THEDACARE MEDICAL CENTER-WILD ROSE INC: Form 990, tax year 2011
View the entire original 990 at ProPublica ↗
- Organization
- THEDACARE MEDICAL CENTER-WILD ROSE INC (EIN 39-6089134)
- Tax period
- 2011-10-01 to 2012-09-30
- Filed
- 2013-08-15
- IRS object ID
- 201302279349302550
- Schema version
- 2011v1.5
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule C
- Schedule D
- Schedule H
- Schedule J
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2013-08-15T12:08:42-05:00 | Timestamp |
| Tax Period End Date | 2012-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390758449 | EIN |
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WIPFLI LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 12237 | AddressLine1 |
| City | GREEN BAY | City |
| State | WI | State |
| ZIP Code | 543072237 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2011-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 396089134 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL INC | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | WILD | NameControl |
| Phone | 9206223257 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 243 | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 549840243 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | DONALD R CAVES | Name |
| Title | CEO | Title |
| Phone | 9206223257 | Phone |
| Date Signed | 2013-08-15 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | TERRI REXRODE CPA | Name |
| PTIN | P00096513 | PTIN |
| Phone | 9206620016 | Phone |
| Date Prepared | 2013-08-15 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2011 | TaxYear |
| Build TS | 2016-02-25 16:41:14Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | DONALD R CAVES | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | PO BOX 243 | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 549840243 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 14995911 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.WILDROSEHOSPITAL.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1956 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | WILD ROSE HOSPITAL PROVIDES INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA. | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 10 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 8 | NbrIndependentVotingMembers |
| Total Nbr Employees | 173 | TotalNbrEmployees |
| Total Nbr Volunteers | 74 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 153539 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 24848 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 13602051 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 14964341 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 5355 | InvestmentIncomePriorYear |
| Investment Income Current Year | 6722 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | 1922 | OtherRevenuePriorYear |
| Other Revenue Current Year | 0 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 13762867 | TotalRevenuePriorYear |
| Total Revenue Current Year | 14995911 | TotalRevenueCurrentYear |
| Grants And Similar Amnts Prior Year | 0 | GrantsAndSimilarAmntsPriorYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members Prior Year | 0 | BenefitsPaidToMembersPriorYear |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 6083063 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 6755574 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 7524737 | OtherExpensePriorYear |
| Other Expenses Current Year | 7692271 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 13607800 | TotalExpensesPriorYear |
| Total Expenses Current Year | 14447845 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 155067 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 548066 | RevenuesLessExpensesCY |
| Total Assets BOY | 6030710 | TotalAssetsBOY |
| Total Assets EOY | 6107089 | TotalAssetsEOY |
| Total Liabilities BOY | 7497268 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 7022973 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | -1466558 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | -915884 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 12646873 | Expense |
| Revenue | 14836046 | Revenue |
| Description | WILD ROSE HOSPITAL'S MISSION IS TO "PROVIDE SUPERIOR SERVICES TO IMPROVE THE HEALTH OF THOSE WE SERVE." IN PURSUIT OF ITS PRIMARY EXEMPT PURPOSE OF PROVIDING INPATIENT AND OUTPATIENT HOSPITAL AND CLINIC SERVICES TO THE WAUSHARA COUNTY AREA, WILD ROSE HOSPITAL PROVIDES MEDICAL CARE AND OTHER FINANCIAL SUPPORT THROUGH VARIOUS PROGRAMS THAT ARE DESIGNED, AMONG OTHER MATTERS, TO ENHANCE THE HEALTH OF THE COMMUNITY. WILD ROSE HOSPITAL BELIEVES IT HAS A SPECIAL DUTY TO MEET THE NEEDS OF THE POOR, INDIGENT, AND MEDICALLY UNDERSERVED IN THE COMMUNITIES AND SURROUNDING AREAS. THEY HAVE PROVIDED CARE TO ALL PATIENTS WITHOUT REGARD FOR THE ABILITY TO PAY.WILD ROSE HOSPITAL ACTIVELY PROVIDED OR PARTICIPATED IN THE FOLLOWING COMMUNITY-BASED ACTIVITIES AND PROGRAMS:- GENERAL HEALTH EDUCATION SERVICES SUCH AS HEALTH FAIRS- PROVIDED HEALTH INFORMATION ON THE CORPORATION'S WEB SITE AND THROUGH HEALTH RELATED PUBLICATIONS DISTRIBUTED AT NO CHARGE- DIABETES EDUCATION AND SUPPORT GROUP AND BALANCE TRAINING (PHYSICAL THERAPY)- HOSTED SELF-HELP AND WELLNESS PROGRAMS SUCH AS AA, AL-ANON, DIET- BLOOD PRESSURE SCREENINGS, CHOLESTEROL TESTING AND SCHOOL-BASED TESTING- GUIDANCE, REFERRAL AND ENROLLMENT ASSISTANCE FOR PUBLIC MEDICAL PROGRAMS AND OTHER FAMILY SUPPORT ASSISTANCE- DISCOUNTED OR FREE MEDICAL SUPPLIES AND EQUIPMENT TO THOSE UNABLE TO PAY- HOSTED FIVE BLOOD DRIVES AND ENCOURAGED EMPLOYEE PARTICIPATION- CONTRIBUTED TO THE EDUCATION OF STUDENT NURSES AND OTHER HEALTH CARE PROFESSIONALS- PROVIDED FIRST AID FOR COMMUNITY SPORTING EVENTS- PARTICIPATED IN WORK HEALTH EDUCATION PROGRAMS THROUGH PRIMARY CARE INITIATIVE PROGRAM- MADE CASH CONTRIBUTIONS TO SUPPORT COMMUNITY SERVICES AND EVENTS- PROVIDED MEETING ROOMS TO COMMUNITY GROUPS AT NO CHARGEWILD ROSE HOSPITAL OPERATES AN EMERGENCY ROOM THAT IS OPEN