2014-02-13T09:17:14-06:00 2013-06-30 390758449 WIPLFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54702 990 2012-07-01 390831153 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT INC CUMB 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 MICHAEL GUTSCH 7158222741 2014-02-10 1 HOLLY POKRANDT CPA P00449155 7158323407 2014-02-05 2012 2015-11-30 17:44:51Z MICHAEL GUTSCH 1110 7TH AVENUE CUMBERLAND WI 54829 19965305 0 X WWW.CUMBERLANDHEALTHCARE.COM X 1955 WI CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. IS COMMITTED TO CREATING A HEALTHIER COMMUNITY THROUGH PROVIDING AN ARRAY OF HIGH-QUALITY ACUTE CARE, AMBULATORY, AND SKILLED NURSING FACILITY SERVICES TO RESIDENTS OF THE SERVICE AREA. 7 0 298 127 1212 0 86518 117358 22522381 19803662 32527 35606 0 1882 22641426 19958508 0 0 0 0 13244081 12127633 0 0 0 8423202 8382276 21667283 20509909 974143 -551401 17177122 17410002 6300432 7084713 10876690 10325289 X TO BE AN INDEPENDENT, COMMUNITY-BASED HEALTH SYSTEM DEDICATED TO PROVIDING EXCEPTIONAL QUALITY CARE, EVERY STEP OF THE WAY. 1 0 14362089 17216829 CUMBERLAND MEMORIAL HOSPITAL-EXTENDED CARE UNIT, INC. IS AN INDEPENDENT, NONPROFIT, COMMUNITY-BASED FACILITY THAT SERVES NORTHWEST WISCONSIN. CUMBERLAND MEMORIAL HOSPITAL BECAME A CRITICAL ACCESS HOSPITAL ON AUGUST 19, 2005, LICENSED FOR 25 ACUTE CARE BEDS, INCLUDING 3 IN THE BIRTHPLACE. THE HOSPITAL ALSO PROVIDED MENTAL HEALTH INPATIENT AND OUTPATIENT SERVICES THROUGH DECEMBER 31, 2012. SERVICES OF THE HOSPITAL INCLUDE, BUT ARE NOT LIMITED TO, THERAPY, OBSTETRICS, AND GENERAL SURGERY. ACUTE CARE DAYS TOTALED 1,582 IN 2013, SWING BED DAYS TOTALED 662, NEWBORN DAYS TOTALED 78, AND BEHAVIORAL HEALTH DAYS TOTALED 765. DURING FISCAL YEAR 2013, CUMBERLAND MEMORIAL HOSPITAL PROVIDED 36 INPATIENT AND 391 OUTPATIENT SURGERIES ALONG WITH 263 SCOPE PROCEDURES. THERE WERE ALSO 2,530 EMERGENCY ROOM VISITS. 3449651 2420484 CUMBERLAND EXTENDED CARE UNIT, A 50 BED SKILLED NURSING HOME, IS DEDICATED TO MEETING THE PHYSICAL, MENTAL, EMOTIONAL, AND SPIRITUAL NEEDS OF THE RESIDENTS AND FAMILIES SERVED. TOTAL NURSING HOME DAYS IN FISCAL YEAR 2013 WERE 14,574. 141108 165137 THE LAKEWOOD REGENCY APARTMENTS ARE ATTACHED TO THE CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT. THESE SPACIOUS APARTMENTS WERE DESIGNED AS A COMFORTABLE AND CONVENIENT LIVING CHOICE FOR SENIORS KEEPING SOCIAL INTEREST AND PERSONAL SAFETY IN MIND. THE OCCUPANCY PERCENTAGE FOR 2013 WAS APPROXIMATELY 75%. 17952848 1 1 0 1 0 0 0 0 0 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 0 1 0 0 0 0 0 0 0 0 0 0 1 51 0 1 298 1 1 1 0 0 0 0 0 0 0 0 0 X 7 0 0 0 1 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ANGIE MARTENS 7158222741 1110 7TH AVENUE CUMBERLAND WI 54829 CHARLES CHRISTENSEN 2.00 X X 4425 0 0 TOM LINGEN MD 1.00 X 4350 0 0 CANDY COTONE 1.00 X X 3525 0 0 ANN HENDRICKS 1.00 X X 4275 0 0 JOSEPH LESCHISIN 1.00 X 3300 0 0 MATT GORES 1.00 X 4050 0 0 MARTIN PETERS 1.00 X X 3225 0 0 MARY ANN CLARK 37.00 X 121388 0 18997 ANGIE MARTENS 40.00 X 135632 0 5522 MIKE GUTSCH 40.00 X 