Form990
Click to see attachment
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Department of the TreasuryInternal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
MediumBullet Do not enter social security numbers on this form as it may be made public.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
A For the 2021 calendar year, or tax year beginning 07-01-2021 , and ending 06-30-2022
BCheck if applicable:
CName of organization
Avera McKennan
 
 
Doing business as
 
 
Number and street (or P.O. box if mail is not delivered to street address)
1325 South Cliff Ave
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Sioux Falls, SD571175045
D Employer identification number

46-0224743
E Telephone number

G Gross receipts $ 1,499,957,286
F Name and address of principal officer:
David Flicek
1325 South Cliff Ave
Sioux Falls,SD571175045
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
avera.org/locations/mckennan/
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. See instructions.
H(c)
Group exemption number MediumBullet0928
K Form of organization:  
L Year of formation: 1911
M State of legal domicile: SD
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: Promotion of Health
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 21
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 14
5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) ...... 5 8,980
6 Total number of volunteers (estimate if necessary) ............. 6 1,995
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 12,536,718
b Net unrelated business taxable income from Form 990-T, Part I, line 11 ......... 7b 4,145,284
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 61,167,062 41,698,551
9 Program service revenue (Part VIII, line 2g) ......... 1,220,053,336 1,279,316,288
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 11,832,394 5,835,460
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 78,006,490 85,878,800
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 1,371,059,282 1,412,729,099
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 1,968,871 724,460
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 642,862,668 700,913,378
16a Professional fundraising fees (Part IX, column (A), line 11e) ..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet243,629    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 634,014,859 703,571,164
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 1,278,846,398 1,405,209,002
19 Revenue less expenses. Subtract line 18 from line 12....... 92,212,884 7,520,097
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 1,439,516,677 1,383,813,699
21 Total liabilities (Part X, line 26)............. 645,566,822 620,515,284
22 Net assets or fund balances. Subtract line 21 from line 20..... 793,949,855 763,298,415
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title
Paid Preparer Use Only
Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2021)
Form 990 (2021)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: 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 and guided by Christian values.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? .....................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ...........................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 1,260,755,871 including grants of $ 724,460 ) (Revenue $ 1,353,905,939 )
Avera McKennan's mission is to provide healthcare services to Sioux Falls, South Dakota residents and residents of the surrounding area. Avera McKennan is a 501(c)(3) organization affiliated with Avera Health. Avera McKennan consists of a 572-bed hospital, a 53-bed heart hospital and a 114-bed nursing home in Sioux Falls, SD. Major service lines include oncology, surgery, obstetrics, pediatrics, neonatology, emergency and trauma, critical care including EICU, radiology and diagnostic imaging, psychiatry, pulmonary, orthopedics, neurology, cardiology and gastroenterology. Transplant services include solid organ (kidney, liver, and pancreas) and bone marrow transplant.Program service statement continued on Schedule O.Avera McKennan owns or leases rural critical hospitals and a nursing home in South Dakota including a 25-bed critical access hospital and a 42-bed nursing home in Gregory, SD, a 25-bed critical access hospital in Milbank, SD, a 23-bed critical access hospital in Dell Rapids, SD, an 18-bed critical access hospital in Flandreau, SD, an 11-bed critical access hospital in Miller (Hand County), SD and an 11-bed critical access hospital in Rock Rapids, IA. Services offered by the rural critical access hospitals include radiology and imaging, colonoscopy and endoscopy, therapy and rehabilitation, 24-hour emergency care, chemotherapy, orthopedics, cardiovascular testing, surgery, dialysis and obstetrics.In addition, Avera McKennan provides clinical care, secondary and primary, through physician clinics in South Dakota, Northwest Iowa, Southwest Minnesota and Northeastern Nebraska. The physician clinics provide primary care and urgent care, and specialties such as cardiology, dermatology, endocrinology, gastroenterology, hematology, hepatology, infectious disease, internal medicine, neonatology, nephrology, neurology, ob/gyn, oncology, ophthalmology, pediatrics, orthopedics, pain management, psychiatry, pulmonology, general surgery, and vascular services. Following is a breakdown of these statistics by facility:Avera McKennan Hospital25,087 Acute patient discharges1,918 Newborn patient discharges427,544 Outpatient visits3,697 Newborn patient days1,097,966 Clinic visitsAvera Heart Hospital2,433 Acute patient discharges10,388 Outpatient visits64,512 Clinic visitsAvera Prince of Peace34,777 Long-term care resident days346 Long Term Care patient dischargesAvera Gregory Hospital (CAH)297 Acute patient discharges91 Swing bed patient discharges11,051 Outpatient visits784 Swing-bed patient days15,731 Clinic visitsAvera Rosebud Country Care Center10,067 Long-term care resident days27 Long Term Care patient dischargesAvera Milbank Hospital (CAH)285 Acute patient discharges41 Newborn patient discharges87 Swing bed patient discharges20,588 Outpatient visits59 Newborn patient days665 Swing-bed patient days28,762 Clinic visitsAvera Dell Rapids Hospital (CAH)119 Acute patient discharges50 Swing bed patient discharges9,999 Outpatient visits518 Swing-bed patient days14,098 Clinic visitsAvera Flandreau Hospital (CAH)173 Acute patient discharges16 Swing Bed patient discharges11,311 Outpatient visits166 Swing-bed patient days9,157 Clinic visitsAvera Hand County Hospital (CAH)194 Acute patient discharges48 Swing Bed patient discharges11,282 Outpatient visits343 Swing-bed patient days9,084 Clinic visitsAvera Merrill Pioneer Hospital (CAH) 113 Acute patient discharges28 Swing Bed patient discharges8,806 Outpatient visits280 Swing-bed patient days6,227 Clinic visitsAvera McKennan maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $78,274,659.Avera McKennan also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera McKennan upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network of persons and institutions. Avera McKennan 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.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet1,260,755,871
Form 990 (2021)
Form 990 (2021)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? See instructions. Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part IClick to see attachment.............
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part IIClick to see attachment.........
4
Yes
 
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Rev. Proc. 98-19? If "Yes," complete Schedule C, Part IIIClick to see attachment..
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part IClick to see attachment.........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part IIClick to see attachment....
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part IIIClick to see attachment..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IVClick to see attachment..............
9
Yes
 
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part V......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X, as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIClick to see attachment.......
11b
Yes
 
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIIIClick to see attachment.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XIIClick to see attachment......................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States? .....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I. See instructions. ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....Click to see attachment
20a
Yes
 
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? Click to see attachment
20b
Yes
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....Click to see attachment
21
 
No
Form 990 (2021)
Form 990 (2021)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........Click to see attachment
22
Yes
 
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............
24c
 
 
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I .... Click to see attachment
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................Click to see attachment
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part IIClick to see attachment...........
26
 
No
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part IIIClick to see attachment.........................
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see the Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................Click to see attachment
28a
 
No
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....Click to see attachment
28b
Yes
 
c
A 35% controlled entity of one or more individuals and/or organizations described in line 28a or 28b? If "Yes," complete Schedule L, Part IV.....................
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...Click to see attachment
35b
Yes
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2............. Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations on Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in box 3 of Form 1096. Enter -0- if not applicable ..
1a
556
b
Enter the number of Forms W-2G included on line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
Form 990 (2021)
Form 990 (2021)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
8,980
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. See instructions.
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
Yes
 
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
Yes
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided? .....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources. (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see the instructions and file Form 4720, Schedule N.
15
 
No
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
No
17
Section 501(c)(21) organizations. Did the trust, any disqualified person, or mine operator engage in any activities that would result in the imposition of an excise tax under section 4951, 4952, or 4953? ..
If "Yes," complete Form 6069.
17
 
 
Form 990 (2021)
Form 990 (2021)
Page 6
Part VI
Governance, Management, and Disclosure. For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
1a
21
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
14
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
Yes
 
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .......................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
 
No
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe on Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe on Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
Yes
 
If "Yes" to line 15a or 15b, describe the process on Schedule O. See instructions.
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
Yes
 
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
No
Section C. Disclosure
17
List the states with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (1024 or 1024-A, if applicable), 990, and 990-T (section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletJamie Schaefer3900 W Avera Dr Ste 300   Sioux Falls,SD57108 (605) 322-3992
Form 990 (2021)
Form 990 (2021)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See the instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (box 5 of Form W-2, Form 1099-MISC, and/or box 1 of Form 1099-NEC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

See the instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) David Flicek......................................................................
President
 42.00
.................
0.00 		X   X       0 1,291,126 45,202
(2) Cristina Hill Jensen MD......................................................................
Board Trustee/Gastroenterology
 42.00
.................
0.00 		X           850,539 0 46,914
(3) Alisa Reindl MD......................................................................
Board Trustee/Family Medicine
 42.00
.................
0.00 		X           239,738 0 23,051
(4) Rick Kooima MD......................................................................
Board Trustee/Chief of Staff
 42.00
.................
0.00 		X           297,775 0 47,414
(5) Mary Dally......................................................................
Chair
 2.00
.................
0.00 		X   X       0 0 0
(6) Tom Biegler......................................................................
Vice Chair
 2.00
.................
0.00 		X   X       0 0 0
(7) Jennifer Bunkers-Board Trustee......................................................................
Philanthropy Council Chair
 2.00
.................
0.00 		X   X       0 0 0
(8) Sister Carmella Luke......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(9) Sister Joan Reichelt......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(10) Sister Mary Carole Curran......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(11) Sister Lucille Welbig......................................................................
Board Trustee
 2.00
.................
5.00 		X           0 0 0
(12) Jawad Nazir MD-Board Trustee......................................................................
Infectious Disease & Internal Med
 42.00
.................
0.00 		X           660,586 0 48,164
(13) Hugh Venrick......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(14) Van Fishback......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(15) J Pat Costello......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(16) Laurie Knutson......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
(17) Alejandro Ramirez......................................................................
Board Trustee
 2.00
.................
0.00 		X           0 0 0
Form 990 (2021)
Form 990 (2021)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) Harriet Yocum........................................................................
Board Trustee
 2.00
.......................0.00 		X           0 0 0
(19) Jennifer Kirby........................................................................
Board Trustee
 2.00
.......................0.00 		X           0 0 0
(20) Randy Knecht........................................................................
Board Trustee
 2.00
.......................0.00 		X           0 0 0
(21) Jared Friedman MD........................................................................
Board Trustee/Chief of Staff
 2.00
.......................40.00 		X           0 515,368 54,730
(22) Julie Lautt........................................................................
CFO Avera Health; Sec/Treas
 0.10
.......................46.30 		    X       0 1,051,228 16,194
(23) Michael Elliott - Sr Vice........................................................................
President Medical Affairs/CMO
 40.00
.......................0.00 		      X     539,629 0 45,755
(24) Lori Popkes........................................................................
Sr Vice President
 40.00
.......................0.00 		      X     389,245 0 44,546
(25) Curtis Hohman........................................................................
Sr Vice President
 40.00
.......................0.00 		      X     401,004 0 25,570
(26) Sandra King........................................................................
Director Operative Services
 40.00
.......................0.00 		      X     198,581 0 20,578
(27) Todd Zimprich MD........................................................................
Neurology
 40.00
.......................0.00 		        X   1,835,525 0 47,414
(28) Brian Knutson MD........................................................................
Dermatology
 40.00
.......................0.00 		        X   1,301,746 0 45,414
(29) Alex Linn MD........................................................................
Neurology
 40.00
.......................0.00 		        X   1,443,254 0 45,415
(30) Travis Liddell MD........................................................................
Surgery/Orthopedics
 40.00
.......................0.00 		        X   1,357,556 0 51,691
(31) Richard Conklin MD........................................................................
Hematology/Oncology
 40.00
.......................0.00 		        X   1,441,491 0 55,440
(32) Steve Petersen - Former Key........................................................................
Employee VP-Pharmacy
 0.00
.......................40.00 		          X 0 287,391 29,444
1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 10,956,669 3,145,113 692,936
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet1,131
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
Yes
 
