002 Medical services - home medical equipment SD N/A Avera Home Medical Equipment of Floyd Valley Hospital LLC 714 E Lincoln St NE Lemars IA 51031 820582350 Medical services - home medical equipment IA N/A Avera Home Medical Equipment of Estherville LLC PO Box 5045 Sioux Falls SD 57117 201686097 Medical services - home medical equipment IA N/A Avera Home Medical Equipment of Sioux Center LLC 38 19th St SW Sioux Center IA 51250 753203100 Medical services - home medical equipment IA N/A Avera Home Medical Equipment of Marshall LLC 1104 East College Drive Marshall MN 56258 205271924 Medical services - home medical equipment MN N/A Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Avenue 102 Sioux Falls SD 57117 800619999 Medical Services - home medical equipment SD N/A Q&M Properties LLC 525 North Foster Mitchell SD 57301 730652049 Medical clinic building SD N/A Surgical Associates Endoscopy Clinic LLC 310 S Pennsylvania St Aberdeen SD 57401 460461429 Surgical associates SD N/A Marshall Medical Services LLC 300 S Bruce St Marshall MN 56258 208874448 Medical Services MN N/A Accounts Management Inc 5132 S Cliff Avenue Suite 101 Sioux Falls SD 57108 460373021 Collection Services SD N/A C Avera Health Plans Inc 3900 West Avera Drive Suite 101 Sioux Falls SD 57105 460451539 HealthCare Benefits SD N/A C Avera Property Insurance Inc 610 W 23rd Street Yankton SD 57078 460463155 Property Insurance SD N/A C Avera Pace 3900 West Avera Drive Sioux Falls SD 57108 460341869 Healthcare Services SD N/A C Valley Health Services 501 Summit Street Yankton SD 57078 460357149 Medical Equipment SD N/A C Northern Dakota Health Company 305 S State Street Aberdeen SD 57401 460385179 Clinics SD N/A C 0 0 1 0 1 0 0 0 0 0 1 1 0 1 1 1 0 0