92489 0 11666 DR CHARLES MAYO II 40.00 X 235221 0 47026 JEFFREY KUEHN 20.00 X 196545 0 37080 DONALD FULLERTON 20.00 X 185935 0 42722 LAURIE POLUBINSKY 40.00 X 255763 0 21559 BENJAMIN BRENNA 40.00 X 115369 0 40883 1365492 0 225455 9 0 1 0 CUMBERLAND CLINIC 1110 7TH AVENUE CUMBERLAND WI 54829 ER PHYSICIANS 586582 SHARED MEDICAL TECHNOLOGY 202 W NEWTON ST RICE LAKE WI 54868 RADIOLOGY 235583 DELTA LOCUM TENENS 1755 WITTINGTON PLACE SUITE 175 DALLAS TX 75234 ER PHYSICIANS 229735 ABM JANITORIAL SERVICES LLC 75 REMITTANCE DRIVE SUITE 3011 CHICAGO IL 60675 JANITORIAL SERVICES 199392 WIPFLI LLP 3703 OAKWOOD HILLS PKWY EAU CLAIRE WI 54701 ACCOUNTING & IT SERVICES 177282 8 11260 8807 97291 117358 HOSPITAL REVENUE 621990 17218041 17216829 1212 NURSING HOME REVENUE 623000 2420484 2420484 APARTMENT REVENUE 623990 165137 165137 19803662 17732 17732 8188 8188 9959 273 9686 9686 9686 8406 11260 6524 1882 1882 19958508 19802450 1212 37488 X 697643 174036 523607 8362244 7966157 396087 187071 176643 10428 2255720 2074662 181058 624955 564583 60372 122420 122420 93340 93340 2397055 2330608 66447 108895 108895 760582 601955 158627 193879 193879 552206 458276 93930 1140800 946750 194050 127579 127579 PROVISION FOR BAD DEBTS 1228550 1228550 BILLABLE MEDICAL SUPPLI 967621 967621 REPAIRS & MAINTENACE 280817 264198 16619 EQUIPMENT RENT & LEASES 214060 49089 164971 194472 149720 44752 20509909 17952848 2557061 0 57828 987426 5052682 5040577 2827477 3046638 379297 376144 55912 55992 21584635 13872063 7326721 7712572 122700 1477205 67953 17177122 17410002 2060726 1543251 204768 4239706 5031694 0 305000 6300432 7084713 X 10876690 10325289 10876690 10325289 17177122 17410002 -551401 0 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 2949 2949 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. (CMH) PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. WHA HAS NOTIFIED CMH THAT $1,329 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. CMH IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, CMH 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 THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT $1,620 OF THE FEES PAID BY CMH IN 2013 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. 320897 320897 12672907 7120856 5552051 8558216 6751207 1807009 32615 32615 7712572 AMOUNTS PAYABLE TO THIRD-PARTY REIMBURSEMENT PROGRAMS 305000 305000 X 19986900 28392 28392 19958508 0 19958508 20538301 28392 28392 20509909 0 20509909 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE FACILITY 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE FACILITY'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. IN 2013 AND 2012, THERE WERE NO PAYMENTS OF INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE FACILITY IN THE FINANCIAL STATEMENTS. THE FACILITY RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2013 OR 2012. FEDERAL RETURNS FOR THE YEARS ENDED JUNE 30, 2010, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE IRS. PART XI, LINE 2D - OTHER ADJUSTMENTS: DIETARY REVENUE NETTED AGAINST DIETARY EXPENSES 