TRI-COUNTY MEMORIAL HOSPITAL INC: Form 990, tax year 2021
View the entire original 990 at ProPublica ↗
- Organization
- TRI-COUNTY MEMORIAL HOSPITAL INC (EIN 39-0704510)
- Tax period
- 2021-01-01 to 2021-12-31
- Filed
- 2022-11-15
- IRS object ID
- 202243199349308309
- Schema version
- 2021v4.2
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2022-11-15T10:35:05-06:00 | ReturnTs |
| Tax Period End | 2021-12-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 390758449 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 1502 LONDON ROAD SUITE 200 | AddressLine1Txt |
| City | DULUTH | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 55812 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2021-01-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390704510 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | TRI- | BusinessNameControlTxt |
| Phone | 7155384361 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | JONI OLSON | PersonNm |
| Person Title | ADMINISTRATOR | PersonTitleTxt |
| Phone | 7155384361 | PhoneNum |
| Signature | 2022-11-14 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Signing Officer SigningOfficerGrp
Person Full Name PersonFullName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person First | JONI | PersonFirstNm |
| Person Last | OLSON | PersonLastNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| SSN | 999009999 | SSN |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | MICHAEL J PETERSON CPA | PreparerPersonNm |
| PTIN | P01833529 | PTIN |
| Phone | 2187224705 | PhoneNum |
| Preparation | 2022-11-14 | PreparationDt |
Additional Filer Information AdditionalFilerInformation
Trusted Customer TrustedCustomerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Trusted Customer | 3 | TrustedCustomerCd |
| Authentication Assurance Level | AAL1 | AuthenticationAssuranceLevelCd |
| Identity Assurance Level | IAL1 | IdentityAssuranceLevelCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2021 | TaxYr |
| Build TS | 2022-09-23 18:48:47Z | BuildTS |
Form 990 IRS990
Doing Business As Name DoingBusinessAsName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | JONI OLSON | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $29,436,157 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1937 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. | ActivityOrMissionDesc |
| Voting Members Governing Body | 9 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 4 | VotingMembersIndependentCnt |
| Total Employee | 298 | TotalEmployeeCnt |
| Total Volunteers | 10 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $2,540,794 | PYContributionsGrantsAmt |
| CY Contributions Grants | $2,515,940 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $25,517,810 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $26,845,860 | CYProgramServiceRevenueAmt |
| PY Investment Income | $24,551 | PYInvestmentIncomeAmt |
| CY Investment Income | $27,525 | CYInvestmentIncomeAmt |
| PY Other Revenue | $44,217 | PYOtherRevenueAmt |
| CY Other Revenue | $46,832 | CYOtherRevenueAmt |
| PY Total Revenue | $28,127,372 | PYTotalRevenueAmt |
| CY Total Revenue | $29,436,157 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $13,338,995 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $13,699,969 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $10,763,537 | PYOtherExpensesAmt |
| CY Other Expenses | $11,491,391 | CYOtherExpensesAmt |
| PY Total Expenses | $24,102,532 | PYTotalExpensesAmt |
| CY Total Expenses | $25,191,360 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $4,024,840 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $4,244,797 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $22,954,738 | TotalAssetsBOYAmt |
| Total Assets EOY | $24,193,413 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $9,673,788 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $6,635,985 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $13,280,950 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $17,557,428 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $18,574,766 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $24,580,599 | RevenueAmt |
| Desc | TRI-COUNTY MEMORIAL HOSPITAL, INC. ("TRI-COUNTY") PROVIDES INPATIENT, OUTPATIENT, AND EMERGENCY HEALTH CARE SERVICES AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY INCLUDING THE HEALTH OF LOW INCOME PATIENTS. THE ORGANIZATION OPERATES A CRITICAL ACCESS HOSPITAL AND PROVIDES INPATIENT ACUTE CARE AND SWING BED SERVICES, ALONG WITH AN EMERGENCY DEPARTMENT, WHICH IS OPEN TWENTY-FOUR HOURS PER DAY, AND OTHER OUTPATIENT SERVICES. VISITING SPECIALISTS FROM AN AFFILIATED ORGANIZATION, GUNDERSEN CLINIC, LTD., PERFORM OUTPATIENT GASTROENTEROLOGY, ORTHOPEDIC, AND OPHTHALMIC SURGICAL PROCEDURES AT THE FACILITY AS WELL. TRI-COUNTY ALSO OPERATES A SKILLED NURSING FACILITY, AN ASSISTED LIVING FACILITY, THREE RURAL HEALTH CLINICS, AND AN AMBULANCE SERVICE. THE CRITICAL ACCESS HOSPITAL HAD 662 INPATIENT ACUTE DAYS, 102 RESPITE DAYS, 1,849 SWING BED DAYS, 428 SURGICAL OPERATIONS, AND 4,720 ER VISITS IN THE PERIOD JANUARY 1 THROUGH DECEMBER 31, 2021.CONSISTENT WITH THE MISSION OF TRI-COUNTY, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO ARE EITHER UNDERINSURED OR CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID HOSPITAL SERVICES, ARE ALSO CONSIDERED PART OF TRI-COUNTY'S BENEFIT PROVIDED TO THE COMMUNITY, SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COSTS OF PROVIDING CARE.PATIENTS WHO MEET CERTAIN CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE AT A SIGNIFICANTLY REDUCED RATE, DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN TRI-COUNTY'S CHARITY CARE POLICY, AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. THE AMOUNT OF HOSPITAL AND CLINIC CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER THIS POLICY DURING 2021 TOTALED $350,661. IN ADDITION, DISCOUNTS TO THE MEDICAID PROGRAM FOR HOSPITAL AND CLINIC SERVICES AMOUNTED TO $3,943,368.BENEFITS FOR SERVING THE COMMUNITY ALSO INCLUDE UNPAID COSTS OF TREATING THE ELDERLY, HEALTH SCREENINGS, COMMUNITY EDUCATION THROUGH SEMINARS AND CLASSES, AND OTHER HEALTH-RELATED SERVICES. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $1,852,441 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $1,980,326 | RevenueAmt |