TO ALL PERSONS REGARDLESS OF ABILITY TO PAY. IT HAS AN OPEN MEDICAL STAFF WITH PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIAN IN THE AREA. THE MAJORITY OF THE BOARD OF DIRECTORS IS COMPRISED OF INDEPENDENT INDIVIDUALS WHO ARE REPRESENTATIVE OF THE COMMUNITY. CONSISTENT WITH WILD ROSE HOSPITAL'S MISSION, CARE IS PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR THOSE WHO ARE UNDERINSURED. WILD ROSE HOSPITAL GIVES DISCOUNTS FROM ESTABLISHED CHARGES TO SELF-PAY PATIENTS WITHOUT REGARD TO ABILITY TO PAY AND CONSIDERS THESE DISCOUNTS A PART OF ITS COMMUNITY BENEFIT. HEALTH CARE SERVICES TO PATIENTS UNDER GOVERNMENT PROGRAMS, SUCH AS MEDICAID, ARE ALSO CONSIDERED PART OF WILD ROSE HOSPITAL'S BENEFIT PROVIDED TO THE COMMUNITY SINCE A SUBSTANTIAL PORTION OF SUCH SERVICES ARE REIMBURSED AT AMOUNTS LESS THAN THE COST OF PROVIDING CARE. PATIENTS WHO MEET CRITERIA FOR CHARITY CARE, GENERALLY BASED ON FEDERAL POVERTY GUIDELINES, ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE. ELIGIBILITY FOR CHARITY CARE IS DETERMINED BASED ON QUALIFYING CRITERIA AS DEFINED IN WILD ROSE HOSPITAL'S CHARITY CARE POLICY AND FROM APPLICATIONS COMPLETED BY PATIENTS AND THEIR FAMILIES. IN 2012 OVER 350 ACCOUNTS RECEIVED CHARITY CARE WITH A TOTAL COST OF OVER $306,000. | Description |
| Total Program Service Expense | 12646873 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 1 | LobbyingActivities |
| Subject To Proxy Tax | 0 | SubjectToProxyTax |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 0 | TermOrPermanentEndowments |
| Report Land Bldg Equip | 1 | ReportLandBldgEquip |
| Report Invest Oth Securities | 0 | ReportInvestOthSecurities |
| Report Prog Rel Invest | 0 | ReportProgRelInvest |
| Report Other Assets | 0 | ReportOtherAssets |
| Report Other Liabilities | 1 | ReportOtherLiabilities |
| Report Fin48 Footnote | 1 | ReportFin48Footnote |
| Independent Audit Financial Stmt | 1 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 0 | ConsolidatedAuditFinancialStmt |
| School | 0 | School |
| Foreign Office | 0 | ForeignOffice |
| Foreign Activities | 0 | ForeignActivities |
| More Than5000 K To Organizations | 0 | MoreThan5000KToOrganizations |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividuals |
| Professional Fundraising | 0 | ProfessionalFundraising |
| Fundraising Activities | 0 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| Financial Stmt Attached | 1 | FinancialStmtAttached |
| Grants To Organizations | 0 | GrantsToOrganizations |
| Grants To Individuals | 0 | GrantsToIndividuals |
| Schedule J Required | 1 | ScheduleJRequired |
| Tax Exempt Bonds | 0 | TaxExemptBonds |
| Excess Benefit Transaction | 0 | ExcessBenefitTransaction |
| Prior Excess Benefit Transaction | 0 | PriorExcessBenefitTransaction |
| Loan To Officer Or DQP | 0 | LoanToOfficerOrDQP |
| Grant To Related Person | 0 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 1 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 0 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 0 | RelatedOrgControlledEntity |
| Transaction Related Entity | 0 | TransactionRelatedEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 11 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 173 | NumberOfEmployees |
| Employment Tax Returns Filed | 1 | EmploymentTaxReturnsFiled |
| Unrelated Business Income | 0 | UnrelatedBusinessIncome |
| Foreign Financial Account | 0 | ForeignFinancialAccount |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTrans |
| Taxable Party Notification | 0 | TaxablePartyNotification |
| Non Deductible Contributions | 0 | NonDeductibleContributions |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributions |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOf |
| Funds To Pay Premiums | 0 | FundsToPayPremiums |
| Premiums Paid | 0 | PremiumsPaid |
| Indoor Tanning Services | 0 | IndoorTanningServices |
| Info In Schedule O Part VI | X | InfoInScheduleOPartVI |
| Nbr Voting Governing Body Members | 10 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 8 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 1 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 1 | DecisionsSubjectToApproval |
| Minutes Of Governing Body | 1 | MinutesOfGoverningBody |
| Minutes Of Committees | 1 | MinutesOfCommittees |
| Officer Mailing Address | 0 | OfficerMailingAddress |
| Local Chapters | 0 | LocalChapters |
| Form990 Provided To Governing Body | 0 | Form990ProvidedToGoverningBody |
| Conflict Of Interest Policy | 1 | ConflictOfInterestPolicy |
| Annual Disclosure Covered Persons | 1 | AnnualDisclosureCoveredPersons |
| Regular Monitoring Enforcement | 1 | RegularMonitoringEnforcement |
| Whistleblower Policy | 1 | WhistleblowerPolicy |
| Document Retention Policy | 1 | DocumentRetentionPolicy |
| Compensation Process CEO | 0 | CompensationProcessCEO |
| Compensation Process Other | 0 | CompensationProcessOther |
| Investment In Joint Venture | 0 | InvestmentInJointVenture |
| States Where Copy Of Return Is Filed | WI | StatesWhereCopyOfReturnIsFiled |
| Upon Request | X | UponRequest |
The Books Are In Care Of TheBooksAreInCareOf
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | THOMAS P KRYSTOWIAK | NamePerson |
| Telephone Number | 9203611313 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 225 MEMORIAL DRIVE | AddressLine1 |
| City | BERLIN | City |
| State | WI | State |
| ZIP Code | 54984 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (16 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | OfficerOfficer | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| LYNN CREAMER | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| RICHARD A HOTCHKISS | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| JAMES ERDMAN | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| PATRICK MORROW | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| MARK KJENTVET MD | |||||||
| BOARD MEMBER | 0.50 | X | 0 | 0 | 0 | ||
| ROGER WILLIAMS | |||||||
| CHAIRMAN OF BOARD | 0.50 | X | 0 | 0 | 0 | X | |