21,868. FUNDRAISING EXPENSES NET AGAINST REVENUE 6,524. PART XII, LINE 2D - OTHER ADJUSTMENTS: DIETARY EXPENSES NETTED AGAINST DIETARY REVENUE 21,868. FUNDRAISING EXPENSES NET AGAINST REVENUE 6,524. GOLF OUTING 19666 11260 8406 6524 19666 11260 8406 6524 6524 1882 1 1 1 X 1 X 150.000000000000 1 1 1 0 1 1 90540 90540 0.00470 2813347 2554407 258940 0.01340 2903887 2554407 349480 0.01810 214748 214748 0.01110 11000 11000 0.00060 3208817 2040770 1168047 0.06060 2595 2595 0.00010 3437160 2040770 1396390 0.07240 6341047 4595177 1745870 0.09050 14000 14000 0.00070 14000 14000 0.00070 0 713128 142626 5466044 5356975 109069 X 1 1 1 1 CUMBERLAND MEMORIAL HOSPITAL INC

1110 7TH AVENUE CUMBERLAND WI 54829

X X X X AMBULANCE SERVICE; CLINIC CUMBERLAND MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X 12 1 1 1 X X X X X X X X X X X 0 0 1 1 100.000000000000 1 150.000000000000 1 X X X X X 1 1 X X 1 X 1 X X X X X 1 X 0 0 2 CUMBERLAND EXTENDED CARE UNIT

1110 7TH AVENUE CUMBERLAND WI 54829

SKILLED NURSING FACILITY LAKEWOOD REGENCY APARTMENTS

1110 7TH AVENUE CUMBERLAND WI 54829

SENIOR LIVING APARTMENTS PART I, LINE 7: 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, EXCLUDING THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST HOSPITAL REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHODOLOGY USED IS BASED ON MEDICARE COST REPORTING METHODS. PART I, LINE 7G: THE COST OF SUBSIDIZED SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. ALLOWABLE COSTS ARE ASSIGNED DIRECTLY TO DEPARTMENTS THROUGHOUT THE YEAR AND THEN THE COST REPORT USES THE ALLOCATION METHODOLOGY TO ASSIGN ALL OTHER COSTS TO CALCULATE SERVICE LINE COSTS. SUBSIDIZED HEALTH SERVICES INCLUDE THE OPERATION OF THE INPATIENT PSYCHIATRIC UNIT THROUGH DECEMBER 31, 2012, THE SKILLED NURSING HOME, THE CLINIC AND THE OPERATION OF THE EMERGENCY ROOM DEPARTMENT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. IT HAS BEEN THE GOAL OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. PART I, L7 COL(F): THERE ARE SOME INDIVIDUALS THAT WOULD QUALIFY UNDER THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY, HOWEVER, THESE INDIVIDUALS ARE UNABLE TO COMPLETE THE REQUIRED FORMS AND THEREFORE ARE DENIED FINANCIAL ASSISTANCE. THE HOSPITAL ESTIMATES A SMALL PERCENTAGE OF THE HOSPITAL'S BAD DEBT EXPENSE IS ATTRIBUTABLE TO THESE PATIENTS WHO WOULD OTHERWISE BE ELIGIBLE FOR CHARITY CARE AS NOTED IN PART III, SECTION A, LINE 3. PART II: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S 'COMMUNITY BENEFIT', THIS IS A WORK IN PROGRESS. CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE HOSPITAL BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. SEE PART 1, LINE 7 FOR THE CALCULATED COST OF PROVIDING COMMUNITY SERVICES. CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC., LIKE MOST RURAL 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 HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES: AMBULANCE SERVICES, BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES & URGENT CARE, EXTENDED CARE, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH, AND SURGICAL SERVICES. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE 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 THE HOSPITAL HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. 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 SMALL AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.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 FISCAL YEAR TO ESTIMATE THE COST OF THE CHARITY CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITY CARE POLICY. 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 OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 8: CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. IS DESIGNATED A CRITICAL ACCESS HOSPITAL AND AS SUCH A PORTION OF ITS REVENUE IS PAID UNDER A COST REIMBURSEMENT SYSTEM. BASED ON THE INSTRUCTIONS, THE TOTAL MEDICARE REVENUE SHOWN ON THIS FORM 990 INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE THAT IS ACTUALLY RECEIVED BY THE HOSPITAL FROM THE MEDICARE PROGRAM. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE SERVICES, INC. OR AMBULANCE SERVICES. PHYSICIAN COVERAGE IS REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT METHODOLOGY AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY AND AMBULANCE 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 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF CUMBERLAND, WISCONSIN. 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 HOSPITAL PATIENT SERVICE REVENUE (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN AND MID-LEVEL PRACTITIONER SERVICES WHICH THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES. 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 HOSPITAL'S COLLECTION AND CHARITABLE CARE POLICIES, CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. MAKES EVERY ATTEMPT TO IDENTIFY AND PROMOTE CHARITY CARE TO PATIENTS. INCLUDED IN THE HOSPITAL'S CHARITABLE 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 FINANCIAL COUNSELOR TO ALLOW THESE PATIENTS THE ABILITY TO COMPLETE THEIR APPLICATION DURING THEIR STAY AT THE HOSPITAL, DEPENDING UPON THE PATIENT'S CONDITION, THE PATIENT'S RESPONSIBLE PARTY MAY BE CONTACTED TO COMPELTE 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 POLICES AS WELL AS THE CHARITY AND COMMUNITY CARE PROGRAM TO ALLOW PATENTS THE OPPORTUNITY TO COMPLETE THE APPROPRIATE FORMS AND QUALIFY UNDER THE PROGRAM. INCLUDED IN THE POLICY, IT IS ALSO NOTED THAT THE HOSPITAL RESERVES THE RIGHT TO MAKE OR GRANT ADDITIONAL CHARITY CARE ON A CASE BY CASE BASIS. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3: AS PART OF THE CHNA PROCESS, CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. GATHERED A GROUP OF HEALTH CARE LEADERS TO FORM A STEERING COMMITTEE TO LEAD THE COMMUNITY HEALTH NEEDS ASSESSMENT FOR BARRON COUNTY. THE STEERING COMMITTEE, WHICH CONSISTED OF HEALTH CARE PROFESSIONALS AND COMMUNITY MEMBERS, WORKED WITH TWO INDIVIDUALS FROM THE WISCONSIN STATE DEPARTMENT OF HEALTH TO PROVIDE EXPERTISE AND TO PROVIDE GUIDANCE ON THE CHNA PROCESS. THE STEERING