2017-05-15T10:19:25-05:00 2016-06-30 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2015-07-01 460233030 CHILDREN'S CARE HOSPITAL AND SCHOOL CHIL 6054449500 2501 WEST 26TH STREET SIOUX FALLS SD 571052498 STEVE WILSON CFO 6054449500 2017-05-15 1 LAURIE HANSON P00851848 6053391999 2017-05-15 2015 2021-01-29 14:40:06Z LIFESCAPE ANNE RIECK MCFARLAND 2501 WEST 26TH STREET SIOUX FALLS SD 571052498 27436742 0 X WWW.LIFESCAPESD.ORG X 1952 SD WE EMPOWER CHILDREN AND ADULTS WITH DISABILITIES TO LEAD FULFILLING LIVES. 16 15 663 909 0 0 1252433 2262134 26040425 24214472 232975 153498 118017 139375 27643850 26769479 0 0 0 0 18346911 16623049 0 0 14757 6653100 8067096 25000011 24690145 2643839 2079334 22650957 24233203 6806181 6340229 15844776 17892974 X WE EMPOWER CHILDREN AND ADULTS WITH DISABILITIES TO LEAD FULFILLING LIVES. 0 0 21381847 24214472 LIFESCAPE PROVIDED SERVICES FOR AN ESTIMATED 2,140 INDIVIDUALS WITH SPECIAL NEEDS IN ALL OF ITS PROGRAMS LAST FISCAL YEAR. CCHS OUTPATIENT/OUTREACH SERVICES (COMMUNITY-BASED SERVICES) SERVED 2028-THE MAJORITY CHILDREN. SERVICES ARE DELIVERED FROM CENTERS IN SIOUX FALLS AND RAPID CITY. THERAPIES (PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY) ARE THE MAIN SERVICES OFFERED AT THESE SITES, PLUS ASSISTIVE TECHNOLOGY, SEATING & POSITIONING, AND POWERED MOBILITY SERVICES. OTHER SERVICES: WHEELCHAIR SEATING & POSITIONING EVALUATIONS; ADAPTIVE AQUATICS (SIOUX FALLS ONLY); AND SUMMER SKILLS "CAMPS" FOR CHILDREN AND SOME ADULTS WITH SPECIAL NEEDS. FREE AUTISM SCREENINGS ARE OFFERED IN SIOUX FALLS AND RAPID CITY AS AN OUTPATIENT SERVICE, AND FULL AUTISM EVALUATIONS ARE PROVIDED BY OUR MULTIDISCIPLINARY AUTISM EVALUATION TEAM, LED BY A PEDIATRIC PSYCHIATRIST. THE TEAM (TONE EVALUATION AND MANAGEMENT) CLINIC FOR CHILDREN WITH CEREBRAL PALSY IS PHYSICIAN-LED. OUTREACH PROVIDES SERVICES TO CHILDREN IN THEIR OWN ENVIRONMENT-THEIR HOME, SCHOOL, OR DAYCARE CENTER. PROFESSIONALS FROM SIOUX FALLS AND RAPID CITY DROVE OVER 223,000 MILES DURING THE FISCAL YEAR ACROSS SOUTH DAKOTA PROVIDING SERVICES TO CHILDREN, INCLUDING PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY, AND CONSULTATION IN SCHOOL PSYCHOLOGY AND SPECIAL EDUCATION.RESIDENTIAL, INPATIENT AND DAY PROGRAMS IN SIOUX FALLS, SD SERVED 166 CHILDREN. CHILDREN WERE MOSTLY FROM SOUTH DAKOTA, WITH CHILDREN FROM MINNESOTA, IOWA, AND ALASKA ALSO SERVED. SERVICES INCLUDE THERAPIES (PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, RESPIRATORY THERAPY, MUSIC THERAPY, AND BEHAVIOR THERAPY), NURSING CARE, PSYCHOLOGY, AND SPECIAL EDUCATION. SPECIAL EDUCATION IS OFFERED THROUGH CLASSROOMS FOR CHILDREN OF DIFFERENT AGES AND VARIOUS DIAGNOSES. STUDENTS INCLUDE THOSE IN RESIDENCE AT LIFESCAPE PLUS DAY STUDENTS. BESIDES TEACHERS, OTHER PROFESSIONALS OFFERING SERVICES INCLUDE CASE MANAGERS, SOCIAL WORKERS, DIETITIANS, SCHOOL PSYCHOLOGISTS, BEHAVIOR ANALYSTS, AND BEHAVIOR THERAPISTS. LIFESCAPE EMPLOYS FIVE BOARD CERTIFIED BEHAVIOR ANALYSTS. AVERAGE DAILY CENSUS FOR 2015-2016 WAS 10.0 FOR SPECIALTY HOSPITAL, 52.9 FOR RESIDENTIAL, AND 39.1 FOR DAY PROGRAMS. THE EXTENDED SCHOOL YEAR (ESY) PROGRAM OFFERS SUMMER SCHOOL FOR CHILDREN WHO NEED YEAR ROUND SCHOOLING, BUT WHOSE SCHOOL DISTRICTS DO NOT OFFER THAT SERVICE. 