2016-05-16T09:55:41-05:00 2015-06-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2014-07-01 420680370 Avera Holy Family AVER 7123626519 826 North 8th Street Estherville IA 51334 Dale Hustedt President & CEO 7123626519 2016-05-12 1 Kim Hunwardsen CPA P00484560 6122536500 2016-05-03 2014 2016-08-17 19:52:53Z Dale Hustedt 826 North 8th Street Estherville IA 51334 25494504 0 0928 X www.avera-holyfamily.org X 1996 IA Promotion of Health 11 8 249 12 2447 0 55243 41213 25603719 24936162 428394 480572 36168 36557 26123524 25494504 30243 33316 0 0 12378012 12232029 0 0 0 11636434 11064874 24044689 23330219 2078835 2164285 36625882 37324543 8370026 7535705 28255856 29788838 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. 0 0 20448423 33316 24968254 Avera Holy Family Health operates a 25-bed critical access hospital and provider-based clinic located in Estherville, Iowa. Inpatient and outpatient medical services are provided. The hospital provided 2,856 inpatient bed days.Avera Holy Family 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 $640,838 for the year ended June 30, 2015.The Hospital also provides community benefit health activities at less than or at no cost to support those in the area served. These activities include community education programs; special programs for the elderly, handicapped, and medically underserved; and a variety of broad community support activities. For the years ended June 30, 2015, specific activities included meals delivered to residential homes; meeting facilities; and programs for patients and families suffering from cancer, diabetes, breathing disorders, and others; assistance to health educators; emergency health care providers; and wellness programs. 20448423 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 38 0 1 249 1 1 1 0 0 0 0 0 0 0 0 0 X 11 8 1 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 1 0 X Shannon Adams 7123626519 826 N 8th Street Estherville IA 51334 Kathy Preston Chair 1.00 0.00 X X 0 0 0 Joe Fitzgibbons Vice Chair 1.00 0.00 X X 0 0 0 Dr Douglas Stangl Board Member 1.00 0.00 X 0 0 0 Dr Anthony Cook Board Member 1.00 0.00 X 0 0 0 Sr Debra Kolecka Board Member 1.00 5.50 X 0 0 0 Sr Mary Jaeger Board Member 1.00 10.00 X 0 0 0 Chris Schiltz Board Member 1.00 0.00 X 0 0 0 Joe Greig Board Member 1.00 0.00 X 0 0 0 Sr Sharon Haas Board Member 1.00 0.00 X 0 0 0 Roslyn Gunderson Board Member 1.00 0.00 X 0 0 0 Scott Stokes Board Member 1.00 0.00 X 0 0 0 Dale Hustedt President & CEO 40.00 0.00 X 0 112958 20011 Shannon Adams Sec/Treas & SrVP Finance 45.00 1.00 X 0 86483 26950 Kristi Hough Pharmacy Manager 40.00 0.00 X 120093 0 16452 April Krull Pharmacist 40.00 0.00 X 104788 0 8147 224881 199441 71560 2 0 0 0 Estherville Medical Center ER 926 N 8th Street Estherville IA 51334 ER Coverage 550605 Acute Care Inc PO Box 4130 Des Moines IA 50333 ER Coverage 412188 Woodward Anesthesia Services PC 203 N 8th St Estherville IA 51334 Anesthesia Services 263638 Fit for Life Physical Therapy LLC 826 N 8th Estherville IA 51334 Physical Therapy 248742 Grapetree Medical Staffing 703 16th Street Spirit Lake IA 51360 Staffing 204392 6 32092 7416 1705 41213 Patient Service Revenu 622110 23854161 23854161 Other Revenue 900099 844656 842209 2447 Change in Foundation 900099 70549 70549 Collaborative Agreement 900099 58708 58708 EHR Incentive Income 900099 56000 56000 52088 52088 24936162 452520 452520 36557 0 36557 36557 36557 28052 0 28052 28052 28052 25494504 24933715 2447 517129 33316 33316 9606808 8459798 1147010 479425 92668 386757 1491653 1286804 204849 654143 577052 77091 352416 30000 322416 3051 3051 37550 37550 1623778 1586201 37577 18696 1002 17694 265388 120701 144687 80106 42478 37628 397607 397607 17030 8232 8798 95137 83402 11735 113871 113871 1464825 1464825 268423 70202 198221 Medical Supplies 4153311 4153311 Locum Fees 1045947 1045947 Bad Debt Expense 508963 508963 Equipment Lease and Ren 156870 151652 5218 461905 220391 241514 23330219 20448423 2881796 0 2837581 3289110 3096031 3545567 40625 3125 579541 749685 78209 145061 27910259 14670207 13437919 13240052 289974 293480 15831842 15680663 157171 198013 276989 179787 36625882 37324543 1984685 1886891 3600000 3246414 160325 55049 2625016 2347351 8370026 7535705 X 27992289 29535949 241025 230347 22542 22542 28255856 29788838 36625882 37324543 2164285 -631303 0 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 823825 85170 908995 721217 102608 823825 680404 40813 721217 680404 680404 680404 680404 0.95000 0.03000 0.02000 0 1 1 470340 470340 17109174 8625341 8483833 9381170 5807022 3574148 949575 237844 711731 13240052 Assets Lmited as to Use - Avera Pooled Investments 13768006 F Investment in Foundation 1912657 F 15680663 Due to Related Party 1250000 Clinic Collaborative Arrangement 619206 Compensated Absences 44652 Estimated Third-Party Payor Settlements 433493 2347351 X 24364916 -631303 -508963 -1140266 25505182 -10678 -10678 25494504 22821256 0 22821256 508963 508963 23330219 Part V, Line 4: The Organization's endowments consist of a portion of their interest in the net assets of the Avera Health Foundation. The Avera Health Foundation includes endowment funds which have been established for a variety of purposes. 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. Part X, Line 2: The Organization is an Iowa nonprofit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Organization is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, the Organization is subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose. The Organization files an Exempt Organization Business Income Tax Return (Form 990T) with the IRS to report its unrelated business taxable income. 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 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 Organization's federal Form 990T filings are no longer subject to federal tax examinations by tax authorities for years before 2012. Part XI, Line 2d - Other Adjustments: Provision for Bad Debts Reported in Revenue on Financial Statements -508,963. Part XI, Line 4b - Other Adjustments: Change in Interest in Net Assets Avera Health Fdtn in Fund Balance for F/S -10,678. Part XII, Line 4b - Other Adjustments: Provision for Bad Debts Reported in Revenue on Financial Statements 508,963. 1 1 X 1 X 1 X 1 1 1 0 1 1 1603 384502 384502 0.01680 2435677 2200815 234862 0.01030 1603 2820179 2200815 619364 0.02710 7 624 33726 33726 0.00150 2 108 109708 109708 0.00480 2 380017 380017 0.01670 1 680 680 0.00000 5 48748 48748 0.00210 17 732 572879 572879 0.02510 17 2335 3393058 2200815 1192243 0.05220 2 40360 40360 0.00180 1 42000 42000 0.00180 3 82360 82360 0.00360 1 508963 0 11486421 11566311 -79890 X 1 1 1 1 Avera Holy Family Health 826 N 8th Street Estherville IA 51334 www.avera-holyfamily.org 320014H X X X X Provider Based Clinic Avera Holy Family 1 0 0 1 X X X X X X X X X 12 1 0 0 1 X www.avera.org/holy-family-hospital X 1 12 1 See Part V statement 0 0 1 X 150.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X see Part V X X 1 X 0 X X X X 1 X 0 1 Avera Holy Family Part V, Section B, Line 5: Avera Holy Family utilized data gathered through input from community partners and services groups, survey responses, community leader interviews, and results from focus groups. The Emmet County Wellness Coalition, Emmet County Public Health, and other health groups in the community served were consulted throughout this process. Avera Holy Family Part V, Section B, Line 11: The Hospital did not address mental health services needs due to the lack of mental health providers in the area. Transportation and environmental issues were not addressed due to lack of financial resources, lack of technical know-how and skill, and other needs taking priority.All other needs from the Community Health Needs Assessment have been addressed and implemented. Avera Holy Family 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 Holy Family 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. Schedule H, Part V, Line 16a, FAP website: www.avera.org/app/files/public/4735/avera-financial-assistance-corp Schedule H, Part V, Line 11: www.avera.org/experience/shared/community-needs-health-assessments/ Part V, Section B, Line 16 Financial Assistance Policy Website Availability Avera Holy Family Part V, Section B, line 16a website: see Part V 2 Avera Parkwood Independent Living Facili 400 Parkwood Drive Pierre SD 57501 Independent living Maryhouse 400 Parkwood Drive Pierre SD 57501 Long term care 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 within 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 and Medicaid were converted to cost using an overall cost-to-charge ratio addressing all patient segments. Community health improvement services, health professions education, subsidized health services, research and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger. Part I, Ln 7 Col(f): The amount of bad debt removed from the denominator of the calculation was $508,963. Part II, Community Building Activities: The Organization supports the free clinic in the community; conducts public health screenings; participates in community health fairs; provides health education to community and schools; conducts a lifestyle challenge for the community; donates to various community organizations and health care scholarships; provides tours for school children; utilizes telecare; and provides Meals on Wheels. Part III, Line 4: The footnote to the Organization's financial statements that describes bad debt expenses is located in Footnote 1 on pages 7 and 8 of the attached 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 set forth by Centers for Medicare and Medicaid Services. Avera Holy Family follows the CHA guidelines in reporting community benefits and therefore any Medicare shortfall 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 collection agency. 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. Avera Holy Family does not report any data to any of the credit agencies, however, the collection agencies Avera Holy Family utilizes may report to the credit agencies. Any extended payment plans offered by the Hospital, or the Hospital's representative, in settling the outstanding bills of patients who qualify for financial assistance shall be interest-free so long as the repayment schedule is met. Part VI, Line 2: The Organization collaborated with the Department of Public Health on a needs assessment. The finalized Community Health Needs Assessment and Implementation Strategy is located on our website. Part VI, Line 3: Information regarding charity care is made available to patients via their billing statements. The Finance Department also informs patients of the policy through their contact with patients. Brochures regarding financial assistance are located in the lobby of the Hospital and the Clinic. Part VI, Line 4: Avera Holy Family Health operates a 25-bed critical access hospital and provider-based clinic located in Estherville, Iowa. Avera Holy Family's service area includes Emmet County and surrounding counties in Iowa. In 2014, the population for Emmet County was 9,990. Approximately 19.2% of the population is age 65 or older. The average per capita income is $28,293 and approximately 11.3% of the population is below the federal poverty level. The nearest hospital in the area is approximately 15 miles from Avera Holy Family's main campus. Part VI, Line 5: The Organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community. Surplus funds are reinvested in facilities to improve patient care.The Organization supports the free clinic in the community; conducts public health screenings; participates in community health fairs; provides health education to community and schools; conducts a lifestyle challenge for the community; donates to various community organizations and health care scholarships; provides tours for school children; utilizes telecare; and provides Meals on Wheels. 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 Iowa Lakes Community College 19 South 7th St Estherville IA 51334 391872497 3 5850 Scholarships 1 0 Part I, Line 2: Avera Holy Family's policy is to provide grants/contributions to not-for-profit entities and governmental divisions that benefit the community and region through programs and activities. A The City of Estherville Iowa 426004647 297542BG6 2012-06-21 3840000 Refund the Series 2000 Bonds issued 12/14/2000 0 0 0 A 480000 3840000 76800 3763200 2000 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 0 0 0 0 0 A 0 Dr Anthony Cook Board member Recruitment X 150000 3125 0 1 1 3125 Estherville Medical Clinic PC 2 Board Members are more than 35% owners 550605 Payment for physician services 0 Form 990, Part VI, Section A, line 2 Doctors Stangl and Cook have a business relationship. 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 the 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, SD ("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 CEO of the Corporation; 8) To approve the 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 There is no committee with authority to act on behalf of the Board. Form 990, Part VI, Section B, line 11 The CEO reviews the 990 in detail. After the CEO's review, the 990 is provided to each Board Member. 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 15 The CEO and officers are compensated by Avera McKennan. Avera McKennan has a process in place for determining compensation for these individuals. 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 available to the general public. Form 990, Part VI, Section B, Line 15: Dale Hustedt is compensated by Avera McKennan, a related organization. Avera McKennan is a nonprofit 501(c)(3) corporation organized and operated in the State of South Dakota. Avera McKennan has a process in place for determining compensaton of these individuals using processes identified in Part I, Line 3. Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization, selects the auditor and reviews the audited financial statements for Avera Holy Family. 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. Avera Health 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) Line 9 N/A 0 Avera Holy Family Foundation 826 N 8th Street Estherville IA 51334 421317452 Support of Holy Family Hospital and Home Health Agency IA 501(c)(3) Line 9 Avera Holy Family 1 Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 68763 470463911 Healthcare Services NE 501(c)(3) Line 3 Avera Health 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 401 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 Avera Queen of Peace Hospital 525 North Foster Street Mitchell SD 57301 460224604 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 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 Avera Marshall 300 S Bruce St Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) Line 3 Avera Health 0 Avera Marshall Foundation 300 S Bruce St Marshall MN 56258 411784801 Fundraising MN 501(c)(3) Line 7 Avera Marshall 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 Mary's 801 East Sioux Avenue Pierre SD 57501 460230199 Healthcare Services SD 501(c)(3) Line 3 Avera Health 0 Avera Home Medical Equipment of Estherville LLC PO Box 5045 Sioux Falls SD 57117 201686097 Medical services - home medical equipment SD Avera McKennan related 8426 187326 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 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 Av 102 Sioux Falls SD 57117 800619999 Medical Services - home medical equipment SD N/A Q&M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical clinic building SD N/A Surgical Associates Endoscopy Clinic LLC 310 S Penn Aberdeen SD 57401 460461429 Surgical associates SD N/A Heart Hospital of South Dakota LLC 10720 Sikes Place Suite 300 Charlotte NC 28277 562143771 Healthcare Services NC 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 Avenue 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 Admin SD N/A C 0 Avera Property Insurance Inc 510 W 23rd Street PO Box 38 Yankton SD 57078 460463155 Insurance SD N/A C 0 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 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0