2011-08-12T13:39:29-05:00 2010-09-30 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2009-10-01 460255944 Mobridge Regional Hospital MOBR 6058453692 1401 10th Ave W Mobridge SD 57601 Angelia Svihovec 6058453692 2011-08-12 1 Laurie Hanson 6053391999 2011-08-12 2009 2016-02-24 21:20:13Z Angelia Svihovec 1401 10th Ave W Mobridge SD 57601 15444894 0 X www.mobridgehospital.org X 1959 SD Providing healthcare to people throughout the region. 12 10 184 150 0 0 166965 1066313 13359976 14215894 58695 77629 62175 85058 13647811 15444894 0 0 6742279 7344583 0 0 5820653 6282650 12562932 13627233 1084879 1817661 15010699 17134975 6929716 7236331 8080983 9898644 The mission of Mobridge Regional Hospital is to provide high quality healthcare services in a compassionate and professional manner for people throughout the region. 0 0 12302945 14215894 Mobridge Regional Hospital (MRH) provides healthcare services to persons throughout the region. During the fiscal year ended September 30, 2010, the hospital had: 1,761 Patient Days 924 Acute Care Days30,911 Outpatient Visits 5,730 Assisted Living Days (Prairie Sunset Village)MRH's charity care program is available to both new and established patients. The charity care policy covers all medically necessary services provided by the institution that are ordered by physicians. The policy does not cover services provided by non-institution healthcare providers, patient convenience items, or insurance co-payments for Medicaid, Medicare or other needs-based programs. MRH's charity care program is available to all patients who indicate an inability to pay for all or a portion of their outstanding hospital bill. In order to be eligible, patients must complete an application and provide all required documentation. 12302945 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 15 0 184 1 0 0 0 0 0 0 0 12 10 0 1 0 0 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 0 X Renae Tisdall 6058458164 PO Box 580 Mobridge SD 57601 Dennis Schnabel 1.00 X X 0 0 0 Delphine Steuck 1.00 X X 0 0 0 Bill Bachmeier 1.00 X X 0 0 0 Heidi Roshau 1.00 X X 0 0 0 Jake Kraft 1.00 X 0 0 0 Wally Schott 1.00 X 0 0 0 Doug Scott 1.00 X 0 0 0 Donald Paulson 1.00 X 0 0 0 Benjamin Stoick 1.00 X 0 0 0 Dr Leonard Linde 1.00 X 0 0 0 Dr Travis Henderson 40.00 X X 206133 0 18879 Dr Robert Marciano 40.00 X X 228767 0 16090 Chad Thue 1.00 X 0 0 0 Angelia Svihovec 40.00 X 132861 0 15775 Renae Tisdall 40.00 X 59326 0 13487 Dr Bela Csaki 40.00 X 258291 0 17137 Dr Colette Ducheneaux 40.00 X 193694 0 13892 Dr Kenric Malmberg 40.00 X 188367 0 14049 Jim Curran 40.00 X 177380 0 14363 Debbie Smith 40.00 X 186480 0 4447 1631299 0 128119 8 0 1 1 St Alexius Medical Center 900 East Broadway Bismarck ND 58506 IT Services, CEO Salary, Supplies, Telem 241560 1 249762 816551 1066313 Patient Service Rev 622110 13580913 13580913 Assisted Living Rev 623110 497080 497080 Ancillary Charges 900099 88534 88534 Chng in Int-Mobridge H 900099 49367 49367 14215894 76629 76629 85058 85058 85058 85058 1000 1000 1000 1000 15444894 14215894 0 162687 795081 537646 257435 5895476 5492664 402812 206556 189525 17031 447470 397635 49835 11177 11177 33561 33561 702433 504854 197579 63505 6449 57056 153193 44701 108492 43107 19215 23892 304616 301006 3610 29159 29159 48349 40013 8336 263384 263384 926117 926117 921755 921755 Medical Supplies 1198700 1198700 Bad Debt 903664 903664 Repairs and Maintenance 329183 286885 42298 Minor Equipment 149354 147679 1675 Equipment Lease and Ren 94212 39093 55119 107181 52801 54380 13627233 12302945 1324288 0 4483612 5476524 2073898 2207030 403695 467670 85834 57774 18504397 10832212 6795319 7672185 455803 546198 712538 707594 15010699 17134975 1432549 1774202 5335000 5050000 87950 298103 74217 114026 6929716 7236331 X 7689344 9284551 391639 614093 8080983 9898644 15010699 17134975 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5575 5575 10527105 5807518 4719587 7647091 4754483 2892608 324626 270211 54415 7672185 Premium on Bonds Payable 14834 Deferred Compensation Plan Payable 99192 114026 15444894 13627233 1817661 0 1817661 15444894 0 15444894 0 15444894 13627233 0 13627233 0 13627233 Part X: Description of Uncertain Tax Positions Under FIN 48: Mobridge Regional 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 Organization has implemented Accounting Standards Codification 740, Income Taxes, (ASC 740). The Organization 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. For the years ended September 30, 2010 and 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. 1 1 X 1 X 1 X 1 1 0 1 1 76307 76307 0.00560 2414888 1780090 634798 0.04660 419089 276758 142331 0.01040 2910284 2056848 853436 0.06260 2910284 2056848 853436 0.06260 0 443576 377039 5082968 5032642 50326 X 1 0 Mobridge Regional Hospital

1401 10th Avenue W Mobridge SD 57601

X X X X Mobridge Medical Clinic

1309 10th Avenue W Mobridge SD 57601

Provider Based Medical Clinic West Dakota Health Clinic

906 Main Timber Lake SD 57656

Provider Based Rural Health Clinic West River Health Clinic

103 1st Avenue E McLaughlin SD 57642

Provider Based Rural Health Clinic Prairie Sunset Village

1320 W Grand Crossing Mobridge SD 57601

Assisted Living & Senior Housing Part I, Line 3c: In addition to using FPG guidelines, MRH utilizes an asset test for free or discounted care along with consideration of the amount of the patient's bill. 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. Part I, Line 7f: Bad debt expense of $903,664 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 9/30/2010.b) When a payment is received or a discount given on a bad debt account it offsets the current fiscal year bad debt expense through a recovery of bad debt account. c) Bad debt expense attributable to charity care is estimated based on income levels. A large portion of MRH charges are generated by the Native American population and those below the poverty level. Statistics prove that most of the mentioned patients qualify for charity care, thus after review MRH estimates approximately 85% 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 and resident receivables is reduced by a valuation allowance that reflects management's best estimate of amounts that will not be collected from patients, residents and third-party payors. Management reviews patient and resident receivables by payor class and uses aging of individual accounts to estimate amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients and residents 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 of charity care is appropriate. Part III, Line 8: Medicare Allowable Cost of Care was calculated from the Medicare Cost Report for fiscal year ending 9/30/10. Part I, Line 6b: MRH's community benefit information is included in the hospital's annual report, which is mailed out to members and made available in the lobbies of the hospital and clinics. Part VI, Line 2: Mobridge Regional Hospital (MRH) is committed to providing high quality healthcare services to all people throughout the region. The facility provides family medicine, internal medicine, OB, ICU, ALS, ambulance service, emergency care, and surgical services to all people who are in need of those services. MRH's management strives to listen to the community needs. If new healthcare needs arise, administration will complete an analysis of cost/benefit for the new service to be offered. MRH's administration believes in being out in the public at events to answer questions that may surface about the facility. Part VI, Line 3: MRH posts its charity care policy, or a summary thereof, and financial assistance contact information in the admissions areas and clinic areas in which eligible patients are likely to be present. The facility provides a copy of the policy, or a summary thereof, and financial assistance contact information to patients with discharge materials. The Patients Account Manager discusses with the patient the availability of various government benefits, such as Medicaid or state programs, and assists the patient with qualification for such programs, where applicable. Part VI, Line 4: MRH is located in a small rural community in Walworth County, South Dakota, known as Mobridge. According to the 2000 Census, Mobridge has a population of 3,574 people racially comprised of mainly Whites (79.52%) and Native Americans (18.13%). The community borders the Standing Rock Reservation and the Cheyenne River Reservation which accounts for the larger Native American population and relations with Indian Health Services. The median household income of Mobridge is $25,583 and the median family income is $31,026. Roughly 21.6% of the population is below the poverty line. The facility owns and operates clinics in Mobridge, McLaughlin and Timber Lake. The facility serves patients from a five county area (Walworth, Corson, Dewey, Campbell and Potter) and is approximately one hundred miles from another hospital with a higher level of care offered. Part VI, Line 5: Part VI, Line 6: The hospital has a Board of Directors comprised of volunteers who reside in the service area. Medical staff privileges are extended to all qualified physicians in the area. All qualified physicians who show an interest must go through a credential review and board approval. Surplus funds, if available, are reinvested in the facilities to improve patient care.MRH is a Certified Level Four Trauma Center under the North Dakota Department of Health. The facility is extremely proud of this accomplishment as South Dakota does not have a statewide trauma system yet, but is in the planning stages for completion in 2012. MRH felt there was a very urgent need for this certification as the facility is in a remote area of South Dakota. MRH also provides various health screenings available to the community and surrounding communities throughout the year. The health screenings include free cholesterol checks, BMI, blood pressure and waist/hip ratios. These preventative health screenings promote the general health of the community. X X 0 0 0 0 0 0 0 0 0 Dr Travis Henderson 179603 0 21127 0 5403 0 8129 0 11095 0 225357 0 0 0 Dr Robert Marciano 185175 0 38344 0 5248 0 8942 0 7504 0 245213 0 0 0 Angelia Svihovec 132468 0 0 0 393 0 5534 0 11473 0 149868 0 0 0 Dr Bela Csaki 249735 0 0 0 8556 0 9989 0 7386 0 275666 0 0 0 Dr Colette Ducheneaux 160666 0 14600 0 18428 0 7131 0 7078 0 207903 0 0 0 Dr Kenric Malmberg 160014 0 12500 0 15853 0 6901 0 7455 0 202723 0 0 0 Jim Curran 174264 0 0 0 3116 0 7229 0 7307 0 191916 0 0 0 Debbie Smith 178911 0 0 0 7569 0 570 0 3927 0 190977 0 0 0 Supplemental Information Part III Schedule J, Part II: Angelia Svihovec's compensation The CEO is compensated for her services through a management agreement with St. Alexius Medical Center in Bismarck, ND. City of Mobridge South Dakota 466000320 607429BA4 2007-05-08 5773898 Refinanced existing tax-exempt bonds and purchase CT, Clinic and EMR. 0 0 5773898 269394 4416499 88005 1000000 2008 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 3 MRH currently has a management agreement with St. Alexius Medical Center in Bismarck, ND. The agreement provides the CEO, Angelia K. Svihovec, and information technology support at a cost to MRH. The original management agreement date was January 1, 2000. Form 990, Part VI, Section A, line 6 There is only one class of member; all members have one vote (same voting rights). Form 990, Part VI, Section A, line 7a The nominating committee nominates candidates for election. The members vote on candidates at the annual meeting. Form 990, Part VI, Section A, line 8b There is no committee with the authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The CEO, CFO, and Finance Committee will review the Form 990 prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The conflict of interest policy covers the entire Board of Directors. If a conflict should arise, it would first go to the CEO for evaluation, then to the Board of Directors for final evaluation. The Board of Directors is responsible for making the final decision in determining if a conflict exists. If a conflict is found, the person(s) involved would be required to abstain from discussions and voting on the item causing the conflict. Form 990, Part VI, Section B, line 15 The Finance Committee determines and approves the physician contracts, including compensation. The CEO's salary is determined using a salary survey and discussions with the management company. The Finance Committee approves the salary of the CEO annually. The Board of Directors approves the Finance Committee minutes, which include discussions regarding the CEO's salary. Salaries for other Officers or Key Employees are determined by the CEO through the use of salary survey information from SDAHO and employee service and experience files. Form 990, Part VI, Section C, line 19 Documents are made available upon request.