2021-07-06T08:10:48-05:00 2020-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-01-01 411842965 LAKEWOOD HEALTH SYSTEM LAKE 2188941515 49725 COUNTY 83 STAPLES MN 56479 LISA BJERGA CFO 2188941515 2021-06-25 1 LISA BJERGA XXX-XX-XXXX MICHAEL J PETERSON CPA P01833529 2187224705 2021-06-18 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z TIM RICE 49725 COUNTY 83 STAPLES MN 56479 115114108 0 X WWW.LAKEWOODHEALTHSYSTEM.COM X 1996 MN TO PROVIDE QUALITY, PERSONALIZED HEALTHCARE FOR A LIFETIME. 12 11 1011 42 0 0 729010 5802397 107665930 107923755 549760 618300 769252 677699 109713952 115022151 0 0 0 0 52582613 51596138 0 0 0 53624850 55563926 106207463 107160064 3506489 7862087 127472858 153437720 57563035 74066639 69909823 79371081 X THE MISSION OF LAKEWOOD HEALTH SYSTEM IS TO PROVIDE QUALITY, PERSONALIZED HEALTHCARE FOR A LIFETIME. 0 0 76052143 0 92663618 HOSPITAL AND CLINICS -LAKEWOOD HEALTH SYSTEM (THE ORGANIZATION) OPERATES A 25-BED CRITICAL ACCESS HOSPITAL PROVIDING INPATIENT, OUTPATIENT, EMERGENCY, AND OTHER SPECIALTY HEALTH CARE SERVICES, INCLUDING A 10-BED GERIATRIC BEHAVIORAL HEALTH UNIT IN STAPLES, MINNESOTA. THE ORGANIZATION ALSO OPERATES RURAL HEALTH CLINICS LOCATED IN STAPLES, MOTLEY, PILLAGER, EAGLE BEND, AND BROWERVILLE, MINNESOTA. PHYSICIANS, PHYSICIAN'S ASSISTANTS, AND NURSE PRACTITIONERS PROVIDE CLINIC PATIENTS WITH PRIMARY CARE AND OTHER HEALTH CARE SERVICES. IN ADDITION, THE ORGANIZATION OPERATES A DERMATOLOGY CLINIC IN SARTELL, MINNESOTA.THE ORGANIZATION PROVIDED FOR 3,760 INPATIENT HOSPITAL AND SWING-BED DAYS, 2,835 INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT DAYS, 75,664 MEDICAL AND MENTAL HEALTH RURAL HEALTH CLINIC VISITS AND 8,465 DERMATOLOGY CLINIC VISITS. 10601268 0 15401936 SENIOR SERVICES -THE ORGANIZATION OPERATES A 100-BED, MEDICARE-CERTIFIED SKILLED NURSING FACILITY IN STAPLES, MINNESOTA, THAT PROVIDES LONG-TERM AND REHABILITATIVE CARE TO RESIDENTS. IN ADDITION TO SKILLED NURSING CARE, THE ORGANIZATION ALSO OPERATES HOME HEALTH CARE AND HOSPICE PROGRAMS TO PROVIDE NURSING CARE AND ASSISTANCE AT THE PATIENT'S RESIDENCE. ASSISTED LIVING AND INDEPENDENT LIVING FACILITIES OPERATED BY THE ORGANIZATION, LOCATED IN STAPLES, MINNESOTA, PROVIDE COMBINATIONS OF HEALTH-RELATED AND SUPPORTIVE SERVICES FOR TENANTS. THE ORGANIZATION PROVIDED FOR 29,277 RESIDENT DAYS IN THE NURSING HOME AND 750 ASSISTED LIVING UNIT RENTED MONTHS. 86653411 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 1 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 1 0 0 0 1 58 0 1011 1 0 0 0 0 0 1 1 0 0 0 0 0 0 X 12 11 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X LISA BJERGA CFO 2188941515 49725 COUNTY 83 STAPLES MN 56479 CAROL CAMPBELL CRNA 40.00 X 313046 0 25544 SHERREE ENGEN CRNA 40.00 X 303928 0 25103 RENEE PETERSON CRNA 40.00 X 251059 0 28368 KATHLEEN DOBSON VP OF SENIOR SERVICES 40.00 X 196593 0 37246 