| Desc | TRI-COUNTY'S NURSING HOME PROVIDES LONG-TERM CARE AND SHORT-TERM REHABILITATIVE SERVICES FOR THE AGED AND DISABLED MEMBERS OF THE COMMUNITY. HEALTH CARE SERVICES TO MEDICAID NURSING HOME RESIDENTS ARE CONSIDERED PART OF TRI-COUNTY'S BENEFIT PROVIDED TO THE COMMUNITY, SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COSTS OF PROVIDING CARE. THE NURSING HOME OFFERS SKILLED NURSING CARE IN BOTH SHORT-TERM REHABILITATION PROGRAMS AND LONG-TERM CARE RESIDENT PROGRAMS. SOME OF THE SPECIALIZED CARE SERVICES OFFERED INCLUDE IV THERAPY CARE, WOUND CARE, PAIN MANAGEMENT, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY AMONG MANY OTHER CARE PROGRAMS PROVIDED. THE NURSING HOME OPERATES IN CONJUNCTION WITH THE HOSPITAL TO PROVIDE A SMOOTH TRANSITION FOR PATIENTS NEEDING EXTENDED REHABILITATION OR LONG-TERM CARE SERVICES. THE COORDINATION OF SERVICES IN THE COMBINED HOSPITAL AND NURSING HOME FACILITIES ALSO ALLOWS THE ORGANIZATION TO SHARE MANY DEPARTMENTS AND SERVICES IN TRI-COUNTY'S CONTINUED EFFORT TO PROVIDE HIGH QUALITY AND LOW-COST CARE TO THE COMMUNITY. TRI-COUNTY PROVIDED 10,619 DAYS OF NURSING HOME RESIDENT CARE BETWEEN JANUARY 1 AND DECEMBER 31, 2021. INCLUDED IN THIS TOTAL WAS 5840 DAYS FOR RESIDENTS COVERED UNDER THE MEDICAID PROGRAM. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $315,240 | ExpenseAmt |
| Grant | $0 | GrantAmt |
| Revenue | $284,935 | RevenueAmt |
| Desc | TRI-COUNTY ALSO OPERATES AN ASSISTED LIVING FACILITY LOCATED DIRECTLY EAST ACROSS THE STREET OF TRI-COUNTY HOSPITAL. THIS CARE IS PROVIDED TO RESIDENTS IN AN EFFORT BY TRI-COUNTY TO PROVIDE A CONTINUUM OF CARE FOR PATIENTS OF THE SURROUNDING COMMUNITIES. SERVICES OFFERED AND PROVIDED TO RESIDENTS INCLUDE ASSISTANCE WITH THE ACTIVITIES OF DAILY LIVING, MEAL PREPARATION, LAUNDRY SERVICES, APARTMENT MAINTENANCE SERVICES, DAILY RECREATIONAL ACTIVITIES, AMONG MANY SERVICE OFFERINGS. RESIDENTS OF THE ASSISTED LIVING FACILITY ALSO HAVE ACCESS TO NURSING STAFF IN THE EVENT OF AN EMERGENCY TWENTY-FOUR HOURS A DAY PROVIDED BY TRI-COUNTY'S NURSING SERVICES STAFF. SOME OF THE RESIDENTS SERVED ARE LOW-INCOME PATIENTS, WHICH ARE SUBSIDIZED THROUGH THE WISCONSIN FAMILY CARE PROGRAM, WHICH OFTEN REIMBURSES TRI-COUNTY AT COST OR BELOW THE TRUE COST OF CARING FOR THESE RESIDENTS. DESPITE RECEIVING REIMBURSEMENT AT AMOUNTS BELOW COST, TRI-COUNTY CONTINUES THIS SERVICE AS IT FURTHERS IT'S MISSION IN THE COMMUNITY. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $20,742,447 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | Yes (1) | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Donor Rstr Or Quasi Endowments | 0 | DonorRstrOrQuasiEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With35 Ctrl Ent | 0 | BusinessRlnWith35CtrlEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 28 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 298 | EmployeeCnt |
| Employment Tax Returns Filed | Yes (1) | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Subj To Tax Rmnrtn Ex Prcht Pymt | 0 | SubjToTaxRmnrtnExPrchtPymtInd |
| Subject To Excs Tax Net Invst Inc | 0 | SubjectToExcsTaxNetInvstIncInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 9 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 4 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | Yes (1) | MembersOrStockholdersInd |
| Election Of Board Members | Yes (1) | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | Yes (1) | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JONI OLSON | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 7155384361 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | Yes (X) | InfoInScheduleOPartVIIInd |
Form990 Part VII Section A Form990PartVIISectionAGrp (16 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | OfficerOfficerInd | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| MARILU BINTZ MD | ||||||||
| TRUSTEE | 0.50 | 40.00 | Yes (X) | $0 | $622,664 | $50,443 | ||
| KIMBERLY BREIDENBACH MD | ||||||||
| TRUSTEE/CHIEF OF STAFF | 0.50 | 40.00 | Yes (X) | $0 | $259,607 | $59,076 | Yes (X) | |
| RANDY LUBAHN | ||||||||
| TRUSTEE | 0.50 | 40.00 | Yes (X) | $0 | $133,747 | $41,230 | ||
| VICKIE BAKALARS | ||||||||
| TRUSTEE | 0.50 | 40.00 | Yes (X) | $0 | $109,161 | $21,367 | ||
| DENNIS STEPHENSON | ||||||||
| CHAIRPERSON | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| BETH LISOWSKI | ||||||||
| VICE-CHAIRPERSON | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| RON GUZA | ||||||||
| TREASURER | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| KATHY KLOCK | ||||||||
| SECRETARY | 0.50 | Yes (X) | $0 | $0 | $0 | Yes (X) | ||
| MARLYS KOLSTAD | ||||||||
| TRUSTEE | 0.50 | Yes (X) | $0 | $0 | $0 | |||
| JONI OLSON | ||||||||
| ADMINISTRATOR | 0.50 | 40.00 | $0 | $204,488 | $51,195 | Yes (X) | ||
| DAN KLIDZEJS | ||||||||
| FINANCE ADMINISTRATOR | 0.50 | 40.00 | $0 | $113,697 | $35,179 | Yes (X) | ||
| KATE CAIN | ||||||||
| PHARMACY DIRECTOR | 40.00 | $164,139 | $0 | $30,752 | Yes (X) | |||
| MARK ZELLMER | ||||||||
| PHYSICIAN ASSISTANT | 40.00 | $176,099 | $0 | $17,989 | Yes (X) | |||
| BRIAN VIKE | ||||||||
| PHYSICIAN ASSISTANT | 40.00 | $148,823 | $0 | $30,075 | Yes (X) | |||
| KATHY BOE | ||||||||
| NURSE PRACTITIONER | 40.00 | $123,239 | $0 | $23,110 | Yes (X) | |||
| GANESH RAM | ||||||||
| PHYSICIAN ASSISTANT | 40.00 | $129,372 | $0 | $6,523 | Yes (X) | |||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $741,672 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $1,443,364 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $366,939 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 5 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| GROTH DESIGN GROUP INC | |||||
| PO BOX 332 | CEDARBURG | WI | 53012 | CONSTRUCTION/DESIGN | $987,617 |
| ROCHE DIAGNOSTICS CORP | |||||
| PO BOX 660367 | DALLAS | TX | 752660367 | LABORATORY | $208,290 |
| ARAMARK UNIFORM AND CAREER | |||||
| 25259 NETWORK PLACE | CHICAGO | IL | 606731252 | LAUNDRY/LINEN | $183,396 |
| HOLOGIC INC | |||||
| 24506 NETWORK PL | CHICAGO | IL | 606731245 | LABORATORY/MEDICAL TESTING | $158,338 |
| STAFFENCY | |||||
| 221 W COLLEGE AVE FLOOR 2 | APPLETON | WI | 54911 | STAFFING | $153,706 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 5 | CntrctRcvdGreaterThan100KCnt |
| Government Grants | $2,515,940 | GovernmentGrantsAmt |
| Total Contributions | $2,515,940 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp (3 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| PATIENT SERVICE REVENUE | 621400 | $24,161,239 | $24,161,239 |
| NURSING HOME REVENUE | 623000 | $1,980,326 | $1,980,326 |
| ASSISTED LIVING REVENUE | 623000 | $284,935 | $284,935 |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $419,360 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $419,360 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $26,845,860 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $21,781 | TotalRevenueColumnAmt |
| Exclusion | $21,781 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $5,744 | OtherAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $0 | OtherAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | $5,744 | OtherAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $5,744 | TotalRevenueColumnAmt |
| Exclusion | $5,744 | ExclusionAmt |