21381847 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 1 0 0 1 39 0 1 663 1 0 0 0 0 0 0 0 0 0 0 X 16 15 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X STEVE WILSON 6054449820 2501 WEST 26TH STREET SIOUX FALLS SD 571052498 DR PATTY PETERS VICE CHAIR 1.00 3.00 X X 0 0 0 H CHIP CARLSON VICE CHAIR (UNTIL APR 2016) 1.00 1.00 X X 0 0 0 P DANIEL DONOHUE TREASURER 1.00 1.00 X X 0 0 0 GAYLE VER HEY SECRETARY 1.00 3.00 X X 0 0 0 JOHN ROZELL MEMBER-AT-LARGE 1.00 5.00 X X 0 0 0 ANNE RIECK MCFARLAND CEO 23.00 27.00 X X 0 221349 20467 JOE HENKIN DIRECTOR 1.00 3.00 X 0 0 0 MOLLY MCCARTHY DIRECTOR 1.00 1.00 X 0 0 0 JON SODERHOLM DIRECTOR 1.00 3.00 X 0 0 0 DR LARRY FENTON DIRECTOR (BEG JAN 2016) 1.00 1.00 X 0 0 0 JACK HOPKINS DIRECTOR 1.00 3.00 X 0 0 0 MARK STERNHAGEN DIRECTOR 1.00 1.00 X 0 0 0 CLAUDIA VUCUREVICH DIRECTOR 1.00 1.00 X 0 0 0 TERRI GRABLANDER DIRECTOR 1.00 1.00 X 0 0 0 JASON HARRIS DIRECTOR 1.00 1.00 X 0 0 0 JEFF HAZARD DIRECTOR 1.00 3.00 X 0 0 0 DR JOHN JACK BILLION DIRECTOR 1.00 3.00 X 0 0 0 BRANDI KOWALCZYK CFO 21.00 29.00 X 0 111419 24088 0 332768 44555 0 0 1 0 LIFESCAPE 2501 W 26TH STREET SIOUX FALLS SD 57105 SHARED SERVICES 1105065 SANFORD USD MEDICAL CENTER PO BOX 5074 SIOUX FALLS SD 571175074 RESP. THERAPY; IT SVCS 383037 HENRY CARLSON CO 1205 W RUSSELL ST SIOUX FALLS SD 57104 CONSTRUCTION SERVICES 199362 JOHNSON CONTROLS PO BOX 730068 DALLAS TX 75373 TECHNOLOGY SERVICES 150913 SANFORD CHILDREN'S SPECIALTY CLINIC PO BOX 5039 SIOUX FALLS SD 571175039 PHYSICIAN SERVICES 121405 5 83957 2097735 80442 2262134 PATIENT/RESIDENT FEES 623000 23841227 23841227 OTHER SERVICE REVENUE 900099 373245 373245 24214472 168373 168373 139354 0 139354 139354 139354 615531 14980 619324 26062 -3793 -11082 -14875 -14875 21898 83957 21877 21 21 26769479 24214472 0 292873 13598123 13541535 56588 239817 227666 12151 1802189 1766432 35757 982920 980359 2561 6305 6305 92145 92145 951240 597169 354071 116372 1820 99795 14757 283284 164277 119007 4510 4510 743528 707909 35619 62396 57335 5061 103303 44608 58695 302014 302014 1204297 1204297 192328 87 192241 SHARED SERVICES 1726209 1726209 OTHER SUPPLIES 1234117 1192242 41875 MAINTENANCE AND REPAIR 344752 244874 99878 BAD DEBTS 107000 107000 593296 544237 49059 24690145 21381847 3293541 14757 1250268 737041 6996418 5594021 16399 19194 17382 14705 28415846 19628552 9413208 8787294 4318748 4232368 638534 4848580 22650957 24233203 -82247 -102771 126478 0 6690000 6370000 71950 73000 6806181 