2022-08-15T12:12:17-05:00 2021-09-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-10-01 390806404 VERNON MEMORIAL HEALTHCARE INC VERN 6086372101 507 SOUTH MAIN STREET VIROQUA WI 54665 SCOTT LECKEY CFO 6086372101 2022-08-09 1 SCOTT LECKEY 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-08-09 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z DAVID HARTBERG 507 SOUTH MAIN STREET VIROQUA WI 54665 91845482 0 X WWW.VMH.ORG X 1946 WI VERNON MEMORIAL HEALTHCARE, INC. WILL STRIVE TO HAVE THE VISION TO CONTINUALLY PROVIDE THE HIGHEST STANDARD OF CARE TO OUR PATIENTS AND THEIR FAMILIES WHILE BEING 'CLOSE TO HOME.' OUR MISSION AFFIRMS OUR COMMITMENT TO BEING THE BEST COMMUNITY HEALTHCARE SYSTEM IN THE REGION. IN SUPPORT OF THIS MISSION, WE CONSIDER IT ESSENTIAL TO PROVIDE COST-EFFECTIVE, ACCESSIBLE CARE AND SERVICES USING PROFESSIONAL TREATMENT TO THE INJURED, AFFLICTED, AND WELL PEOPLE WHO NEED THE RESOURCES WE HAVE AT OUR COMMAND, WITHOUT REGARD TO RACE, CREED, COLOR, SEX, HANDICAP, NATIONAL ORIGIN, OR ABILITY TO PAY. IT IS OUR INTENTION TO ENSURE THAT IN EACH AND EVERY CASE OUR PATIENTS SHALL BE TREATED WITH COMPASSION, UNDERSTANDING AND DIGNITY. FURTHER, THE RIGHTS AND PRIVILEGES OF THE PEOPLE WE SERVE SHALL ALWAYS BE HELD IN THE HIGHEST REGARD, AND THEIR WELL-BEING MUST ALWAYS HAVE FIRST CONSIDERATION. 9 9 623 85 0 0 2915153 4601406 74131912 78538766 2874731 -459984 284722 299822 80206518 82980010 14703 37000 0 0 37679616 36646913 0 0 0 35026314 36496441 72720633 73180354 7485885 9799656 109351678 121939170 31616627 31827955 77735051 90111215 X WE ARE COMMITTED TO BEING THE BEST COMMUNITY HEALTHCARE SYSTEM IN THE REGION. 0 0 58025731 37000 74342472 VERNON MEMORIAL HEALTHCARE ("VMH") OPERATES A 25-BED CRITICAL ACCESS HOSPITAL LOCATED IN VIROQUA, WISCONSIN, FOUR PROVIDER-BASED RURAL HEALTH CLINICS (VIROQUA, LA FARGE, SOLDIERS GROVE, AND WESTBY), AND THREE RETAIL PHARMACY LOCATIONS. VMH MAINTAINS A CLEAR AND CONSISTENT COMMITMENT TO ITS CHARITABLE PURPOSE THROUGH THE PROVISION OF HEALTH AND WELLNESS SERVICES TO THE COMMUNITIES SERVED WITHOUT REGARD TO AGE, RACE, GENDER, CREED, NATIONAL ORIGINAL, ABILITY TO PAY, AND PHYSICAL OR MENTAL HANDICAP. VMH'S DEDICATED WORKFORCE EXEMPLIFY SERVICE IN ALIGNMENT WITH ORGANIZATIONAL VALUE STATEMENTS: GREAT EXPERIENCES. RESPECTING EVERYONE. EXCELLENCE IN EVERYTHING WE DO. ALWAYS A HELPFUL ATTITUDE. TAKING CARE OF ONE ANOTHER.IN RESPONSE TO THE NEEDS OF THE COMMUNITIES SERVED, VMH IS PROUD TO PROVIDE HIGH QUALITY INPATIENT ACUTE CARE FOR MEDICAL, SURGICAL, OBSTETRICAL, AND NEWBORN SERVICE NEEDS. VMH FURTHER SUPPORTS THE NEEDS OF ITS PATIENTS BY OFFERING ACCESS TO SWING BED (SKILLED) NURSING CARE. WITH A CONSTANT FOCUS ON QUALITY AND PATIENT SAFETY, VMH OFFERS OUTPATIENT AND ANCILLARY HEALTHCARE SERVICES INCLUDING 24-HOUR EMERGENCY SERVICES, SURGICAL SERVICES, LABORATORY, X-RAY, ULTRASOUND, CT SCANS, MRI, MAMMOGRAPHY, CARDIAC REHABILITATION, SLEEP STUDY SERVICES, INFUSION AND GASTROINTESTINAL SERVICES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, AND NUTRITIONAL THERAPY INCLUDING DIABETIC EDUCATION. PATIENTS SERVED BY THE HOSPITAL IN FISCAL 2021 INCLUDED 3,530 ADULT AND PEDIATRIC INPATIENT DAYS AND 135 NEWBORN DELIVERIES. THERE WAS A TOTAL OF 1,314 SURGERY CASES (INPATIENT AND OUTPATIENT COMBINED) AND THERE WERE 94,539 TOTAL OUTPATIENT VISITS. THE VMH EMERGENCY ROOM PROVIDED IMMEDIATE ACCESS TO CARE IN RESPONSE TO 6,840 EMERGENCY ROOM VISITS.AS A PART OF VMH'S MISSION, AND IN KEEPING WITH ITS STATUS AS A NOT-FOR-PROFIT HEALTHCARE ORGANIZATION, VMH HAS ESTABLISHED A PATIENT FINANCIAL ASSISTANCE POLICY THAT SETS FORWARD THE CRITERIA BY WHICH A PATIENT MAY QUALIFY TO RECEIVE CARE AT AMOUNTS