TRACY HUNTINGTON CRNA 40.00 X 191701 0 6110 CRAIG WOLHOWE VP OF HOSPITAL & CLINIC SERVICES 40.00 X 274945 0 44286 LYNN RICE VP OF SUPPORT SERVICES 40.00 X 263809 0 22203 CORRINE NEISESS VP OF NURSING 40.00 X 180412 0 30387 CHRISTINE ALBRECHT CHIEF MEDICAL OFFICER 40.00 X 0 0 0 JOHN HALFEN CHIEF MEDICAL OFFICER (THRU MAY) 40.00 X 9865 0 0 LISA BJERGA CFO 40.00 X 293280 0 5776 TIM RICE PRESIDENT 40.00 X X 548880 0 67748 JIM HOFER CHAIRMAN 1.00 X X 2490 0 0 JEF CICHOS VICE CHAIRMAN 1.00 X X 2652 0 0 CURT MCILRAVY CHAIR-ELECT 1.00 X X 2548 0 0 MARY THEURER SECRETARY 1.00 X X 3172 0 0 KEVIN NELSON TREASURER 1.00 X X 1456 0 0 ARDEN BEACHY MD BOARD MEMBER 1.00 X 468 0 0 LANA HANSEN BOARD MEMBER 1.00 X 1820 0 0 MICHAEL HUDALLA MD BOARD MEMBER 1.00 X 1040 0 0 NORMAN KRAUSE BOARD MEMBER 1.00 X 1560 0 0 JORDAN MOE MD BOARD MEMBER 1.00 X 1092 0 0 KAITLYN SCHOECK MD BOARD MEMBER 1.00 X 520 0 0 2846336 0 292771 58 0 1 0 LAKEWOOD CLINIC PA 49725 COUNTY 83 STAPLES MN 56479 PHYSICIAN SERVICES 11619868 BIG STONE THERAPIES 309 WASHINGTON AVE ORTONVILLE MN 56278 THERAPY SERVICES 2411481 QUEST DIAGNOSTICS PO BOX 775460 CHICAGO IL 606775460 LAB READINGS 1232666 CENTRAL MN DIAGNOSTIC INC 150 10TH ST NW MILACA MN 56353 MRI, CT & NUC MED SERVICES 1144815 ESSENTIA HEALTH 532 EAST FIRST STREET DULUTH MN 55805 ONCOLOGY & ORTHO PROVIDER SERVICES 1007204 20 16317 5719107 66973 5802397 NET PATIENT AND RESIDENT SERVICE 621110 104229699 104229699 340B PHARMACY 621300 2276930 2276930 OCCUPATIONAL HEALTH 621300 356324 356324 RENT REVENUE 531120 293924 293924 766878 766878 107923755 635302 635302 3675 20677 -17002 -17002 -17002 0 16317 7601 -7601 -7601 112950 63679 49271 49271 FOOD SERVICE 900099 494230 494230 EHR INCENTIVE 900099 141799 141799 636029 115022151 108065554 0 1154200 X 2668000 2668000 38261920 30162255 8099665 1183813 938612 245201 6672940 4973034 1699906 2809465 2052988 756477 85522 85522 136218 136218 23143137 21698538 1444599 336901 30620 306281 11351479 9780885 1570594 797683 797683 3711539 2341836 1369703 349106 283346 65760 169100 122504 46596 1296055 1171186 124869 5979387 5840180 139207 373389 373389 MN CARE TAX 1782759 1782759 BAD DEBT EXPENSE 1762082 1762082 OPERATING ROOM SUPPLIES 1754090 1754090 DUES & SUBSCRIPTIONS 761530 367895 393635 1773949 1590601 183348 107160064 86653411 20506653 0 4815 4890 37929290 42630921 13445859 11971833 4401 15391 1649634 2483956 2491440 1414757 125815238 70794989 57813215 55020249 10873855 38619449 934647 771539 2325702 504735 127472858 153437720 6951630 9712107 200372 4426679 3125153 2968810 37609 36247 42949704 42147471 4298567 14775325 57563035 74066639 X 68777328 78080710 1132495 1290371 69909823 79371081 127472858 153437720 X 7862087 1665169 -65998 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 805 805 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF MINNESOTA HOSPITAL ASSOCIATION AND 2.9% OF THE $27,751 MEMBERSHIP FEE WAS RELATED LOBBYING ACTIVITIES. MINNESOTA HOSPITAL ASSOCIATION (MHA) IS AN ORGANIZATION OF 142 MEMBER HOSPITALS AND HEALTH SYSTEMS. MHA ADVOCATES ON BEHALF OF ITS MEMBERS WITH LAWMAKERS, EDUCATING THEM ON COMPLEX ISSUES IN HEALTH CARE AND ENSURING THEY HAVE THE TOOLS THEY NEED TO MAKE INFORMED DECISIONS. THE MISSION OF MHA IS TO ADVOCATE SO THEIR MEMBERS CAN ACHIEVE THEIR MISSIONS BETTER. 