2016-05-12T15:09:35-05:00 2015-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2014-07-01 460224604 Avera Queen of Peace Hospital AVER 6059952251 525 North Foster Street Mitchell SD 57301 William E Flett Sec/Treas & VP of Finance 6059952251 2016-05-12 0 Kim Hunwardsen CPA P00484560 6122536500 2016-05-12 2014 2016-08-17 19:52:53Z Avera Queen of Peace Health Service Thomas A Clark 525 North Foster Street Mitchell SD 57301 108574088 0 0928 X www.averaqueenofpeace.org X 1905 SD Promotion of health 18 15 969 57 0 0 865066 283044 99738113 106176795 1920627 1600903 63191 -299256 102586997 107761486 163753 1604567 0 0 54264575 55155185 35130 0 195353 42814333 45276679 97277791 102036431 5309206 5725055 136395220 142177140 45965069 48060314 90430151 94116826 X 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. 1 1 85345651 1604567 106176795 Avera Queen of Peace's mission is to provide healthcare services to Mitchell, SD residents and the surrounding area. They provide acute care and long-term healthcare services, of which there were 7,941 acute patient days, 2,595 swing-bed patient days, 1,060 nursery patient days, 29,473 nursing home resident days, 8,872 assisted living resident days, and 2,190 independent living days. The breakout of these statistics per facility is as follows.Avera Queen of Peace Hospital7,518 Acute patient days1,918 Swing-bed patient days1,060 Newborn patient daysAvera Brady Health and Rehabilitation29,473 Long-term care resident days8,872 Assisted living days2,190 Independent living daysAvera Weskota Memorial Medical Center (CAH)337 Acute patient days348 Swing-bed patient daysAvera De Smet Memorial Hospital (CAH)86 Acute patient days329 Swing-bed patient days Avera Queen of Peace maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $4,108,663.Avera Queen of Peace also provides community benefit health activities at less than or at no cost to support those in the area serviced. 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 year ended June 30, 2015, specific activities include meals delivered to residential homes; meeting facilities; programs for patients and families suffering from cancer, diabetes, breathing disorders, and others; assistance to health educators; emergency healthcare providers and wellness programs.As a member of the Avera Health network, Avera Queen of Peace upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide a quality, effective health ministry and to improve the health care of individuals and our communities through a regionally integrated network of persons and institutions. Avera Queen of Peace engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed. 85345651 1 1 0 1 0 0 0 0 1 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 1 1 1 0 0 1 132 0 1 969 1 0 0 0 0 0 0 0 0 0 0 X 18 15 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 0 X William E Flett 6059952251 525 North Foster Mitchell SD 57301 Terry Torgerson Chairperson 2.50 0.00 X X 0 0 0 Diane Sandhoff Vice Chair 2.50 0.00 X X 0 0 0 Loren Noess Board Member 2.50 0.00 X 0 0 0 Charles Bergeleen Board Member 2.50 0.00 X 0 0 0 Sister Kathleen Crowley Board Member 2.50 4.00 X 0 0 0 Gopal Vyas Board Member 2.50 0.00 X 0 0 0 Sister Bonita Gacnik Board Member 2.50 0.00 X 0 0 0 David Olson Board Member 2.50 0.00 X 0 0 0 Jacquelyn Johnson Board Member 2.50 0.00 X 0 0 0 Lori Essig Board Member 2.50 0.00 X 0 0 0 Jerry Thomsen Board Member 2.50 0.00 X 0 0 0 Sharry Knock Board Member 2.50 0.00 X 0 0 0 Michael Krause DO Board Member/Physician 7.50 0.00 X 40336 0 0 Patricia Malters MD Board Member/Physician 42.50 0.00 X 243147 0 25280 Greg Van Wald Board Member 2.50 0.00 X 0 0 0 Sister Joan Reichelt Board Member 2.50 3.30 X 0 0 0 William Graham DOBoard Member Physician (thru Jan 31 2015) 2.50 0.00 X 0 0 0 Martin Christensen MDBoard Member/Physician (as of Feb 1, 2015) 2.50 0.00 X 500 0 0 Thomas Clark President & CEO 40.00 0.00 X X 0 419051 33042 William E Flett Sec/Treas & VP of Finance 40.00 0.00 X 167419 0 36850 Brian Kampmann MD Orthopedics, Sports Medici 40.00 0.00 X 877660 0 40750 Anwarul Haq MD Hematology and Oncology 40.00 0.00 X 639041 0 21724 Chris Krouse DO Orthopedics, Sports Medici 40.00 0.00 X 995415 0 39550 Dileep Bhat MD Urology 40.00 0.00 X 501772 0 37056 Dennis Leland MD FACS General Surgery 40.00 0.00 X 481031 0 43328 3946321 419051 277580 57 0 1 0 Avera Health 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 Shared Services 7735662 Journey Group Companies 800 South 7th Ave Sioux Falls SD 57104 Construction Services 829631 Perspective Inc 196 E 6th St Ste 100 Sioux Falls