Other Revenue Misc OtherRevenueMiscGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | DIETARY | Desc |
| Business | 722210 | BusinessCd |
| Total Revenue Column | $46,832 | TotalRevenueColumnAmt |
| Exclusion | $46,832 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Revenue Total | $46,832 | OtherRevenueTotalAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $29,436,157 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $26,845,860 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $74,357 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $10,788,778 | TotalAmt |
| Program Services | $9,167,361 | ProgramServicesAmt |
| Management And General | $1,621,417 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $333,067 | TotalAmt |
| Program Services | $285,771 | ProgramServicesAmt |
| Management And General | $47,296 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,863,736 | TotalAmt |
| Program Services | $1,599,085 | ProgramServicesAmt |
| Management And General | $264,651 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $714,388 | TotalAmt |
| Program Services | $612,945 | ProgramServicesAmt |
| Management And General | $101,443 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,185,532 | TotalAmt |
| Management And General | $1,185,532 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $845 | TotalAmt |
| Management And General | $845 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $29,129 | TotalAmt |
| Management And General | $29,129 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $4,136,155 | TotalAmt |
| Program Services | $3,612,324 | ProgramServicesAmt |
| Management And General | $523,831 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $92,687 | TotalAmt |
| Program Services | $19,647 | ProgramServicesAmt |
| Management And General | $73,040 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,024,948 | TotalAmt |
| Program Services | $657,107 | ProgramServicesAmt |
| Management And General | $367,841 | ManagementAndGeneralAmt |
Information Technology InformationTechnologyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $23,156 | TotalAmt |
| Program Services | $14,977 | ProgramServicesAmt |
| Management And General | $8,179 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $326,941 | TotalAmt |
| Program Services | $326,624 | ProgramServicesAmt |
| Management And General | $317 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $23,120 | TotalAmt |
| Program Services | $22,614 | ProgramServicesAmt |
| Management And General | $506 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,469 | TotalAmt |
| Program Services | $1,458 | ProgramServicesAmt |
| Management And General | $11 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,896 | TotalAmt |
| Program Services | $37,663 | ProgramServicesAmt |
| Management And General | $6,233 | ManagementAndGeneralAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $762,695 | TotalAmt |
| Program Services | $654,392 | ProgramServicesAmt |
| Management And General | $108,303 | ManagementAndGeneralAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $56,574 | TotalAmt |
| Management And General | $56,574 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (4 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| MEDICAL SUPPLIES AND EQ | $2,811,756 | $2,786,069 | $25,687 |
| PROVISION FOR BAD DEBTS | $517,717 | $517,717 | |
| REPAIRS AND MAINTENANCE | $266,123 | $249,143 | $16,980 |
| DIETARY FOOD EXPENSE | $144,753 | $143,823 | $930 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $43,895 | TotalAmt |
| Program Services | $33,727 | ProgramServicesAmt |
| Management And General | $10,168 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $25,191,360 | TotalAmt |
| Program Services | $20,742,447 | ProgramServicesAmt |
| Management And General | $4,448,913 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $47,426 | BOYAmt |
| EOY | $52,691 | EOYAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $12,702,915 | BOYAmt |
| EOY | $13,196,141 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $4,002,531 | BOYAmt |
| EOY | $3,939,521 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $348,935 | BOYAmt |
| EOY | $386,617 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $124,961 | BOYAmt |
| EOY | $101,900 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $20,692,573 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $14,629,463 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,022,340 | BOYAmt |
| EOY | $6,063,110 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $705,630 | BOYAmt |
| EOY | $453,433 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,954,738 | BOYAmt |
| EOY | $24,193,413 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,866,520 | BOYAmt |
| EOY | $2,114,923 | EOYAmt |
Deferred Revenue DeferredRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,275,448 | BOYAmt |
| EOY | $333,024 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,331,814 | BOYAmt |
| EOY | $918,292 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,200,006 | BOYAmt |
| EOY | $3,269,746 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,673,788 | BOYAmt |
| EOY | $6,635,985 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows FASB117 | Yes (X) | OrganizationFollowsFASB117Ind |
No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,280,950 | BOYAmt |
| EOY | $17,557,428 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,280,950 | BOYAmt |
| EOY | $17,557,428 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $22,954,738 | BOYAmt |
| EOY | $24,193,413 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $4,244,797 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $31,681 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | Yes (1) | FederalGrantAuditRequiredInd |
| Federal Grant Audit Performed | Yes (1) | FederalGrantAuditPerformedInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | VolunteersInd |
| Paid Staff Or Management | 0 | PaidStaffOrManagementInd |
| Media Advertisements | 0 | MediaAdvertisementsInd |
| Mailings Members | 0 | MailingsMembersInd |
| Publications Or Broadcast | 0 | PublicationsOrBroadcastInd |
| Grants Other Organizations | 0 | GrantsOtherOrganizationsInd |
| Direct Contact Legislators | 0 | DirectContactLegislatorsInd |
| Rallies Demonstrations | 0 | RalliesDemonstrationsInd |
| Other Activities | Yes (1) | OtherActivitiesInd |
| Other Activities | $5,938 | OtherActivitiesAmt |
| Total Lobbying Expenditures | $5,938 | TotalLobbyingExpendituresAmt |
| Not Described Section501c3 | 0 | NotDescribedSection501c3Ind |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART II-B, LINE 1: | FormAndLineReferenceDesc |