0 1 X 851207 851207 45023385 22028049 22995336 79096963 48766940 30330023 843683 843683 55020249 DUE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 5681770 CONTRACT LIABILITIES 9093555 14775325 112822194 1665169 51203 1716372 111105822 3916329 3916329 115022151 103518812 0 103518812 3641252 3641252 107160064 PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF VARIOUS RESIDENT FUNDS AND HAS A FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION AND DISTRIBUTION OF THESE FUNDS FOR THE RESIDENTS. THE ORGANIZATION ALSO HOLDS TENANT SECURITY DEPOSITS FOR RESIDENTS OF LAKEWOOD PINES AND LAKEWOOD MANOR. THESE FUNDS ARE ON DEPOSIT IN SEPARATE BANK ACCOUNTS AND ARE REPORTED AS AN ASSET AND LIABILITY ON PART X OF THE 990. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN CASH SURRENDER VALUE OF LIFE INSURANCE 12,055. CHANGE IN INVESTMENT IN UNCONSOLIDATED AFFILIATES 39,148. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,762,082. CONTRIBUTIONS TO RESTRICTED NET ASSETS 268,734. FUNDRAISING EVENT 6,343. EXPENSES RECORDED AS REVENUE 1,879,170. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,762,082. EXPENSES RECORDED AS REVENUE 1,879,170. 6 16317 16317 7601 16317 16317 7601 7601 -7601 1 1 X 1 X 1 X 240.000000000000 1 1 1 0 1 1 606163 606163 0.00580 18445907 20090002 0 0.00000 19052070 20090002 606163 0.00580 298705 9300 289405 0.00270 5000 5000 0.00000 301792 105819 195973 0.00190 26036 26036 0.00020 631533 115119 516414 0.00480 19683603 20205121 1122577 0.01060 5191 5191 0.00000 5191 5191 0.00000 1 1022010 0 16453788 16601364 -147576 X 1 1 1 1 LAKEWOOD HEALTH SYSTEM 49725 COUNTY ROAD 83 STAPLES MN 56479 WWW.LAKEWOODHEALTHSYSTEM.COM 1295726362 X X X X RURAL PROVIDER LAKEWOOD HEALTH SYSTEM 1 0 0 1 X X X X X X X X X 19 1 0 0 1 X SEE SUPPLEMENTAL INFORMATION X X 1 20 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 100.000000000000 240.000000000000 X X X X X 1 1 X X X X 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X X X X X X X 1 X 0 X X X X 1 X 0 1 LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 5: THE CHNA PROCESS WAS CONDUCTED DURING 2018-2019. DATA WAS COLLECTED IN CONJUNCTION WITH TRI-COUNTY HEALTH CARE, CHI ST. GABRIEL'S HEALTH, CENTRACARE HEALTH LONG PRAIRIE, TODD COUNTY PUBLIC HEALTH, WADENA COUNTY PUBLIC HEALTH AND MORRISON COUNTY PUBLIC HEALTH. COMMUNITY STAKEHOLDER INTERVIEWS AND A COMMUNITY SURVEY IDENTIFIED COMMUNITY PERCEPTION OF HEALTH NEEDS AND WHAT MAKES A HEALTHY COMMUNITY IN MORRISON, TODD AND WADENA COUNTIES. FOR THE PURPOSES OF THIS ASSESSMENT, DATA GATHERED REFLECTS THE CORE SERVICE AREA OF LHS (ZIP CODES 56479 AND 56466) AND THE THREE COUNTIES MENTIONED PREVIOUSLY. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 6B: THE DATA COLLECTED FOR THE CHNA WAS DONE IN CONJUNCTION WITH TODD-WADENA HEALTHY CONNECTIONS, WHICH HAS MEMBERS REPRESENTING LHS, TRI-COUNTY HEALTH CARE, TODD COUNTY HEALTH & HUMAN SERVICES, AND WADENA COUNTY PUBLIC HEALTH.PART V, SECTION B, LINE 7A:HTTPS://WWW.LAKEWOODHEALTHSYSTEM.COM/COMMUNITY-HEALTH/COMMUNITY-HEALTH-NEED LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 7D: COMMUNITY PRESENTATIONS OCCURRED AT AREA SERVICE CLUBS, TO OUR DISTRICT TOWNSHIP ANNUAL MEETINGS, AND KEY COMMUNITY STAKEHOLDER GROUPS (ROTARY, LIONS, SCHOOL DISTRICT, CITY OF STAPLES) JAN-FEB 2020. PART V, SECTION B, LINE 10:HTTPS://WWW.LAKEWOODHEALTHSYSTEM.COM/COMMUNITY-HEALTH/COMMUNITY-HEALTH-NEED LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 11: AN INTERNAL COMMUNITY HEALTH NEEDS ASSESSMENT TASK FORCE ANALYZED AND RANKED THE INDICATORS BASED ON COMMUNITY IMPACT, POTENTIAL FOR CHANGE, ECONOMIC FEASIBILITY AND ALIGNMENT TO THE MISSION OF LHS. TAKING INTO ACCOUNT WHAT OTHER COMMUNITY RESOURCES ARE CURRENTLY AVAILABLE TO MEET NEEDS IDENTIFIED, THE FOLLOWING HEALTH NEEDS WERE DETERMINED TO BETHE TOP PRIORITY FOR LHS:1. HEALTHY BODY WEIGHT ADULT & CHILD2. MENTAL WELLBEING 3. SOCIAL DETERMINANTSEACH OF THESE HEALTH NEEDS WILL BE ADDRESSED BY THE DEVELOPMENT AND IMPLEMENTATION OF INTERVENTIONS STARTING IN EARLY 2020. ALL IMPLEMENTED STRATEGIES WILL BE MEASURED AND EVALUATED OVER THE THREE-YEAR PERIOD TO DETERMINE IF HEALTH NEEDS ARE BEING MET AND IF THE INTERVENTIONS ARE EFFECTIVELY IMPACTING THE PRIORITIES IDENTIFIED. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 13H: THE AMOUNT INVOICED DOES NOT CHANGE, HOWEVER A DISCOUNT AMOUNT IS DETERMINED BY INCOME LEVEL AND UNINSURED STATUS THAT WILL RESULT IN THE AMOUNT OF PAYMENT, IF ANY, FROM THE FAP-ELIGIBLE PATIENT. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 16J: EACH APPLICABLE ADMISSION AREA HAS A POLICY AVAILABLE FOR THE PATIENT AS NEEDED AND UPON REQUEST.FAP:HTTPS://LAKEWOODHEALTHSYSTEM.COM/BILL-PAY/FAP APPLICATION:HTTPS://LAKEWOODHEALTHSYSTEM.COM/BILL-PAY/FAP PLAIN LANGUAGE SUMMARY:HTTPS://LAKEWOODHEALTHSYSTEM.COM/BILL-PAY/ LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 24: THERE ARE CHARGES THAT ARE EXEMPT FROM THE FAP DISCOUNTS, SO IN THIS CASE YES WE WOULD CHARGE THE AMOUNT EQUAL TO THE GROSS CHARGE. EXAMPLES WOULD BE A DOT PHYSICAL, A COPAY BALANCE THAT INSURANCE WOULD LEAVE FOR THE CLIENT AS WE CANNOT DISCOUNT COPAYS AND IN VITRO FERTILIZATION SERVICES. 