6340229 X 15569863 17614162 258142 262041 16771 16771 15844776 17892974 22650957 24233203 2079334 -31136 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 0 1 392 0 1 138 1 19756 0 0 20286 0 PART II-B, LINE 1: CHILDREN'S CARE HOSPITAL AND SCHOOL (CCHS) CONTRACTS FOR LOBBYING SERVICES. THE LOBBYIST IS IN DIRECT CONTACT WITH LEGISLATORS, THEIR STAFFS AND GOVERNMENT OFFICIALS DURING THE STATE'S 30-40 DAY LEGISLATIVE SESSION. THE LOBBYIST HELPS CCHS DEFINE ISSUES AND MAKE CONTACT WITH APPROPRIATE LEGISLATIVE AND EXECUTIVE BRANCH PERSONNEL TO MAKE SURE THEY TRULY UNDERSTAND HOW ISSUES THAT MAY BE IN FRONT OF THEM WILL AFFECT CCHS. LOBBYING REVOLVES AROUND PROPOSED BUDGETARY ISSUES AS WELL AS ADVOCATING FOR THE WELFARE OF PEOPLE SERVED BY CCHS. DUES PAID TO OTHERS FOR LOBBYING REPRESENTS THE LOBBYING PORTION OF DUES PAID TO THE AMERICAN NETWORK OF COMMUNITY OPTIONS AND RESOURCES FOR THE FISCAL YEAR JULY 1, 2015 THROUGH JUNE 30, 2016. 430216 430216 21146151 14043785 7102366 6650356 5399885 1250471 189123 184882 4241 8787294 DEFERRED FINANCING FEES 75452 INVESTMENT IN DAKOTA TRUCK UNDERWRITERS 98350 DUE FROM RELATED ORGANIZATIONS 4674778 4848580 ASSETS HELD IN TRUST 25627 ORIGINAL ISSUE PREMIUM DISCOUNT 47373 73000 X PART X, LINE 2: LIFESCAPE AND MOST OF ITS AFFILIATED ORGANIZATIONS ARE ORGANIZED AS SOUTH DAKOTA NONPROFIT CORPORATIONS AND HAVE BEEN RECOGNIZED BY THE INTERNAL REVENUE SERVICE (IRS) AS EXEMPT FROM FEDERAL INCOME TAXES UNDER INTERNAL REVENUE CODE SECTION 501(C)(3). THESE ORGANIZATIONS ARE ANNUALLY REQUIRED TO FILE A RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX (FORM 990) WITH THE IRS. TOGETHER THESE ORGANIZATIONS HAVE DETERMINED THAT THEY ARE NOT SUBJECT TO UNRELATED BUSINESS INCOME TAX AND HAVE NOT FILED AN EXEMPT ORGANIZATION BUSINESS INCOME TAX RETURN (FORM 990T) WITH THE IRS. REHABILITATION MEDICAL SUPPLY IS A TAXABLE NON-PROFIT ORGANIZATION AND IS SUBJECT TO FEDERAL INCOME TAXES. THE ORGANIZATION BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE FINANCIAL STATEMENT. THE ORGANIZATION WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE IF SUCH INTEREST AND PENALTIES ARE INCURRED. REHABILITATION MEDICAL SUPPLY'S TAX RETURN IS NO LONGER SUBJECT TO FEDERAL TAX EXAMINATIONS BY TAX AUTHORITIES FOR YEARS BEFORE 2013. MALL WALK 2016 88822 83957 4865 4865 2500 88822 83957 4865 4865 2500 7365 -2500 1 1 X 1 X 1 X 175.000000000000 1 0 1 1 15284802 14870090 414712 0.01690 15284802 14870090 414712 0.01690 2625 2625 0.00010 2625 2625 0.00010 15287427 14870090 417337 0.01700 0 107000 0 18654 45886 -27232 X 1 1 1 1 CHILDREN'S CARE HOSPITAL & SCHOOL 2501 W 26TH ST 1020 W 18TH ST SIOUX FALLS SD 57105 WWW.LIFESCAPESD.ORG 10562 X X CHILDREN'S CARE HOSPITAL & SCHOOL 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE 7D X X 1 15 1 SEE 7D 0 0 1 X 100.000000000000 175.000000000000 X X X X X 1 1 X X X X 1 X HTTP://WWW.LIFESCAPESD.ORG/BILLING_COLLECTIONS_FINANCIAL_ASSISTANCE/ X HTTP://WWW.LIFESCAPESD.ORG/BILLING_COLLECTIONS_FINANCIAL_ASSISTANCE/ X X X 1 X 0 X X 1 X 0 0 CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 5: A GROUP OF COMMUNITY STAKEHOLDERS WITH A WIDE RANGE OF BACKGROUNDS WERE IDENTIFIED WHICH INCLUDED COMMUNITY SUPPORT PROVIDERS, COMMUNITY HEALTH CLINICS/CENTERS, INDIAN HEALTH SERVICES, PARENTS, HEALTH & HUMAN SERVICES STATE AGENCIES, PARENT RESOURCE CENTERS, PHYSICIANS, AS WELL AS OTHER AGENCIES WITH KNOWLEDGE OF COMMUNITY HEALTH NEEDS. THESE STAKEHOLDERS WERE INTERVIEWED TO GATHER INFORMATION AND OPINIONS REPRESENTING THE BROAD INTEREST OF THE COMMUNITY SERVED WHICH DIRECTLY LEAD TO THE OUTCOME OF THE COMMUNITY HEALTH NEEDS ASSESSMENT. CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 7D: HTTP://WWW.LIFESCAPESD.ORG/COMMUNITY-HEALTH-NEEDS-ASSESMENT/THE IMPLEMENTATION STRATEGY CAN BE FOUND ON PAGE 26 OF THE CHNA REPORT. CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 11: THE COMMUNITY HEALTH NEEDS ASSESSMENT IDENTIFIED TWO KEY PRIORITY AREAS OF NEED: 1) LACK OF MENTAL HEALTH SERVICES AND PROVIDERS AND 2) BARRIERS THAT IMPEDE ACCESS TO HEALTHCARE FOR NON-ENGLISH SPEAKING IMMIGRANTS. ADDITIONALLY, THERE WERE OTHER PRIORITIES IDENTIFIED THAT WE WILL NOT ADDRESS: 1) BROADEN GUIDELINES/INCREASE ACCESS TO LOW FEE/SLIDING SCALE SERVICES FOR PEOPLE IN POVERTY/WORKING POOR WHO ARE UNDERSERVED. AS A PROVIDER WITH LIMITED REIMBURSEMENT, WE ARE NOT ABLE TO IMPACT GUIDELINES FOR THESE SERVICES. 2) IMPROVE RESPONSIVENESS, TIMELINESS OF SERVICES ON INDIAN RESERVATIONS; INCREASE SERVICES FOR NATIVE AMERICANS WHO ARE UNDERSERVED; PROVIDE PRENATAL CARE TO NATIVE AMERICANS. LIFESCAPE SERVES MANY PEOPLE WHO ARE NATIVE AMERICAN THROUGH INPATIENT, OUTPATIENT AND OUTREACH SERVICES WITH OUTREACH SERVICES LIMITED TO SCHOOL BASED THERAPY ONLY. IT IS BEYOND OUR SCOPE TO PROVIDE MEDICAL SERVICES ON THE RESERVATIONS AND ALSO BEYOND OUR SCOPE TO PROVIDE PRENATAL CARE TO WOMEN. 3) INCREASE OUTREACH PROGRAMS INTO RURAL AREAS INCLUDING TELEMEDICINE. AS STATED, LIFESCAPE'S OUTREACH SERVICES ARE PRIMARILY SCHOOL-BASED. REIMBURSEMENT AND LICENSING REQUIREMENTS LIMIT EXPANSION OF OUTREACH EFFORTS. CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 13B: THERE ARE INSTANCES WHEN A PATIENT MAY APPEAR ELIGIBLE FOR CHARITY CARE DISCOUNTS, BUT THERE IS NO FINANCIAL ASSISTANCE FORM ON FILE DUE TO A LACK OF SUPPORTING DOCUMENTATION. OFTEN THERE IS ADEQUATE INFORMATION PROVIDED BY THE PATIENT THROUGH OTHER SOURCES, WHICH COULD PROVIDE SUFFICIENT EVIDENCE TO PROVIDE THE PATIENT WITH CHARITY CARE ASSISTANCE. IN THE EVENT THERE IS NO EVIDENCE TO SUPPORT A PATIENT'S ELIGIBILITY FOR CHARITY CARE, CHILDREN'S CARE HOSPITAL AND SCHOOL COULD USE OUTSIDE AGENCIES IN DETERMINING ESTIMATE INCOME AMOUNTS FOR THE BASIS OF DETERMINING CHARITY CARE ELIGIBILITY AND POTENTIAL DISCOUNT AMOUNTS. PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1. STATE-FUNDED PRESCRIPTION PROGRAMS;2. HOMELESS OR RECEIVED CARE FROM A HOMELESS CLINIC;3. PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC);4. FOOD STAMP ELIGIBILITY;5. SUBSIDIZED SCHOOL LUNCH PROGRAM ELIGIBILITY;6. ELIGIBILITY FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAM THAT ARE UNFUNDED (E.G., MEDICAID SPEND-DOWN);7. LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; AND,8. PATIENT IS DECEASED WITH NO KNOWN ESTATE. CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 15E: THE FINANCIAL ASSISTANCE POLICY STATES NOTIFICATION ABOUT CHARITY CARE AVAILABLE FROM CCHS SHALL INCLUDE A CONTACT NUMBER AND WILL BE DISSEMINATED BY VARIOUS MEANS, INCLUDING BUT NOT LIMITED TO, THE PUBLICATION OF NOTICES IN PATIENT BILLS AND BY POSTING NOTICES IN EMERGENCY ROOMS, ADMITTING AND REGISTRATION DEPARTMENTS, AND IN THE BUSINESS OFFICE. CHILDREN'S CARE HOSPITAL & SCHOOL PART V, SECTION B, LINE 20E: LIFESCAPE WILL NOTIFY INDIVIDUALS THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS AT LEAST 30 DAYS PRIOR TO PURSUING ECAS TO OBTAIN PAYMENT FOR THE CARE PROVIDED BY THE HOSPITAL BY DOING THE FOLLOWING:1. PROVIDE WRITTEN NOTICE TO THE INDIVIDUAL INDICATING THAT FINANCIAL ASSISTANCE IS AVAILABLE TO ELIGIBLE INDIVIDUALS, INDICATING THAT LIFESCAPE INTENDS TO INITIATE OR HAVE A THIRD-PARTY INITIATE TO OBTAIN PAYMENT FOR CARE, AND PROVIDES A DEADLINE AFTER WHICH ECAS MAY BE PURSUED AND WHICH IS NO LATER THAN 30 DAYS AFTER THE DATE OF WRITTEN NOTICE;2. PROVIDE THE INDIVIDUAL A PLAIN LANGUAGE SUMMARY OF THE FINANCIAL ASSISTANCE POLICY WITH THIS WRITTEN NOTICE; AND3. MAKE REASONABLE EFFORTS TO ORALLY NOTIFY INDIVIDUALS ABOUT THE FINANCIAL ASSISTANCE POLICY.ECAS FOR HOSPITAL SERVICES WILL NOT COMMENCE FOR A PERIOD OF 120 DAYS AFTER THE DATE OF FIRST POST-DISCHARGE BILLING STATEMENT FOR THE APPLICABLE MEDICALLY NECESSARY OR EMERGENCY MEDICAL CARE. 1 1 - CHILDREN'S CARE HOSPITAL & SCHOOL 7110 JORDAN DRIVE RAPID CITY SD 57702 OUTPATIENT REHABILITATION CENTER PART I, LINE 3C: IN ADDITION TO FEDERAL POVERTY GUIDELINES, CCHS TAKES THE FOLLOWING INTO CONSIDERATION WHEN DETERMINING FINANCIAL ASSISTANCE ELIGIBILITY: ASSET LEVEL, MEDICAL INDIGENCY, INSURANCE STATUS, AND UNDERINSURANCE STATUS.PART I, LINE 6B:THE ORGANIZATION'S COMMUNITY BENEFIT REPORT CAN BE FOUND ON ITS WEBSITE AT WWW.LIFESCAPESD.ORG PART I, LINE 7: LINE 7B) UNREIMBURSED MEDICAID IS THE COST OF MEDICAID PROVIDED FOR INPATIENTS, PATIENTS AT THE RAPID CITY REHAB CENTER, RAPID CITY OUTREACH AND SIOUX FALLS OUTREACH. THE COST IS CALCULATED BY MULTIPLYING THE MEDICAID CHARGES TIMES THE COST-TO-CHARGE RATIO, AS DETERMINED THROUGH USE OF THE GENERAL LEDGER. THE AMOUNTS ON LINE 7I ARE RELATED TO THE DIRECT COSTS AS RECORDED IN THE GENERAL