| Explanation | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS (TRI-COUNTY) PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PAID PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. THE AHA AND WHA HAVE NOTIFIED TRI-COUNTY THAT APPROXIMATELY $3,902 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTH CARE ENVIRONMENT. TRI-COUNTY IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR THE ORGANIZATION PAYS MEMBERSHIP FEES TO THE RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO PROVIDES AN ANALYSIS OF CURRENT HEALTH CARE ISSUES IN AN EFFORT TO PROMOTE AND PROVIDE BETTER HEALTH CARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES A SMALL AMOUNT OF LOBBYING ON THE PART OF THE MEMBER HOSPITALS. THE RWHC DETERMINED THAT APPROXIMATELY $2,036 OF THE FEES PAID BY TRI-COUNTY IN 2021 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTH CARE ENVIRONMENT IN THE STATE OF WISCONSIN. | ExplanationTxt |
Schedule D IRS990ScheduleD
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $314,302 | OtherCostOrOtherBasisAmt |
| Book Value | $314,302 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $14,302,858 | OtherCostOrOtherBasisAmt |
| Depreciation | $10,803,721 | DepreciationAmt |
| Book Value | $3,499,137 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $4,999,793 | OtherCostOrOtherBasisAmt |
| Depreciation | $3,825,742 | DepreciationAmt |
| Book Value | $1,174,051 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,075,620 | OtherCostOrOtherBasisAmt |
| Book Value | $1,075,620 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $6,063,110 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp (5 entries)
| DescDesc | AmtAmt |
|---|---|
| 3RD PARTY REIMBURSEMENT PROGRAMS | $22,636 |
| OPERATING LEASE OBLIGATION | $60,974 |
| ADVANCE COVID PAYMENTS | $2,829,267 |
| ASSET RETIREMENT OBLIGATION | $258,537 |
| DUE TO RELATED PARTY | $98,332 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $3,269,746 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART X, LINE 2: | FormAndLineReferenceDesc |
| Explanation | GUNDERSEN HEALTH SYSTEM HAS REVIEWED TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2016 AND PRIOR YEARS. | ExplanationTxt |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent200 | Yes (X) | Percent200Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent400 | Yes (X) | Percent400Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | 0 | ExpensesExceedBudgetInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $183,657 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $183,657 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00730 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,223,595 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,211,513 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,012,082 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04020 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,407,252 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,211,513 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,195,739 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04750 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $23,196 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $640 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $22,556 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00090 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $146,952 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $146,952 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00580 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,472,850 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,265,261 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,207,589 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04790 | TotalExpensePct |
Cash And In Kind Contributions CashAndInKindContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $6,618 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $6,618 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00030 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $3,649,616 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,265,901 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,383,715 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05490 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $7,056,868 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $4,477,414 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,579,454 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.10240 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $271,152 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $135,576 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $6,761,465 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $6,713,852 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | $47,613 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 18601 LINCOLN STREET | AddressLine1Txt |
| City | WHITEHALL | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54773 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY | WebsiteAddressTxt |
| State License | 1019 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| General Medical And Surgical | Yes (X) | GeneralMedicalAndSurgicalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TRI-COUNTY MEMORIAL HOSPITAL INC | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Prior CHNA Impact | Yes (X) | PriorCHNAImpactInd |
| Other | Yes (X) | OtherInd |
| CHNA Conducted | 21 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | Yes (1) | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | SEE SUPPLEMENTAL INFORMATION | OwnWebsiteURLTxt |
| Other Website | Yes (X) | OtherWebsiteInd |
| Other Website URL | HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ | OtherWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 19 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | SEE SUPPLEMENTAL INFORMATION | StrategyWebsiteURLTxt |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 200.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 400.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Other Criteria | Yes (X) | OtherCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| Notified FAP Copy Bill Display | Yes (X) | NotifiedFAPCopyBillDisplayInd |
| FAP Translated | Yes (X) | FAPTranslatedInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| Provided Written Notice | Yes (X) | ProvidedWrittenNoticeInd |
| Made Effort Orally Notify | Yes (X) | MadeEffortOrallyNotifyInd |
| Processed FAP Application | Yes (X) | ProcessedFAPApplicationInd |