| FREDERICK GELLERUP | |||||||
| SECRETARY OF BOARD | 0.50 | X | 0 | 0 | 0 | X | |
| CAROL WILLIAMS | |||||||
| TREASURER OF BOARD | 0.50 | X | 0 | 0 | 0 | X | |
| ALLEN STEA | |||||||
| VICE-CHAIRMAN OF BOARD | 0.50 | X | 0 | 0 | 0 | X | |
| DONALD R CAVES | |||||||
| CEO/BOARD MEMBER | 9.00 | X | 42527 | 114475 | 15580 | X | |
| MICHAEL STAUDINGER MD | |||||||
| CHIEF OF MEDICAL STAFF | 40.00 | X | 0 | 338475 | 28546 | X | |
| THOMAS KRYSTOWIAK | |||||||
| CFO | 1.00 | 4215 | 164409 | 28960 | X | ||
| CHAD VOSKUIL MD | |||||||
| PHYSICIAN | 40.00 | 0 | 265568 | 34496 | X | ||
| REGINALDO ABOLEDA MD | |||||||
| PHYSICIAN | 40.00 | 0 | 240837 | 19352 | X | ||
| CHANDLER CAVES MD | |||||||
| PHYSICIAN | 40.00 | 0 | 322610 | 32517 | X | ||
| CATHERINE TRUEHL | |||||||
| DIRECTOR OF AMBULATORY SERVICES | 40.00 | 106446 | 0 | 6775 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 153188 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 1446374 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 166226 | TotalOtherCompensation |
| Number Individuals GT100 K | 1 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (3 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| COMMUNITY HEALTH NETWORK | |||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | MANAGEMENT AND PHYSICIAN SERVICES | 3562989 |
| SHARED MEDICAL EQUIPMENT | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 53527 | EQUIPMENT LEASES | 150000 |
| SHARED MEDICAL SERVICES INC | |||||
| PO BOX 330 | COTTAGE GROVE | WI | 53527 | TECHNICAL SUPPORT | 109853 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 3 | NumberOfContractorsGT100K |
| Government Grants | 17000 | GovernmentGrants |
| All Other Contributions | 7848 | AllOtherContributions |
| Total Contributions | 24848 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome | ExclusionExclusionAmount |
|---|---|---|---|---|
| NET PATIENT SERVICE RE | 621990 | 14836046 | 14836046 | |
| OTHER OPERATING REVENU | 900099 | 128295 | $128,295 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 14964341 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 6722 | TotalRevenueColumn |
| Exclusion | $6,722 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 14995911 | TotalRevenueColumn |
| Related Or Exempt Function Income | 14836046 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $135,017 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 407968 | Total |
| Management And General | 407968 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 4952418 | Total |
| Program Services | 4141663 | ProgramServices |
| Management And General | 810755 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 117967 | Total |
| Program Services | 97283 | ProgramServices |
| Management And General | 20684 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 915394 | Total |
| Program Services | 905032 | ProgramServices |
| Management And General | 10362 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 361827 | Total |
| Program Services | 301279 | ProgramServices |
| Management And General | 60548 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 47795 | Total |
| Management And General | 47795 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 11500 | Total |
| Management And General | 11500 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2840393 | Total |
| Program Services | 2807660 | ProgramServices |
| Management And General | 32733 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 15107 | Total |
| Program Services | 145 | ProgramServices |
| Management And General | 14962 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1745436 | Total |
| Program Services | 1678859 | ProgramServices |
| Management And General | 66577 | ManagementAndGeneral |
Information Technology InformationTechnology
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 83985 | Total |
| Program Services | 83985 | ProgramServices |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 823226 | Total |
| Program Services | 747008 | ProgramServices |
| Management And General | 76218 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 62872 | Total |
| Program Services | 59391 | ProgramServices |
| Management And General | 3481 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2901 | Total |
| Program Services | 2901 | ProgramServices |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 232261 | Total |
| Program Services | 188725 | ProgramServices |
| Management And General | 43536 | ManagementAndGeneral |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 182629 | Total |
| Program Services | 148396 | ProgramServices |
| Management And General | 34233 | ManagementAndGeneral |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 42183 | Total |
| Program Services | 42183 | ProgramServices |
Other Expenses OtherExpenses (4 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| PROVISION FOR BAD DEBT | 1349193 | 1349193 | |
| MISCELLANEOUS | 195161 | 53186 | 141975 |
| LICENSE AND CERTIFICATI | 32895 | 26879 | 6016 |
| ASSOCIATION DUES | 17539 | 10175 | 7364 |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 7195 | Total |
| Program Services | 2930 | ProgramServices |
| Management And General | 4265 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 14447845 | Total |
| Program Services | 12646873 | ProgramServices |
| Management And General | 1800972 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Cash Non Interest Bearing CashNonInterestBearing
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1338349 | BOY |
| EOY | 1179177 | EOY |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 71372 | BOY |
| EOY | 66568 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2633387 | BOY |
| EOY | 2477353 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 224683 | BOY |
| EOY | 207879 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 35281 | BOY |
| EOY | 30722 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 5328362 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 3185580 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1727638 | BOY |