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
Avera Health

3900 West Avera Drive
Sioux Falls,SD57108 		Shared & eCare services 136,937,437
Journey Group Companies

4500 W 58th St
Sioux Falls,SD57108 		Construction services 30,032,348
AMN Healthcare Inc

12400 High Bluff Dr
San Diego,CA92130 		Contract labor 11,386,465
Surgical Institute of South Dakota PC

911 E 20th St 700
Sioux Falls,SD57105 		Medical Dir & Prof Fees 5,354,138
Sanford School of Medicine

1400 W 22nd St
Sioux Falls,SD57105 		Physician services 4,312,164
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet70
Form 990 (2021)
Form 990 (2021)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, Grants, and OtherAmt Similar Amounts 1a Federated campaigns..1a 43,324
b Membership dues..1b  
c Fundraising events..1c  
d Related organizations1d 1,689,457
e Government grants (contributions)1e 27,351,472
f All other contributions, gifts, grants, and similar amounts not included above1f 12,614,298
g Noncash contributions included in lines 1a - 1f:$ 1g  
h Total. Add lines 1a-1f.......MediumBullet 41,698,551
Program Service RevenueAmt Business Code
2a Patient service revenue 622110 1,154,581,212 1,154,581,212    
b Patient and clinic 621500 93,677,384 89,999,535 3,677,849  
c Inc from subsidiaries 423000 360,692 360,692    
d
e
f All other program service revenue. 30,697,000 30,697,000    
g Total. Add lines 2a–2f .....MediumBullet 1,279,316,288
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 888,819     888,819
4 Income from investment of tax-exempt bond proceedsMediumBullet        
5 Royalties...........MediumBullet        
(ii) Personal (i) Real
6a Gross rents   2,591,779 6a
b Less: rental expenses   3,839,348 6b
c Rental income or (loss)   -1,247,569 6c
d Net rental income or (loss).......MediumBullet -1,247,569     -1,247,569
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory 331,735 4,614,906 7a
b Less: cost or other basis and sales expenses 0 0 7b
c Gain or (loss) 331,735 4,614,906 7c
d Net gain or (loss).........MediumBullet 4,946,641     4,946,641
8a Gross income from fundraising events (not including $   of contributions reported on line 1c). See Part IV, line 18 ....
8a  
b Less: direct expenses ... 8b  
c Net income or (loss) from fundraising events..MediumBullet      
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a  
b Less: direct expenses ... 9b  
c Net income or (loss) from gaming activities..MediumBullet        
10a Gross sales of inventory, less
returns and allowances ..
10a 166,124,426
b Less: cost of goods sold .. 10b 83,388,839
c Net income or (loss) from sales of inventory..MediumBullet 82,735,587 78,162,538 4,573,049  
Business Code Miscellaneous Revenue
11a Commercial testing 621500 2,283,744   2,283,744  
b Sports program 900099 2,002,076   2,002,076  
c A/R Interest Income 900099 104,962 104,962    
d All other revenue ....        
e Total. Add lines 11a–11d ...... MediumBullet 4,390,782
12 Total revenue. See instructions.....MediumBullet 1,412,729,099 1,353,905,939 12,536,718 4,587,891
Form 990 (2021)
Form 990 (2021)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising
expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 173,352 173,352
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ........... 551,108 551,108
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............    
4 Benefits paid to or for members .......    
5 Compensation of current officers, directors, trustees, and key employees ........... 4,504,433 2,839,370 1,665,063  
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ......... 473,552 473,552    
7 Other salaries and wages........ 568,561,127 560,030,597 8,530,530  
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 27,013,371 26,515,531 497,840  
9 Other employee benefits ....... 63,516,289 62,416,385 1,099,904  
10 Payroll taxes ........... 36,844,606 36,057,644 786,962  
11 Fees for services (non-employees):        
a Management ......        
b Legal ......... 340,726 4,710 336,016  
c Accounting ...........        
d Lobbying ........... 49,283   49,283  
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ......        
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) 257,837,864 148,807,455 108,984,927 45,482
12 Advertising and promotion .... 1,169,456 743,229 284,902 141,325
13 Office expenses ....... 15,467,068 13,449,357 2,008,616 9,095
14 Information technology ...... 7,877,418 6,600,221 1,252,365 24,832
15 Royalties ..        
16 Occupancy ........... 24,580,362 18,811,427 5,761,195 7,740
17 Travel ............ 4,045,845 3,922,825 123,020  
18 Payments of travel or entertainment expenses for any federal, state, or local public officials .        
19 Conferences, conventions, and meetings .... 3,042,146 2,966,196 75,950  
20 Interest ........... 14,343,324 11,765,991 2,577,333  
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .. 51,529,681 45,923,205 5,605,927 549
23 Insurance ... 6,539,223 3,418,064 3,121,159  
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a Medical supplies 279,459,788 278,407,011 1,038,408 14,369
b Repairs and maintenance 23,171,850 22,761,748 410,102  
c Research 2,780,973 2,780,973    
d UBI tax 997,820 997,820    
e All other expenses 10,338,337 10,338,100   237
25 Total functional expenses. Add lines 1 through 24e 1,405,209,002 1,260,755,871 144,209,502 243,629
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2021)
Form 990 (2021)
Page 11
Part X
Balance Sheet
Check if Schedule O contains a response or note to any line in this Part IX..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ........   1  
2 Savings and temporary cash investments ......... 64,283,720 2 21,314,824
3 Pledges and grants receivable, net ...... 5,127,502 3 0
4 Accounts receivable, net ............. 166,789,819 4 195,753,862
5 Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
  5  
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
  6  
7 Notes and loans receivable, net ...........   7  
8 Inventories for sale or use ............ 44,363,461 8 34,209,513
9 Prepaid expenses and deferred charges ...... 6,764,427 9 7,925,277
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 1,165,928,143
b Less: accumulated depreciation 10b 574,861,197 565,837,102 10c 591,066,946
11 Investments—publicly traded securities . 35,860,483 11 42,829,413
12 Investments—other securities. See Part IV, line 11 ..... 384,512,480 12 321,138,318
13 Investments—program-related. See Part IV, line 11 .. 14,406,808 13 16,074,703
14 Intangible assets ............... 38,085,871 14 38,076,281
15 Other assets. See Part IV, line 11 ........... 113,485,004 15 115,424,562
16 Total assets. Add lines 1 through 15 (must equal line 33)... 1,439,516,677 16 1,383,813,699
Liabilities 17 Accounts payable and accrued expenses ..... 105,991,971 17 113,510,876
18 Grants payable ...   18  
19 Deferred revenue ......... 14,277,434 19 895,292
20 Tax-exempt bond liabilities ......... 398,831,895 20 393,513,883
21 Escrow or custodial account liability. Complete Part IV of Schedule D   21  
22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
  22  
23 Secured mortgages and notes payable to unrelated third parties .. 73,086,703 23 78,034,916
24 Unsecured notes and loans payable to unrelated third parties ..   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D 53,378,819 25 34,560,317
26 Total liabilities. Add lines 17 through 25.. 645,566,822 26 620,515,284
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions .......... 768,340,216 27 742,764,230
28 Net assets with donor restrictions ........... 25,609,639 28 20,534,185
Organizations that do not follow FASB ASC 958, check here MediumBullet and complete lines 29 through 33.
29 Capital stock or trust principal, or current funds .....   29  
30 Paid-in or capital surplus, or land, building or equipment fund ...   30  
31 Retained earnings, endowment, accumulated income, or other funds   31  
32 Total net assets or fund balances ........... 793,949,855 32 763,298,415
33 Total liabilities and net assets/fund balances ........ 1,439,516,677 33 1,383,813,699
Form 990 (2021)
Form 990 (2021)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
1,412,729,099
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
1,405,209,002
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
7,520,097
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
793,949,855
5
Net unrealized gains (losses) on investments ...............
5
-34,201,011
6
Donated services and use of facilities .................
6
 
7
Investment expenses .....................
7
 
8
Prior period adjustments .....................
8
 
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
-3,970,526
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
763,298,415
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII.............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain on
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
 
No
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
 
 
Form 990 (2021)
Form 990 (2021)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990)

Department of the Treasury
Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.
right arrow Attach to Form 990 or Form 990-EZ.
right arrow Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Reason for Public Charity Status (All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 12, check only one box.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(i) Name of supported organization (ii) EIN (iii) Type of organization (described on lines 1- 10 above (see instructions)) (iv) Is the organization listed in your governing document? (v) Amount of monetary support (see instructions) (vi) Amount of other support (see instructions)
Yes No
Total
 
   
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization failed to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..            
2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....            
3 The value of services or facilities furnished by a governmental unit to the organization without charge..            
4 Total. Add lines 1 through 3            
5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) ..  
6 Public support. Subtract line 5 from line 4.  
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
7 Amounts from line 4..            
8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...            
9 Net income from unrelated business activities, whether or not the business is regularly carried on..            
10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.)..            
11 Total support. Add lines 7 through 10  
12
12
 
13
First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .            
2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose            
3 Gross receipts from activities that are not an unrelated trade or business under section 513 .....            
4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...            
5 The value of services or facilities furnished by a governmental unit to the organization without charge            
6 Total. Add lines 1 through 5            
7a Amounts included on lines 1, 2, and 3 received from disqualified persons            
b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.            
c Add lines 7a and 7b..            
8 Public support. (Subtract line 7c from line 6.)  
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
9 Amounts from line 6...            
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..            
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.            
c Add lines 10a and 10b.            
11 Net income from unrelated business activities not included on line 10b, whether or not the business is regularly carried on.            
12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) ..            
13 Total support. (Add lines 9, 10c, 11, and 12.)..            
14
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
 
 
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.
3a
 
 
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.
3b
 
 
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.
4a
 
 
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.
4b
 
 
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).
5a
 
 
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.
6
 
 
7
Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).
8
 
 
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
 
 
b
Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.
9c
 
 
10a
Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.
10a
 
 
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).
10b
 
 
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described on lines 11b and 11c below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described on 11a above?
11b
 
 
c
A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.
11c
 
 
Section B. Type I Supporting Organizations
Yes
No
1
Did the officers, directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.
1
 
 
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?
1
 
 
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).
2
 
 
3
By reason of the relationship described in line 2 above, did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer lines 2a and 2b below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.
2a
 
 
b
Did the activities described on line 2a, above constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.
2b
 
 
3
Parent of Supported Organizations. Answer lines 3a and 3b below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations?If "Yes" or "No", provide details in Part VI.
3a
 
 
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.
3b
 
 
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
Section A - Adjusted Net Income (A) Prior Year (B) Current Year
(optional)
1 Net short-term capital gain 1    
2 Recoveries of prior-year distributions 2    
3 Other gross income (see instructions) 3    
4 Add lines 1 through 3 4    
5 Depreciation and depletion 5    
6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6    
7 Other expenses (see instructions) 7    
8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8    
Section B - Minimum Asset Amount (A) Prior Year (B) Current Year
(optional)
1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): 1
a Average monthly value of securities 1a    
b Average monthly cash balances 1b    
c Fair market value of other non-exempt-use assets 1c    
d Total (add lines 1a, 1b, and 1c) 1d    
e Discount claimed for blockage or other factors
(explain in detail in Part VI):  
2 Acquisition indebtedness applicable to non-exempt use assets 2    
3 Subtract line 2 from line 1d 3    
4 Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). 4    
5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5    
6 Multiply line 5 by 0.035 6    
7 Recoveries of prior-year distributions 7    
8 Minimum Asset Amount (add line 7 to line 6) 8    
Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1  
2 Enter 85% of line 1 2  
3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3  
4 Enter greater of line 2 or line 3 4  
5 Income tax imposed in prior year 5  
6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6  
7
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 7
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)
Section D - Distributions Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes 1  
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in
excess of income from activity 		2  
3 Administrative expenses paid to accomplish exempt purposes of supported organizations 3  
4 Amounts paid to acquire exempt-use assets 4  
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) 5  
6 Other distributions (describe in Part VI). See instructions 6  
7Total annual distributions. Add lines 1 through 6. 7  
8 Distributions to attentive supported organizations to which the organization is responsive (provide
details in Part VI). See instructions 		8  
9 Distributable amount for 2021 from Section C, line 6 9  
10 Line 8 amount divided by Line 9 amount 10  
Section E - Distribution Allocations (see instructions) (i)
Excess Distributions 		(ii)
Underdistributions
Pre-2021 		(iii)
Distributable
Amount for 2021
1 Distributable amount for 2021 from Section C, line 6  
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI).
See instructions.		  
3 Excess distributions carryover, if any, to 2021:
a From 2016.......  
b From 2017.......  
c From 2018.......  
d From 2019.......  
e From 2020.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2021 distributable amount  
i Carryover from 2016 not applied (see
instructions) 		 
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.  
4Distributions for 2021 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2021 distributable amount  
c Remainder. Subtract lines 4a and 4b from line 4.  
5 Remaining underdistributions for years prior to
2021, if any. Subtract lines 3g and 4a from line 2.
If the amount is greater than zero, explain in Part VI.
See instructions. 		 
6 Remaining underdistributions for 2021. Subtract
lines 3h and 4b from line 1. If the amount is greater
than zero, explain in Part VI. See instructions. 		 
7 Excess distributions carryover to 2022. Add lines
3j and 4c. 		 
8 Breakdown of line 7:
a Excess from 2017.....  
b Excess from 2018.....  
c Excess from 2019.....  
d Excess from 2020.....  
e Excess from 2021.....  
Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021
Page 8
Part VI
Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Return Reference Explanation
Schedule A (Form 990) 2021


Additional Data


Software ID:  
Software Version:  
Schedule B
(Form 990)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors

Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ






Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......... Arrow Bullet $  
Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990) (2021)
Schedule B (Form 990) (2021) Page 2
Name of organization
Avera McKennan
  		Employer identification number
46-0224743
Part I
Contributors
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
 
 
 
 
  ,    

$ RESTRICTED


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page 3
Name of organization
Avera McKennan
  		Employer identification number

46-0224743
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page 4
Name of organization
Avera McKennan
  		Employer identification number

46-0224743
Part III
Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
Schedule B (Form 990) (2021)
Additional Data


Software ID:  
Software Version:  
SCHEDULE C
(Form 990)

Department of the Treasury
Internal Revenue Service
Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet Complete if the organization is described below. SchCMd Bullet Attach to Form 990 or Form 990-EZ.
SchCMd BulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet Section 501(c)(4), (5), or (6) organizations: Complete Part III.
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I-A
Complete if the organization is exempt under section 501(c) or is a section 527 organization.

1
Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

2
Political campaign activity expenditures. See instructions ....................................................................SchCMd Bullet
$  
3
Volunteer hours for political campaign activities. See instructions ..................................................................
 

Part I-B
Complete if the organization is exempt under section 501(c)(3).
1
Enter the amount of any excise tax incurred by the organization under section 4955 ................................SchCMd Bullet
$  
2
Enter the amount of any excise tax incurred by organization managers under section 4955 .......................SchCMd Bullet
$  
3
If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................
4a
Was a correction made? ......................................................................................................................
b
If "Yes," describe in Part IV.
Part I-C
Complete if the organization is exempt under section 501(c), except section 501(c)(3).
1
Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet
$  
2
Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................SchCMd Bullet

$  
3
Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b...........SchCMd Bullet

$  
4
Did the filing organization file Form 1120-POL for this year? ...................................................................
5
Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.
(a) Name (b) Address (c) EIN (d) Amount paid from filing organization's funds. If none, enter -0-. (e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6
For Paperwork Reduction Act Notice, see the instructions for Form 990.
Cat. No. 50084S
Schedule C (Form 990) 2021

Schedule C (Form 990) 2021
Page 2
Part II-A
Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).
A Check SchCMd Bulletexpenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet
Limits on Lobbying Expenditures
(The term "expenditures" means amounts paid or incurred.) 		(a) Filing
organization's
totals 		(b) Affiliated group totals
1a Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................    
b Total lobbying expenditures to influence a legislative body (direct lobbying) ........................    
c Total lobbying expenditures (add lines 1a and 1b) ............................................................    
d Other exempt purpose expenditures ...............................................................................    
e Total exempt purpose expenditures (add lines 1c and 1d) ..................................................    
f Lobbying nontaxable amount. Enter the amount from the following table in both
columns.		    
If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
Not over $500,00020% of the amount on line 1e.
Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
Over $17,000,000$1,000,000.
g Grassroots nontaxable amount (enter 25% of line 1f) .................................................    
h Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................    
i Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................    
j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting
section 4911 tax for this year? ...................................................................................................................

4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five
columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year
beginning in) 		(a) 2018 (b) 2019 (c) 2020 (d) 2021 (e) Total
2a Lobbying nontaxable amount          
b Lobbying ceiling amount
(150% of line 2a, column(e)) 		 
c Total lobbying expenditures          
d Grassroots nontaxable amount          
e Grassroots ceiling amount
(150% of line 2d, column (e))		  
f Grassroots lobbying expenditures          
Schedule C (Form 990) 2021


Schedule C (Form 990) 2021
Page 3
Part II-B
Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).
For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.
(a)
Yes|No
(b)
Amount
1
During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:
a
Volunteers? ...........................................................................................................
 