| Made Presumptive Elig Determ | Yes (X) | MadePresumptiveEligDetermInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Look Back Medicare Private | Yes (X) | LookBackMedicarePrivateInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (9 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 3J: THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) DOES NOT DIRECTLY DESCRIBE THE EXISTING HEALTH CARE FACILITIES AND RESOURCES WITHIN THE COMMUNITY THAT ARE AVAILABLE TO RESPOND TO THE HEALTH NEEDS OF THE COMMUNITY, AS THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH OTHER HOSPITALS LISTED IN QUESTION 4 BELOW. HOWEVER, GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS PREPARED AN IMPLEMENTATION STRATEGY, AS AN ADDENDUM TO THE CHNA, WHICH SPECIFICALLY DESCRIBES THE EXISTING HEALTH CARE FACILITIES AND RESOURCES THAT ARE AVAILABLE WITHIN THE COMMUNITY. |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 5: DETAILS LISTED ON THE CHNA AVAILABLE AT HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT/ |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 6A: THE CHNA WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS:-GUNDERSEN LUTHERAN MEDICAL CENTER- MAYO CLINIC HEALTH SYSTEM - LA CROSSE- MAYO CLINIC HEALTH SYSTEM - SPARTA- TOMAH MEMORIAL HOSPITAL- GUNDERSEN ST. JOSEPH'S HOSPITAL- VERNON MEMORIAL HEALTHCARE |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 6B: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER ORGANIZATIONS:- GREAT RIVERS UNITED WAY- OTTO BREMER FOUNDATION- LA CROSSE COMMUNITY FOUNDATION- LA CROSSE COUNTY HEALTH DEPARTMENT- MONROE COUNTY HEALTH DEPARTMENT- VERNON COUNTY HEALTH DEPARTMENT- TREMPEALEAU COUNTY HEALTH DEPARTMENT- HOUSTON COUNTY PUBLIC HEALTH DEPARTMENT |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 11: THE CHNA NOTED AREAS OF NEED IN HEALTH, COMMUNITY, EDUCATION, AND ECONOMICS. HEALTH AREAS INCLUDE CHRONIC DISEASE, MENTAL HEALTH AND/OR SUBSTANCE ABUSE. GTCHC IS ADDRESSING THESE NEEDS BY COLLABORATING WITH SEVERAL LOCAL AGENCIES TO PROMOTE EXERCISE AND NUTRITION, BY COLLABORATING WITH LOCAL SCHOOLS TO ADDRESS YOUTH RESILIENCE AND BULLYING. ADDITIONAL ACTIVITIES DESIGNED TO IMPROVE COMMUNITY HEALTH INCLUDE BLOOD PRESSURE BOOTHS AT COMMUNITY EVENTS, A 5K RUN AND 3K RUN/WALK EVENT, AND THE SMARTEST LOSER PROGRAM. THE CHNA NOTED COMMUNITY NEEDS IN THE AREAS OF ADVERSE CHILDHOOD EXPERIENCES, VIOLENCE, AND ENVIRONMENT. PLANNED ACTIVITIES TO ADDRESS COMMUNITY NEEDS INCLUDE HOSTING A FAMILY FUN NIGHT, PARTICIPATING IN LOCAL PARADES, AND HAVING A BOOTH AT THE DAIRY BREAKFAST. TO ADDRESS THE EDUCATION NEEDS OF ACADEMIC READINESS, YOUTH RESILIENCE, AND WORKFORCE READINESS, GTCHC PLANS TO HOST A HEALTH ACADEMY PROGRAM WITH WHITEHALL SCHOOLS AND A REACH OUT AND READ PROGRAM. GTCHC SUPPORTS THE LOCAL ECONOMY BY SUPPORTING LOCAL FOOD PANTRY'S AND PROVIDING STABLE EMPLOYMENT FOR MANY PEOPLE. |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 13H: A CATASTROPHIC CARE DISCOUNT IS AVAILABLE FOR PATIENTS WITH INCOME IN EXCESS OF 400% OF THE FPL, ASSETS BELOW 600% OF THE FPL, AND AN OUT-OF-POCKET LIABILITY TO GTC OF GREATER THAN 25% OF THE FAMILY'S INCOME. THE EFFECT OF THE DISCOUNT IS TO LIMIT THE PATIENT'S LIABILITY TO 25% OF THE FAMILY INCOME. |
| TRI-COUNTY MEMORIAL HOSPITAL, INC. | PART V, SECTION B, LINE 16J: REFERENCE TO AVAILABILITY OF FINANCIAL ASSISTANCE IS INCLUDED IN THE "PATIENT RIGHTS AND RESPONSIBILITIES" DOCUMENT, WHICH IS DISTRIBUTED TO PATIENTS UPON ADMISSION. ALSO, THE FINANCIAL ASSISTANCE POLICY IS REFERENCED IN A LETTER SENT WITH EVERY SELF-PAY STATEMENT. |
| SCHEDULE H, PART V, LINE 7A | HTTP://WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY/COMMUNITY-ASSESSMENT-AND-PLAN |
| SCHEDULE H, PART V, LINE 10 | HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 5 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp (5 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | FacilityFacilityTxt |
|---|---|---|---|---|
| 1 - WHITEHALL CLINIC | ||||
| 18606 ERVIN STREET | WHITEHALL | WI | 54773 | PROVIDER BASED RURAL HEALTH CLINIC |
| 2 - TRI-COUNTY MEMORIAL NURSING HOME | ||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | SKILLED NURSING FACILITY |
| 3 - BLAIR CLINIC | ||||
| 420 SOUTH PETERSON AVE | BLAIR | WI | 54616 | PROVIDER BASED RURAL HEALTH CLINIC |
| 4 - INDEPENDENCE CLINIC | ||||
| 35791 OSSEO ROAD | INDEPENDENCE | WI | 54747 | PROVIDER BASED RURAL HEALTH CLINIC |
| 5 - SUNRISE ASSISTED LIVING | ||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | RESIDENTIAL CARE APARTMENT COMPLEX |
Supplemental Information Detail SupplementalInformationDetail (16 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| PART I, LINE 3C: | IN ADDITION TO THE INCOME LEVEL THRESHOLDS, ASSETS MUST BE BELOW 600% OF FPG. AN ADDITIONAL DISCOUNT IS AVAILABLE FOR CATASTROPHIC CARE, IF A PATIENT'S INCOME IS MORE THAN 400% OF THE FPL, ASSETS ARE BELOW 600% OF THE FPL, AND OUT-OF-POCKET OBLIGATIONS TO GTCHC EXCEED 25% OF THE FAMILY'S INCOME. THIS EFFECT OF THE DISCOUNT IS TO LIMIT THE PATIENT'S LIABILITY TO 25% OF FAMILY INCOME. |
| PART I, LINE 6A: | TRI-COUNTY PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON THE WHA'S WEBSITE. |
| 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 VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. |
| PART I, LINE 7G: | SUBSIDIZED HEALTH SERVICES AT GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS INCLUDE THE OPERATION OF A SKILLED NURSING FACILITY (THE "NURSING HOME"), THE SUNRISE ASSISTED LIVING FACILITY. THE NURSING HOME AND ASSISTED LIVING SERVICES ARE OPERATED TO PROVIDE A CONTINUUM OF CARE FOR ELDERLY AND DISABLED PERSONS WHO NEED ADDITIONAL CARE IN BOTH LONG-TERM AND SHORT-TERM PROGRAMS. THE NURSING HOME AND ASSISTED LIVING SERVICES RECEIVE A LARGE PORTION OF THEIR PROGRAM REVENUES FROM GOVERNMENT PAY SOURCES SUCH AS THE WISCONSIN MEDICAID AND FAMILY CARE PROGRAMS, WHICH OFTEN REIMBURSE THE NURSING HOME AT COSTS WELL BELOW THE COST OF PROVIDING CARE TO THE PATIENTS; HOWEVER, WITHOUT THIS PROGRAM, THESE RESIDENTS WOULD NEED TO TRAVEL TO FACILITIES OUTSIDE OF THEIR COMMUNITY TO FIND THE NEEDED MEDICAL SERVICES. (SEE ALSO PART III, LINES 4B AND 4C, FOR A FURTHER DESCRIPTION OF THE NURSING HOME AND ASSISTED LIVING SERVICES PROVIDED.) |
| PART II, COMMUNITY BUILDING ACTIVITIES: | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS SUPPORTS MANY PROGRAMS THAT ARE OFFERED AT NOMINAL CHARGE OR FREE TO THE COMMUNITY AT LARGE. THESE PROGRAMS INCLUDE BUT ARE NOT LIMITED TO AN ANNUAL FITNESS RUN/WALK, SEMI-ANNUAL BLOOD DRIVES, MONTHLY SUPPORT GROUP FOR SUFFERERS OF DYSPHAGIA, AND PERIODIC PRESENTATIONS ON NUTRITION EDUCATION. THE COST TO PROVIDE THESE SERVICES IS OUTLINED IN THE COMMUNITY BENEFITS SCHEDULE. |
| PART III, LINE 2: | THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO, WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES EXCLUDING THE PROVISION FOR BAD DEBT, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE YEAR TO ESTIMATE THE COST OF CARE OF PATIENTS WHO HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE EXCLUDED FROM GROSS PATIENT SERVICE REVENUE ON THE CONSOLIDATED FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. |