SD 57104 Architectural 590965 Puetz Corporation 800 N Kimball Mitchell SD 57301 Construction Services 375695 Aegis Therapies Inc 1000 Fianna Way Fort Smith AR 72919 PT, OT & Speech Therapy Services 365614 15 235583 47461 283044 Net Patient & Resident Services 622110 102989449 102989449 Other Revenue 900099 1842704 1842704 Meaningful Use Revenue 900099 627974 627974 Cafeteria 900099 466286 466286 Interest in Avera Health Fnd 900099 135256 135256 115126 115126 106176795 32547 32547 343813 706788 -362975 -362975 -362975 1479075 194906 0 105625 1479075 89281 1568356 1568356 490 189 301 301 Operating Interest 900099 63418 63418 63418 107761486 106176795 0 1301647 X 1604567 1604567 519567 312575 206992 213380 213380 42898804 37811297 4962225 125282 2508445 2213614 287419 7412 6393367 5630268 744414 18685 2621622 2304668 309351 7603 258519 258519 530 530 11903532 4990137 6906567 6828 29752 20998 8754 8036850 6335003 1674719 27128 266356 153457 112899 2000451 1421131 579320 270725 207458 61484 1783 122209 60882 60892 435 552506 552506 4103066 4103066 750555 750555 Medical Supplies 11041820 11041820 Bad Debt Expense 5105233 5105233 Equipment Lease and Ren 44389 34123 10266 790186 219864 570125 197 102036431 85345651 16495427 195353 4243794 4498284 18708790 13125887 1402519 1425877 2342808 1496103 109735397 61063491 42284000 48671906 959046 966799 49788645 59440525 1356132 1665495 1142822 1785026 14166664 9101238 136395220 142177140 7533002 10497229 105274 71908 35799553 35433963 6359 2527240 2050855 45965069 48060314 X 87085253 90773261 2543121 2539692 801777 803873 90430151 94116826 136395220 142177140 X 5725055 -981064 -1057316 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 9278 9278 0 Part II-B, Line 1: Avera Queen of Peace Hospital paid dues to organizations which have a portion of the dues attributed to lobbying activities. 0 1 X 2681098 326197 95588 222117 21042 2859724 1065019 1990675 117527 473098 19025 2681098 1040814 24205 1065019 1034190 6624 1040814 793583 109334 131273 1034190 0.21000 0.09000 0.70000 0 1 1 1002970 2908464 3911434 57341465 30739901 26601564 36871923 29047298 7824625 11610575 1276292 10334283 48671906 Investment in affiliated organizations 420869 C Interest in Avera Health Foundation 3144402 F Interest in net assets of Mabee Trust 838780 F Assets Limited to use - Avera Pooled Investments 55036474 F 59440525 Due from related parties 973542 Custodial funds held by related party 8127696 9101238 Derivative liability 1965855 Estimated third-party payor settlements 85000 2050855 X Part IV, Line 2b: The Organization holds funds in trust on behalf of its residents. Part V, Line 4: The organization's endowments consist of a portion of their interest in the net assets of Avera Health Foundation and their beneficial interest in the Mabee Trust. Avera Health Foundation includes endowment funds which have been established for a variety of purposes. The endowment fund assets included in the Organization's beneficial interest in the Mabee Trust have been established to purchase equipment and furnishings for the Organization. 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. The Organization's permanently restricted endowment funds are donor restricted. The Organization currently does not have any board-designated endowment funds. Part X, Line 2: Avera Health and most of its sponsored organizations are considered nonprofit corporations as described in Section 501(c)(3) of the Internal Revenue Code and are exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. These organizations are required to file a Return of Organization Exempt from Income Tax (Form 990) with the Internal Revenue Service (IRS). Avera Health and certain sponsored organizations also file an Exempt Organization Business Income Tax Return (Form 990T) with the IRS to report their unrelated business taxable income. Avera Health and its sponsored organizations believe that they have 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 statements. 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. The federal Form 990T filings for consolidated subsidiaries are no longer subject to federal tax examinations by tax authorities for years before 2012. 