2014-08-11T13:13:17-05:00 2013-12-31 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2013-01-01 390872080 SAUK PRAIRIE MEMORIAL HOSPITAL INC SAUK 6086433311 260 26TH STREET PRAIRIE DU SAC WI 53578 CAROL J MAY CFO 6086433311 2014-08-04 0 HOLLY POKRANDT CPA P00449155 7158323407 2014-08-04 2013 2015-11-30 17:44:51Z X SAUK PRAIRIE HEALTHCARE CAROL J MAY 260 26TH STREET PRAIRIE DU SAC WI 53578 88887503 0 X WWW.SAUKPRAIRIEHEALTHCARE.ORG X 1956 WI EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME. 11 2 603 111 14703 -22510 4584045 1167810 62255934 67796747 1422042 718436 -207536 -141455 68054485 69541538 90792 104235 0 0 33100731 38287233 0 0 110979 25618608 27869686 58810131 66261154 9244354 3280384 84288271 159225299 11106633 83039101 73181638 76186198 X MISSION: EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME.VISION: WE WILL SET THE STANDARD FOR COMMUNITY-BASED HEALTHCARE THAT IMPROVES THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE WE SERVE.SEE CONTINUATION OF MISSION AND VISION INFORMATION UNDER STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS PART 4C. 1 0 45274320 104235 59261653 SAUK PRAIRIE MEMORIAL HOSPITAL, INC. (THE "HOSPITAL"), A 36-BED ACUTE CARE GENERAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO SAUK CITY, PRAIRIE DU SAC, AND THE SURROUNDING COMMUNITIES.TOTAL ADMISSIONS FOR 2013 WERE 1,697 WITH PATIENT DAYS OF 4,022. KEY PATIENT SERVICES INCLUDING 258 BIRTHS IN THE NURSERY, 5,344 SURGICAL PROCEDURES, 58,516 REHABILITATION THERAPY SERVICES, 24,638 MEDICAL IMAGING SERVICES, AND 12,987 EMERGENCY ROOM VISITS ARE AMONG MANY OF THE SERVICES PROVIDED TO PATIENTS DURING 2013. 10539781 8520391 THE HOSPITAL ALSO OWNS AND OPERATES PHYSICIAN PRACTICES IN SPRING GREEN, BLACK EARTH, PLAIN, AND LODI, WISCONSIN. TOTAL CLINIC VISITS TO THESE FOUR SITES FOR 2013 WAS 32,905.DURING 2013, THE HOSPITAL ASSUMED THE CLINICAL PRACTICE OPERATIONS OF ORTHOPEDIC ASSOCIATES OF SAUK PRAIRIE AND SURGICAL ASSOCIATES, WHICH WERE PREVIOUSLY OPERATED BY UNRELATED PHYSICIAN ORGANIZATIONS. THE CLINICAL PRACTICES' ARE LOCATED IN SPACE WITHIN THE HOSPITAL FACILITY. TOTAL ORTHOPEDIC VISITS FROM APRIL-DECEMBER 2013 WERE 8,332. TOTAL SURGICAL ASSOCIATES' VISTS FROM JULY-DECEMBER 2013 WERE 824. THE HOSPITAL FULFILLS ITS MISSION AND VISION BY OFFERING HIGH-QUALITY SERVICES IN RURAL COMMUNITIES, THEREBY ALLOWING OUR PATIENTS TO BE TREATED LOCALLY WITHOUT LENGTHY COMMUTES OR WAITING. THE HOSPITAL HAS GAINED A REGIONAL REPUTATION OF EXCELLENCE IN ORTHOPEDICS, GENERAL SURGERY, SPINE SURGERY, AND GYNECOLOGIC SURGERY. THE HOSPITAL TREATED MORE THAN 1,100 INPATIENTS IN 2013, 258 BABIES ENTERED THE WORLD HERE, AND THE HOSPITAL HAD 54,900 OUTPATIENT VISITS. THE HOSPITAL OPERATES FOUR CLINICS IN RURAL AREAS: LODI, SPRING GREEN, PLAIN, AND BLACK EARTH, BRINGING PRIMARY CARE TO THOSE COMMUNITIES. THE CLINICS HAD CLOSE TO 33,000 VISITS IN 2013. AS A CHARITABLE ORGANIZATION, THE HOSPITAL PROVIDED OVER $2.7 MILLION IN FREE CARE TO PATIENTS IN OUR SERVICE AREA IN 2013, IN ADDITION TO SUBSIDIZING SERVICES THAT DO NOT COVER COSTS, FREE HEALTH SCREENINGS, EDUCATIONAL PROGRAMS, AND YOUTH OUTREACH.AS THE LARGEST EMPLOYER IN THE COMMUNITY, THE HOSPITAL HAS A POSITIVE ECONOMIC IMPACT ON ITS COMMUNITIES. IT DIRECTLY AND INDIRECTLY CREATES 1,044 JOBS AND ITS IMPACT ON THE LOCAL ECONOMY IS OVER $100 MILLION ANNUALLY. 55814101 1 1 0 1 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 33 0 603 1 1 1 0 0 0 0 0 0 0 0 0 X 11 2 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X CAROL J MAY 6086433311 260 26TH STREET PRAIRIE DU SAC WI 53578 NANCY BREUNIG TRUSTEE 3.90 X 15840 0 0 NEIL BISHOP TRUSTEE 3.00 X 11440 0 0 RICHARD MARINO TRUSTEE 4.00 X 17400 0 0 PHILLIP KEISER TRUSTEE 2.40 X 10400 0 0 ROXI MAIER TRUSTEE 2.80 X 10900 0 0 VICKIE WENZEL TRUSTEE 2.40 X 9800 0 0 TODD SCHAD MD TRUSTEEE 0.60 X 12205 0 0 TOM SCHWARZ PRESIDENT 4.50 X X 19125 0 0 TAMMY ADLER VICE PRESIDENT 3.90 X X 16300 0 0 DALE CARLSON TREASURER 2.70 X X 11900 0 0 ALLAN PECKHAM SECRETARY 3.90 X X 16700 0 0 LARRY SCHROEDER CEO 50.00 X 336810 0 24473 CAROL MAY VP, FINANCE & OPERATIONS 50.00 X 183459 0 16824 ROBERTA BOS VP, HUMAN RESOURCES 50.00 X 136586 0 13814 KENNETH CARLSON VP, PLANNING & BUSINESS DE 50.00 X 159889 0 13398 CARLA PECK VP, QUALITY & COMPLIANCE 50.00 X 122716 0 17790 MARGARET SHEEKS VP, PATIENT SERVICES 50.00 X 143115 0 16643 MICHAEL LAMSON MD SURGEON 40.00 X 497902 0 19958 DAVID MARCU MD SURGEON 40.00 X 462698 0 20539 MATTHEW HEBERT MD SURGEON 40.00 X 463802 0 17480 WILLIAM BODEMER MD SURGEON 40.00 X 439661 0 16820 ARNOLD ROSENTHAL MD SURGEON 40.00 X 429875 0 24331 3528523 0 202070 57 0 1 0 KRAEMER BROTHERS LLC PO BOX 219 PLAIN WI 53577 CONSTRUCTION SERVICES 1522381 SHARED IMAGING SERVICES