| PART III, LINE 3: | MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS DO NOT COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS, A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. |
| PART III, LINE 4: | THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE.ACCOUNTS RECEIVABLE AND CREDIT POLICY:ACCOUNTS RECEIVABLE ARE REPORTED AT THE AMOUNT THAT REFLECTS THE CONSIDERATION TO WHICH TRI-COUNTY EXPECTS TO BE ENTITLED, IN EXCHANGE FOR PROVIDING PATIENT AND RESIDENT CARE SERVICES. ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND IMPLICIT PRICE CONCESSIONS WHICH REFLECTS MANAGEMENT'S ESTIMATE OF THE TRANSACTION PRICE. TRI-COUNTY ESTIMATES THE TRANSACTION PRICE BASED ON NEGOTIATED CONTRACTUAL AGREEMENTS, HISTORICAL EXPERIENCE, AND CURRENT MARKET CONDITIONS. THE INITIAL ESTIMATE OF THE TRANSACTION PRICE IS DETERMINED BY REDUCING THE STANDARD CHARGE BY ANY CONTRACTUAL ADJUSTMENTS, DISCOUNTS, AND IMPLICIT PRICE CONCESSIONS AND IS RECORDED THROUGH A REDUCTION OF GROSS REVENUE AND A CREDIT TO ACCOUNTS RECEIVABLE. SUBSEQUENT CHANGES TO THE ESTIMATE OF THE TRANSACTION PRICE ARE GENERALLY RECORDED AS ADJUSTMENTS TO PATIENT AND RESIDENT SERVICE REVENUE IN THEPERIOD OF THE CHANGE. TRI-COUNTY DOES NOT HAVE A POLICY TO CHARGE INTEREST ON PAST DUE ACCOUNTS.FROM NET PATIENT AND RESIDENT SERVICE REVENUE FOOTNOTE:CONSISTENT WITH TRI-COUNTY'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THEREFORE, TRI-COUNTY HAS DETERMINED IT HAS PROVIDED IMPLICIT PRICE CONCESSIONS TO UNINSURED PATIENTS AND PATIENTS WITH OTHER UNINSURED BALANCES (FOR EXAMPLE, COPAYS AND DEDUCTIBLES). THE IMPLICIT PRICE CONCESSIONS INCLUDED IN ESTIMATING THE TRANSACTION PRICE REPRESENT THE DIFFERENCE BETWEEN AMOUNTS BILLED TO PATIENTS AND THE AMOUNTS TRI-COUNTY EXPECTS TO COLLECT BASED ON ITS COLLECTION HISTORY WITH THOSE PATIENTS. TRI-COUNTY'S POLICY PROVIDED A 32% DISCOUNT IN BOTH 2019 AND 2018 FROM ESTABLISHED CHARGES TO UNINSURED PATIENTS. THIS POLICY DID NOT CHANGE IN 2019 OR 2018. |
| PART III, LINE 8: | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND, AS SUCH, A PORTION OF ITS MEDICARE REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN INCLUDES ONLY A PORTION OF THE TOTAL GROSS MEDICARE REVENUE TRI-COUNTY RECEIVES AND DOES NOT CONSIDER ALL OF THE CONTRACTUAL ADJUSTMENTS FOR THE REIMBURSEMENT THAT IS ACTUALLY RECEIVED FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE REVENUE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS RADIOLOGIST OR URGENT CARE PROFESSIONAL SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHOD 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 TRI-COUNTY PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF TREMPEALEAU COUNTY, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 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 SERVICES, WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTH CARE 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: | PATIENTS WHO QUALIFY FOR CHARITY CARE ARE AWARDED THE DISCOUNTS TO WHICH THEY ARE ENTITLED ACCORDING TO THEIR INCOME BASED ON FACILITY POLICY AND ALSO AGREE TO PAY ANY REMAINING BALANCE AFTER THE DISCOUNT FOR CHARITY CARE IS CREDITED TO THEIR ACCOUNT. IF NECESSARY, ANY REMAINING BALANCE DUE WILL BE SET UP ON A PAYMENT PLAN AT AMOUNTS THAT THE PATIENT IS ABLE TO PAY OVER TIME. THE COLLECTION PROCESS WOULD NOT BE INITIATED UNLESS THE PATIENT DEFAULTED ON THE AGREED-UPON REPAYMENT PLAN. |
| PART VI, LINE 2: | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES IT SERVES BY PARTNERING WITH OTHER ENTITIES SUCH AS OTHER HEALTH CARE PROVIDERS, AREA COLLEGES, AND GOVERNMENT AGENCIES. THROUGH A PARTNERSHIP WITH UNITED WAY, AREA HEALTH CARE ORGANIZATIONS, AND COUNTY HEALTH DEPARTMENTS, A NEEDS ASSESSMENT WAS COMPLETED WITH A FINAL REPORT OF DATA PROVIDED IN 2018. THE GOAL OF THIS PROJECT WAS TO ASSESS THE NEEDS OF THE COMMUNITY AND TO SET IN MOTION STRATEGIC PLANS AND TACTICS TO RESPOND TO THE NEEDS AND SOLVE THE PROBLEMS IDENTIFIED. A STRATEGIC PLAN WAS REVIEWED BY THE TRI-COUNTY BOARD OF TRUSTEES TO ADDRESS THESE NEEDS. THE REPORT IDENTIFIED ISSUES IN THE FOLLOWING AREAS. 1. HEALTH AND WELLNESS CONCERNS IN THE FOLLOWING AREAS: ALCOHOL USE, HEALTH CARE ACCESS & COST, MENTAL HEALTH, OBESITY2. ECONOMIC: LIMITED ECONOMIC DEVELOPMENT, LOW LIVING WAGES, UNEMPLOYMENT 3. EDUCATION: SCHOOL READINESS, JOB SKILL TRAINING4. COMMUNITY PROBLEMS: TRANSPORTATION, FOOD AVAILABILITY, CHILDCARE IN ADDITION, GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS MAINTAINS A PATIENT ADVISORY COMMITTEE OF COMMUNITY MEMBERS WHO MEET QUARTERLY, PROVIDE INPUT, AND ARE INVOLVED IN PROPOSED CHANGES TO CERTAIN ASPECTS OF THE ORGANIZATIONS OPERATIONS. THE ORGANIZATION IS ALSO AN ACTIVE MEMBER OF THE COMMUNITY. BY COLLABORATING WITH LOCAL LAW ENFORCEMENT, LOCAL SCHOOL DISTRICTS, AND OTHER ORGANIZATIONS AND PARTICIPATING IN VARIOUS COMMUNITY EVENTS, GUNDERSEN TRI-COUNTY IS ABLE TO REMAIN KNOWLEDGEABLE ABOUT THE COMMUNITY'S HEALTH NEEDS. ADDITIONALLY, MUCH OF GUNDERSEN TRI-COUNTY'S MANAGEMENT PARTICIPATES IN ROUNDTABLES OR OTHER PROFESSIONAL NETWORKING ACTIVITIES IN ORDER TO REMAIN KNOWLEDGEABLE ABOUT CURRENT HEALTHCARE ISSUES. |
| PART VI, LINE 3: | THE FINANCIAL ASSISTANCE POLICY IS POSTED ON THE ORGANIZATION'S WEBSITE AND AT EVERY REGISTRATION POINT THERE IS A POSTER ABOUT PROGRAMS THAT EXIST TO HELP PATIENTS PAY FOR THEIR CARE. ALL PATIENTS WHO HAVE SELF-PAY BALANCES (EITHER UNINSURED OR SELF-PAY AFTER INSURANCE) ARE MADE AWARE OF AVAILABLE ASSISTANCE VIA STATEMENT MESSAGES AND COURTESY NOTICES. PHONE CALLS TO FOLLOW UP WITH PATIENTS ARE ALSO MADE IN CASES WHERE MAIL IS RETURNED AS UNDELIVERABLE. |
| PART VI, LINE 4: | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS, A FEDERALLY-DESIGNATED, CRITICAL ACCESS HOSPITAL, ALONG WITH ITS NURSING HOME, ASSISTED LIVING, AND THREE FEDERALLY DESIGNATED RURAL HEALTH CLINICS, SERVES THE CENTRAL AREA OF TREMPEALEAU COUNTY, WISCONSIN, AND PRIMARILY THE ZIP CODES OF WHITEHALL (54773), INDEPENDENCE (54747), AND BLAIR (54616). AS AN AFFILIATE HOSPITAL OF THE GUNDERSEN LUTHERAN HEALTH SYSTEM OF LA CROSSE, WI, TRI-COUNTY ALSO SUPPORTS A GUNDERSEN-CONTRACTED INDUSTRIAL IN-PLANT EMPLOYEE AND DEPENDENTS PRIMARY CARE MEDICAL CLINIC IN NEARBY ARCADIA, AS WELL FEDERALLY DESIGNATED SKILLED NURSING FACILITY/NURSING FACILITIES IN WHITEHALL, PIGEON FALLS, AND BLAIR. TREMPEALEAU COUNTY IS SERVED BY TWO HOSPITALS, INCLUDING TRI-COUNTY IN WHITEHALL AND MAYO CLINIC HEALTH SYSTEM OAKRIDGE HOSPITAL IN OSSEO. THE PRIMARY CORE PART OF THIS SERVICE AREA CONTAINS A U.S. HEALTH AND HUMAN SERVICES (HHS) PRIMARY CARE HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) OF THE GEOGRAPHICAL AREA TYPE, THE "CENTRAL TREMPEALEAU SERVICE AREA," COMPRISED OF CHIMNEY ROCK TOWNSHIP (RUSSELL, WI); BURNSIDE TOWNSHIP (INDEPENDENCE, WI); LINCOLN TOWNSHIP (WHITEHALL, WI); PIGEON TOWNSHIP (PIGEON FALLS, WI); AND PRESTON TOWNSHIP (BLAIR, WI). THIS PRIMARY CARE HPSA IS FLANKED ON THE EAST, NORTHEAST, AND SOUTH BY SIMILAR PRIMARY CARE GEOGRAPHIC AREA HPSAS FOR MONDOVI (NORTHERN HALF OF BUFFALO COUNTY), AUGUSTA/OSSEO SERVICE AREA (PARTS OF TREMPEALEAU, EAU CLAIRE, AND JACKSON COUNTIES), AND GALESVILLE/TREMPEALEAU (SOUTHERN HALF OF TREMPEALEAU COUNTY), RESPECTIVELY. TRI-COUNTY SERVES PATIENTS FROM ALL OF THESE AREAS. |
