2022-11-15T10:35:05-06:00 2021-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2021-01-01 390704510 TRI-COUNTY MEMORIAL HOSPITAL INC TRI- 7155384361 18601 LINCOLN STREET WHITEHALL WI 54773 JONI OLSON ADMINISTRATOR 7155384361 2022-11-14 1 JONI OLSON 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-11-14 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z GUNDERSEN TRI-COUNTY HOSPITAL AND CLINICS JONI OLSON 18601 LINCOLN STREET WHITEHALL WI 54773 29436157 0 X WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY X 1937 WI WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 9 4 298 10 0 0 2540794 2515940 25517810 26845860 24551 27525 44217 46832 28127372 29436157 0 0 0 0 13338995 13699969 0 0 0 10763537 11491391 24102532 25191360 4024840 4244797 22954738 24193413 9673788 6635985 13280950 17557428 X WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 18574766 0 24580599 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. 1852441 0 1980326 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. 315240 0 284935 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. 20742447 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 28 0 298 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 4 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X JONI OLSON 7155384361 18601 LINCOLN STREET WHITEHALL WI 54773 X MARILU BINTZ MD TRUSTEE 0.50 40.00 X 0 622664 50443 KIMBERLY BREIDENBACH MD TRUSTEE/CHIEF OF STAFF 0.50 40.00 X X 0 259607 59076 RANDY LUBAHN TRUSTEE 0.50 40.00 X 0 133747 41230 VICKIE BAKALARS TRUSTEE 0.50 40.00 X 0 109161 21367 DENNIS STEPHENSON CHAIRPERSON 0.50 X X 0 0 0 BETH LISOWSKI VICE-CHAIRPERSON 0.50 X X 0 0 0 RON GUZA TREASURER 0.50 X X 0 0 0 KATHY KLOCK SECRETARY 0.50 X X 0 0 0 MARLYS KOLSTAD TRUSTEE 0.50 X 0 0 0 JONI OLSON ADMINISTRATOR 0.50 40.00 X 0 204488 51195 DAN KLIDZEJS FINANCE ADMINISTRATOR 0.50 40.00 X 0 113697 35179 KATE CAIN PHARMACY DIRECTOR 40.00 X 164139 0 30752 MARK ZELLMER PHYSICIAN ASSISTANT 40.00 X 176099 0 17989 BRIAN VIKE PHYSICIAN ASSISTANT 40.00 X 148823 0 30075 KATHY BOE NURSE PRACTITIONER 40.00 X 123239 0 23110 GANESH RAM PHYSICIAN ASSISTANT 40.00 X 129372 0 6523 741672 1443364 366939 5 0 1 0 GROTH DESIGN GROUP INC PO BOX 332 CEDARBURG WI 53012 CONSTRUCTION/DESIGN 987617 ROCHE DIAGNOSTICS CORP PO BOX 660367 DALLAS TX 752660367 LABORATORY 208290 ARAMARK UNIFORM AND CAREER 25259 NETWORK PLACE CHICAGO IL 606731252 LAUNDRY/LINEN 183396 HOLOGIC INC 24506 NETWORK PL CHICAGO IL 606731245 LABORATORY/MEDICAL TESTING 158338 STAFFENCY 221 W COLLEGE AVE FLOOR 2 APPLETON WI 54911 STAFFING 153706 5 2515940 2515940 PATIENT SERVICE REVENUE 621400 24161239 24161239 NURSING HOME REVENUE 623000 1980326 1980326 ASSISTED LIVING REVENUE 623000 284935 284935 419360 419360 26845860 21781 21781 5744 0 5744 5744 5744 DIETARY 722210 46832 46832 46832 29436157 26845860 0 74357 X 10788778 9167361 1621417 333067 285771 47296 1863736 1599085 264651 714388 612945 101443 1185532 1185532 845 845 29129 29129 4136155 3612324 523831 92687 19647 73040 1024948 657107 367841 23156 14977 8179 326941 326624 317 23120 22614 506 1469 1458 11 43896 37663 6233 762695 654392 108303 56574 56574 MEDICAL SUPPLIES AND EQ 2811756 2786069 25687 PROVISION FOR BAD DEBTS 517717 517717 REPAIRS AND MAINTENANCE 266123 249143 16980 DIETARY FOOD EXPENSE 144753 143823 930 43895 33727 10168 25191360 20742447 4448913 0 47426 52691 12702915 13196141 4002531 3939521 348935 386617 124961 101900 20692573 14629463 5022340 6063110 705630 453433 22954738 24193413 3866520 2114923 3275448 333024 1331814 918292 1200006 3269746 9673788 6635985 X 13280950 17557428 13280950 17557428 22954738 24193413 X 4244797 31681 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 5938 5938 0 PART II-B, LINE 1: 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. 314302 314302 14302858 10803721 3499137 4999793 3825742 1174051 1075620 1075620 6063110 3RD PARTY REIMBURSEMENT PROGRAMS 22636 OPERATING LEASE OBLIGATION 60974 ADVANCE COVID PAYMENTS 2829267 ASSET RETIREMENT OBLIGATION 258537 DUE TO RELATED PARTY 98332 3269746 X PART X, LINE 2: 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. 1 1 X 1 X 1 X 1 1 0 1 1 183657 183657 0.00730 3223595 2211513 1012082 0.04020 3407252 2211513 1195739 0.04750 23196 640 22556 0.00090 146952 146952 0.00580 3472850 2265261 1207589 0.04790 6618 6618 0.00030 3649616 2265901 1383715 0.05490 7056868 4477414 2579454 0.10240 0 271152 135576 6761465 6713852 47613 X 1 1 1 1 TRI-COUNTY MEMORIAL HOSPITAL INC 18601 LINCOLN STREET WHITEHALL WI 54773 WWW.GUNDERSENHEALTH.ORG/TRI-COUNTY 1019 X X X X TRI-COUNTY MEMORIAL HOSPITAL INC 1 0 0 1 X X X X X X X X X X 21 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X HTTPS://WWW.GREATRIVERSUNITEDWAY.ORG/OUR-WORK/COMMUNITY-NEEDS-ASSESSMENT/ X 1 19 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 200.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X HTTP://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X X X X X X 1 X 0 X X X X 1 X 0 0 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 5 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 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 0 0 0 0 0 0 0 0 0 MARILU BINTZ MD TRUSTEE 0 615241 0 2000 0 5423 0 42050 0 8393 0 673107 0 0 KIMBERLY BREIDENBACH MD TRUSTEE/CHIEF OF STAFF 0 251496 0 4500 0 3611 0 37338 0 21738 0 318683 0 0 JONI OLSON ADMINISTRATOR 0 199663 0 2000 0 2825 0 29459 0 21736 0 255683 0 0 KATE CAIN PHARMACY DIRECTOR 153691 0 4000 0 6448 0 8014 0 22738 0 194891 0 0 0 MARK ZELLMER PHYSICIAN ASSISTANT 173086 0 2000 0 1013 0 8797 0 9192 0 194088 0 0 0 BRIAN VIKE PHYSICIAN ASSISTANT 143052 0 3088 0 2683 0 7511 0 22564 0 178898 0 0 0 RANDY LUBAHN TRUSTEE 0 125751 0 2000 0 5996 0 19492 0 21738 0 174977 0 0 PART I, LINE 3 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. 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. 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 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 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 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 1 GUNDERSEN LUTHERAN HEALTH SYSTEM INC 1836 SOUTH AVENUE LA CROSSE WI 54601 391866425 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12B, II N/A 0 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 1 GUNDERSEN LUTHERAN ENVISION LLC 1836 SOUTH AVENUE LA CROSSE WI 54601 264706546 RENEWABLE ENERGY WI N/A C 1 3REALESTATE LLC 1900 SOUTH AVENUE LA CROSSE WI 54601 RENTAL WI N/A C 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 0 0