7 1 - STAPLES CLINIC 49725 COUNTY ROAD 83 STAPLES MN 56479 CLINIC 2 - LHS CARE CENTER 401 PRAIRIE AVE NE STAPLES MN 56479 SKILLED NURSING FACILITY 3 - SARTELL DERMATOLOGY 161 19TH ST S SUITE 106 SARTELL MN 56377 CLINIC 4 - PILLAGER CLINIC 653 PILLSBURY ST N STE 1 PILLAGER MN 56473 CLINIC 5 - EAGLE VALLEY CLINIC 815 HWY 71 S EAGLE BEND MN 56446 CLINIC 6 - BROWERVILLE CLINIC 30535 241ST AVE BROWERVILLE MN 56438 CLINIC 7 - MOTLEY CLINIC 1233 HWY 10 MOTLEY MN 56466 CLINIC PART I, LINE 7G: AMOUNTS USED FOR SUBSIDIZED SERVICES WERE CALCULATED USING DETAILED REPORT DATA KEPT BY THE ORGANIZATION. DATA INCLUDED THE TOTAL CHARGES, LESS ALLOWANCES AND DISCOUNTS, MEDICAID; AND ACTUAL COST OF SERVICES PROVIDED. SUBSIDIZED SERVICES INCLUDED TRANSPORTATION SERVICES FOR 2020. THERE ARE NO PHYSICIAN CLINICS. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1,762,082. PART II, COMMUNITY BUILDING ACTIVITIES: LAKEWOOD HEALTH SYSTEM HAS SET ASIDE A SMALL AREA OF LAND ON WHICH A COMMUNITY PARK WAS ESTABLISHED. TO PROMOTE PHYSICAL ACTIVITY IN CHILDREN, LHS PURCHASED PLAYGROUND EQUIPMENT FOR THE PARK. THIS PARK IS THE ONE MOST OFTEN UTILIZED BY CHILDREN AND IS AFFECTIONATELY KNOWN AS THE "DINO PARK" DUE TO SOME OF THE EQUIPMENT HAVING A DINOSAUR THEME. PART III, LINE 2: THE AMOUNT IS CALCULATED BY MULTIPLYING THE TOTAL CHARGES FOR SERVICES WRITTEN OFF AS BAD DEBT BY THE COST-TO-CHARGE RATIO. PART III, LINE 3: THE AMOUNT OF BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY FINANCIAL ASSISTANCE POLICY IS NOT REASONABLE TO CALCULATE FOR THE ORGANIZATION. LAKEWOOD DOES NOT DO PRESUMPTIVE CHARITY CARE OR PARO (PAYMENT ASSISTANCE RANK ORDER) SCORING SO THERE IS NO ESTIMATE ELECTED.LAKEWOOD DOES HAVE A FINANCIAL ASSISTANCE POLICY THAT PROVIDES DISCOUNTED OR FREE CARE. LAKEWOOD IS ALSO COMMITTED TO PROVIDING OTHER COMMUNITY BENEFIT AND COMMUNITY BUILDING FUNCTIONS. THE OPPORTUNITY TO PROVIDE MORE DISCOUNTED OR FREE CARE OR PERFORM ADDITIONAL COMMUNITY BENEFIT AND COMMUNITY BUILDING ACTIVITIES IS LIMITED AS BAD DEBT COSTS INCREASE. PART III, LINE 4: MANAGEMENT PROVIDES FOR POTENTIALLY 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 MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO VALUATION ALLOWANCE AND A CREDIT TO PATIENTS ACCOUNTS RECEIVABLE. PART III, LINE 8: THE MEDICARE ALLOWABLE COST OF CARE RELATING TO PAYMENTS ON LINE 5 WERE CALCULATED USING INFORMATION PREPARED FROM OUR FILED 2020 MEDICARE COST REPORT.A LARGE PERCENTAGE OF LAKEWOOD PATIENTS ARE MEDICARE ELIGIBLE AND LAKEWOOD WILL CONTINUE TO PROVIDE SERVICES DESPITE ANY SHORTFALL. PART III, LINE 9B: PATIENTS ARE REQUIRED TO APPLY FOR MEDICAL ASSISTANCE IN ORDER TO RECEIVE A 50% OR GREATER DISCOUNT PER LAKEWOOD'S CUSTOMER ASSISTANCE PROGRAM. PART VI, LINE 2: THE ORGANIZATION CONDUCTS COMMUNITY SURVEYS AND USES PATIENT FEEDBACK TO ASSESS THE NEEDS OF THE COMMUNITIES IT SERVES. PART VI, LINE 3: PATIENT FINANCIAL SERVICES (PFS) STAFF ARE AVAILABLE AND UTILIZED THROUGHOUT THE PATIENT EXPERIENCE. PFS STAFF EDUCATE PATIENTS ON MEANS-TESTED PROGRAMS