| PART VI, LINE 5: | A NUMBER OF MEMBERS OF TRI-COUNTY'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE ORGANIZATION, NOR FAMILY MEMBERS THEREOF. THE ORGANIZATION EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS TO BETTER MEET THE DEMANDS AND REQUESTS OF PATIENTS.TRI-COUNTY PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, TRI-COUNTY BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. TRI-COUNTY, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: PRIMARY HEALTH CARE AND DIAGNOSIS, DIAGNOSTIC RADIOLOGY, EMERGENCY SERVICES, URGENT CARE, SKILLED NURSING, INFUSION SERVICES, SWING BED SERVICES, LABORATORY SERVICES, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH PATHOLOGY, SURGICAL SERVICES, WOMEN'S SERVICES, AND ASSISTED LIVING SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. |
| PART VI, LINE 6: | GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS IS AN AFFILIATE OF GUNDERSEN LUTHERAN HEALTH SYSTEM. THE ORGANIZATIONS WORK COLLABORATIVELY TO MEET AND EXCEED THE HEALTH CARE NEEDS OF PATIENTS IN THE WHITEHALL, WISCONSIN AREA. A COMMON GOAL OF WORKING WITH THE HEALTH SYSTEM IS TO FOCUS THE ORGANIZATIONS ON CONTINUING TO BE ABLE TO PROVIDE HIGH QUALITY, LOW COST HEALTHCARE TO AREA RESIDENTS AS WELL AS TO CONTINUOUSLY ALIGN CLINICAL AND HOSPITAL STAFF AT TRI-COUNTY, THE REGIONAL HEALTH SYSTEM CLINICS, VISITING SPECIALISTS FROM GUNDERSEN HEALTH SYSTEM, AND OTHER AREA PROVIDERS TO INCREASE ACCESS TO LOCAL HEALTHCARE. |
| PART VI, LINE 7, REPORTS FILED WITH STATES | WI |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | 0 | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (7 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| MARILU BINTZ MD | ||||||||||||||
| TRUSTEE | $0 | $615,241 | $0 | $2,000 | $0 | $5,423 | $0 | $42,050 | $0 | $8,393 | $0 | $673,107 | $0 | $0 |
| KIMBERLY BREIDENBACH MD | ||||||||||||||
| TRUSTEE/CHIEF OF STAFF | $0 | $251,496 | $0 | $4,500 | $0 | $3,611 | $0 | $37,338 | $0 | $21,738 | $0 | $318,683 | $0 | $0 |
| JONI OLSON | ||||||||||||||
| ADMINISTRATOR | $0 | $199,663 | $0 | $2,000 | $0 | $2,825 | $0 | $29,459 | $0 | $21,736 | $0 | $255,683 | $0 | $0 |
| KATE CAIN | ||||||||||||||
| PHARMACY DIRECTOR | $153,691 | $0 | $4,000 | $0 | $6,448 | $0 | $8,014 | $0 | $22,738 | $0 | $194,891 | $0 | $0 | $0 |
| MARK ZELLMER | ||||||||||||||
| PHYSICIAN ASSISTANT | $173,086 | $0 | $2,000 | $0 | $1,013 | $0 | $8,797 | $0 | $9,192 | $0 | $194,088 | $0 | $0 | $0 |
| BRIAN VIKE | ||||||||||||||
| PHYSICIAN ASSISTANT | $143,052 | $0 | $3,088 | $0 | $2,683 | $0 | $7,511 | $0 | $22,564 | $0 | $178,898 | $0 | $0 | $0 |
| RANDY LUBAHN | ||||||||||||||
| TRUSTEE | $0 | $125,751 | $0 | $2,000 | $0 | $5,996 | $0 | $19,492 | $0 | $21,738 | $0 | $174,977 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form And Line Reference | PART I, LINE 3 | FormAndLineReferenceDesc |
| Explanation | FOR THE PURPOSES OF DETERMINING EXECUTIVE COMPENSATION, GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS RELIED ON AN AFFILIATED ORGANIZATION WITHIN GUNDERSEN HEALTH SYSTEM, TO ESTABLISH COMPENSATION OF THE CEO, CFO, AND OTHER OFFICERS. GUNDERSEN HEALTH SYSTEM USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION SURVEY OR STUDY, COMPENSATION COMMITTEE, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. | ExplanationTxt |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (12 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 3 | AS AN AFFILIATE OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., TRI-COUNTY WILL ROUTINELY DELEGATE VARIOUS MANAGEMENT OR SUPPORT FUNCTIONS TO RELATED ENTITIES. FOR EXAMPLE, THE CEO AND CFO OF TRI-COUNTY ARE EMPLOYED BY THE HOME OFFICE OF THE PARENT ORGANIZATION, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. SEVERAL MEMBERS OF THE BOARD OF DIRECTORS ARE ALSO EMPLOYEES OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATED ORGANIZATIONS, WHICH ARE ALSO TAX-EXEMPT ORGANIZATIONS. |
| FORM 990, PART VI, SECTION A, LINE 6 | THE ARTICLES OF INCORPORATION OF TRI-COUNTY PROVIDE FOR TWO CLASSES OF MEMBERSHIP IN THE CORPORATION. THE FIRST CLASS OF MEMBERSHIP IS A CORPORATE MEMBER CLASS, AND THE SOLE MEMBER OF THIS CLASS IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE SECOND CLASS OF MEMBERSHIP IS A PUBLIC MEMBERSHIP, WHICH IS MADE UP OF PERSONS OVER THE AGE OF 18 WHO ARE INTERESTED IN PROMOTING AIMS, PURPOSES, AND WELFARE OF TRI-COUNTY. |
| FORM 990, PART VI, SECTION A, LINE 7A | THE ARTICLES OF INCORPORATION OF TRI-COUNTY PROVIDE FOR TWO CLASSES OF MEMBERSHIP. ONE CLASS IS HELD BY A SOLE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., WHICH MAY APPOINT SEVEN OF THE TWELVE MEMBERS OF THE BOARD OF DIRECTORS. GUNDERSEN ALSO HAS THE RESERVE RIGHT TO APPROVE OR DISAPPROVE OF THE OTHER FIVE MEMBERS OF THE BOARD OF DIRECTORS. |
| FORM 990, PART VI, SECTION A, LINE 7B | APPROVAL OF TRI-COUNTY'S OPERATING BUDGET AND PLAN, CAPITAL EXPENDITURES GREATER THAN $100,000, ADDITIONAL INDEBTEDNESS OVER $100,000, DISAFFILIATION, AND AMENDMENTS OR CHANGES TO THE ARTICLES OF INCORPORATION AND BYLAWS IS SUBJECT TO APPROVAL BY THE BOARD OF DIRECTORS OF ITS MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. |
| FORM 990, PART VI, SECTION B, LINE 11B | THE RETURN IS REVIEWED BY MANAGEMENT AND MADE AVAILABLE TO THE BOARD OF DIRECTORS PRIOR TO FILING. |
| FORM 990, PART VI, SECTION B, LINE 12C | TRI-COUNTY MONITORS CONFLICTS ON AN ANNUAL BASIS BY REVIEWING DISCLOSURES ON COMPLETED CONFLICT OF INTEREST STATEMENTS. ANY MEMBERS WITH NOTED CONFLICTS ARE ASKED TO ABSTAIN FROM VOTING ON ANY POTENTIALLY CONFLICTED MATTERS. |
| FORM 990, PART VI, SECTION B, LINE 15 | FOR THE PURPOSES OF DETERMINING COMPENSATION, TRI-COUNTY RELIED ON AN AFFILIATED ORGANIZATION WITHIN GUNDERSEN HEALTH SYSTEM TO ESTABLISH COMPENSATION OF THE CEO, CFO, AND OTHER OFFICERS. GUNDERSEN HEALTH SYSTEM USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION SURVEY OR STUDY, COMPENSATION COMMITTEE, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. |
| FORM 990, PART VI, SECTION C, LINE 19 | TRI-COUNTY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. |