| EOY | 2142782 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 0 | BOY |
| EOY | 2608 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6030710 | BOY |
| EOY | 6107089 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 863472 | BOY |
| EOY | 897385 | EOY |
Mort Notes Pybl Secured Invest Prop MortNotesPyblSecuredInvestProp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 679549 | BOY |
| EOY | 619141 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 5954247 | BOY |
| EOY | 5506447 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 7497268 | BOY |
| EOY | 7022973 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -1466558 | BOY |
| EOY | -918492 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| EOY | 2608 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | -1466558 | BOY |
| EOY | -915884 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 6030710 | BOY |
| EOY | 6107089 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 548066 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | 2608 | ReconcilationOtherChanges |
| Info In Schedule O Part XII | X | InfoInScheduleOPartXII |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Separate | X | FinancialStatementSeparate |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequired |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital170b1 Aiii | X | Hospital170b1Aiii |
Schedule B IRS990ScheduleB
Contributor Info ContributorInfo
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor Number | RESTRICTED | ContributorNumber |
Contributor Name Business ContributorNameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor Address US ContributorAddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Aggregate Contributions | RESTRICTED | AggregateContributions |
Schedule C IRS990ScheduleC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Volunteers | 0 | Volunteers |
| Paid Staff Or Management | 0 | PaidStaffOrManagement |
| Media Advertisements | 0 | MediaAdvertisements |
| Mailings Members | 0 | MailingsMembers |
| Publications Or Broadcast | 0 | PublicationsOrBroadcast |
| Grants Other Organizations | 0 | GrantsOtherOrganizations |
| Direct Contact Legislators | 0 | DirectContactLegislators |
| Rallies Demonstrations | 0 | RalliesDemonstrations |
| Other Activities | 1 | OtherActivities |
| Other Activities | $1,275 | OtherActivitiesAmount |
| Total Lobbying Expenditures IIB | 1275 | TotalLobbyingExpendituresIIB |
| Not Described In501c3 | 0 | NotDescribedIn501c3 |
Form990 Schedule C Part IV Form990ScheduleCPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | EXPLANATION OF LOBBYING ACTIVITIES: | Identifier |
| Return Reference | PART II-B, LINE 1: | ReturnReference |
| Explanation | WHA DUES OF $1,275 | Explanation |
Schedule D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 71372 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 3129 | InvestmentEarningsOrLosses |
| Other Expenditures | 5325 | OtherExpenditures |
| End Of Year Balance | 69176 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 63947 | BeginningOfYearBalance |
| Contributions | 6904 | Contributions |
| Investment Earnings Or Losses | 521 | InvestmentEarningsOrLosses |
| End Of Year Balance | 71372 | EndOfYearBalance |
Current Year Minus2 Years CurrentYearMinus2Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 162815 | BeginningOfYearBalance |
| Investment Earnings Or Losses | 520 | InvestmentEarningsOrLosses |
| Other Expenditures | 99388 | OtherExpenditures |
| End Of Year Balance | 63947 | EndOfYearBalance |
Current Year Minus3 Years CurrentYearMinus3Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 0 | BeginningOfYearBalance |
| Contributions | 96338 | Contributions |
| Investment Earnings Or Losses | 66477 | InvestmentEarningsOrLosses |
| Other Expenditures | 0 | OtherExpenditures |
| End Of Year Balance | 162815 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated EOY Balance | 1.00000 | BoardDesignatedEOYBalance |
| Endowments Held By Unrelated Orgs | 1 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 1 | EndowmentsHeldByRelatedOrgs |
| Are Related Orgs Listed Schedule R | 0 | AreRelatedOrgsListedScheduleR |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 72982 | OtherCostOrOtherBasis |
| Book Value | 72982 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2321462 | OtherCostOrOtherBasis |
| Depreciation | 1367405 | Depreciation |
| Book Value | 954057 | BookValue |
Leasehold Improvements LeaseholdImprovements
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 66340 | OtherCostOrOtherBasis |
| Depreciation | 60294 | Depreciation |
| Book Value | 6046 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 2316223 | OtherCostOrOtherBasis |
| Depreciation | 1757881 | Depreciation |
| Book Value | 558342 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 551355 | OtherCostOrOtherBasis |
| Book Value | 551355 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 2142782 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (3 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| LONG TERM NOTES PAYABLE TO RELATED PARTY | $4,000,000 |
| DUE TO THIRD-PARTY REIMBURSEMENT PROGRAM | $1,403,919 |
| ACCOUNTS PAYABLE DUE TO RELATED PARTY | $102,528 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 5506447 | TotalOfAmounts |
| Total Revenue | 14995911 | TotalRevenue |
| Total Expenses | 14447845 | TotalExpenses |
| Excess Or Deficit For Year | 548066 | ExcessOrDeficitForYear |
| Other | $2,608 | OtherAmount |
| Total Adjustments | 2608 | TotalAdjustments |
| Excess Or Deficit Per FS | 550674 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 14995911 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 14995911 | RevenueSubtotal |
| Revenue Not Rptd On Fin Stmt | 0 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 14995911 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 14447845 | TotExpensesEtcAuditedFinclStmt |
| Expenses Not Rptd F990 | 0 | ExpensesNotRptdF990 |
| Expenses Subtotal | 14447845 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 14447845 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: | PART V, LINE 4: | ENDOWMENT EARNINGS ARE TO BE UTILIZED TO SUPPORT THE ORGANZIATIONS MISSION AND PURPOSE. |
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X: | IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2012 OR 2011. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE, AND THEREFORE TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED SEPTEMBER 30, 2012 AND 2011, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE FINANCIAL STATEMENTS. |
| PART XI, LINE 8 - OTHER ADJUSTMENTS: | CHANGE IN INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. 2,608. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | EXPENSE ALLOCATION TO RENTAL INCOME | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | EXPENSE ALLOCATION TO RENTAL INCOME |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Charity Care Policy | 1 | CharityCarePolicy |
| Written Policy | 1 | WrittenPolicy |
| Policy Applied To All Hospitals | X | PolicyAppliedToAllHospitals |
| FPG Reference Free Care | 1 | FPGReferenceFreeCare |
| Pcent150 | X | Pcent150 |
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent300 | X | Pcent300 |
| Free Disc Care Medically Indigent | 1 | FreeDiscCareMedicallyIndigent |
| Amounts Budgeted For Charity Care | 1 | AmountsBudgetedForCharityCare |
| Expenses Exceeded Budget | 1 | ExpensesExceededBudget |
| Unable To Provide Care | 0 | UnableToProvideCare |
| Annual Community Benefit Report | 1 | AnnualCommunityBenefitReport |
| Report Publically Available | 1 | ReportPublicallyAvailable |
Charity Care At Cost CharityCareAtCost
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 306919 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 0 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 306919 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02340 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 1791895 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 642808 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1149087 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.08770 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 2098814 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 642808 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1456006 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.11110 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 6 | NumberOfActivitiesOrPrograms |
| Persons Served | 595 | PersonsServed |
| Total Community Benefit Expense | 7793 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 225 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 7568 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00060 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 885 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 885 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Cash And In Kind Contributions CashAndInKindContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 155 | NumberOfActivitiesOrPrograms |
| Total Community Benefit Expense | 12334 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 12334 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00090 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 161 | NumberOfActivitiesOrPrograms |
| Persons Served | 595 | PersonsServed |
| Total Community Benefit Expense | 21012 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 225 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 20787 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00160 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Activities Or Programs | 161 | NumberOfActivitiesOrPrograms |
| Persons Served | 595 | PersonsServed |
| Total Community Benefit Expense | 2119826 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 643033 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1476793 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.11270 | PercentOfTotalExpense |
Community Support CommunitySupport
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 660 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 660 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
Total Total
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Building Expense | 660 | TotalCommunityBuildingExpense |
| Net Community Building Expense | 660 | NetCommunityBuildingExpense |
| Percent Of Total Expense | 0.00010 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $649,786 | BadDebtExpenseAmount |
| Amount Attributable To | 0 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 4124774 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 3813851 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 310923 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cost To Charge Ratio | X | CostToChargeRatio |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | 1 | WrittenDebtCollectionPolicy |
| Provision For Charity Care | 1 | ProvisionForCharityCare |
| Number Of Hospital Facilities | 1 | NumberOfHospitalFacilities |
Form990 Schedule H Part V Section A Form990ScheduleHPartVSectionA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility Number | 1 | FacilityNumber |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 601 GROVE AVE | AddressLine1 |
| City | WILD ROSE | City |
| State | WI | State |
| ZIP Code | 54984 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| General Medical And Surgical | X | GeneralMedicalAndSurgical |
| Critical Access Hospital | X | CriticalAccessHospital |
| Er24 Hours | X | Er24Hours |
Form990 Schedule H Part V Section B Form990ScheduleHPartVSectionB
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
| CHNA Conducted | 1 | CHNAConducted |
| Community Definition | X | CommunityDefinition |
| Community Demographics | X | CommunityDemographics |
| Existing Resources | X | ExistingResources |
| Community Health Needs | X | CommunityHealthNeeds |