AVAILABLE TO THE PATIENT AS WELL AS ASSIST THE PATIENT WITH THE CUSTOMER ASSISTANCE APPLICATION PROCESS. PAYMENT PLANS ARE ALSO ESTABLISHED TO ASSIST PATIENTS IN PAYING OFF OBLIGATIONS OWED TO THE ORGANIZATION. PART VI, LINE 4: LAKEWOOD HEALTH SYSTEM OFFERS A BROAD SPECTRUM OF CARE. OUR SYSTEM INCLUDES A STATE-OF-THE-ART MAIN CAMPUS WITH A 25-BED, CRITICAL ACCESS HOSPITAL AND CLINIC (STAPLES, MN); FOUR MODERN SATELLITE CLINICS (BROWERVILLE, PILLAGER, MOTLEY & EAGLE BEND, MN), SENIOR SERVICES CARE AND HOUSING, A SPECIALIZED SENIOR BEHAVIORAL HEALTH UNIT (STAPLES, MN), AND A DERMATOLOGY CLINIC (SARTELL, MN). WE ALSO HAVE ON-STAFF MEDICAL SPECIALISTS AND VISITING MEDICAL PARTNERS, WHICH ALLOWS US TO OFFER COMPREHENSIVE CARE IN THESE VARIOUS COMMUNITIES. ITS NEIGHBOR, MOTLEY, IS JUST A FEW MILES AWAY AND HAS ANOTHER 1,000 PEOPLE. THE TWO TOWNS COLLABORATE ON MANY COMMUNITY-WIDE INITIATIVES, INCLUDING THE LOCAL SCHOOL SYSTEM. STAPLES BOASTS MANY ATTRACTIVE STORE FRONTS AND BUSINESSES IN THE DOWNTOWN AREA, GIVING IT A "MAIN STREET USA" FEEL. STAPLES IS PROUD OF ITS RICH HISTORY AND ACCOMPLISHMENTS IN THE AREAS OF BUSINESS, EDUCATION, HEALTH CARE, ATHLETICS AND CULTURAL ACTIVITIES. COMMUNITY INVOLVEMENT, PASSION, AND LOYALTY IS ALIVE AND WELL IN STAPLES - FROM THE TOWN RALLYING AROUND LOCAL SPORTS TEAMS, TO ATTENDING CONCERTS AND OTHER FINE ARTS - RELATED EVENTS, TO SUPPORTING LOCAL PHILANTHROPIC EFFORTS, TO CULTURAL ACTIVITIES REPRESENTING THE STRONG SCANDINAVIAN & FINNISH ANCESTRIES IN THE AREA. PART VI, LINE 5: A MAJORITY OF THE ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE WITHIN LAKEWOOD'S PRIMARY SERVICE AREA.LHS PROVIDES SPECIAL SERVICES INCLUDING PALLIATIVE CARE, MEDICAL HOME, AND HOME HEALTH, FOR THE COMMUNITY. LHS'S EMERGENCY ROOM IS AVAILABLE TO ALL DESPITE PATIENT FINANCIAL IMPLICATIONS. THERE ARE NO LIMITS IN REGARD TO THE AMOUNT OF CHARITY CARE OR CAP PROGRAM PARTICIPANTS. GOVERNMENT HEALTH SPONSORED PROGRAMS WOULD INCLUDE MEDICARE AND MEDICAID. LHS IS THE SOLE COMMUNITY PROVIDER IN THE STAPLES AREA. PART VI, LINE 6: N/A X X X 1 0 0 0 0 0 0 0 0 CAROL CAMPBELL CRNA 229922 0 0 0 83124 0 4330 0 21214 0 338590 0 0 0 SHERREE ENGEN CRNA 215984 0 0 0 87944 0 7074 0 18029 0 329031 0 0 0 RENEE PETERSON CRNA 182741 0 0 0 68318 0 6289 0 22079 0 279427 0 0 0 KATHLEEN DOBSON VP OF SENIOR SERVICES 164313 0 20398 0 11882 0 5401 0 31845 0 233839 0 0 0 TRACY HUNTINGTON CRNA 191201 0 500 0 0 0 5483 0 627 0 197811 0 0 0 CRAIG WOLHOWE VP OF HOSPITAL & CLINIC SERVICES 231597 0 28799 0 14549 0 7422 0 36864 0 319231 0 0 0 LYNN RICE VP OF SUPPORT SERVICES 219370 0 26748 0 17691 0 7072 0 15131 0 286012 0 0 0 CORRINE NEISESS VP OF NURSING 152256 0 18534 0 9622 0 4881 0 25506 0 210799 0 0 0 LISA BJERGA CFO 252777 0 27357 0 13146 0 4816 0 960 0 299056 0 0 0 TIM RICE PRESIDENT 416609 0 94071 0 38200 0 66494 0 1254 0 616628 0 0 0 PART I, LINE 4A THE FOLLOWING HIGHEST COMPENSATED EMPLOYEES RECEIVED SEVERANCE PAYMENTS AND THEIR SEVERANCE PAYMENTS ARE INCLUDED IN SCH J PART II COLUMN B(II): CAROL CAMPBELL $72,916 SHERREE ENGEN $72,915 RENEE PETERSON $68,318 A UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 88903ACN8 2016-11-15 4168729 REFINANCING 0 0 0 A 625000 4168729 4098626 70103 2004 1 0 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 LAKEWOOD CLINIC PA BOARD MEMBERS HAVE OWNERSHIP INTEREST IN LAKEWOOD CLINIC, PA. 12729394 THE ORGANIZATION HAS A MEDICAL SERVICE AGREEMENT WITH LAKEWOOD CLINIC, PA FOR THE PROVISION OF PHYSICIAN AND OTHER PROFESSIONAL MEDICAL SERVICES. THE AGREEMENT EXPIRES IN 2022. LAKEWOOD CLINIC, PA IS PAID PER A NEGOTIATED PRICE OF RELATIVE VALUE UNIT (RVU). THE RVU IS DETERMINED BASED ON THIRD-PARTY COMPENSATION DATA. IN ADDITION, THERE ARE COMPENSATION AGREEMENTS FOR SERVICES THAT USE HOURLY RATES DETERMINED USING MARKET DATA TO ENSURE COMPENSATION IS REASONABLE. THERE ARE SPECIALIST POSITIONS THAT RECEIVE AN ANNUAL COMPENSATION THAT IS ALSO DETERMINED USING MARKET DATA. THE FOLLOWING LAKEWOOD HEALTH SYSTEM BOARD MEMBERS HAVE OWNERSHIP INTEREST IN OR ARE MEMBERS OF LAKEWOOD CLINIC, PA: - ARDEN BEACHY, MD - MICHAEL HUDALLA, MD - JORDAN MOE, MD - KAITLYN SCHOECK, MD - CHRISTINE ALBRECHT, MD - JOHN HALFEN, MD (THRU MAY) 0 FORM 990, PART VI, SECTION A, LINE 2 TIM RICE, PRESIDENT/CEO, IS MARRIED TO LYNN NEWTON RICE, VP OF SUPPORT SERVICES. FORM 990, PART VI, SECTION B, LINE 11B THE PREPARER OF FORM 990 EMAILS A COPY OF THE FINAL 990 TO THE ORGANIZATION'S CFO. THE CFO PERFORMS A DETAIL REVIEW OF FORM 990 AND PROVIDES EACH VOTING BOARD MEMBER WITH A COPY OF FORM 990 BEFORE IT IS FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C ANY INTERESTS WHICH WERE IDENTIFIED AS PART OF THE ANNUAL CONFLICT OF INTEREST DISCLOSURE WOULD BE DOCUMENTED IN THE BOARD OF DIRECTOR MEETING MINUTES. THE OFFICERS, DIRECTORS, AND KEY EMPLOYEES COMPLETE A FORMAL CONFLICT OF INTEREST DISCLOSURE ANNUALLY. INTERESTS THAT ARISE BETWEEN COMPLETING FORMS MUST BE DISCLOSED BY THE INTERESTED MEMBER TO THE REST OF THE BOARD. FOR ANY BOARD ACTION THAT REQUIRED A VOTE AND COULD BE INFLUENCED BY A CONFLICT, THE AFFECTED BOARD MEMBER IS NOT PERMITTED TO VOTE ON THE ACTION. THE ORGANIZATION ALSO CONSIDERS WHETHER OTHER POTENTIAL CONFLICTS OF INTEREST COULD RESULT FOR ANY OF THESE INDIVIDUALS BASED ON POSSIBLE ACTIONS UNDER CONSIDERATION BY THE ORGANIZATION DURING THE YEAR. FORM 990, PART VI, SECTION B, LINE 15 FOR THE CEO, INITIAL COMPENSATION CONSIDERATION IS MADE BASED ON A REVIEW OF SALARY SURVEY DATA COMPILED BY THE MINNESOTA HOSPITAL ASSOCIATION. THIS DATA IS THEN REVIEWED BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. AFTER THIS REVIEW, THE DATA IS SUBMITTED TO THE FULL FINANCE COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW ALONG WITH THE ENTIRE