PO BOX 45686 MADISON WI 53744 NUCLEAR MED, ECHO, ULTRASOUND SERVICES 831334 KB DISTRIBUTION CO PO BOX 219 PLAIN WI 53577 CONSTRUCTION SERVICES 791682 KAHLER SLATER INC 111 W WISCONSIN AVE MILWAUKEE WI 53203 ARCHITECTURAL SERVICES 623728 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI SERVICES 465270 13 1152779 15031 1167810 HOSPITAL PATIENT REVENUE 621990 56254334 56254334 CLINIC REVENUE 621110 9085218 9085218 OTHER HOSPITAL SERVICES 621990 2246649 2231946 14703 CAFETERIA AND VENDING 621990 210546 210546 67796747 352615 352615 169096 310551 -141455 -141455 -141455 19401235 18969346 66068 431889 -66068 365821 365821 69541538 67782044 14703 576981 104235 104235 1337527 1337527 30034589 26113572 3836574 84443 1206418 1048920 154106 3392 3838443 3337334 490317 10792 1870256 1581012 283481 5763 48900 48900 289549 289549 2398504 1398857 999647 511571 364510 147061 144244 115815 28429 265144 265144 1037770 979330 56842 1598 54349 37237 17112 163148 122527 40621 3987635 3987635 1502633 159383 1343250 SUPPLIES 16912644 16165371 742282 4991 REPAIRS & MAINTENANCE 418399 418027 372 OTHER EXPENSES 358715 103855 254860 BAD DEBT EXPENSE 87032 87032 -310551 -310551 66261154 55814101 10336074 110979 83605 0 10117751 28357637 7090553 8364640 1021571 1047122 1109941 1332549 119186469 31806605 44005164 87379864 17061165 24794493 367117 3431404 7948994 84288271 159225299 9139801 12995540 68000000 990495 722397 976337 1321164 11106633 83039101 X 67575074 70452458 4419653 4458677 1186911 1275063 73181638 76186198 84288271 159225299 X 3280384 -403000 127176 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 0 0 1 0 1 10232 10232 0 PART II-B, LINE 1: SAUK PRAIRIE MEMORIAL HOSPITAL, INC. (THE "HOSPITAL") PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE AHA AND WHA HAVE NOTIFIED THE HOSPITAL THAT APPROXIMATELY $7,719 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. THE HOSPITAL IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE HOSPITAL PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGH WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. THE RWHC DETERMINED THAT APPROXIMATELY $2,513 OF THE FEES PAID BY THE HOSPITAL IN 2013 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. PART II-B, LINE 1 (D AND G): REPRESENTATIVES FROM SAUK PRAIRIE MEMORIAL HOSPITAL, INC. ANNUALLY PARTICIPATE IN THE WISCONSIN HOSPITAL ASSOCIATION'S ADVOCACY DAY WHERE THE REPRESENTATIVES ARE GIVEN THE OPPORTUNITY TO GATHER WITH OTHER HEALTHCARE ORGANIZATIONS IN THE STATE OF WISCONSIN AND ALSO MEET WITH STATE GOVERNMENT REPRESENTATIVES WITH THE PURPOSE OF IMPROVING THE DELIVERY OF HEALTHCARE NOT ONLY AT SAUK PRAIRIE MEMORIAL HOSPITAL, INC. BUT ALSO COLLECTIVELY IN THE STATE OF WISCONSIN. AS ISSUES OR PROPOSED LEGISLATION ARISE THROUGHOUT THE YEAR, OFFICIALS OF SAUK PRAIRIE MEMORIAL HOSPITAL, INC. WILL SEND LETTERS OF COMMENT TO LOCAL, STATE, AND FEDERAL GOVERNMENT REPRESENTATIVES TO EITHER SHOW SUPPORT OF PROPOSED CHANGES OR VOICE AN OPINION TO IMPROVE THE OUTCOME OF PROPOSED LEGISLATION OR OTHER CHANGES. THESE ACTIVITIES RESULT IN MINIMAL COST TO THE OPERATION OF SAUK PRAIRIE MEMORIAL HOSPITAL, INC. 1329586 166254 1495840 1196971 132615 1329586 1147396 49575 1196971 1084880 92516 30000 1147396 0.00000 0.85240 0.14760 0 1 1 7474554 7474554 19473625 13342618 6131007 28206222 18463987 9742235 64032068 64032068 87379864 DEFERRED COMPENSATION PLAN LIABILITY 1321164 1321164 X 68207822 -403000 310551 -92449 68300271 1241267 1241267 69541538 66380438 310551 310551 66069887 191267 191267 66261154 PART V, LINE 4: THE SCHNELLER SISTERS FUND SHALL BE HELD AS A SEPARATE PERMANENT ENDOWMENT FUND ON THE BOOKS AND RECORDS OF THE FOUNDATION, THE INCOME FROM WHICH SHALL BE DISTRIBUTED TO SAUK PRAIRIE MEMORIAL HOSPITAL, INC. FOR UNRESTRICTED NEEDS. ALL DISTRIBUTIONS FROM THE SCHNELLER SISTERS FUND SHALL BE DESIGNATED AS HAVING BEEN MADE "IN MEMORY OF THE SCHNELLER SISTERS: CECELIA SCHNELLER MUELLER, ADLYNN F. BALFANZ, AND MARY ANN ROSAR." PART X, LINE 2: THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN CERTAIN ACTIVITIES SUBJECT TO TAXATION AS UNRELATED BUSINESS INCOME (UBI). UBI IS NOT SIGNIFICANT. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL ASSESSES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OR 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 ACCOMPANYING FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNRECOGNIZED TAX BENEFITS FROM UNCERTAIN TAX POSITIONS IN 2013 OR 2012. FEDERAL TAX RETURNS FOR YEARS 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NET AGAINST RENTAL INCOME 310,551. PART XI, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC SERVICES PROVIDED 104,235. CONTRIBUTIONS FROM RELATED ORGANIZATION 1,050,000. BAD DEBT EXPENSE 87,032. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES NET AGAINST RENTAL INCOME 310,551. PART XII, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC SERVICES PROVIDED 104,235. BAD DEBT EXPENSE 87,032. 1 1 1 X 1 X 1 1 1 0 1 1 1201344 1201344 0.01820 4171923 2471315 1700608 0.02570 5373267 2471315 2901952 0.04390 482395 139721 342674 0.00520 105135 105135 0.00160 12405983 8272493 4133490 0.06250 233586 233586 0.00350 13227099 8412214 4814885 0.07280 18600366 10883529 7716837 0.11670 19616 19616 0.00030 10178 10178 0.00020 12019 12019 0.00020 624 624 0.00000 11108 11108 0.00020 53545 53545 0.00090 0 39458 19729 13050617 17215038 -4164421 X 1 1 1 1 SAUK PRAIRIE MEMORIAL HOSPITAL INC 260 26TH STREET PRAIRIE DU SAC WI 53578 X X X SAUK PRAIRIE MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X X 12 1 1 1 X WWW.SAUKPRAIRIEHEALTHCARE.ORG/ABOUT/COMMU X X X X X X X X X X X 0 0 1 1 100.000000000000 1 400.000000000000 1 X X X X X X X 1 1 X X X X X X X 1 X X 1 X X X X X X 1 X 0 0 SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 1J: INPUT FROM LOCAL PHYSICIANS WITH REGARD TO THE HIGHEST COMMUNITY HEALTH NEEDS WAS ALSO INCLUDED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3: IN FEBRUARY AND MARCH 2011, A MORE FORMALIZED PROCESS WAS COMPLETED TO UPDATE THE 2010 PRELIMINARY COMMUNITY HEALTH NEEDS ASSESSMENT. THE HOSPITAL HIRED MATOUSEK AND ASSOCIATES, A MARKETING RESEARCH AND CONSULTING FIRM LOCATED IN GREEN BAY, WISCONSIN, TO CONDUCT FOCUS GROUPS WITH MORE THAN 150 RESIDENTS FROM THROUGHOUT THE SERVICE AREA TO IDENTIFY UNMET NEEDS OF KEY COMMUNITIES WE SERVE. A TOTAL OF 14 FOCUS GROUPS WERE HELD IN FIVE COMMUNITIES WITH RESIDENTS INVOLVED WITH SAUK COUNTY HOSPITALS, SCHOOLS AND LAW ENFORCEMENT, MENTAL HEALTH, ENVIRONMENTAL HEALTH, BUSINESS, PUBLIC HEALTH, BOARD OF HEALTH MEMBERS, DISABILITY AND AGING ADVOCATES, ABUSE ADVOCATES, LONG TERM CARE PROVIDERS AND RANDOMLY SELECTED WOMEN. EACH FACILITATED SESSION RESULTED IN A LIST OF PRIORITIZED HEALTH NEEDS AND ISSUES. IN ADDITION TO THE FOCUS GROUPS, A COMMUNITY LISTENING SESSION WAS CONDUCTED IN SPANISH WITH EIGHT RESIDENTS OF THE BLUFFVIEW NEIGHBORHOOD LOCATED ACROSS FROM THE FORMER BADGER ORDINANCE PLANT ON HIGHWAY 12. MANY RESIDENTS OF THE BLUFFVIEW NEIGHBORHOOD ARE CONSIDERED LOW-INCOME AND MANY ARE ETHNICALLY HISPANIC. FINALLY, ADDITIONAL INPUT WAS PROVIDED BY MEMBERS OF THE HOSPITAL'S LEADERSHIP TEAM. MEMBERS OF THE LEADERSHIP TEAM ARE ACTIVELY ENGAGED IN COMMUNITY ORGANIZATIONS INCLUDING THE GOOD NEIGHBOR CLINIC BOARD (LOCAL FREE CLINIC), DEVELOPMENT OF A DENTAL CLINIC FOR LOW-INCOME INDIVIDUALS, SAFETY COALITION, AND VARIOUS COMMUNITY ORGANIZATIONS. IN THAT CAPACITY, THE LEADERSHIP TEAM DISCUSSES COMMUNITY HEALTH ISSUES WITH AREA COMMUNITY MEMBERS. THE HOSPITAL IS ALSO REPRESENTED BY 11 COMMUNITY MEMBERS ON ITS BOARD OF DIRECTORS WHO SERVE AS THE COMMUNITY "EARS" OF THE HOSPITAL. INDIVIDUAL INTERVIEWS WERE ALSO CONDUCTED WITH HOSPITAL BOARD MEMBERS AS PART OF THE DATA GATHERING PROCESS FOR THE COMMUNITY HEALTH NEEDS ASSESSMENT. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 4: THE COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS: - ST. CLARE HOSPITAL (BARABOO, WI)- REEDSBURG AREA MEDICAL CENTER (REEDSBURG, WI) SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5D: THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) WAS MADE PUBLICLY AVAILABLE IN MARCH 2013. THIS WAS ANNOUNCED VIA A COMMUNITY NEWSLETTER TO MORE THAN 20,000 HOUSEHOLDS, AND IT WAS INTERNALLY ANNOUNCED TO EMPLOYEES AND MEDICAL STAFF OF THE HOSPITAL. THE CHNA HAS ALSO BEEN PRESENTED AT VARIOUS COMMUNITY SERVICE ORGANIZATION MEETINGS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 6I: THE PRIMARY OBJECTIVE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IS TO "DECREASE OBESITY AND INCREASE PHYSICAL ACTIVITY."IN THE PAST YEAR, THE HOSPITAL HAS ENGAGED IN FOUR ACTIVITIES TO ADDRESS THE REDUCTION OF OBESITY AND INCREASING PHYSICAL ACTIVITY. THESE INCLUDE: 1) "KIDS COUNT" OBESITY REDUCTION PROJECT: IN COLLABORATION WITH THE SAUK PRAIRIE SCHOOL DISTRICT, THE HOSPITAL HAS DEVELOPED A 5-YEAR PROJECT TARGETED TOWARD 3RD GRADERS TO INCREASE CLASSROOM ACTIVITY, IMPROVE NUTRITION, AND INCREASE PHYSICAL ACTIVITIES. THIS PROJECT HAS NOW EXPANDED TO INCLUDE THE INCOMING 3RD GRADE CLASS AND NEW 4TH GRADERS (LAST YEAR'S 3RD GRADERS).2) WISCONSIN HEIGHTS COMMUNITY GARDEN: THE HOSPITAL ORGANIZED LOCAL VOLUNTEERS IN THE WISCONSIN HEIGHTS SCHOOL DISTRICT TO CREATE A 2-ACRE COMMUNITY GARDEN IN AN EFFORT TO IMPROVE ACCESS TO NUTRITIONAL FOOD AND TO RAISE AWARENESS ABOUT THE VALUE OF HEALTHY EATING HABITS. THE INITIAL TARGET NUMBER OF GARDENERS WAS SET AT 10. THIS GOAL WAS FAR EXCEEDED AS THE GARDEN ATTRACTED 30 PARTICIPANTS.3) SAUK PRAIRIE WELLNESS MOVEMENT: THIS GROUP WAS ORIGINALLY FORMED AS THE SAUK PRAIRIE OBESITY REDUCTION COLLABORATION BY PRAIRIE CLINIC, S.C., A LOCAL PRIMARY CARE CLINIC. THE GROUP'S ORIGINAL MISSION TO "WORK TOGETHER AS A COMMUNITY TO CHAMPION THE REDUCTION OF OBESITY IN OUR COMMUNITY" REMAINS INTACT. SINCE THE GROUP'S ORIGINAL MEETING IN OCTOBER 2010, THE GROUP HAS GROWN IN NUMBER OF PARTICIPANTS, CREATED A NEW IDENTITY AS THE WELLNESS MOVEMENT, PARTICIPATED IN A HEALTH NEEDS ASSESSMENT, AND DETERMINED ITS FIRST TWO INITIATIVES, THE KIDS COUNT INITIATIVE (DESCRIBED ABOVE) AND WELLNESS IN THE WORKPLACE. 