1 1 X 1 X 1 X 1 1 1 0 1 1 3313 1410763 1410763 0.01460 7677 8298055 6038921 2259134 0.02330 10990 9708818 6038921 3669897 0.03790 7 90 4974 120 4854 0.00010 1 55000 55000 0.00060 3 6787 1051090 792591 258499 0.00270 18 1726781 1726781 0.01780 29 6877 2837845 792711 2045134 0.02120 29 17867 12546663 6831632 5715031 0.05910 1 250 200 200 0.00000 1 82545 57044 25501 0.00030 1 5500 5500 0.00010 3 250 88245 57044 31201 0.00040 1 5105233 0 32620543 41077728 -8457185 X 1 1 3 1 Avera Queen of Peace Hospital 525 North Foster Street Mitchell SD 57301 www.averaqueenofpeace.org 10552 X X X 5 Provider Based Clinics 2 Avera Weskota Memorial Medical Center 609 1st Street NE Wessington Springs SD 57382 www.avera.org/weskota 48209 X X X 3 Avera De Smet Memorial Hospital 306 Prairie Avenue SW De Smet SD 57231 www.avera.org/de-smet 50726 X X X Avera Queen of Peace Hospital 1 0 0 1 X X X X X X X X 12 1 0 0 1 X www.avera.org/queen-of-peace X www.avera.org X 1 12 1 see Part V 0 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. X http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A X http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance X X X X 1 X 0 X X X X 1 X 0 1 Avera Weskota Memorial Medical Center 2 0 0 1 X X X X X X X X 12 1 0 0 1 X www.avera.org/weskota/ X www.avera.org X 1 12 1 See Part V 0 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. X http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A X http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance X X X X 1 X 0 X X X X 1 X 0 1 Avera De Smet Memorial Hospital 3 0 0 1 X X X X X X X X 12 1 0 0 1 X www.avera.org/de-smet/ X www.avera.org X 1 12 1 See Part V 0 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X 1 X http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. X http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A X http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance X X X X 1 X 0 X X X X 1 X 0 1 Avera Queen of Peace Hospital Part V, Section B, Line 5: Six focus groups were held to collect primary data from community leaders, senior citizens, single parents, small business representatives, large business representatives, and post-secondary students. In addition, the following individuals were consulted in conducting the needs assessment: Principal, Longfellow Elementary School; Director of Adult Services and Aging, Davison County; Public Health Nurse, Davison County; Director of Family Planning, Davison County; and Parish Health Nurse, First Lutheran Church. Avera Weskota Memorial Medical Center Part V, Section B, Line 5: Avera Weskota Memorial Hospital gathered both secondary and primary data for the assessment. A Community Development Specialist with the Planning and Development District gathered primary data by conducting focus groups and a number of key informant interviews. Avera Weskota also collected primary data through a survey tool. The survey was utilized to reach the broader community and was distributed to the following four groups of people throughout the Wessington Springs area: 1) community & county members 2) health care providers, staff & board members 3) uninsured/underinsured populations & 4) community leaders. Avera De Smet Memorial Hospital Part V, Section B, Line 5: Input was gathered from individuals representing the following groups: Public Safety, Healthcare, Low income, Contractors/self employed, schools, SD Dept of Health Office of Rural Health Avera Queen of Peace Hospital Part V, Section B, Line 11: Behavioral Health Services: Avera Queen of Peace has been involved with Avera Health in the establishment of Service Lines. The Service Line model is a systematic approach to integrating appropriate levels of care with system-wide resources. Regardless of a patient's geographical or clinical location and using existing resources within the system, the service line model insures patients have access to the care they need, where they need it. The model reduces unnecessary duplication of resources and increases opportunities to access services that would otherwise be unavailable in a facility or region due to limitations such as geography, utilization and affordability. Launched in 2012, Behavioral Health Services was the first Service Line established within Avera. The Behavioral Health Service Line Steering Team has identified long-term viability for support of a clinical psychologist and a psychiatrist within the Avera Queen of Peace Region. Avera Queen of Peace hired a clinical psychologist within a local Avera Medical Group primary care clinic in February 2014. Disease Prevention and Wellness: Avera Queen of Peace currently offers several educational and wellness initiatives to the community. These initiatives come in the form of support groups, fitness incentives, fitness classes, nutrition education, demonstrations (i.e. cooking demos), etc. While Avera Queen of Peace will continue to offer these programs, it will pursue additional partnering within the community, including deeper dialogue with public health agencies serving the area. The intention is to establish efficient and efficacious partnerships and programming that reaches those most in need, including youth and young adults. Avera Queen of Peace has developed strong partnerships with Dakota Wesleyan University, the Mitchell Recreation Center and Mitchell High School. The first activity has been to increase and organize the resources and programming across the community in the areas of athletic training, sports medicine and sports performance. One anticipated benefit of these partnerships is better utilization and less duplication of current resources.In January 2014 Avera Queen of Peace committed $2.5 million towards a joint-use sports and community wellness complex on the Dakota Wesleyan University Campus. Ground was broken for the Avera/DWU Sports and Wellness facility in September 2014 and is anticipated to be completed in February 2016.Primary Care Access: Avera Queen of Peace is actively recruiting both family practice and internal medicine physicians. To date a family practice physician, three emergency medicine physicians, a part-time pediatrician, and fellowship-trained sports medicine physician have begun practices. Fiscal year 2016 physician recruitments include two pediatricians, a urologist, a medical oncologist and two obstetrician/gynecologists. Fiscal year 2017 physician recruitments include an internal medicine physician, pediatrician and dermatologist.In August 2014, Avera Queen of Peace started construction of a 70,000 square foot medical office and outpatient building to house family medicine, internal medicine, pediatrics, general surgery, urology, dialysis, laboratory, radiology and dialysis services. The location of the clinic will be near Interstate 90 with easier access for patients travelling from outside the city limits. The facility will place many of Avera Medical Group practices under one roof, in a location that is more visible and accessible than current locations and nearer to a portion of the economically poor in the community. Construction of this facility is anticipated to be completed in March 2016.Items not being addressed:Adequate and Affordable housing: Avera Queen of Peace currently has representation on the Mitchell Development Corporation. The Mitchell Development Corporation is active in attracting investment in affordable housing.Affordable dental care: A mobile dental care clinic currently assists local dentists in providing free dental services to needy children. Our findings of patients who are unable to find a dentist with available appointments or willing to accept uninsured patients will be communicated with dentists. Affordable and reliable public transportation: The City of Mitchell currently operates a public transit system; additionally, a local company also provides transportation services. Our findings of wait times for transportation have been communicated with transportation providers. Avera Weskota Memorial Medical Center Part V, Section B, Line 11: Poor Nutrition Among Youth: A clinical staff member serves on the Wessington Springs School Strategic Plan nutrition subgroup. Recommendations are made related to nutrition for the students. Changes in menus have occurred. Vegetables and fruits are supplied to the children for an afternoon snack.Lack of Assisted Living Housing: This finding was reported to the local Nursing Home Board of Directors to address in their strategic planning as they currently provide independent senior housing and may be able to add or convert space for assisted living.Smoking:*Marketed Freedom From Smoking sessions offered at AQOP to Wessington Springs community members 10/22/12. *Offered SD Quit Line information and other smoking cessation information at Health and Education Committee booth Wessington Springs Farm and Home Show, February 2013 and February 14. Perceived lack of healthcare services*Worked in cooperation with Jerauld County Health Services Clinic to identify services offered on campus. *Presented a program for the public at Wessington Springs Farm and Home Show highlighting the services offered.*Ads in newspaper highlighting physical therapy services *Programs at Springs Area Community Club highlighting various departments and services Perceived high incidence of cancer*Annual Fourth of July Walk and Run for Wellness with funds going to support Heart and Sole Cancer Fund *Information made available regarding cancer rates at Walk and Run and Farm and Home Show. *Provide corporate sponsorship to American Cancer Society's Jerauld-Sanborn Relay for Life events. Avera De Smet Memorial Hospital Part V, Section B, Line 11: Hospital to address two priorities:Specialty Physicians: ADMH worked with the Medical Staff to identify needs. Established outreach services for two surgeons - General and Orthopedic Surgeon. Maintained telemedicine services of 19 medical doctors in a variety of specialties. Cancer: ADMH offered yearly mini health fair and heart health which included a variety of screenings including but not limited to skin cancer and education on breast and colorectal cancer.Due to limited financial, physical space and time limitations, the interdisciplinary CHNA team did not prioritize/assign for implementation at this time:Water Quality: All comments and concerns will be addressed by the City of De Smet.Physical Activity: The City of De Smet is addressing the wellness needs of the community with plans for construction of a Community Center and Wellness Center.Domestic Abuse: This need will be addressed by the Brookings Abuse Shelter Rural Outrach Program as this program is best qualified to address this need. Avera Queen of Peace Hospital Part V, Section B, Line 16i: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera Weskota Memorial Medical Center Part V, Section B, Line 16i: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera De Smet Memorial Hospital Part V, Section B, Line 16i: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Avera Queen of Peace Hospital Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Avera Weskota Memorial Medical Center Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Avera De Smet Memorial Hospital Part V, Section B, Line 24: Individuals eligible for financial assistance are not charged gross charges for emergency or other medically necessary care; however may be charged gross charges for elective care. Part V, Section B, Line 10a The most recently adopted implementation strategy for each of the facilities has been posted to the following website:http://www.avera.org/experience/shared/community-needs-health-assessments/ Part V, Section B, Line 16 Financial Assistance Policy Website Availability Avera Queen of Peace Hospital Part V, Section B, line 16a website: http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. Avera Queen of Peace Hospital Part V, Section B, line 16b website: http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A Avera Queen of Peace Hospital Part V, Section B, line 16c website: http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance Avera Weskota Memorial Medical Center Part V, Section B, line 16a website: http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. Avera Weskota Memorial Medical Center Part V, Section B, line 16b website: http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A Avera Weskota Memorial Medical Center Part V, Section B, line 16c website: http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance Avera De Smet Memorial Hospital Part V, Section B, line 16a website: http://www.avera.org/app/files/public/4735/avera-financial-assistance-corp. Avera De Smet Memorial Hospital Part V, Section B, line 16b website: http://www.avera.org/app/files/public/4732/pdf-avera-corp-Avera-Financial-A Avera De Smet Memorial Hospital Part V, Section B, line 16c website: http://www.avera.org/app/files/public/52352/Summary-of-Financial-Assistance 2 Avera Brady Health and Rehab 500 S Ohman St Mitchell SD 57301 Nursing Home Avera Brady Assisted Living 1414 W Cedar Ave Mitchell SD 57301 Assisted Living Part I, Line 3c: A combination of income and assets test is utilized to determine eligibility for free or discounted care. Points are assigned based on income as a percentage of FPG and net assets owned with points deducted for ongoing medical expenses such as drugs. Patients with the fewest points receive the largest discount. 0-1 points receive 100% discount on bills while remaining discounts range from 10-90% depending on point totals and dollar amount of charges. 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 expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b was calculated using the costing methods to prepare the cost reports. Community health improvement services, line 7e, health professions education, line 7f, and cash and in-kind donations, line 7i were compiled using actual costs recorded in the CBISA software. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): Avera Queen of Peace bad debt expense of $5,105,233 is included on Form 990, Part IX, Line 25, Column (A) but excluded for purposes of calculating this percentage. Part II, Community Building Activities: Avera Queen of Peace supports numerous economic development organizations with participation at meetings and donations throughout its service area. Additionally, Avera Queen of Peace works with Dakota Wesleyan University, the Mitchell Technical Institute, and local high schools to address healthcare worker shortages in the communities of its service area. Avera Queen of Peace also partners with the Mitchell Senior Meals program to ensure access to nutritious meals for the elderly. Part III, Line 4: The footnote to the Organization's financial statements that describes bad debt expenses is located in Footnote 1 on page 10 of the attached audited financial statements. 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 Centers for Medicare and Medicaid Services. Avera Queen of Peace follows the CHA guidelines in reporting community benefits and therefore any Medicare shortfall (as calculated including our non-cost report entities) is excluded from our community benefit report. However, Medicare is the Organization's largest payer and patients with Medicare coverage are accepted regardless of whether or not a surplus or deficit is realized from providing the services. This basis therefore means providing Medicare services promotes access to healthcare services which is a key advantage for our community. Part III, Line 9b: If the patient qualifies for the Organization's financial assistance policy for low-income, uninsured patients and is cooperating with the Organization with regard to efforts to settle an outstanding bill within a reasonable time period, the Organization or its agent shall not send, nor indicate that it will send, the unpaid bill to any outside agency if doing so may negatively impact a patient's credit. At such time as the organization sends the uncollected account to an outside collection agency, the amount referred to the agency shall reflect the reduced-payment level for which the patient was eligible under the Organization's financial assistance policy for low-income uninsured patients. Any extended payment plans offered by a hospital in settling the outstanding bills of low income, uninsured patients who qualify for financial assistance shall be interest-free so long as the repayment schedule is met. Part VI, Line 2: Avera Queen of Peace conducted a Community Health Needs Assessment for each facility during 2012 and 2013. The CHNA Implementation Plans for Avera Weskota Memorial Medical Center and Avera De Smet Memorial Hospital were adopted by the Avera Queen of Peace Governing Board on May 28, 2013. The CHNA implementation plan for Avera Queen of Peace Hospital was adopted by the Avera Queen of Peace Governing Board on June 25, 2013. Part VI, Line 3: A summary of the financial assistance policy is posted in the Hospital facility's emergency rooms, waiting rooms, and admissions office and is included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility. Part VI, Line 4: Avera Queen of Peace's service area includes Davison County and surrounding counties in South Dakota. In 2013, the population for Davison County was estimated to be 19,823. Approximately 17.2% of the population is age 65 or older. The average per capita income is $24,597 and approximately 12.2% of individuals are below the federal poverty level. The nearest like hospital in the area is approximately 72 miles from Avera Queen of Peace. Part VI, Line 5: Avera Queen of Peace is a verified Level II trauma center and operates an emergency department staffed 24 hours per day with board certified physicians. Emergency care is provided on an open door basis regardless of ability to pay. Avera Queen of Peace leases two critical access hospitals which provide a broad range of inpatient, outpatient services and 24 hour emergency rooms in two very rural communities.Avera Queen of Peace owns three rural health clinics which provide primary care services in three rural communities.Similar to the hospitals in the Avera Queen of Peace region, the clinics are operated on an open door basis and care is provided regardless of ability to pay.Medical staff privileges are extended to all licensed and qualified applicants. The Avera Queen of Peace Board of Directors is principally comprised of community members from the primary and secondary services areas. Members come from a variety of backgrounds including banking, education, agriculture, healthcare and private industry. Part VI, Line 6: 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 Dakota Wesleyan University 1200 W University Ave Mitchell SD 57301 460224589 501(c)(3) 1504000 Donation De Smet Community Foundation PO Box 42 De Smet SD 57231 461401425 501(c)(3) 25000 Donation Mitchell Tech Institution Foundation 1800 E Spruce St Mitchell SD 57301 460452950 501(c)(3) 10000 Donation 3 0 Part I, Line 2: The Organization only makes grants to other organizations which are tax-exempt under Section 501(c)(3). 0 0 0 0 0 0 0 0 0 Patricia Malters MD Board Member/Physician 227887 0 11000 0 4260 0 19112 0 6671 0 268930 0 0 0 Thomas Clark President & CEO 0 333797 0 0 0 85254 0 11306 0 22443 0 452800 0 0 William E Flett Sec/Treas & VP of Finance 166587 0 180 0 652 0 14022 0 23228 0 204669 0 0 0 Brian Kampmann MD Orthopedics, Sports Medici 700695 0 174117 0 2848 0 20422 0 21858 0 919940 0 0 0 Anwarul Haq MD Hematology and Oncology 549530 0 12500 0 77011 0 20500 0 2478 0 662019 0 0 0 Chris Krouse DO Orthopedics, Sports Medici 966498 0 24000 0 4917 0 20422 0 20724 0 1036561 0 0 0 Dileep Bhat MD Urology 423872 0 36250 0 41650 0 20500 0 16894 0 539166 0 0 0 Dennis Leland MD FACS General Surgery 445017 0 30000 0 6014 0 20500 0 23862 0 525393 0 0 0 Schedule J, Part I Line 3: The President/CEO's compensation is paid by a related organization, Avera Health. Avera Queen of Peace relied on the related organization for determining the compensation for the President/CEO using the methods described in Part I, Line 3. David Malters MD Family member of board member 182244 Compensation 0 Andrea Malters Family member of board member 31137 Compensation 0 Form 990, Part III, line 2 Added Avera Medical Group Internal Medicine Olegario Clinic, October 2014 Added Integrated Therapy Services, LLC, November 2014 Added Advanced Physical Therapy, May 2015 Form 990, Part III, line 3 Hospitality House ceased operations during the fiscal year ending 06/30/15. Form 990, Part VI, Section A, line 2 Sister Kathleen Crowley has a business relationship with Thomas Clark. 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 A, line 8b Avera Queen of Peace Hospital does not have committees with authority to act on behalf of the governing body. Form 990, Part VI, Section B, line 11 The return is reviewed initially by the CFO. The return is made available to the Board of Directors for review prior 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 15b The CEO is compensated by Avera Health. Annually the Compensation Committee of Avera Health, which is comprised of six (6) System Members appointed by the Religious Orders, meets with an independent consultant regarding fair market value of officers and key employees. The Compensation Committee approves all salaries based on comparable data and documents the basis for their decision in meeting minutes. The compensation of the VP of Finance is determined by Human Resources based on a market analysis of comparable positions. The compensation is approved by the CEO. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not available to the general public. The Organization's financial statements are attached to the Form 990 per IRS instructions and therefore are available to the general public. Form 990, Part IX, line 11g Recruitment: Program service expenses 113,355. Management and general expenses 39,317. Fundraising expenses 0. Total expenses 152,672. Repairs and Maintenance: Program service expenses 1,398,735. Management and general expenses 40,137. Fundraising expenses 0. Total expenses 1,438,872. Purchased Services: Program service expenses 2,659,947. Management and general expenses 533,958. Fundraising expenses 6,828. Total expenses 3,200,733. ACS Fees: Program service expenses 818,100. Management and general expenses 6,293,155. Fundraising expenses 0. Total expenses 7,111,255. Form 990, Part XI, line 9: Change in Fair Value of Interest Rate Swap 44,985. Equity Transfers -1,102,301. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the consolidated audited financial statements of Avera Health, which includes Avera Queen of Peace. Form 990, Part VI, Section B, Line 16b: There is no written policy or procedure since in the event of any such proposed transaction the board or a committee with delegated authority reviews all materials, valuations and operational aspects for any proposed transaction. Such transaction would be evaluated in accordance with the exempt status of the organization and its applicable purposes. Any transaction also would be approved by the board and the member. Form 990, Part X, Line 20: The issue price includes the filing Organization's share of the entire bond issue, which was issued to Avera Health on behalf of the Avera Obligated Group. The Avera Obligated Group consists of Avera Health, Avera McKennan, Avera St. Luke's, Avera Queen of Peace, Avera Marshall, Avera St. Mary's, and Avera Sacred Heart. In accordance with IRS instructions, information related to the tax exempt bond reporting is being reported on Avera Health's tax return (EIN 46-0422673). Integrated Therapy Services LLC 525 N Foster St Mitchell SD 57301 320450803 Physical, Occupational, and Speech Therapy SD 548368 926009 Avera Queen of Peace Avera Health 3900 West Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) Line 9 N/A 0 Avera Gettysburg 606 East Garfield Gettysburg SD 57442 460234354 Healthcare Services SD 501(c)(3) Line 3 Avera St Mary's 0 Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 68763 470463911 Healthcare Education NE 501(c)(3) Line 3 Avera Health 0 Avera Holy Family 826 North 8th Street Estherville IA 51334 420680370 Healthcare Services IA 501(c)(3) Line 3 Avera Health 0 Avera Holy Family Foundation 826 North 8th Street Estherville IA 51334 421317452 Fundraising IA 501(c)(3) Line 9 Avera Holy Family 0 Avera Marshall 300 S Bruce Street Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) Line 3 Avera Health 0 Avera Marshall Foundation 300 S Bruce Street Marshall MN 56258 411784801 Fundraising MN 501(c)(3) Line 7 Avera Marshall 0 St Benedict Health Center 401 West Glynn Drive Parkston SD 57366 460226738 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 St Benedict Health Center Foundation West Glynn Drive PO Box B Parkston SD 57366 460458725 Support Health Related Services SD 501(c)(3) Line 11a, I St Benedict Health Center 0 Avera McKennan 1325 S Cliff Ave PO Box 5045 Sioux Falls SD 57117 460224743 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera St Mary's 801 East Sioux Avenue Pierre SD 57501 460230199 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera at Home 5116 S Solberg Ave Sioux Falls SD 57108 460399291 Home Services SD 501(c)(3) Line 9 Avera Health 0 Lewis and Clark Health Education and Service Agency 1000 W 4th Street Suite 9 Yankton SD 57078 460337013 Healthcare Education SD 501(c)(3) Line 9 Sacred Heart Health Services 0 Avera St Luke's 305 South State Street Aberdeen SD 57401 460224598 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Q & M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical clinic building SD Avera Queen of Peace Related -509 367501 0 1 0.50000 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 Home Medical Equipment 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 Lincoln St NE Lemars IA 51031 820582350 Medical services - home medical equipment SD N/A Avera Home Medical Equipment of Estherville LLC PO Box 5045 Sioux Falls SD 57117 201686097 medical services - home medical equipment SD N/A Avera Home Medical Equipment of Sioux Center LLC 38 19th ST SW Sioux Center IA 51250 753203100 medical services - home medical equipment SD N/A Avera Home Medical Equipment of Marshall LLC 1104 East College Drive Marshall MN 56258 205271924 medical services - home medical equipment SD N/A Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Ave 102 Sioux Falls SD 57117 800619999 medical services - home medical equipment SD N/A Surgical Associates Endoscopy Clinic LLC 310 S Pennsylvania St Aberdeen SD 57401 460461429 surgical associates SD N/A Heart Hospital of South Dakota LLC 4500 W 69th Street Sioux Falls SD 57108 562143771 healthcare services SD N/A Brookings Health System - Avera HME LLC 101 22nd Ave Suite 101 Brookings SD 57006 453204123 Medical Services - Home Medical Equipment SD N/A Accounts Management Inc 5132 S Cliff Ave Suite 101 Sioux Falls SD 57108 460373021 collection agency SD N/A C 0 Avera Health Plans Inc 3900 West Avera Drive Suite 101 Sioux Falls SD 57108 460451539 health financing and health plan administration SD N/A C 0 Avera Property Insurance Inc 610 W 23rd St Ste 1 PO Box 38 Yankton SD 57078 460463155 insurance SD N/A C 0 Dr Donald & Marguerite Mabee Trust c/o First National Bank of South Da Mitchell SD 57301 466056202 investing SD Avera Queen of Peace Hospital T 18143 838780 1.00000 1 Valley Health Services 501 Summit Street Yankton SD 57078 460357149 rental real estate SD N/A C 0 Alucent Medical Inc 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 571175045 471818349 biotech research SD N/A C 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 1 1 Avera McKennan L 1014500 General Ledger Avera Home L 50886 General Ledger Avera St Luke's M 129636 General Ledger