LESS THAN THE ESTABLISHED RATES; TO RECEIVE CHARITY CARE. VMH MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE PROVIDED, THE TOTAL HEALTHCARE SERVICES PROVIDED TO PATIENTS UNDER THIS POLICY ARE MEASURED IN BOTH TOTAL CHARGES AND AT THE ESTIMATED COST OF PROVIDING CARE TO PATIENTS WITH BOTH FIGURES REPORTED AND AVAILABLE BY REFERRING TO SCHEDULE H. IN ADDITION, VMH IS A PROVIDER UNDER THE WISCONSIN MEDICAID PROGRAM. UNDER THE PROGRAM, VMH IS LEGALLY BOUND TO ACCEPT THE AMOUNT DETERMINED BY THE STATE OF WISCONSIN AS PAYMENT IN FULL FOR EACH PATIENT'S CHARGES EVEN THOUGH REIMBURSEMENT IS LESS THAN THE COST TO PROVIDE THE CARE, THEREFORE, SERVICE TO PATIENTS UNDER THIS PROGRAM SHOULD ALSO BE CONSIDERED PART OF THE ORGANIZATION'S BENEFIT PROVIDED TO THE COMMUNITY. (FOR ADDITIONAL INFORMATION ON VMH'S CHARITY CARE AND/OR THE COST OF PARTICIPATION IN THE WISCONSIN MEDICAID PROGRAM, PLEASE REFER TO SCHEDULE H OF THE FORM 990.) IN ADDITION, VMH ENGAGES IN A VARIETY OF COMMUNITY BENEFIT ACTIVITIES, PROVIDING A CRITICALLY IMPORTANT COMMUNITY BENEFIT THAT WOULD NOT OTHERWISE BE AVAILABLE IN THE COMMUNITIES SERVED WITHOUT THE EFFORTS AND SPECIALIZED KNOWLEDGE OF THE LOCAL HEALTHCARE TEAM. 3275288 0 4196294 VERNON MEMORIAL HEALTHCARE, INC. OPERATES FOUR RURAL HEALTH CLINICS LOCATED IN VIROQUA, LAFARGE, SOLDIERS GROVE, AND WESTBY. TOGETHER, THESE CLINICS STRIVE TO MEET THE HEALTHCARE NEEDS OF PATIENTS AND FAMILIES WHO LIVE AND WORK IN THE COMMUNITIES THEY SERVE. A TOTAL OF 34,571 RURAL HEALTH CLINIC VISITS OCCURRED IN FISCAL YEAR 2021. THE CLINICS ARE DESIGNATED AS RURAL HEALTH CLINICS BY THE MEDICARE AND MEDICAID PROGRAMS AND, BY DEFINITION OF THE REQUIREMENTS FOR THAT DESIGNATION, ARE LOCATED IN RURAL OR UNDERSERVED AREAS OF THE COUNTRY. THESE CLINICS PROVIDE CARE TO A LARGE PORTION OF MEDICARE AND MEDICAID BENEFICIARIES WHO, WITHOUT ACCESS TO CARE LOCALLY, WOULD BE REQUIRED TO TRAVEL FARTHER DISTANCES FOR QUALITY HEALTHCARE. 61301019 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 63 0 623 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 9 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 0 1 1 1 0 WI X SCOTT LECKEY 6086374964 507 SOUTH MAIN STREET VIROQUA WI 54665 NATHAN CAMPBELL CHAIR 1.00 X X 0 0 0 MARILYN CLAUSON VICE CHAIR 1.00 X X 0 0 0 PAUL LARSEN TREASURER 1.00 X 0 0 0 KATHY STITTLEBURG TREASURER (THRU DECEMBER) 1.00 X X 0 0 0 VICKI ANDERSON SECRETARY 1.00 X 0 0 0 DAVE SARNOWSKI SECRETARY (THRU DECEMBER) 1.00 X X 0 0 0 MARY GAJEWSKI MEMBER 1.00 X 0 0 0 MELISSA HUGHES MEMBER 1.00 X 0 0 0 STACY KRING MEMBER 1.00 X 0 0 0 DORI MICKELSON MEMBER 1.00 X 0 0 0 SHARON NELSON MEMBER (THRU OCTOBER) 1.00 X 0 0 0 JOAN PETERSON MEMBER 1.00 X 0 0 0 TOM WESTON MEMBER 1.00 X 0 0 0 SCOTT LECKEY CFO 40.00 X 0 0 0 KAREN TRAYNOR CFO (THRU JULY) 40.00 X 255580 0 5281 DAVID HARTBERG CEO 40.00 X 303028 0 25429 DR BRIAN LYLE PHYSICIAN 40.00 X 482648 0 14359 DR ANTHONY MACASAET ER PHYSICIAN 30.00 X 356106 0 25448 BRIAN MILLER CRNA 40.00 X 369957 0 61882 DR ANDREW MANSPEAKER ER PHYSICIAN 36.00 X 373135 0 31398 JEFFREY SCHEIDT CRNA 40.00 X 372459 0 30583 2512913 0 194380 56 0 1 0 BURLINGTON HEALTHCARE PROVIDERS W329 N 4476 LAKELAND DR NASHOTA WI 53122 STAFFING SERVICE, EMERGENCY PHYSICIANS 422344 ATLAS PHYSICIANS MIDWEST 125 N 123RD ST WAUWATOSA WI 53226 STAFFING SERVICE 263912 WIPFLI LLP PO BOX 3160 MILWAUKEE WI 53201 ACCOUNTING/LAW FIRM SERVICES 123387 JEFFREY M LAWRENCE MD E8869 APPLE LANE VIROQUA WI 54665 SURGEON SERVICES 114813 4 4499297 102109 4601406 HOSPITAL 621990 66725992 66725992 RETAIL PHARMACY 446110 7468954 7468954 CLINIC 621110 4196294 4196294 CBRF 623000 147526 147526 78538766 604227 604227 299822 0 299822 299822 299822 7051426 