| Other Health Issues | X | OtherHealthIssues |
| Identifying Process | X | IdentifyingProcess |
| Consulting Process | X | ConsultingProcess |
| Information Gaps | X | InformationGaps |
| Needs Assessment Conducted | 11 | NeedsAssessmentConducted |
| Take Into Account | 1 | TakeIntoAccount |
| Other Facilities | 1 | OtherFacilities |
| CHNA Widely Available | 1 | CHNAWidelyAvailable |
| On Request | X | OnRequest |
| Other Method | X | OtherMethod |
| Adopt Implement Strategy | X | AdoptImplementStrategy |
| Execute Implement Strategy | X | ExecuteImplementStrategy |
| Develop Community Plan | X | DevelopCommunityPlan |
| Participate Community Plan | X | ParticipateCommunityPlan |
| Prioritize Health Needs | X | PrioritizeHealthNeeds |
| Prioritize Services | X | PrioritizeServices |
| All Needs Addressed | 0 | AllNeedsAddressed |
| Eligibility Criteria Explained | 1 | EligibilityCriteriaExplained |
| Uses FPG Free | 1 | UsesFPGFree |
| FPG Free Percent | 150.000000000000 | FPGFreePercent |
| Uses FPG Discounted | 1 | UsesFPGDiscounted |
| FPG Discount Percent | 300.000000000000 | FPGDiscountPercent |
| Explains Basis | 1 | ExplainsBasis |
| Income Level | X | IncomeLevel |
| Asset Level | X | AssetLevel |
| Insurance Status | X | InsuranceStatus |
| Uninsured Discount | X | UninsuredDiscount |
| Medicaid Medicare | X | MedicaidMedicare |
| State Regulation | X | StateRegulation |
| Explains Application Method | 1 | ExplainsApplicationMethod |
| Includes Publicity Measures | 1 | IncludesPublicityMeasures |
| Available On Request | X | AvailableOnRequest |
| Other Publicity | X | OtherPublicity |
| Actions On Nonpayment | 1 | ActionsOnNonpayment |
| Collection Activities | 0 | CollectionActivities |
| Nondiscrim Emergency Care Policy | 1 | NondiscrimEmergencyCarePolicy |
| Used Other Method | X | UsedOtherMethod |
| Amounts Generally Billed | 0 | AmountsGenerallyBilled |
| Gross Charges | 0 | GrossCharges |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 4 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (4 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| WFP WILD ROSE | ||||
| 701 GROVE AVE | WILD ROSE | WI | 54984 | OUTPATIENT PHYSICIAN CLINIC |
| WFP PLAINFIELD | ||||
| N6493 VALLEY CIRCLE ROAD | PLAINFIELD | WI | 54966 | OUTPATIENT PHYSICIAN CLINIC |
| WFP WAUTOMA | ||||
| N2934 HWY 22 NORTH | WAUTOMA | WI | 54982 | OUTPATIENT PHYSICIAN CLINIC |
| WFP COLOMA | ||||
| 141 FRONT STREET | COLOMA | WI | 54930 | OUTPATIENT PHYSICIAN CLINIC |
Form990 Schedule H Part VI Form990ScheduleHPartVI (18 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 7: COST TO CHARGE RATIO. | ||
| PART I, L7 COL(F): BAD DEBT EXPENSE OF $1,349,193 FROM FORM 990, PART IX, LINE 25 WAS REMOVED FOR THE PURPOSE OF CALCULATING THE PERCENTAGES IN PART 1, LINE 7, COLUMN (F). | ||
| PART II: WILD ROSE HOSPITAL ENGAGES IN SEVERAL COMMUNITY BUILDING ACTIVITIES. OUR DISASTER READINESS PROGRAMS ARE DEVELOPED TO EXCEED THE MINIMUM REQUIREMENTS IN ORDER TO PROVIDE A RESPONSIBLE LEVEL OF SERVICE TO THE COMMUNITY. WE PARTICIPATE ON THE COUNTY PUBLIC SAFETY COMMITTEE, THE LOCAL EMERGENCY COMMITTEE, AND THE REGIONAL HOSPITAL EMERGENCY PREPAREDNESS COMMITTEE. ALL OF THESE EFFORTS ARE FOCUSED ON MINIMIZING THE HEALTH IMPACT OF CATASTROPHES, LARGE AND SMALL, AS WELL AS SUPPORTING HEALTHY ACTIVITIES AND GROUPS WITH A QUALITY OF LIFE FOCUS. | ||
| PART III, LINE 4: THE COSTING METHODOLOGY USED IN DETERMINING THE AMOUNTS ABOVE IS A COST TO CHARGE RATIO BASED ON THE TOTAL OPERATING EXPENSE NET OF COMMUNITY BENEFIT EXPENSES AND NON-PATIENT CARE OPERATIONS, AND PATIENT CHARGES NET OF COMMUNITY BENEFIT CHARGES. MANY PATIENTS WHOSE ACCOUNTS/OUT-OF-POCKET LIABILITY ARE WRITTEN OFF TO BAD DEBT ARE UNABLE TO PAY BUT DID NOT COMPLETE THE PROCESS FOR CHARITY CARE/FINANCIAL ASSISTANCE. BECAUSE THESE PATIENTS WOULD HAVE QUALIFIED FOR CHARITY CARE, BUT DIDN'T COMPLETE THE PROCESS, THESE BAD DEBT WRITE-OFFS SHOULD BE CONSIDERED COMMUNITY BENEFIT AS CHARITY CARE. IN ADDITION, WILD ROSE HOSPITAL CONTINUES TO SERVE PATIENTS WHOSE ACCOUNTS ARE WRITTEN OFF TO BAD DEBT EVEN THOUGH THERE IS A GOOD CHANCE FUTURE SERVICES MAY CONTINUE TO BE WRITTEN OFF TO BAD DEBT, WHICH DEMONSTRATES A COMMUNITY BENEFIT, SERVING PATIENTS EVEN THOUGH WE MAY NOT BE PAID. | ||
| PART III, LINE 8: THE ORGANIZATION USES A COST TO CHARGE RATIO TO CALCULATE ALLOWABLE COSTS ABOVE. ANY SHORTFALL SHOULD BE TREATED AS COMMUNITY BENEFIT BECAUSE WILD ROSE HOSPITAL CONTINUES TO SERVE THE MEDICARE POPULATION REGARDLESS OF WHETHER THEY COVER THEIR COSTS. WILD ROSE HOSPITAL HAS A SURPLUS BECAUSE IT IS A CRITICAL ACCESS HOSPITAL AND AS A CRITICAL ACCESS HOSPITAL, IT RECEIVES 101% OF ITS COST PER MEDICARE. | ||
| PART III, LINE 9B: PATIENTS WHO HAVE AN APPLICATION OUTSTANDING ARE NOT KNOWINGLY SENT TO COLLECTIONS. PATIENTS WHO QUALIFY FOR 100% CHARITY HAVE THE ENTIRE AMOUNT OF THE BILL WRITTEN OFF AND NO FURTHER COLLECTION PROCEDURES ARE DONE. BALANCES REMAINING AFTER CHARITY CARE PERCENTAGE HAS BEEN DETERMINED (THOSE WHO QUALIFY FOR FINANCIAL ASSITANCE/PARTIAL CHARITY CARE) ARE CONSIDERED SELF PAY AND PAYMENT ARRANGEMENTS MUST BE MADE. SHOULD THE PATIENT FAIL TO MAKE PAYMENT ARRANGEMENTS OR MAINTAIN THE PAYMENTS AGREED UPON THEY WILL BE NOTIFIED IN WRITTING THAT THE ACCOUNT BALANCE IS PAST DUE AND THE ACCOUNT WILL BE SUBJECT TO NORMAL COLLECTION PROCEDURES. | ||
