2013-05-14T00:10:45-05:00 2012-06-30 861065772 Deloitte Tax LLP 50 South Sixth Street Suite 2800 Minneapolis MN 55402 990 2011-07-01 420733472 St Anthony Regional Hospital and Nursing Home STAN 7127928246 311 South Clark Street PO Box 628 Carroll IA 51401 John Munson 7127928246 2013-05-02 1 Kristina Rasmussen P00143920 6123974000 2011 2016-03-07 17:11:31Z Gary P Riedmann 311 South Clark Street PO Box 628 Carroll IA 51401 91662379 0 0928 X www.stanthonyhospital.org X 1905 IA Consistently providing high quality healthcare services to meet patient and community needs. 10 9 739 478 217 0 925626 149934 56792216 64337847 2593343 2835658 -173036 -423758 60138149 66899681 3000 3000 0 0 26747098 30026394 0 0 0 27439579 30280643 54189677 60310037 5948472 6589644 122380058 126551178 25845594 23117178 96534464 103434000 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 53815774 3000 63981180 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, 2012 St. Anthony Regional Hospital and Nursing Home provided heath care services to approximately 2,346 inpatients, 71,472 outpatients, and 27,065 clinic visits. St. Anthony Regional Hospital provided services for 1,788 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 Statement 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 physical therapy. In the year ended June 30, 2012, St. Anthony serviced 10,923 in physical therapy, 7,721 in laboratory, and 8,297 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. 3254404 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. 57070178 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 1 0 0 0 0 0 1 1 1 0 0 1 98 0 1 739 1 0 0 0 0 0 0 0 0 0 0 0 X 10 9 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 X Gary McMinimee 0.30 X X 0 0 0 Fred Dolezal 0.30 X X 0 0 0 Sr Helen Elsbernd 0.30 X X 0 0 0 Tom Gronstal 0.30 X X 0 0 0 Urban Knobbe 0.30 X 0 0 0 Wayne Seaman 0.30 X 0 0 0 Sr Rita Heires 0.30 X 0 0 0 Sr Romana Klaubauf 0.30 X 0 0 0 Art Neu 0.30 X 0 0 0 Sr Theresa Keller 0.30 X 0 0 0 Gary P Riedmann 0.30 X 382661 0 65950 Edward H Smith Jr 0.30 X 190874 0 8912 John Munson 0.30 X 58119 0 386 Nelson H Lo 40.00 X 327136 0 12812 Robert J Langenfeld 40.00 X 216678 0 8583 Dominick C Ervelli 40.00 X 197559 0 11455 Brian L Pratt 40.00 X 190429 0 9699 David P Nystrom 40.00 X 190153 0 9756 1753609 0 127553 21 0 1 0 Dell Marketing LP PO Box 416634 Boston MA 022416634 Computer Consulting Services 1096265 Shared Medical Services Inc PO Box 330 Cottage Grove WI 53527 Imaging Services 319130 Deloitte & Touche LLP PO Box 7247-6446 Philadelphia PA 191706446 Accounting Fees 203430 Dr Jed Hagen 2313 Skyline Dr Carroll IA 51401 Pathology Services 127000 Corepoint Health LLC 3010 Gaylord Parkway Frisco TX 75034 Computer Services 116000 5 149934 149934 Patient Svc Revenue 621400 38619698 38619698 Medicare/Medicaid Pmts 621400 25329839 25329839 Cafeteria Sales 621400 356450 356450 Radiation Oncology Svc 621400 31643 31643 Inc. from Partnership 900004 217 217 64337847 843472 843472 1441920 1865678 -423758 -423758 -423758 24421777 467429 22558029 338991 1863748 128438 1992186 1992186 66899681 63981180 217 2768350 3000 3000 614314 614314 24136602 23191551 