2011-05-13T10:57:00-05:00 2010-06-30 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2009-07-01 460226283 Wagner Community Memorial Hospital WAGN 6053843611 513 Third Street SW Wagner SD 573800280 Bryan Slaba 6053843611 2011-05-13 1 Laurie Hanson 6053391999 2011-05-13 2009 2016-02-24 21:20:13Z Bryan Slaba 513 Third Street SW Wagner SD 573800280 7877984 0 X N/A X 1947 SD To provide healthcare services. 9 9 78 9 0 0 303526 930609 5892851 6901908 23754 30440 16102 14652 6236233 7877609 2688 0 2565572 3336694 0 0 3378956 3971601 5944528 7310983 291705 566626 7175456 8125154 3919190 4100156 3256266 4024998 Wagner Community Memorial Hospital's mission is to provide care and treatment of the sick; provide care and support of the aged, disabled, and indigent; and to provide for those in need of hospitalization regardless of race, color, creed, or ability to pay. 1 0 6312157 6901908 It is the objective and purpose to provide care and treatment of the sick, to provide care and support of the aged, disabled and indigent and to provide for those in need of hospitalization, regardless of race, color, creed or ability to pay. WCMH is a 20 bed critical access hospital equipped with extensive advanced services, including areas for Medical/Surgical, Pediatric, Intensive/Coronary Care, Swing Bed/Long Term Care. The clinic is adjacent to the hospital making it convenient to see hospital patients, share laboratory services and other diagnostic equipment. Outreach services include OB/GYN, Pediatrics, Orthopedic Surgery, General Surgery, Urology, Podiatry, ENT & Audiology. The people of the community truly believe in having access to care and support their local medical providers. During the 2009-10 fiscal year WCMH provided more than $623,643 of free care to our patients who were unable to afford payment. The facility serves as the inpatient unit for the local Indian Health Services clinic and works collaboratively with the IHS physicians and leaders to care for the Native American population. WCMH experienced 1218 Inpatient days, 707 Swing Bed days, 1,839 Emergency Department visits, 1,640 Urgent Care visits and 1,350 clinic visits.WCMH provides Community Health Improvement Services which include: Community CPR classes, sponsorship to the Dakota Smiles Mobile Dental Program, Blood Pressure screenings at area events, assisting with community disasters and award scholarships to the local high school graduates.eEmergency/eStroke Services-are a two way video link to emergency-trained specialists to assist local providers in cases of trauma, heart attacks, stroke and other critical situations. These services assist rural hospitals by having specialists available for consultation, streamline emergency transport when needed, diagnose and begin treatment earlier and keep patients nearby home. Approximately $10,257 was expensed for this service, with no charge to the patients.Patient Satisfaction is monitored through Press Ganey services. The organization is proud to report our scores have continually improved and have seen an overall satisfaction approval from our patients in all areas. WCMH strives to provide a high quality of healthcare for the community and is very proud of the physicians and staff whose expertise and compassion allows that achievement. 6312157 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 13 0 1 78 1 0 0 0 0 0 0 0 9 9 0 1 0 0 1 1 1 1 1 0 0 1 0 1 1 1 1 0 X Lisa Weisser 6053843611 513 3rd Street SW Wagner SD 573800280 Jan Coleman 0.50 X X 0 0 0 Ken Thaler 0.50 X X 0 0 0 David Kotab 0.50 X X 0 0 0 Elden Ridgeway 0.50 X X 0 0 0 Jean Pirner 0.50 X X 0 0 0 Merle Bartunek 0.50 X X 0 0 0 Dorothy Holzbauer 0.50 X 0 0 0 Joan Wagner 0.50 X 0 0 0 Ann Freier-Metzger 0.50 X 0 0 0 Dave Andrews 0.50 X 0 0 0 Bill Frei 0.50 X 0 0 0 Daryl Dusharm 0.50 X 0 0 0 Bryan Slaba 40.00 X 79681 0 19801 Ahmed H Dessouki 40.00 X 188183 0 15904 Robert Hubley 40.00 X 179043 0 11656 446907 0 47361 2 0 1 1 Avera Sacred Heart Hospital 501 S Summit Street Yankton SD 57078 Management Services, CEO and IT Services 386305 Dr Jeffery Pinter 27952 323rd Avenue Winner SD 57580 Physician ER Coverage 243880 Avera Sacred Heart Rural Health 501 S Summit Street Yankton SD 57078 Contract Physician Labor 141982 Wagner Building and Supply 39379 SD Hwy 46 Wagner SD 57380 Construction/Remodel 138009 Dr Gary A Bubak 