| FORM 990, PART VII, SECTION A, LINE 1, EXPLANATION OF HOURS WORKED: | SOME OFFICERS AND BOARD MEMBERS ARE EMPLOYED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. AND ITS AFFILIATES ("GUNDERSEN"). IN ADDITION TO THE HOURS WORKED AS A DIRECTOR ON TRI-COUNTY'S BOARD, THEY ALSO WORK A MINIMUM OF 40 HOURS PER WEEK PERFORMING OTHER SERVICES FOR GUNDERSEN. THESE HOURS ARE REFLECTED IN LINE 2 OF COLUMN B. |
| FORM 990, PART IX, LINE 11G | PATIENT BILLING SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 90,415. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 90,415. CLINIC SERVICES: PROGRAM SERVICE EXPENSES 996,469. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 996,469. EMERGENCY SERVICES: PROGRAM SERVICE EXPENSES 1,214,100. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,214,100. ANESTHESIA SERVICES: PROGRAM SERVICE EXPENSES 103,945. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 103,945. SURGERY SERVICES: PROGRAM SERVICE EXPENSES 144,590. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 144,590. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 1,153,220. MANAGEMENT AND GENERAL EXPENSES 433,416. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,586,636. |
| FORM 990, PART XI, LINE 9: | EQUITY CHANGE IN UNCONSOLIDATED AFFILIATES 31,681. |
| FORM 990, PART XII, LINE 2C, OVERSIGHT OF THE AUDIT: | THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS BY AN INDEPENDENT ACCOUNTANT. THE BOARD OF DIRECTORS GIVES THE FINAL APPROVAL OF THE AUDIT FIRM AND AUDIT REPORTS AND TAKES TIME ANNUALLY TO MEET WITH THE AUDITORS WITHOUT MANAGEMENT PRESENT. THERE WAS NO CHANGE TO THIS PROCESS DURING THE FILING PERIOD. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp (21 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Exempt Code SectionExemptCodeSectionTxt | Public Charity StatusPublicCharityStatusTxt | Business Name Line1DirectControllingEntityName/BusinessNameLine1Txt | Controlled OrganizationControlledOrganizationInd | Direct Controlling NADirectControllingNACd |
|---|---|---|---|---|---|---|---|---|---|---|---|
| COMMUNITY HOUSING OF LA CROSSE INC | |||||||||||
| 1900 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391586700 | INDEPENDENT LIVING | WI | 501(C)(3) | LINE 10 | LUTHERAN REAL ESTATE HOLDING CORP | Yes (1) | |
| GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES INC | |||||||||||
| 1910 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391606449 | SUPPORTING ORGANIZATION | WI | 501(C)(3) | LINE 12B, II | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| GUNDERSEN CLINIC LTD | |||||||||||
| 1836 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391028657 | HEALTH CARE | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| GUNDERSEN LUTHERAN CREDENTIALING SERVICES INC | |||||||||||
| 1910 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391856898 | CREDENTIALING SERVICE | WI | 501(C)(3) | LINE 12C, III-FI | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| GUNDERSEN LUTHERAN HEALTH SYSTEM INC | |||||||||||
| 1836 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391866425 | SUPPORTING ORGANIZATION | WI | 501(C)(3) | LINE 12B, II | 0 | N/A | |
| GUNDERSEN LUTHERAN MEDICAL CENTER INC | |||||||||||
| 1910 SOUTH AVENUE | LA CROSSE | WI | 54601 | 390813416 | HEALTH CARE | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| GUNDERSEN LUTHERAN MEDICAL FOUNDATION INC | |||||||||||
| 1836 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391249705 | FOUNDATION | WI | 501(C)(3) | LINE 7 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| HARMONY COMMUNITY HEALTHCARE INC | |||||||||||
| 815 MAIN AVENUE S | HARMONY | MN | 55939 | 410711606 | HEALTH CARE | MN | 501(C)(3) | LINE 10 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| LUTHERAN HOUSING OF LA CROSSE INC | |||||||||||
| 1900 SOUTH AVENUE | LA CROSSE | WI | 54601 | 391751934 | INDEPENDENT LIVING | WI | 501(C)(3) | LINE 10 | LUTHERAN REAL ESTATE HOLDING CORP | Yes (1) | |
| LUTHERAN REAL ESTATE HOLDING CORPORATION | |||||||||||
| 1910 SOUTH AVENUE | LA CROSSE | WI | 56401 | 391480826 | HOUSING | WI | 501(C)(3) | LINE 12C, III-FI | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO | |||||||||||
| 402 WEST LAKE STREET | FRIENDSHIP | WI | 53934 | 391775074 | FOUNDATION | WI | 501(C)(3) | LINE 12A, I | MOUNDVIEW MEMORIAL HOSPITAL & CLINICS | Yes (1) | |
| MEMORIAL HOSPITAL OF BOSCOBEL | |||||||||||
| 205 PARKER STREET | BOSCOBEL | WI | 53805 | 390845590 | HEALTH CARE | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| MOUNDVIEW MEMORIAL HOSPITAL | |||||||||||
| 402 WEST LAKE STREET | FRIENDSHIP | WI | 53934 | 390944012 | HEALTH CARE | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| PALMER LUTHERAN HEALTH CENTER | |||||||||||
| 112 JEFFERSON STREET | WEST UNION | IA | 52175 | 421320763 | HEALTH CARE | IA | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| ST JOSEPH'S HEALTH SERVICES INC | |||||||||||
| 400 WATER AVENUE | HILLSBORO | WI | 54634 | 390929538 | HEALTH CARE | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| ST JOSEPH'S MEMORIAL FOUNDATION INC | |||||||||||
| 400 WATER AVENUE | HILLSBORO | WI | 54634 | 391455787 | FOUNDATION | WI | 501(C)(3) | LINE 12A, I | ST JOSEPH'S HEALTH SERVICES INC | Yes (1) | |
| TRI-COUNTY MEMORIAL FOUNDATION INC | |||||||||||
| 18601 LINCOLN STREET | WHITEHALL | WI | 54773 | 300093022 | FOUNDATION | WI | 501(C)(3) | LINE 12A, I | TRI-COUNTY MEMORIAL HOSPITAL INC | Yes (1) | |
| TRI-STATE AMBULANCE INC | |||||||||||
| 235 CAUSEWAY BLVD | LA CROSSE | WI | 54603 | 391965415 | MEDICAL TRANSPORTATION | WI | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| TRI-STATE REGIONAL AMBULANCE INC | |||||||||||
| 235 CAUSEWAY BLVD | LA CROSSE | WI | 54603 | 391962965 | MEDICAL TRANSPORTATION | WI | 501(C)(3) | LINE 10 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| TWEETEN LUTHERAN HEALTHCARE CENTER INC | |||||||||||
| 125 FIFTH AVENUE SE | SPRING GROVE | MN | 55974 | 411565003 | HEALTH CARE | MN | 501(C)(3) | LINE 10 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
| SAINT ELIZABETH'S HOSPITAL OF WABASHA | |||||||||||
| 1200 5TH GRANT BLVD W | WABASHA | MN | 55981 | 410693877 | HEALTH CARE | MN | 501(C)(3) | LINE 3 | GUNDERSEN LUTHERAN HEALTH SYSTEM INC | Yes (1) | |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (2 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|
| GUNDERSEN LUTHERAN ENVISION LLC | |||||||||
| 1836 SOUTH AVENUE | LA CROSSE | WI | 54601 | 264706546 | RENEWABLE ENERGY | WI | N/A | C | Yes (1) |
| 3REALESTATE LLC | |||||||||
| 1900 SOUTH AVENUE | LA CROSSE | WI | 54601 | RENTAL | WI | N/A | C | Yes (1) | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | Yes (1) | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | Yes (1) | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | Yes (1) | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | Yes (1) | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |