2011-08-15T14:30:30-05:00 2010-12-31 Eide Bailly LLP 5601 Green Valley Drive Ste 700 Minneapolis MN 554371145 990 2010-01-01 363311936 Stevens Community Medical Center STEV 3205891313 PO Box 660 Morris MN 56267 John Rau 3205891313 2011-08-15 1 Kim Hunwardsen CPA 9529446166 2011-08-15 2010 2016-02-24 21:20:13Z John Rau PO Box 660 Morris MN 56267 37638895 0 X www.scmcinc.org X 1984 MN promotion of health 13 9 369 128 276 0 99761 113032 36708367 37064417 362051 361836 45264 54376 37215443 37593661 18680 26656 0 0 19908541 20208768 23311 0 0 14254957 15109142 34205489 35344566 3009954 2249095 46236448 48218647 17883279 17644664 28353169 30573983 X Stevens Community Medical Center's mission is to strive for excellence in the delivery of inpatient and outpatient care through cooperation with qualified health care providers; through the provision of appropriate facilities and technology; and through active promotion of health education among the public.Our pledge to the recipients of this medical center's health care is to address their needs in as expert, efficient, compassionate, and convenient manner as possible. 0 0 29484127 26656 37064141 Stevens Community Medical Center is a not-for-profit integrated health care system. The Mission of the Medical Center is to make available high quality health care. The Medical Center serves the population of West Central Minnesota and is becoming a regional health care center."CARING IS OUR REASON FOR BEING"SCMC provides quality medical healthcare regardless of race, creed, sex, national origin, handicap, age or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of SCMC, it is recognized that not all individuals possess the ability to purchase essential medical services. To further that, our mission is to serve the community with respect to providing health care services and health care education. For example, the medical center is committed to providing medical services to all members of its community, provide free care and/or subsidized care, promote health activities and programs to support the community, and provide care to persons covered by governmental programs at below cost. Therefore, financial assistance will be considered where the need and/or an individual's inability to pay coexists. SCMC had 32,665 hospital outpatient visits, 31,143 clinic and urgent care visits, 4,689 inpatient days, 7,333 outpatient counseling visits, 101 deliveries, 660 surgeries, 2,718 emergency room visits, and 19,969 therapy treatments in 2010. SCMC also owns and operates the Courage Cottage, an adult foster care facility specializing in care for the terminally ill. 23 residents were served in 2010, and the cost to provide their care was subsidized by community donations.Recognizing its mission to the community, SCMC provides services to Medicare, Medicaid, and other patients covered by governmental programs, sometimes at a reimbursement below cost. The total discounts accepted for providing care to patients was $21,001,702 in 2010. The charges foregone for services supplied under SCMC's charity care policy (free and/or subsidized care) was $802,178 in 2010.Charity care is also provided through many reduced price services and free SCMC programs and information offered throughout the year based on activities and services which SCMC believes will serve a bona fide community need. These include: various brochures to educate patients; staff speaking for a variety of community events including SCMC sponsored "health nights," elderly and adult education; sponsoring a smoking cessation program and a variety of other "wellness" type programs at subsidized cost; providing meeting facilities for various community groups; offering support groups; and providing assistance to educators through our work with student nurses. 29484127 1 1 0 0 0 0 0 1 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 128 0 1 369 1 0 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 1 0 0 MN X Kerrie McEvilly 3205897627 400 E 1st St Morris MN 56267 Alan Tonn 1.00 X X 35 0 0 David Paul 1.00 X X 305 0 0 Paul Groneberg 1.00 X X 270 0 0 Jan Hagen 1.00 X X 270 0 0 Ward Voorhees 1.00 X X 300 0 0 Pieranna Garavaso 1.00 X 175 0 0 Jodi DeCamp 1.00 X 200 0 0 Bart Finzel 1.00 X 175 0 0 Paul Martin 1.00 X 200 0 0 Mark Frederickson 1.00 X 100 0 0 Dr Olyn Wernsing 40.00 X 264377 0 34863 Kim Tatsumi MD 40.00 X 256169 0 35851 Dr Joan Goering 40.00 X 213011 0 30812 John Rau 40.00 X X 272744 0 41192 Kerrie McEvilly 40.00 X 130326 0 26949 Andrea Giambi DO 40.00 X 643316 0 19497 Michael Holte MD 40.00 X 652589 0 32326 Randell Lussenden 40.00 X 407471 0 29968 Robert Bosl MD 40.00 X 413594 0 41192 James Green MD 40.00 X 645426 0 9545 3901053 0 302195 22 0 1 0 North Star Physicians Services 709 West 12th Avenue Webster SD 57105 ER and urgent care MD services 1007400 Siemens Medical Solutions USA 51 Valley Stream Parkway Malvern PA 19355 IS support/implementation 856116 NovaCare Rehabilitation 4714 Gettysburg Rd Mechanicsburg PA 17055 Therapy services 528951 Beth Jackson 151 20th Street S Benson MN 56215 CRNA services 205061 Gwen Ann Stein 30525 Mikes Lane Dalton MN 54324 Psychiatry services 199550 12 113032 113032 Net patient service re 621110 36963674 36963674 Other revenue 900099 100743 100467 276 37064417 355899 355899 53042 53042 53042 53042 38070 32133 5937 5937 5937 14435 13101 1334 1334 37593661 37064141 276 416212 26656 26656 1322687 844385 478302 15581709 12864303 2717406 780857 648752 132105 1521038 1262776 258262 1002477 815301 187176 2299 2299 60750 60750 4296754 3860281 436473 119902 42594 77308 4846217 4133984 712233 386132 386132 433100 36069 397031 138325 129669 8656 40433 34127 6306 578557 578557 2233085 2233085 412231 412231 Bad Debts Expense 995432 995432 MN Care Tax 563419 563419 Miscellaneous 1718 1718 Auxiliary Expenses 788 788 35344566 29484127 5860439 0 234189 123070 5753830 8582746 6411713 7135454 1143200 1121681 322686 345037 32640185 14609183 18442499 18031002 12932471 12383680 995860 495977 46236448 48218647 4522987 4831347 11661077 11247317 1400000 1400000 299215 166000 17883279 17644664 X 28278580 30481358 74589 92625 28353169 30573983 46236448 48218647 X 2249095 -28281 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 27735 14435 13889 28281 0 195776 195776 19063734 6955023 12108711 13057055 7477657 5579398 323620 176503 147117 18031002 Estimated Third-Party Payor Settlements 166000 166000 37593661 35344566 2249095 -27735 -546 -28281 2220814 37489665 0 37489665 103996 103996 37593661 35343778 0 35343778 788 788 35344566 Part IV, Line 1b: The organization holds the assets for the Stevens Community Medical Center Ladies' Auxiliary/Gift Shop. Description of Uncertain Tax Positions Under FIN 48: Part X: The Medical Center undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities, as defined by Financial Accounting Standards Board (FASB) Accounting Standards Codification Topic ASC 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes). As of December 31, 2010, no amounts were recorded as a result of this analysis. If the Medical Center is subject to interest or penalties on underpaid income taxes, they will be recorded as income tax expense. Under normal circumstances, the Medical Center is no longer subject to Federal and state tax examinations by tax authorities for years before 2008. Part XI, Line 8 - Other Adjustments: Net change in auxiliary assets -546. Part XII, Line 4b - Other Adjustments: Contributions recorded in fund balance for financial statements 102,662. Net income from auxiliary not included in financial statements 1,334. Part XIII, Line 4b - Other Adjustments: Expenses from auxiliary not included in financial statements 788. 1 1 X 1 X 1 X 101.000000000000 1 1 0 1 1 458398 458398 0.01330 3166585 2114351 1052234 0.03060 3414020 2728748 685272 0.02000 7039003 4843099 2195904 0.06390 141306 141306 0.00410 15538 15538 0.00050 8643 8643 0.00030 165487 165487 0.00490 7204490 4843099 2361391 0.06880 26656 26656 0.00080 66900 66900 0.00190 93556 93556 0.00270 0 568831 113766 9782848 9685988 96860 X 1 0 1 1 Stevens Community Medical Center

400 East 1st Street Morris MN 56267

X X X X Stevens Community Medical Center 1 4 Stevens Community Medical Center

400 East 1st Street Morris MN 56267

Family practice clinic/specialty clinic Starbuck Clinic

501 Poler Street Starbuck MN 56381

Family practice clinic Stevens Community Medical Center Allergy

7900 Chapin Drive NE New London MN 56273

Specialty clinic Courage Cottage

409 East 1st Street Morris MN 56267

Adult foster care facility Part I, Line 3c: The organization provides a 20% to 80% discount when income levels meet 190% down to 101% of the Federal Poverty Guidelines (FPG). For example, an 80% discount is given for income ranges from 101% to 120% of the FPG. Part I, Line 7: Charity care, Medicaid and Other Mean's Tested was converted to cost using the cost-charge-ratio derived from Worksheet 2. Community health improvement services, Health Professions education, and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger. Part I, Line 7g: N/A Part I, L7 Col(f): The amount of bad debt expense removed from the denominator of the calculation was $995,432. Part II: In 2010 SCMC supported several significant health related community initiatives such as the Regional Fitness Center, Habitat For Humanity, the Chokio Pool Fund, and the local chapter of The American Cancer Society to name just a few. We also paid over $66,000 in local real estate taxes for our three medical clinics, which would certainly have a positive impact on the health of the communities we serve. Part III, Line 4: Bad debt was converted to cost using the cost-charge-ratio derived from Worksheet 2.The estimated amount of bad debt expense attributable to patients eligible under the organization's charity care policy is 20% because that is the amount of applications that were denied due to lack of information or no response to Charity Care application process. The full amount of this is not reflected in Part I, line 7 and is considered community benefit. Had the appropriate information been provided and applications completed, this amount would have been considered charity care.Bad debt expense is reported net of discounts and contractual allowances. A payment on an account previously written off reduces bad debt expense in the current year.Financial Statement Note:The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write-off and recovery information in determining the estimated bad debt provision. Part III, Line 8: Medicare allowable cost is based on the Medicare Cost Report. The Medicare Cost report is completed based on the rules & regulations set forth by CMS. Part III, Line 9b: However, we follow the "MN Attorney General Agreement" guidelines regarding debt collection. Part VI, Line 2: Many of our department heads are members of other boards or organizations throughout the community. These include the Chamber of Commerce, the Morris Area Community Development Committee, and Morris Area Child Care Center in addition to others. The information obtained from participating in these committees is utilized to continually assess the appropriateness of existing services and the need for potential new areas of health related opportunities. Conference committee meetings are also used to get input from all employees, who are also consumers of our services, regarding areas of potential growth. Part VI, Line 3: Stevens Community Medical Center provides a copy of our charity guidelines and financial assistance contact information to interested patients as part of our intake/screening process; self-pay patients (particularly inpatients) are asked if they have financial concerns and are referred to a financial counselor thereafter if need is discovered. A variety of tools are used to determine potential need through the registration, prior authorization, and billing processes - social worker's referral, identification of uninsured or underinsured status, and/or a previous history of inability to pay. We also post Financial Assistant contact information for persons interested in applying for Charity Care and/or Medicaid in patient common areas like registration, waiting areas, physician rooms and by the Business Office window.In addition, if payments are not being made after 2-3 statements have been sent, a Financial Counselor will call to inform the patient of their options. At that time, we would send out an application for Charity Care, discuss with the patient the availability of various government benefits, such as Medicaid or state programs, and assist the patient with qualification for such programs, where applicable. Part VI, Line 4: Stevens Community Medical Center serves the County of Stevens including the towns of Morris, Donnelly, Hancock, Chokio and Alberta. We also serve areas of Pope, Swift, Traverse, Grant, Big Stone and, with our Dermatology, Allergy, and Therapy Clinic in New London, Kandiyohi County. We anticipate the total primary service area to be approximately 15,000, with a secondary market of an additional 20,000.The service area is primarily rural, with a strong agricultural base. We are also fortunate to have a university presence with the University of Minnesota, Morris. Approximately 60% of our inpatients are Medicare and/or Medicare HMO and another 8% are Medicaid and/or MN Care.There are three hospitals in the area that are larger than SCMC located in towns 50 miles from Morris in different directions. There are also hospitals in Benson, Wheaton, Graceville, Glenwood, Elbow Lake and Appleton, all of which are within a 30 miles radius of Morris.We are considered a federally designated medically underserved area for mental health services. Part VI, Line 6: The community health service activities are designed to complement the identified health needs in our area. Some of the specific reported services, such as Men's and Women's Health Nights, have educated the public on preventative health initiatives and have also identified previously undetected health risk factors for participants.This is also true of the Diabetes presentations to local service groups and our annual Diabetes Health Awareness Night. Much of the emphasis associated with these events is toward prevention and early detection.We are also acutely aware of the fact that a large percentage of the population we serve are senior citizens and value the benefit of the free transit services we provide for clinic appointments.As described earlier, Stevens Community Medical Center has a community Board of Directors. Medical staff privileges are extended to all qualified physicians in the community. All surplus funds are reinvested in the organization, including effectively funding the depreciation of our building and equipment. We also own and operate an adult foster care facility which specializes in the terminally ill. This is currently subsidized by community donations. All our employed physicians attend several educational opportunities, as do the balance of our licensed and professional staff.Every dollar generated in excess of expenses at SCMC is reinvested in the organization to improve the services offered to the communities we serve. Reports Filed With States Part VI, Line 7 MN 1 X Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The organization makes donations to other organizations exempt under 501(c)(3) to ensure the funds will be used for charitable purposes. X X X X 0 0 0 1 0 0 0 0 0 Dr Olyn Wernsing 162476 0 83857 0 18044 0 18988 0 18996 0 302361 0 0 0 Kim Tatsumi MD 160334 0 78822 0 17013 0 18988 0 19972 0 295129 0 0 0 Dr Joan Goering 212616 0 102 0 293 0 15686 0 18198 0 246895 0 0 0 John Rau 213579 0 33525 0 25640 0 18988 0 25365 0 317097 0 0 0 Kerrie McEvilly 113102 0 17102 0 122 0 10167 0 18682 0 159175 0 0 0 Andrea Giambi DO 146564 0 494430 0 2322 0 17763 0 5262 0 666341 0 0 0 Michael Holte MD 593876 0 38651 0 20062 0 14700 0 21154 0 688443 0 0 0 Randell Lussenden 127256 0 277205 0 3010 0 18988 0 14400 0 440859 0 0 0 Robert Bosl MD 160071 0 250442 0 3081 0 18988 0 25636 0 458218 0 0 0 James Green MD 573364 0 44102 0 27960 0 2961 0 10112 0 658499 0 0 0 Part I, Line 5 The physicians are eligible to receive quarterly incentive compensation based on their personal gross revenue production for non-ancillary services, according to the terms of their contracts. The CRNA also receives quarterly bonuses contingent on the services he provides to patients of SCMC. City of Morris Stevens County Minnesota 416005393 2006-08-29 7000000 finance an approx 23,000 sq ft addition, refinance Note Series 1998 0 0 0 City of Hancock Stevens County Minnesota 416005213 2006-08-29 5577750 finance an approx 23,000 sq ft addition, refinance Note Series 1998 0 0 0 7000000 1327349 107268 5565383 2007 1 0 1 1 5577750 1057660 85473 4434617 2007 1 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 0 0 0 1 0 1 0 0 0 1 Form 990, Part VI, Section A, line 8b The organization does not have any committees with authority to act on behalf of the governing board. Form 990, Part VI, Section B, line 11 Prior to filing, the 990 is reviewed in detail by the Finance Director and President/CEO. The Board of Directors is given the opportunity to review a copy prior to filing. A copy of the Form 990 is attached to the state filing. The state filing requires a Board Resolution approving the filing. During that time the board is briefed on information contained within the Form 990. Form 990, Part VI, Section B, line 12c The organization has two conflict of interest policies - one that covers officers and directors and one that covers other management staff (including other key employees, if applicable). Potential conflicts identified by officers and directors are reviewed by the remaining board members; those identified by management are reviewed by the President/CEO. Officers and directors are to abstain from voting on any such matter where they have a potential conflict of interest. The President/CEO evaluates each potential conflict identified by management on an individual basis in order to determine the appropriate restrictions to put in place. Form 990, Part VI, Section B, line 15a SCMC participates in the MN Hospital Association compensation survey as well as refers to a compensation review that includes 49 hospitals in MN. In addition, SCMC has hired a compensation consultant to review the CEO salary on occasion. The board entered into a 5-year compensation contract with the CEO at the beginning of 2010, which fixed his salary for that length of time, based on market analysis. The President/CEO reviews salary ranges for officers and key employees of the organization on an annual basis. SCMC receives an annual assessment from Merritt-Hawkins (a recruiting firm) regarding compensation ranges for primary care and specialty physicians. This information is specific to different geographic regions, as well as for groups versus private practices. The President/CEO also reviews the AMGA (American Medical Group Association) compensation survey for physician compensation and the MHA (Minnesota Hospital Associaton) compensation survey for the Director of Finance compensation annually. Form 990, Part VI, Section C, line 19 The audited financial statements, governing documents and conflict of interest policy are made available to the general public upon request. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Prior period adjustments: -27,735. Net change in auxiliary assets -546. Total to Form 990, Part XI, Line 5: -28,281. Form 990 Schedule D, Part XI, line 7 The 2009 Form 990, Part X Balance Sheet included the net assets of the organization's gift shop that operates under the EIN of Steven's Community Medical Center. For 2010, the revenue and expenses related to the gift shop are included on Form 990, Part VIII and Part IX and the disclosure related to the net assets is recorded on Schedule D Part IV Line 1.