945051 358199 308866 49333 3159959 3081529 78430 1757320 1712804 44516 34090 34090 244048 244048 3826148 3072659 753489 252499 29150 223349 2805677 2681949 123728 408411 408411 1415436 1414873 563 246921 211736 35185 911332 911332 5557985 5557985 321296 279498 41798 Medical Supplies 10926632 10926632 0 0 Bad Debts 2257123 2257123 0 0 Repair and Maintenance 1066729 1019185 47544 0 Miscellaneous expenses 6316 1895 4421 0 60310037 57070178 3239859 0 2280808 1129952 8821955 12434526 3 3 1405643 1509025 151835 330280 110693019 45450350 64877448 65242669 35118342 37152099 4964399 1149432 4759625 7603192 122380058 126551178 5100620 5275477 18816606 17160848 449528 42309 1478840 638544 25845594 23117178 X 96166987 101551358 367477 1782642 0 100000 96534464 103434000 122380058 126551178 X 6589644 309892 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8178 8178 0 Explanation of Lobbying Activities: Part II-B, Line 1: St. Anthony Hospital is a member of Iowa Hospital Association. A percentage of the membership dues paid to IHA is related to lobbing activities. 995357 3662163 -30442 3500 1205 4622373 680736 190774 129468 3500 2121 995357 362632 265297 55307 2500 680736 207355 196019 -33742 7000 362632 0.56000 0.44000 0 1 1 756466 756466 78690205 27584504 51105701 27546437 16248355 11298082 3699911 1617491 2082420 65242669 Deferred Compensation Investments 638544 Beneficial interest in net assets of the Foundation 4382642 Investment in Joint Venture 2304137 Other 277869 7603192 Deferred Compensation 638544 638544 66899681 60310037 6589644 -998311 1308203 309892 6899536 69152989 -998312 3251620 2253308 66899681 0 66899681 62253453 0 62253453 -1943416 -1943416 60310037 Description of Intended Use of Endowment Funds: 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. Description of Uncertain Tax Positions Under FIN 48: Part X: 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, 2012 and 2011. The Hospital is engaged in certain activities that result in unrelated business income. Part XI, Line 8 - Other Adjustments: Transfer to St. Anthony Foundation for Op. cash requirements -206,745. Change in beneficial interest of net assets of Foundation 1,515,165. Income from Partnerships -217. Total to Schedule D, Part XI, Line 8: 1,308,203. Part XII, Line 2d - Other Adjustments: Rental expenses 1,865,678. Realized loss on sale of assets -128,438. Change in beneficial interest of net assets of Foundation 1,515,165. Income from Partnerships -217. Miscellaneous Adjustment -568. Part XIII, Line 4b - Other Adjustments: Rental expenses -1,865,678. Transfer to St. Anthony Foundation for Op. Cash Requirements -206,744. Realized loss on sale of assets 128,438. Miscellaneous Adjustment 568. 1 1 X 1 X 1 X 1 1 1 0 1 1 864628 0 864628 0.01430 4416675 2980111 1436564 0.02380 5281303 2980111 2301192 0.03810 184289 49770 134519 0.00220 297538 5000 292538 0.00490 7579162 4977949 2601213 0.04310 224102 72899 151203 0.00250 8285091 5105618 3179473 0.05270 13566394 8085729 5480665 0.09080 18085 18085 0.00030 21117 15603 5514 0.00010 5178 5178 0.00010 44380 15603 28777 0.00050 1 1019820 17501954 19262968 -1761014 X 1 1 1 1 St Anthony Regional Hospital

311 South Clark St Box 628 Carroll IA 51401

X X X St Anthony Regional Hospital 1 1 1 200.000000000000 1 399.000000000000 1 X X X X X X 1 1 X X X X X 1 0 1 X 0 0 5 St Anthony Regional Hospice

311 South Clark Street Carroll IA 51401

Hospice services St Anthony Regional Hospital

311 South Clark Street Carroll IA 51401

Dialysis services St Anthony Regional Home Health Agency

311 South Clark Street Carroll IA 51401

Home Health Services St Anthony Regional Hospital

311 South Clark Street Carroll IA 51401

Psychiatric services Wall Lake Medical Clinic

311 First St Wall Lake IA 51466

Rural Health Clinic 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 FCG 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 I, line 7, with the exception of line 7g, subsidized health services. Subsidized health services are reported using departmental cost from the 2012 cost report. Part I, Line 7g: St. Anthony Regional Hospital has eight physician clinics that are included in subsidized health services where the cost exceed the reimbursements. Part I, L7 Col(f): Bad debt expense of 2,257,123 was subtracted for purposes of calculating the percentage in schedule H, part I, line 7. Column f. Part II: 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 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. The bad debt at cost amount is calculated with the same cost to charge ratio used for the charity care at cost, time the estimated bad debt charges. 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. St. Anthony Regional Hospital Part V, Section B, Line 19d: 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 the federal poverty guidelines are eligible for a discount of 25%. All individuals that earn less 200% of the federal poverty guidelines pay 0% of gross 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 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 in 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 web site. 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 seven 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 30 active staff, 8 associate staff in the community, and 115 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. Reports Filed With States Part VI, Line 7 IA X X X X 0 1 0 0 0 0 0 1 0 Gary P Riedmann 300367 0 71384 0 10910 0 55324 0 10626 0 448611 0 0 0 Edward H Smith Jr 171055 0 19421 0 398 0 0 0 8912 0 199786 0 0 0 Nelson H Lo 323721 0 1078 0 2337 0 0 0 12812 0 339948 0 0 0 Robert J Langenfeld 204038 0 6616 0 6024 0 0 0 8583 0 225261 0 0 0 Dominick C Ervelli 194785 0 1348 0 1426 0 0 0 11455 0 209014 0 0 0 Brian L Pratt 172207 0 1590 0 16632 0 0 0 9699 0 200128 0 0 0 David P Nystrom 176373 0 2263 0 11517 0 0 0 9756 0 199909 0 0 0 Part I, Line 4b St. Anthony Hospital and Nursing Home had an IRC Section 457F Deferred Compensation Plan. The following participants of the plan received payments during the year: Gary P. Riedmann: $0 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. Carroll County Iowa 426004323 2003-09-29 10000000 Construction of Hospital Addition 0 0 0 Carroll County Iowa 426004323 144813AB8 2006-11-22 6672573 Construction of Hospital Addition 0 0 0 City of Carroll Iowa 426004322 145181CK7 2006-11-22 5402508 Construction of Hospital Addition 0 0 0 10445730 35220 10410510 2006 0 0 1 1 6969080 133451 6835629 2009 0 0 1 1 1445000 5637070 107254 5529816 2009 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 0 0 1 Citi Group 1.900000000000 1 0 0 0 0 0 1 Citi Group 1.900000000000 1 0 0 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 proceeds (Part II, line 3) are due to investment earnings and (for column C) to a small excess amount (less than $1,000) that was used to pay principal on the bonds. Mid Iowa Insurance Fred Dolezal - VP 299369 Insurance 0 Mid Iowa Insurance: Fred Dolezal Vice President, Insurance services for St. Anthony Regional Hospital and Nursing Home. 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 operations. The form was prepared by the St. Anthony Regional Hospital's 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 size 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 VII: Gary P. Reidmann, CEO, John Munson, CFO, and Edward H. Smith Jr., Vice President, hold positions at both St. Anthony Regional Hospital and St. Anthony Foundation. On average, 40 hours per week are spent completing work within these roles. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -998,311. Transfer to St. Anthony Foundation for Op. cash requirements -206,745. Change in beneficial interest of net assets of Foundation 1,515,165. Income from Partnerships -217. Total to Form 990, Part XI, Line 5: 309,892. St Anthony Foundation 311 South Clark Street PO Box 628 Carroll IA 51401 421419695 Fundraising IA 501(c)(3) Line 11, Type I: 509 St Anthony Regional Hospital 1 Franciscan Sisters of Perpetual Adoration 912 Market Street La Crosse WI 546014782 390806386 Religious Order WI 501(c)(3) Line 1: 170(b)(1)(a) N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 St Anthony Foundation C 149934 FMV St Anthony Foundation O 206745 FMV St Anthony Foundation Q 2500000 FMV