2015-02-11T13:49:06-06:00 2014-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-07-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 DONALD HEINZ CFO 6083393331 2015-02-07 1 TERRI REXRODE CPA MST P00096513 9206620016 2015-02-07 2013 2016-03-07 17:11:31Z DONALD HEINZ 402 WEST LAKE STREET FRIENDSHIP WI 53934 18344615 0 X WWW.MOUNDVIEW.ORG X 1959 WI MOUNDVIEW MEMORIAL HOSPITAL & CLINICS PROVIDES INPATIENT HOSPITAL AND GENERAL HEALTH CARE SERVICES WITH THE PRIMARY MARKET OF ADAMS COUNTY WISCONSIN BY OPERATING A 25 BED CRITICAL ACCESS HOSPITAL. 7 7 161 60 0 0 182577 36858 16534881 17692925 20195 35499 521585 505972 17259238 18271254 0 0 0 0 7930676 8122000 0 0 0 8978258 10023117 16908934 18145117 350304 126137 15762089 15047529 9224495 8367132 6537594 6680397 X MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED, AS A COMMUNITY HEALTH RESOURCE WILL PROVIDE MODERN FACILITIES AND EQUIPMENT TO ENSURE THE DELIVERY OF SERVICES WITH AN EMPHASIS ON PRIMARY HEALTH CARE TO THE PEOPLE OF THE HOSPITAL SERVICE AREA. THE HOSPITAL'S LEADERSHIP, WITH ITS RESOURCES WILL RESPOND IN A TIMELY MANNER TO PHYSICAL, PSYCHOLOGICAL AND SPIRITUAL NEEDS, EMPHASIZING THE 'WHOLE PERSON.' MOUNDVIEW MEMORIAL HOSPITAL AND CLINCS, INCORPORATED WILL PROVIDE MANAGEMENT, AND WELL TRAINED STAFF TO PROVIDE COMPASSIONATE HEALTH CARE. MOUNDVIEW MEMORIAL HOSPITAL AND CLINICS, INCORPORATED SHALL EXPLORE THOSE PROPOSALS FOR NETWORKS, AFFILIATIONS, MERGERS, AND PARTICIPATE IN HMO'S AS DEEMED IN THE BEST INTEREST OF THOSE WE SERVE. 0 0 15930080 18015022 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 2014, THE HOSPITAL HAD 294 ACUTE INPATIENT DAYS AND 281 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 4,915 EMERGENCY ROOM VISITS, 1,000 URGENT CARE VISITS AND 29,421 OUTPATIENT CLINIC AND OTHER OUTPATIENT ANCILLARY VISITS. 15930080 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 171 0 1 161 1 0 0 0 0 0 0 0 0 0 0 X 7 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X DONALD HEINZ 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 MARY POLIVKA PRESIDENT 2.50 X X 0 0 0 DEBRA SEGINA VICE PRESIDENT 2.50 X X 0 0 0 RICHARD STERNHAGEN TREASURER 2.50 X X 0 0 0 DIANA BRONIEC SECRETARY 2.50 X X 0 0 0 PETER MURPHY BOARD MEMBER 2.50 X 0 0 0 RENEE SCHINDLBECK BOARD MEMBER 2.50 X 0 0 0 BARBARA ALBRECHT BOARD MEMBER 2.50 X 0 0 0 JEREMY NORMINGTON CEO 40.00 X 247979 0 39089 DONALD HEINZ CFO 40.00 X 154649 0 27757 RICARDO ALMONTE PHYSICIAN 32.00 X 134196 0 5368 MARK HATTON PHYSICIAN 40.00 X 210788 0 21122 STEPHEN C PAULK PHYSICIAN 16.00 X 140465 0 0 JASON BELLAK PHYSICIAN 40.00 X 284900 0 26045 DAVID SHAPIRO PHARMACIST 40.00 X 127338 0 15132 1300315 0 134513 11 0 1 0 EMCARE 350 WEST CEDAR STREET FOURTH FLOOR PENSACOLA FL 32502 ER PHYSICIAN COVERAGE 1202927 CERNER CORPORATION 2800 ROCKCREEK PARKWAY NORTH KANSAS CITY MO 64117 SOFTWARE MAINTENANCE/SUPPORT 336740 SHARED IMAGING SVCS 801 PHOENIX AVENUE STREAMWOOD IL 60107 MEDICAL IMAGING SERVICES 332801 FIRST REFLECTIONS 228 N PINE ST ADAMS WI 53910 CRNA PROFESSIONAL SERVICES 219649 RURAL WI HOSPITAL ASSOCIATION 880 INDEPENDENCE LANE SAUK CITY WI 53583 EDUCATIONAL/COMMUNITY SERVICES 122788 11 32565 4293 36858 NET PATIENT REVENUE 900099 17534114 17534114 MISCELLANEOUS 900099 134621 134621 DIETARY INCOME 900099 24190 24190 17692925 35499 35499 98425 73361 25064 25064 25064 EHR INCENTIVE 900099 480908 480908 480908 18271254 18015022 0 219374 X 469475 469475 6070877 5580696 490181 144046 116465 27581 998005 926772 71233 439597 385136 54461 7963 7963 45700 45700 2990410 2553111 437299 61802 61802 1641774 1505287 136487 22279 15628 6651 233288 210391 22897 82730 64012 18718 51 51 296170 267238 28932 916769 828088 88681 245852 217604 28248 BAD DEBT EXPENSE 2421603 2421603 REPAIRS & MAINTENANCE 578972 476178 102794 EQUIPMENT RENTS & LEASE 364622 309697 54925 COLLECTION EXPENSE 47097 47097 66035 52174 13861 18145117 15930080 2215037 0 600 700 1963529 1458913 2121379 2532203 60000 40000 28856 419444 381291 274880 165484 19356285 9548573 10198833 9807712 694568 661226 15762089 15047529 1935667 1847633 1134509 817666 5149883 4410000 1004436 1291833 9224495 8367132 X 5903278 6187400 634316 492997 6537594 6680397 15762089 15047529 X 126137 16666 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1710 1710 0 PART II-B, LINE 1: WHA MEMBERSHIP DUES 63641 63641 12128881 4398909 7729972 123411 18347 105064 7040352 5131317 1909035 9807712 X 16003550 -2341065 -2341065 18344615 -73361 -73361 18271254 15796875 73361 73361 15723514 2421603 2421603 18145117 PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS AS OF JUNE 30, 2014 OR 2013. FEDERAL INCOME TAX RETURNS FOR THE YEARS ENDED JUNE 30, 2011, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION MARKET ADJUSTMENT 80,538. BAD DEBT EXPENSE -2,421,603. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -73,361. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 73,361. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 2,421,603. 1 1 1 X 175.000000000000 1 X 175.000000000000 1 1 0 1 1 61102 61102 0.00390 2889810 1871450 1018360 0.06480 2950912 1871450 1079462 0.06870 201442 34575 166867 0.01060 5820 5820 0.00040 207262 34575 172687 0.01100 3158174 1906025 1252149 0.07970 0 2454603 1156856 5558828 5611857 -53029 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL 402 WEST LAKE STREET FRIENDSHIP WI 53934 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 1 X X X X X X X 13 1 0 1 X HTTP://WWW.MOUNDVIEW.ORG/IMAGES/PDFS/COUN X X X X X X X X X X 0 0 1 1 175.000000000000 1 175.000000000000 1 X X 1 1 X X X X X X 1 0 X X X X 1 X 0 0 MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 3: MOUNDVIEW MEMORIAL HOSPITAL & CLINICS IS IN THE FIRST YEAR A THREE YEAR CHNA IMPLEMENTATION. FIRST, KEY STAKEHOLDERS AND COMMUNITY REPRESENTATIVES WERE IDENTIFIED AND INVITED TO JOIN A COMMUNITY TEAM AND DEVELOP THE NEEDS ASSESSMENT. AGENCIES INCLUDED THE ADAMS COUNTY HEALTH AND HUMAN SERVICES DEPARTMENT, THE ADAMS-FRIENDSHIP AREA SCHOOL DISTRICT, THE ADAMS COUNTY UNIVERSITY OF WISCONSIN-EXTENSION, AND THE ADAMS COUNTY CHAMBER OF COMMERCE. INPUT WAS ALSO SOUGHT FROM THE GENERAL COMMUNITY THROUGH A COMMUNITY OPINION SURVEY AND FOCUS GROUPS. SURVEY RESPONSES WERE RANKED BY IDENTIFIED NEEDS BY ORDER OF SERIOUSNESS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 5D: A DISPLAY BOARD ON THE NEEDS ASSESSMENT FINDINGS WAS ALSO CREATED AND DISPLAYED AT LARGE SCALE COMMUNITY EVENTS AND AT THE ADAMS COUNTY COMMUNITY CENTER. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 7: MOUNDVIEW HAS ADDRESSED THE NEEDS OF NUTRITION/PHYSICAL ACTIVITY AND SOCIAL SUPPORT/COHESION AS INDICATED IN OUR IMPLEMENTATION PLAN, ADAPTING THE PLAN AS NEEDED. ADDITIONALLY, MOUNDVIEW HAS WORKED ON ISSUES REGARDING "SUBSTANCE ABUSE" WHICH WAS NOT CHOSEN AS A NEEDS ASSESSMENT PRIORITY, BUT WAS IDENTIFIED BY MOUNDVIEW AS AN IMPORTANT HEALTH ISSUE. MOUNDVIEW IS LIMITED IN WHAT WE CAN DO TO SUPPORT THE "EMPLOYMENT" PRIORITY THAT WAS IDENTIFIED THROUGH THE NEEDS ASSESSMENT. MOUNDIVEW STAFF HAD PLANNED TO SERVE ON THE PROMISE NEIGHBORHOOD COMMUNITY WORK GROUP TASKED WITH ADDRESSING THIS ISSUE BUT THE GROUP IS NOT ACTIVE DUE TO THE PROMISE NEIGHBORHOOD GRANT ENDING. MOUNDVIEW WILL CONTINUE TO LOOK FOR OPPORTUNITIES TO WORK WITH OUR COMMUNITY PARTNERS ON THIS ISSUE. MOUNDVIEW DOES CONTINUE TO PROVIDE CAREER SHADOWING/JOB EXPLORATION OPPORTUNITIES AND CLINICAL EXPERIENCES TO HIGH SCHOOL AND COLLEGE STUDENTS, ATTEND JOB FAIRS, SPEAK TO AREA YOUTH AT HIGH SCHOOL CAREER DAYS AND ENCOURAGE THOSE PURSUING HEALTH CARE CAREERS TO CONSIDER RETURNING TO ADAMS COUNTY TO WORK. 1 MOUNDVIEW CLINIC 402 WEST LAKE STREET FRIENDSHIP WI 53934 CLINIC PART I, LINE 6A: WI HOSPITAL ASSOCIATION PART I, LINE 7: UTILIZE THE MEDICARE COST TO CHARGE METHODOLOGY. 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 $ 2,421,603. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. PART III, LINE 4: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUES AND IDENTIFIED COMMUNITY BENEFIT EXPENSES BY GROSS PATIENT REVENUES. THIS PERCENTAGE WAS THEN MULTIPLIED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 8: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. PART VI, LINE 2: THE HOSPITAL DEVELOPS COMMUNITY SURVEY WITH CONJUNCTION OF THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. PART VI, LINE 3: THE HOSPITAL ANNUALLY PUBLISHES IN THE LOCAL PAPER THE EXISTENCE OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. PART VI, LINE 4: THE ORGANIZATION SERVES ADAMS COUNTY WISCONSIN BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. PART VI, LINE 5: THE HOSPITAL WORKS WITH THE LOCAL PUBLIC HEALTH AGENCIES TO COORDINATE COMMUNITY HEALTH SERVICES TO MEET THE NEEDS OF THE LOCAL COMMUNITY. LONG-RANGE STRATEGIC AND CAPITAL BUDGET PLANNING WITH ADMINISTRATION, MEDICAL STAFF AND BOARD OF DIRECTORS. SURVEY OF OPINIONS FROM HOSPITAL ASSOCIATION. X X X 0 0 0 0 0 0 0 0 0 JEREMY NORMINGTON CEO 216728 0 31251 0 0 0 9038 0 30051 0 287068 0 0 0 DONALD HEINZ CFO 136492 0 14470 0 3687 0 6406 0 21351 0 182406 0 0 0 MARK HATTON PHYSICIAN 210788 0 0 0 0 0 0 0 21122 0 231910 0 0 0 JASON BELLAK PHYSICIAN 244900 0 0 0 40000 0 9796 0 16249 0 310945 0 0 0 A VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 A 1640000 5000000 110000 4890000 2005 0 0 1 1 A 0 0 0 0 1 0 1 A 0 1 0 0 0 0 0 0 0 A 0 FORM 990, SCHEDULE K, PART III, LINE 7 MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. JASON BELLAK PHYSICIAN TO ENABLE PHYSICIAN TO COMPLETE FELLOWSHIP AT THE UNIVERSITY OF WISCONSIN X 90000 40000 0 1 1 40000 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON OVER THE AGE OF EIGHTEEN YEARS WHO IS A RESIDENT OF ADAMS COUNTY MAY BE A MEMBER OF THE CORPORATION. MEMBERSHIP MAY BE ATTRAINED BY ANY SUCH PERSON WHO SHALL AGREE IN WRITING TO BECOME A MEMBER OF THIS CORPORATION BY SUBSCRIBING TO A MEMBERSHIP LIST OF SAID CORPORATION. ANNUAL MEMBERSHIPS WILL BE IN EFFECT FROM JULY 1ST TO JUNE 30TH OF EACH FISCAL YEAR. FORM 990, PART VI, SECTION A, LINE 7A EACH PERSON WHO WAS A MEMBER IN GOOD STANDING AS OF THE PREVIOUS JUNE 30TH IS ENTITLED TO ONE VOTE FOR EACH SEAT OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OF THE ORGANIZATION MUST APPROVE BYLAW CHANGES. FORM 990, PART VI, SECTION B, LINE 11 THE 990 IS REVIEWED BY THE CEO AND CFO PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. FORM 990, PART IX, LINE 11G MEDICAL PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 2,148,980. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,148,980. HUMAN RESOURCES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 29,067. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 29,067. FISCAL SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 181,758. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 181,758. COMMUNITY RELATIONS: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 30,069. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 30,069. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 404,131. MANAGEMENT AND GENERAL EXPENSES 196,405. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 600,536. FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST 42,089. FOUNDATION PAYABLE -25,423. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. MEMORIAL HEALTHCARE FOUNDATION OF ADAMS CO PO BOX 40 FRIENDSHIP WI 53934 391775074 RAISE FUNDS FOR MOUNDVIEW MEMORIAL HOSPITAL & CLINICS WI 501(C)(3) 11B, TYPE II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0