| PART V, SECTION B, LINE 3: MEMBERS OF THE COMMUNITY WERE SURVEYED AT THE WAUSHARA COUNTY FAIR, WILD ROSE HOSPITAL PERSONNEL ALSO CONSULTED WITH THE WAUSHARA COUNTY PUBLIC HEALTH OFFICE REGARDING THE NEEDS OF THE AMISH COMMUNITY AND WITH LA CLINICA FOR INPUT ON THE HISPANIC RESIDENTS OF WAUSHARA COUNTY. | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART V, SECTION B, LINE 4: BERLIN MEMORIAL HOSPITAL | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART V, SECTION B, LINE 5C: WAUSHARA COUNTY PUBLIC HEALTH WEBSITE | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART V, SECTION B, LINE 7: NEEDS WERE PRIORITIZED BASED ON THE LARGEST POSITIVE IMPACT TO THE COMMUNITY. ANY NEEDS NOT ADDRESSED ARE DUE TO LIMITATIONS ON RESOURCES AVAILABLE. | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART V, SECTION B, LINE 13G: THE POLICY IS PROVIDED TO PATIENTS UPON ADMISSION IF THEY HAVE NO INSURANCE AND OR EXPRESS CONCERNS ABOUT THE ABILITY TO PAY. | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART V, SECTION B, LINE 19D: COMMUNITY CARE WILL BE APPROVED IN A THREE (3) TIER PROGRAM PER POLICY. 100% FOR APPLICANTS AT OR BELOW 150% OF THE FEDERAL POVERTY GUIDELINES. 5% FOR APPLICANTS BETWEEN 150% AND 200% OF FEDERAL POVERTY GUIDELINES. 25% FOR APPLICANTS BETWEEN 200% AND 300% OF FEDERAL POVERTY GUIDELINES. THE PATIENT MUST MAKE ARRANGEMENTS TO PAY THE REMAINDER OF THE BALANCE AFTER THE COMMUNITY CARE ADJUSTMENT. | WILD ROSE COMMUNITY MEMORIAL HOSPITAL | |
| PART VI, LINE 2: WILD ROSE HOSPITAL WORKS IN COLLABORATION WITH WAUSHARA COUNTY WELLNESS COALITION TO ASSESS COMMUNITY NEEDS IN ORDER TO CREATE A HEALTH IMPROVEMENT PLAN BASED ON THOSE ISSUES AND CONCERNS IDENTIFIED. THE WAUSHARA WELLNESS COALITION CONSISTS OF MULTIDISCIPLINARY TEAM THAT INCLUDES THE AGING AND DISABILITY RESOURCE CENTER AND PUBLIC HEALTH. IN THE EFFORT TO PROVIDE COMPREHENSIVE CARE, THE WAUSHARA WELLNESS COALITION ALSO STRIVES TO DECREASE INEFFICIENCIES DUE TO OVERLAP OF CARE PROVIDERS AND ORGNAIZATIONS IN THE AREA. | ||
| PART VI, LINE 3: SELF PAY PATIENTS ARE CONTACTED BY A MEMBER OF THE PATIENT ACCOUNTING STAFF TO INFORM THEM OF AVAILABLE GOVERNMENT PROGRAMS AND CHARITY CARE. IF APPROPRIATE THE PATIENT ACCOUNTING STAFF WILL OFFER ASSISTANCE WITH THE COMPLETION OF THE COMMUNITY CARE (CHARITY CARE) APPLICATION. | ||
| PART VI, LINE 4: WILD ROSE HOSPITAL IS IN AN HPSA AREA AND IS THE ONLY HOSPITAL IN WAUSHARA COUNTY. AS OF THE CENSUS OF 2007 THERE WERE 25,215 RESIDENTS OCCUPYING 9,500 HOUSEHOLDS WITH A 75% INCREASE IN POPULATION DURING THE SUMMER. THE ELDERLY COMPRISE 18.3% OF THE POPULATION COMPARED WITH 15.2% STATEWIDE. THE AVERAGE ANNUAL WAGE IN 2009 WAS ABOUT 30% LESS THAN THE STATE AVERAGE. APPROXIMATELY 10.3% OF THE POPULATION LIVE BELOW THE POVERTY LEVEL . THERE ARE NO MAJOR POPULATION CENTERS IN WAUSHARA COUNTY WITH THE LARGEST COMMUNITY BEING WAUTOMA HAVING A POPULATION OF 2194. THE POPULATION CONSISTS OF 20% UNDER THE AGE OF 20, 12% FROM 20 TO 29, 33% FROM 30 TO 54, 16% FROM 55 TO 64 AND 19% WHO WERE 65 AND OLDER. THE MEDIAN AGE WAS 42 YEARS AND THE GENDER PERCENTAGE IS 50.39% MALE, 49.61% FEMALE. | ||
| PART VI, LINE 5: THE 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 ORGANIZATION, NOR FAMILY MEMBERS THEREOF. WILD ROSE HOSPITAL CONDUCTS HEALTH FAIRS AND CAREER FAIRS FOR THE COMMUNITY TO ENCOURAGE HEALTHY LIFESTYLES AND TO RAISE AWARENESS OF HEALTH ISSUES AND TRENDS AS WELL AS CAREER OPPORTUNITIES WITHIN THE LOCAL HEALTH FACILITIES.WE ALSO CONDUCT CPR AND FIRST AID CLASSES, EDUCATION AND OUTREACH FOR SENIOR CITIZENS, EDUCATIONAL OPPORTUNITIES FOR RESIDENTS AND MEDICAL STUDENTS, AS WELL AS CHOLESTEROL SCREENING. IN ADDITION, WE ADMINISTER A DIABETES SUPPORT GROUP. | ||
| PART VI, LINE 6: WILD ROSE HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK THROUGH PARTNERS HEALTH SYSTEM (PHS). THE BENEFIT IS A COORDINATED EFFORT TO PROVIDE COMPREHENSIVE HEALTH CARE TO AN EXTENDED, MULTI-COUNTY RURAL AREA. AN ADDITIONAL BENEFIT IS INCREASED EFFICIENCIES THROUGH SHARED RESOURCES, THEREFORE PROVIDING A WIDER RANGE OF HEALTH SERVICES THROUGHOUT THE ENTIRE COMBINED SERVICE AREA. | ||
| WI | REPORTS FILED WITH STATES | PART VI, LINE 7 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Employment Contract | X | WrittenEmploymentContract |
| Compensation Survey | X | CompensationSurvey |
| Board Or Committee Approval | X | BoardOrCommitteeApproval |
| Severance Payment | 0 | SeverancePayment |
| Supplemental Nonqual Retire Plan | 1 | SupplementalNonqualRetirePlan |
| Equity Based Comp Arrangement | 0 | EquityBasedCompArrangement |
| Comp Based On Revenue Of Filing Org | 0 | CompBasedOnRevenueOfFilingOrg |
| Comp Based On Revenue Related Orgs | 0 | CompBasedOnRevenueRelatedOrgs |
| Comp Based Net Earnings Filing Org | 0 | CompBasedNetEarningsFilingOrg |
| Comp Based Net Earnings Relate Orgs | 0 | CompBasedNetEarningsRelateOrgs |
| Any Non Fixed Payments | 0 | AnyNonFixedPayments |
| Initial Contract Exception | 0 | InitialContractException |
Form990 Schedule J Part II Form990ScheduleJPartII (6 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DONALD R CAVES | |||||||||||||
| 33689 | 70938 | 0 | 0 | 8838 | 43537 | 699 | 3443 | 1957 | 9481 | 45183 | 127399 | 0 | 0 |
| MICHAEL STAUDINGER MD | |||||||||||||
| 0 | 316171 | 0 | 20092 | 0 | 2212 | 0 | 7350 | 0 | 21196 | 0 | 367021 | 0 | 0 |
| THOMAS KRYSTOWIAK | |||||||||||||
| 3840 | 149778 | 0 | 0 | 375 | 14631 | 219 | 8540 | 505 | 19696 | 4939 | 192645 | 0 | 0 |
| CHAD VOSKUIL MD | |||||||||||||
| 0 | 265568 | 0 | 0 | 0 | 0 | 0 | 7350 | 0 | 27146 | 0 | 300064 | 0 | 0 |
| REGINALDO ABOLEDA MD | |||||||||||||
| 0 | 240837 | 0 | 0 | 0 | 0 | 0 | 9736 | 0 | 9616 | 0 | 260189 | 0 | 0 |
| CHANDLER CAVES MD | |||||||||||||
| 0 | 287317 | 0 | 6264 | 0 | 29029 | 0 | 7350 | 0 | 25167 | 0 | 355127 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Reference | PART I, LINE 4B | ReturnReference |
| Explanation | MICHAEL STAUDINGER, MD, CHAD VOSKUIL, MD, REGINALDO ABOLEDA, MD, AND CHANDLER CAVES, MD PARTICIPATED BUT DID NOT RECEIVE PAYMENT FROM A NONQUALIFIED RETIREMENT PLAN. | Explanation |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (2 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| ANDREEN KJENTVET | |||
| SPOUSE OF BOARD MEMBER. | 35001 | COMPENSATION | 0 |
| CHANDLER CAVES MD | |||
| SON OF CEO | 355127 | COMPENSATION - COMMON LAW EMPLOYEE. CHANDLER IS EMPLOYED BY CHN (RELATED PARTY) BUT WORKS EXCLUSIVELY AT WILD ROSE HOSPITAL. | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (10 entries)