4) GETTING BETTER PROGRAM: THIS PROGRAM FOCUSES ON MORBIDLY OBESE/CHRONICALLY SYMPTOMATIC ADULTS WHO INDICATE A DESIRE TO CHANGE THEIR CURRENT STATE OF HEALTH. CLINICAL AND BEHAVIORAL DATA OF THE 24 STUDY PARTICIPANTS INDICATES A SIGNIFICANT CHANGE IN BODY MASS INDEX, HGA1C LEVELS, AND A WILLINGNESS TO MAINTAIN CHANGES IN EXERCISE AND DIETARY HABITS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 7: AS WITH ALL HEALTHCARE ORGANIZATIONS, ADEQUATE RESOURCES ARE NOT AVAILABLE TO ADDRESS EVERY UNMET HEALTH NEED IN THE COMMUNITIES THE HOSPITAL SERVES. THERE IS NO LIMIT TO THE NUMBER OF ISSUES TO WHICH A HEALTHCARE INSTITUTION COULD DEVOTE RESOURCES. TIME, PEOPLE, AND MONEY OFTEN ARE LIMITING FACTORS FOR WHY THE HOSPITAL CANNOT MEET EVERY UNMET NEED OF THE COMMUNITY. HOWEVER, SAUK PRAIRIE MEMORIAL HOSPITAL, INC. WILL FOCUS ON A FEW HIGH PRIORITY PROJECTS AND MAKE EVERY EFFORT TO AVOID DUPLICATION AND ENCOURAGE COLLABORATION AND COORDINATION WITH OTHER ORGANIZATIONS AND COMMUNITY GROUPS. AS SAUK PRAIRIE MEMORIAL HOSPITAL, INC. ASSESSED UNMET HEALTH NEEDS AND DETERMINED ITS PRIORITIES, THE HOSPITAL ALSO EVALUATED THOSE ISSUES THAT WERE BEING ADDRESSED BY OTHERS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC.'S PHILOSOPHICAL POSITION REGARDING THE HEALTH OF THE COMMUNITY IS TO FOCUS ON FEWER, RATHER THAN MANY, INITIATIVES SO THAT THOSE WE WORK ON HAVE A HIGHER CHANCE OF SUCCESS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 14G: INFORMATION ABOUT THE POLICY IS INCLUDED ON BILLING INVOICES, ON ADMISSION INFORMATION, ON THE WEBSITE, AND IS REFERENCED IN COLLECTION EFFORTS. IT IS ALSO MENTIONED IN COMMUNITY TALKS OF HEALTH INSURANCE. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 17E: THE HOSPITAL ATTEMPTS TO CONTACT THE PATIENT TO SEE IF THEY QUALIFY FOR COMMUNITY CARE. IF THE HOSPITAL CANNOT CONTACT THE PATIENT OR IF THE PATIENT HAS OTHER ACCOUNTS IN BAD DEBT, THE ACCOUNTS GO INTO THE HOSPITAL'S NORMAL COLLECTION PROCESS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 20D: THE HOSPITAL FOLLOWS ITS NORMAL PROCEDURES FOR COLLECTION OF THESE ACCOUNTS, INCLUDING DISCOUNTS BASED ON INCOME/ASSET LEVELS, PROMPT PAYMENT, OR MEDICAL INDIGENCE. THE AVERAGE DISCOUNT OF THE THREE LARGEST MANAGED CARE CONTRACTS IS USED TO CALCULATE THE MAXIMUM RATE CHARGED TO FAP ELIGIBLE PATIENTS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 22: PATIENTS WITHOUT INSURANCE AND NOT ELIGIBLE FOR FINANCIAL ASSISTANCE ARE GIVEN OPPORTUNITIES FOR DISCOUNTS UNDER INTERNAL PROGRAMS. IF PATIENTS DO NOT AVAIL THEMSELVES OF SUCH OPPORTUNITIES, THEY MAY BE CHARGED THE GROSS CHARGE. 6 ORTHOPEDIC ASSOCIATES OF SAUK PRAIRIE 80 FIRST STREET PRAIRIE DU SAC WI 53578 ORTHOPEDIC CLINIC LODI MEDICAL CLINIC 160 VALLEY DRIVE LODI WI 53555 PHYSICIAN CLINIC RIVER VALLEY MEDICAL CLINIC 436 SUNRISE DRIVE SPRING GREEN WI 53588 RURAL HEALTH CLINIC BLACK EARTH MEDICAL CLINIC 1529 STATE STREET A BLACK EARTH WI 53515 PHYSICIAN CLINIC PLAIN MEDICAL CLINIC 825 MAIN STREET PLAIN WI 53577 RURAL HEALTH CLINIC SURGICAL ASSOCIATES 80 FIRST STREET PRAIRIE DU SAC WI 53578 SURGICAL CLINIC PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS PRIMARILY 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 METHOD FOR SUBSIDIZED HEALTH SERVICES IS BASED ON INTERNAL RECORDS AND ALLOCATIONS WHICH ARE SIMILAR TO A DIRECT COSTING ACCOUNTING SYSTEM FOR THESE SERVICES NOTED AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT SAUK PRAIRIE MEMORIAL HOSPITAL, INC. INCLUDE THE OPERATION OF SEVERAL HOSPITAL DEPARTMENTS THAT OPERATE AT A LOSS FROM OPERATIONS, BUT ARE CONSIDERED VITAL HOSPITAL AND CLINIC SERVICES SUCH AS THE INTENSIVE CARE UNIT, OUTPATIENT PHYSICIAN CLINICS, INCLUDING INTERNAL MEDICINE, AND SEVERAL OTHER DEPARTMENTS. A LARGE PORTION OF THESE SERVICES ARE ACCESSED BY COMMUNITY MEMBERS THROUGH THE HOSPITAL'S EMERGENCY SERVICES DEPARTMENT. IT IS THE GOAL OF SAUK PRAIRIE MEMORIAL HOSPITAL, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, LN 7 COL(F): MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE HOSPITAL PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING EFFORTS PROMOTE BOTH THE PHYSICAL AND ECONOMIC HEALTH OF THE COMMUNITIES IT SERVES. FROM AN ECONOMIC PERSPECTIVE, SAUK PRAIRIE MEMORIAL HOSPITAL, INC. STAFF CONTRIBUTES HUNDREDS OF HOURS TO CHAMBERS OF COMMERCE ACTIVITIES AND SUPPORT WORKFORCE DEVELOPMENT THROUGH COMMUNITY AND EDUCATIONAL PROGRAMS. THE PHYSICAL HEALTH OF THE COMMUNITY IS SUPPORTED THROUGH THE DEVELOPMENT OF HEALTH-RELATED COALITIONS, PARTICULARLY THE SAUK PRAIRIE WELLNESS MOVEMENT. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE 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 YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY REPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. THE AUDITED FINANCIAL STATEMENTS DO NOT CONTAIN A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PATIENTS, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMMUNITY, 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.THE TOTAL MEDICARE REVENUE SHOWN ON SCHEDULE H IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY THE CHARGES FROM MEDICARE PROGRAM BENEFICIARIES THAT ARE REPORTED ON THE HOSPITAL'S MEDICARE COST REPORT. THE AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT SAUK PRAIRIE MEMORIAL HOSPITAL, INC., PHYSICIAN SERVICES FOR THE INTERNAL MEDICINE (HOSPITALIST) PROGRAM, PHYSICIAN SERVICES PROVIDED AT TWO OF THE FOUR OUTLYING PHYSICIAN CLINICS, CRNA SERVICES PROVIDED TO PATIENTS UNDERGOING ANESTHESIA AT THE HOSPITAL, AND A SIGNIFICANT PORTION OF LAB AND PHYSICAL THERAPY SERVICES WHICH ARE REIMBURSED BY THE MEDICARE PROGRAM UNDER ANOTHER METHODOLOGY. PHYSICIAN COVERAGE OUTPATIENT LAB SERVICES AND OUTPATIENT PHYSICAL THERAPY SERVICES ARE REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY 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 SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE DIVIDED BY HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES, WHICH ARE REIMBURSED ON A COST REPORTING METHODOLOGY. INCLUDING THE FEE SCHEDULE ITEMS, SUCH AS PHYSICIAN SERVICES, WOULD PRODUCE A LARGER LOSS OR SHORTFALL ON THESE SERVICES TO BE REPORTED ON THE FORM 990 IN ANY GIVEN YEAR. PART III, LINE 9B: IT IS THE POLICY OF SAUK PRAIRIE MEMORIAL HOSPITAL, INC. THAT EACH PATIENT RECEIVES CARE REGARDLESS OF THE ABILITY TO PAY. IF DURING THE COLLECTION PROCESS A PATIENT DOES NOT COMPLETE THE NECESSARY PAPERWORK OR RESPOND TO ATTEMPTS BY THE HOSPITAL TO PROVIDE CHARITY SERVICES, THE PATIENT MAY STILL REQUEST CHARITY INFORMATION AND COMPLETE THE INFORMATION AT ANY TIME DURING THE COLLECTION PROCESS. THE PATIENT WILL BE REFERRED TO THE HOSPITAL'S CHARITY CARE POLICY AND CAN QUALIFY FOR CHARITY CARE, AND HAVE ANY COLLECTION ISSUES REVERSED BY THE ORGANIZATION, IF THEY SHOW A NEED FOR THE CARE BASED ON THE HOSPITAL'S POLICY. PART VI, LINE 2: THE HOSPITAL ENGAGES IN THE FOLLOWING ACTIVITIES TO ASSESS THE HEALTHCARE NEEDS OF THE 42,000 RESIDENTS THROUGHOUT ITS 700 SQUARE MILE PRIMARY SERVICE AREA: - ANALYZE HEALTH STATUS INFORMATION, EPIDEMIOLOGICAL DATA, AND HOSPITAL DISCHARGE DATA FURNISHED BY THE STATE OF WISCONSIN AND SAUK COUNTY TO IDENTIFY ISSUES AND TRENDS.- MEET PERIODICALLY WITH THE COUNTY HEALTH DEPARTMENT AND TWO OTHER NEARBY HOSPITALS TO ASSESS HIGH PRIORITY HEALTH NEEDS AND COORDINATE ACTION.- PARTICIPATE IN AND HELP COORDINATE COUNTY-WIDE INPUT SESSIONS WITH THE COUNTY HEALTH DEPARTMENT.- LEAD AND PARTICIPATE IN COMMUNITY WELLNESS GROUPS AND INITIATIVES THROUGHOUT THE SERVICE AREA.- CONDUCT "COMMUNITY HEALTH NEED" FOCUS GROUPS CONSISTING OF COMMUNITY LEADERS AND RANDOMLY SELECTED RESIDENTS. - ANALYZE THE POPULATION-BASED NEED FOR MEDICAL PROVIDERS BY SPECIALTY. THIS INFORMATION IS ASSESSED AND MODIFIED BY MEMBERS OF THE HOSPITAL MEDICAL STAFF.- LEADER PARTICIPATION AND LEADERSHIP IN CIVIC AND COMMUNITY SERVICE ORGANIZATIONS.- ACTIVELY ENGAGE HOSPITAL BOARD MEMBERS IN COMMUNITY HEALTH IMPROVEMENT INITIATIVES AND PROVIDE THE BOARD WITH MONTHLY UPDATES REGARDING COMMUNITY HEALTH ACTIVITIES. PART VI, LINE 3: 1. AT THE TIME OF REGISTRATION, A REGISTRATION SPECIALIST WILL INQUIRE IF THERE IS HEALTH INSURANCE. IF NOT, THEY WILL BE ADVISED OF THE HOSPITAL'S COMMUNITY CARE PROGRAM IF THEY RESIDE WITHIN OUR SERVICE AREA. THOSE WHO HAVE A SAUK PRAIRIE BASED PHYSICIAN WILL ALSO BE CONSIDERED FOR ELIGIBILITY. COMMUNITY CARE INFORMATION IS ALSO POSTED ON THE HOSPITAL WEBSITE AND BILLS STATE THAT IF THE PATIENT IS HAVING DIFFICULTY PAYING THEY SHOULD CONTACT A HOSPITAL REPRESENTATIVE, AS THEY MAY BE ELIGIBLE FOR FREE OR REDUCED FEES.2. ANY PATIENT REQUESTING ADDITIONAL INFORMATION ABOUT THE COMMUNITY CARE PROGRAM WILL BE REFERRED TO THE PATIENT ACCOUNTS SPECIALIST, WHO WILL EXPLAIN THE PROGRAM AND ITS ELIGIBILITY CRITERIA. WHEN APPLICABLE, ALL GOVERNMENT ASSISTANCE PROGRAMS SUCH AS MEDICAID, BADGER CARE, AND CRIME