LEDGER ACCOUNTING SYSTEM. PART I, LN 7 COL(F): BAD DEBT EXPENSE OF $107,000 WAS SUBTRACTED FROM TOTAL OPERATING EXPENSE. PART III, LINE 2: PAYMENTS ON ACCOUNTS THAT ARE WRITTEN OFF ARE NORMALLY MADE DIRECTLY TO THE COLLECTION AGENCY. IN THE RARE EVENT THAT A PAYMENT IS RECEIVED DIRECTLY BY CCHS, CCHS NOTIFIES THE COLLECTION AGENCY OF ITS RECEIPT OF THE PAYMENT SO THE PATIENT'S ACCOUNT BALANCE CAN BE ADJUSTED. PART III, LINE 3: NO PART OF THE AMOUNT ON LINE 2 WAS DETERMINED TO BE CHARITY CARE ELIGIBLE. PART III, LINE 4: THE FINANCIAL STATEMENTS THAT DESCRIBE THE BAD DEBT EXPENSE ARE ON NOTE 1 PAGE 10. THE AMOUNT REPORTED AS BAD DEBT EXPENSE IS $117,877 FROM THE AUDIT REPORT LESS $10,877 ATTRIBUTABLE TO REHABILITATION MEDICAL SUPPLY, A RELATED ORGANIZATION. PART III, LINE 8: NO PART OF THE SHORTFALL ON LINE 7 IS TREATED AS COMMUNITY BENEFIT. THE HOSPITAL HAS MEDICARE CERTIFICATION BECAUSE IT IS REQUIRED IN ORDER TO OPERATE. THE OVERALL COST-TO-CHARGE RATIO BASED ON AUDITED FINANCIAL STATEMENTS WAS USED TO CALCULATE COST. PART III, LINE 9B: PRIOR TO ENGAGING IN ECAS, LIFESCAPE'S REVENUE CYCLE STAFF WILL IDENTIFY WHETHER REASONABLE EFFORTS WERE MADE TO DETERMINE WHETHER AN INDIVIDUAL IS ELIGIBLE FOR FINANCIAL ASSISTANCE. IF A PATIENT SUBMITS A COMPLETE HOSPITAL FINANCIAL ASSISTANCE APPLICATION DURING THE APPLICATION PERIOD, LIFESCAPE WILL SUSPEND ECAS AND MAKE AN ELIGIBILITY DETERMINATION BEFORE RESUMING ECA ACTIVITY. PART VI, LINE 2: CCHS RELIES ON ITS BOARD MEMBERS AND BOARD MEMBERS OF LIFESCAPE FOUNDATION WHO REPRESENT ALL REGIONS OF THE STATE, ITS MEDICAL STAFF, AND SCHOOL DISTRICTS WHOSE STUDENTS IT SERVES TO HELP ADVISE OF HEALTH CARE NEEDS OF THEIR RESPECTIVE COMMUNITIES. CCHS ALSO CONDUCTS REGULAR MEETINGS WITH PARENTS AND PATIENTS TO HELP ASSESS THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES. PART VI, LINE 3: RESIDENTIAL AND INPATIENT SERVICES ARE ALWAYS PRE-AUTHORIZED BY A THIRD PARTY PAYER AND ANY PATIENT RESPONSIBILITY IS DISCUSSED WITH THE RESIDENT'S GUARANTOR UPON ADMISSION. FINANCIAL COUNSELING IS AVAILABLE FOR OUTPATIENT SERVICES. THIS STARTS WITH CCHS VERIFYING THAT PATIENT'S INSURANCE IS EFFECTIVE AND CONTACTING INSURANCE WITH DIAGNOSIS AND PROCEDURE CODES TO CHECK COVERAGE. NEXT, THE PARENT/GUARANTOR IS CONTACTED TO INFORM THEM OF THE APPROXIMATE AMOUNT FOR WHICH THEY'LL BE FINANCIALLY RESPONSIBLE. THEY ARE ASKED TO SIGN A PRIVATE PAY AGREEMENT BEFORE SERVICES ARE PROVIDED. PART VI, LINE 4: CCHS SERVES APPROXIMATELY 2,140 CHILDREN AND THEIR FAMILIES IN 63 COUNTIES THROUGHOUT SOUTH DAKOTA EVERY YEAR. ADDITIONAL CHILDREN AND FAMILIES ARE SERVED THROUGHOUT NORTHWEST IOWA, SOUTHWEST MINNESOTA, NEBRASKA, WYOMING AND ALASKA. 