749835 6079527 2785945 971899 -2036110 -1064211 -1064211 82980010 78538766 0 -160162 35000 35000 2000 2000 785422 785422 28809941 24597607 4212334 778222 685126 93096 4329279 3735548 593731 1944049 1667564 276485 313536 313536 123387 123387 6886349 5679456 1206893 179526 147323 32203 376498 161981 214517 882250 882250 2273067 961809 1311258 42548 14353 28195 117332 99946 17386 955510 799875 155635 4231621 3549833 681788 249359 38910 210449 PHARMACEUTICALS 7843046 7843046 SUPPLIES 7352359 7334315 18044 BAD DEBT EXPENSE 2604232 2604232 EQUIPMENT RENTAL & MAIN 1195850 1062104 133746 869971 280991 588980 73180354 61301019 11879335 0 27882131 31428122 2955149 11559783 1182878 236224 7132211 7629455 2435540 2690001 427787 351890 89761623 51566565 42173975 38195058 21960301 25985909 158335 112501 3043371 3750227 109351678 121939170 6027891 5661788 4300000 7757510 16363541 15504945 3017329 565693 1907866 2338019 31616627 31827955 X 76511667 89834485 1223384 276730 77735051 90111215 109351678 121939170 9799656 2576508 0 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4923 4923 0 PART II-B, LINE 1: VERNON MEMORIAL HEALTHCARE, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION AND RURAL WISCONSIN HEALTH COOPERATIVE. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. A SMALL PORTION OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 1538608 1538608 65038614 34991159 30047455 23060892 16575406 6485486 123509 123509 38195058 DEFERRED COMPENSATION PLAN LIABILITY - FUNDED 2338019 2338019 83726508 2576508 -2599021 -22513 83749021 -769011 -769011 82980010 70581333 0 70581333 2599021 2599021 73180354 PART XI, LINE 2D - OTHER ADJUSTMENTS: WELLNESS CENTER EXPENSE 5,211. BAD DEBT EXPENSE NET AGAINST REVENUE -2,604,232. PART XI, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS TO RESTRICTED NET ASSETS 25,057. NET ASSETS RELEASED FROM RESTRICTIONS -794,068. PART XII, LINE 4B - OTHER ADJUSTMENTS: WELLNESS CENTER EXPENSE -5,211. BAD DEBT EXPENSE NET AGAINST REVENUE 2,604,232. 1 1 X 0 1 X 1 1 0 1 1 656820 656820 0.00900 8436495 7663989 772506 0.01060 9093315 7663989 1429326 0.01960 9093315 7663989 1429326 0.01960 0 1123434 561717 14197294 13927616 269678 X 1 1 1 1 VERNON MEMORIAL HOSPITAL INC 507 SOUTH MAIN ST VIROQUA WI 54665 WWW.VMH.ORG 1053 X X X X VERNON MEMORIAL HEALTHCARE INC 1 0 0 1 X X X X X X X X X X 20 1 1 1 1 X SEE PART V, SECTION C, LINE 7D X SEE PART V, SECTION C, LINE 7D X 1 20 1 SEE PART V, SECTION C, LINE 7D 0 1 X 0.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.VMH.ORG/MEDIA/IMKNGPCC/FAP-POLICY-6-2022.PDF X HTTPS://WWW.VMH.ORG/MEDIA/20MLXWEK/2022-FAP-APPLICATION.PDF X HTTPS://WWW.VMH.ORG/MEDIA/HRIF32AL/BRANDING-BROCHURE-FINANCIALASSISTANCEONL X X X X X X 1 X 0 X X X X 1 X 0 0 VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 3J: 1. USE OF EPIC ELECTRONIC HEALTH RECORD'S POPULATION HEALTH MANAGEMENT MODULE FOR MONITORING PROCESSES. 2. DIABETIC EDUCATION PROGRAM OFFERS PATIENTS EDUCATION AND SUPPORT ON MANAGING DIABETES AND SUPPORTS OVERALL HEALTH. 3. CARE COORDINATION PROGRAM, WHICH OFFERS SOCIAL WORK SUPPORT TO ASSIST PATIENTS IN REACHING THEIR OPTIMAL HEALTH. 4. PARTNERSHIP WITH VERNON COUNTY PARTNERSHIP COUNCIL, WHICH EXISTS TO DEVELOP AND SUPPORT PROGRAMMING THAT ADDRESSES DRUG, ALCOHOL, AND TOBACCO CONCERNS. 