2016-05-14T07:10:32-05:00 2015-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 55402 990 2014-07-01 420733472 St Anthony Regional Hospital and Nursing Home STAN 7127945246 311 South Clark Street PO Box 628 Carroll IA 51401 John Munson Vice President/CFO 7127945246 2016-05-13 1 Kristina Rasmussen P00143920 6123974000 2014 2016-08-17 19:52:53Z Edward H Smith Jr 311 South Clark Street PO Box 628 Carroll IA 51401 93729113 0 0928 X www.stanthonyhospital.org X 1905 IA Consistently providing high quality healthcare services to meet patient and community needs. 11 11 772 542 1983 0 1036420 467616 60588241 68320240 4960180 4959424 -532238 -403520 66052603 73343760 0 0 0 0 31275823 34097214 0 0 0 28445852 31962469 59721675 66059683 6330928 7284077 140493049 145455995 21134812 21348840 119358237 124107155 X St. Anthony Regional Hospital is a catholic healthcare organization sponsored by the Franciscan Sisters of Perpetual Adoration and a regional leader in providing consistently high quality healthcare services responsive to patient and community needs. 0 0 60170818 67956710 St. Anthony Regional Hospital is a 99 bed acute care facility and St. Anthony Nursing Home has 79 beds in Carroll, IA. In the year ended June 30, 2015, St. Anthony Regional Hospital and Nursing Home provided heath care services to approximately 2,560 inpatients, 79,061 outpatients, and 36,722 clinic visits. St. Anthony Regional Hospital provided services for 1,577 acute care inpatients, and provided psychiatric, swing bed, and nursing home services for the remainder of the inpatients. Outpatient services were provided to patients through ancillary departments, emergency room, and clinics.See Schedule O.St. Anthony Hospital provides services of cardiac rehabilitation, dialysis, hospice care, laboratory, observation, chemotherapy, pathology, radiology, respiratory therapy, physical therapy, occupational therapy, speech therapy, diabetes and surgical services. St. Anthony's largest patient service area is laboratory. In the year ended June 30, 2015, St. Anthony serviced 16,476 in laboratory, 7,462 in physical therapy, and 7,633 in radiology. The activities pursued by St. Anthony Regional Hospital and Nursing Home in the provision of health care services are consistent with its exempt purpose. 1788977 As part of its mission, St. Anthony Regional Hospital provides medical care to individuals who are unable to pay for services, incurs costs in excess of reimbursement for services to medicaid beneficiaries, and carries out other activities and programs free of charge to support the community in which it operates. Community benefit projects include community health education, health care support services, behavioral health services, community health improvement advocacy, and other traditional charity care. 61959795 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 120 0 1 772 1 1 1 0 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 IA X John R Munson 7127945115 311 South Clark St Carroll IA 51401 Fred Dolezal Chairman 0.30 0.00 X X 0 0 0 Tom Gronstal Vice-Chairman 0.30 0.00 X X 0 0 0 Sr Romana Klaubauf Secretary 0.30 0.00 X X 0 0 0 Wayne Seaman Treasurer 0.30 0.30 X X 0 0 0 Nick Badding Board Member 0.30 0.00 X 0 0 0 Howard J Drees Board Member 0.30 0.00 X 0 0 0 Thomas Dulaney MD Board Member 0.30 0.00 X 0 0 0 Sr Theresa Keller Board Member 0.30 0.00 X 0 0 0 Sr Maris Kerwin Board Member 0.30 0.00 X 0 0 0 Sr Donna Venteicher Board Member 0.30 0.00 X 0 0 0 Peggy White Board Member 0.30 0.30 X 0 0 0 Edward H Smith Jr CEO/President 40.00 0.30 X 307354 0 45915 John Munson Vice President/CFO 40.00 0.30 X 154874 0 17809 Nelson H Lo MD Physician 40.00 0.00 X 394949 0 27053 Tina F Schechinger MD Physician 40.00 0.00 X 247693 0 19942 Richard Sazama Physician 40.00 0.00 X 258588 0 0 David C Pederson Anesthesist 40.00 0.00 X 238612 0 16759 Dominick C Ervelli MD Physician 40.00 0.00 X 213422 0 22190 1815492 0 149668 26 0 1 0 Deloitte & Touche LLP PO Box 844708 Dallas TX 752844708 Accounting Services 131803 Dr Jed Hagen 2313 Sykline Dr Carroll IA 51401 Pathology Services 127000 Professional Medical Management 4200 University Av West Des Moines IA 50266 Imaging Services 117988 Park Place International LLC 7227 Chagrin Rd Chagrin Falls OH 44023 Computer Services 110759 4 467616 467616 Patient Svc Revenue 621400 