COMMITTEE CONDUCTED A SURVEY TO ENGAGE THE COMMUNITY IN THE PROCESS AND TO GATHER INPUT ON WHAT THE COMMUNITY AT LARGE FELT WERE THE HEALTH CONCERNS FOR BARRON COUNTY. THE SURVEYS WERE DISTRIBUTED BY THE COMMITTEE MEMBERS TO LIBRARIES, HOSPITALS, CLINICS, THE FREE CLINIC, FOOD PANTRIES, AND SENIOR CENTERS. IN ADDITION, IN MARCH OF 2012, A PRESS RELEASE WAS RELEASED TO MULTIPLE LOCAL NEWSPAPERS ANNOUNCING THE INITIATIVE AND ASKING FOR COMMUNITY PARTICIPATION. THE SURVEY WAS TRANSLATED INTO BOTH THE SPANISH AND SOMALI LANGUAGES, WHICH ARE BOTH PREVALENT LANGUAGES IN BARRON COUNTY, TO ENSURE THAT THE OPINIONS OF THOSE COMMUNITIES WERE INCLUDED AND DISTRIBUTED AT KEY COMMUNITY CENTERS FOR BOTH POPULATIONS. OVER 1,100 SURVEYS WERE COMPLETED BOTH ONLINE AND ON PAPER AND THE RESULTS WERE TABULATED.IN ADDITION TO THE SURVEY, THE COMMITTEE HOSTED A COMMUNITY PLANNING DAY, IN SEPTEMBER 2012 AND INVITED BUSINESS LEADERS, HEALTH EXPERTS AND THE GENERAL COMMUNITY TO COME TOGETHER TO HELP SELECT THE TOP THREE HEALTH PRIORITIES FOR BARRON COUNTY. EIGHTY FIVE COMMUNITY MEMBERS FROM BARRON COUNTY WERE IN ATTENDANCE. AFTER THE DAY OF DISCUSSION AND DATA SHARING, PARTICIPANTS WERE EACH GIVEN THREE VOTES AND ASKED TO VOTE FOR THEIR TOP THREE HEALTH FOCUS CONCERNS. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 4: CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. WORKED WITH BARRON COUNTY PUBLIC HEALTH (BARRON, WI), LAKEVIEW MEDICAL CENTER/MARSHFIELD CLINIC (RICE LAKE, WI) AND MAYO CLINIC HEALTH SYSTEM - NORTHLAND (BARRON, WI) TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5C: COPIES OF THE COMMUNITY HEALTH NEEDS ASSESSMENT WERE DISTRIBUTED TO THE SENIOR CENTER AND TO THE PUBLIC LIBRARY. THE HOSPITAL ALSO BRINGS EXTRA COPIES OF THE CHNA TO THE COMMUNITY EVENTS IN WHICH THEY PARTAKE. CUMBERLAND 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 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. SERVES. THERE WERE ITEMS IDENTIFIED IN THE CHNA WHICH WERE NOT ADDRESSED, HOWEVER, ALL ITEMS WERE CONSIDERED IF A NEED WAS BROUGHT TO THE ATTENTION OF THE STEERING COMMITTEE DURING THE INFORMATION GATHERING PHASE OF THE CHNA PROCESS. SEVERAL OF THE ITEMS WHICH WERE NOT ADDRESSED PRIMARILY WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE. OVER THE NEXT THREE YEARS, THE HOSPITAL WILL CONTINUE TO PLAY A LEADING ROLE IN ADDRESSING THE HEALTH NEEDS OF THOSE WITHIN THE COMMUNITY, CONGRUENT WITH THE HOSPITAL'S MISSION. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 14G: THE FINANCIAL ASSISTANCE POLICY IS AVAILABLE THROUGH THE BUSINESS OFFICE STAFF. PATIENTS ARE ENCOURAGED TO CONTACT A FINANCIAL COUNSELOR FOR FURTHER INFORMATION ON THE FINANCIAL ASSISTANCE POLICY. THE HOSPITAL'S WEBSITE ALSO ENCOURAGES PATIENTS TO INQUIRE ABOUT THE FINANCIAL ASSISTANCE POLICY. CUMBERLAND MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 20D: THE HOSPITAL DETERMINES THE AMOUNT CHARGED TO FAP-ELIGIBLE INDIVIDUALS USING AN INCOME-BASED SLIDING FEE BASED ON FEDERAL POVERTY GUIDELINES. IF THE INDIVIDUAL IS AT 100% OR