67 SOUTH DAKOTA PUBLIC AND TRIBAL SCHOOL DISTRICTS ALSO RELY ON CCHS. CHILDREN FROM 14 PUBLIC OR PRIVATE AGENCIES AND PROGRAMS ARE ALSO SERVED. NO OTHER HOSPITALS IN THE AREA PROVIDE SIMILAR SERVICES. PART VI, LINE 5: - ALL CCHS GOVERNING BODY MEMBERS RESIDE IN DIFFERENT PARTS OF ITS PRIMARY SERVICE AREA IN SOUTH DAKOTA. ALL BOARD MEMBERS ARE INDEPENDENT OF CCHS AND SERVE IN A VOLUNTEER CAPACITY.- CCHS EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITIES.- CCHS USES SURPLUS FUNDS TO ENHANCE SERVICES TO PATIENTS, FUND BUILDING IMPROVEMENTS OR EXPANSIONS, AND IMPROVE CARE BY PROVIDING ADDITIONAL TRAINING TO STAFF.- CCHS IS THE ONLY PROVIDER IN SOUTH DAKOTA OFFERING 24-HOUR, INTEGRATED MEDICAL, BEHAVIORAL, AND SPECIAL EDUCATION SERVICES FOR CHILDREN AGES BIRTH TO 21. CCHS SERVES FAMILIES AND SCHOOLS WHO ARE UNABLE TO SUPPORT CHILDREN WITH SEVERE BEHAVIORS WHO MAY HARM THEMSELVES OR OTHERS. MEDICAL PROGRAMMING IS PROVIDED TO FILL THE GAP BETWEEN SERVICES PROVIDED IN THE HOME AND SCHOOL DISTRICT AND SERVICES PROVIDED AT ACUTE CARE HOSPITALS.- CCHS HAS SEVERAL CLINICAL AFFILIATION AGREEMENTS WITH SURROUNDING AREA SCHOOLS TO PROVIDE TRAINING EXPERIENCE FOR PHYSICAL, OCCUPATIONAL AND SPEECH THERAPISTS, NURSES AND PSYCHOLOGY STUDENTS.- CCHS PARTICIPATES IN THE MEDICARE PROGRAM, SEVERAL STATE MEDICAID PROGRAMS, AND THE BIRTH TO 3 PROGRAM.- 909 VOLUNTEERS ASSISTED WITH ALL ASPECTS OF CCHS OPERATIONS. VOLUNTEERS ASSIST CCHS STAFF WITH ADMINISTRATIVE TASKS IN RECEPTION, FINANCE, MEDICAL RECORDS AND FUNDRAISING, AND PROVIDE SUPPORT TO PROFESSIONALS IN RESIDENTIAL AREAS. 0 0 0 0 0 0 0 0 0 ANNE RIECK MCFARLAND CEO 0 220575 0 0 0 774 0 12600 0 8470 0 242419 0 0 SCHEDULE J, PART II THE ORGANIZATION RELIED ON A RELATED PARTY, LIFESCAPE, TO DETERMINE COMPENSATION FOR THE CEO AND CFO. LIFESCAPE USES THE METHODS LISTED IN PART I, LINE 3 TO DETERMINE THE COMPENSATION. A SOUTH DAKOTA HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 460315509 83755VLQ5 2007-03-29 8705000 DEFEASANCE OF BONDS ISSUED NOVEMBER 1, 1999 0 0 0 A 2335000 8859230 639536 177184 8043636 2007 0 1 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 0 0 0 A 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: SOUTH DAKOTA HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 03/29/2013 SCHEDULE K, PART II THE DIFFERENCE BETWEEN THE TOTAL PROCEEDS OF ISSUE ON PART II LINE 3 AND THE ISSUE PRICE ON PART I LINE A COLUMN (E) OF $154,230 REPRESENTS THE NET ORIGINAL ISSUE PREMIUM ON THE 2007 BOND. SCHEDULE K, PART IV, LINE 7 MANAGEMENT IS AWARE OF THE PROVISIONS IN THE BOND DOCUMENTS FOR MONITORING ARBITRAGE, AND THE CFO MONITORS FOR COMPLIANCE. HENRY CARLSON COMPANY DIRECTOR H. CHIP CARLSON III OWNS MORE THAN 35% OF HENRY CARLSON CO 122028 CONSTRUCTION WORK PROVIDED TO CCHS 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE IS COMPRISED OF THE CHAIR, VICE CHAIR, SECRETARY, TREASURER, IMMEDIATE PAST CHAIR, CHIEF EXECUTIVE OFFICER, AND ONE DIRECTOR. THE COMMITTEE CAN ACT ON BEHALF OF THE BOARD BETWEEN BOARD MEETINGS. ALL ACTIONS TAKEN BY THE EXECUTIVE COMMITTEE MUST BE RATIFIED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 2 ANNE MCFARLAND HAS A BUSINESS RELATIONSHIP WTIH DR. PATTY PETERS, CHIP CARLSON, P DANIEL DONOHUE, GAYLE VER HEY, JOHN ROZELL, JOE HENKIN, MOLLY MCCARTHY, JON SODERHOLM, DR. LARRY FENTON, JACK HOPKINS, MARK STERNHAGEN, CLAUDIA VUCUREVICH, TERRI GRABLANDER, JASON HARRIS, JEFF HAZARD, AND DR. JOHN BILLION. THE BUSINESS RELATIONSHIP EXISTS BECAUSE ANNE MCFARLAND IS PAID BY LIFESCAPE EFFECTIVE 1/1/15. PERSONS LISTED AS HAVING A BUSINESS RELATIONSHIP WITH HER SERVE ON THE BOARD OF LIFESCAPE. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE ORGANIZATION IS LIFESCAPE, A SOUTH DAKOTA NON-PROFIT, EXEMPT UNDER INTERNAL REVENUE CODE 501(C)(3). FORM 990, PART VI, SECTION A, LINE 7A THE DIRECTORS SHALL BE ELECTED BY THE MEMBER AND SHALL BE THE SAME PERSONS WHO SERVE AS THE DIRECTORS OF THE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE CHIEF FINANCIAL OFFICER AND A FINAL COPY OF THE 990 IS SHARED WITH THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C LIFESCAPE HAS A CONFLICT OF INTEREST POLICY THAT IS SIGNED ANNUALLY BY EACH MEMBER OF THE BOARD OF DIRECTORS. IN ADDITION, A CONFLICT LETTER IS SENT TO ALL BOARD MEMBERS AND SENIOR LEADERS OF LIFESCAPE TO COMPLETE AND TO DISCLOSE ANY POTENTIAL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 THE CEO AND CFO OF CCHS ARE COMPENSATED BY LIFESCAPE, A RELATED ORGANIZATION. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS AVAILABLE UPON REQUEST. LIFESCAPE 4100 S WESTERN AVE SIOUX FALLS SD 57105 465151247 ASSIST CHILDREN'S CARE HOSPITAL & SCHOOL AND SD ACHIEVE SD 501(C)(3) LINE 11A, I N/A 0 SOUTH DAKOTA ACHIEVE DBA LIFESCAPE 4100 S WESTERN AVE SIOUX FALLS SD 57105 237072116 PROVIDE SUPPORT SERVICES TO PEOPLE WITH DEVELOPMENTAL DISABILITIES SD 501(C)(3) LINE 2 LIFESCAPE 0 LIFESCAPE FOUNDATION 2501 WEST 26TH STREET SIOUX FALLS SD 57105 460353254 SUPPORT PROGRAMS & SERVICES OF LIFESCAPE ENTITIES SD 501(C)(3) LINE 11A, I LIFESCAPE 0 SIOUX RESIDENTIAL SERVICES INC - AKA HARVEST APARTEMENTS 4100 S WESTERN AVE SIOUX FALLS SD 57105 460378935 HUD PROPERTY FOR INDIVIDUALS SUPPORTED BY SDA SD 501(C)(3) LINE 9 SOUTH DAKOTA ACHIEVE DBA LIFESCAPE 0 HAYWARD MEMORIAL TESTAMENTARY TRUST 100 S PHILIPS AVE SIOUX FALLS SD 57104 466010897 PROVIDE BENEFITS TO ORGANIZATIONS THAT PROMOTE CHARITABLE PUSPOSES SD 501(C)(3) LINE 11A, I N/A 0 BEACON APARTMENTS LIMITED PARTNERSHIP 4100 S WESTERN AVE SIOUX FALLS SD 57105 471232136 LOW INCOME HOUSING SD N/A REHABILITATION MEDICAL SUPPLY 1020 W 18TH ST SIOUX FALLS SD 57104 411936988 SALES & SERVICE OF DURABLE MEDICAL EQUIPMENT, ORTHOTICS, & PROSTHETICS SD CHILDREN'S CARE HOSPITAL AND SCHOOL C -1870 1976719 1.00000 1 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 1 1 0 0 REHABILITATION MEDICAL SUPPLY Q 3450000 FMV