2014-11-12T09:42:10-06:00 2013-12-31 390758449 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2013-01-01 411842965 LAKEWOOD HEALTH SYSTEM LAKE 2188941515 49725 COUNTY 83 STAPLES MN 56479 JIM DREGNEY CHIEF FINANCIAL OFFICER 2188941515 2014-11-05 1 TIM A RITTER CPA P00732856 9525483400 2014-11-05 2013 2015-11-30 17:44:51Z JIM DREGNEY 49725 COUNTY 83 STAPLES MN 56479 95912161 0 X WWW.LAKEWOODHEALTHSYSTEM.COM X 1996 MN TO PROVIDE PERSONALIZED HEALTHCARE FOR A LIFETIME. 12 11 1054 150 23990 0 291186 438626 91137423 92778803 19310 394642 782839 2009398 92230758 95621469 0 0 0 0 47975460 49193428 0 0 111467 40673909 44670808 88649369 93864236 3581389 1757233 85105756 83151564 53013599 49338462 32092157 33813102 X THE MISSION OF LAKEWOOD HEALTH SYSTEM IS TO PROVIDE PERSONALIZED HEALTHCARE FOR A LIFETIME. 0 0 67176482 0 80919804 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 4,296 INPATIENT HOSPITAL AND SWING-BED DAYS, 3,163 INPATIENT GERIATRIC BEHAVIORAL HEALTH UNIT DAYS, 61,179 MEDICAL AND MENTAL HEALTH RURAL HEALTH CLINIC VISITS. 6391967 0 13179281 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 35,398 RESIDENT DAYS IN THE NURSING HOME, 666 ASSISTED LIVING UNIT RENTED MONTHS. 73568449 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 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 0 1 0 0 0 0 0 1 1 0 0 0 1 83 0 1054 1 1 1 0 0 0 0 1 1 0 0 0 0 X 12 11 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 MN X JIM 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 BARB PETERSON BOARD MEMBER 1.00 X 0 0 0 CAROLYN BISEL BOARD MEMBER 1.00 X 0 0 0 WILLIAM MENNIS MD BOARD MEMBER 1.00 X 0 0 0 MARIE ROSE 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 SARAH ISRAELSON MD SECRETARY 1.00 X X 0 0 0 LARRY LUNDBLAD TREASURER 1.00 X X 0 0 0 TIM RICE PRESIDENT 40.00 X X 370747 0 44092 JAMES DREGNEY CHIEF FINANCIAL OFFICER 40.00 X 200764 0 37865 CRAIG WOLHOWE DIVISION DIRECTOR 40.00 X 192102 0 40229 DANIEL DONAHUE DIVISION DIRECTOR 40.00 X 189635 0 38142 LAURIE BACH DIVISION DIRECTOR 40.00 X 225810 0 16876 LYNN NEWTON RICE DIVISION DIRECTOR 40.00 X 193173 0 13257 JEFFREY D OSEGARD DIVISION DIRECTOR 40.00 X 151120 0 34661 ROBERT SCHMIEG DIRECTOR ANESTHESIA, CRNA 40.00 X 320427 0 27389 SHERREE ENGEN ANESTHETIST 40.00 X 268377 0 37178 REBECCA LYNN BENNETT PHYSICIAN ASSISTANT 40.00 X 156094 0 37432 AMY LYNN WINKELS PHYSICIAN ASSISTANT 40.00 X 154935 0 34543 2423184 0 361664 40 0 1 0 LAKEWOOD CLINIC PA 49725 COUNTY 83 STAPLES MN 56479 PHYSICIAN SERVICES 10705193 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 LOCUM COVERAGE 689887 CENTRAL MINNESOTA DIAGNOSTIC INC PO BOX 158 MILICA MN 56353 MRI & CT SERVICES 584850 QUEST DIAGNOSTICS 12989 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB TEST SERVICES 465497 STATE COLLECTION SERVICE INC PO BOX 6250 MADISON WI 53716 COLLECTION SERVICES 420568 23 62831 157067 218728 438626 NET PATIENT AND RESIDENT SERVICE 621110 91480165 91480165 OCCUPATIONAL HEALTH 621300 439228 439228 RENT REVENUE 531120 238178 238178 PHARMACY 621300 235540 235540 OTHER SERVICE REVENUE 621110 117908 117908 267784 267784 92778803 378932 23990 354942 268318 252608 15710 15710 15710 25187 62831 38084 -12897 -12897 EHR INCENTIVE 900099 1320282 1320282 FOOD SERVICE 900099 691961 691961 10052 10052 2022295 95621469 94099085 23990 1059768 1505788 1505788 35814990 26402716 9392642 19632 51858 40280 11550 28 