VICTIMS MUST BE EXHAUSTED BEFORE APPLYING FOR COMMUNITY CARE (EXCEPTION: THE GOVERNMENT PROGRAM APPLICATION MAY BE WAIVED BASED ON RELIGIOUS BELIEFS). COMMUNITY CARE IS NOT AVAILABLE FOR ELECTIVE PROCEDURES. PERSONS RESIDING IN THE SAUK PRAIRIE MEMORIAL HOSPITAL, INC.'S PRIMARY SERVICE AREA WILL BE CONSIDERED FOR ELIGIBILITY DETERMINATION. IN THE CASE OF EMERGENCY SERVICES, COMMUNITY CARE MAY BE EXTENDED TO THOSE RESIDING OUTSIDE OF THE PRIMARY SERVICE AREA.3. THE INFORMATION IS ALSO POSTED ON OUR WEBSITE UNDER "PREPARING FOR YOUR STAY." IF AT ANY TIME PRIOR TO, DURING, OR AFTER THE SERVICES ARE PROVIDED THE PATIENT EXPRESSED CONCERNS ABOUT PAYMENT, THE COMMUNITY CARE PROGRAM IS EXPLAINED. INFORMATION IS ALSO PRINTED ON PATIENT STATEMENTS AND DISCUSSED WITH THE PATIENT DURING THE BILLING PROCESS. PART VI, LINE 4: THE HOSPITAL'S PRIMARY SERVICE AREA ENCOMPASSES A 700 SQUARE MILE REGION IN RURAL SOUTH CENTRAL WISCONSIN, INCLUDING SAUK, SOUTHERN COLUMBIA, NORTHWEST DANE, NORTHERN IOWA AND EASTERN RICHLAND COUNTIES. THE HOSPITAL IS LOCATED IN SAUK PRAIRIE (COMMON NAME FOR THE NEIGHBORING MUNICIPALITIES OF SAUK CITY AND PRAIRIE DU SAC) AND THE CLINICS ARE LOCATED IN FOUR TOWNS SURROUNDING SAUK PRAIRIE (BLACK EARTH, SPRING GREEN, PLAIN, AND LODI). NO OTHER HOSPITALS ARE LOCATED WITHIN THE PRIMARY SERVICE AREA, HOWEVER, EIGHT INPATIENT HOSPITALS (INCLUDING 5 RURAL AND 3 TERTIARY FACILITIES) ARE LOCATED WITHIN A 30 MILE RADIUS OF SAUK PRAIRIE MEMORIAL HOSPITAL, INC.DEMOGRAPHIC ANALYSIS INDICATES A 5-YEAR GROWTH RATE OF 2.5% COMPARED TO THE STATE OF WISCONSIN'S RATE OF 1.9%. AGE GROUPS THAT WILL GROW AT A CONSIDERABLY FASTER RATE THAN THE STATE INCLUDE 0-17 YEAR OLDS (1.9%), 25-34 (15.2%), AND 65+ (16.6%). HEALTH ISSUES AFFECTING THESE AGE SEGMENTS INCLUDE PRENATAL SCREENING, TEEN PREGNANCY, LACK OF ACCESS TO HEALTHCARE, AND MEDICAL ISSUES ASSOCIATED WITH AGING.THE AREA HAS LITTLE RACIAL AND ETHNIC DIVERSITY, ALTHOUGH THE NUMBER OF HISPANIC RESIDENTS HAS INCREASED CONSIDERABLY SINCE 2000. BY 2018, THIS POPULATION SEGMENT WILL REPRESENT 5.1% OF THE TOTAL POPULATION. SPECIFIC HEALTH-RELATED ISSUES CONFRONTING THIS POPULATION INCLUDE DIABETES, ACCESS TO CARE, AND LANGUAGE BARRIERS.AVERAGE HOUSEHOLD INCOME OF SERVICE AREA RESIDENTS IS 10% HIGHER THAN THE STATE AVERAGE. THIS DIFFERENCE IS DUE IN LARGE PART BECAUSE OF THE RELATIVELY STRONG JOB MARKET IN MADISON, WHICH ATTRACTS COMMUTERS FROM THE SERVICE AREA. THROUGHOUT THE SERVICE AREA, HOWEVER, AGRICULTURE AND TOURISM REPRESENT A CONSIDERABLE NUMBER OF LOW-PAYING JOBS, TYPICALLY WITHOUT HEALTH BENEFITS.A PORTION OF THE HOSPITAL PRIMARY SERVICE AREA IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA/POPULATION. THIS AREA IS LOCATED IN THE TOWN OF ARENA (MCD 02575). PART VI, LINE 5: SAUK PRIARIE MEMORIAL HOSPITAL, INC. IS AN INDEPENDENT COMMUNITY HOSPITAL GOVERNED BY AN 11-MEMBER BOARD OF DIRECTORS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. THE BOARD IS ELECTED BY THE 1,200 MEMBER COMMUNITY HOSPITAL ASSOCIATION. AN INDEPENDENT HOSPITAL IS A CRUCIAL PART OF THE HOSPITAL'S VISION, BECAUSE IT KEEPS CONTROL AT THE LOCAL LEVEL, NOT IN A CORPORATE HEADQUARTERS LOCATED ELSEWHERE. LOCAL CONTROL ALLOWS THE HOSPITAL TO MAKE DECISIONS THAT ARE BEST FOR THE LOCAL COMMUNITIES.THE SAUK PRAIRIE MEMORIAL HOSPITAL, INC. MEDICAL STAFF PRIVILEGES QUALIFIED PHYSICIANS IN ITS COMMUNITIES. THE VAST MAJORITY OF THE ACTIVE MEDICAL STAFF PRACTICE SOLELY AT THE SAUK PRAIRIE MEMORIAL HOSPITAL, INC. OR ASSOCIATED CLINICS. THE HOSPITAL STRATEGIC PLAN SPECIFICALLY ADDRESSES OUR DESIRE TO "IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE" AND THE ORGANIZATION'S EFFORTS TO ASSESS THE NEEDS OF THE COMMUNITY AND ADDRESS THOSE NEEDS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PROMOTES COMMUNITY HEALTH THROUGH A BROAD ARRAY OF APPROACHES. THE FOLLOWING LIST DESCRIBES SPECIFIC PROGRAMS AND ACTIVITIES THAT CONTRIBUTE TO IMPROVING THE HEALTH OF THE COMMUNITY AND ENHANCING THE PROVISION OF MEDICAL CARE:- TRAINING MEDICAL STUDENTS, NURSING STUDENTS, AND OTHER HEALTH PROFESSIONS- CONTRIBUTE TIME AND FINANCIAL RESOURCES IN THE DEVELOPMENT OF A DENTAL CLINIC, COLLABORATIVE WITH OTHER INDIVIDUALS AND ORGANIZATIONS IN THE COMMUNITY, TO PROVIDE DENTAL SERVICES TO UNINSURED AND UNDERINSURED MEMBERS OF THE COMMUNITIES SERVED WHO WOULD OTHERWISE NOT HAVE ACCESS OR THE ABILITY TO ACCESS THESE SERVICES ON A REGULAR BASIS- ORGANIZE AND/OR PARTICIPATE IN FREE COMMUNITY HEALTH EDUCATION EVENTS AND SEMINARS- ORGANIZE AND/OR PARTICIPATE IN HEALTH FAIRS- OFFER CPR/FIRST AID CLASSES- ISSUE EDUCATIONAL NEWS RELEASES- CONDUCT COMMUNITY-BASED CLINICAL SCREENINGS (HEARING AID CHECKS, BLOOD PRESSURE AND CHOLESTEROL SCREENING)- PROVIDE SERVICES FOR THE GOOD NEIGHBOR CLINIC OF SAUK PRAIRIE, INC. (LOCAL FREE CLINIC)- MEDICATION TAKE BACK DAY- DISCOUNTED EQUIPMENT AND SUPPLIES- ADVANCED DIRECTIVES COUNSELING- BLOOD DRIVES- BREASTFEEDING EDUCATION- CANCER EDUCATION- CLINICS FOR UNDERINSURED/LAB & MEDICATION COSTS- COMMUNITY GARDEN- COMMUNITY HEALTH IMPROVEMENT ADVOCACY- DIABETES EDUCATION- FAMILTY/PARENTING/SIBLING EDUCATION- IMMUNIZATIONS/PERTUSSIS- MOBILE MEALS- PRESCRIPTION DRUG COLLECTION- SCHOOL-BASED HEALTH EDUCATION PROGRAMS- SCREENING/HEARING- SELF-HELP/CARDIAC REHAB- SELF-HELP/FITNESS AND EXERCISE- SELF-HELP/NUTRITION AND WEIGHT MANAGEMENT- SELF-HELP/SPORTS INJURY PREVENTION- SHARPS COLLECTION- SUPPORT GROUPS-BEREAVEMENT/GRIEF- SUPPORT GROUPS-BREASTFEEDING- SUPPORT GROUPS-DIABETES- SUPPORT GROUPS-NEW MOM- SUPPORT GROUPS-SLEEP APNEA- TRANSPORTATION TOKENS (BUS, CAB FARE) PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 THE GOOD NEIGHBOR CLINIC OF SAUK PRAIRIE INC 1906 NORTH ST PRAIRIE DU SAC WI 53578 391963290 501(C)3 0 104235 COST MEDICAL SERVICES AND SUPPLIES TO PROVIDE MEDICAL ASSISTANCE TO THOSE WHO NORMALLY COULD NOT AFFORD IT 1 0 PART I, LINE 2: SAUK PRAIRIE MEMORIAL HOSPITAL, INC. FOLLOWS THE FOLLOWING PROCESS TO PROVIDE ADDITIONAL SUPPLIES TO THE GOOD NEIGHBOR CLINIC ("GNC"): - GNC STAFF REQUESTS PRODUCT FROM MATERIALS STAFF. - IF TOTAL VALUE EXCEEDS $100, MATERIALS STAFF PROVIDES LIST OF PRODUCTS AND ASSOCIATED COSTS (WITHOUT MARK UPS) IN AN E-MAIL TO CFO AND COPY OF EMAIL TO FINANCE & MATERIALS DIRECTORS. - CFO WILL RESPOND BACK TO THE E-MAIL (VIA REPLY TO ALL) INDICATING WHETHER THE REQUEST SHOULD BE BILLABLE OR A CHARITABLE CONTRIBUTION. - MATERIALS STAFF PULLS CENTRAL STORES PRODUCTS AND FORWARDS TO GNC. - IF REQUIRED, PURCHASE ORDER WILL BE CUT FOR NON-STOCK PRODUCTS. - FINANCE USES THE REPLY TO ALL FROM CFO AS INFORMATION REQUIRED FOR BILLING GNC FOR THE PRODUCTS IF REQUIRED. - FINANCE CAN FIND GENERAL LEDGER BREAKDOWNS FOR PRODUCTS VIA A GENERAL LEDGER DISTRIBUTION REPORT FOR GOOD NEIGHBOR CLINIC AS REQUIRED. IF THE REQUEST IS UNDER $100, THE REQUESTS WILL BE PROCESSED THROUGH AND WILL BE CONSIDERED A CHARITABLE CONTRIBUTION. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. ALSO PROVIDES A SIGNIFICANT AMOUNT OF MEDICAL SERVICES TO PATIENTS OF THE GOOD NEIGHBOR CLINIC. THE HOSPITAL RELIES UPON THE INCOME REQUIREMENTS SCREENING PROCESS BY THE GOOD NEIGHBOR CLINIC TO REFER PATIENTS IN NEED OF FREE CARE FOR SERVICES. X 1 1 X X X X X 0 0 0 0 0 0 0 0 0 LARRY SCHROEDER CEO 303060 0 31000 0 2750 0 12750 0 11723 0 361283 0 0 0 CAROL MAY VP, FINANCE & OPERATIONS 171894 0 10575 0 990 0 9243 0 7581 0 200283 0 0 0 ROBERTA BOS VP, HUMAN RESOURCES 127292 0 9150 0 144 0 6947 0 6867 0 150400 0 0 0 KENNETH CARLSON VP, PLANNING & BUSINESS DE 148833 0 10791 0 265 0 8042 0 5356 0 173287 0 0 0 MARGARET SHEEKS VP, PATIENT SERVICES 127504 0 9405 0 6206 0 6916 0 9727 0 159758 0 0 0 MICHAEL LAMSON MD SURGEON 373489 0 124062 0 351 0 12750 0 7208 0 517860 0 0 0 DAVID MARCU MD SURGEON 383990 0 78427 0 281 0 12750 0 7789 0 483237 0 0 0 MATTHEW HEBERT MD SURGEON 373548 0 89903 0 351 0 12750 0 4730 0 481282 0 0 0 WILLIAM BODEMER MD SURGEON 384356 0 54989 0 316 0 12750 0 4070 0 456481 0 0 0 ARNOLD ROSENTHAL MD SURGEON 339694 0 87866 0 2315 0 12750 0 11581 0 454206 0 0 0 PART I, LINE 1A THE BOARD HAS APPROVED A POLICY TO COMPENSATE THE CEO FOR THE TRAVEL OF HIS/HER SPOUSE FOR HOSPITAL RELATED BUSINESS ACTIVITY. THE CEO WILL BE COMPENSATED FOR REASONABLE TRAVEL EXPENSES INCURRED BY HIS/HER SPOUSE. BOARD APPROVAL NEEDS TO BE RECEIVED PRIOR TO MAKING THE TRAVEL ARRANGEMENTS. THE COST OF ANY SUCH TRAVEL REIMBURSEMENTS ARE ADDED TO THE CEO'S W-2 FOR TAX REPORTING PURPOSES. DURING 2013, THE CEO RECEIVED $404 OF TRAVEL REIMBURSEMENTS FROM THE HOSPITAL, WHICH WAS INCLUDED IN TAXABLE WAGES ON HIS W-2 AND IS INCLUDED ON SCHEDULE J. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710B6V9 2013-01-19 38000000 CONSTRUCTION OF NEW HOSPITAL 0 0 0 B WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2013-01-19 30000000 CONSTRUCTION OF NEW HOSPITAL 0 0 0 A 38000000 3384222 562253 25843493 8210032 0 0 1 1 B 30000000 1987633 542647 24269832 7175154 0 0 1 1 A 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 A 0 1 0 0 0 0 0 0 0 B 0 1 0 0 1 0 0 0 0 A 0 B 0 FORM 990, PART III, LINE 2 DURING 2013, THE HOSPITAL ASSUMED THE CLINICAL PRACTICE OPERATIONS OF ORTHOPEDIC ASSOCIATES OF SAUK PRAIRIE AND SURGICAL ASSOCIATES, WHICH WERE PREVIOUSLY OWNED BY UNRELATED PHYSICIAN ORGANIZATIONS. THE PRACTICES' ARE LOCATED IN SPACE WITHIN THE HOSPITAL FACILITY. SEE ADDTIONAL INFORMATION IN PART III, LINE 4B. FORM 990, PART VI, SECTION A, LINE 6 ANNUAL MEMBERSHIP WILL BE CONFERRED FOR ONE YEAR UPON PERSONS CONTRIBUTING THE SUM OF TEN DOLLARS TO THE CORPORATION AND/OR THE SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. LIFE MEMBERSHIP WILL BE CONFERRED UPON PERSONS CONTRIBUTING THE SUM OF ONE HUNDRED DOLLARS TO THE CORPORATION AND/OR SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. TWO LIFE MEMBERSHIPS WILL BE CONFERRED UPON TWO PERSONS CONTRIBUTING THE SUM OF TWO HUNDRED DOLLARS OR MORE TO THE CORPORATION AND/OR SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A AN ANNUAL AND LIFE MEMBERSHIP SHALL BE ENTITLED TO ONE VOTE AT THE ANNUAL MEETING OR AT ANY SPECIAL MEETINGS OF THE MEMBERSHIP. THOSE WITH LIFE MEMBERSHIPS MAY ALSO HOLD OFFICE AS A DIRECTOR OF THE CORPORATION OR SERVE ON A COMMITTEE. MEMBERS MAY VOTE ON ELECTIONS OF BOARD MEMBERS, CHANGES TO THE BYLAWS, AND OTHER BUSINESS ALLOWED BY LAW. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS REVIEWS THE 990 AT ITS MONTHLY MEETING PRIOR TO SUBMISSION. IN THE EVENT MEETING AND DUE DATES ARE SUCH THAT THIS IS NOT POSSIBLE, THE BOARD WILL REVIEW AT THE FIRST MEETING AFTER SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C SINCE SAUK PRAIRIE MEMORIAL HOSPITAL, INC. IS A PART OF A SMALL COMMUNITY, CONFLICTS ARE GENERALLY KNOWN, IF NOT DISCLOSED THROUGH THE ANNUAL PROCESS CONDUCTED BY HUMAN RESOURCES. THE ANNUAL PROCESS INCLUDES ALL DIRECTOR LEVEL EMPLOYEES AND ABOVE OF THE HOSPITAL. THE BOARD OF DIRECTORS HAS A CONFLICT OF INTEREST POLICY AND MUST ANNUALLY SIGN A DISCLOSURE FORM STATING ANY POTENTIAL CONFLICTS OF INTEREST. THE BOARD PRESIDENT THEN DISCLOSES ANY CONFLICTS TO THE FULL BOARD OF DIRECTORS. CONFLICT OF INTEREST STATEMENTS COMPLETED BY BOARD MEMBERS ARE REVIEWED BY THE BOARD PRESIDENT AND EMPLOYEE'S CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY STAFF LEADERSHIP AND/OR ADMINISTRATION. THESE INDIVIDUALS ARE CHARGED WITH THE RESPONSIBILITY OF ENSURING THAT BUSINESS IS CONDUCTED IN A MANNER THAT ADHERES TO THE HOSPITAL'S FORMALLY APPROVED CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS HAS ESTABLISHED POLICY BG-8 TO ESTABLISH ITS COMPENSATION PHILOSOPHY WITH RESPECT TO EXECUTIVE COMPENSATION AND TO DEFINE PRACTICES ASSOCIATED IN ACCORDANCE WITH IRC 4958. HOSPITAL EXECUTIVE SALARY IS SET ANNUALLY USING COMPARABILITY DATA FROM OUTSIDE CONSULTANTS AND THIRD-PARTY SURVEY DATA. THE EXECUTIVE COMMITTEE IS RESPONSIBLE FOR SETTING SALARY FOR THE CEO BASED ON THE CEO'S JOB PERFORMANCE. THE COMMITTEE RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. THE BOARD REVIEWS BG-8 ANNUALLY AT THE GOVERNANCE COMMITTEE. COMPENSATION FOR OTHER KEY EMPLOYEES IS ESTABLISHED BY APPLICATION OF THE HOSPITAL'S COMPENSATION PHILOSOPHY, WHEREIN RATES OF PAY ARE COMPARED TO MARKET RATES OBTAINED THROUGH PARTICIPATION IN WAGE AND BENEFIT SURVEYS. PAY RANGES ARE OBTAINED FROM SURVEYS OF SIMILARLY SITUATED HOSPITALS LOCATED WITHIN THE STATE OF WISCONSIN IN TERMS OF SIZE AND REVENUE CATEGORY. THE HOSPITAL ADOPTED A "MEET THE MARKET" APPROACH TO COMPENSATION FOR POSITIONS AT THESE LEVELS. THIS MEANS THAT SAUK PRAIRIE MEMORIAL HOSPITAL, INC. TARGETS THE MIDPOINT OF THE PAY RANGE ASSOCIATED WITH EACH POSITION. FORM 990, PART VI, SECTION C, LINE 19 THE ABBREVIATED FINANCIAL STATEMENTS ARE A PART OF THE HOSPITAL'S ANNUAL REPORT PRESENTED TO THE PUBLIC AT THE ANNUAL MEETING AND POSTED ON THE HOSPITAL'S WEBSITE. THE ABBREVIATED FINANCIAL STATEMENTS ARE ALSO MADE PUBLICLY AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION. THE HOSPITAL'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 1,279,955. NET ASSETS RELEASED FROM RESTRICTONS FROM FOUNDATION -1,152,779. FORM 990, PART XII, LINE 2C, SELECTION OF INDEPENDENT ACCOUNTANT: THE HOSPITAL ANSWERED "YES" TO QUESTION 2C UNDER PART XII OF THE 990, INDICATING THAT THE HOSPITAL DOES HAVE A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE FULL BOARD OF DIRECTORS REVIEWS THE FINANCIAL STATEMENTS AND HEARS THE AUDIT FIRM PRESENTATION. THE FOLLOWING PROCESS WAS IMPLEMENTED BY THE BOARD FOR REVIEW OF THE AUDIT FIRM. FOR AUDIT FIRM SELECTION, A REQUEST FOR PROPOSAL IS PREPARED, INTERNAL STAFF SELECTS THE TOP TWO OR THREE CANDIDATES, AND THE FINANCE AND AUDIT COMMITTEE RECOMMENDS AN AUDIT FIRM TO THE FULL BOARD. BASED ON THE PROPOSAL RESPONSES AND INTERVIEWS/PRESENTATIONS BY THE AUDIT FIRMS, THE FULL BOARD OF DIRECTORS THEN VOTES BASED ON THIS RECOMMENDATION AND SELECTS THE INDEPENDENT ACCOUNTING FIRM. THERE WAS NO CHANGE TO THIS PROCESS IN 2013. SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION LTD 80 FIRST STREET PRAIRIE DU SAC WI 53578 930841113 FUNDRAISING WI 501(C)3 LINE 9 N/A 0 FRIENDS OF SAUK PRAIRIE MEMORIAL HOSPITAL 260 26TH STREET PRAIRIE DU SAC WI 53578 391453754 VOLUNTEERING WI 501(C)3 LINE 11 - TYPE III-F N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0