5. VMH OFFERS MENTAL HEALTH SERVICES THROUGH THREE LICENSED CLINICAL SOCIAL WORKERS AND ONE PSYCHIATRIST, WHO ALSO OFFERS CHILD AND ADOLESCENT PSYCHIATRY. WE ARE CURRENTLY RECRUITING ADDITIONAL STAFF. VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 5: DATA WAS COLLECTED BY RANDOM HOUSEHOLD SURVEY TO 6,000 HOUSEHOLDS AND WAS STRATIFIED BY COUNTY TO ASSURE THAT EVERY JURISDICTION WOULD BE REPRESENTED. IN ADDITION, A SUPPLEMENTAL CONVENIENCE SURVEY WAS CONDUCTED TO GENERATE SURVEY RESPONSES FROM POPULATIONS THAT MAY HAVE BEEN UNDER-REPRESENTED IN THE RANDOM HOUSEHOLD SURVEY. VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 6A: THE COMPASS NOW 2021 PARTNERSHIP WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS:1. GUNDERSEN HEALTH SYSTEM, LA CROSSE2. MAYO CLINIC HEALTH SYSTEM LA CROSSE3. GUNDERSEN ST. JOSEPH'S HOSPITAL AND CLINICS, HILLSBORO4. GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS, WHITEHALL 5. TOMAH HEALTH, TOMAH VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 6B: THE COMPASS NOW 2021 PARTNERSHIP WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING ORGANIZATIONS:1. GREAT RIVERS UNITED WAY2. TREMPEALEAU COUNTY HEALTH DEPARTMENT3. MONROE COUNTY HEALTH DEPARTMENT4. GUNDERSEN HEALTH SYSTEM, LA CROSSE, AS WELL AS GUNDERSEN ST. JOSEPH'S HOSPITAL AND CLINICS IN HILLSBORO AND GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS IN WHITEHALL5. VERNON COUNTY HEALTH DEPARTMENT6. APTIV, INC.7. LA CROSSE COUNTY HEALTH DEPARTMENT8. BUFFALO COUNTY HEALTH DEPARTMENT9. HOUSTON COUNTY HEALTH DEPARTMENT (MINNESOTA)10. COULEECAP11. MAYO CLINIC HEALTH SYSTEM IN BOTH LA CROSSE AND SPARTA VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 7D: PART V, LINE 7A:HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/WP-CONTENT/UPLOADS/2021/06/2021-COMPASS-NOW-REPORT_FINAL-WEB.PDFPART V, LINE 7B:HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/WP-CONTENT/UPLOADS/2021/06/2021-COMPASS-NOW-REPORT_FINAL-WEB.PDFPART V, LINE 10A:HTTPS://WWW.VMH.ORG/MEDIA/HYLMLGHQ/COMMUNITY-HEALTH-NEEDS-IMPLEMENTATION-PLAN2021.PDF VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 11: THREE OF THE KEY ISSUES IDENTIFIED FOR VERNON COUNTY IN THE 2021 COMPASS NOW CHNA INCLUDE: 1. MENTAL HEALTH, 2. POVERTY/LIVABLE WAGES, 3. CHILDCARE. INCREASED ACCESS TO MENTAL HEALTHCARE SERVICES PER THE 2021 COMMUNITY HEALTHCARE NEEDS ASSESSMENT, "THERE ARE ACCESS ISSUES FOR THESE SERVICES IN VERNON COUNTY. THE PERCENT OF ADULTS THAT NEED TREATMENT AND ARE NOT RECEIVING IT IN VERNON COUNTY IS 56% THE PERCENT OF YOUTH THAT NEED TREATMENT AND ARE NOT RECEIVING IT IN VERNON COUNTY IS 55%". IN ADDITION, 5% OF RANDOM HOUSEHOLD SURVEY (RHS) RESPONDENTS AND 12% OF CONVENIENCE SURVEY (CS) RESPONDENTS REPORTED THEIR ACCESS TO MENTAL HEALTH CARE AS "POOR".VMH IS ATTEMPTING TO EXPAND BEHAVIORAL HEALTH SERVICES, ALONG WITH IDENTIFYING AREA ORGANIZATIONS THAT VMH CAN COLLABORATE WITH IN EXPANDING ACCESS TO PATIENTS IN THE VMH SERVICE AREA.CURRENTLY EMPLOYED MENTAL HEALTH PROVIDERS INCLUDE: ONE PSYCHIATRIST, GENERAL PSYCHIATRY, INCLUDING CHILD AND ADOLESCENT, ONE PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER AND TWO LICENSED CLINICAL SOCIAL WORKERS. VMH IS ACTIVELY RECRUITING ADDITIONAL STAFF. VERNON MEMORIAL HEALTHCARE WILL ALSO RESEARCH WORKING WITH OTHER AREA HEALTHCARE ORGANIZATIONS TO POOL RESOURCES AND PROVIDE IMPROVED ACCESS AND COLLABORATIVELY PUBLICIZE ACCESS OPPORTUNITIES IN THESE COMMUNITIES TO HEIGHTEN AWARENESS.POVERTY/FINANCIAL STABILITYPER THE 2021 COMMUNITY HEALTHCARE NEEDS ASSESSMENT, THE FOLLOWING FACTORS INDICATE POVERTY AND/OR FINANCIAL STABILITY OF VERNON COUNTY RESIDENTS: - 11% OF SURVEY RESPONDENTS FROM VERNON COUNTY REPORT THEY ARE UNINSURED. - 46% OF SURVEY RESPONDENTS FROM VERNON COUNTY REPORT A HOUSEHOLD INCOME OF LESS THAN $50,000 PER YEAR (23% REPORT A HOUSEHOLD INCOME OF LESS THAN $25,000 PER YEAR).VMH INFORMS PATIENTS OF FINANCIAL ASSISTANCE AND/OR CHARITY CARE WHEN THEY RECEIVE HEALTHCARE AT VERNON MEMORIAL HEALTHCARE. INFORMATION ABOUT FINANCIAL ASSISTANCE IS AVAILABLE AT PATIENT REGISTRATION DESKS AND ON THE VERNON MEMORIAL HEALTHCARE WEBSITE. PATIENTS ARE ALSO VERBALLY INFORMED OF FINANCIAL ASSISTANCE OPTIONS. IN ADDITION, VERNON MEMORIAL HEALTHCARE WILL COLLABORATE WITH AREA ORGANIZATIONS IN PROVIDING EDUCATION ON RESOURCES AND PROGRAMS AVAILABLE TO PATIENTS NEEDING FINANCIAL ASSISTANCE.IN ADDITION, WMH WILL WORK TO INFORM THE PUBLIC OF COMMUNITY RESOURCES, SUCH AS FOOD BANKS, THAT COULD BE USEFUL TO FAMILIES STRUGGLING WITH FINANCIAL STABILITY.VERNON MEMORIAL HEALTHCARE WILL IMPLEMENT THE FOLLOWING STRATEGIES TO INFORM THE PUBLIC OF RESOURCES: - FACEBOOK POSTS - PRINTED MATERIAL - WEBSITE LINKS- SOCIAL WORKER INTERACTIONCHILDCAREPER THE 2021 COMMUNITY HEALTHCARE NEEDS ASSESSMENT, 10% OF RHS RESPONDENTS AND 22% OF CS RESPONDENTS REPORT THEY ARE EITHER "MODERATELY CONCERNED OR "VERY CONCERNED" ABOUT ACCESS TO CHILDCARE.VERNON MEMORIAL HEALTHCARE WILL WORK WITH ECONOMIC, SCHOOL, AND CIVIC LEADERS TO ADDRESS THE NEED FOR CHILDCARE AND LEND SUPPORT. IN ADDITION, THROUGH PARTNERSHIPS WITH CHAMBERS OF COMMERCE, SCHOOL DISTRICTS, AND OTHER GROUPS, VERNON MEMORIAL HEALTHCARE WILL SUPPORT EFFORTS TO BRING ADDITIONAL CHILDCARE OPTIONS TO THE AREA. VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 13B: PATIENTS' RELIANCE ON MEDICARE OR MEDICAL ASSISTANCE. VERNON MEMORIAL HEALTHCARE, INC. PART V, SECTION B, LINE 13H: THE ORGANIZATION PROVIDES "CATASTROPHIC CARE" FOR PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY. THESE PATIENTS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY VERNON MEMORIAL HEALTHCARE, INC. THAT EXCEED 25% OF THE ADJUSTED GROSS INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD.IF A PATIENT HAS A BALANCE OF $500 OR MORE AND INCOME IS BELOW 100% FPG, THEY WILL QUALIFY FOR CATASTROPHIC CARE. 9 1 - HIRSCH CLINIC 407 S MAIN ST SUITE 400 VIROQUA WI 54665 PROVIDER BASED RURAL HEALTH CLINIC 2 - LAFARGE MEDICAL CLINIC 206 N MILL ST LAFARGE WI 54639 PROVIDER BASED RURAL HEALTH CLINIC 3 - VERNON MEMORIAL HEALTHCARE PHARMACY 407 S MAIN ST SUITE 400 VIROQUA WI 54665 PHARMACY 4 - BLAND CLINIC 100 MELBY ST WESTBY WI 54667 PROVIDER BASED RURAL HEALTH CLINIC 5 - VERNON MEMORIAL PHARMACY - LAFARGE 206 N MILL STREET LAFARGE WI 54639 PHARMACY 6 - SOLAR TOWN PHARMACY 104 SUNSET AVE SOLDIERS GROVE WI 54655 PHARMACY 7 - KICKAPOO VALLEY MEDICAL CLINIC 102 SUNSET AVE SOLDIERS GROVE WI 54655 PROVIDER BASED RURAL HEALTH CLINIC 8 - FAIR HAVEN 601 ARENA DRIVE VIROQUA WI 54665 ASSISTED LIVING 9 - OLD TIMES 206 POLLY RUDE WAY WESTBY WI 54667 ASSISTED LIVING PART I, LINE 3C: CATASTROPHIC CARE: PATIENTS NOT MEETING FINANCIAL ASSISTANCE ELIGIBILITY THRESHOLDS MAY BE ELIGIBLE FOR ASSISTANCE UNDER CIRCUMSTANCES WHEN MEDICAL BILLS WOULD RESULT IN SEVERE FINANCIAL HARDSHIP. PATIENTS, OR THEIR GUARANTORS, MAY BE ELIGIBLE FOR CATASTROPHIC CARE ASSISTANCE IF THEY INCURRED OUT-OF-POCKET OBLIGATIONS RESULTING FROM MEDICAL SERVICES PROVIDED BY VERNON MEMORIAL HEALTHCARE, INC. THAT EXCEED 25% OF THE ADJUSTED GROSS INCOME AND HAVE ASSETS BELOW THE EQUIVALENT OF 600% OF THE FPL THRESHOLD.IF INCOME IS BELOW 100% FPG, THEY WILL QUALIFY FOR CATASTROPHIC CARE. PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS COSTING METHODS FOR THE FORM 990. PART II, COMMUNITY BUILDING ACTIVITIES: OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES AND URGENT CARE, HOME CARE, HOSPICE, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMEN'S HEALTH. PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICY:IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: VERNON MEMORIAL HEALTHCARE, INC. IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT VERNON MEMORIAL HEALTHCARE, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREA. THE COSTING METHOD USED ABOVE FOR IRS FORM 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST-TO-CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS FROM SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THE RECIPIENTS ARE TYPICALLY ELDERLY AND/OR DISABLED MEMBERS OF THE COMMUNITY AND ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: IN ORDER TO PROVIDE THE LEVEL OF AID NECESSARY TO THE GREATEST NUMBER OF PATIENTS IN NEED, AND PROTECT THE RESOURCES NEEDED TO DO SO, THE FOLLOWING GUIDELINES APPLY: 1) SERVICES ARE PROVIDED UNDER CHARITY CARE ONLY WHEN DEEMED MEDICALLY NECESSARY AND AFTER PATIENTS ARE FOUND TO HAVE MET ALL FINANCIAL CRITERIA BASED ON THE DISCLOSURE OF PROPER INFORMATION AND DOCUMENTATION. 2) CHARITY CARE IS NOT AVAILABLE FOR ELECTIVE PROCEDURES. 3) PATIENTS ARE EXPECTED TO CONTRIBUTE PAYMENT FOR CARE BASED ON THEIR INDIVIDUAL FINANCIAL SITUATION; THEREFORE, EACH CASE WILL BE REVIEWED SEPARATELY. 4) CHARITY CARE IS NOT CONSIDERED AN ALTERNATIVE OPTION FOR PAYMENT AND PATIENTS MAY BE ASSISTED IN FINDING OTHER MEANS OF PAYMENT OR FINANCIAL ASSISTANCE BEFORE APPROVAL FOR CHARITY CARE. 5) UNINSURED PATIENTS WHO ARE BELIEVED TO HAVE THE FINANCIAL ABILITY TO PURCHASE HEALTH INSURANCE MAY BE ENCOURAGED TO DO SO IN ORDER TO ENSURE HEALTHCARE ACCESSIBILITY AND OVERALL WELL-BEING. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) CONDUCTED IN CONJUNCTION WITH AREA HEALTH CARE FACILITIES, THE GREAT RIVERS UNITED WAY AND COUNTY HEALTH DEPARTMENTS, VERNON MEMORIAL HEALTHCARE CONTINUALLY GATHERS AND REVIEWS DATA RELATED TO COMMUNITY NEEDS BY UTILIZING MORE INFORMAL FOCUS AND ADVISORY GROUPS, DISCUSSIONS WITH AREA EMPLOYERS, AS WELL AS THROUGH SERVING ON LOCAL AND STATE BOARDS AND COMMITTEES. THE ORGANIZATION COLLABORATES WITH COMMUNITY ORGANIZATIONS, CHURCHES, BUSINESSES, AGENCIES, AND LOCAL K-12 SCHOOLS, COLLEGES, AND UNIVERSITIES TO DETERMINE THE NEEDS OF THE COMMUNITIES SERVED. BOARD MEMBERS REPRESENT NOT ONLY THE CITY OF VIROQUA, BUT COME FROM THE DIFFERENT AREAS SERVED BY THE ORGANIZATION. THESE BOARD MEMBERS REGULARLY MEET WITH THE PEOPLE IN THEIR AREAS TO UTILIZE THE SERVICES OFFERED BY THE ORGANIZATION AND BRING BACK THEIR ISSUES AND CONCERNS. ADDITIONAL RESOURCES ADDED TO COLLECTING DATA AND UNDERSTANDING THE COMMUNITIES VERNON MEMORIAL HEALTHCARE SERVES ARE INSIGHT DATA COLLECTED ON SOCIAL MEDIA AND FOLLOWING ONLINE AREA TRENDS. INFORMATION HAS ALSO BEEN COLLECTED VIA PATIENT SURVEYS SENT TO PATIENTS POST-VISIT REGARDING THE CARE THEY RECEIVED. PART VI, LINE 3: VERNON MEMORIAL HEALTHCARE MAKES EVERY EFFORT TO EDUCATE PATIENTS ABOUT FINANCIAL ASSISTANCE AVAILABLE AT THE TIME OF REGISTRATION AND FOLLOWING DISCHARGE. REGISTRATION HAS A HARD STOP IN EPIC TO REMIND STAFF TO OFFER FINANCIAL ASSISTANCE TO THE PATIENTS. IF A PATIENT REFUSES FINANCIAL ASSISTANCE AT TIME OF REGISTRATION, IT IS DOCUMENTED. FORMS AND INSTRUCTIONS ARE AVAILABLE AT ALL REGISTRATION AREAS, INCLUDING THE MAIN ENTRANCE TO THE HOSPITAL, OUTPATIENT SERVICES, EMERGENCY ROOM, AND OUTLYING CLINICS. FINANCIAL COUNSELORS ARE AVAILABLE DURING DAYTIME HOURS TO ASSIST PATIENTS WITH THE COMPLETION OF FORMS, EITHER IN PERSON, OVER THE PHONE OR THROUGH MYCARE. INFORMATION ABOUT CHARITY CARE AND DISCOUNT PROGRAMS IS ALSO AVAILABLE ON THE ORGANIZATION'S WEBSITE. SIGNS AND PAMPHLETS REGARDING THE FINANCIAL ASSISTANCE PROGRAM ARE POSTED AT ALL REGISTRATION LOCATIONS. PART VI, LINE 4: VERNON MEMORIAL HEALTHCARE SERVES THE CITY OF VIROQUA AND THE SURROUNDING AREA. OTHER TOWNS IN THE PRIMARY SERVICE AREA INCLUDE WESTBY, READSTOWN, SOLDIERS GROVE, CASHTON, AND LAFARGE. THE SECONDARY SERVICE AREA EXTENDS TO THE CITIES OF DESOTO, FERRYVILLE, HILLSBORO, COON VALLEY, RICHLAND CENTER, GAYS MILLS, VIOLA, AND ONTARIO. THE COMMUNITIES AND SURROUNDING RURAL AREAS IN THE PRIMARY SERVICE HAVE AN APPROXIMATE POPULATION OF 28,000. THE SECONDARY SERVICE AREA INCLUDES AN ADDITIONAL 25,000 PERSONS. THE ENTIRE AREA IS RURAL WITH AN AGING POPULATION AND RELATIVELY LOW INCOME LEVELS. PART VI, LINE 5: VERNON MEMORIAL HEALTHCARE PROVIDES A FULL RANGE OF INPATIENT AND OUTPATIENT SERVICES TO THE PEOPLE IN THE COMMUNITIES IT SERVES. SERVICES ARE PROVIDED WITHOUT REGARD TO RACE, COLOR, CREED, RELIGION, GENDER ORIENTATION, DISABILITY, AGE, OR NATIONAL ORIGIN. VERNON MEMORIAL HEALTHCARE OPERATES A 24/7 EMERGENCY ROOM THAT IS OPEN TO SERVE ALL IN NEED, REGARDLESS OF ABILITY TO PAY. THE ORGANIZATION OWNS AND OPERATES FOUR RURAL HEALTH CLINICS LOCATED IN THE CITIES OF VIROQUA, WESTBY, SOLDIERS GROVE AND LAFARGE, AS WELL AS THREE RETAIL PHARMACIES LOCATED IN VIROQUA, LAFARGE, AND SOLDIERS GROVE. VERNON MEMORIAL HEALTHCARE COLLABORATES WITH COMMUNITIES, CHURCHES, BUSINESSES, AND OTHER HEALTH CARE ORGANIZATIONS IN THE REGION TO FACILITATE AND STRENGTHEN ACCESSIBILITY OF QUALITY COMPREHENSIVE HEALTHCARE SERVICES. THE ORGANIZATION SUPPORTS THE LOCAL COMMUNITIES BY PROVIDING CONVENIENT LOCATIONS FOR PRIMARY CARE AND PHARMACY SERVICES. THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT COMMUNITY MEMBERS WHO REPRESENT THE MAKE-UP OF THE AREAS SERVED BY THE ORGANIZATION. VERNON MEMORIAL HEALTHCARE HAS AN OPEN MEDICAL STAFF MADE UP OF QUALIFIED PHYSICIANS WHO WORK WITH THE HOSPITAL TO PROVIDE CARE TO THE COMMUNITIES SERVED. ALL QUALIFIED PHYSICIANS AND AFFILIATED STAFF WHO ARE GRANTED PRIVILEGES UNDERGO A THOROUGH AND COMPREHENSIVE CREDENTIALING AND ORIENTATION PROCESS. ANY SURPLUS FUNDS GENERATED THROUGH OPERATIONS ARE USED TO CONTINUE TO MEET THE NEEDS OF THE PEOPLE THAT ARE SERVED THROUGH THE ADDITION OF NEW FACILITIES AND EQUIPMENT, OR THE ADDITION OR EXPANSION OF NEEDED SERVICES. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 RESTORING HOPE TRANSPLANT HOUSE 7457 TERRACE AVE MIDDLETON WI 53562 204786829 501(C)(3) 15000 RENOVATION PROJECT SMRT BUS (LA CROSSE COUNTY) 212 6TH STREET NORTH ROOM 1300 LA CROSSE WI 54601 396005709 GOV'T ORGANIZATION 10000 ANNUAL PLEDGE PAYMENT - PROGRAM MAINT VIROQUA AREA FOUNDATION PO BOX 262 VIROQUA WI 54665 391603279 501(C)(3) 10000 FIRE TRAINING TOWER PLEDGE PAYMENT 3 0 PART I, LINE 2: CHARITABLE CONTRIBUTIONS MADE BY VERNON MEMORIAL HEALTHCARE (CMH) WILL BE LIMITED TO ELIGIBLE ORGANIZATIONS THAT SET FORWARD A FUNDING REQUEST THAT DEMONSTRATE AN ALIGNMENT WITH THE VMH MISSION, VMH VISION AND VALUES, AND/OR TARGETED TO SUPPORT A NEED SET FORWARD IN THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR THE COMMUNITIES SERVED BY VMN. ALL ELIGIBLE ORGANIZATIONS MUST BE RECOGNIZED AS A 501(C)(3) ENTITY BY THE INTERNAL REVENUE SERVICE. THE MARKETING MANAGER IS RESPONSIBLE FOR EVALUATION OF ALL APPLICATIONS TO DETERMINE ALIGNMENT WITH THIS POLICY AND TO ENSURE THAT VMH MAINTAINS APPROPRIATE OVERALL FISCAL CONTROL ON EXPENDITURE OF COMMUNITY SUPPORT FUNDS. IT IS HER/HIS INDIVIDUAL AUTHORITY TO DENY ANY REQUEST THAT DOES NOT MEET ESTABLISHED CRITERIA OR THAT IS NOT IN ALIGNMENT WITH THE VMH FISCAL NEEDS AND SHE/HE HAS FINAL AUTHORITY FOR THAT DECISION. FOR THOSE APPLICATIONS DEEMED TO MEET THE CRITERIA OF THIS POLICY, THE FOLLOWING TABLE HIGHLIGHTS AUTHORITY LIMITS: MARKETING MANAGER -$5,000 AND BELOW -AND ONE-TIME DONATION -AND TOTAL ANNUAL COMMITMENT REMAINS AT OR BELOW BUDGET CEO -$5,001 AND UP -AND ONE-TIME DONATION -AND TOTAL ANNUAL COMMITMENT REMAINS AT OR BELOW BUDGET BOARD OF DIRECTORS -DONATIONS CAUSE THE ENTITY TO EXCEED THE ANNUAL APPROVED BUDGET VALUE -AND/OR ALL MULTI-YEAR COMMITMENTS X X X X 0 0 0 0 0 0 0 0 0 DR BRIAN LYLE PHYSICIAN 482648 0 0 0 0 0 7040 0 7319 0 497007 0 0 0 BRIAN MILLER CRNA 359957 0 10000 0 0 0 9758 0 52124 0 431839 0 0 0 DR ANDREW MANSPEAKER ER PHYSICIAN 373135 0 0 0 0 0 8979 0 22419 0 404533 0 0 0 JEFFREY SCHEIDT CRNA 359959 0 12500 0 0 0 5514 0 25069 0 403042 0 0 0 DR ANTHONY MACASAET ER PHYSICIAN 356106 0 0 0 0 0 8912 0 16536 0 381554 0 0 0 DAVID HARTBERG CEO 293028 0 0 0 10000 0 1000 0 24429 0 328457 0 0 0 KAREN TRAYNOR CFO (THRU JULY) 251229 0 0 0 4351 0 0 0 5281 0 260861 0 0 0 A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97712DGX8 2014-12-09 19445225 REFINANCE 2005 BONDS 0 0 0 A 4485225 19445225 286481 19158744 1 0 1 1 A 0 0 0 0 0 0 1 A 0 0 0 1 0 0 0 0 1 A 1 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY DATE THE REBATE COMPUTATION WAS PERFORMED: 12/09/2019 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON WHO IS EIGHTEEN YEARS OF AGE OR OLDER AND A BONA FIDE RESIDENT OF VERNON COUNTY, WISCONSIN, OR THE AREA WITHIN A RADIUS OF TWENTY-FIVE MILES OF THE CITY OF VIROQUA, WISCONSIN, AND WHO HAS HERETOFORE OR MAY HEREAFTER CONTRIBUTE TEN DOLLARS OR MORE TO VERNON MEMORIAL HEALTHCARE, INC. (THE ORGANIZATION") SHALL BE A MEMBER THEREOF. ALL MEMBERS OF THE ORGANIZATION SHALL BE VOTING MEMBERS. EACH MEMBER SHALL HAVE ONE VOTE ON ANY MATTER SUBMITTED TO A VOTE OF THE MEMBERS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE DUTIES OF THE MEMBERS OF THE ORGANIZATION SHALL BE: THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE ORGANIZATION, THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE ORGANIZATION, AND THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7B THE DUTIES OF THE MEMBERS OF THE VERNON ORGANIZATION SHALL ALSO INCLUDE: THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE ORGANIZATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE ORGANIZATION, THE DISSOLUTION OF THE ORGANIZATION, OR ITS MERGER WITH ANOTHER CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS DISTRIBUTED TO THE BOARD OF DIRECTORS OF VERNON MEMORIAL HEALTHCARE, INC. FOR REVIEW AFTER FILING THE RETURN. FORM 990, PART VI, SECTION B, LINE 12C ALL BOARD MEMBERS OF VERNON MEMORIAL HEALTHCARE, INC. ARE REQUIRED TO DISCLOSE ALL POSSIBLE CONFLICTS OF INTEREST WHEN FIRST ELECTED TO THE BOARD OF DIRECTORS. DURING THEIR TERMS, IF ANY BUSINESS RELATIONSHIPS ARE ENTERED INTO WHICH MAY AFFECT THEIR INDEPENDENCE AS A MEMBER, THE MEMBER MUST IMMEDIATELY DISCLOSE THESE RELATIONSHIPS. FORM 990, PART VI, SECTION B, LINE 15 TO DETERMINE APPROPRIATE SALARY RANGES FOR UPPER MANAGEMENT POSITIONS, VERNON MEMORIAL HEALTHCARE, INC. UTILIZES BENCHMARK DATA FROM SURVEYS CONDUCTED BY RELEVANT TRADE ORGANIZATIONS. THE CEO HAS THE RIGHT TO AMEND THE DETERMINED AMOUNT FOR THE CFO. THE BOARD HAS THE RIGHT TO AMEND THE AMOUNT FOR THE CEO. A COMMITTEE OF THE BOARD REVIEWS THE DATA FOR THE CEO ANNUALLY TO DETERMINE THE AMOUNT OF HIS COMPENSATION AND ANY CHANGES IN COMPENSATION ARE MAINTAINED IN THE PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 19 VERNON MEMORIAL HEALTHCARE, INC. MAKES ITS FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS. THE FORM 990 IS ALSO AVAILABLE TO THE PUBLIC ON A THIRD-PARTY WEBSITE CALLED GUIDESTAR. FORM 990, PART XI, LINE 2C: OVERSIGHT OF AUDIT: VERNON MEMORIAL HEALTHCARE, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR SELECTION OF THE INDEPENDENT ACCOUNTANT. NO CHANGES HAVE BEEN MADE IN THE PAST YEAR REGARDING THIS OVERSIGHT FUNCTION OF THE GOVERNING BODY. VERNON MEMORIALGUNDERSEN LUTHERAN MEDICAL BUILDING CONDOMINIUM ASSOC LTD 507 S MAIN ST VIROQUA WI 54665 320182492 PROPERTY MANAGEMENT WI N/A C 167481 9442 0.50000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0