No
b
Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........
 
No
c
Media advertisements? ...................................................................................................
 
No
 
d
Mailings to members, legislators, or the public? .............................................................................
 
No
 
e
Publications, or published or broadcast statements? ...........................................................
 
No
 
f
Grants to other organizations for lobbying purposes? ..........................................................
 
No
 
g
Direct contact with legislators, their staffs, government officials, or a legislative body? .......................
 
No
 
h
Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................
 
No
 
i
Other activities? ...................................................................................................................
Yes
 
49,283
j
Total. Add lines 1c through 1i ....................................................................................................
49,283
2a
Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....
 
No
b
If "Yes," enter the amount of any tax incurred under section 4912 ...........................................
 
c
If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................
 
d
If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................
 
 
Part III-A
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).
Yes
No
1
Were substantially all (90% or more) dues received nondeductible by members? ...............................................
1
 
 
2
Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................
2
 
 
3
Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................
3
 
 
Part III-B
Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."
1
Dues, assessments and similar amounts from members ......................................................................
1
 
2
Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).
a
Current year .............................................................................................................................
2a
 
b
Carryover from last year ............................................................................................................
2b
 
c
Total ...........................................................................................................................................
2c
 
3
Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .
3
 
4
If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................
4
 
5
Taxable amount of lobbying and political expenditures. See Instructions .........................................
5
 
Part IV
Supplemental Information
Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.
Return Reference Explanation
Part II-B, Line 1: Avera McKennan participates through various hospital organizations to promote legislation that would result in strengthening health care delivery systems on a national, regional, and local level. Dues were paid to the following organizations and a portion is attributable to lobbying. South Dakota Association of Healthcare Organizations $33,715 Sioux Falls Chamber of Commerce 14,245 National Rural Health Association 61 Iowa Hospital Association 1,262
Schedule C (Form 990) 2021


Additional Data


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SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet Attach to Form 990.
SchDMd Bullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate value of contributions to (during year)    
3 Aggregate value of grants from (during year)    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ...................... 2a  
b Total acreage restricted by conservation easements .................... 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............
6
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenue included on Form 990, Part VIII, line 1 .........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b If "Yes," explain the arrangement in Part XIII and complete the following table: Amount
c Beginning balance ............................. 1c 19,524
d Additions during the year ............................ 1d 58,598
e Distributions during the year .......................... 1e 64,252
f Ending balance ................................ 1f 13,870
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....
Part V
Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.
(a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back
1a Beginning of year balance .... 5,588,451 5,469,827 4,797,240 4,256,565 3,764,520
b Contributions ...          
c Net investment earnings, gains, and losses 895,615 118,624 672,587 540,675 492,045
d Grants or scholarships ...          
e Other expenditures for facilities
and programs ... 		         
f Administrative expenses ....          
g End of year balance ...... 6,484,066 5,588,451 5,469,827 4,797,240 4,256,565
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet0 %
b
Permanent endowment SchDMd Bullet100.000 %
c
Term endowment SchDMd Bullet0 %
The percentages on lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) Unrelated organizations .................
3a(i)
 
No
(ii) Related organizations .................
3a(ii)
Yes
 
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
Yes
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis
(investment) 		(b) Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land ..... 29,608,656 28,209,754 57,818,410
b Buildings .... 4,327,649 677,509,722 296,787,565 385,049,806
c Leasehold improvements   12,423,096 10,799,263 1,623,833
d Equipment ....   361,002,890 260,163,278 100,839,612
e Other .....   52,846,376 7,111,091 45,735,285
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 591,066,946
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 3
Part VII
Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) Financial derivatives.........    
(2) Closely-held equity interests........    
(3) Other
(A) Avera Pooled Investments		 273,768,683 F

(B) Interest in Avera Health Foundation		 21,516,785 F

(C) Investment in Heart Hospital of South Dakota, LLC		 22,128,190 F

(D) Investments in affiliated companies		 2,821,057 F

(E) Investment in Alucent		 903,603 F
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet 321,138,318
Part VIII
Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1)Other Assets 5,126,614
(2)Other Receivables 38,855,972
(3)Due from Related party 11,158,406
(4)Right of use assets 60,283,570
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 115,424,562
Part X
Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
(1) Federal income taxes  
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 34,560,317
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1 Total revenue, gains, and other support per audited financial statements ....... 1  
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains (losses) on investments .... 2a  
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d ..................... 2e  
3 Subtract line 2e from line 1.................. 3  
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a  
b Other (Describe in Part XIII.) ........... 4b  
c Add lines 4a and 4b.................... 4c  
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5  
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1 Total expenses and losses per audited financial statements ........... 1  
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities ......... 2a  
b Prior year adjustments ............ 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d  
e Add lines 2a through 2d.................... 2e  
3 Subtract line 2e from line 1................... 3  
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a  
b Other (Describe in Part XIII.) ............ 4b  
c Add lines 4a and 4b..................... 4c  
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5  
Part XIII
Supplemental Information
Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Return Reference Explanation
Part IV, Line 1b: The Organization holds funds in trust on behalf of its long-term care residents. Many small dollar transactions flow in and out of this account. The account is managed by the nursing home staff. The state has strict guidelines on how these accounts are managed.
Part V, Line 4: The Organization's endowment consists of a portion of their interest in the net assets of 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. 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 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 consolidated 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.
Schedule D (Form 990) 2021


Additional Data


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Software Version:  




SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Go to www.irs.gov/Form990EZ for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
 
No
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
 
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    19,268,248   19,268,248 1.370 %
b Medicaid (from Worksheet 3, column a) . . . . .     103,170,029 77,886,072 25,283,957 1.800 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .     2,559,461 1,545,059 1,014,402 0.070 %
d Total Financial Assistance and Means-Tested Government Programs . . . . .     124,997,738 79,431,131 45,566,607 3.240 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     4,802,797 504,099 4,298,698 0.310 %
f Health professions education (from Worksheet 5) . . .     10,484,514 1,756,490 8,728,024 0.620 %
g Subsidized health services (from Worksheet 6) . . . .     60,121,494 49,258,958 10,862,536 0.770 %
h Research (from Worksheet 7) .     13,916,254 8,015,510 5,900,744 0.420 %
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .     1,371,005   1,371,005 0.100 %
j Total. Other Benefits . .     90,696,064 59,535,057 31,161,007 2.220 %
k Total. Add lines 7d and 7j .     215,693,802 138,966,188 76,727,614 5.460 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing     75,000   75,000 0.010 %
2 Economic development     281,502   281,502 0.020 %
3 Community support     7,500   7,500 0 %
4 Environmental improvements            
5 Leadership development and
training for community members		     22,069   22,069 0 %
6 Coalition building     6,682   6,682 0 %
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total     392,753   392,753 0.030 %
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
36,239,541
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
0
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
286,824,425
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
311,914,736
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-25,090,311
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)How many hospital facilities did the organization operate during the tax year?8Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (describe) Facility reporting group
1 Avera McKennan
1325 S Cliff Ave
Sioux Falls,SD57117
See Part V Section C
10563 		X X X X   X X   40 Provider Based Clinics  
2 Heart Hospital of South Dakota LLC
4500 W 69th Street
Sioux Falls,SD57108
See Part V Section C
41953 		X X         X   2/3 Owner in Joint Venture  
3 Avera Milbank Area Hospital
901 Virgil Ave
Milbank,SD57252
See Part V Section C
48451 		X X     X   X   2 Provider Based Clinics & 2 Rural Health PB Clinics  
4 Avera Gregory Healthcare Center
400 Park Ave
Gregory,SD57533
See Part V Section C
54875 		X X     X   X   2 Provider Based Clinics & 2 Rural Health PB Clinics  
5 Avera Dells Area Health Center
909 N Iowa Avenue
Dell Rapids,SD57022
See Part V Section C
50754 		X X     X   X   3 Provider Based Clinics  
6 Avera Flandreau Medical Center
214 N Prairie
Flandreau,SD57028
See Part V Section C
10540 		X X     X   X   1 Rural Health Provider Based Clinic  
7 Avera Hand County Memorial Hospital
300 W 5th St
Miller,SD57362
See Part V Section C
53862 		X X     X   X   1 Provider Based Clinic  
8 Avera Merrill Pioneer Hospital
1100 S 10th Ave
Rock Rapids,IA51246
See Part V Section C
600118H 		X X     X   X   2 Rural Health Provider Based Clinics  
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera McKennan
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera McKennan
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera McKennan
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera McKennan
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Heart Hospital of South Dakota LLC
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		2
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b Yes  
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Heart Hospital of South Dakota LLC
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Heart Hospital of South Dakota LLC
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Heart Hospital of South Dakota LLC
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Gregory Healthcare Center
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		4
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Gregory Healthcare Center
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Gregory Healthcare Center
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Gregory Healthcare Center
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Milbank Area Hospital
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		3
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Milbank Area Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Milbank Area Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Milbank Area Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Dells Area Health Center
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		5
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Dells Area Health Center
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Dells Area Health Center
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Dells Area Health Center
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Flandreau Medical Center
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		6
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Flandreau Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Flandreau Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Flandreau Medical Center
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Hand County Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		7
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Hand County Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Hand County Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Hand County Memorial Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Avera Merrill Pioneer Hospital
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		8
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 21
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a   No
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 21
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): See Part V, Section C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b    
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
Avera Merrill Pioneer Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Was widely publicized within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
See Part V, Section C
b
See Part V, Section C
c
d
e
f
g
h
i
j
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 6
Part VFacility Information (continued)

Billing and Collections
Avera Merrill Pioneer Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon nonpayment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
f
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
e
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 7
Part VFacility Information (continued)

Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
Avera Merrill Pioneer Hospital
Name of hospital facility or letter of facility reporting group  
Yes No
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 8
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16j, 18e, 19e, 20a, 20b, 20c, 20d, 20e, 21c, 21d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
Avera McKennan Part V, Section B, Line 5: Avera McKennan solicited community input in a variety of methods. A survey of residents in the Sioux Falls Metropolitan Statistical area was conducted. Three focus groups were conducted in April 2021. Key informant individual interviews were conducted in May 2021. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources and improvements. Those providing community input represented the medically underserved, low-income and minority populations as they serve these populations through their activities.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 5: Heart Hospital of South Dakota, LLC solicited community input in a variety of methods. A survey of residents in the Sioux Falls Metropolitan Statistical area was conducted. Three focus groups were conducted in April 2021. Key informant individual interviews were conducted in May 2021. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources and improvements. Those providing community input represented the medically underserved, low-income and minority populations as they serve these populations through their activities.
Avera Gregory Healthcare Center Part V, Section B, Line 5: This year the Avera Gregory Hospital completed our 2021 Community Health Needs Assessment. We used an outside consultation to bring together multiple community members and organizations to answer the question: "What health needs can our facility be a partner in addressing?" Our organization used primary evidence gathering techniques with one-on-one interviews, online surveys, and town hall events. We also met with local organizations including the lions club, rotary club, city council, county commissioners, the local EMS providers, the volunteer fire department, and various church organization that represented at risk community members. The Avera Gregory Hospital Advisory Board approved the Community Health Needs Assessment.
Avera Milbank Area Hospital Part V, Section B, Line 5: The assessment process, initiated by Milbank Area Hospital Avera, is an effort to identify significant unmet health needs in the community. Community input was solicited through surveys and personal interviews with community members with special knowledge of the needs of the community. Throughout the data collection process, steps were taken to ensure the hospital's community health needs assessment took into account input from persons who represent the broad interests of the community, including the medically underserved, minority, senior citizens, children and low-income populations.
Avera Dells Area Health Center Part V, Section B, Line 5: Community input was solicited using a variety of methods. To gather a broad range of interests and ensure accurate community input and representation, individual personalized invitations went out to various groups and individuals. In addition, medically underserved, low income, and minority population groups were also invited. In addition, there were two weeks of community surveys conducted in July 2021.
Avera Flandreau Medical Center Part V, Section B, Line 5: Community input was solicited using a variety of methods. The Avera Flandreau Hospital identified individuals, and the Avera Flandreau Hospital Advisory Board was instrumental in generating community member involvement. Personalized invitations were extended to engage individuals in the CHNA process. Involved individuals and organizations include: Food Pantry, Public Health, Senior Meals Program, the Ministerial Association, the Avera Medical Group Flandreau Medical Staff, Avera Medical Group Flandreau Clinic Manager, Avera Flandreau Hospital Administrator, and the Avera Flandreau Hospital Director of Nursing and focus groups and paper surveys from May 23, 2022 to June 13, 2022.
Avera Hand County Memorial Hospital Part V, Section B, Line 5: The CHNA process began by defining the community and collecting secondary data and resources. Once that was completed, the process continued with primary data collection including online and paper surveys. The internal CHNA committee reviewed the data collected and identified the community health needs to improve overall health of the community. The needs were then prioritized. The Avera Hand County Memorial Hospital Board of Directors approved the Community Health Needs Assessment.
Avera Merrill Pioneer Hospital Part V, Section B, Line 5: Avera Merrill Pioneer Hospital conducted a community survey to collect a broad view of the community. The survey was implemented through an online format to residents in Lyon County. The survey was promoted on Facebook, with the goal of reaching a wide demographic representative of the overall county population. Paper copies of the survey were also dispersed at the Avera Medical Group Clinics in Rock Rapids, George, and Larchwood. Key informant interviews were conducted to get a closer look at problem areas identified from a previous community health needs assessment and to connect with individuals serving vulnerable/medically underserved populations. The key informant interviews were conducted over the phone with Lyon County Public Health, Sioux Rivers Regional Disability Services Coordinator, Lyon County Ambulance Director, Rock Rapids Health Center Director of Nursing, and the Central Lyon and West Lyon High School Superintendents. Throughout the data collection process, steps were taken to ensure the hospital's community health needs assessment took into account input from persons who represent the broad interests of the community, including the medically underserved, minority, senior citizens, children and low-income populations.
Avera McKennan Part V, Section B, Line 6a: The CHNA was conducted with Heart Hospital of South Dakota, LLC, Sioux Falls VA Medical Center, and Sanford USD Medical Center.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 6a: The CHNA was conducted with Avera McKennan, Sioux Falls VA Medical Center, and Sanford USD Medical Center.
Avera McKennan Part V, Section B, Line 6b: City of Sioux Falls Health Department
Heart Hospital of South Dakota, LLC Part V, Section B, Line 6b: City of Sioux Falls Health Department
Avera McKennan Part V, Section B, Line 11: The community health needs assessment was completed during fiscal year 2022. The community health priority areas identified were: Active Living, Healthy Eating, Mental Health and Substance Use, Oral Health and Preventative Care. The identified needs will be addressed through a three-year, collaborative Community Health Improvement Plan (CHIP). The CHIP is a multi-partner collaboration spearheaded by the Sioux Falls Health Department, Avera McKennan Hospital & University Health Center (including Avera Heart Hospital), Sanford USD Medical Center and the Sioux Falls VA Health Care System. Lead agencies were identified to lead the three work groups established to address the five priority areas. Avera McKennan is co-leading efforts, in partnership with Sanford Health, to address Mental Health and Substance Abuse and Preventative Care strategies. In addition, Avera McKennan and the Avera Heart Hospital will participate in efforts to support strategies to improve Active Living, Healthy Eating and Oral Health. The following actions will be taken in future years to address the identified and prioritized community health needs:PRIORITY AREA #1: ACTIVE LIVINGGOAL: Get People Moving MoreOBJECTIVE 1: Decrease percentage of adults who do not participate in any leisure time activity by 2024.STRATEGIES Create a comprehensive community directory of resources and programs and distribute it across multiple channels to ensure it is accessible to residents of all ages. Track and promote active lifestyle programming activities in the community on an ongoing basis. Implement a "Physical Activity Screening and Tailored Prescription" program in clinical settings. Promote use of the Sioux Falls recreation trail system for exercise and transportation. Explore the underlying drivers of the high rate of fall deaths in Minnehaha County and promote evidence-based Falls Prevention programs in the community.OBJECTIVE 2: Add complete streets elements to the Sioux Falls network of streets and sidewalks by 2024.STRATEGIES Advocate for creation of an Active Transportation Advisory Board. Conduct an evaluation of the implementation of the City of Sioux Falls Complete Streets Policy. Promote safety for biking and walking in residential areas and on the recreation trail. Utilize the City of Sioux Falls Health in All Policies Committee to identify and promote collaboration across city master plans (e.g. Bicycle Plan, Pedestrian Plan, and Sustainability and Climate Action Plan) to improve active transportation infrastructure in the built environment.PRIORITY AREA #2: HEALTHY EATING GOAL: Increase Consumption of Healthy FoodsOBJECTIVE 1: Establish two new sites where residents can access fresh produce in low-income low access census tracts by 2024.STRATEGIES Promote establishment of community gardens and/or farmer's markets in Food Access Priority census tracts. Incentivize the private and non-profit sectors to establish new grocery stores or innovative programs to increase residents' access to health foods in Food Access Priority census tracts. Establish an active local food coalition by aligning key players such as the Food Council and the urban agriculture task force. OBJECTIVE 2: Increase the number of worksites with evidence-based healthy food and beverage policies by 2024.STRATEGIES Promote healthy eating in the workplace and advocate for healthy nutrition policies at worksites. Partner with organizations to establish baseline measures through a workplace survey. Re-launch Healthy Place program for restaurants and expand to include recognition for worksites.PRIORITY AREA #3: MENTAL HEALTH AND SUBSTANCE USEGOAL: Reduce Deaths Due to Intentional and Unintentional InjuriesOBJECTIVE 1: Reduce the rate of suicide in Minnehaha County by 2024.STRATEGIES Create a city-wide campaign to normalize mental health conversations and care using evidence-based methodologies (e.g. "I go to therapy"). Promote 988 phone number (starting in July 2022) as access point for behavioral health and crisis support along with the Helpline Center mental health resource database to increase awareness of health and social service resources. Provide mental health first aid trainings in worksites, schools and organizations across the community to broaden early intervention impact. Promote Lethal Means Safety trainings in the community to reduce individuals' access to lethal means such as medications and firearms.OBJECTIVE 2: Decrease the percentage of driving deaths with alcohol involvement in Minnehaha County by 2024. STRATEGIES Media campaign against alcohol overuse and driving while under the influence. Responsible server training for bars and restaurants. School-based education/programs for teens and college campuses on alcohol abuse.OBJECTIVE 3: Decrease the drug poisoning death rate in Minnehaha County by 2024. STRATEGIES Implement community campaigns targeting opioid and other drug use, highlighting harmful substances & safe storage of medications at home. Expand youth mentoring programs. Promote drug take back events, neutralizing packets, and daily pharmacy drops. Improve access to Medication-assisted treatment (MAT) and Naloxone.PRIORITY AREA #4: ORAL HEALTHGOAL: Improve Oral Health Through The Reduction Of Dental DiseasesOBJECTIVE 1: Increase the proportion of individuals utilizing the oral health system by 2024. STRATEGIES Develop an education and awareness campaign to increase the number of individuals in priority populations who have a dental visit, including 1-2 year olds, pregnant women, Medicaid recipients, and aging populations. Develop an advocacy plan to address access to care issues including Medicaid expansion and Medicaid reimbursement. Partner with local dental clinics to host free clinic events. Promote oral health assessments and referral to a dental home at medical appointments. Assist in re-implementation of the 3rd grade survey in the MSA and other related data collection. Simplify consent process to enable provision of dental care services to more children at elementary schools. PRIORITY AREA #5: Preventive CareGOAL: Increase Utilization of Preventative CareOBJECTIVE 1: Increase the percentage of residents who have had a preventative care visit in the last year by 2024. STRATEGIES Explore a system for data-sharing among local health systems to get baseline data on number of residents who had a preventative care visit. Utilize Community Health Workers to share information about primary care, cancer screenings, immunizations, and mental health resources in the community and to help individuals get connected to a provider. Educate policy and decision makers on the resident need and economic benefits of Medicaid expansion that can help people access primary care. Utilize education and engagement resources for providers to communicate with patients about screenings (e.g. information about All Women Count, etc.). Encourage worksites and employees to access screenings through primary care providers and provide on-site immunization clinics. Increase options to access transportation at no cost to individuals without transportation to attend appointments. Develop resources for use at The Link to connect clients with preventive care services.Avera McKennan and Avera Heart Hospital are addressing, or collaborating to address, all aspects of all top needs identified in the 2022 Community Health Needs Assessment.Statement continued to Part V, Section C.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 11: The community health needs assessment was completed during fiscal year 2022. The community health priority areas identified were: Active Living, Healthy Eating, Mental Health and Substance Use, Oral Health and Preventative Care. The identified needs will be addressed through a three-year, collaborative Community Health Improvement Plan (CHIP). The CHIP is a multi-partner collaboration spearheaded by the Sioux Falls Health Department, Avera McKennan Hospital & University Health Center (including Avera Heart Hospital), Sanford USD Medical Center and the Sioux Falls VA Health Care System. Lead agencies were identified to lead the three work groups established to address the five priority areas. Avera McKennan is co-leading efforts, in partnership with Sanford Health, to address Mental Health and Substance Abuse and Preventative Care strategies. In addition, Avera McKennan and the Avera Heart Hospital will participate in efforts to support strategies to improve Active Living, Healthy Eating and Oral Health. The following actions will be taken in future years to address the identified and prioritized community health needs:PRIORITY AREA #1: ACTIVE LIVINGGOAL: Get People Moving MoreOBJECTIVE 1: Decrease percentage of adults who do not participate in any leisure time activity by 2024.STRATEGIES Create a comprehensive community directory of resources and programs and distribute it across multiple channels to ensure it is accessible to residents of all ages. Track and promote active lifestyle programming activities in the community on an ongoing basis. Implement a "Physical Activity Screening and Tailored Prescription" program in clinical settings. Promote use of the Sioux Falls recreation trail system for exercise and transportation. Explore the underlying drivers of the high rate of fall deaths in Minnehaha County and promote evidence-based Falls Prevention programs in the community.OBJECTIVE 2: Add complete streets elements to the Sioux Falls network of streets and sidewalks by 2024.STRATEGIES Advocate for creation of an Active Transportation Advisory Board. Conduct an evaluation of the implementation of the City of Sioux Falls Complete Streets Policy. Promote safety for biking and walking in residential areas and on the recreation trail. Utilize the City of Sioux Falls Health in All Policies Committee to identify and promote collaboration across city master plans (e.g. Bicycle Plan, Pedestrian Plan, and Sustainability and Climate Action Plan) to improve active transportation infrastructure in the built environment.PRIORITY AREA #2: HEALTHY EATING GOAL: Increase Consumption of Healthy FoodsOBJECTIVE 1: Establish two new sites where residents can access fresh produce in low-income low access census tracts by 2024.STRATEGIES Promote establishment of community gardens and/or farmer's markets in Food Access Priority census tracts. Incentivize the private and non-profit sectors to establish new grocery stores or innovative programs to increase residents' access to health foods in Food Access Priority census tracts. Establish an active local food coalition by aligning key players such as the Food Council and the urban agriculture task force. OBJECTIVE 2: Increase the number of worksites with evidence-based healthy food and beverage policies by 2024.STRATEGIES Promote healthy eating in the workplace and advocate for healthy nutrition policies at worksites. Partner with organizations to establish baseline measures through a workplace survey. Re-launch Healthy Place program for restaurants and expand to include recognition for worksites.PRIORITY AREA #3: MENTAL HEALTH AND SUBSTANCE USEGOAL: Reduce Deaths Due to Intentional and Unintentional InjuriesOBJECTIVE 1: Reduce the rate of suicide in Minnehaha County by 2024.STRATEGIES Create a city-wide campaign to normalize mental health conversations and care using evidence-based methodologies (e.g. "I go to therapy"). Promote 988 phone number (starting in July 2022) as access point for behavioral health and crisis support along with the Helpline Center mental health resource database to increase awareness of health and social service resources. Provide mental health first aid trainings in worksites, schools and organizations across the community to broaden early intervention impact. Promote Lethal Means Safety trainings in the community to reduce individuals' access to lethal means such as medications and firearms.OBJECTIVE 2: Decrease the percentage of driving deaths with alcohol involvement in Minnehaha County by 2024. STRATEGIES Media campaign against alcohol overuse and driving while under the influence. Responsible server training for bars and restaurants. School-based education/programs for teens and college campuses on alcohol abuse.OBJECTIVE 3: Decrease the drug poisoning death rate in Minnehaha County by 2024. STRATEGIES Implement community campaigns targeting opioid and other drug use, highlighting harmful substances & safe storage of medications at home. Expand youth mentoring programs. Promote drug take back events, neutralizing packets, and daily pharmacy drops. Improve access to Medication-assisted treatment (MAT) and Naloxone.PRIORITY AREA #4: ORAL HEALTHGOAL: Improve Oral Health Through The Reduction Of Dental DiseasesOBJECTIVE 1: Increase the proportion of individuals utilizing the oral health system by 2024. STRATEGIES Develop an education and awareness campaign to increase the number of individuals in priority populations who have a dental visit, including 1-2 year olds, pregnant women, Medicaid recipients, and aging populations. Develop an advocacy plan to address access to care issues including Medicaid expansion and Medicaid reimbursement. Partner with local dental clinics to host free clinic events. Promote oral health assessments and referral to a dental home at medical appointments. Assist in re-implementation of the 3rd grade survey in the MSA and other related data collection. Simplify consent process to enable provision of dental care services to more children at elementary schools. PRIORITY AREA #5: Preventive CareGOAL: Increase Utilization of Preventative CareOBJECTIVE 1: Increase the percentage of residents who have had a preventative care visit in the last year by 2024. STRATEGIES Explore a system for data-sharing among local health systems to get baseline data on number of residents who had a preventative care visit. Utilize Community Health Workers to share information about primary care, cancer screenings, immunizations, and mental health resources in the community and to help individuals get connected to a provider. Educate policy and decision makers on the resident need and economic benefits of Medicaid expansion that can help people access primary care. Utilize education and engagement resources for providers to communicate with patients about screenings (e.g. information about All Women Count, etc.). Encourage worksites and employees to access screenings through primary care providers and provide on-site immunization clinics. Increase options to access transportation at no cost to individuals without transportation to attend appointments. Develop resources for use at The Link to connect clients with preventive care services.Avera McKennan and Avera Heart Hospital are addressing, or collaborating to address, all aspects of all top needs identified in the 2022 Community Health Needs Assessment.Statement continued to Part V, Section C.
Avera Gregory Healthcare Center Part V, Section B, Line 11: The community health needs assessment was completed during tax year 2021. Three needs were identified in the CHNA: need for new facilities in our area to administer healthcare, increase diagnostic capabilities of our imaging department to eliminate unnecessary travel, and increased need for dialysis in our community. The following actions will be taken in future years to address the identified and prioritized community health needs:Construction of new facilities: hospital, clinic, long term care center Conduct community assessment to determine needs in the new healthcare structures. Fundraising efforts in the community to raise money and awareness for the project. Complete construction of the new facility by 2024.Long travel for MRI services Data analysis on number of MRI screenings conducted in our area per month. Work with providers and Emergency medical personnel to determine which diagnostic device would be best for the area. Develop and implement construction plans for a MRI suite at our new proposed construction location.Lack of dialysis services in the area Data analysis on the medical need of dialysis in our service area vs availability of those services. Work with our nephrology team and local dialysis experts to determine the number of units required and staffing Integrate a new dialysis unit into the local construction project.Other topics that came forward through the assessment processes but were not found evident or impactful enough to focus on: COVID-19 concerns including noncompliance by community and vaccination and booster rates. Housing options that are available for new people moving to the community, safe and affordable, and assistive to the aging population. Workforce concerns in how we will continue to keep the healthcare campus, local EMS service, and home health and hospice services adequately staffed, including recruitment of a doctor of medicine (MD) and registered nurses to the community. Healthy eating options including access to fresh produce at the local grocery store, more restaurants with healthy food options, nutrition classes, and healthy snack options for staff on the healthcare campus.The community health needs assessment completed during tax year 2018 identified two needs: public awareness of hospital/clinic services and nutrition education. The following were addressed during fiscal year 2022.Public awareness of hospital/ clinic services:One identified weakness was our social media presence in our community. Our posting and engagement pattern was usually one or two wellness posts per quarter. Sometimes more frequently when we had to announce a clinic closure due to weather. With the onset of the COVID-19 pandemic our posting rate increased to almost weekly for over a year. We sent out information based on CDC recommendations, new PPE requirements for visitation in both the hospital and long term care center, and vaccine information. In addition to this we utilized other more traditional forms of media to include the local newspaper and radio advertisement. In 2021 we used all of these communication channels to update the community on the building status of the new facility as well as when we expect the project to be complete.Nutrition education: Initially in the three year CHNA period this was a huge focus for us as heart disease continues to be the number one cause of death in our service area year after year. We increased the hours of our contracted dietician and offered more counseling sessions with her for the community. We also used our coordinated care team to identify low income vulnerable patients that were most at risk for heart disease and provided one-on-one care to educate and assist with their nutritional needs. Assistance was provided to the local schools to assist teachers with nutritional education and teaching children at a young age the importance of a healthy diet combined with exercise.
Avera Milbank Area Hospital Part V, Section B, Line 11: Milbank Area Hospital Avera conducted a community health needs assessment during FY2022. After review of the primary and secondary data, the Milbank Area Hospital Avera leadership team weighed the findings against available resources and potential sustainability. These criteria were used as they prioritized the identified needs.Based on the results of this assessment, Milbank Area Hospital Avera is committed to addressing the following identified significant community health need: Addition of mental health services. Greater outreach to ethnic minority patients. Health education and health screenings.The following actions will be taken in future years to address the identified and prioritized community health needs:Addition of mental health services Focus on adding mental health professionals to provide mental health services in the community. Educate and promote the 211 suicide prevention hot line. Collaborate with local school and community to provide education to school-age children about mental health in a relatable way. Continue grief support group in the community. Mental health screenings of patients at clinic and hospital registration.Greater outreach to ethnic minority patients Develop and strengthen relationships and partnerships with organizations currently serving ethnic minority populations. Distribute information packages to local corporation that employs large number of individuals with Hispanic background. Enhance offering and activities inclusive of all local cultural groups. When recruiting for various positions in the hospital and clinic, include the need for bilingual employees. Develop a community health worker program - focus on health disparities and advance health equities within underserved populations.Health education and health screenings Expand community health education and screenings, including lung and heart screening. Continue to provide bi-monthly radio interviews to educate on services available and promote health screenings such as mammograms and colon cancer screening.Milbank Area Hospital Avera will not be directly addressing other areas of concern identified through the assessment process. While the leadership team recognizes that other concerns exist, the hospital does not have the resources to address at this time.Milbank Area Hospital Avera continued to address the community health needs identified in the community health needs assessment completed in 2018. The following includes actions taken toward the previous report.FY2022 Update: Three primary care physicians have been recruited. A hospitalist program was formed which has improved workloads amongst medical staff, improving job satisfaction and patient care. There in an ongoing relationship with the local high school to offer curriculum and encourage heath careers. Students connect with all departments in the hospital during the class. FY2022 Update: Continued partnership with National Alliance on Mental Illness (NAMI) and a local group referred to as "Moving to Wellness" to offer and support classes and educational materials on mindfulness, grief, depression and anxiety. Resources have been provided to educate on ending the stigma of mental illness. FY2022 Update: Successful efforts have been made to improve communication with non-English speaking patients. Access to phone translation service has been implemented throughout the hospital campus. Focus has been placed on translation of appropriate patient materials. Effort and steps are being taken to add another translator.
Avera Dells Area Health Center Part V, Section B, Line 11: The community health needs assessment was completed during fiscal year 2022. Two needs were identified in the CHNA: Offer additional local healthcare services, and access/convenience to medical care.The following actions will be taken in future years to address the identified and prioritized community health needs:Avera Dells Area Hospital will seek to expand the list of services offered by seeking out new internal and external partnerships. The focus will be on services identified in the survey portion of the CHNA prioritization including therapy services, wound care, diabetes, specialty, and imaging procedures. The hospital is committed to investing resources to promote these services to the community once implemented. To track progress of this goal, Avera Dells Area Hospital will closely monitor usage of these services to verify the strategy is effective. Results will be shared with the leadership team at Avera Dell Rapids as well as the advisory board. Avera Dells Area Hospital will seek to expand access to care and make medical care more convenient in several ways. Many of the services offered are only offered once or twice per month. To provide patients with more convenient access to care, Avera Dells Area Hospital will focus on expanding access through additional days and times for both the current services and any additional services that are implemented as part of this CHNA. To track the progress of this goal, patient volumes will be assessed during expanded hours to ensure added value to patients. Results will be shared with the leadership team at Avera Dell Area Hospital as well as the advisory board. Avera Dells Area Hospital identified the following needs not being addressed in the 2022 Implementation Strategy: tobacco education/cessation, mental health, physical activity, outreach services, and nutrition education. Each of these needs were presented to the Avera Dells Area Medical Staff, Advisory Board, and Hospital Leadership Teams during the prioritization process, all of which felt there were other more impactful areas to focus on.Avera Dells Area Hospital continued to address the community health needs identified in the community health needs assessment completed in 2018. The following community health priority areas were identified and the following actions were taken during FY22.Improve public awareness of local health care service options, which will improve community engagement around health and wellness. Awareness can be improved and generated through the new Avera Dells Area Hospital webpage, as well as through other social media avenues and public events.FY2022 Update: Continued to use social media and online portals to promote local health care services available in the community. Participated in community events to promote local health services and educate the public on preventative health and wellness programs and opportunities. Continue to promote free dietary consultations to all community members living in the Avera Dells Area Hospital service area.FY2022 Update: Continued to use community events to promote healthy eating and education on the benefits of good nutrition on health.
Avera Flandreau Medical Center Part V, Section B, Line 11: The community health needs assessment was completed during fiscal year 2022. Two needs were identified in the CHNA: access to healthcare through affordability and chemical dependency. The following actions will be taken in future years to address the identified and prioritized community health needs:Access to Healthcare through Affordability- Avera is compliant with the Health Care Price Transparency Act and provides its pricing information to the public via its website. Avera has recently begun to provide out-of-pocket cost estimates for scheduled patients who will be paying for services with their own resources (not using a third-party payer). This process provides patients an estimate of what they will be responsible for after their visit. Avera is also nearing completion of a more automated process for all patients in which they will have an estimate of out-of-pocket costs they will incur for scheduled visits to Avera Flandreau Hospital and Avera Medical Group-Flandreau. - Avera offers charity care to those eligible for the service and for those who complete the necessary paperwork. Opportunities may exist to create greater awareness and greater ease of use of this process.- Avera Flandreau Hospital is actively participating in an effort to gain approval for Medicaid expansion along with Avera Health, and other hospitals in South Dakota. The facility is working to put the proposed legislation on a ballot measure and brought before the voters of South Dakota. An estimated 43,000 South Dakotans would be eligible for this expanded health insurance. Additional coverage would improve access to care and improve health outcomes for Moody County residents. Chemical Dependency Services- In 2020 Avera built the Avera Addiction Care Center in Sioux Falls. It is a residential addiction treatment facility, which offers programming and residential life for adults 18 and older. It is hoped that the expansion of services will create greater access to chemical dependency services.- Avera Behavioral Health Urgent Care is another possible resource to address chemical dependency situations in a timely manner. - The Avera Behavioral Health Assessment Team is available to our patients 24/7; this is a free service to the public. - Moody County Cares mental health board is community based and run by county residents. Avera Flandreau employees are active on the mental health board and will look for ways to partner toward meeting our goal. - The opportunity exists to partner with Flandreau area law enforcement such as the Flandreau Police Department, Moody County Sheriff, and the Santee Sioux Tribal Police. Avera Flandreau Hospital identified the following needs not being addressed in the 2021 Implementation Strategy: mental health, outreach services, and nutrition education. Each of these needs were presented to the Avera Flandreau Medical Staff, Advisory Board, and Hospital Leadership Team during the prioritization process, all which felt there were more impactful areas to focus on and utilize resources.Avera Flandreau continued to address the community health needs identified in the community health needs assessment completed in 2018. The following community health priority areas were identified and the following actions were taken during FY22.Mental Health and Chemical DependencyFY2022 Update: Avera Flandreau continued to improve public awareness of health care service options for individuals dealing with mental health concerns or chemical dependency. In January 2022, Avera Flandreau provided space in the clinic for a community mental health counselor and routinely makes referrals to this professional. Avera Flandreau Hospital provides financial support for the Hope Squad for education on suicide prevention through the Flandreau High School. The hope-squad program is an educational-school based, peer to peer curriculum. Their goals are preventing suicide though public awareness and education, reducing the stigma, and serving as a resource to those touched by suicide. Also in January 2022, Avera Flandreau co-sponsored an event at the high school that brought in a speaker from Emily's Hope to share the personal experience of the difficulties of dealing with a family member's drug overdose and how the drug use affected the whole family. The talk was followed by a question and answer session from the students.
Avera Hand County Memorial Hospital Part V, Section B, Line 11: Avera Hand County conducted a community health needs assessment during FY2022. After review of the primary and secondary data, the Hand County leadership team weighed the findings against available resources and potential sustainability. These criteria were used as they prioritized the identified needs.Based on the results of this assessment, Avera Hand County is committed to addressing the following prioritized community health needs: Mental Health Access and Resources. Health & Weight Management and Maintenance.The following actions will be taken in future years to address the identified and prioritized community health needs:Mental Health Access and Resources Work with the 211 center to review and update resource availability for the Hand County area. Evaluate contracting a Psychologist or Psychiatrist to aid in mental health care. Evaluate expansion ideas within the current resources to assist with mental health needs of the community. Evaluate the feasibility of expanding local mental health provider services. If deemed feasible, the hospital will commit financial resources and staff time for development, implementation, and sustainability. Increasing outpatient mental health care availability may decrease emergency visits due to mental health diagnoses.Health & Weight Management and Maintenance Use the hospital and clinic's Facebook platform to offer health, fitness and lifestyle education. Work with our primary clinic and contracted dietician to increase referrals through primary care to the dietician service. Identify opportunity areas for increased referrals, collaborate with the dietician, and implement the plan. Increase patient knowledge regarding proper nutrition habits, helping improve overall health outcomes.Avera Hand County continued to address the community health needs identified in the community health needs assessment completed in 2018. The following actions were taken to address the identified needs:Disease prevention and maintenanceAvera Hand County Memorial Hospital, along with Avera Medical Group-Miller, has created a Facebook page to provide education for the public. Avera has assisted with educational information to be posted on a regular basis to keep the community informed. This tool has provided positive feedback in the past year with the pandemic. FY2022 Update: The Facebook page continued to be an excellent source to provide education to the public regarding disease prevention and health maintenance. The hospital and clinic distributed at least one healthcare conditional topic per month. In January 2022, the hospital and clinic participated in the local Farm and Home Show by offering immunization information, educational handouts on fall risk and balance impairments, and complimentary blood pressure checks. In an effort to improve access and safety to entering the wellness center, the Avera Hand County CHNA committee met with the local wellness center board to request the installation of an automatic door opener. The installation was complete in fall 2021.Access to Specialty CareThe need for more access to specialty providers and a local dialysis program were a top priority. While we have a number of specialists who do outreach here, there is a need for more. We implemented eCare access to social workers for mental health services and continued to work with Community Counseling services from Huron. The eConsult program was started to offer visits for specialty providers within the Avera system. FY2022 Update: Avera Hand County continues to utilize the eservices allowing for more access to specialty care in the community. The specialties available through eConsult platform include hepatology, gynecology, and gastroenterology. Virtual Psychiatry services are available through eEmergency/eBehavioral Health in the emergency department. This includes 24/7 access to psychiatry assessment and consult for emergency department patients.
Avera Merrill Pioneer Hospital Part V, Section B, Line 11: Avera Merrill Pioneer conducted a community health needs assessment during FY2022. After review of the primary and secondary data, the Avera Merrill Pioneer leadership team weighed the findings against available resources and potential sustainability. These criteria were used as they prioritized the identified needs.Based on the results of this assessment, Avera Merrill Pioneer is committed to addressing the following identified significant community health needs:1. Improving the mental health of the community 2. Obesity3. Improve utilization of preventative careThe following actions will be taken by the hospital in future years to address the community health priority areas.Improve access to Mental Health services in Lyon County- Screen all patients for depression or mental health care needs.- Continue to participate in the Lyon County Mental Health Coalition to discuss mental health amongst school age individuals.- Utilize the services available through the expanded Avera Behavioral Hospital.Provide services and promote a healthy lifestyle- Collaborate with local grocery store to provide healthy recipes for community members to utilize.- Provide education to promote healthy eating.- Collaborate with the City of Rock Rapids to provide additional exercise opportunities for the community.Provide preventative care services to promote the health of the community- Improve immunization compliance with patients.- Improve management of chronic health conditions.- Promote completion of preventative health screenings.Avera Merrill Pioneer decided to do an abbreviated CHNA in 2020 due to the COVID pandemic. By performing a second CHNA in 2022, Avera Merrill Pioneer was able to align with Avera McKennan's CHNA schedule. Due to the COVID pandemic, information was obtained utilizing different methods to limit the exposure of those collecting the data. The short timeframe between the two Community Health Needs Assessments made it difficult to effectively evaluate the impact the initiated interventions had on the health of the community the facility serves.The following actions were taken during FY2022 to address the needs identified, mental health, obesity and chronic health conditions, in the prior community health needs assessment:Telehealth equipment has been added to the Avera Medical Group Clinic to provide telehealth services for mental health counseling. This does not add to the number of mental health providers for Lyon County, but it does help bridge the gap in areas lacking Mental Health Providers professionals. Avera Merrill continues to screen for depression and mental health care needs for patients with each admission.Interventions were implemented to manage chronic health conditions and improve the quality of life of these individuals. Interventions implemented included promotion of physical activity, promotion and education related to healthy eating, identification of individuals with chronic health conditions to optimize their health care regimen, reviewing immunizations at clinic appointments and offering vaccines to eligible patients, and offering screening of chronic disease to improve quality of life through early treatment and management of disease process. Patients seen within the facility are assessed for diabetes and pre-diabetes. Patients diagnosed with diabetes/pre-diabetes are offered diabetic education classes with our facilities' diabetic educator and dietician. Patients are taught healthy eating, maintenance of blood glucose levels, maintenance of a healthy weight, and medication management of diabetes. Patients with chronic health conditions are referred to coordinated care upon discharge from facility to ensure that patients' care plans continue to be met post-discharge. These patients receive post discharge phone calls and follow-up appointments seven to fourteen days after discharge to ensure continued improvement in their condition.
Avera McKennan Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Gregory Healthcare Center Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Milbank Area Hospital Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Dells Area Health Center Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Flandreau Medical Center Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Hand County Memorial Hospital Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera Merrill Pioneer Hospital Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.
Avera McKennan Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement.
Avera Gregory Healthcare Center Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera Milbank Area Hospital Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera Dells Area Health Center Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera Flandreau Medical Center Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera Hand County Memorial Hospital Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera Merrill Pioneer Hospital Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency rooms, waiting rooms, and admissions office and included on the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.
Avera McKennan Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Gregory Healthcare Center Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Milbank Area Hospital Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Dells Area Health Center Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Flandreau Medical Center Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Hand County Memorial Hospital Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera Merrill Pioneer Hospital Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.
Avera McKennan Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Heart Hospital of South Dakota, LLC Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Gregory Healthcare Center Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Milbank Area Hospital Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Dells Area Health Center Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Flandreau Medical Center Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Hand County Memorial Hospital Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Avera Merrill Pioneer Hospital Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.
Part V, Section B, line 7a: Hospital facility's website for CHNA:avera.org/about/community-health-needs-assessments/
Part V, Section B, line 10a: Hospital facility's website for Implementation Strategy:avera.org/about/community-health-needs-assessments/
Part V, Section A website addresses: Avera McKennanavera.org/locations/mckennan/Heart Hospital of South Dakota, LLCavera.org/locations/heart-hospital/Avera Milbank Area Hospitalavera.org/locations/profile/milbank-area-health-care-campus/Avera Gregory Healthcare Centeravera.org/locations/profile/avera-gregory-hospital/Avera Dells Area Health Centeravera.org/locations/profile/avera-dells-area-hospital/Avera Flandreau Medical Centeravera.org/locations/profile/avera-flandreau-hospital/Avera Hand County Memorial Hospitalavera.org/locations/profile/avera-hand-county-memorial-hospital/Avera Merrill Pioneer Hospitalavera.org/locations/profile/avera-merrill-pioneer-hospital/
Part V, Section B, line 11 Avera McKennan: Implementation Strategy continued for Avera McKennan and Heart Hospital of South Dakota, LLC:Avera McKennan and Heart Hospital of South Dakota, LLC continued to address the community health needs identified in the community health needs assessment completed in 2018. The following community health priority areas were identified and the following actions were taken during FY22.ACCESS TO CAREExpand patient transportation program. Review current partnerships and explore new opportunities with transportation providers.Workforce transportation pilot program. Conduct a pilot program to assist qualified staff with transportation on a case-by-case basis.Avera's transportation program slowed during Covid due to the lack of drivers in the market and the transition of in-person visits to virtual care. Overall, however, Avera's transportation program has expanded to include additional departments and users and continues to be an important community health benefit directed at reducing barriers to care. Avera's workforce transportation program has continued and is also utilized on a case-by-case basis for qualifying employees in high-needs areas. Additionally, Avera applied for and received grant funding to supplement paratransit services for patients accessing health care services located outside paratransit service boundaries. FY2022 Update: The Paratransit Grant project began service in the fall of 2021 and has expanded to include qualifying patients on an inpatient and outpatient basis. Avera continues to explore additional transportation options to address community and workforce needs.BEHAVIORAL HEALTH AND SUBSTANCE ABUSEInvestigate adding a 4th wing at Avera Behavioral HealthFY2022 Update: A new 4-story wing at Avera Behavioral Health opened in March 2022. The new wing will increase access to services for all ages and specifically include an additional child behavioral health unit, an adolescent addiction inpatient residential unit, bringing the senior unit onto the campus, adding four new adult beds, expanding the partial hospital program, and 24/7 psychiatric urgent care unit.Partner with Community-Based Triage Center. Support the development of a community-based triage center to assist residents in accessing resources for addiction treatment, behavioral health, and other needs.FY2022 Update: Opened community triage center "The Link" in partnership with Sanford, City of Sioux Falls, Minnehaha County and Avera. Avera BHS was chosen as the operator. Over 2,500 clients have benefitted from the services since opening on June 1, 2021.CHRONIC DISEASE PREVENTIONOne Sioux Falls Project. Address social determinants of health, seek opportunities to actively support the One Sioux Falls framework that includes accessible housing, engaging people, health and safety, and workforce development.FY2022 Update: Avera remains part of the One Sioux Falls Project and is a primary stakeholder in establishing the Community Health Needs priorities through a new CHIP (community health improvement program) process. One Sioux Falls established a guiding framework for addressing social determinants of health and improving the quality of life in the Sioux Falls area. The framework included four core elements: engaging people, workforce, safety & health, and accessible housing.FY2022 Update: Avera continues to offer the Planet Heart program in communities in their footprint. The Planet Heart program offers heart and vascular screening. The program, along with tests for cholesterol and other factors, help people know their numbers as they relate to cardiac health.Healthy Food Program. Pursue program designed to prevent and limit weight gain and improve overall physical health for qualified individuals in Avera's Coordinated Care Program.Food Education Program. Create education programming focused on selecting, storing and utilizing healthier food options. Partner with Healthy Weight Project. Pursue policy, system and environmental changes to maintain or increase the percentage of people living at a healthy body weight.Avera is committed to being our patients' partner in good health. Healthy eating and maintaining a healthy weight are important steps in good health. Avera has adopted policies to encourage healthy eating. All Avera McKennan kitchens always offer healthier meal options including, but not limited to, lean entrees, salads, sides and desserts. Food vendors must meet specific criteria to ensure the health and safety of customers and patients. Avera looks for local, fresh, and sustainable products to promote health and wellness of patients and the community. Vending machine operators are encouraged to offer healthier options. Avera has developed and promoted various healthy eating and weight loss education materials. Education materials can be found on the Avera website, in physician clinics, Avera hospitals, as well as various locations around the community. Avera hosts and participates in community events to educate and promote healthy eating and healthy weight lifestyles.
Part V, Section B, Line 16a, 16b, and 16c: www.avera.org/patients-visitors/charity-patient-assistance-programs/
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 9
Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?42
Name and address Type of Facility (describe)
1 1 - Avera McKennan Behavioral Health Center
4400 W 69th St
Sioux Falls,SD57108 		Inpatient & Outpatient behavioral health services
2 2 - Avera Plaza 2 Pharmacy
1301 S Cliff Avenue
Sioux Falls,SD57105 		Retail pharmacy
3 3 - Avera Prince of Peace
4500 S Prince of Peace Place
Sioux Falls,SD57103 		Skilled nursing facility
4 4 - Avera McKennan Home Infusion
1020 S Cliff Avenue
Sioux Falls,SD57105 		Comprehensive home infusion therapies & supplies
5 5 - McKennan Regional Laboratory
1325 S Cliff Avenue
Sioux Falls,SD57105 		Laboratory services
6 6 - Avera Medical Group Worthington
1216 Ryans Road
Worthington,MN56187 		Primary care clinic
7 7 - Avera Rosebud Country Care Center
300 Park Avenue
Gregory,SD57533 		Skilled nursing facility
8 8 - Avera McKennan Fitness Center
3400 S Southeastern Drive
Sioux Falls,SD57105 		Fitness center
9 9 - Avera 69th Street Pharmacy - Behavioral
4400 W 69th St Suite 300
Sioux Falls,SD57108 		Retail pharmacy
10 10 - Avera Medical Group Windom
820 - 2nd Avenue
Windom,MN56101 		Primary care clinic
11 11 - Avera McKennan Hosp & Univ Campus Pharm
1325 S Cliff Avenue
Sioux Falls,SD57105 		Retail pharmacy
12 12 - Avera Institute for Human Genetics
4400 W 69th St Suite 200
Sioux Falls,SD57108 		Genetic research program
13 13 - Laurel Oaks Apartments
4510 S Prince of Peace Place
Sioux Falls,SD57103 		Independent living apartments
14 14 - Avera Medical Group Sibley
600-9th Avenue North
Sibley,IA51249 		Primary care clinic
15 15 - Avera Research Institute
3720 W 69th St
Sioux Falls,SD57108 		Clinical research studies
16 16 - Avera Dermatology Pharmacy
6701 South Minnesota Avenue
Sioux Falls,SD57108 		Retail pharmacy
17 17 - Avera Medical Group Occupational Med
2100 S Marion Rd
Sioux Falls,SD57106 		Business and corporate health care clinic
18 18 - Avera Medical Group Women's Midlife Care
911 East 20th Street - Suite 200
Sioux Falls,SD57105 		Women's services clinic
19 19 - AveraNow Clinic
3000 S Minnesota Ave
Sioux Falls,SD57105 		Primary care clinic
20 20 - Avera Medical Group Big Stone City
451 Main Street
Big Stone City,SD57216 		Primary care clinic
21 21 - Hegg Medical Clinic Avera
2121 Hegg Drive
Rock Valley,IA51247 		Primary care clinic
22 22 - Health Care Clinic
300 North Dakota Avenue Suite 117
Sioux Falls,SD57104 		Free healthcare clinic
23 23 - Community Blood Bank
1301 South Cliff Avenue Suite 3
Sioux Falls,SD57105 		Community blood services
24 24 - Yorkshire Eye Clinic
2311 Yorkshire Drive
Brookings,SD57006 		Ophthalmology and optometry clinic
25 25 - Avera Medical Group Estherville
926 North 8th Street
Estherville,IA51334 		Primary care clinic
26 26 - Rural Medical Clinics
301 South Walnut Street
Freeman,SD57029 		Primary care clinic
27 27 - Dakota Family Medical Center
101 South Front PO Box 27
Chamberlain,SD57325 		Primary care clinic
28 28 - Pipestone Medical Group Avera
920 - 4th Avenue SW
Pipestone,MN56164 		Primary care clinic
29 29 - Avera Medical Group McGreevy Salem
740 South Hill
Salem,SD57058 		Primary care clinic
30 30 - Avera Medical Group Larchwood
916 Holder Street PO Box 8
Larchwood,IA51241 		Primary care clinic
31 31 - Avera Medical Group Butte
730 Wilson Street
Butte,NE68722 		Satellite primary care clinic
32 32 - Avera Medical Group Elkton
203 Elk Street
Elkton,SD57026 		Satellite primary care clinic
33 33 - Avera Medical Group Fulda
201 N St Paul Avenue
Fulda,MN56131 		Satellite primary care clinic
34 34 - Avera Medical Group Lakefield
221 - 3rd Avenue
Lakefield,MN56150 		Satellite primary care clinic
35 35 - Avera Medical Group Volga
210 Kasan Avenue
Volga,SD57071 		Satellite primary care clinic
36 36 - Avera Addiction Care Center
6140 S Curae Lane
Sioux Falls,SD57108 		Addiction care facility
37 37 - Avera Human Performance
6800 S Louise Avenue
Sioux Falls,SD57108 		Sports medicine and training facility
38 38 - Avera Medical Group George
101 N Main Street
George,IA51237 		Primary care clinic
39 39 - AMG-McGreevy Dawley Farm Urgent Care
1035 South Highline Place
Sioux Falls,SD571101000 		Urgent care
40 40 - AMG-McGreevy Family Hlth Ctr Urgent Care
2100 S Marion Rd
Sioux Falls,SD571063646 		Urgent care
41 41 - Avera on Louise Health Campus
6100 S Louise Ave
Sioux Falls,SD57108 		Inpatient & Outpatient Surgical Hospital
42 42 - Avera Pharmacy - SF Louise Avenue
6100 S Louise Ave
Sioux Falls,SD57108 		Retail pharmacy
Schedule H (Form 990) 2021
Schedule H (Form 990) 2021
Page 10
Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
Part I, Line 3c: The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted.
Part I, Line 7: A combination of costing methodology was used to calculate the amounts reported in the table. A cost accounting system was used to calculate Medicaid and Means-tested Government Program expenses and shortfalls and Subsidized Health Services for our tertiary medical center. A cost to charge ratio derived from Worksheet 2, Ratio of Patient Care Cost-to-Charges was used to calculate charity care at cost for all entities and Medicaid and Means-tested Government Program expenses and shortfalls and Subsidized Health Services for any operations outside of the tertiary medical center. For all other amounts, costs and revenues as reflected by the general ledger system were used.
Part I, Line 7g: Physician clinic costs for transplant services are included in subsidized health services. Revenue of $915,182 and costs of $3,163,731 were included for a net community benefit of $2,248,549. Our facility is the principal provider of bone marrow, pancreas, kidney and liver transplant services throughout our service area, with the clinics as a crucial component of successful pre- and post-transplant care.
Part II, Community Building Activities: The community building activities include monetary assistance to organizations that focus their efforts on providing neighborhood improvement projects in high needs areas, children and youth development programs, local economic development, and job creation and training programs.
Part III, Line 2: The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents.
Part III, Line 4: The footnote to the Organization's financial statements that describes implicit price concession is located in the audited financial statement report on pages 17 and 18.
Part III, Line 8: The Medicare revenues received (line 5), allowable costs (line 6), and the resulting loss (line 7) does not include a significant portion of the Organization's expenses. These lines require use of the Medicare cost report as prepared by the required guidelines which disallows numerous costs of hospitals, particularly if they are part of an integrated system such as Avera McKennan. In these cases, the entity must file a home office cost report which "steps down" overhead to non-cost report entities disproportionately to actual allowable share and essentially removes the costs from the hospital's cost report entirely. Examples of a portion of these overhead costs would be finance, business office, information technology, human resources and administration. Examples of non-cost report entities operated by Avera McKennan include clinics, mobile imaging services, long-term care facilities, and other health care related businesses. There are also costs completely disallowed by cost report rules such as bad debt expense, hospitalists care, CRNA's, and interest expense. Avera McKennan also receives a Medicare Disproportionate Share Hospital (DSH) adjustment as part of the cost report due to its significant number of low-income patients served. Part III, line 5 requires inclusion of this revenue though expenses included are much lower. Schedule H instructions also require the exclusion of $9,642,591 of Medicare losses because they are included in Schedule H, Part 1, Line 7f or 7g. Including the Medicare percentage of disallowed costs, entities which don't file a cost report but nevertheless care for Medicare patients, and the impact of the home office cost report, the Medicare shortfall is $109,984,426 as opposed to a shortfall of $25,090,311.Avera McKennan follows the Catholic Health Association 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.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 & Medicaid Services.
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 current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven.
Part VI, Line 2: Community needs assessment occurs at various points in the system. Through annual strategic planning sessions, community leaders are brought in to update and educate Avera McKennan board members and administrative council on the successes, challenges, and service gaps in the community. Examples include community health workers, community health program leaders, community non-profit leaders, school district officials, state health department officials, and community health organizations. Leaders also serve on boards of various community organizations which seek to address the health and well-being of community members. Local governing boards of outlying facilities, who are members of the community, discuss and help direct resources to areas of targeted needs as well.
Part VI, Line 3: Uninsured patients who hold an inpatient status are counseled by a Patient Advocate to screen them for coverage eligibility and to assist in payer source enrollment. Those that are not eligible are provided a charity care application along with instructions on how to fill out the application. All patients receive statements that indicate who to contact should they need financial assistance. In addition, all patients receive a summary of financial assistance upon registration, as well as in their final statement. Should a patient contact Patient Financial Services and indicate inability to pay, they are transferred to a financial counselor to assist them with the financial assistance application process. Also, inpatient and same day surgery patients receive a brochure in their admissions packet. Pre-collection letters also include information regarding the financial assistance and uninsured programs.
Part VI, Line 4: Avera McKennan's service area is a largely rural population. Services are provided through a health care network of clinics, critical access hospitals and tertiary facilities covering communities in four states. The main tertiary facility is in a population center of over 196,500 served by another non-profit hospital of similar size, Veterans Administration Hospital, a hospital dedicated to diagnosis and treatment of heart disease, and a hospital for children with special health care needs. Outside of this population center, most of the communities served have less than 4,000 residents. The primary service area includes four counties covering approximately 2,600 square miles and contains seven federally designated medically underserved communities. Per the 2021 U.S. Census Bureau QuickFacts data, an average of 8.075% of residents in the primary service area are at or below the poverty level. Our secondary service area covers an additional 17 counties in South Dakota, Iowa, and Minnesota.
Part VI, Line 5: Surplus funds are reinvested in facilities to improve patient care.Medical staff privileges are extended to all qualified physicians in the community. The Avera McKennan Board of Trustees is principally comprised of community members from the primary service area. Members come from a variety of backgrounds ranging from private industry and banking to healthcare.Avera McKennan is a verified Level II trauma center and was the first such Center in the State of South Dakota. Avera McKennan's Emergency Department is staffed 24 hours a day with board-certified emergency specialists and provides emergency care regardless of ability to pay. Avera McKennan had 38,730 Emergency Department visits in FY 2022. Operating both Fixed Wing and Helicopter medical air transports, Avera McKennan's flight teams cover a large geographic area providing state-of-the-art air transport services and access to critical care, with 2,627 flights in the past year.Health Care Clinic: In 1992, Avera McKennan established a Health Care Clinic to provide free care for people who are uninsured or underinsured in the community. The clinic is managed by a Registered Nurse and staffed by Registered Nurses, two midlevel providers, medical residents and volunteer health care providers. The goal of the clinic is to prevent or treat patients' medical conditions before they become catastrophic. The clinic averages 366 visits per month. The clinic provides preventative care, diagnosis and treatment of illnesses and injuries, medication assistance and assistance in obtaining specialist care for patients with complex cases. The clinic also serves to train physicians, nurses and other health care students. It provides a free evening clinic one evening per month, staffed by medical students under supervision of physicians. Avera McKennan is the only health care organization to provide free services such as this in the state of South Dakota. The clinic had 4,394 visits in 2022 and was operated at an annual cost of $1,176,955. Partnership in Live Well Sioux Falls: The City of Sioux Falls received a Community Health Transformation Grant from the South Dakota Department of Health, sparking a project to improve the health and well-being of the citizens of Sioux Falls. Guided by the City of Sioux Falls Health Department, this ongoing project is known as Live Well Sioux Falls. It involves more than 24 community partner organizations. Among these partners are Avera McKennan and the other major health care system in Sioux Falls, Sanford Health. Avera plans to work in partnership with the City of Sioux Falls and Sanford Health to address the priorities of Live Well Sioux Falls and arrive at solutions which are collaborative in nature.Avera McKennan collaborates with Live Well Sioux Falls to promote the Big Squeeze, a hypertension initiative in April to promote blood pressure screening and education, with the goal of diagnosing high blood pressure. One in three American adults have high blood pressure, but only half of them have it under control, adding to the risk of stroke, heart attack and vascular disease.Residency/Health Professions Training and Internships: In 2021, Avera McKennan had approximately 55 medical residents in training at Avera McKennan in Internal Medicine, Family Practice, Psychiatry, Geriatrics and Transitional Residency Programs offered in partnership with the University of South Dakota School of Medicine. Over 1,000 students in medicine, nursing, pharmacy, physician assistant programs, medical assisting, radiology and respiratory therapy also completed clinical rotations at Avera McKennan. In non-clinical areas, Avera McKennan offers paid and nonpaid internships in the areas of research, finance, administration, therapies, exercise science and social work. Avera McKennan is currently legally affiliated with approximately 158 institutions of higher education.Patient and Community Education: Avera McKennan is a regional leader in offering educational programs for a variety of learners, leaders and employees. Utilizing advanced technology, many of these programs are provided electronically throughout the tri-state area. Educational sessions are offered to medical staff, employees, health care professionals, students at all levels and the general public. Utilizing Avera McKennan's Education Center, a broad cross-section of classes involving diverse audiences are provided as a community service each year.1. Online resources: Avera McKennan offers vast free patient educational online resources on its public website on numerous health topics, with suggestions for lifestyle change, behavior modification and management for improved health.2. To Be Well free education events were held on topics including orthopedics, cancer, diabetes, weight loss/healthy eating, multiple sclerosis, anxiety and acupuncture. 3. Forums: The Avera Behavioral Health Center offers free Friday Forums, in which school counselors and therapists are invited to presentations on children's mental health topics such as conflict cycles, reactive attachment disorder, depression and bipolar disorder in children, and teen substance use, abuse and addiction. 4. The Avera Behavioral Health Center offers free monthly educational sessions on various topics followed by discussion for adults who have been impacted by a loved one's mental illness. Topics have included grief and loss, anxiety, and parenting strategies for managing challenging behaviors.5. Women's & Children's Services: Avera McKennan's Women's & Children's Services offers a number of parenting and community education opportunities, for free or at a minimal cost. In fiscal year 2022, 52 childbirth education classes were held with 194 attendees. A total of 16 parent and family education classes were held with 249 attendees. A total of 55 car seats were issued through the South Dakota Child Safety Seat Distribution Program. Free burn education was provided to 6,055 students during presentations in schools.6. Daycare training: Free of charge, Avera McKennan offers two in-service training sessions per month to daycare providers through EmBe, with a total of 12 scheduled annually, and additional sessions for requested topics. Support groups: Avera McKennan offers approximately 10 free support groups. They range in topic from cancer to liver disease, diabetes, bone marrow transplant, stroke and grief and loss. The organization provides free meeting space as well as speakers and leaders. Information and Assistance: Avera McKennan operates a 24-hour Medical Call Center, through which patients have access to nurse triage at no cost to the patient. Patients can call a toll-free number and talk personally with a Registered Nurse to ask health questions or receive general health information. Avera McKennan's web site also provides an extensive health library that consumers can access free of charge.Interpreter service: Avera McKennan employs two full-time, two part-time and one PRN Spanish interpreter in-house, and also employs two Community Outreach Consultants that can serve as interpreters for Arabic, Amharic, Oromo, Russian and Kunama. Their services are offered to patients free of charge. In addition, in cooperation with external agencies, Avera McKennan is able to handle 210 different languages and dialects through phone, video remote interpreting and other means. Interpretation services are available for patients when they are at Avera McKennan in person, or when they call by phone. All the above services are provided at no cost to the patient.Transport to Transplant: Avera McKennan developed the Transport to Transplant project, which removes transportation barriers for patients from rural areas which may prevent them from completing the evaluation and testing needed for kidney and/or pancreas transplant. A van funded through a grant from the Avera McKennan Foundation is used to transport patients who demonstrate a financial need. Patients are brought to the Avera Transplant Institute for a condensed multi-day evaluation with all testing and visits completed in less than one week. Ultimately, the project results in improved morbidity and mortality, as kidney transplant doubles patient survival as compared to remaining on dialysis.Continued below.
Part VI, Line 6: Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance.
Part VI, Line 5, continued: Avera Family Wellness: This program is designed to support families and children in need of early intervention mental health services. The families have direct access to mental health services when needed. This program combines positive activities like mental health therapy (our therapists are specifically trained in dealing with high need families, a variety of play therapies and addressing issues of childhood trauma), psychiatry, family and school coordination and classroom enrichment services. Referrals come from the early childhood program, as well as our four partner elementary schools. The goal is to lessen the number of adverse childhood experiences to improve the chances for children living in poverty to be successful in school and in life. Families with the most difficult situations are being referred by the school district. We have plans to increase our staff to grow this program as we will see now more than ever, there is a need for these services due to the impact of COVID-19 and other stressors in our community, schools and families.The Walsh Family Village: This hospitality house complex adjacent to the Avera McKennan campus provides a home away from home for patients and their families who come for care at Avera McKennan from outside of Sioux Falls. The project was funded by donations and is operated by Avera McKennan. Eleven guest rooms are available. Avera McKennan also donates use of the building in the complex for a Ronald McDonald House for families of pediatric patients. If they can afford it, guests are charged a low fee per night. Guests are not turned away due to inability to pay the fee. Employees regularly donate non-perishable food items to stock a food pantry for guests. In fiscal year 2022, the Walsh Family Village served 430 guests, staying in 1,959 nightly rooms, a 77.76% occupancy. Avera McKennan provides a subsidy of approximately $128,336 per year to operate the hospitality complex. Prevention and support of substance use disorder: Avera McKennan is a partner with Face it TOGETHER, Inc., a nonprofit organization which serves as the local face and voice of recovery from addiction through its recovery support services, advocacy and awareness programs. Avera has been a partner with Face it TOGETHER since its inception, and in a recent awareness campaign.Community Connections: Avera McKennan reaches out to people and communities throughout eastern South Dakota, southwestern Minnesota and northwest Iowa through Home Town Connections. Providing a critical feedback link to local referring doctors, this program completes the communications link necessary to keep local health care providers current on the treatment of their patients at Avera McKennan.Support of the arts and cultural life: Avera McKennan hosts Sioux Falls' only indoor SculptureWalk. Artists donate sculptures for one year, which are placed at locations throughout Avera McKennan's campus, in buildings connected by skywalks. Brochures contain a map, and visitors who follow the route suggested walk approximately 1 mile, making this a healthy as well as a cultural journey.Community Benefits: Avera McKennan provides additional community benefits including: support of youth programs; homeless programs; community arts programming; health prevention; awareness and education about cancer, heart disease and other conditions; and support of the Sioux Empire United Way and other services in the region. All the programs did continue at least virtually during the pandemic. All our partners were able to be nimble and deliver services in new and creative ways, always keeping safety at top of mind during the pandemic.
Schedule H (Form 990) 2021
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Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
lBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
Avera McKennan
 
Employer identification number
46-0224743
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient
that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC section
(if applicable)		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
noncash assistance		 (h) Purpose of grant
or assistance
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
 
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2021

Schedule I (Form 990) 2021
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of
recipients		 (c) Amount of
cash grant		 (d) Amount of
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1) Scholarships 29 38,946      
(2) Assistance with medical expenses 3934 512,162      
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.
Return Reference Explanation
Part I, Line 2: The governing board and management develop programs which enhance the charitable mission of the Organization. Disbursement for grants or assistance for these programs are made in accordance with prescribed procedures and are subject to conditions established by the Organization's governing board and management, which are designed to ensure that individuals and organizations receiving grants or assistance are adequately investigated to ensure that they are qualified recipients.
Schedule I (Form 990) 2021



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Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? .............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
 
No
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ....................
5a
 
No
b
Any related organization? .......................
5b
 
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ..................
6a
 
No
b
Any related organization? ......................
6b
 
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation in column (B) reported as deferred on prior Form 990
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1Todd Zimprich MD
Neurology 		(i)

(ii)		 855,062
-------------
0 		959,691
-------------
0 		20,772
-------------
0 		14,500
-------------
0 		32,914
-------------
0 		1,882,939
-------------
0 		0
-------------
0
2Richard Conklin MD
Hematology/Oncology 		(i)

(ii)		 1,404,282
-------------
0 		9,100
-------------
0 		28,109
-------------
0 		14,500
-------------
0 		40,940
-------------
0 		1,496,931
-------------
0 		0
-------------
0
3Alex Linn MD
Neurology 		(i)

(ii)		 979,153
-------------
0 		373,743
-------------
0 		90,358
-------------
0 		14,500
-------------
0 		30,915
-------------
0 		1,488,669
-------------
0 		0
-------------
0
4Travis Liddell MD
Surgery/Orthopedics 		(i)

(ii)		 1,038,026
-------------
0 		193,240
-------------
0 		126,290
-------------
0 		14,500
-------------
0 		37,191
-------------
0 		1,409,247
-------------
0 		0
-------------
0
5Brian Knutson MD
Dermatology 		(i)

(ii)		 1,059,836
-------------
0 		232,378
-------------
0 		9,532
-------------
0 		14,500
-------------
0 		30,914
-------------
0 		1,347,160
-------------
0 		0
-------------
0
6David Flicek
President 		(i)

(ii)		 0
-------------
1,254,501 		0
-------------
10,650 		0
-------------
25,975 		0
-------------
14,500 		0
-------------
30,702 		0
-------------
1,336,328 		0
-------------
0
7Julie Lautt
CFO Avera Health; Sec/Treas 		(i)

(ii)		 0
-------------
1,032,072 		0
-------------
10,440 		0
-------------
8,716 		0
-------------
14,500 		0
-------------
1,694 		0
-------------
1,067,422 		0
-------------
0
8Cristina Hill Jensen MD
Board Trustee/Gastroenterology 		(i)

(ii)		 728,663
-------------
0 		115,824
-------------
0 		6,052
-------------
0 		14,500
-------------
0 		32,414
-------------
0 		897,453
-------------
0 		0
-------------
0
9Jawad Nazir MD-Board Trustee
Infectious Disease & Internal Med 		(i)

(ii)		 520,133
-------------
0 		134,124
-------------
0 		6,329
-------------
0 		14,500
-------------
0 		33,664
-------------
0 		708,750
-------------
0 		0
-------------
0
10Michael Elliott - Sr Vice
President Medical Affairs/CMO 		(i)

(ii)		 533,578
-------------
0 		285
-------------
0 		5,766
-------------
0 		14,500
-------------
0 		31,255
-------------
0 		585,384
-------------
0 		0
-------------
0
11Jared Friedman MD
Board Trustee/Chief of Staff 		(i)

(ii)		 0
-------------
512,162 		0
-------------
240 		0
-------------
2,966 		0
-------------
14,500 		0
-------------
40,230 		0
-------------
570,098 		0
-------------
0
12Lori Popkes
Sr Vice President 		(i)

(ii)		 384,052
-------------
0 		285
-------------
0 		4,908
-------------
0 		11,791
-------------
0 		32,754
-------------
0 		433,790
-------------
0 		0
-------------
0
13Curtis Hohman
Sr Vice President 		(i)

(ii)		 382,864
-------------
0 		5,480
-------------
0 		12,660
-------------
0 		14,500
-------------
0 		11,070
-------------
0 		426,574
-------------
0 		0
-------------
0
14Rick Kooima MD
Board Trustee/Chief of Staff 		(i)

(ii)		 268,353
-------------
0 		22,825
-------------
0 		6,597
-------------
0 		14,500
-------------
0 		32,914
-------------
0 		345,189
-------------
0 		0
-------------
0
15Steve Petersen - Former Key
Employee VP-Pharmacy 		(i)

(ii)		 0
-------------
139,372 		0
-------------
0 		0
-------------
148,019 		0
-------------
14,394 		0
-------------
15,249 		0
-------------
317,034 		0
-------------
0
16Alisa Reindl MD
Board Trustee/Family Medicine 		(i)

(ii)		 204,484
-------------
0 		32,885
-------------
0 		2,369
-------------
0 		11,995
-------------
0 		11,056
-------------
0 		262,789
-------------
0 		0
-------------
0
17Sandra King
Director Operative Services 		(i)

(ii)		 186,098
-------------
0 		9,616
-------------
0 		2,867
-------------
0 		9,878
-------------
0 		10,700
-------------
0 		219,159
-------------
0 		0
-------------
0
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference Explanation
Part I, Line 4a Steve Petersen received $136,074 as a former key employee VP Pharmacy.
Schedule J, Part I, Line 3: The President is compensated by Avera Health. Avera McKennan relied on the related organization for determining the compensation for the President using the methods described in Part I, Line 3.
Schedule J (Form 990) 2021

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Schedule L
(Form 990)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ.
MediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No
2
Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e) Original principal amount (f) Balance due (g) In default? (h) Approved by board or committee? (i) Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990) 2021
Schedule L (Form 990) 2021
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) Deann Matthiesen Family of Key Employee 140,537 Employee compensation   No
(2) Kristy Mickelson Family of Key Employee 40,166 Employee compensation   No
(3) Grant Flicek Family of Officer and Board Trustee 99,128 Employee Compensation   No
(4) Ashley Steffen Family of Former Key Employee 90,040 Employee Compensation   No
(5) Kelsey Knecht Family of Board Trustee 51,265 Employee Compensation   No
(6) Tina Lautt Family of Officer 52,416 Employee Compensation   No
Part V
Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).
Return Reference Explanation
Schedule L (Form 990) 2021


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SCHEDULE O
(Form 990)

Department of the Treasury
Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Return Reference Explanation
Form 990, Part III, line 2 A new four-story wing on the Avera Behavioral Health Hospital was opened adding several new and enhanced services for children, youth, adults and seniors. The services include 24/7 Behavioral Health Urgent Care, 23-Hour observation care, residential addiction care for youth, partial hospitalization services for youth and specialized care unit for children and adolescents. The new wing also houses the Avera senior behavioral unit which will allow for continuity of mental health services while enhancing and expanding the behavioral health program.
Form 990, Part VI, Section A, line 2 David Flicek, Steve Petersen, Jared Friedman, MD and Julie Lautt 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 section 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, all members of the board of directors.
Form 990, Part VI, Section A, line 7b Avera Health, as the sole member, 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. 16) To initiate and give final approval to equity and asset transfers by and between the Member and the Corporation and any affiliates or subsidiaries of the Member. 17) To initiate and give final approval to (i) any and all issuances of obligations under any existing or future master indentures binding the Corporation, any indebtedness (including, without limitation, capitalized leases) in excess of dollar thresholds as may be from time to time established by the Member, and (ii) any pledges of collateral for such indebtedness and any pledges of real estate as collateral for any indebtedness regardless of amount. 18) Full and exclusive power to execute supplemental master indentures, including, without limitation, those authorizing the issuance of obligations or series of obligations, (ii) full and exclusive power to prepare, or authorize the preparation of, any and all documents, agreements, swap agreements, investment contracts, certificates and disclosure materials (including, without limitation, Official Statements and any supplements thereto) reasonably and ordinarily prepared in connection with the issuance of obligations thereunder, or related bonds associated therewith and to execute and deliver such items to the appropriate parties in connection therewith and (iii) full and exclusive power to authorize the entrance of members to, or withdrawal of members from, any obligated group, subject to the other requirements of the applicable master indenture for such entrance or withdrawal.
Form 990, Part VI, Section A, line 8b Avera does not have any committees with authority to act on behalf of the governing body.
Form 990, Part VI, Section B, line 11b The Form 990 is reviewed by the Avera Health VP of Financial Reporting, Tax Manager, Facility CEO and Finance Committee (if applicable). After initial review the Form 990 is made available to the Board and other Operation Finance Leaders.
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 and CFO-Avera Health are 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. Depending on the individual's role with the organization, some officers and key employees are compensated by Avera McKennan.
Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not made 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 16b: There is no written policy or procedure requiring the Organization to evaluate its participation in joint venture arrangements. 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 must be approved by the board and the member.
Form 990, Part IX, line 11g Centralized services: Program service expenses 37,257,903. Management and general expenses 106,818,333. Fundraising expenses 0. Total expenses 144,076,236. Purchased services: Program service expenses 91,920,597. Management and general expenses 2,132,627. Fundraising expenses 45,482. Total expenses 94,098,706. Medical professional fees: Program service expenses 19,628,955. Management and general expenses 33,967. Fundraising expenses 0. Total expenses 19,662,922.
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 Sacred Heart, Avera Marshall, Avera St. Mary's, Avera St. Anthony's, Avera St. Benedict, Avera Holy Family, Avera Tyler, Avera Granite Falls, Avera Gettysburg and Avera at Home. 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).
Form 990, Part XI, line 9: Capital transfers, net 767,558. Other changes in unrestricted net assets 313,544. Change in interest of Avera Health Foundation -5,051,628.
Form 990, Part XII, Line 2c: The Audit Committee of Avera Health, parent organization of Avera McKennan, selects the auditor and reviews the consolidated audited financial statements for Avera Health, which inclues Avera McKennan.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990) 2021


Additional Data


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SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Avera McKennan
 
Employer identification number

46-0224743
Part I
Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity
(1) Sioux Falls Hospital Management LLC
1325 S Cliff Ave PO Box 5045
Sioux Falls,SD571175045
56-2141521 		Management company of Heart Hospital NC 2,870,694 19,565,415 West 69th Street LLC
 
(2) West 69th Street LLC
1325 S Cliff Ave PO Box 5045
Sioux Falls,SD571175045
46-0224743 		Holding company SD 2,870,694 19,565,415 Avera McKennan
 
(3) Alumend LLC
1325 S Cliff Ave PO Box 5045
Sioux Falls,SD571175045
46-0224743 		Research and development SD -2,780,973 47,817,022 Avera McKennan
 
(4) MRIS LLC
1325 S Cliff Ave PO Box 5045
Sioux Falls,SD571175045
47-0874983 		Healthcare Services SD 0 0 Avera McKennan
 




Part II
Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1)Avera St Anthony's Hospital
300 N 2nd Street

ONeill,NE68763
47-0463911 		Healthcare Services NE 501(c)(3) Line 3 Avera Health
 
 
No
(2)Avera Holy Family
826 North 8th Street

Estherville,IA51334
42-0680370 		Healthcare Services IA 501(c)(3) Line 3 Avera Health
 
 
No
(3)Holy Family Hospital Foundation
826 North 8th Street

Estherville,IA51334
42-1317452 		Support Health Related Services IA 501(c)(3) Line 10 Avera Holy Family
 
 
No
(4)St Benedict Health Center
401 West Glynn Drive

Parkston,SD57366
46-0226738 		Healthcare Services SD 501(c)(3) Line 3 Avera Health
 
 
No
(5)St Benedict Health Center Foundation
West Glynn Drive PO Box B

Parkston,SD57366
46-0458725 		Support Health Related Services SD 501(c)(3) Line 12a, I St Benedict Health Center
 
 
No
(6)Avera Health
3900 West Avera Drive STE 300

Sioux Falls,SD57108
46-0422673 		Promotion of Health SD 501(c)(3) Line 10 N/A
 
No
(7)Avera Queen of Peace
525 North Foster

Mitchell,SD57301
46-0224604 		Healthcare Services SD 501(c)(3) Line 3 Avera Health
 
 
No
(8)Sacred Heart Health Services
501 Summit Street

Yankton,SD57078
46-0225483 		Healthcare Services SD 501(c)(3) Line 3 Avera Health
 
 
No
(9)Avera Gettysburg
606 East Garfield

Gettysburg,SD57442
46-0234354 		Healthcare Services SD 501(c)(3) Line 3 Avera St Mary's
 
 
No
(10)Avera at Home
5116 S Solberg Ave

Sioux Falls,SD57108
46-0399291 		Home Services SD 501(c)(3) Line 10 Avera Health
 
 
No
(11)Lewis and Clark Health Education and Service Agency
1000 W 4th Street Suite 9

Yankton,SD57078
46-0337013 		Healthcare Services SD 501(c)(3) Line 10 Sacred Heart Health Services
 
 
No
(12)Avera St Luke's
305 South State Street

Aberdeen,SD57401
46-0224598 		Healthcare Services SD 501(c)(3) Line 3 Avera Health
 
 
No
(13)Avera St Mary's
801 East Sioux Avenue

Pierre,SD57501
46-0230199 		Healthcare Services SD 501(c)(3) Line 3 Avera Health
 
 
No
(14)Avera Marshall
300 S Bruce Street

Marshall,MN56258
41-0919153 		Healthcare Services MN 501(c)(3) Line 3 Avera Health
 
 
No
(15)Avera Tyler
240 Willow Street

Tyler,MN56178
41-0853163 		Healthcare Services MN 501(c)(3) Line 3 Avera Marshall
 
 
No
(16)Avera Health Plans Inc
3900 West Avera Drive STE 300

Sioux Falls,SD57108
46-0451539 		Health Financing and Health Plan Admin SD 501(c)(4)   Avera Health
 
 
No
(17)Avera Granite Falls
345 10th Ave

Granite Falls,MN56241
84-3156881 		Healthcare Services MN 501(c)(3) Line 3 Avera Marshall
 
 
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) Avera Home Medical Equipment of Floyd Valley Hospital LLC

714 Lincoln St NE
Lemars,IA51031
82-0582350 		Medical Services - Home Medical Equipment SD N/A
         No     No  
(2) Avera Home Medical Equipment of Sioux Center LLC

38 19th St SW
Sioux Center,IA51250
75-3203100 		Medical Services - Home Medical Equipment SD N/A
         No     No  
(3) Surgical Associates Endoscopy Clinic LLC

310 S Pennsylvania St
Aberdeen,SD57401
46-0461429 		Surgical Associates SD N/A
         No     No  
(4) Avera HME of Spencer Hospital LLC

2400 S Minnesota Avenue 102
Sioux Falls,SD57117
80-0619999 		Medical Services - Home Medical Equipment SD N/A
         No     No  
(5) Heart Hospital of South Dakota LLC

4500 W 69th Street
Sioux Falls,SD57108
56-2143771 		Healthcare Services SD Avera McKennan
  		Related 5,741,388 39,130,830   No     No 66.670 %
(6) Brookings Health System - Avera HME LLC

101 22nd Ave Suite 101
Brookings,SD57006
45-3204123 		Medical Services - Home Medical Equipment SD N/A
         No     No  
(7) Caravan Health ACO 41 dba Prairie View Care Organization

7509 NW Tiffany Springs Parkway
Kansas City,MO64153
82-1447782 		Accountable Care Organization MO N/A
         No     No  
(8) Avera Home Medical Equipment of Lakes Regional Healthcare LLC

2301 Hwy 71 South Ste D
Spirit Lake,IA51360
86-2949748 		Medical Services - Home Medical Equipment IA N/A
         No     No  
(9) Caravan Health ACO 15 LLC dba Prairie Vista Care Organization

7509 NW Tiffany Springs Parkway Ste
Kansas City,MO64153
61-1843657 		Accountable Care Organization MO N/A
         No     No  
Part IV
Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Accounts Management Inc

5132 S Cliff Ave Suite 101
Sioux Falls,SD57108
46-0373021 		Collection Agency SD N/A
 C         No
(2) Avera Property Insurance Inc

1000 West 4th Street Suite 1
Yankton,SD57078
46-0463155 		Insurance SD N/A
 C         No
(3) Valley Health Services

501 Summit Street
Yankton,SD57078
46-0357149 		Rental Real Estate SD N/A
 C         No
(4) Alucent Biomedical Inc

675 S Arapeen Dr Ste 102
Salt Lake City,UT84108
47-1818349 		Biotechnology SD Alumend LLC
  		C -13,719,318 13,866,434 65.410 % Yes  
(5) South Dakota State Medical Holding Company Inc

5300 South Broadband Lane
Sioux Falls,SD57108
46-0401087 		Insurance SD N/A
 C         No
(6) DakotaCare Administrative Services Inc

5300 South Broadband Lane
Sioux Falls,SD57108
46-0424322 		Insurance SD N/A
 C         No
(7) Alucent Australia Pty Ltd

Level 10 30 Collings Street
Melbourne,VIC 3000  
AS
Biotech Research AS Alucent Biomedical Inc
  		  -399,015 137,244 65.400 % Yes  
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 3
Part V
Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................
1a
 
No
b Gift, grant, or capital contribution to related organization(s) ............................
1b
 
No
c Gift, grant, or capital contribution from related organization(s) ............................
1c
Yes
 
d Loans or loan guarantees to or for related organization(s) ............................
1d
Yes
 
e Loans or loan guarantees by related organization(s) ............................
1e
 
No
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
Yes
 
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
 
No
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
Yes
 
q Reimbursement paid by related organization(s) for expenses ............................
1q
Yes
 
r Other transfer of cash or property to related organization(s) ............................
1r
Yes
 
s Other transfer of cash or property from related organization(s) ............................
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1) Avera Heart Hospital of South Dakota LLC

 R 3,155,296 Intercompany detail from GL
(2) Avera Heart Hospital of South Dakota LLC

 S 7,544,972 Intercompany detail from GL
(3) Avera Heart Hospital of South Dakota LLC

 L 2,540,275 Intercompany detail from GL
(4) Avera Heart Hospital of South Dakota LLC

 Q 1,389,321 Intercompany detail from GL


Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference Explanation
Schedule R (Form 990) 2021

Additional Data


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