37661762 37661762 Medicare/Medicaid Pmts 621400 29418828 29418828 Radiation Oncology Svc 621400 876120 876120 Cafeteria Sales 621400 361547 361547 Inc. from Partnership 900004 1983 1983 68320240 1451430 1451430 1156442 1559962 -403520 -403520 -403520 22249640 83745 18794370 31021 3455270 52724 3507994 3507994 73343760 67956710 1983 4917451 479759 479759 27121781 26163789 957992 563111 507995 55116 3988933 3780600 208333 1943630 1853425 90205 265622 265622 168826 168826 294532 294532 4574875 3621539 953336 245873 37076 208797 1934730 1740117 194613 442981 442981 1908856 1908856 319675 241463 78212 629790 629790 6707883 6707883 351988 308651 43337 Medical Supplies 12668452 12667588 864 Repair and Maintenance 1448386 1348042 100344 66059683 61959795 4099888 0 1372855 1420467 10493173 11717203 8 13 1652306 2007239 409495 409964 124145121 63066501 61327957 61078620 51744827 53176378 813956 413817 12678472 15232294 140493049 145455995 5867242 5629473 14228000 13391000 22205 1264336 1017365 1064031 21134812 21348840 X 115915503 119540473 3342734 4466682 100000 100000 119358237 124107155 140493049 145455995 X 7284077 -3428091 892932 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8127 8127 0 Part II-B, Line 1: St. Anthony Hospital is a member of the Iowa Hospital Association. A percentage of the membership dues paid to IHA is related to lobbying activities. 9950534 1706686 510919 3500 443975 11720664 7852058 1626938 1547970 4000 1072432 9950534 4622373 3018705 739105 2500 525625 7852058 995357 3662163 -30442 3500 1205 4622373 680736 190774 129468 3500 2121 995357 0.57000 0.43000 0 1 1 632934 632934 83429950 35622827 47807123 34112718 25513474 8599244 5969519 1930200 4039319 61078620 Deferred Compensation Investments 1064031 Beneficial Interest in Net Assets of the Foundation 11066682 Investment in Joint Venture 2933031 Other 168550 15232294 Deferred Compensation 1064031 1064031 X 72250340 -3428091 1123948 -2304143 74554483 294532 -1505255 -1210723 73343760 67501422 1736271 1736271 65765151 294532 294532 66059683 Part V, Line 4: All restricted endowed funds held at St. Anthony Foundation are used for the benefit of St. Anthony Regional Hospital for pastoral care and scholarships. Part X, Line 2: Accounting for income taxes provides that a tax benefit from an uncertain tax position may be recognized when it is more likely than not that the position will be sustained upon examination, including resolutions of any related appeals or litigation processes, based on the technical merits. The Hospital recorded no liabilities for unrecognized tax benefits as of June 30, 2015 and 2014. The Hospital is engaged in certain activities that result in unrelated business income. Part XI, Line 2d - Other Adjustments: Change in Beneficial Interest of Net Assets of Foundation 1,123,948. Part XI, Line 4b - Other Adjustments: Rental Expenses -1,559,962. Realized Gain on Sale of Assets 52,724. Income from Partnerships 1,983. Part XII, Line 2d - Other Adjustments: Rental Expenses 1,559,962. Realized Gain on Sale of Assets -52,724. Transfer to Foundation - Reimbursed Expenses 229,033. 1 1 X 1 X 1 X 399.000000000000 1 1 0 1 1 510545 510545 0.00780 6916030 5540671 1375359 0.02090 0.00000 7426575 5540671 1885904 0.02870 182533 33180 149353 0.00230 299172 9750 289422 0.00440 9381240 6615178 2766062 0.04210 0.00000 207147 63575 143572 0.00220 10070092 6721683 3348409 0.05100 17496667 12262354 5234313 0.07970 9495 9495 0.00010 19154 14476 4678 0.00010 3921 3921 0.00010 32570 14476 18094 0.00030 1 580899 19309363 25008739 -5699376 X 1 1 1 1 St Anthony Regional Hospital 311 South Clark St PO Box 628 Carroll IA 51401 www.stanthonyhospital.org 14009OH X X X St Anthony Regional Hospital 1 0 0 1 X X X X X X X X X 12 1 0 1 1 X See Part V, Section C X 1 12 0 1 0 1 X 200.000000000000 399.000000000000 X X X X 1 1 X X 1 X www.stanthonyhospital.org/images/sarpdf/st_anothy_cares_2016.pdf X www.stanthonyhospital.org/images/sarpdf/financial_application_cares.pdf X www.stanthonyhospital.org/images/sarpdf/st_anothy_cares_2016.pdf X X X X X 1 X 0 X X X X 1 X 0 0 St. Anthony Regional Hospital Part V, Section B, Line 5: In 2012, St. Anthony Regional Hospital conducted a CHNA assessment. A total of 24 individuals were interviewed, including internal stakeholders - those affiliated or employed by St. Anthony Regional