9186666 7040124 2141507 5035 2634126 2045994 586688 1444 123240 123240 47704 47704 8692135 8621211 51665 19259 228815 177571 50963 281 10193963 7910964 2270460 12539 12063 9361 2687 15 2591199 2010885 577127 3187 497670 386214 110844 612 35818 27796 7978 44 1972937 1531086 439424 2427 5321651 4871416 443689 6546 274163 274163 MEDICAL FEES 8439658 8439658 PROVISION FOR BAD DEBTS 3240208 3240208 MN CARE TAX 1230907 67866 1163041 SURCHARGES 862729 862729 905948 745099 120431 40418 93864236 73568449 20184320 111467 11117 10735 4334388 11471553 20410976 13799394 1529945 224858 1302882 1717900 1674745 1878093 87934869 38479098 51751372 49455771 680129 580931 3410202 4012329 85105756 83151564 8631584 6684059 0 1939420 38934881 39653995 33073 38226 5414061 1022762 53013599 49338462 X 31940899 33466220 151258 346882 32092157 33813102 85105756 83151564 X 1757233 -36288 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 1020 1020 0 PART II-B, LINE 1: THE ORGANIZATION IS A MEMBER OF MINNESOTA HOSPITAL ASSOCIATION AND 3.8% OF THE $26,822 MEMBERSHIP FEE WAS RELATED LOBBYING ACTIVITIES. 0 1 X 838858 838858 33553553 14526269 19027284 165063 35346 129717 51627885 23369047 28258838 1749510 548436 1201074 49455771 X 92235103 0 92235103 3386366 3386366 95621469 90477870 0 90477870 3386366 3386366 93864236 PART IV, LINE 2B: THE ORGANIZATION IS THE TRUSTEE OF TENANTS' FUNDS AND HAS FIDUCIARY RESPONSIBILITY FOR THE ADMINISTRATION AND DISTRIBUTION OF THESE FUNDS FOR TENANTS. 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, 2013 AND 2012. THE ORGANIZATION'S FEDERAL RETURNS FOR TAX YEARS 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 3,240,208. LOSS ON REFINANCING OF LONG TERM NOTE 146,158. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 3,240,208. LOSS ON REFINANCING OF LONG TERM DEBT 146,158. DINNER AUCTION 21104 6180 14924 3496 GOLF TOURNAMENT 18795 8532 10263 3622 13 48119 48119 30966 88018 62831 25187 38084 38084 -12897 1 1 1 X 75.000000000000 1 X 240.000000000000 0 1 1 0 1 0 1861278 1861278 0.02050 21470104 19709488 1760616 0.01940 23331382 19709488 3621894 0.03990 227476 227476 0.00250 9270 9270 0.00010 3444949 1763192 1681757 0.01860 19326 19326 0.00020 3701021 1763192 1937829 0.02140 27032403 21472680 5559723 0.06130 1000 4674 4674 0.00010 7973 7973 0.00010 1000 12647 12647 0.00020 0 1979114 760514 14398438 15577537 -1179099 X 1 1 1 1 LAKEWOOD HEALTH SYSTEM 49725 COUNTY ROAD 83 STAPLES MN 56479 X X X X LAKEWOOD HEALTH SYSTEM 1 1 X X X X X X X X 13 1 0 1 X HTTP://LAKEWOODHEALTHSYSTEM.COM/COMMUNITY X X X X X 0 0 1 1 75.000000000000 1 240.000000000000 1 X X X 1 1 X X X X X 1 0 1 X 0 0 LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 3: 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 7: 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 11: INCOME OF 75% TO 240% OF FPG WOULD BE ELIGIBLE FOR DISCOUNTED CARE. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 12I: 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 14G: EACH APPLICABLE ADMISSION AREA HAS A POLICY AVAILABLE FOR THE PATIENT AS NEEDED AND UPON REQUEST. LAKEWOOD HEALTH SYSTEM PART V, SECTION B, LINE 20D: 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 $ 3,240,208. 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 DETERMINED BY THE ORGANIZATION USING INFORMATION AVAILABLE TO MAKE AN EDUCATED ESTIMATE. 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 50.8% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2012, TO 41.3% OF SELF-PAY ACCOUNTS RECEIVABLE AT DECEMBER 31, 2013. BAD DEBT WRITE-OFFS WERE APPROXIMATELY $1,074,000 AND $4,079,000 FOR THE YEARS ENDED DECEMBER 31, 2013 AND 2012, RESPECTIVELY. IN 2013, THE ORGANIZATION ADDED ADDENDUMS TO THE CHARITY CARE AND UNINSURED DISCOUNT POLICIES THAT ARE EXPECTED TO INCREASE CHARITY CARE AMOUNTS THAT 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 2013 MEDICARE COST REPORT. 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 1 0 0 0 0 0 0 0 0 TIM RICE PRESIDENT 370747 0 0 0 0 0 15883 0 28209 0 414839 0 0 0 JAMES DREGNEY CHIEF FINANCIAL OFFICER 200764 0 0 0 0 0 11923 0 25942 0 238629 0 0 0 CRAIG WOLHOWE DIVISION DIRECTOR 192102 0 0 0 0 0 12407 0 27822 0 232331 0 0 0 DANIEL DONAHUE DIVISION DIRECTOR 189635 0 0 0 0 0 12314 0 25828 0 227777 0 0 0 LAURIE BACH DIVISION DIRECTOR 110668 0 0 0 115142 0 12409 0 4467 0 242686 0 0 0 LYNN NEWTON RICE DIVISION DIRECTOR 193173 0 0 0 0 0 11933 0 1324 0 206430 0 0 0 JEFFREY D OSEGARD DIVISION DIRECTOR 151120 0 0 0 0 0 11710 0 22951 0 185781 0 0 0 ROBERT SCHMIEG DIRECTOR ANESTHESIA, CRNA 320427 0 0 0 0 0 2277 0 25112 0 347816 0 0 0 SHERREE ENGEN ANESTHETIST 268377 0 0 0 0 0 11411 0 25767 0 305555 0 0 0 REBECCA LYNN BENNETT PHYSICIAN ASSISTANT 156094 0 0 0 0 0 9987 0 27445 0 193526 0 0 0 AMY LYNN WINKELS PHYSICIAN ASSISTANT 154935 0 0 0 0 0 9569 0 24974 0 189478 0 0 0 PART I, LINE 4A LAURIE S. BACH, VICE PRESIDENT RECEIVED A SEVERANCE OF $115,142 UPON LEAVING THE ORGANIZATION DURING THE FISCAL YEAR. A UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 88903ABXX 2004-12-01 32000000 NEW HOSPITAL CONSTRUCTION 0 0 0 B UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2003-09-15 5093625 CONSTRUCTION OF MEDICAL CLINIC AND REFINANCE DEBT 0 0 0 C UNITED HOSPITAL DISTRICT TODD MORRISON CASS AND WADENA COUNTIES MN 416005558 2003-09-15 612000 LAND OF NEW HOSPITAL 0 0 0 D UNITED HOSPITAL DISTRICT MEDICAL FACILITY MORTGAGE REVENUE NOTES SERIES 2 416005558 2013-04-24 7846512 REFINANCING OF 2007 NOTE, 2009 NOTE, 2012 NOTE 0 0 0 A 3285000 32000000 549307 31450693 2006 0 0 1 1 B 2153445 5093625 101872 1275505 3716248 2004 1 0 1 1 C 264754 612000 612000 2004 0 0 1 1 D 194943 7846512 156930 5800010 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. 10705193 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 IN 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 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. INTERESTS THAT ARISE BETWEEN COMPLETING FORMS MUST BE DISCLOSED BY THE INTETERESTED 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 AND THE OTHER DIVISION DIRECTORS, THE PROCESS IS THE SAME EXCEPT THAT THE INDEPENDENT EXTERNAL DATA TYPICALLY STARTS WITH WHAT INTEGRATED HEALTHCARE SYSTEMS PROVIDES. ADDITIONALLY, WE HAVE INCLUDED THE MHA SALARY SURVEY DATA. 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 XI, LINE 9: NET ASSETS RELEASED FROM RESTRICTIONS -36,288. 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. THIS PROCESS HAS NOT CHANGED FROM PRIOR YEAR. MEDICAL SPA LLC 49725 CTY 83 STAPLES MN 56479 800807773 DERMATOLOGY CLINIC AND MEDICAL SPA MN N/A UNRELATED 23990 323946 0 23990 1 0.50000 LAKEWOOD-CENTRACARE LLC 49725 CTY 83 STAPLES MN 56479 411974939 CLINICAL SERVICES MN N/A RELATED 14481 299541 0 1 0.50000 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0