LESS OF THE FEDERAL POVERTY GUIDELINES THEN THEY GENERALLY RECEIVE FREE CARE. IF THE INDIVIDUAL EARNS BETWEEN 100% AND 150% OF THE FEDERAL POVERTY GUIDELINES THEN THEY RECEIVE A DISCOUNTED PRICE BASED ON A SLIDING FEE SCALE. PART VI, LINE 2: THE HOSPITAL ASSESSES THE NEEDS OF THE COMMUNITY THROUGH SURVEYS AND BY RECOGNIZING WHY CERTAIN PATIENTS ARE REFERRED OUT OF THE AREA. THE HOSPITAL THEN ATTEMPTS TO GET SPECIALISTS IN THE IDENTIFIED AREAS INTO THE FACILITY TO SEE PATIENTS AND MEET THEIR NEEDS.AS PART OF THE STRATEGIC PLANNING PROCESS, CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) TO IDENTIFY COMMUNITY NEEDS. DURING FY 2013, THE HOSPITAL AQUIRED CUMBERLAND MEDICAL CLINIC AND BEGAN PROVIDING CLINICAL CARE SERVICES. OVER THE NEXT FEW YEARS, THE HOSPITAL WILL CONTINUE TO WORK TO ADDRESS ALL OF THE HEALTH NEEDS OF THOSE WITHIN THE COMMUNITY. PART VI, LINE 3: IF A PATIENT IS IDENTIFIED AS UNINSURED, HOSPITAL STAFF WORKS WITH THE PATIENT OR THEIR FAMILY TO DETERMINE IF THEY ARE ELIGIBLE FOR ANY TYPE OF GOVERNMENT PROGRAM OR QUALIFY FOR THE HOSPITAL'S CHARITY CARE PROGRAM. PART VI, LINE 4: THE HOSPITAL SERVES THE COMMUNITIES OF CUMBERLAND, WI AND ALMENA, WI AND SURROUNDING COMMUNITIES WITHIN A 20 MILE RADIUS. THERE ARE THREE OTHER HOSPITALS LOCATED IN THE RURAL AREA THAT THE ORGANIZATION SERVES. PART VI, LINE 5: A MAJORITY OF OUR ORGANIZATION'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE ORGANIZATION'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL, NOR FAMILY MEMBERS THEREOF. OUR HOSPITAL EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN ITS COMMUNITY FOR SOME OR ALL OF ITS DEPARTMENTS. WE ALSO PARTICIPATE IN COMMUNITY HEALTH FAIRS AND PROVIDE SERVICE AT SPORTING EVENTS. SURPLUS FUNDS ARE INVESTED BACK INTO THE HOSPITAL AND ITS EQUIPMENT TO ENSURE THE NEEDED SERVICES ARE CONTINUED TO BE PROVIDED IN THIS COMMUNITY. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X X X 1 0 0 0 0 0 0 0 0 DR CHARLES MAYO II 235221 0 0 0 0 0 9695 0 37331 0 282247 0 0 0 JEFFREY KUEHN 196545 0 0 0 0 0 8081 0 28999 0 233625 0 0 0 DONALD FULLERTON 185935 0 0 0 0 0 5811 0 36911 0 228657 0 0 0 LAURIE POLUBINSKY 252192 0 0 0 3571 0 7640 0 13919 0 277322 0 0 0 BENJAMIN BRENNA 113065 0 0 0 2304 0 3675 0 37208 0 156252 0 0 0 PART I, LINE 4A DEB KUNFERMAN, CEO RESIGNED FROM THE ORGANIZATION IN FISCAL YEAR 2012 AND RECEIVED 90 DAYS SEVERANCE PAY IN CALENDAR YEAR 2012 TOTALING $44,636. THIS AMOUNT IS NOT INCLUDED ON FORM 990, SCHEDULE J AS THE AMOUNT IS BELOW THE REPORTING THRESHOLDS. A CITY OF CUMBERLAND 396005423 230849FE6 2008-10-23 5166566 REMODELING PROJECT 0 0 0 A 1411566 5166566 517000 103400 2524863 2021303 2009 1 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 0 A 0 0 0 0 0 0 0 0 0 A 0 JORENE OSTERMAN RN FAMILY MEMBER OF DR. TOM LINGEN, BOARD MEMBER 68977 EMPLOYMENT COMPENSATION 0 LAURI RANALLO FAMILY MEMBER OF CHARLES CHRISTENSEN, CHAIRMAN 40475 EMPLOYMENT COMPENSATION 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 DURING FISCAL YEAR 2013, CMH-ECU AQUIRED CUMBERLAND MEDICAL CLINIC AND BEGAN PROVIDING CLINICAL CARE SERVICES ON MARCH 1, 2013. TOTAL CLINIC VISITS FOR THE FIRST FOUR MONTHS OF OPERATIONS TOTALED 6,902. FORM 990, PART VI, SECTION A, LINE 4 THE BOARD OF DIRECTORS APPROVED AN AMENDMENT TO THE BYLAWS IN APRIL 2013. THE AMENDMENT REMOVED THE LANGUAGE THAT STATED THAT A MEMBER OF THE CITY COUNCIL WAS REQUIRED TO SIT ON THE GOVERNING BOARD. NO FURTHER CHANGES WERE MADE. FORM 990, PART VI, SECTION B, LINE 11 THE CHIEF FINANCIAL OFFICER REVIEWED THE RETURN. THE BOARD MEMBERS OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. AND EXTENDED CARE UNIT, INC. WERE THEN GIVEN A COPY OF FORM 990 AND GIVEN AN OPPORTUNITY TO COMMENT BEFORE SUBMISSION TO THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. REQUIRES ITS BOARD MEMBERS TO SIGN A CONFLICT OF INTEREST STATEMENT ANNUALLY. OFFICERS AND KEY EMPLOYEES OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. SIGN A CODE OF CONDUCT STATEMENT. IN THE CODE OF CONDUCT STATEMENT IT MENTIONS THE CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINE 15 EXECUTIVE SALARIES ARE SET ANNUALLY CONSIDERING COMPENSATION LEVELS AT SIMILARLY SITUATED ORGANIZATIONS (TYPICALLY NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS IN SIMILAR REVENUE CATEGORIES). THE BOARD OF DIRECTORS IS RESPONSIBLE FOR SETTING THE SALARY OF THE CEO BASED ON THEIR JOB PERFORMANCE. THE BOARD RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. ALL OTHER NON-UNION WAGES ARE REVIEWED SEMI-ANNUALLY IN COMPARISON TO THE RURAL WISCONSIN HEALTH COOPERATIVE WAGE SURVEY. THIS WAGE SURVEY INCLUDES WAGE DATA OF 27 RURAL HEALTHCARE ORGANIZATIONS. THE GOAL OF CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. IS TO REMAIN WITHIN THE WAGE SURVEY AVERAGES, BASED ON YEARS OF SERVICE TO BE COMPETITIVE WITH SIMILAR ORGANIZATIONS. FORM 990, PART VI, SECTION C, LINE 19 CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. OTHER FEES FORM 990, PART IX, LINE 11G FEE FOR SERVICES: PROGRAM SERVICE EXPENSES 592,800. MANAGEMENT AND GENERAL EXPENSES 66,447. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 659,247. PURCHASED NURSING SERVICES: PROGRAM SERVICE EXPENSES 182,272. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 182,272. PURCHASED RADIOLOGY/NUCLEAR MEDICINE SERVICES: PROGRAM SERVICE EXPENSES 502,044. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 502,044. CONSTRACTED PHYSICIANS: PROGRAM SERVICE EXPENSES 450,206. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 450,206. CONTRACTED ER PHYSICIANS: PROGRAM SERVICE EXPENSES 603,286. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 603,286. OVERSIGHT OF THE AUDIT AND INDEPENDENT ACCOUNTANT: FORM 990, PART XII, LINE 2C CUMBERLAND MEMORIAL HOSPITAL & EXTENDED CARE UNIT, INC.'S ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE INDEPENDENT ACCOUNTANT. THE AUDITED FINANCIAL STATEMENTS ARE REVIEWED BY THE BOARD OF DIRECTORS ANNUALLY AND ANY QUESTIONS OR CONCERNS REGARDING THE STATEMENTS ARE ADDRESSED BY THE INDEPENDENT ACCOUNTANTS. THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR.