2019-07-25T08:46:12-05:00 2018-09-30 391140373 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-10-01 391140373 COLUMBUS COMMUNITY HOSPITAL INC COLU 9206232200 1515 PARK AVENUE COLUMBUS WI 539251618 FRANCIS J FISH VP OF FINANCE & CFO 9206232200 2019-07-24 1 TERRI REXRODE CPA MST P00096513 9206620016 2019-07-24 74.87.127.216 2019-07-24 13:24:03 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z JOHN D RUSSELL 1515 PARK AVENUE COLUMBUS WI 539251618 58941416 0 X WWW.CCH-INC.COM X 1970 WI ACUTE-CARE HOSPITAL 11 9 376 126 0 0 249087 177422 45720641 48506921 462868 754156 251671 0 46684267 49438499 0 0 0 0 22550624 23161927 0 0 0 21459883 22276845 44010507 45438772 2673760 3999727 69204733 73716721 24439569 24844880 44765164 48871841 X BY BUILDING CARING RELATIONSHIPS WITH THOSE WE SERVE, WE GUIDE THE JOURNEY TO HEALTH AND WELLNESS. OUR TEAM WILL BE YOUR PREFERRED CHOICE FOR PERSONALIZED HIGH QUALITY HEALTH CARE, WELLNESS AND EDUCATION PROVIDED IN A COMPASSIONATE AND INNOVATIVE ENVIRONMENT. 0 0 34959356 0 48404110 COLUMBUS COMMUNITY HOSPITAL, INC. (CCH) PROVIDES INPATIENT, OUTPATIENT, AND CLINIC MEDICAL SERVICES TO PATIENTS. CCH PROVIDES MEDICAL, OBSTETRIC, SURGICAL, AND INTENSIVE CARE INPATIENT SERVICES. FOR THE FISCAL YEAR ENDED 9/30/18, 887 ACUTE ADMISSIONS RESULTED IN 2,431 INPATIENT DAYS. IN ADDITION, THERE WERE 78 DELIVERIES AND 157 NEWBORN DAYS AND 331 INPATIENT SURGERIES. ON THE OUTPATIENT SIDE, CCH PROVIDES A MULTITUDE OF SERVICES INCLUDING EMERGENCY ROOM, LAB, RADIOLOGY, REHABILITATION, SURGERY, INFUSION THERAPY, AND NUTRITION SERVICES. FOR THE FISCAL YEAR ENDED 9/30/18, CCH SAW 11,447 PATIENTS IN THE EMERGENCY ROOM AND URGENT CARE. 703 PATIENTS HAD OUTPATIENT SURGERY AND 775 GI PROCEDURES WERE PERFORMED. CCH ALSO OPERATES THREE PHYSICIAN CLINICS LOCATED IN COLUMBUS, BEAVER DAM, AND MARSHALL. OUR EXPERIENCED AND CARING PROVIDERS SPECIALIZE IN ORTHOPEDICS, GENERAL SURGERY, OB/GYN, FAMILY MEDICINE, INTERNAL MEDICINE AND PHYSICAL AND OCCUPATIONAL THERAPY AND IMAGING SERVICES. FOR THE FISCAL YEAR ENDED 9/30/18, THERE WERE 12,615 CLINIC VISITS, 4,060 THERAPY VISITS AND 1,208 IMAGING SCANS. 34959356 1 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 51 0 376 1 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 0 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X FRANCIS J FISH VP OF FINANCE & CFO 9206231368 1515 PARK AVENUE COLUMBUS WI 53925 LARRY BARTRUFF DIRECTOR 0.40 X 0 0 0 GARY GALVIN MD CHIEF OF STAFF (THRU 1/18), DIRECTOR 0.40 X 411633 0 34053 DANIELLE GINDLESBERGER MD DIRECTOR 0.40 X 0 0 0 BRUCE KRAUS MD DIRECTOR (THRU 1/18) 0.40 X 219519 0 32573 ELIZABETH LARSON MD DIRECTOR, CHIEF OF STAFF (BEG. 1/18) 0.40 X 17500 0 0 DAN MEISTER DIRECTOR (THRU 6/18) 0.40 X 0 0 0 NATHAN ROBERTS DIRECTOR 0.40 X 0 0 0 JON ROZENFELD DIRECTOR 0.40 X 0 0 0 TOM TER HORST DIRECTOR 0.40 X 0 0 0 BRUCE ZANDER CHAIR 0.40 X X 0 0 0 JENNIFER HOMMAN VICE CHAIR 0.40 X X 0 0 0 JO ANN EVANS SECRETARY 0.40 X X 0 0 0 RANDALL BOBHOLZ TREASURER 0.40 X X 0 0 0 JOHN D RUSSELL PRESIDENT & CEO 40.00 X 417691 0 36053 PHILLIP G ROBERTS VP OF FINANCE & CFO 40.00 X 261999 0 32134 JAMIE E HENDRIX VP OF PATIENT CARE SERVICE 40.00 X 224028 0 31923 ANN ROUNDY VP OF EMPLOYEE SERVICES 40.00 X 234353 0 34691 ROBERT COE PHYSICIAN 30.00 X 445530 0 34969 CRAIG HABERMAN PHYSICIAN 40.00 X 383064 0 31130 MATTHEW NIESEN PHYSICIAN 40.00 X 668461 0 34053 KATHERINE SKAGGS PHYSICIAN 40.00 X 228529 0 17716 KATY GEIGER DIRECTOR OF OUTPATIENT SERVICES 40.00 X 118400 0 28164 3630707 0 347459 20 0 1 0 MADISON EMERGENCY PHYSICIANS 700 S PARK STREET SUITE A404 MADISON WI 53715 ER PHYSICIAN SERVICES 1997910 COLUMBIA ANESTHESIA LLC W12748 HWY 60 LODI WI 53555 ANESTHESIA SERVICES 892715 SHARED IMAGING SERVICES LLC 915 17TH STREET PRAIRIE DU SAC WI 53578 NUCLEAR MEDICINE & ULTRASOUND SERVICES 680533 SSM HEALTHCARE OF WISCONSIN 2901 LANDMARK PLACE SUITE 300 MADISON WI 53713 HEALTHCARE SERVICES 660944 COMPHEALTH PO BOX 972651 DALLAS TX 75397 PHYSICIAN SERVICES 315828 9 77737 20000 79685 213 177422 PATIENT SERVICE REVENUE 621110 47327055 47327055 CLINIC RENTAL REVENUE 531120 404668 404668 CAFETERIA REVENUE 722210 102811 102811 672387 672387 48506921 532806 532806 9715014 9253 9486817 16100 228197 -6847 221350 221350 49438499 48404110 0 856967 X 1468095 1468095 16665131 13250446 3414685 450056 357840 92216 3432997 2729576 703421 1145648 910905 234743 67006 67006 45750 45750 5763446 5433872 329574 481805 481805 2294603 1824439 470164 953614 758218 195396 998067 793563 204504 58561 46562 11999 70695 56210 14485 850767 676445 174322 3314430 2635303 679127 172238 136946 35292 MEDICAL SUPPLIES 4991666 4991666 BAD DEBTS 1615429 1615429 RECRUITMENT 149309 149309 PROFESSIONAL DUES 83437 66341 17096 366022 291024 74998 45438772 34959356 10479416 0 4882684 6858521 1452909 2387168 6666990 7014589 344677 386261 906217 817057 285272 294456 64201007 34701131 31320885 29499876 22383030 7124078 0 18221158 63950 45679 898119 1067878 69204733 73716721 3826020 5260729 20613549 19584151 24439569 24844880 X 43877045 47830413 688489 818855 199630 222573 44765164 48871841 69204733 73716721 X 3999727 -23416 130366 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 1 0 1 7941 7941 0 PART II-B, LINE 1: A PERCENTAGE OF DUES PAID TO AMERICAN HOSPITAL ASSOCIATION, HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION, RURAL WISCONSIN HEALTH COOPERATIVE, WISCONSIN HOSPITAL ASSOCIATION AND WISCONSIN INSTITUTE OF CPAS ARE CONSIDERED LOBBYING. SOME TEAM MEMBERS ATTENDED THE WHA ADVOCACY DAY ALONG WITH SEVERAL OTHER AREA HOSPITALS. 334410 22943 35388 392741 282972 12086 39352 334410 241143 13111 28718 282972 229929 16297 -5083 241143 191964 13833 24132 229929 0.00000 0.56670 0.43330 0 1 1 63509 63509 45936984 21974106 23962878 17761634 12727025 5034609 438880 438880 29499876 U.S. GOVERNMENT, AGENCY, AND MUNICIPAL OBLIGATIONS 6040804 F CORPORATE BONDS 12180354 F 18221158 47930020 -23416 -1485063 -1508479 49438499 0 49438499 43823343 0 43823343 1615429 1615429 45438772 PART V, LINE 4: THE ENDOWMENT FUNDS, WHICH ARE HELD BY THE FOUNDATION, CONSIST OF FOUR SEPARATE FUNDS ESTABLISHED TO BENEFIT THE HOSPITAL: FOR WOMEN'S HEALTH, INFRASTRUCTURE IMPROVEMENTS, COMMUNITY HEALTH, AND GENERAL OPERATIONS OF THE HOSPITAL. EACH FUND IS MAINTAINED BY THE FOUNDATION IN VARIOUS INVESTMENTS, AND THE FOUNDATION IS RESPONSIBLE FOR ALL INVESTMENT DECISIONS. PART XI, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN ASSETS OF COLUMBUS COMMUNITY FOUNDATION, INC. 130,366. PROVISION FOR BAD DEBTS -1,615,429. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR BAD DEBTS 1,615,429. 1 1 1 X 1 X 1 1 0 1 1 264376 264376 0.00600 3689135 2194997 1494138 0.03410 3953511 2194997 1758514 0.04010 109293 33405 75888 0.00170 18288 18288 0.00040 7529641 2680787 4848854 0.11060 71272 71272 0.00160 7728494 2714192 5014302 0.11430 11682005 4909189 6772816 0.15440 1 1615429 0 13759307 13686882 72425 X 1 1 1 1 COLUMBUS COMMUNITY HOSPITAL INC 1515 PARK AVE COLUMBUS WI 53925 WWW.COLUMBUSCOMMUNITYHOSPITAL.ORG 1042 X X X COLUMBUS COMMUNITY HOSPITAL INC 1 0 0 1 X X X X X X X X X 15 1 0 0 1 X SEE RESPONSE FOR PART V LINE 7D X X 1 15 1 WWW.CCH-INC.COM/EN/COMMUNITY-HEALTH-NEEDS-ASSESSMENT 0 1 X 200.000000000000 400.000000000000 X X X 1 1 X X X 1 X WWW.CCH-INC.COM/EN/PATIENT-BILLING/COMMUNITY-CARE X WWW.CCH-INC.COM/EN/PATIENT-BILLING/COMMUNITY-CARE X WWW.CCH-INC.COM/EN/PATIENT-BILLING/COMMUNITY-CARE X X X X X X X 1 X 0 X X X X 1 X 0 0 COLUMBUS COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 5: CCH BENEFITED FROM INPUT DERIVED THROUGH CONSULTATION OF NUMEROUS COMMUNITY LEADERS REPRESENTING DIVERSE CONSTITUENCIES. IN ADDITION, CCH BENEFITED FROM GUIDANCE AND INPUT FROM INDIVIDUALS WITH EXPERTISE IN PUBLIC/POPULATION HEALTH. THOSE CONSULTED INCLUDED: DAN MEISTER, COLUMBUS CHIEF OF POLICE; JO ANN EVANS, ADMINISTRATION - GOLDEN LIVING CENTER, RANDOLPH; TRULA HENSLER, SENIOR MARKETING MANAGER - BAKER TILLY VIRCHOW KRAUSE LLC; BRUCE KRAUS, MD, INTERNAL MEDICINE PHYSICIAN - PRAIRIE RIDGE HEALTH CLINIC; JAMIE LOGSDON, REGIONAL DIRECTOR OF MARKETING & COMMUNICATIONS - SSM HEALTHCARE OF WI; BRUCE ZANDER, PRESIDENT OF BRZ CONSTRUCTION MANAGEMENT; JENNIFER HOMMAN, INVESTMENT ADVISOR - INVESTMENT CENTRE, LLC; RANDALL BOBHOLZ, CEO OF FARMERS & MERCHANTS UNION BANK; GARY GALVIN, MD, GENERAL SURGEON - PRAIRIE RIDGE HEALTH CLINIC; LARRY BARTRUFF, GENERAL MANAGER - RHODES BAKE-N-SERV; RUSSELL HERMUS, MD, VP OF MEDICAL AFFAIRS - DEAN CLINIC; DAMOND BOATWRIGHT, REGIONAL PRESIDENT OF HOSPITAL OPERATIONS, SSM HEALTHCARE OF WISCONSIN; BERIT POSER, CLINIC MANAGER - POSER CLINIC; SUSAN LORENZ, HEALTH OFFICER - PUBLIC HEALTH DEPT COLUMBIA COUNTY; ANNETTE DEUMAN, ADMINISTRATOR - COLUMBUS SCHOOL DISTRICT; HEIDI WALLACE, SOCIAL WORKER - COLUMBUS COMMUNITY HOSPITAL; CHRIS JOSHEFF, PATIENT FINANCIAL COUNSELOR - COLUMBUS COMMUNITY HOSPITAL; LINDA TAPLIN STATZ, REGIONAL VP OF HUMAN SERVICES - SSM HEALTHCARE OF WISCONSIN. COLUMBUS COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 7D: WWW.CCH-INC.COM/EN/COMMUNITY-HEALTH-NEEDS-ASSESSMENT COLUMBUS COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 11: THE FOLLOWING THREE SIGNIFICANT NEEDS AND HOW THE HOSPITAL IS ADDRESSING THESE NEEDS ARE LISTED BELOW:PRIORITIES #1 AND #2 OBESITY AND PHYSICAL INACTIVITY:STRATEGY #1: OPERATION OVERHAUL 2.0- THROUGH THE FORMATION OF YOUR BETTER LIFE COALITION, A WELLNESS PROGRAM WILL BE DEVELOPED, TAILORED TO THE MANUFACTURING INDUSTRY (ASSEMBLY LINE PRODUCTION), TO REDUCE OBESITY AND IMPACT CERTAIN CHRONIC HEALTH CONDITIONS. INTERVENTIONS WITHIN THE OPERATION OVERHAUL 2.0 PROGRAM INCLUDE, BUT ARE NOT LIMITED TO, EDUCATION AND INFORMATION STRATEGIES, BEHAVIORAL AND SOCIAL STRATEGIES, ENVIRONMENTAL AND EMPLOYER POLICY STRATEGIES, AND WORKSITE WEIGHT CONTROL STRATEGIES, INCLUDING MEASURABLE CHANGES OF WEIGHT (CONSIDERING HEIGHT AND MUSCLE MASS), BODY FAT, MINUTES OF EXERCISE, PERCENTAGE OF WEIGHT GAIN/LOSS, WAIST CIRCUMFERENCE, ENDURANCE, FLEXIBILITY, AND BLOOD PRESSURE. SMOKING CESSATION IS OFFERED AS WELL.- ESTIMATED IMPACT IS 380 ADULTS, POTENTIAL IMPACT IS ABOUT 1,197 ADULTS- INSTRUCTORS WILL BE CCH'S EDUCATION MANAGER, REGISTERED DIETICIANS, SMOKING CESSATION SPECIALIST AND OCCUPATIONAL THERAPISTS- METHODS TO INCLUDE FAMILY PARTICIPATION TO GROW THE SUPPORT NETWORK OF PARTICIPANTS - COMPETITION BETWEEN ORGANIZATIONS AND WITHIN ORGANIZATIONS IN ORDER TO IMPROVE MOTIVATION OF PARTICIPANTSSTRATEGY #2: LIVE IT! REAL LIFE NUTRITION FOR TEENS- REACHING CHILDREN AND CORRECTING UNHEALTHY BEHAVIORS IS A PROACTIVE APPROACH TO COMBATING ADULT OBESITY. THE LIVE IT! PROGRAM, ORIGINATED FROM THE OREGON DAIRY COUNCIL AND CUSTOMIZED BY THE FOOD FOR THOUGHT COALITION, IS GEARED TOWARD 6TH GRADERS.- THE PROGRAM CONSISTS OF AN ENGAGING CURRICULUM THAT AIMS TO MOTIVATE STUDENTS TO MAKE NUTRIENT-RICH FOOD CHOICES WHILE PERFORMING PHYSICAL ACTIVITY TO ENHANCE THE WELLNESS OF MIDDLE SCHOOL CHILDREN WITHIN THE COMMUNITY. - 16 LESSON CURRICULUM: 1 INTRODUCTORY, 11 NUTRITION, 3 PHYSICAL ACTIVITY AND 1 WRAP UP FOR 7-8 GROUPS OF STUDENTS - CCH'S EDUCATION MANAGER WILL INSTRUCT PHYSICAL ACTIVITY LESSONS- CCH REGISTERED DIETITIANS, UNIVERSITY OF WISCONSIN DIETETIC STUDENTS AND/OR INTERNS WILL INSTRUCT NUTRITION LESSONS- COMPETITION BETWEEN CLASSES WHERE THE CLASS ACCUMULATING THE MOST POINTS WINS A HEALTHY COOKING CLASS LEAD BY CCH'S EXECUTIVE CHEF TO INCREASE MOTIVATION AND ENGAGEMENT OF STUDENTS- ALL TOOLS USED WILL BE OPEN TO THE PUBLIC THROUGH CCH'S WEBSITE TO ENCOURAGE COMMUNITY PARTICIPATION.PRIORITY #3: MAMMOGRAPHY SCREENINGSBY FACILITATING INCREASED EDUCATION AND AWARENESS WITH PROVIDERS AND THE COMMUNITY AT LARGE, COLUMBUS COMMUNITY HOSPITAL AIMS TO INCREASE THE RATE OF MAMMOGRAPHY SCREENINGS IN ORDER TO DETECT BREAST CANCER EARLY; THUS, DECREASING THE DEATH RATE DUE TO BREAST CANCER.STRATEGY #1: EXPAND PROGRAM TO MEET COMMUNITY NEEDSCOLUMBUS COMMUNITY HOSPITAL CURRENTLY HAS A BREAST CANCER NAVIGATION PROGRAM. THIS PROGRAM WILL BE EXPANDED UPON WITH HELP FROM THE COLUMBUS COMMUNITY HOSPITAL FOUNDATION AND LOCAL HIGH SCHOOL VOLLEYBALL AND BASKETBALL TEAMS THROUGH VOLLEY FOR A CAUSE AND HOOPS FOR A CURE EVENTS.STRATEGY #2: IMPROVE ACCESS IN COLLABORATION WITH THE COLUMBUS COMMUNITY HOSPITAL FOUNDATION, A PROGRAM WILL BE ESTABLISHED TO HELP THOSE WITH FINANCIAL NEED TO OBTAIN MAMMOGRAPHY SCREENINGS REGARDLESS OF ABILITY TO PAY. THIS WILL DECREASE THE ECONOMIC DISPARITY GAP WHILE INCREASING THE HEALTH AND WELLNESS OF THOSE IN NEED THROUGH EARLY DEDICATION. STRATEGY #3: INCREASE AWARENESS INCREASE OUTREACH EFFORTS TO ENHANCE COMMUNITY AWARENESS REGARDING SELF EXAMINATIONS AND DISCUSSIONS WITH PRIMARY CARE PHYSICIANS.EDUCATE THE COMMUNITY REGARDING THE IMPORTANCE OF MAMMOGRAPHY SCREENINGS FOCUSED ON: CHANCE OF HAVING BREAST CANCER, SELF EXAMINATIONS, ENVIRONMENTAL, GENETIC AND BEHAVIORAL FACTORS; SPECIFICALLY EDUCATING ON RECENT DEVELOPMENTS REGARDING OBESITY, ALCOHOL USE AND HEREDITARY FACTORS, AS THESE WOULD INDICATE AN EARLIER SCREEN IS WARRANTED.EDUCATE PRIMARY CARE PROVIDERS TO INCREASE MAMMOGRAPHY SCREENINGS, FOCUSING ON WHO SHOULD BE SCREENED, WHEN, AND WHY, INCLUDING SCREENING THOSE WITH HEREDITARY FACTORS, OBESITY, AND ALCOHOL USE AT AN EARLIER AGE AS THESE ARE FACTORS THAT INCREASE THE INCIDENCE OF BREAST CANCER.NO HOSPITAL FACILITY CAN ADDRESS ALL OF THE HEALTH NEEDS PRESENT IN ITS COMMUNITY. COLUMBUS COMMUNITY HOSPITAL'S IMPLEMENTATION STRATEGY FOCUSES ON THE SPECIFIED COMMUNITY HEALTH NEEDS AND NOT ON THE FOLLOWING NEEDS:- ALCOHOL ABUSE AND DRINKING EXCESSIVELY IS CONTINUING TO FLUCTUATE AND HAS BEEN SINCE 2003. THIS IS A STATEWIDE ISSUE AND COLUMBUS COMMUNITY HOSPITAL IS AWARE OF THIS NEED IN THE COUNTY. HOWEVER, AT THIS TIME, COLUMBUS COMMUNITY HOSPITAL DOES NOT HAVE THE STAFF OR RESOURCES TO PROPERLY ADDRESS THIS NEED. RESOURCES ARE AVAILABLE AT THE PAUQUETTE CENTER IN PORTAGE, WHICH IS THE COUNTY SEAT.- SMOKING/TOBACCO USE IS BEING ADDRESSED BY HEALTH EXPERTS AT A STATE LEVEL, THROUGH THE IMPLEMENTATION OF A STATEWIDE SMOKING BAN, EFFECTIVE JULY 2010, AND REMEDIATION PROGRAMS. SINCE 2012, THE PERCENTAGE OF ADULT SMOKERS IN COLUMBIA COUNTY HAS DECREASED. IN ADDITION, COLUMBUS COMMUNITY HOSPITAL OFFERS SMOKING CESSATION CLASSES. AS MORE SPECIFIC DATA BECOMES AVAILABLE REGARDING TOBACCO USE, COLUMBUS COMMUNITY HOSPITAL MAY CONSIDER THIS A POTENTIAL INITIATIVE IN THE 2018 CHNA.- DRUG ABUSE, SPECIFICALLY OPIOID ABUSE, IS CURRENTLY BEING ADDRESSED BY NUMEROUS ORGANIZATIONS IN COLUMBIA COUNTY, INCLUDING COLUMBUS COMMUNITY HOSPITAL THROUGH PROJECT CLEAN - COMMUNITY LEADERS ELIMINATING THE ABUSE OF NARCOTICS. THIS PROGRAM IS AIMED AT ELIMINATING THE ABUSE OF OPIOIDS. RESOURCES ARE AVAILABLE AT THE PAUQUETTE CENTER IN PORTAGE, WHICH IS THE COUNTY SEAT. AS MORE SPECIFIC DATA BECOMES AVAILABLE REGARDING OPIOID ABUSE SPECIFICALLY, COLUMBUS COMMUNITY HOSPITAL MAY CONSIDER THIS A POTENTIAL INITIATIVE IN THE 2018 CHNA.- AGE ADJUSTED DEATH RATE DUE TO SUICIDE IS A RECOGNIZED ISSUE. AT THIS TIME, COLUMBUS COMMUNITY HOSPITAL DOES NOT HAVE THE STAFF OR RESOURCES TO PROPERLY ADDRESS THIS NEED. COLUMBUS COMMUNITY HOSPITAL IS WORKING WITH SSM HEALTH TO INVESTIGATE THE POSSIBILITY OF TELEHEALTH, SPECIFICALLY TELENEUROLOGY AND/OR TELEPSYCHOLOGY. - HIGH RATES OF UNINTENTIONAL INJURY AND TRAFFIC ACCIDENTS ARE BEING ADDRESSED BY OTHERS, INCLUDING LAW ENFORCEMENT AND STATE LEVEL EXPERTS THROUGH INITIATIVES SUCH AS MANDATORY SEAT BELT LAWS AND SPEED LIMIT ENFORCEMENT. AS A RURAL COMMUNITY, FARM SAFETY CONTINUES TO BE A PRIORITY. THE HOSPITAL SUPPORTS SAFETY EDUCATION THROUGH PARTICIPATION IN ANNUAL EVENTS LIKE SAFETY FUN NIGHT, NATIONAL NIGHT OUT, BIKE SAFETY, CAR SEAT SAFETY CHECKS, ETC.- ACCESS TO MENTAL AND BEHAVIORAL HEALTH SERVICES IS A RECOGNIZED NEED RESULTING IN POOR MENTAL HEALTH STATUS. COLUMBUS COMMUNITY HOSPITAL IS AWARE OF THIS NEED IN THE COUNTY. HOWEVER, AT THIS TIME, CCH DOES NOT HAVE THE STAFF OR RESOURCES TO PROPERLY ADDRESS THIS NEED. RESOURCES ARE AVAILABLE AT THE PAUQUETTE CENTER IN PORTAGE, WHICH IS THE COUNTY SEAT. A MONTHLY NAMI SUPPORT GROUP ALSO MEETS AT THE PORTAGE PUBLIC LIBRARY.- COLORECTAL CANCER IS A RECOGNIZED NEED IN COLUMBIA COUNTY. COLUMBUS COMMUNITY HOSPITAL RECENTLY EXPANDED ITS CANCER NAVIGATION PROGRAM TO INCLUDE COLON AND LUNG CANCER. IT IS RECOGNIZED THAT IT WILL TAKE TIME TO BUILD THIS RESOURCE AS A VIABLE OPPORTUNITY FOR THOSE IN NEED. HOWEVER, AT THIS TIME, COLUMBUS COMMUNITY HOSPITAL DOES NOT HAVE FURTHER RESOURCES TO RESPOND TO THE RECOGNIZED NEED OF PROSTATE CANCER.- THE LACK OF DENTAL CARE IN THE COMMUNITY PROVES TO BE A LARGE ISSUE, BUT THE HOSPITAL CANNOT IMPACT THIS. MANY OF THE FOCUS GROUP PARTICIPANTS MENTIONED A LACK OF DENTISTS. MANY PEOPLE DO NOT RECEIVE THE DENTAL CARE THEY NEED BECAUSE THEY EITHER CANNOT MAKE AN APPOINTMENT, DO NOT HAVE THE TRANSPORTATION TO GET TO AN APPOINTMENT OR THEIR INSURANCE IS NOT ACCEPTED. THE HOSPITAL WILL CONTINUE TO WORK WITH LOCAL DENTISTS WHEN A PATIENT PRESENTS TO THE EMERGENCY DEPARTMENT OR EXPRESSES A NEED.- VIOLENT CRIME IN COLUMBIA COUNTY IS A NEED BEING ADDRESSED BY LOCAL LAW ENFORCEMENT OFFICIALS WITHIN THE HOSPITAL'S COMMUNITY. COLUMBUS COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 13H: PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE:1. HOMELESS OR RECEIVED CARE FROM A HOMELESS OR FREE CLINIC; 2. PATIENT IS DECEASED WITH NO KNOWN ESTATE;3. ACCOUNTS UNCOLLECTIBLE DUE TO DISCHARGE OF DEBTOR BY BANKRUPTCY;4. ALL DATES OF SERVICE WITHIN 30-DAYS PRIOR TO WHEN A PATIENT HAS BEEN APPROVED FOR MEDICAL ASSISTANCE;5. OUT-OF-STATE MEDICAL ASSISTANCE COVERAGE NOT CONTRACTED WITH CCH OR ARE LISTED AS NO FUNDS AVAILABLE. 6. QUALIFICATION FOR TREATMENT UNDER THE MEMORANDUM OF UNDERSTANDING BETWEEN COLUMBIA COUNTY HEALTH AND HUMAN SERVICES AND CCH COLUMBUS COMMUNITY HOSPITAL, INC. PART V, SECTION B, LINE 16J: PROVIDED TO PATIENTS UPON ADMISSION 2 1 - PRAIRIE RIDGE HEALTH CLINIC 118 W MAPLE AVENUE BEAVER DAM WI 53916 PHYSICIAN CLINIC 2 - PRAIRIE RIDGE HEALTH CLINIC 301 W MAIN STREET SUITE A MARSHALL WI 53559 PHYSICIAN CLINIC PART I, LINE 3C: PATIENTS WHOSE FAMILY INCOME AND FAMILY ASSETS ARE AT OR BELOW 200% OF THE FPG ARE ELIGIBLE TO RECEIVE FREE CARE AND PATIENTS WHOSE FAMILY INCOME AND FAMILY ASSETS ARE ABOVE 200% OF THE FPG BUT NOT MORE THAN 400% OF THE FPG ARE ELIGIBLE TO RECEIVE SERVICES AT AMOUNTS TO GREATER THAN THE AMOUNTS GENERALLY BILLED. IN ADDITION, PATIENTS WHOSE FAMILY INCOME AND ASSET EXCEED 400% OF THE FPG MAYBE BE ELIGIBLE TO RECEIVE DISCOUNTED RATES BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE, AT THE DISCRETION OF CCH. PART I, LINE 6A: COLUMBUS COMMUNITY HOSPITAL, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON 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 SERVICES REVENUES. 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. (THE COSTING METHODOLOGY FOR SUBSIDIZED HEALTH SERVICES FOR LINE 7G ON THE FIRST PAGE OF SCHEDULE H OF THE FORM 990 IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. THIS ALLOCATION METHOD AND PRINCIPLES OF ALLOCATION WERE USED TO DERIVE A SPECIFIC AMOUNT OF COST ALLOCATION TO THE VARIOUS PROGRAMS AND COST CENTERS OPERATED BY THE ORGANIZATION.) PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT COLUMBUS COMMUNITY HOSPITAL INC. INCLUDE THE OPERATION OF THE HOSPITAL INPATIENT MEDICAL/SURGICAL NURSING UNIT AND THE INTENSIVE CARE UNIT. THESE DEPARTMENTS ARE OFTEN OPERATED AT MINIMAL STAFFING REQUIREMENTS BUT ARE REQUIRED TO MAINTAIN CONSISTENT STAFFING, WHICH LEADS TO HIGHER COSTS, IN ORDER TO ALLOW FOR EMERGENCY ADMISSIONS TO THE UNIT AND FLUCTUATING PATIENT DEMANDS. THE HOSPITAL ADJUSTS ITS STAFFING BASED ON PATIENT TRENDS AND CURRENT CENSUS LEVELS TO ENSURE THAT LOW COST HEALTHCARE IS BEING PROVIDED, HOWEVER THERE IS A LARGE AMOUNT OF FIXED COSTS IN THESE UNITS AND A MINIMAL LEVEL OF STAFFING MUST BE MAINTAINED IN ORDER TO PROVIDE THESE HIGHER LEVEL OF SERVICES TO THE COMMUNITY. IT IS THE GOAL OF COLUMBUS COMMUNITY HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. 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 $ 1,615,429. PART II, COMMUNITY BUILDING ACTIVITIES: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT", THESE EFFORTS CONTINUE TO BE A WORK IN PROGRESS. COLUMBUS COMMUNITY HOSPITAL INC. PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT BENEFIT WHICH IS NOT QUANTIFIED. COLUMBUS COMMUNITY HOSPITAL, LIKE MOST COMMUNITY 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 ORGANIZATION PROVIDES LOCAL ACCESS TO MANY SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES, SWING BED SERVICES, LABORATORY SERVICES, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH PATHOLOGY, SURGICAL SERVICES, LIFELINE, OCCUPATIONAL HEALTH, AND WOMENS' SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. PART III, LINE 2: THE ORGANIZATION UTILIZES HFMA 15. PLEASE SEE EXPLANATION AT PART III, LINE 4. PART III, LINE 3: USING HFMA 15 WOULD NOT ALLOW ANY ADDITIONAL AMOUNT TO BE DEEMED CHARITY CARE. PART III, LINE 4: THE HOSPITAL ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE HOSPITAL ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES FOR AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE AMOUNTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID BASED ON THE AGING OF THOSE RECEIVABLES. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE HOSPITAL RECORDS A PROVISION FOR BAD DEBTS ON THE BASIS OF ITS PAST EXPERIENCE AND THE AGING OF THOSE RECEIVABLES. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE ORGANIZATION'S TOTAL OPERATING EXPENSES LESS PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE ORGANIZATION. THE ORGANIZATION ALSO RECOGNIZES THAT IT ALSO PROVIDES A DISCOUNT TO SELF-PAY OR UNINSURED PATIENTS. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE 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 ORGANIZATION. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE ORGANIZATION, AND ALSO DOES NOT CONSIDER ALL CONTRACTUAL ADJUSTMENTS FOR SERVICES REIMBURSED BY THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT THE HOSPITAL AS WELL AS ANESTHESIA PROFESSIONAL SERVICES, RESPIRATORY THERAPY PHYSICIAN PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN PROFESSIONAL SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENTS AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND CLINICAL PHYSICIAN 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 COLUMBUS COMMUNITY HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED SEPTEMBER 30, 2018, 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).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UNDER THE ORGANIZATION'S COLLECTION AND CHARITY CARE POLICIES, COLUMBUS COMMUNITY HOSPITAL MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE ORGANIZATION'S CHARITY CARE POLICY IT IS NOTED THAT PATIENTS MAY QUALIFY FOR CHARITY CARE EITHER PRIOR TO ADMISSION OR FOLLOWING DISCHARGE. ALL INPATIENT SELF-PAY ADMISSIONS ARE SCREENED BY THE HOSPITAL'S PATIENT FINANCIAL COUNSELOR OR SOCIAL WORKERS TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, OR THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPLETE AND RETURN THE FORMS AT A LATER TIME WHEN THEIR CARE ALLOWS THIS COMPLETION.DURING THE PATIENT ACCOUNT COLLECTION PROCESS, SELF-PAY PATIENTS ARE ALSO INFORMED OF THE HOSPITAL'S COLLECTION POLICIES AS WELL AS THE CHARITY CARE PROGRAM TO ALLOW PATIENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. PART VI, LINE 2: COLUMBUS COMMUNITY HOSPITAL INC. ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITIES AND AREAS IT SERVES BY REVIEWING LOCAL DEMOGRAPHICS AND TRENDS IN PATIENT SERVICE UTILIZATION TO DETERMINE WHICH SERVICES COULD AND SHOULD BE MADE AVAILABLE TO THE COMMUNITY IN A COST-EFFECTIVE MANNER TO BE CONSISTENT WITH COLUMBUS COMMUNITY HOSPITAL'S MISSION IN THE COMMUNITY. COLUMBUS COMMUNITY HOSPITAL ALSO REVIEWS STATISTICS IN THE HOSPITAL, NURSING HOME, CLINIC, HOME HEALTH, AND OTHER ORGANIZATIONAL DEPARTMENTS TO REVIEW THE CURRENT SERVICES BEING OFFERED AND ENSURE THAT RESOURCES ARE BEING APPROPRIATELY ALLOCATED TO AREAS IN NEED BY COMMUNITY MEMBERS AND PATIENTS. THE ORGANIZATION ALSO MEETS WITH LOCAL COMMUNITY MEMBERS AND ITS PHYSICIAN GROUP TO DETERMINE WHICH SERVICES MAY BENEFIT THE COMMUNITY. A FORMAL COMMUNITY NEEDS ASSESSMENT WAS COMPLETED BY SEPTEMBER 2016. PART VI, LINE 3: UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH ONE OF THE ORGANIZATION'S FINANCIAL COUNSELORS EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAL ASSISTANCE OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR COLUMBUS COMMUNITY HOSPITAL INC. ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30 MILE RADIUS OF THE HOSPITAL. COLUMBUS COMMUNITY HOSPITAL IS THE ONLY HOSPITAL LOCATED IN ITS IMMEDIATE SERVICE AREA. THE HOSPITAL PROVIDES A SIGNIFICANT PORTION OF ITS PATIENT SERVICES TO BENEFICIARIES OF THE MEDICARE AND MEDICAL ASSISTANCE PROGRAMS, ESPECIALLY THOSE BENEFICIARIES WHO ARE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY AND RURAL SURROUNDING AREAS WHO OTHERWISE WOULD HAVE A DIFFICULT TIME TRAVELING TO LARGER FACILITIES AND IN SOME CASES COULD BE MORE THAN 20+ MILES AWAY FROM COLUMBUS COMMUNITY HOSPITAL. IN FISCAL YEAR 2018, THESE MEDICARE AND MEDICAL ASSISTANCE PATIENTS ACCOUNTED FOR OVER 54 PERCENT OF THE GROSS PATIENT SERVICE REVENUE PROVIDED BY THE ORGANIZATION DURING THE YEAR. PART VI, LINE 5: CCH HAS AN 11 MEMBER BOARD OF DIRECTORS, 6 OF WHICH ARE COMMUNITY MEMBERS THAT RESIDE IN COLUMBIA COUNTY. CCH ALSO MAINTAINS AN OPEN MEDICAL STAFF. SURPLUS FUNDS ARE USED TO REINVEST IN EQUIPMENT, TECHNOLOGY, AND INFRASTRUCTURE IN ORDER TO ENSURE THAT CCH IS ABLE TO SUPPORT THE PROMOTION OF COMMUNITY HEALTH WELL INTO THE FUTURE. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 1 0 0 0 0 0 0 0 0 GARY GALVIN MD CHIEF OF STAFF (THRU 1/18), DIRECTOR 329454 0 80889 0 1290 0 10800 0 23253 0 445686 0 0 0 BRUCE KRAUS MD DIRECTOR (THRU 1/18) 171400 0 46214 0 1905 0 8809 0 23764 0 252092 0 0 0 JOHN D RUSSELL PRESIDENT & CEO 324523 0 47383 0 45785 0 10800 0 25253 0 453744 0 0 0 PHILLIP G ROBERTS VP OF FINANCE & CFO 207070 0 23501 0 31428 0 9282 0 22852 0 294133 0 0 0 JAMIE E HENDRIX VP OF PATIENT CARE SERVICE 179790 0 19812 0 24426 0 8089 0 23834 0 255951 0 0 0 ANN ROUNDY VP OF EMPLOYEE SERVICES 167514 0 40774 0 26065 0 10564 0 24127 0 269044 0 0 0 ROBERT COE PHYSICIAN 122600 0 321640 0 1290 0 10800 0 24169 0 480499 0 0 0 CRAIG HABERMAN PHYSICIAN 251646 0 72634 0 58784 0 10800 0 20330 0 414194 0 0 0 MATTHEW NIESEN PHYSICIAN 564863 0 48542 0 55056 0 10800 0 23253 0 702514 0 0 0 KATHERINE SKAGGS PHYSICIAN 189526 0 17308 0 21695 0 0 0 17716 0 246245 0 0 0 PART I, LINE 4A CRAIG HABERMAN RECEIVED SEVERANCE PAY AT HIS LAST REGULAR WEEKLY SALARY RATE OF $5,769 PER WEEK, LESS REGULAR AND REQUIRED PAYROLL WITHHOLDINGS, FOR UP TO TWELVE WEEKS, AMOUNTING TO A TOTAL OF $34,615. KATHERINE SKAGGS RECEIVED SEVERANCE PAY AT HER LAST REGULAR WEEKLY SALARY RATE OF $4,327 PER WEEK, LESS REGULAR AND REQUIRED PAYROLL WITHHOLDINGS, FOR UP TO FOUR WEEKS, AMOUNTING TO A TOTAL OF $17,308. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2010-12-01 5500000 FINANCE THE RENOVATION AND EQUIPPING OF THE HOSPITAL FACILITIES 0 0 0 B CITY OF COLUMBUS WISCONSIN 396005417 2005-06-06 2000000 FINANCE THE IMPROVEMENT OF THE EXISTING HOSPITAL FACILITY 0 0 0 C CITY OF COLUMBUS WISCONSIN 396005417 2004-12-14 10000000 FINANCE THE IMPROVEMENT AND EQUIPPING OF THE EXISTING HOSPITAL FACILITY 0 0 0 D CITY OF COLUMBUS WISCONSIN 396005417 2013-12-12 8000000 FINANCE THE RENOVATION AND EQUIPPING OF THE HOSPITAL FACILITIES 0 0 0 A 1384017 5500000 5500000 2011 0 0 1 1 B 959077 2000000 40000 1960000 2006 0 0 1 1 C 4676991 10000000 200000 9800000 2006 0 0 1 1 D 601457 8000000 8000000 2015 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 C 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 D 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 A 0 1 0 0 1 0 0 0 1 B 0 0 1 0 0 0 0 0 1 C 0 0 0 0 0 0 0 0 1 D 0 0 0 0 1 0 0 0 1 A 1 B 1 C 1 D 1 A CITY OF COLUMBUS WISCONSIN 396005417 2014-06-25 2000000 FINANCE THE RENOVATION AND EQUIPPING OF THE HOSPITAL FACILITIES 0 0 0 A 142421 2000000 2000000 2016 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 1 0 1 A 0 0 0 0 1 0 0 0 1 A 1 FORM 990, PART VI, SECTION A, LINE 7A SSM HEALTH CARE OF WISCONSIN, INC. APPOINTS THREE DIRECTORS TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING DECISIONS BY THE BOARD OF DIRECTORS REQUIRE PRIOR WRITTEN APPROVAL OF SSM HEALTH CARE OF WISCONSIN, INC.: APPROVAL OF ANY AMENDMENT OR RESTATEMENT OF THE CORPORATION'S RESTATED ARTICLES OF INCORPORATION OR OF THE RESTATED BYLAWS; APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION; APPROVAL OF ANY MERGER OR CONSOLIDATION INVOLVING THE CORPORATION AND APPROVAL OF THE DISSOLUTION OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY EITHER THE SENIOR ACCOUNTANT OR DIRECTOR OF FINANCIAL SERVICES FOR COMPLETION AND ACCURACY AND THEN ALSO BY THE CHIEF FINANCIAL OFFICER. THE BOARD OF DIRECTORS ARE GIVEN THE OPPORTUNITY TO REVIEW THE RETURN BEFORE BEING FILED WITH THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS CHECKS COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY WHENEVER THERE IS A CHANGE IN PEOPLE GOVERNING ANY PART OF THE HOSPITAL OPERATIONS. EACH DIRECTOR AND OFFICER SHALL, SHOULD A CONFLICT ARISE AT ANY TIME, PROMPTLY DISCLOSE SUCH CONFLICT IN WRITING TO THE BOARD OF DIRECTORS AND THE INTERESTED PERSON DOES NOT VOTE ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS REVIEW MARKET DATA FOR ALL ADMINISTRATION POSITIONS AS WELL AS EVALUATES THE PRESIDENT & CEO. A REVIEW OF THE CRITERIA NECESSARY FOR INCENTIVE COMPENSATION IS ALSO DONE ANNUALLY. 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. FORM 990, PART IX, LINE 11G HOSPITAL PROFESSIONAL FEES AND PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 461,270. MANAGEMENT AND GENERAL EXPENSES 118,871. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 580,141. CONTRACTED LABORATORY SERVICES: PROGRAM SERVICE EXPENSES 267,197. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 267,197. MEDICAL IMAGING SERVICES: PROGRAM SERVICE EXPENSES 890,351. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 890,351. OTHER MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 23,528. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 23,528. LAUNDRY SERVICES: PROGRAM SERVICE EXPENSES 95,064. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 95,064. AGENCY LABOR: PROGRAM SERVICE EXPENSES 175,179. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 175,179. CONTRACTED LABOR: PROGRAM SERVICE EXPENSES 3,371,245. MANAGEMENT AND GENERAL EXPENSES 197,308. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,568,553. EKG/PFT: PROGRAM SERVICE EXPENSES 42,083. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 42,083. PRESS GANEY: PROGRAM SERVICE EXPENSES 26,337. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 26,337. PATHOLOGY: PROGRAM SERVICE EXPENSES 29,640. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 29,640. CLEANING SERVICES: PROGRAM SERVICE EXPENSES 51,978. MANAGEMENT AND GENERAL EXPENSES 13,395. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 65,373. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN ASSETS OF COLUMBUS COMMUNITY HOSPITAL FOUNDATION 130,366. FORM 990, PART XII, LINE 2C: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. COLUMBUS COMMUNITY HOSPITAL FOUNDATION INC 1515 PARK AVE COLUMBUS WI 53925 391656161 TO SUPPORT COLUMBUS COMMUNITY HOSPITAL, INC. WI 501(C)(3) LINE 12B, II COLUMBUS COMMUNITY HOSPITAL INC 1 VOLUNTEERS OF COLUMBUS COMMUNITY HOSPITAL INC 1515 PARK AVE COLUMBUS WI 53925 391707234 TO SUPPORT COLUMBUS COMMUNITY HOSPITAL, INC. WI 501(C)(3) LINE 12C, III-FI COLUMBUS COMMUNITY HOSPITAL INC 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 COLUMBUS COMMUNITY HOSPITAL FOUNDATION INC C 59286 FMV