2012-08-02T13:44:40-05:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2011-01-01 410726171 INTERNATIONAL FALLS MEMORIAL HOSPITAL ASSOCIATION INTE 2182835410 1400 HIGHWAY 71 INTERNATIONAL FALLS MN 56649 VERA SCHUMANN 2182835410 2012-07-25 1 DARRYN MCGARVEY P00958683 6123764500 2011 2016-02-24 21:20:13Z RAINY LAKE MEDICAL CENTER BOB HALEY 1400 HIGHWAY 71 INTERNATIONAL FALLS MN 56649 25314980 0 X WWW.RAINYLAKEMEDICAL.COM X 1945 MN TO SERVE PATIENTS AND PROMOTE WELLNESS. 14 8 216 24 14044 -146 37872 76573 24242608 24425477 185085 149080 1443939 611203 25909504 25262333 0 0 0 0 10032913 10073101 0 0 8417 16682600 15724278 26715513 25797379 -806009 -535046 23686442 22089557 3906991 3195497 19779451 18894060 X TO SERVE PATIENTS AND PROMOTE WELLNESS. 0 0 21149976 0 24425477 PROVIDED HEALTH SERVICES TO THE COMMUNITY OF INTERNATIONAL FALLS. IN ADDITION TO PROVIDING DIRECT PATIENT CARE AND IN FURTHERANCE OF ITS CHARITABLE PURPOSE, RAINY LAKE MEDICAL CENTER (RLMC) PROVIDES A WIDE VARIETY OF BENEFITS TO THE COMMUNITY INCLUDING OFFERING VARIOUS COMMUNITY BASED SERVICE PROGRAMS, CASH CONTRIBUTIONS TO NON PROFIT AGENCIES, THE DONATION OF SPACE FOR USE BY COMMUNITY GROUPS, AND STAFF TIME FOR MENTORING/JOB SHADOWING. ADDITIONALLY, A NUMBER OF HEALTH RELATED EDUCATION PROGRAMS ARE PROVIDED FOR THE BENEFIT OF THE COMMUNITY, INCLUDING HEALTH ENHANCEMENTS AND WELLNESS, CLASSES ON SPECIFIC CONDITIONS, AND PROGRAMS DESIGNED TO IMPROVE THE GENERAL STANDARDS OF THE HEALTH OF THE COMMUNITY. RLMC ALSO ACTIVELY PROMOTES ITS COMMUNITY CARE PROGRAM, WHICH PROVIDES FREE OR REDUCED-COST HEALTHCARE TO PATIENTS WHO ARE UNABLE TO PAY FULLY FOR SERVICES RECEIVED. DURING 2011,THERE WERE 8,445 EMERGENCY/URGENT CARE VISITS, 88 BIRTHS, 542 ACUTE CARE ADMISSIONS, AND 2,010 TOTAL PATIENT DAYS. 21149976 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 40 0 216 1 1 1 0 0 0 0 0 0 0 0 0 X 14 8 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X VERA SCHUMANN 2182835410 1400 HIGHWAY 71 INTERNATIONAL FALLS MN 56649 ROBERT ANDERSON 4.00 X X 0 0 21 CHARLES HELLELOID MD 4.00 X X 0 0 32 NORMAN LARSEN 4.00 X X 0 0 11 MIKE MOTLEY 4.00 X X 0 0 32 JOSEPH BIANCO MD 4.00 X 0 0 32 GAIL ROGNERUD 4.00 X 0 0 21 GARY BIGLER 4.00 X 0 0 32 DON BILLIG 4.00 X 0 0 11 SUSAN CONGRAVE 4.00 X 0 0 32 BILL DOUGHERTY 4.00 X 0 0 32 JEFF HARDWIG MD 4.00 X 0 0 32 BRAD REINERS 4.00 X 0 0 32 ANTHONY STONE MD 4.00 X 0 0 32 JON TALSNESS MD 4.00 X 0 0 21 STEVE ERIXON 40.00 X 152923 0 48203 VERA SCHUMANN 40.00 X 116457 0 43477 KATIE CHEZICK 40.00 X 116239 0 9534 LORI CONSTANTINE 40.00 X 102163 0 8408 487782 0 109995 4 0 1 0 ESSENTIA HEALTHDULUTH CLINIC 400 EAST 3RD STREET DULUTH MN 55805 PROFESSIONAL & MANAGEMENT SERVICES FOR C 3940183 WAPITI MEDICAL GROUP 603 S DAKOTA ST MILBANK SD 57252 ER PHYSICIAN FEES 1203147 QUORUM HEALTH RESOURCES 105 CONTINENTAL PLACE BRENTWOOD TN 37027 MANAGEMENT SERVICES; CONTRACT CEO & CFO 661513 CMDI 1301 33RD STREET SOUTH ST CLOUD MN 56301 CT / ULTRASOUND SERVICES 635589 KRAUS ANDERSON 27040 COUNTY ROAD 9 BEMIDJI MN 56601 S/B CONSTRUCTION 449514 19 7206 8280 61087 76573 PATIENT SERVICE REVENU 621990 24425477 24411433 14044 24425477 198560 198560 3167 52647 -49480 -49480 -49480 CT SERVICES 900099 380870 380870 OTHER REVENUE 900099 125527 125527 WATER DAMAGE RECOVERIE 900099 104806 104806 611203 25262333 24411433 14044 760283 361437 361437 7735473 6350123 1376933 8417 219727 184063 35664 1156186 1017735 138451 600278 528396 71882 661513 661513 39182 39182 33123 33123 7560027 5969692 1590335 29890 29890 539050 352731 186319 294808 290990 3818 17350 6645 10705 800787 800787 83026 83026 CLINIC PATIENT SERVICES 3098850 3098850 PROVISION FOR DOUBTFUL 1415879 1415879 TAXES AND SURCHARGES 406922 406922 HOSPITAL LABORATORY SUP 325347 325347 418524 147225 271299 25797379 21149976 4638986 8417 11386567 11539547 4162625 2820275 367376 357501 156540 143574 14456999 7945216 7001947 6511783 611387 716877 23686442 22089557 3124084 2444558 782907 750939 3906991 3195497 X 19769700 18872281 9751 21779 19779451 18894060 23686442 22089557 X -535046 -350345 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 187370 187370 7407172 2866564 4540608 156684 116159 40525 6060291 4962493 1097798 645482 645482 6511783 DUE TO RELATED PARTY 750939 750939 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE CENTER HAS ELECTED TO ADOPT GUIDANCE IN THE INCOME TAX STANDARD REGARDING THE RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE CENTER FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES FOR EVALUATING UNCERTAIN TAX POSITIONS. THE ADOPTION OF THIS STANDARD HAS NO EFFECT OF THE CENTER'S CONSOLIDATED FINANCIAL STATEMENTS. THE CENTER'S INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. THE TAX RETURNS FOR THE YEARS 2009 TO 2011 ARE OPEN TO EXAMINATION BY FEDERAL, STATE AND LOCAL AUTHORITIES. 1 1 X 1 X 1 X 1 1 0 1 1 227234 227234 0.00880 4829185 3700435 1128750 0.04380 5056419 3700435 1355984 0.05260 6992 6992 0.00030 21427 21427 0.00080 2587165 1112497 1474668 0.05720 4223 4223 0.00020 2619807 1112497 1507310 0.05850 7676226 4812932 2863294 0.11110 2224 2224 0.00010 374 374 0.00000 2598 2598 0.00010 1 919966 45830 5731854 6211094 -479240 X 1 0 1 1 RAINY LAKE MEDICAL CENTER

1400 HIGHWAY 71 INTERNATIONAL FALLS MN 56649

X X X X PROVIDER-BASED CLINIC RAINY LAKE MEDICAL CENTER 1 1 1 100.000000000000 1 200.000000000000 1 X X X X X X 1 1 X X X X 1 0 1 X 0 0 PART I, LINE 6A: RLMC MAKES ITS COMMUNITY BENEFIT REPORT AVAILABLE TO THE PUBLIC BY INCLUDING IT IN THEIR FINANCIAL STATEMENTS AND THROUGH THE MINNESOTA HOSPITAL ASSOCIATION ANNUAL REPORT. PART I, LINE 7: COSTING METHODOLOGY USED WAS A COST-TO-CHARGE RATIO DERIVED FROM WORKSHEET 2 FOR LINES A, B, AND G. ACTUAL COSTS WERE USED TO DERIVE AMOUNTS ON LINES E, F, AND I. PART I, L7 COL(F): BAD DEBT EXPENSE OF $1,415,879 WAS SUBTRACTED WHEN CALCULATING THE COMMUNITY BENEFIT EXPENSE AS A PERCENT OF TOTAL EXPENSE. PART II: RLMC INVESTS RESOURCES TOWARDS EMERGENCY PREPAREDNESS, PARTICULARLY A "DECONTAMINATION TEAM" THAT CONDUCTS DRILLS THROUGHOUT THE YEAR. THE TEAM IS SKILLED IN SETTING UP A PORTABLE DECONTAMINATION TENT, DRESSING IN AN APPROPRIATE LEVEL OF PPE AND PRACTICING DECONTAMINATING PATIENTS. PART III, LINE 4: THE RATIO OF COSTS TO CHARGES CALCULATED ON WORKSHEET 2 WAS USED TO DETERMINE THE AMOUNTS ON LINES 2 AND 3. ACCOUNTS THAT WENT TO BAD DEBT WERE REVIEWED AND COMPARED TO THE COMMUNITY CARE LOG TO IDENTIFY THOSE THAT WERE NOT PROCESSED AS COMMUNITY CARE DUE TO NON-RETURN OF THE APPLICATION. TAKEN FROM FOOTNOTE 1 "AN ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS IS ESTIMATED ON AN AGGREGATE BASIS BY USING HISTORICAL WRITE-OFF DATA WHILE FACTORING IN CURRENT ECONOMIC AS WELL AS OTHER TRENDS AFFECTING THE CENTER'S ABILITY TO COLLECT OUTSTANDING AMOUNTS. UNCOLLECTIBLE AMOUNTS ARE WRITTEN OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS IN THE PERIOD THEY ARE DETERMINED TO BE UNCOLLECTIBLE. AT DECEMBER 31, 2011 AND 2010, THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS WAS APPROXIMATELY $853,000 AND $705,000, RESPECTIVELY.MANAGEMENT DETERMINES THE ALLOWANCE FOR DOUBTFUL ACCOUNTS BY IDENTIFYING TROUBLED ACCOUNTS AND BY USING HISTORICAL EXPERIENCE APPLIED TO AN AGING OF ACCOUNTS. PATIENT ACCOUNTS ARE WRITTEN OFF WHEN DEEMED UNCOLLECTIBLE. RECOVERIES OF RECEIVABLES PREVIOUSLY WRITTEN OFF ARE RECORDED WHEN RECEIVED. PART III, LINE 8: THE METHODOLOGY DESCRIBED IN THE INSTRUCTIONS TO SCHEDULE H, PART III, SECTION B, LINE 6 DOES NOT TAKE INTO ACCOUNT ALL COSTS INCURRED BY THE HOSPITAL AND DOES NOT REPRESENT THE TOTAL COMMUNITY BENEFIT CONFERRED IN THIS AREA. THE MEDICARE SHORTFALL REFLECTED ON SCHEDULE H, PART III, SECTION B WAS DETERMINED USING INFORMATION FROM THE ORGANIZATION'S MEDICARE COST REPORT. PART III, LINE 9B: RLMC'S POLICY STATES THAT A PATIENT'S ACCOUNT WILL NOT BE REFERRED TO COLLECTION UNLESS THE PATIENT HAS BEEN GIVEN REASONABLE OPPORTUNITY TO SUBMIT AN APPLICATION FOR THE COMMUNITY CARE PROGRAM IF THE FACTS AND CIRCUMSTANCES SUGGEST THE PATIENT MAY BE ELIGIBLE FOR COMMUNITY CARE. RAINY LAKE MEDICAL CENTER PART V, SECTION B, LINE 13G: ON BILLING STATEMENTS IT IS STATED TO CONTACT PATIENT FINANCIAL COUNCELOR FOR COMMUNITY CARE OR OTHER FINANCIAL ASSISTANCE. INCLUDES CONTACT PHONE NUMBER. RAINY LAKE MEDICAL CENTER PART V, SECTION B, LINE 17E: RLMC WORKS WITH PATIENTS TO SET UP PAYMENT PLANS AND/OR IDENTIFY OTHER FINANCIAL ASSISTANCE SUCH AS MEDICAID. RLMC IS A MNCAA FACILITY THAT EMPLOYS 3 CERTIFIED STAFF MEMBERS. RAINY LAKE MEDICAL CENTER PART V, SECTION B, LINE 19D: THE RATE OF RAINY LAKE MEDICAL CENTER'S MOST FAVORED NON-GOVERNMENTAL CONTRACTED PAYOR (BLUE CROSS 22% DISCOUNT). PART VI, LINE 2: A GOAL OF THE FIVE YEAR STRATEGIC PLAN IS TO "COMMIT TIME AND RESOURCES TO RESPONDING TO COMMUNITY NEEDS WHERE THEY FEEL THERE ARE GAPS IN SERVICE". THIS IS DONE WITH TACTICS INCLUDING CONDUCTING A MARKET ASSESSMENT OF SERVICE GAPS EVERY THREE YEARS, AS WELL AS ASSESSING THE NEED FOR A DIALYSIS UNIT, ALZHEIMER'S UNIT, AND VARIOUS OUTREACH SPECIALTIES. PART VI, LINE 3: RLMC COMMUNICATES TO PATIENTS OUR COMMUNITY CARE PROGRAM (CHARITY CARE) IS THE FOLLOWING PROCESS:1. PATIENTS ARE GIVEN A COMMUNITY CARE BROCHURE AT TIME OF SERVICE.2. STATEMENTS AND LETTERS SENT TO PATIENTS OFFER COMMUNITY CARE.3. PHONE CALLS MADE TO PATIENTS DISCUSS AND OFFER COMMUNITY CARE.4. ALL EMPLOYEES ARE EDUCATED ANNUALLY ABOUT OUR COMMUNITY CARE PROGRAM.5. UPON REQUEST, COMMUNITY CARE PACKETS WITH APPLICATIONS AND POLICIES ARE SENT OR GIVEN TO PATIENTS.6. THE RLMC WEBSITE DISPLAYS PAYMENT OPTIONS WHERE OUR COMMUNITY CARE PROGRAM IS DISCUSSED.7. ONE OF THE REQUIREMENTS FOR RLMC COMMUNITY CARE IS A DENIAL FROM THE COUNTY IN REGARDS TO FINANCIAL ASSISTANCE UNLESS THEY ARE ENROLLED IN THE MN SENIOR PROGRAM. PART VI, LINE 4: RLMC PRIMARILY SERVES THE POPULATION OF KOOCHINCHING COUNTY, MINNESOTA. THE COUNTY IS LARGE AND SPARSELY POPULATED WITH INTERNATIONAL FALLS AS THE MAIN POPULATION CENTER. OTHER NEARBY SMALLER COMMUNITIES INCLUDE LITTLEFORK, BIG FALLS, RANIER, BIRCHDALE AND LOMAN. COLLECTIVELY THESE COMMUNITIES MAKE UP THE PRIMARY SERVICE AREA (PSA). THE PSA HAS AN ESTIMATED POPULATION OF AROUND 12,000 AND IS PROJECTED TO CONTINUALLY DECLINE. THE AVERAGE DISPOSABLE HOUSEHOLD INCOME IS AROUND $49,000 WHICH IS 6% LOWER THAN THE U.S. AVERAGE. APPROXIMATELY 19% OF THE POPULATION IS OVER THE AGE OF 65. PART VI, LINE 5: REPRESENTATION ON THE BOARD IS PREDOMINANTLY LOCAL AS THE BYLAWS STATE THAT NO MORE THAN 4 TRUSTEES MAY RESIDE OUTSIDE OF THE SERVICE AREA. RLMC HAS IN PLACE AN OPEN MEDICAL STAFF MODEL. X X 0 0 0 0 0 0 0 0 0 STEVE ERIXON 147384 0 0 0 5539 0 0 0 48203 0 201126 0 0 0 VERA SCHUMANN 109430 0 0 0 7027 0 0 0 43477 0 159934 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS CHARLES HELLELOID, MIKE MOTLEY, JOSEPH BIANCO, JEFF HARDWIG, BRAD REINERS, AND ANTHONY STONE ARE EMPLOYEES OF SMDC. FORM 990, PART VI, SECTION A, LINE 3 THE HOSPITAL'S CEO AND CFO ARE EMPLOYEES OF QUORUM HEALTH RESOURCES. THE HOSPITAL HAS AN AGREEMENT WITH QUORUM AND PAYS THEM MANAGEMENT FEES. FORM 990, PART VI, SECTION A, LINE 7A SAINT MARY'S DULUTH CLINIC (SMDC) APPOINTS ONE HALF OF THE TRUSTEES OF RLMC. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CONTROLLER, CEO, AND FINANCE COMMITTEE. IN ADDITION, A COPY OF THE RETURN IS PROVIDED TO THE BOARD OF DIRECTORS FOR REVIEW BEFORE IT IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S OFFICERS, TRUSTEES, AND KEY EMPLOYEES ARE REMINDED OF THE CONFLICT OF INTEREST POLICY AND ARE REQUIRED TO SIGN A CONFLICT OF INTEREST POLICY ON AN ANNUAL BASIS. WHEN A CONFLICT OF INTEREST EXISTS, THE INTERESTED TRUSTEE MAY BE PRESENT FOR DISCUSSION TO ANSWER QUESTIONS, BUT MAY NOT ADVOCATE FOR THE ACTION TO BE TAKEN AND MAY BE ASKED TO LEAVE THE ROOM WHILE A VOTE IS TAKEN. THE MINUTES OF ALL ACTIONS TAKEN ON SUCH MATTERS WILL CLEARLY REFLECT THAT THESE REQUIREMENTS HAVE BEEN MET. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, FINANCIAL STATEMENTS, AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN RECOGNIZED PENSION COSTS -350,345. TOTAL TO FORM 990, PART XI, LINE 5: -350,345. FALLS MEMORIAL HOSPITAL FOUNDATION INC 1400 HIGHWAY 71 INTERNATIONAL FALLS MN 56649 204585807 SUPPORT MN 501(C)(3) LINE 11A, I N/A 1 0 0 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 RAINY LAKE MEDICAL CENTER FOUNDATION C 7206 ACTUAL EXPENDITURE