Hospital and Nursing Home - and external stakeholders from across the area. The interviews were conducted using a structured questionnaire with key stakeholders being asked to discuss community health issues, as well as the social determinants of health. Interviewees were asked about issues related to access to particular health services, prevalence and treatment of chronic health conditions, compliance with care treatment plans, health disparities, and other issues. All interviews were reviewed and comments analyzed to identify the most frequently mentioned community health issues. The interviews were conducted during the months of March through May 2013. St. Anthony Regional Hospital Part V, Section B, Line 6b: St Anthony Regional Hospital & Nursing Home contracted with Community Health Advisors, LLC for assistance with the Community Health Needs Assessment. St. Anthony Regional Hospital Part V, Section B, Line 7d: www.stanthonyhospital.org/images/sarpdf/CHNA.13/CHNA13Final.pdf St. Anthony Regional Hospital Part V, Section B, Line 11: The following health needs were identified in the St. Anthony Regional Hospital and Nursing Home service area: - Access to health care- Alcohol and tobacco use- Cancer- Chronic Disease Management- Mental Health- Obesity- Prevention Services- Unintentional injury and motor vehicle accident deathsSt. Anthony Regional Hospital and Nursing Home worked to meet these identified health needs this year in the following ways:Access to Healthcare:- Distributed outreach and education materials on the St. Anthony Cares financial assistance program.- Staff members received certification as certified application counselors to help people in the community sign up in health exchanges. - Developed Spanish materials to help non-English speaking population. Cancer:- Expanded capacity and remodeled radiation oncology department.- Created public awareness campaign aimed at cancer screening. Chronic Disease Management:- Hired Health Coach to help patients navigate system and access appropriate care.- Designed new space called St. Anthony Chronic Care Clinic that offers diabetes education, wound care and health coaching. - Implemented Healthy Bodies exercise program for at risk patients. Mental Health:- Partnered with mental health providers to extend coverage to include additional providers and adolescent care.- Supported Carroll County Supervisors and area schools' efforts to increase access to mental health in area. Obesity:- Made part of Chronic Care Clinic Diabetes education and healthy bodies exercise program. - Worked with local employers to promote wellness programs. Prevention Services:- Collaborated with Public Health departments to promote and administer vaccines.- Designed a public education message on the importance of flu vaccine. The hospital facility did not address all the significant needs identified in its most recently conducted CHNA. Alcohol Use:The objective to reduce alcohol use among residents is not being addressed because New Opportunities, a non-profit agency in Carroll, Iowa, is addressing the use of alcohol among residents.Unintentional Injury and Motor Vehicle Accident Deaths:The objective to reduce the number of accidental injuries and motor vehicle deaths among area residents is not being addressed because local law enforcement agencies are addressing this issue among area residents. St. Anthony Regional Hospital Part V, Section B, Line 13h: Additional eligibility criteria for financial assistance include Medicaid/Medicare coverage, and State regulations. St. Anthony Regional Hospital Part V, Section B, Line 22d: St. Anthony uses annual poverty guidelines to determine FAP eligibility. The maximum amount a FAP eligible patient would pay is 75% of gross charges. Individuals that earn 301-399% of federal poverty guidelines are eligible for a discout of 25%. All individuals that earn less than 200% of federal poverty guidelines pay 0% of gross charges. Part V, Section B, Line 16 Financial Assistance Policy Website Availability St. Anthony Regional Hospital Part V, Section B, line 16a website: www.stanthonyhospital.org/images/sarpdf/st_anothy_cares_2016.pdf St. Anthony Regional Hospital Part V, Section B, line 16b website: www.stanthonyhospital.org/images/sarpdf/financial_application_cares.pdf St. Anthony Regional Hospital Part V, Section B, line 16c website: www.stanthonyhospital.org/images/sarpdf/st_anothy_cares_2016.pdf 6 St Anthony Regional Hospice 311 South Clark St Carroll IA 51401 Hospice Services St Anthony Regional Hospital 311 South Clark St Carroll IA 51401 Dialysis Services St Anthony Regional Home Hlth Agency 311 South Clark St Carroll IA 51401 Home Health Services St Anthony Regional Hospital 311 South Clark St Carroll IA 51401 Psychiatric Services Wall Lake Medical Clinic 311 W First St Wall Lake IA 51466 Rural Health Clinic St Anthony Nursing Home 311 South Clark St Carroll IA 51401 Nursing Home Part I, Line 3c: The family or household income must be less than or equal to 200% of the FPG to qualify for free care. For discounted care, the family or household income must be equal to the FPG as follows: 201% - 250% of FPG for a 75% discount, 251% - 300% of FPG for a 50% discount, and 301% - 399% of FPG for a 25% discount. Part I, Line 7: The cost to charge ratio was used when calculating the amounts reported in Part 1, line 7, with the exception of line 7g, subsidized heath services. Subsidized heath services are reported using departmental cost from the 2015 cost report. Part I, Line 7g: St. Anthony Regional Hospital has eight physician clinics that are included in subsidized health services where cost exceeds the reimbursements. Part I, Ln 7 Col(f): Bad debt expense of $1,275,580 is not included in total expenses for purposes of calculating the percentage in Schedule H, Part I, Line 7, Column f. Part II, Community Building Activities: The Hospital CEO and VP participate in the Carroll Area Development board that is active in workforce development. The hospital emergency room director attended regional meetings on disaster readiness. The CEO is a board member of the Iowa Hospital Association Board of Directors. There are managers of the Hospital that serve on local health advisory boards. Part III, Line 2: St. Anthony Regional Hospital reports bad debt in accordance with generally accepted accounting principles (GAAP). Bad debt at cost is calculated with the same cost to charge ratio used for the charity care at cost multiplied by the estimated debt charges.Part III, Line 3:St. Anthony Regional Hospital works with those qualifying for charity care along every step of the process including accepting applications for financial assistance after previous attempts to work with the patient fail. Every effort is made to work with the patient to provide financial assistance when appropriate. While there are people who do not cooperate with the Hospital regarding payment plans, financial assistance or with those trying to help them get on government programs. For individuals not providing necessary information it is impossible to know the reason for not cooperating and therefore know whether they will qualify for charity care. St. Anthony Regional Hospital is unable to reasonably determine whether any amount of bad debt could have been classified as charity care if individuals do not provide the necessary information to evaluate their situation to determine qualification with the charity care policy.Part III, Line 4: The financial statements for St. Anthony Regional Hospital do not include a footnote regarding bad debts; however, the bad debt expense from the financial statement is a percent of revenue that is an estimate of the historical bad debt written off. Part III, Line 8: The amount of Medicare short fall on line 7 should be included in the community benefit because Medicare pays less than the cost for rendering services. The medicare allowable costs are taken from the medicare cost report and determined based on the cost to charge ratios from the Medicare report. Part III, Line 9b: The policy states that St. Anthony Regional Hospital offers charity care to all patients who meet the criteria for financial aid and want assistance. Patients who do not have insurance may qualify for St. Anthony Cares based on annual income and family size. Patients with insurance may also qualify for St. Anthony Cares for bills not covered by insurance. Charity information is available upon admission and disclosed in monthly billing statements. An application is completed by the patient and based on the income and family size the amount of charity is determined based on the federal poverty guidelines. Patients receive statements and make payment arrangements with Preferred Medical Deposits (PMD). Accounts at PMD with no activity after 60 days are then turned over to our collection agency Avadyne Health. Part VI, Line 2: The Hospital and county perform a community needs assessment every three years to identify specific health concerns of the county. Meetings are held with community partners to identify needs from their daily work and with clients, students, educators, health care, volunteer services, case management, behavior medicine, and others in the county. A survey was developed to gather county residents' identified needs. The survey was placed on the county website and hard copies were placed in the courthouse and public library. There was a link to the web and survey on the St. Anthony Hospital website. The goal was to receive 300 surveys and just under 300 were received. The survey data results were reviewed and top areas of concern identified for the county. The community partners were invited to a meeting to review needs and assigned to work groups. These needs will be assigned to committees and assessed over the next three years and action plans will be developed. Reports will be sent to the state to report progress and action. Part VI, Line 3: The financial counselor from the organization informs and educates patients about eligibility of federal, state, and local government programs and charity care policies. The charity care policy is made available to patients in the admissions office and provided in the admission packets. If patients have questions they can stop in the business office and discuss them with a financial counselor. Part VI, Line 4: The Hospital is located in the city of Carroll in West Central Iowa with a population of 21,500. St. Anthony Hospital also serves portions of 6 surrounding counties within a radius of 50 miles. St. Anthony Hospital operates 5 satellite physician clinics in the service area, in addition to 3 physician clinics in the hospital. Part VI, Line 5: St. Anthony Regional Hospital has demonstrated a commitment to promoting health care to further its exempt purpose providing quality health care in the community and surrounding counties for one hundred and ten years. The majority of the Hospital's board members are from local business and reside in the community. The Hospital's medical staff consists of 31 active staff, 7 associate staff in the community, and 92 courtesy staff from outside the community. St. Anthony Regional Hospital is a regional provider and is committed to providing quality health care to the community. Part VI, Line 7, Reports Filed With States IA X X X X 0 1 0 0 0 0 0 1 0 Edward H Smith Jr CEO/President 262527 0 40985 0 3842 0 30712 0 15203 0 353269 0 0 0 John Munson Vice President/CFO 147038 0 6565 0 1271 0 4606 0 13203 0 172683 0 0 0 Nelson H Lo MD Physician 392201 0 0 0 2748 0 11350 0 15703 0 422002 0 0 0 Tina F Schechinger MD Physician 216942 0 9930 0 20821 0 6739 0 13203 0 267635 0 0 0 Richard Sazama Physician 256842 0 0 0 1746 0 0 0 0 0 258588 0 0 0 David C Pederson Anesthesist 219504 0 15025 0 4083 0 7015 0 9744 0 255371 0 0 0 Dominick C Ervelli MD Physician 211383 0 360 0 1679 0 6487 0 15703 0 235612 0 0 0 Part I, Line 4b St. Anthony Regional Hospital and Nursing Home has a non-qualified deferred compensation plan that complies with Section 457(f) of the Internal Revenue Code and the short-term deferral provisions of section 409A of the Code. The plan is to be an unfunded plan maintained primarily for the purpose of providing deferred compensation benefits for a select group of management or highly compensated employees. Part I, Line 7 In their roles as executives employed by St. Anthony Regional Hospital, the executives are eligible for incentive payouts. The incentive award will be a percentage of the base pay compensation for the CEO, CFO, and other executives. The ultimate payout includes a reduction/increase multiplier depending on whether the organization reached specified performance metrics identified by the Board of Directors. A Carroll County Iowa 426004323 144813AB8 2006-11-22 6672573 Construction of Hospital Addition 0 0 0 B City of Carroll Iowa 426004322 145181CK7 2006-11-22 5402508 Construction of Hospital Addition 0 0 0 A 6969080 133451 6835629 2009 0 0 1 1 B 2465000 5637070 107254 5529816 2009 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 1 0 0 1 Citi Group 1.900000000000 1 0 0 B 0 0 0 1 0 0 1 Citi Group 1.900000000000 1 0 0 A 0 B 0 Schedule K, Supplemental Information: The two 2006 issues actually comprise a single issue for tax purposes, but are reported separately herein because the two series were issued by two different issuers (each of which filed a form 8038) and were accounted for separately. Differences between the issue price (Part 1) and total prodeeds (Part II, Line 3) are due to investment earnings and (for column B ) to a small excess amount (less than $1,000 ) that was used to pay principal on the bonds. Part IV, Line 2c: The rebate computation was performed on 11/19/2012 for the 2006 bonds outstanding. Form 990, Part VI, Section A, line 6 The members of the St. Anthony Regional Hospital are the sisters of the religious community known as the Congregation of the Sisters of the Third Order of St. Francis of Perpetual Adoration (FSPA). The members have the power to elect the board of directors, amend the articles of incorporation and bylaws of the organizations, and dissolve the organization. Form 990, Part VI, Section A, line 7a The Franciscan Sisters of Perpetual Adoration, as members of the St. Anthony Regional Hospital, elect and approve the board of directors for St. Anthony Regional Hospital. Form 990, Part VI, Section A, line 7b All decisions, including dissolution of the organization, made by the Board of Directors of St. Anthony Regional Hospital are subject to the approval of the Franciscan Sisters of Perpetual Adoration. Form 990, Part VI, Section B, line 11 St. Anthony Regional Hospital gathers the necessary information for the completion of the Form 990 within the finance department and with assistance from the human resources and operation departments. The form was prepared by an independent accounting firm. Drafts of the form were reviewed by the CFO and the Audit committee. After the internal reviews were complete, the final version of the form 990 was given to each member of the Board of Directors prior to filing the return. Form 990, Part VI, Section B, line 12c The board members annually disclose in writing, "any interest which would be inconsistent with the expeditious, proper, and impartial performance of duties." Defining disclosable conflict or duality of interest as any matter in which the corporations are "interested which affects the financial interest or employment of such member, a member of his/her family by blood or marriage, or any business enterprise in which he/she or such family member is employed or has a financial interest." Board members are required to disclose the facts surrounding any possible conflict of interest throughout the year. Form 990, Part VI, Section B, line 15 At the direction of the Board of Directors the CEO gathers compensation information (salary and benefits) from various sources including Iowa Hospital Association and benefit consultants for like-sized organizations. The Executive Committee then determines the annual compensation for the CEO, other officers, and any key employees for the total board approval. Form 990, Part VI, Section C, line 19 St. Anthony Regional Hospital mails its consolidated audited financial statements to financial institutions, governmental institutions, board members, and the Iowa Hospital Association. The Form 990 is available at guidestar.org. St. Anthony Regional Hospital discloses financial statements to bondholders, the IHA, and the Iowa Attorney General's office. St. Anthony Regional Hospital's governing documents, conflict of interest policy, and financial statements are available to the public upon request. Form 990, Part XI, line 9: Transfer to Foundation - Reimbursed Expenses -229,033. Change in Beneficial Interest of Net Assets of Foundation 1,123,948. Income from Partnership -1,983. St Anthony Foundation 311 South Clark Street PO Box 628 Carroll IA 51401 421419695 Fundraising IA 501(c)(3) 1 St Anthony Regional Hospital 1 Franciscan Sisters of Perpetual Adoration 912 Market Street La Crosse WI 546014782 390806386 Religious Order WI 501(c)(3) 11a N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 St Anthony Foundation C 467616 FMV St Anthony Foundation P 229033 FMV St Anthony Foundation R 1000000 FMV