2015-11-12T14:20:03-06:00 2014-12-31 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2014-01-01 411842965 LAKEWOOD HEALTH SYSTEM LAKE 2188941515 49725 COUNTY 83 STAPLES MN 56479 JAMES DREGNEY CHIEF FINANCIAL OFFICER 2188941515 2015-11-10 1 TIM A RITTER CPA P00732856 9525483400 2015-11-10 2014 2016-04-25 22:37:26Z JAMES DREGNEY 49725 COUNTY 83 STAPLES MN 56479 102808595 0 X WWW.LAKEWOODHEALTHSYSTEM.COM X 1996 MN TO PROVIDE QUALITY, PERSONALIZED HEALTHCARE FOR A LIFETIME. 12 7 995 125 33349 0 438626 525668 92778803 100274607 394642 366654 2009398 1569587 95621469 102736516 0 0 0 0 49193428 47396948 0 0 161962 44670808 44798290 93864236 92195238 1757233 10541278 83151564 92699277 49338462 48481497 33813102 44217780 X THE MISSION OF LAKEWOOD HEALTH SYSTEM IS TO PROVIDE QUALITY, PERSONALIZED HEALTHCARE FOR A LIFETIME. 0 0 64887534 0 87614649 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 MENTAL HEALTH UNIT IN STAPLES, MINNESOTA.THE ORGANIZATION ALSO OPERATES 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.THE ORGANIZATION PROVIDED FOR 4,308 INPATIENT HOSPITAL AND SWING-BED DAYS, 3,163 INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT DAYS, 59,283 MEDICAL AND MENTAL HEALTH RURAL HEALTH CLINIC VISITS. 6335172 0 13587770 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 35,208 RESIDENT DAYS IN THE NURSING HOME AND 701 ASSISTED LIVING UNIT RENTED MONTHS. 71222706 1 1 0 1 0 0 0 0 1 0 1 0 0 0 1 1 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 96 0 995 1 1 1 0 0 0 0 1 1 0 0 0 0 X 12 7 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X JAMES DREGNEY CHIEF FINANCIAL OFFICER 2188941515 49725 COUNTY 83 STAPLES MN 56479 CHRISTINE ALBRECHT MD BOARD MEMBER 1.00 X 0 0 0 JULIE BENSON MD BOARD MEMBER 1.00 X 0 0 0 CAROLYN BISEL BOARD MEMBER (THRU JUNE) 1.00 X 0 0 0 MICHAEL HUDALLA MD BOARD MEMBER 1.00 X 0 0 0 CURT MCILRAVY BOARD MEMBER 1.00 X 0 0 0 WILLIAM MENNIS MD BOARD MEMBER 1.00 X 0 0 0 BARB PETERSON BOARD MEMBER (THRU JUNE) 1.00 X 0 0 0 RON STORBAKKEN BOARD MEMBER 1.00 X 0 0 0 PAUL WICK BOARD MEMBER 1.00 X 0 0 0 LOREN MOREY CHAIRMAN 1.00 X X 0 0 0 JIM HOFER VICE-CHAIRMAN 1.00 X X 0 0 0 MARY THEURER SECRETARY 1.00 X X 0 0 0 SARAH ISRAELSON MD SECRETARY (THRU JUNE) 1.00 X X 0 0 0 LARRY LUNDBLAD TREASURER 1.00 X X 0 0 0 TIM RICE PRESIDENT 40.00 X X 383313 0 61786 JAMES DREGNEY CHIEF FINANCIAL OFFICER 40.00 X 207946 0 55138 JOHN HALFEN CHIEF MEDICAL OFFICER 40.00 X 589730 0 0 CRAIG WOLHOWE VP OF HOSPITAL & CLINIC SERVICES 40.00 X 200175 0 47080 LYNN RICE VP OF SUPPORT SERVICES 40.00 X 200164 0 20016 SHERREE ENGEN CRNA 40.00 X 296337 0 55843 ROBERT SCHMIEG CRNA 40.00 X 237658 0 16149 AMY WINKELS PHYSICIAN ASSISTANT 40.00 X 166937 0 44630 REBECCA BENNETT PHYSICIAN ASSISTANT 40.00 X 162807 0 46307 BRIAN HINMAN PHARMACY DIRECTOR 40.00 X 153915 0 42669 2598982 0 389618 43 0 1 0 LAKEWOOD CLINIC PA 49725 COUNTY 83 STAPLES MN 56479 PHYSICIAN SERVICES 10014097 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM COVERAGE 940333 REHABCARE GROUP INC PO BOX 503534 ST LOUIS MO 63150 THERAPY MANAGEMENT SERVICES 507112 CENTRAL MINNESOTA DIAGNOSTIC INC PO BOX 158 MILICA MN 56353 MRI & CT SERVICES 483700 QUEST DIAGNOSTICS 12989 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB TEST SERVICES 409629 27 65934 286527 173207 525668 NET PATIENT AND RESIDENT SERVICE 621110 98480661 98480661 PHARMACY 621300 806596 806596 OCCUPATIONAL HEALTH 621300 392065 392065 RENT REVENUE 531120 238401 238401 MRI 621500 89677 89677 267207 267207 100274607 384289 33349 350940 7000 24635 -17635 -17635 -17635 27432 65934 47444 -20012 -20012 EHR INCENTIVE 900099 927812 927812 FOOD SERVICE 900099 621686 621686 40101 40101 1589599 102736516 101202419 33349 975080 X 1770347 1770347 32492808 24737720 7740211 14877 2368418 1801107 563481 3830 8368304 6373313 1993909 1082 2397071 21848 2374126 1097 22772 22772 45484 45484 9279924 7592197 1671227 16500 201593 10909 190684 9635843 8884601 628114 123128 9938 9938 2776143 2269851 506292 536707 315651 221056 33201 33201 1784471 1784471 6781823 6781823 305688 305688 MEDICAL FEES 7572305 7341488 230817 PROVISION FOR BAD DEBTS 1734185 1734185 HOSPITAL & NH SURCHARGE 984521 984521 MN CARE TAX 968241 968241 2125451 1563604 560399 1448 92195238 71222706 20810570 161962 10735 12027 11471553 28591297 13799394 13827036 224858 98257 1717900 1533875 1878093 1777663 89484296 44950043 49455771 44534253 734961 580931 550657 4012329 1039251 83151564 92699277 6684059 7963348 1939420 1375874 39653995 38226044 38226 40518 1022762 201365 0 674348 49338462 48481497 X 33466220 43803194 346882 414586 33813102 44217780 83151564 92699277 X 10541278 -136600 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 1204 1204 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF MINNESOTA HOSPITAL ASSOCIATION AND 3.9% OF THE $30,861 MEMBERSHIP FEE WAS RELATED LOBBYING ACTIVITIES. 0 1 X 838858 838858 33618499 15548206 18070293 165063 68586 96477 53077963 28806112 24271851 1783913 527139 1256774 44534253 DUE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 674348 674348 X 101002331 0 101002331 1734185 1734185 102736516 90461053 0 90461053 1734185 1734185 92195238 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 X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION BY THE TAXING AUTHORITIES, BASED ON 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ORGANIZATION HAS NOT RECORDED ANY ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS AS OF DECEMBER 31, 2014 AND 2013. THE ORGANIZATION'S FEDERAL RETURNS FOR TAX YEARS 2011 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,734,185. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,734,185. DINNER AUCTION 27241 9131 18110 7423 GOLF TOURNAMENT 18788 9466 9322 3923 8 47337 47337 36098 93366 65934 27432 47444 47444 -20012 1 1 1 X 1 X 240.000000000000 0 1 0 1 0 436550 436550 0.00480 20869858 18884834 1985024 0.02190 21306408 18884834 2421574 0.02670 202581 1780 200801 0.00220 6000 6000 0.00010 3423722 1262791 2160931 0.02390 29292 29292 0.00030 3661595 1264571 2397024 0.02650 24968003 20149405 4818598 0.05320 1000 4766 4766 0.00010 3200 3200 0.00000 1000 7966 7966 0.00010 0 1044283 0 13624880 16826499 -3201619 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 13 1 1 0 1 X SEE SUPPLEMENTAL INFORMATION X X 1 13 1 SEE SUPPLEMENTAL INFORMATION 1 0 1 X 100.000000000000 240.000000000000 X X X X 1 1 X X X X 1 X X X X X X 1 X 0 X 1 X 0 0 LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 5: THE PRIMARY DATA COLLECTION WAS DONE IN PARTNERSHIP WITH TODD WADENA HEALTHY CONNECTIONS BY SENDING A SURVEY TO 1,200 RANDOMLY SELECTED RESIDENTS IN EACH OF THE 4 COUNTIES SERVED BY LHS (4800 TOTAL RESIDENTS). IN ADDITION, LHS MET WITH CIVIC GROUPS AND CONDUCTED FOCUS GROUPS TO GAIN A BETTER UNDERSTANDING WHAT THE PERCEPTION OF A HEALTHY COMMUNITY IS IN THE IMMEDIATE AREA. THESE GROUPS INCLUDED: BUSINESS LEADERS, CIVIC GROUPS, COLLEGE STUDENTS OVER 18 YEARS OF AGE, COMMUNITY MEMBERS FROM VARIOUS ECONOMIC AND SOCIAL BACKGROUNDS, EDUCATORS, PARENTS OF YOUNG CHILDREN, PUBLIC HEALTH, AND RELIGIOUS LEADERS. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 7D: HTTP://LAKEWOODHEALTHSYSTEM.COM/COMMUNITY/COMMUNITY-HEALTH-NEEDS-ASSESSMENT LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 11: RATHER THAN INADEQUATELY ADDRESSING ALL HEALTH NEEDS, LHS WILL FOCUS RESOURCES, BOTH FINANCIAL AND OTHERWISE, ON ADULT & CHILDHOOD OBESITY AND MENTAL HEALTH IN ORDER TO ENHANCE POTENTIAL SUCCESS IN MEETING THESE HEALTH NEEDS. DESPITE NOT DIRECTLY FOCUSING ON THESE CONCERNS, INTERVENTIONS ADDRESSING THE PRIORITIZED HEALTH NEEDS MAY PARTIALLY OVERLAP, POSITIVELY IMPACTING ONE OR MORE NEEDS. OTHER NEEDS AND CONCERNS INCLUDE ISSUES RELATED TO POVERTY, UNDER OR UNINSURED PERSONS, ALCOHOL ABUSE, AND SMOKING AMONGST OTHER ITEMS. 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 16I: EACH APPLICABLE ADMISSION AREA HAS A POLICY AVAILABLE FOR THE PATIENT AS NEEDED AND UPON REQUEST. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 22D: UNINSURED PATIENTS MEETING INCOME GUIDELINES WILL NOT BE CHARGED MORE IN WHICH THE PROVIDER WOULD BE REIMBURSED FROM OUR MOST FAVORED INSURER. CHARITY CARE DISCOUNTS ARE DETERMINED BASED ON INCOME LEVELS USING THE FPG. 7 STAPLES CLINIC 49725 COUNTY ROAD 83 STAPLES MN 56479 CLINIC PILLAGER CLINIC 653 PILLSBURY ST N STE 1 PILLAGER MN 56473 CLINIC MOTLEY CLINIC 1233 HWY 10 MOTLEY MN 56466 CLINIC BROWERVILLE CLINIC 30535 241ST AVE BROWERVILLE MN 56438 CLINIC EAGLE VALLEY CLINIC 815 HWY 71 S EAGLE BEND MN 56446 CLINIC LHS CARE CENTER 401 PRAIRIE AVE NE STAPLES MN 56479 SKILLED NURSING FACILITY ST CLOUD DERMATOLOGY CLINIC 2251 CONNETICUT AVE SO SUITE 3800 SARTELL MN 56377 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, ALLOWANCES AND DISCOUNTS, MEDICAID, AND ACTUAL COST OF SERVICES PROVIDED. SUBSIDIZED SERVICES ARE DETERMINED BY THE ORGANIZATION DUE TO THE NEED IN THE COMMUNITY THAT CAN ONLY BE FILLED BY THE ORGANIZATION. THERE ARE NO PHYSICIANS CLINIC. 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 $ 1,734,185. 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: THIS 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 (PRESEMPTIVE 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 PROBABLY 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 THE VALUATION ALLOWANCE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE.FINANCIAL STATEMENT FOOTNOTE 3 ACCOUNTS RECEIVABLE: THE ORGANIZATION'S ALLOWANCE FOR DOUBTFUL ACCOUNTS FOR SELF-PAY PATIENTS DECREASED FROM 41.3% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2013, TO 39.5% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2014. BAD DEBT WRITE-OFFS, NET OF RECOVERIES, WERE APPROXIMATELY $2,315,000 AND $493,000 FOR THE YEARS ENDED DECEMBER 31, 2014 AND 2013,RESPECTIVELY. IN 2013, THE ORGANIZATION ADDED ADDENDUMS TO THE CHARITY CARE AND UNINSURED DISCOUNT POLICIES THAT ARE EXPECTED TO INCREASE CHARITY CARE AMOUNTS WHICH ARE AVAILABLE TO THE LOWEST-INCOME PATIENTS AND REDUCE CHARITY CARE AMOUNTS THAT ARE AVAILABLE TO THOSE PATIENTS WITH A GREATER ABILITY TO PAY. PART III, LINE 8: THE MEDICARE ALLOWABLE COST OF CARE RELATING TO PAYMENTS ON LINE 5 WERE CALCULATED USING OUR FILED 2014 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 ASSITANCE 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, HOUSING AND A SPECIALIZED SENIOR BEHAVIORAL HEALTH UNIT (STAPLES, MN), AND A MEDICAL SPA (BAXTER, MN). WE ALSO HAVE ON-STAFF SPECIALISTS AND VISITING 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 HEATLH, FOR THE COMMUNITY. LHS'S EMERGENCY ROOM IS AVAILABLE TO ALL DESPITE PATIENT FINANCIAL IMPLICATIONS. THERE ARE NO LIMITS IN REGARDS 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 0 0 0 0 0 0 0 0 0 TIM RICE PRESIDENT 383313 0 0 0 0 0 26000 0 35786 0 445099 0 0 0 JAMES DREGNEY CHIEF FINANCIAL OFFICER 207946 0 0 0 0 0 21627 0 33511 0 263084 0 0 0 JOHN HALFEN CHIEF MEDICAL OFFICER 589730 0 0 0 0 0 0 0 0 0 589730 0 0 0 CRAIG WOLHOWE VP OF HOSPITAL & CLINIC SERVICES 200175 0 0 0 0 0 20648 0 26432 0 247255 0 0 0 LYNN RICE VP OF SUPPORT SERVICES 200164 0 0 0 0 0 20016 0 0 0 220180 0 0 0 SHERREE ENGEN CRNA 296337 0 0 0 0 0 22493 0 33350 0 352180 0 0 0 ROBERT SCHMIEG CRNA 237658 0 0 0 0 0 1726 0 14423 0 253807 0 0 0 AMY WINKELS PHYSICIAN ASSISTANT 166937 0 0 0 0 0 17179 0 27451 0 211567 0 0 0 REBECCA BENNETT PHYSICIAN ASSISTANT 162807 0 0 0 0 0 16956 0 29351 0 209114 0 0 0 BRIAN HINMAN PHARMACY DIRECTOR 153915 0 0 0 0 0 8687 0 33982 0 196584 0 0 0 A UNITED HOSPITAL DISTRICT 416005558 88903ABXX 2004-12-01 32000000 NEW HOSPITAL CONSTRUCTION 0 0 0 B UNITED HOSPITAL DISTRICT 416005558 2003-09-15 5093625 CONSTRUCTION OF MEDICAL CLINIC AND REFINANCE DEBT 0 0 0 C UNITED HOSPITAL DISTRICT 416005558 2003-12-17 612000 LAND OF NEW HOSPITAL 0 0 0 D UNITED HOSPITAL DISTRICT 416005558 2013-04-24 7846512 REFINANCING OF 2007 NOTE, 2009 NOTE, 2012 NOTE 0 0 0 A 4058111 31953111 534000 31419111 2006 0 0 1 1 B 2410674 5093625 1217043 101872 3774710 2004 1 0 1 1 C 295133 612000 12240 599760 2004 0 0 1 1 D 515286 7846512 5800010 156930 1889572 2004 1 0 1 1 A 0 1 0 0 0.00400 0.00400 0 0 1 B 0 1 0 0 0.02290 0.02290 0 0 1 C 0 0 0 0 0 0 1 D 0 0 0 0 0 0 1 A 0 1 0 0 1 0 0 0 0 B 0 1 0 0 1 0 0 0 0 C 0 1 0 0 1 0 0 0 0 D 0 1 0 0 1 0 0 0 0 A 0 B 0 C 0 D 0 LAKEWOOD CLINIC BOARD MEMBERS HAVE OWNERSHIP INTEREST IN LAKEWOOD CLINIC, PA. 10014097 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 2016. 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: - CHRISTINE ALBRECHT MD - JULIE BENSON MD - SARAH ISRAELSON MD - WILLIAM MENNIS MD 0 FORM 990, PART VI, SECTION A, LINE 2 TIM RICE, PRESIDENT/CEO, IS MARRIED TO LYNN NEWTON RICE, DIVISION DIRECTOR. FORM 990, PART VI, SECTION B, LINE 11 THE PREPARER OF FORM 990 EMAILS A COPY OF THE FINAL 990 TO THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. THE CHIEF FINANCIAL OFFICER PERFORMS A DETAIL REVIEW OF FORM 990. THE CHIEF FINANCIAL OFFICER 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 CONFLICT OF 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. CONFLICTS 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 PACKAGE. FINALLY, THE FULL BUDGET PACKAGE, ALONG WITH ALL SPECIFIC SALARY PROPOSALS ARE 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 EACH YEAR WITH A ONE YEAR TERM. FOR THE CFO, CNO/COO, 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 OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 3,794,782. MANAGEMENT AND GENERAL EXPENSES 1,671,227. FUNDRAISING EXPENSES 16,500. TOTAL EXPENSES 5,482,509. EMERGENCY ROOM: PROGRAM SERVICE EXPENSES 2,034,970. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,034,970. CLINICAL FEES: PROGRAM SERVICE EXPENSES 1,762,445. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,762,445. FORM 990, PART XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTIONS -136,600. FORM 990, PART XII, LINE 2C THE BOARD OF DIRECTORS ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT THROUGH THEIR AUDIT COMMITTEE. THE AUDIT COMMITTEE IS AN EXTENSION OF THE FINANCE COMMITTEE AND MEETS WITH THE INDEPENDENT AUDITOR PRIOR TO AND AFTER THE COMPLETION OF THE AUDIT. MEDICAL SPA LLC 49725 CTY 83 STAPLES MN 56479 800807773 DERMATOLOGY CLINIC AND MEDICAL SPA MN N/A UNRELATED 33349 370498 0 33349 1 0.50000 LAKEWOOD-CENTRACARE LLC 49725 CTY 83 STAPLES MN 56479 411974939 CLINICAL SERVICES MN N/A RELATED 14965 304623 0 1 0.50000 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0