29778 398th Avenue Wagner SD 57380 Physician ER Coverage 125525 5 924974 5635 930609 Patient Service Rev 622110 6744344 6744344 Apartment Revenue 900099 100101 100101 Other Revenue 900099 36975 36975 Patient Int Revenue 900099 20488 20488 6901908 28629 28629 14652 14652 14652 14652 2186 375 1811 1811 1811 7877609 6901908 0 45092 2688 2688 2882185 2443280 438905 45253 38465 6788 233713 198656 35057 175543 149212 26331 42000 42000 384459 263475 120984 43961 43961 24501 3336 21165 30435 12556 17879 108946 105506 3440 30988 24044 6944 29887 22073 7814 172634 172634 442051 442051 44871 44871 Supplies 1529422 1476751 52671 Bad Debt Expense 528776 528776 Repairs and Maintenance 246435 241246 5189 Equipment Lease and Ren 134099 125005 9094 ACS Fees 106179 106179 71957 17532 54425 7310983 6312157 998826 0 993900 1267479 15000 8201 1482625 1377552 60415 70226 54622 66638 8432391 3959665 3800122 4472726 757969 841404 10803 20928 7175456 8125154 740209 630979 13180 37000 3165801 3432177 3919190 4100156 X 3069644 3671277 186622 353721 3256266 4024998 7175456 8125154 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 4246 4246 5735113 2619012 3116101 2420847 1312180 1108667 272185 28473 243712 4472726 Interest in Pooled Investment Fund 804148 F Interest in Net Assets of Avera Health Foundation 37256 F 841404 7877609 7310983 566626 22653 179453 202106 768732 8079715 22653 179453 202106 7877609 0 7877609 7310983 0 7310983 0 7310983 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. Part XI, Line 8 - Other Adjustments: Change in Interest in Net Assets of Avera Health Foundation: 179453. Part XII, Line 2d - Other Adjustments: Change in Net Assets of Avera Health Foundation: 179453. 1 1 X 1 X 1 X 1 1 1 0 0 55 37579 19073 18506 0.00250 984368 1302337 -317969 0.00000 55 1021947 1321410 -299463 0.00250 8171 8171 0.00110 4058 4058 0.00060 614930 83369 531561 0.07270 5666 5666 0.00080 632825 83369 549456 0.07520 55 1654772 1404779 249993 0.07770 2 26 110443 101064 9379 0.00130 16311 16311 0.00220 14 834 407 407 0.00010 16 860 127161 101064 26097 0.00360 0 176342 73358 2842593 2835910 6683 X 1 1 Wagner Community Memorial Hospital

PO Box 280 Wagner SD 57380

X X X X Community Villa

208 Grant Avenue SE Wagner SD 57380

Subsidized Independent Living Facility Westside Estates

315 Birch Avenue SW Wagner SD 57380

Subsidized Independent Living Facility Part I, Line 7: Lines 7a and 7b were determined using the ratio of patient care costs to charges calculated by WCMH's general ledger accounting system. 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 $613,218. Part I, Line 7f: Bad debt expense of $528,776 was subtracted from total operating expense. Part III, Line 4: a) The cost-to-charge ratio was calculated using Worksheet 2.b) Bad debt recoveries and discounts applied during the collection process are rare, but when they do occur they are posted against the bad debt account.c) WCMH applied the poverty level percentage from the U.S. Census Bureau for its service area to the total amount sent to collections during the fiscal year ended June 30, 2010 to determine an estimate of eligible charity care reported as bad debt. 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: All services provided at the Wagner Community Memorial Hospital & Clinic are expected to be paid in full after receiving the bill of services. Medicare, Medicaid and Commercial Insurance will be sent at the request of the patient provided we have the correct insurance information. Any co-insurance or deductibles must be paid at the time of services or other arrangements need to be made before discharge. - A statement will be sent out monthly to the responsible party allowing them to pay in full or make arrangements to pay in full. Arrangements must be confirmed in writing.- An interest charge of 1% monthly may be charged to all services 90 days old or older.- Patients may receive a final notice if no payment agreement has been made for services 90 days or older.- Patients may receive a final notice if no payment agreement has been made after third party payors have made payment.-Following the final notice, patient accounts may be turned over to Small Claims Court or to a Collection Agency. This may result in additional fees that will be charged to the account.-All account collections are treated the same, and the policy does not outline any provisions for the collection pratices to be followed for patients who are known to qualify for charity care or financial assistance. However, a review may be made either at the request of the patient or hospital staff to determine if the account may qualify for Charity Care. Part VI, Line 2: Through constant communication with patients and providers, primary and specialists, as well as state and federal governmental health agency, WCMH strives to consistently investigate, analyze, and determine the greatest needs of our community. Part VI, Line 3: WCMH has a written charity care policy. First reference is given to the patient upon admission. A second reference as to the patient qualifying/needing financial assistant and contact information accompanies the third request for payment. If neither notice is acted upon and the account continues to be unpaid a patient advocate will try to contact the patient if it is believed they may qualify for financial assistance. If the patient expresses interest in financial assistance the patient advocate determines if any other opportunities are available for the patient. If the only option available is WCMH's charity care, the proper documentation is completed. The amount of reduction a patient may receive is based on a sliding scale point system. Part VI, Line 4: Wagner is a rural community located in southern Charles Mix County of South Dakota which has many health disparities with unmet needs. If one looks at the county as a whole, the average individual income is $39,438 with the median family income at $53,800. Inhabitants below the poverty level total 31%. County education demographics include 72.75% of residents having a high school degree and 13.72% holding a Bachelor's Degree in comparison to the national average of 80.4% and 24.4%, accordingly. According to the US Census Bureau Fact Finder most recent data, 28.3% of residents in the county are of American Indian descent, almost all members of the Yankton Sioux Tribe. All of Charles Mix County is considered medically underserved by HRSA and the SD Department of Health. The county is also considered a health professional shortage area with few providers and many miles in between these rural communities. Wagner provides the only local hospital facility since Indian Health Services (IHS) closed their facility in 1992. In 2008, the IHS emergency room closed putting a burden on the Wagner facility until a new clinic was built by the Wagner Hospital. There are only a few rural health clinics available in addition to the IHS clinic and the newly built VA facility. Many clinics provide only primary care services and are often staffed by Physician Assistants. If more specialized care is needed, patients must travel to either Yankton, South Dakota, which is about 115 miles round trip or they drive the 280 round trip miles to Sioux Falls, which is the area's tertiary care hub with all types of specialty care available. In addition to the shortage of quality health care services, residents of Southern Charles Mix County also suffer from many chronic health conditions. The percent of the population over 65 years of age is almost double the national average in more than half of the county. The disability status of the county's inhabitants is consistent with, if not higher than, the national average of 19.3% in a majority of the communities. Gaps exist among socioeconomic groups in the rate of diabetes and its associated complications in South Dakota as well as throughout the United States. Certain racial and ethnic communities including American Indians, as well as economically disadvantaged or older people, suffer disproportionately compared to other populations. Diabetes prevalence for adults located in Central SD surpasses South Dakota and U.S. percentages. The American Indian population in Wagner and Lake Andes is between 34-42% as compared to the national average of 0.9%. American Indian population in the nearby towns of Marty and Ravinia are 90% and 80%, respectively. Part VI, Line 5: WCMH owns two elderly and disabled independent living facilities. The facilities are both rent subsidized and combined have a total of 26 units. WCMH was also able to recruit and retain a PA-C to assist with the needs of the area. Fourteen different healthcare career fairs were sponsored and presented by WCMH throughout southern Charles Mix County. Part VI, Line 6: WCMH is a community hospital with an open board selected from associates, all of which are community members and can not be WCMH employees. All providers who wish to obtain privileges at WCMH are encouraged and welcome to use the appointment/reappointment privileging application process. In 2010 WCMH lead the establishment of the Southern Charles Mix County Healthcare Consortium (SCMCHC). The mission of the consortium is to determine the greatest needs of the area maximizing resources of the eight member facilities and agencies to address the determined needs. SCMCHC has applied for a USDA-RD planning grant to accomplish this task which includes the completion of an independent needs assessment. WCMH uses surplus funds to fund building improvements to enhance services to its patients. Part VI, Line 7: N/A X X X 0 0 0 0 0 0 0 0 0 Bryan Slaba 79183 0 282 0 216 0 2405 0 18051 0 100137 0 0 0 Ahmed H Dessouki 188183 0 0 0 0 0 0 0 15904 0 204087 0 0 0 Robert Hubley 179043 0 0 0 0 0 0 0 11656 0 190699 0 0 0 Supplemental Information Part III Form 990, Part VII, Section A, Line 5 & Form 990, Schedule J, Part II: Bryan Slaba, CEO/Administrator, is paid by Avera Sacred Heart Hospital, 501 Summit Street, Yankton, SD 57078. Dr. Robert Hubley, Physician, is paid by Avera Sacred Heart Hospital, 501 Summit Street, Yankton, SD 57078. Form 990, Part III, line 2 New Program Services eEmergency and eStroke Services were added during the fiscal year ending June 30, 2010. Form 990, Part VI, Section A, line 1 The Executive Committee consists of the President, as Chairman, and two other members of the board of directors appointed by the President. The executive committee will have power to transact all regular business of the Hospital during the interim between the meetings of the board of directors provided any action taken does not conflict with the policies and expressed wishes of the board of directors, and that it shall refer all matters of major importance to the board of directors. Form 990, Part VI, Section A, line 3 Sevices provided by the CEO are through a management agreement with Avera Sacred Heart Health Services in Yankton, South Dakota. Form 990, Part VI, Section A, line 6 There is only one class of member. Any individual, partnership, corporation or association having legal entity, who has contributed $25 or more to the Corporation with request of membership at the time of donation, shall be a member thereof and each member shall have one vote at all meetings of the members of the corporation. Membership of any individual who shall become deceased shall revert by request to that individual's next of kin or according to his will. Any member who has contributed $50 or more shall have the right to transfer such membership to his or her spouse. Said transfer to be approved by the Board of Directors. The basis for membership is on non-refundable contributions. Form 990, Part VI, Section A, line 7a Only one class of member exists. At the annual meeting, members approve the minutes of the last annual meeting, elect board members of the Wagner Community Memorial Hospital, and vote on other business that may be properly brought before the members. Form 990, Part VI, Section A, line 7b The Board of Directors may adopt amendments at any regular or special meeting of the Board and the same shall be effective until the next regular or special meeting of the members, at which time, the same will be ratified or rejected, and, if ratified, the same shall be binding as incorporated by-laws of the corporation. Form 990, Part VI, Section B, line 11 The CEO will review the 990. After the form 990 has been reviewed, it will be forwarded to the members of the Governing Body for their review. It will be presented at a board meeting, and filed subsequent to that. Form 990, Part VI, Section B, line 15 Avera Sacred Heart Health Services and Wagner Community Memorial Hospital Compensation Committee use comparability data to determine appropriate compensation of the CEO based on experience and performance. Wagner Community Memorial Hospital uses comparability data and demographic data to determine the appropriate compensation of its key employees. Form 990, Part VI, Section C, line 19 Documents are made available upon request.