ANNUAL BUDGET PACKET. FINALLY, THE FULL BUDGET PACKAGE, ALONG WITH ALL SPECIFIC SALARY PROPOSALS IS SUBMITTED TO THE FULL BOARD OF DIRECTORS FOR FINAL APPROVAL. AT ANY TIME IN THIS PROCESS, ANY OF THE COMMITTEES OR BOARD COULD REQUEST ADDITIONAL INDEPENDENT SALARY INFORMATION SUPPORTING THE PROPOSED SALARY. THIS COMPENSATION AMOUNT IS INCLUDED IN THE CEO EMPLOYMENT CONTRACT WHICH IS PREPARED EVERY OTHER YEAR WITH A TWO-YEAR TERM. FOR THE CFO, CMO AND VP'S, THE PROCESS STARTS WITH A COMPENSATION SURVEY PERFORMED BY INTEGRATED HEALTHCARE STRATEGIES (IHS). IHS IS CONTRACTED BIENNIALLY TO COMPLETE A COMPENSATION MARKET SURVEY FOR THESE POSITIONS. THIS DATA IS AGAIN THEN REVIEWED BY THE COMPENSATION COMMITTEE WITH THE REMAINING PROCESS BEING IDENTICAL TO THAT FOR THE CEO. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. THESE DOCUMENTS CAN BE REQUESTED FROM THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. FORM 990, PART IX, LINE 11G OPERATING ROOM PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 581,467. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 581,467. SURGICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 876,289. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 876,289. TECHNICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,710,823. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,710,823. BEHAVIORAL HEALTH PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 887,445. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 887,445. EMERGENCY ROOM PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,058,738. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,058,738. REHAB/THERAPY PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,010,448. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,010,448. NURSING PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 982,436. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 982,436. PHYSICIAN PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 9,644,386. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 9,644,386. OTHER PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 1,268,525. MANAGEMENT AND GENERAL EXPENSES 605,084. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,873,609. CLINIC & ADMIN FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 839,515. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 839,515. PHARMACY PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 677,981. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 677,981. FORM 990, PART XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTIONS -117,201. CHANGE IN CASH SURRENDER VALUE OF LIFE INSURANCE 12,055. CHANGE IN INVESTMENTS IN UNCONSOLIDATED AFFILIATES 39,148. LAKEWOOD-CENTRACARE LLC 49725 CTY 83 STAPLES MN 56479 411974939 CLINICAL SERVICES MN N/A RELATED -31595 13379 0 1 0.50000 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0