| Return ReferenceReturnReference | ExplanationExplanation | IdentifierIdentifier |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | MARK KJENTVET HAS A FAMILY RELATIONSHIP WITH ANDREEN KJENTVET, EMPLOYEE OF WILD ROSE HOSPITAL. DONALD CAVES HAS A FAMILY RELATIONSHIP WITH CHANDLER CAVES M.D. WHOM IS EMPLOYED BY RELATED PARTY. | |
| FORM 990, PART VI, SECTION A, LINE 3 | WILD ROSE COMMUNITY MEMORIAL HOSPITAL IS AFFILIATED WITH COMMUNITY HEALTH NETWORK (CHN), A 501(C)(3) ORGANIZATION, THROUGH AN AFFILIATION AGREEMENT BETWEEN THE TWO ORGANIZATIONS. THE AFFILIATION AGREEMENT IS DATED AUGUST 19, 2009, EFFECTIVE OCTOBER 1, 2009. BOTH ORGANIZATIONS HAVE FORMED PARTNERS HEALTH SYSTEM (PHS), A 501(C)(3) ORGANIZATION, WITH THE INTENT OF CREATING AN INTEGRATED HEALTH CARE DELIVERY SYSTEM. THROUGH PHS, SOME OF WILD ROSE HOSPITAL'S MANAGEMENT DUTIES ARE DELEGATED TO PHS OR CHN SUCH AS: - CONTRACTING FOR SERVICES AND PURCHASING OF EQUIPMENT AND SUPPLIES - SETTING OF CHARGES - BILLING AND COLLECTIONS - DEVELOPMENT OF POLICIES AND PROCEDURES - PREPARATION OF BUDGETS - PREPARATION OF FINANCIAL AND COST REPORTS - CONTRACTING FOR SERVICES BY HEALTH CARE PROVIDERS - HANDLING OF MATTERS INVOLVING MEDICAL STAFF RELATIONS - PROVIDE ANESTHESIA COVERAGE | |
| FORM 990, PART VI, SECTION A, LINE 7B | WILD ROSE HOSPITAL(WRH) HAS DELEGATED TO THE PARTNERS HEALTH SYSTEM (PHS) BOARD THE FOLLOWING AUTHORITY: - PHS SHALL ESTABLISH OVERALL STRATEGIC & BUDGETARY OBJECTIVES FOR THE SYSTEM (INCLUDES WRH) - PHS SHALL REVIEW, CONSOLIDATE, MODIFY AND APPROVE OR DISAPPROVE STRATEGIC PLANS PREPARED BY THE PARTIES - PHS SHALL INITIATE AND APPROVE CAPITAL PROJECTS FOR OR ON BEHALF OF THE PARTIES - PHS SHALL INITIATE AND APPROVE THE INCURRENCE OF DEBT BY THE PARTIES - PHS MAY CONTRACT ON BEHALF OF THE PARTIES - PHS SHALL ESTABLISH CHARGE RATES FOR THE PARTIES - PHS CEO SHALL HIRE THE CEOS OF THE PARTIES SUBJECT TO APPROVAL OF THE BOARD OF DIRECTORS OF THE APPLICABLE PARTY - PHS CEO SHALL HAVE THE AUTHORITY TO TERMINATE THE CEO OF A PARTY, SUBJECT TO THE CONSENT OF THE CHAIR OF THE BOARD OF THE PARTY. - PHS SHALL MANAGE THE SYSTEMS EMPLOYED PHYSICIANS | |
| FORM 990, PART VI, SECTION B, LINE 11 | THE BOD HAS DELEGATED THE DETAILED REVIEW OF THE FORM 990 TO MANAGEMENT OF THE CORPORATION. THEY COMPLETED THE REVIEW PRIOR TO SUBMISSION. | |
| FORM 990, PART VI, SECTION B, LINE 12C | PERIODIC REVIEWS ARE PERFORMED. | |
| THE PRESIDENT OF WILD ROSE HOSPITAL WAS EMPLOYED BY COMMUNITY HEALTH NETWORK (CHN) UNTIL THE 4TH QUARTER. ONCE A YEAR, CHN'S CEO REVIEWS COMPENSATION BENCHMARK DATA AND COMPARES THE DATA WITH WILD ROSE HOSPITAL PRESIDENT'S CURRENT SALARY AND THE PROPOSED INCREASE. BASED ON THE DATA, THE CEO DETERMINES THE PRESIDENT'S SALARY FOR THE COMING YEAR. THE QUESTION IS MARKED "NO" BECAUSE THE PROCESS IS NOT DOCUMENTED. THE COMPENSATION FOR THE NEW CEO POSITION FOR WILD ROSE WAS DETERMINED USING A CONSULTANT AND COMPARATIVE DATA FOR SIMILAR POSITIONS. | ||
| FORM 990, PART VI, SECTION C, LINE 19 | THE ORGANIZATION'S FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, AND GOVERNING DOCUMENTS ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR INSPECTION, EXCEPT DISCLOSURE OF THE FINANCIAL STATEMENTS WITH THE FORM 990, AS REQUIRED. | |
| FORM 990, PART VII, SECTION A, COLUMN B | DONALD CAVES WORKED AT RELATED ORGANIZATION AN AVERAGE OF 9 HOURS PER WEEK FOR 9 MONTHS OF THE CALENDAR YEAR AND 40.0 HOURS PER WEEK FOR 3 MONTHS OF THE CALENDAR YEAR. THOMAS KRYSTOWIAK WORKED AN AVERAGE OF 39.0 HOURS PER WEEK AT A RELATED ORGANIZATION. | AVERAGE HOURS WORKED AT RELATED ORGANIZATIONS: |
| FORM 990, PART XI, LINE 5: | CHANGE IN INTEREST IN PARTNERS HEALTH SYSTEM FOUNDATION, INC. 2,608. TOTAL TO FORM 990, PART XI, LINE 5: 2,608. | CHANGES IN NET ASSETS OR FUND BALANCES: |
| FORM 990, PART XI, LINE 2C | MANAGEMENT PROVIDES OVERSIGHT OF THE AUDIT. AUDIT RESULTS ARE PRESENTED TO MANAGEMENT AND THE BOARD OF DIRECTORS. THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. | OVERSIGHT OF AUDIT |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII (3 entries)
| Address Line1AddressUS/AddressLine1 | CityAddressUS/City | StateAddressUS/State | ZIP CodeAddressUS/ZIPCode | EINEIN | Primary ActivitiesPrimaryActivities | Legal Domicile StateLegalDomicileState | Exempt Code SectionExemptCodeSection | Public Charity StatusPublicCharityStatus | Business Name Line1DirectControllingEntityName/BusinessNameLine1 | Controlled OrgControlledOrg | Direct Controlling Entity NADirectControllingEntityNA |
|---|---|---|---|---|---|---|---|---|---|---|---|
| COMMUNITY HEALTH NETWORK INC | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 390806359 | HOSPITAL | WI | 501(C)(3) | LINE 3 | PARTNERS HEALTH SYSTEM INC | 0 | |
| PARTNERS HEALTH SYSTEM INC | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 271119447 | SUPPORTING ORGANIZATION | WI | 501(C)(3) | LINE 11B, II | 0 | N/A | |
| PARTNERS HEALTH SYSTEM FOUNDATION | |||||||||||
| 225 MEMORIAL DRIVE | BERLIN | WI | 54923 | 731639346 | SUPPORTING ORGANIZATION | WI | 501(C)(3) | LINE 11B, II | PARTNERS HEALTH SYSTEM INC | 0 | |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Ann Rents Royalties | 0 | ReceiptOfIntAnnRentsRoyalties |
| Gift Grant Or Cap Contr To Other Org | 0 | GiftGrantOrCapContrToOtherOrg |
| Gift Grant Or Cap Contr Fr Other Org | 0 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 1 | LoansOrGuaranteesFromOtherOrg |
| Sale Of Assets To Other Org | 0 | SaleOfAssetsToOtherOrg |
| Purchase Of Assets From Other Org | 0 | PurchaseOfAssetsFromOtherOrg |
| Exchange Of Assets | 0 | ExchangeOfAssets |
| Rental Of Facilities To Other Orgs | 0 | RentalOfFacilitiesToOtherOrgs |
| Rental Of Facilities Fr Other Orgs | 1 | RentalOfFacilitiesFrOtherOrgs |
| Perform Of Services For Other Orgs | 0 | PerformOfServicesForOtherOrgs |
| Perform Of Services By Other Orgs | 0 | PerformOfServicesByOtherOrgs |
| Sharing Of Facilities | 0 | SharingOfFacilities |
| Sharing Of Paid Employees | 1 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 1 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 1 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |