2012-08-14T11:07:46-05:00 2011-12-31 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PKWY/PO BOX 690 EAU CLAIRE WI 547020690 990 2011-01-01 390872080 SAUK PRAIRIE MEMORIAL HOSPITAL INC SAUK 6086433311 80 FIRST STREET PRAIRIE DU SAC WI 53578 CAROL J MAY 6086433311 2012-08-10 0 PAUL M TRACZEK CPA P01368830 7158323407 2012-08-10 2011 2016-02-24 21:20:13Z SAUK PRAIRIE MEMORIAL HOSPITAL & CLINICS CAROL J MAY 80 FIRST STREET PRAIRIE DU SAC WI 53578 76146374 0 X WWW.SPMH.ORG X 1956 WI EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME. 11 1 552 150 7353 -14761 399816 277316 58575786 57852534 896938 621744 -237596 -213678 59634944 58537916 100855 119289 0 0 28665526 30437774 0 0 93514 23944125 23226236 52710506 53783299 6924438 4754617 65343589 72991043 6689879 8864607 58653710 64126436 X MISSION: EXTRAORDINARY HEALTHCARE FROM THE HEART - ONE PERSON AT A TIME.VISION: WE WILL SET THE STANDARD FOR COMMUNITY-BASED HEALTHCARE THAT IMPROVES THE HEALTH AND QUALITY OF LIFE OF THE PEOPLE WE SERVE.SEE CONTINUATION OF MISSION AND VISION INFORMATION UNDER STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS PART 4C. 1 0 39687590 94392 53281119 SAUK PRAIRIE MEMORIAL HOSPITAL, INC. (SPMHC), A 36-BED ACUTE CARE GENERAL HOSPITAL, IS A NONPROFIT, NONSTOCK WISCONSIN CORPORATION PROVIDING SERVICES TO SAUK CITY, PRAIRIE DU SAC, AND THE SURROUNDING COMMUNITIES.TOTAL ADMISSIONS FOR 2011 WERE 1,769 WITH PATIENT DAYS OF 4,650. KEY PATIENT SERVICES INCLUDED 269 BIRTHS IN THE NURSERY, 5,203 SURGICAL PROCEDURES, 53,768 REHABILITATION THERAPY SERVICES, 24,353 MEDICAL IMAGING SERVICES, AND 13,783 EMERGENCY ROOM VISITS ARE AMONG MANY OF THE SERVICES PROVIDED TO PATIENTS IN 2011. 4848517 4564062 SPMH ALSO OWNS AND OPERATES PHYSICIAN PRACTICES IN SPRING GREEN, BLACK EARTH, PLAIN, AND LODI, WISCONSIN. TOTAL CLINIC VISITS TO THESE FOUR SITES FOR 2011 WAS 35,109. SPMHC FULFILLS ITS MISSION AND VISION BY OFFERING HIGH-QUALITY SERVICES IN RURAL COMMUNITIES, THEREBY ALLOWING OUR PATIENTS TO BE TREATED LOCALLY WITHOUT LENGTHY COMMUTES OR WAITING. SPMHC HAS GAINED A REGIONAL REPUTATION OF EXCELLENCE IN ORTHOPEDICS, GENERAL SURGERY, SPINE SURGERY, AND GYNECOLOGIC SURGERY. THE HOSPITAL TREATED MORE THAN 1,700 INPATIENTS IN 2011, 269 BABIES ENTERED THE WORLD HERE, AND THE HOSPITAL HAD 55,500 OUTPATIENT VISITS. SPMHC OPERATES FOUR CLINICS IN RURAL AREAS: LODI, SPRING GREEN, PLAIN, AND BLACK EARTH, BRINGING PRIMARY CARE TO THOSE COMMUNITIES. THE CLINICS HAD MORE THAN 35,000 VISITS IN 2011. AS A CHARITABLE ORGANIZATION, SPMHC PROVIDED OVER $2 MILLION IN FREE CARE TO PATIENTS IN OUR SERVICE AREA IN 2011, IN ADDITION TO SUBSIDIZING SERVICES THAT DO NOT COVER COSTS, FREE HEALTH SCREENINGS, EDUCATIONAL PROGRAMS, AND YOUTH OUTREACH.AS THE LARGEST EMPLOYER IN THE COMMUNITY, SPMHC HAS A POSITIVE ECONOMIC IMPACT ON ITS COMMUNITIES. IT DIRECTLY AND INDIRECTLY CREATES 847 JOBS AND ITS IMPACT ON THE LOCAL ECONOMY IS OVER $54 MILLION ANNUALLY. 44536107 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 37 0 1 552 1 1 1 0 0 0 0 0 0 0 0 0 X 11 1 0 0 1 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X CAROL J MAY 6086433311 80 FIRST STREET PRAIRIE DU SAC WI 53578 NANCY BREUNIG 4.80 X 18200 0 0 TAMMY ADLER 4.60 X X 20300 0 0 NEIL BISHOP 4.80 X 18100 0 0 RICHARD MARINO 4.60 X 18800 0 0 TOM SCHWARZ 5.60 X X 25206 0 0 ALLAN PECKHAM 3.30 X X 13900 0 0 JOHN DEGIOVANNI 1.60 X 7171 0 0 PHILLIP KEISER 2.50 X 10600 0 0 DALE CARLSON 3.00 X X 12400 0 0 ROXI MAIER 3.60 X 14221 0 0 VICKIE WENZEL SCHLICK 2.50 X 10400 0 0 ROBERTA ECCHER 50.00 X 135273 0 14543 CAROL MAY 50.00 X 178753 0 18260 LARRY SCHROEDER 50.00 X 284595 0 23309 KEN CARLSON 50.00 X 150955 0 15787 CARLA PECK 50.00 X 131928 0 13181 MARGARET SHEEKS 50.00 X 141931 0 14864 MARK STARR 40.00 X 232018 0 19690 MILES MORGAN 40.00 X 261488 0 10275 THOMAS MURPHY 40.00 X 230313 0 13644 ERIC WARBASSE 40.00 X 226913 0 18473 ROLLAND TAYLOR 40.00 X 217669 0 10984 2361134 0 173010 42 0 1 0 KAHLER SLATER INC 111 W WISCONSIN AVE MILWAUKEE WI 53203 ARCHITECTURAL SERVICES 1031024 SHARED IMAGING SERVICES PO BOX 45686 MADISON WI 53744 NUCLEAR MED, ECHO, ULTRASOUND SERVICES 856770 CENTRAL MINNESOTA DIAGNOSTIC INC 150 10TH ST NW MILACA MN 56353 MRI SERVICE 630700 SHARED MEDICAL SERVICES INC PO BOX 330 COTTAGE GROVE WI 53527 CT SCAN SERVICE 457080 KRAEMER BROTHERS PO BOX 219 PLAIN WI 53577 CONSTRUCTION/BUILDING SERVICES 442195 13 153184 49132 75000 277316 HOSPITAL PATIENT REVEN 621990 52043794 52043794 CLINIC REVENUE 621110 4564062 4564062 OTHER HOSPITAL SERVICE 621990 978736 971383 7353 CAFETERIA AND VENDING 621990 206817 206817 LIFELINE SERVICES 621990 59125 59125 57852534 633842 633842 275692 489370 -213678 -213678 -213678 17106540 450 17091915 27173 14625 -26723 -12098 -12098 58537916 57845181 7353 408066 119289 119289 1231322 1231322 23374004 20019527 3283038 71439 980014 839369 137650 2995 3236620 2772123 454605 9892 1615814 1374056 236696 5062 51937 51937 102973 102973 1923697 1250203 673494 197627 26341 171286 149584 113445 36134 5 239039 239039 995925 943448 50728 1749 29333 23137 6196 165594 104146 61448 2208106 2208106 1504820 94082 1410738 SUPPLIES 14860861 14179357 679132 2372 BAD DEBT EXPENSE 513515 513515 OTHER EXPENSES 391441 67652 323789 REPAIRS & MAINTENANCE 381154 377681 3473 -489370 -489370 53783299 44536107 9153678 93514 58135 129498 14951206 11453265 5346579 6265081 955466 979178 640445 923503 54133832 28449706 19942751 25684126 17009420 23239127 115188 356917 6324399 3960348 65343589 72991043 5854760 6807135 150653 1262770 684466 794702 6689879 8864607 X 53076103 57419720 4521671 5601205 1055936 1105511 58653710 64126436 65343589 72991043 X 4754617 718109 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 1 0 0 0 1 0 0 1 9767 9767 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: SAUK PRAIRIE MEMORIAL HOSPITAL PAYS ANNUAL ASSOCIATION MEMBERSHIP TO THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. AHA AND WHA HAVE NOTIFIED SPMHC THAT APPROXIMATELY $6,863 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. SPMHC IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, SPMHC PAYS MEMBERSHIP FEES TO THE RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGH WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT APPROXIMATELY $2,904 OF THE FEES PAID BY SPMHC IN 2011 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. PART IV, SUPPLEMENTAL INFORMATION: PART II-B, LINE 1 (D AND G): REPRESENTATIVES FROM SPMHC ANNUALLY PARTICIPATE IN THE WISCONSIN HOSPITAL ASSOCIATION'S ADVOCACY DAY WHERE THE REPRESENTATIVES ARE GIVEN THE OPPORTUNITY TO GATHER WITH OTHER HEALTHCARE ORGANIZATIONS IN THE STATE OF WISCONSIN AND ALSO MEET WITH STATE GOVERNMENT REPRESENTATIVES WITH THE PURPOSE OF IMPROVING THE DELIVERY OF HEALTHCARE NOT ONLY AT SPMHC BUT ALSO COLLECTIVELY IN THE STATE OF WISCONSIN. AS ISSUES OR PROPOSED LEGISLATION ARISE THROUGHOUT THE YEAR, OFFICIALS OF SPMHC WILL SEND LETTERS OF COMMENT TO LOCAL, STATE, AND FEDERAL GOVERNMENT REPRESENTATIVES TO EITHER SHOW SUPPORT OF PROPOSED CHANGES OR VOICE AN OPINION TO IMPROVE THE OUTCOME OF PROPOSED LEGISLATION OR OTHER CHANGES. THESE ACTIVITIES RESULT IN MINIMAL COST TO THE OPERATION OF SPMHC. 1147396 49575 1196971 0 1084880 92516 30000 1147396 0.00000 0.92360 0.07640 0 1 1 5585154 5585154 19747004 10735970 9011034 25976449 17713736 8262713 2825225 2825225 25684126 ACCRUED INTEREST RECEIVABLE 1232 INVESTMENT IN CENTRAL MN DIAGNOSTIC 755000 INTEREST IN NET ASSETS OF FOUNDATION 3204116 3960348 DEFERRED COMPENSATION PLAN LIABILITY 794702 794702 58537916 53783299 4754617 -411000 1129109 718109 5472726 58932894 489370 489370 58443524 94392 94392 58537916 54178277 489370 489370 53688907 94392 94392 53783299 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE SCHNELLER SISTERS FUND SHALL BE HELD AS A SEPARATE PERMANENT ENDOWMENT FUND ON THE BOOKS AND RECORDS OF THE FOUNDATION, THE INCOME FROM WHICH SHALL BE DISTRIBUTED TO SAUK PRAIRIE MEMORIAL HOSPITAL FOR UNRESTRICTED NEEDS. ALL DISTRIBUTIONS FROM THE SCHNELLER SISTERS FUND SHALL BE DESIGNATED AS HAVING BEEN MADE "IN MEMORY OF THE SCHNELLER SISTERS: CECELIA SCHNELLER MUELLER, ADLYNN F. BALFANZ, AND MARY ANN ROSAR." DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. 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 OR THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. 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 ENDING DECEMBER 31, 2011 AND 2010, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE FINANCIAL STATEMENTS. IN ADDITION, THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2011 AND 2010. FEDERAL TAX RETURNS FOR YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS -81,184. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 1,210,293. TOTAL TO SCHEDULE D, PART XI, LINE 8: 1,129,109. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES NETTED 489,370. PART XII, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC SERVICES PROVIDED 94,392. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENT EXPENSES NETTED 489,370. PART XIII, LINE 4B - OTHER ADJUSTMENTS: GOOD NEIGHBOR CLINIC DONATIONS 94,392. 1 1 1 X 1 X 1 1 1 0 1 1 995017 995017 0.01870 3550806 2651672 899134 0.01690 4545823 2651672 1894151 0.03560 576601 120017 456584 0.00860 55636 55636 0.00100 9255636 6672008 2583628 0.04850 172783 172783 0.00320 10060656 6792025 3268631 0.06130 14606479 9443697 5162782 0.09690 18583 18583 0.00030 1653 1653 0.00000 1408 1408 0.00000 11674 11674 0.00020 2964 2964 0.00010 36282 36282 0.00060 0 252698 126349 11823410 15536988 -3713578 X 1 1 1 1 SAUK PRAIRIE MEMORIAL HOSPITAL INC

80 FIRST ST PRAIRIE DU SAC WI 53578

X X X ALSO OPERATES 4 OUTPATIENT CLINICS SAUK PRAIRIE MEMORIAL HOSPITAL INC 1 1 X X X X X X X X X 10 1 1 0 X X X X X X X X X 0 1 1 100.000000000000 1 400.000000000000 1 X X X X X 1 1 X X X 1 X 0 1 X 0 1 4 LODI MEDICAL CLINIC

160 VALLEY DRIVE LODI WI 53555

PHYSICIAN CLINIC RIVER VALLEY MEDICAL CLINIC

436 SUNRISE DRIVE SPRING GREEN WI 53588

RURAL HEALTH CLINIC BLACK EARTH MEDICAL CLINIC

1529 STATE STREET A BLACK EARTH WI 53515

PHYSICIAN CLINIC PLAIN MEDICAL CLINIC

825 MAIN STREET PLAIN WI 53577

RURAL HEALTH CLINIC PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS PRIMARILY BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICES REVENUES. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. THE COSTING METHOD FOR SUBSIDIZED HEALTH SERVICES IS BASED ON INTERNAL RECORDS AND ALLOCATIONS WHICH ARE SIMILAR TO A DIRECT COSTING ACCOUNTING SYSTEM FOR THESE SERVICES NOTED AS SUBSIDIZED HEALTH SERVICES. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT SAUK PRAIRIE MEMORIAL HOSPITAL INCLUDE THE OPERATION OF SEVERAL HOSPITAL DEPARTMENTS THAT OPERATE AT A LOSS FROM OPERATIONS, BUT ARE CONSIDERED VITAL HOSPITAL AND CLINIC SERVICES SUCH AS THE INTENSIVE CARE UNIT, OUTPATIENT PHYSICIAN CLINICS, INCLUDING INTERNAL MEDICINE, AND SEVERAL OTHER DEPARTMENTS. A LARGE PORTION OF THESE SERVICES ARE ACCESSED BY COMMUNITY MEMBERS THROUGH THE HOSPITAL'S EMERGENCY SERVICES DEPARTMENT. IT IS THE GOAL OF SAUK PRAIRIE MEMORIAL HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF A PATIENT'S ABILITY TO PAY. 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 $ 513515. PART II: SPMHC'S COMMUNITY BUILDING EFFORTS PROMOTE BOTH THE PHYSICAL AND ECONOMIC HEALTH OF THE COMMUNITIES WE SERVE. FROM AN ECONOMIC PERSPECTIVE, SPMHC STAFF CONTRIBUTE HUNDREDS OF HOURS TO CHAMBERS OF COMMERCE ACTIVITIES AND SUPPORT WORKFORCE DEVELOPMENT THROUGH THE "CLUB SCRUB" PROGRAM. THE PHYSICAL HEALTH OF THE COMMUNITY IS SUPPORTED THROUGH THE DEVELOPMENT OF HEALTH-RELATED COALITIONS, PARTICULARLY THE SAUK PRAIRIE WELLNESS MOVEMENT. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY REPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE ORGANIZATION PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.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 CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. PART III, LINE 8: WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PATIENTS, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY.THE TOTAL MEDICARE REVENUE SHOWN ON SCHEDULE H IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY THE CHARGES FROM MEDICARE PROGRAM BENEFICIARIES THAT ARE REPORTED ON THE HOSPITAL'S MEDICARE COST REPORT. THE AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT AT SAUK PRAIRIE MEMORIAL HOSPITAL, PHYSICIAN SERVICES FOR THE INTERNAL MEDICINE (HOSPITALIST) PROGRAM, PHYSICIAN SERVICES PROVIDED AT THE FOUR OUTLYING PHYSICIAN CLINICS, CRNA SERVICES PROVIDED TO PATIENTS UNDERGOING ANESTHESIA AT THE HOSPITAL, AND A SIGNIFICANT PORTION OF LAB SERVICES WHICH ARE REIMBURSED BY THE MEDICARE PROGRAM UNDER ANOTHER METHODOLOGY. PHYSICIAN COVERAGE AND OUTPATIENT LAB SERVICES ARE REIMBURSED PRIMARILY ON A FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY PHYSICIAN SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT SAUK PRAIRIE MEMORIAL HOSPITAL AND CLINICS PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE DIVIDED BY HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE). THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES, WHICH ARE REIMBURSED ON A COST REPORTING METHODOLOGY. INCLUDING THE FEE SCHEDULE ITEMS, SUCH AS PHYSICIAN SERVICES, WOULD PRODUCE A LARGER LOSS OR SHORTFALL ON THESE SERVICES TO BE REPORTED ON THE FORM 990 IN ANY GIVEN YEAR. PART III, LINE 9B: IT IS THE POLICY OF SAUK PRAIRIE MEMORIAL HOSPITAL AND CLINICS THAT EACH PATIENT RECEIVES CARE REGARDLESS OF THE ABILITY TO PAY. IF DURING THE COLLECTION PROCESS A PATIENT DOES NOT COMPLETE THE NECESSARY PAPERWORK OR RESPOND TO ATTEMPTS BY THE HOSPITAL TO PROVIDE CHARITY SERVICES, THE PATIENT MAY STILL REQUEST CHARITY INFORMATION AND COMPLETE THE INFORMATION AT ANY TIME DURING THE COLLECTION PROCESS. THE PATIENT WILL BE REFERRED TO THE ORGANIZATION'S CHARITY CARE POLICY AND CAN QUALIFY FOR CHARITY CARE AND HAVE ANY COLLECTION ISSUES REVERSED BY THE ORGANIZATON IF THEY SHOW A NEED FOR THE CARE BASED ON THE ORGANIZATION'S POLICY. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 1J: INPUT FROM LOCAL PHYSICIANS WITH REGARD TO THE HIGHEST COMMUNITY HEALTH NEEDS WAS ALSO INCLUDED IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 3: IN FEBRUARY-MARCH 2011 A MORE FORMALIZED PROCESS WAS DONE TO UPDATE THE 2010 PRELIMINARY COMMUNITY HEALTH NEEDS ASSESSMENT. SPMHC COMMISSIONED MATOUSEK & ASSOCIATES, A MARKETING RESEARCH AND CONSULTING FIRM LOCATED IN GREEN BAY, WI, TO CONDUCT RESEARCH WITH RESIDENTS OF KEY COMMUNITIES WE SERVE. A TOTAL OF 14 FOCUS GROUPS WERE HELD IN FIVE COMMUNITIES WITH COMMUNITY AND BUSINESS LEADERS, AND WITH RANDOMLY SELECTED WOMEN. A TOTAL OF 140 INDIVIDUALS PARTICIPATED IN GROUP INTERVIEWS. EACH FACILITATED SESSION RESULTED IN A LIST OF PRIORITIZED HEALTH NEEDS AND ISSUES.ADDITIONALLY, INDIVIDUAL INTERVIEWS WERE ALSO CONDUCTED WITH HOSPITAL BOARD MEMBERS.ADDITIONAL INPUT WAS ALSO PROVIDED BY MEMBERS OF THE HOSPITAL'S LEADERSHIP TEAM. MEMBERS OF OUR LEADERSHIP TEAM ARE ACTIVELY ENGAGED IN COMMUNITY ORGANIZATIONS INCLUDING THE GOOD NEIGHBOR CLINIC BOARD (LOCAL FREE CLINIC), DEVELOPMENT OF A DENTAL CLINIC FOR LOW-INCOME INDIVIDUALS, SAFETY COALITION, AND VARIOUS COMMUNITY ORGANIZATIONS. IN THAT CAPACITY, THEY INTERACT ABOUT COMMUNITY HEALTH ISSUES WITH COMMUNITY MEMBERS. SPMHC IS ALSO REPRESENTED BY 11 COMMUNITY MEMBERS ON ITS BOARD OF DIRECTORS WHO SERVE AS THE COMMUNITY "EARS" OF OUR ORGANIZATION. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 4: SPMHC WORKED WITH REEDSBURG AREA MEDICAL CENTER (REEDSBURG, WI) AND ST. CLARE HOSPITAL (BARABOO, WI) AND THE SAUK COUNTY DEPARTMENT OF HEALTH TO IDENTIFY AND PRIORITIZE HEALTH NEEDS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 5C: THE COMMUNITY HEALTH NEEDS ASSESSMENT WILL BE MADE PUBLICLY AVAILABLE IN SEPTEMBER 2012. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 6I: THE PRIMARY OBJECTIVE OF THE SPMHC COMMUNITY HEALTH NEEDS ASSESSMENT ("CHNA") IS TO "DECREASE OBESITY AND INCREASE PHYSICAL ACTIVITY."IN THE PAST YEAR, SPMHC HAS ENGAGED IN FOUR ACTIVITIES TO ADDRESS THE REDUCTION OF OBESITY AND INCREASING PHYSICAL ACTIVITY. THESE INCLUDE: 1) "KIDS COUNT" OBESITY REDUCTION PROJECT: IN COLLABORATION WITH THE SAUK PRAIRIE SCHOOL DISTRICT, SPMHC HAS DEVELOPED A 5-YEAR PROJECT TARGETED TOWARD 3RD GRADERS TO INCREASE CLASSROOM ACTIVITY, IMPROVE NUTRITION, AND INCREASE PHYSICAL ACTIVITIES. THIS PROJECT HAS NOW EXPANDED TO INCLUDE THE INCOMING 3RD GRADE CLASS AND NEW 4TH GRADERS (LAST YEAR'S 3RD GRADERS).2) WISCONSIN HEIGHTS COMMUNITY GARDEN: SPMHC ORGANIZED LOCAL VOLUNTEERS IN THE WISCONSIN HEIGHTS SCHOOL DISTRICT TO CREATE A 2-ACRE COMMUNITY GARDEN IN AN EFFORT TO IMPROVE ACCESS TO NUTRITIONAL FOOD AND TO RAISE AWARENESS ABOUT THE VALUE OF HEALTHY EATING HABITS. THE INITIAL TARGET NUMBER OF GARDENERS WAS SET AT 10. THIS GOAL WAS FAR EXCEEDED AS THE GARDEN ATTRACTED 30 PARTICIPANTS.3) SAUK PRAIRIE WELLNESS MOVEMENT: ORIGINALLY FORMED AS THE SAUK PRAIRIE OBESITY REDUCTION COLLABORATION BY PRAIRIE CLINIC, S.C., A LOCAL PRIMARY CARE CLINIC, THE GROUP'S ORIGINAL MISSION TO "WORK TOGETHER AS A COMMUNITY TO CHAMPION THE REDUCTION OF OBESITY IN OUR COMMUNITY" REMAINS INTACT. SINCE THE GROUP'S ORIGINAL MEETING IN OCTOBER 2010, THE GROUP HAS GROWN IN NUMBER OF PARTICIPANTS, CREATED A NEW IDENTITY AS THE WELLNESS MOVEMENT, PARTICIPATED IN A HEALTH NEEDS ASSESSMENT, AND DETERMINED ITS FIRST TWO INITIATIVES, THE KIDS COUNT INITIATIVE (DESCRIBED ABOVE) AND WELLNESS IN THE WORKPLACE. 4) GETTING BETTER PROGRAM: THIS PROGRAM FOCUSES ON MORBIDLY OBESE/CHRONICALLY SYMPTOMATIC ADULTS WHO INDICATE A DESIRE TO CHANGE THEIR CURRENT STATE OF HEALTH. CLINICAL AND BEHAVIORAL DATA OF THE 24 STUDY PARTICIPANTS INDICATES A SIGNIFICANT CHANGE IN BODY MASS INDEX, HGA1C LEVELS, AND A WILLINGNESS TO MAINTAIN CHANGES IN EXERCISE AND DIETARY HABITS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 7: AS WITH ALL HEALTHCARE ORGANIZATIONS, ADEQUATE RESOURCES ARE NOT AVAILABLE TO ADDRESS EVERY UNMET HEALTH NEED IN THE COMMUNITIES SPMHC SERVES. SPMHC'S PHILOSOPHICAL POSITION REGARDING THE HEALTH OF THE COMMUNITY IS TO FOCUS ON FEWER, RATHER THAN MANY, INITIATIVES SO THAT THOSE WE WORK ON HAVE A HIGHER CHANCE OF SUCCESS. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: INFORMATION ABOUT THE POLICY IS INCLUDED ON BILLING INVOICES, ON ADMISSION INFORMATION, ON THE WEBSITE, AND IS REFERENCED IN COLLECTION EFFORTS. IT IS ALSO MENTIONED IN COMMUNITY TALKS ON HEALTH INSURANCE. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 19D: THE HOSPITAL FOLLOWS ITS NORMAL PROCEDURES FOR COLLECTION OF THESE ACCOUNTS, INCLUDING DISCOUNTS BASED ON INCOME/ASSET LEVELS, PROMPT PAYMENT, OR MEDICAL INDIGENCE. SAUK PRAIRIE MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 21: PATIENTS WITHOUT INSURANCE AND NOT ELIGIBLE FOR FINANCIAL ASSISTANCE ARE GIVEN OPPORTUNITIES FOR DISCOUNTS UNDER INTERNAL PROGRAMS. IF PATIENTS DO NOT AVAIL THEMSELVES OF SUCH OPPORTUNITIES, THEY MAY BE CHARGED THE GROSS CHARGE. PART VI, LINE 2: SPMHC ENGAGES IN THE FOLLOWING ACTIVITIES TO ASSESS THE HEALTHCARE NEEDS OF THE 42,000 RESIDENTS THROUGHOUT ITS 700 SQUARE MILE PRIMARY SERVICE AREA: - ANALYZE HEALTH STATUS INFORMATION, EPIDEMIOLOGICAL DATA, AND HOSPITAL DISCHARGE DATA FURNISHED BY THE STATE OF WISCONSIN AND SAUK COUNTY TO IDENTIFY ISSUES AND TRENDS.- MEET PERIODICALLY WITH THE COUNTY HEALTH DEPARTMENT AND TWO OTHER NEARBY HOSPITALS TO ASSESS HIGH PRIORITY HEALTH NEEDS AND COORDINATE ACTION.- PARTICIPATE IN AND HELP COORDINATE COUNTY-WIDE INPUT SESSIONS WITH THE COUNTY HEALTH DEPARTMENT.- LEAD AND PARTICIPATE IN COMMUNITY WELLNESS GROUPS AND INITIATIVES THROUGHOUT THE SERVICE AREA.- CONDUCT "COMMUNITY HEALTH NEED" FOCUS GROUPS CONSISTING OF COMMUNITY LEADERS AND RANDOMLY SELECTED RESIDENTS. - ANALYZE THE POPULATION-BASED NEED FOR MEDICAL PROVIDERS BY SPECIALTY. THIS INFORMATION IS ASSESSED AND MODIFIED BY MEMBERS OF THE SPMHC MEDICAL STAFF.- SPMHC LEADER PARTICIPATION AND LEADERSHIP IN CIVIC AND COMMUNITY SERVICE ORGANIZATIONS.- ACTIVELY ENGAGE SPMHC BOARD MEMBERS IN COMMUNITY HEALTH IMPROVEMENT INITIATIVES AND PROVIDE THE BOARD WITH MONTHLY UPDATES REGARDING COMMUNITY HEALTH ACTIVITIES. PART VI, LINE 3: 1. AT THE TIME OF REGISTRATION, A REGISTRATION SPECIALIST WILL INQUIRE IF THERE IS HEALTH INSURANCE. IF NOT, THEY WILL BE ADVISED OF SPMHC'S COMMUNITY CARE PROGRAM IF THEY RESIDE WITHIN OUR SERVICE AREA OR THOSE WHO HAVE A SAUK PRAIRIE BASED PHYSICIAN WILL ALSO BE CONSIDERED FOR ELIGIBILITY. COMMUNITY CARE INFORMATION IS ALSO POSTED ON THE HOSPITAL WEBSITE AND BILLS STATE THAT IF THE PATIENT IS HAVING DIFFICULTY PAYING THEY SHOULD CONTACT A HOSPITAL REPRESENTATIVE, AS THEY MAY BE ELIGIBLE FOR FREE OR REDUCED FEES.2. ANY PATIENT REQUESTING ADDITIONAL INFORMATION ABOUT THE COMMUNITY CARE PROGRAM WILL BE REFERRED TO THE PATIENT ACCOUNTS SPECIALIST, WHO WILL EXPLAIN THE PROGRAM AND ITS ELIGIBILITY CRITERIA. WHEN APPLICABLE, ALL GOVERNMENT ASSISTANCE PROGRAMS SUCH AS MEDICAL ASSISTANCE, BADGER CARE, AND CRIME VICTIMS MUST BE EXHAUSTED BEFORE APPLYING FOR COMMUNITY CARE (EXCEPTION: THE GOVERNMENT PROGRAM APPLICATION MAY BE WAIVED BASED ON RELIGIOUS BELIEFS). COMMUNITY CARE IS NOT AVAILABLE FOR ELECTIVE PROCEDURES. PERSONS RESIDING IN THE SAUK PRAIRIE MEMORIAL HOSPITAL & CLINICS PRIMARY SERVICE AREA WILL BE CONSIDERED FOR ELIGIBILITY DETERMINATION. IN THE CASE OF EMERGENCY ROOM SERVICES COMMUNITY CARE MAY BE EXTENDED TO THOSE RESIDING OUTSIDE OF THE PRIMARY SERVICE AREA.3. THE INFORMATION IS ALSO POSTED ON OUR WEBSITE UNDER "PREPARING FOR YOUR STAY." IF AT ANY TIME PRIOR TO, DURING, OR AFTER THE SERVICES ARE PROVIDED THE PATIENT EXPRESSED CONCERNS ABOUT PAYMENT, THE COMMUNITY CARE PROGRAM IS EXPLAINED. INFORMATION IS ALSO PRINTED ON PATIENT STATEMENTS AND DISCUSSED WITH THE PATIENT DURING THE BILLING PROCESS. PART VI, LINE 4: SPMHC'S PRIMARY SERVICE AREA ENCOMPASSES A 700 SQUARE MILE REGION IN RURAL SOUTH CENTRAL WISCONSIN, INCLUDING SAUK, SOUTHERN COLUMBIA, NORTHWEST DANE, NORTHERN IOWA AND EASTERN RICHLAND COUNTIES. THE HOSPITAL IS LOCATED IN SAUK PRAIRIE (COMMON NAME FOR THE NEIGHBORING MUNICIPALITIES OF SAUK CITY AND PRAIRIE DU SAC) THE CLINICS ARE LOCATED IN FOUR TOWNS SURROUNDING SAUK PRAIRIE (BLACK EARTH, SPRING GREEN, PLAIN, AND LODI). NO OTHER HOSPITALS ARE LOCATED WITHIN THE PRIMARY SERVICE AREA, HOWEVER, EIGHT INPATIENT HOSPITALS (INCLUDING 5 RURAL AND 3 TERTIARY FACILITIES) ARE LOCATED WITHIN A 30 MILE RADIUS OF SPMHC.DEMOGRAPHIC ANALYSIS INDICATES A 5-YEAR GROWTH RATE OF 2.5% COMPARED TO THE STATE OF WISCONSIN'S RATE OF 1.9%. AGE GROUPS THAT WILL GROW AT A CONSIDERABLY FASTER RATE THAN THE STATE INCLUDE 0-17 YEAR OLDS (1.9%), 25-34 (15.2%), AND 65+ (16.6%). HEALTH ISSUES AFFECTING THESE AGE SEGMENTS INCLUDE PRENATAL SCREENING, TEEN PREGNANCY, LACK OF ACCESS TO HEALTHCARE, AND MEDICAL ISSUES ASSOCIATED WITH AGING.THE AREA HAS LITTLE RACIAL AND ETHNIC DIVERSITY, ALTHOUGH THE NUMBER OF HISPANIC RESIDENTS INCREASED CONSIDERABLY SINCE 2000. SPECIFIC HEALTH-RELATED ISSUES CONFRONTING THIS POPULATION INCLUDE DIABETES, ACCESS TO CARE, AND LANGUAGE BARRIERS.AVERAGE HOUSEHOLD INCOME OF SERVICE AREA RESIDENTS IS 10% HIGHER THAN THE STATE AVERAGE. THIS DIFFERENCE IS DUE IN LARGE PART BECAUSE OF THE RELATIVELY STRONG JOB MARKET IN MADISON, WHICH ATTRACTS COMMUTERS FROM THE SERVICE AREA. THROUGHOUT THE SERVICE AREA, HOWEVER, AGRICULTURE AND TOURISM REPRESENT A CONSIDERABLE NUMBER OF LOW-PAYING JOBS, TYPICALLY WITHOUT HEALTH BENEFITS.A PORTION OF THE SPMHC PRIMARY SERVICE AREA IS DESIGNATED AS A MEDICALLY UNDERSERVED AREA/POPULATION. THIS AREA IS LOCATED IN THE TOWN OF ARENA (MCD 02575). PART VI, LINE 5: SPMHC IS AN INDEPENDENT COMMUNITY HOSPITAL GOVERNED BY AN 11-MEMBER BOARD OF DIRECTORS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA. THE BOARD IS ELECTED BY THE 1,200 MEMBER COMMUNITY HOSPITAL ASSOCIATION. AN INDEPENDENT HOSPITAL IS A CRUCIAL PART OF SPMHC'S VISION, BECAUSE IT KEEPS CONTROL AT THE LOCAL LEVEL, NOT IN A CORPORATE HEADQUARTERS LOCATED ELSEWHERE. LOCAL CONTROL ALLOWS THE HOSPITAL TO MAKE DECISIONS THAT ARE BEST FOR THE LOCAL COMMUNITIES.THE SPMHC MEDICAL STAFF PRIVILEGES ALL QUALIFIED PHYSICIANS IN ITS COMMUNITIES. THE VAST MAJORITY OF THE ACTIVE MEDICAL STAFF PRACTICE SOLELY AT THE SAUK PRAIRIE MEMORIAL HOSPITAL OR ASSOCIATED CLINICS. THE SPMHC STRATEGIC PLAN SPECIFICALLY ADDRESS OUR DESIRE TO "IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE" AND THE ORGANIZATION'S EFFORTS TO ASSESS THE NEEDS OF THE COMMUNITY AND ADDRESS THOSE NEEDS. SPMHC PROMOTES COMMUNITY HEALTH THROUGH A BROAD ARRAY OF APPROACHES. THE FOLLOWING LIST DESCRIBES SPECIFIC PROGRAMS AND ACTIVITIES THAT CONTRIBUTE TO IMPROVING THE HEALTH OF THE COMMUNITY AND ENHANCING THE PROVISION OF MEDICAL CARE.- TRAINING MEDICAL STUDENTS, NURSING STUDENTS, AND OTHER HEALTH PROFESSIONS- CONTRIBUTE TIME AND FINANCIAL RESOURCES IN THE DEVELOPMENT OF A DENTAL COLLABORATIVE, WITH OTHER INDIVIDUALS AND ORGANIZATIONS IN THE COMMUNITY, TO OPEN A DENTAL CLINIC WHICH WILL PROVIDE SERVICES TO UNINSURED AND UNDERINSURED MEMBERS OF THE COMMUNITIES SERVED WHO WOULD OTHERWISE NOT HAVE ACCESS OR THE ABILITY TO ACCESS THESE SERVICES ON A REGULAR BASIS- ORGANIZE AND/OR PARTICIPATE IN FREE COMMUNITY HEALTH EDUCATION EVENTS AND SEMINARS- ORGANIZE AND/OR PARTICIPATE IN HEALTH FAIRS- ORGANIZE AND/OR PARTICIPATE IN HEALTH EDUCATION LECTURES AND WORKSHOPS- OFFER CPR/FIRST AID CLASSES- OFFER CHILDBIRTH CLASSES- ISSUE EDUCATIONAL NEWS RELEASES- CONDUCT SCHOOL HEALTH EDUCATION PROGRAMS- CONDUCT SELF-HELP PROGRAMS- CONDUCT COMMUNITY-BASED CLINICAL SCREENINGS (HEARING AID CHECKS, BLOOD PRESSURE AND CHOLESTEROL SCREENING)- CONDUCT IMMUNIZATION CLINICS- PROVIDE SERVICES FOR THE GOOD NEIGHBOR CLINIC- MEDICATION TAKE BACK DAY- MOBILE MEALS- DISCOUNTED EQUIPMENT AND SUPPLIES- TRANSPORTATION TOKENS (FOR LOCAL TAXI) REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 THE GOOD NEIGHBOR CLINIC OF SAUK PRAIRIE INC 1906 NORTH ST PRAIRIE DU SAC WI 53578 391963290 501(C)3 0 95389 COST MEDICAL SERVICES AND SUPPLIES TO PROVIDE MEDICAL ASSISTANCE TO THOSE WHO NORMALLY COULD NOT AFFORD IT ST VINCENT DE PAUL SOCIETY OF SAUK-PRAIRIEROXBURY INC 815 19TH STREET PRAIRIE DU SAC WI 53578 391802875 501(C)3 23900 TO PROVIDE DENTAL SERVICES TO THOSE THAT COULD NOT NORMALLY AFFORD THESE SERVICES. 2 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: SAUK PRAIRIE MEMORIAL HOSPITAL FOLLOWS THE FOLLOWING PROCESS TO PROVIDE ADDITIONAL SUPPLIES TO THE GOOD NEIGHBOR CLINIC ("GNC"): - GNC STAFF REQUESTS PRODUCT FROM MATERIALS STAFF. - IF TOTAL VALUE EXCEEDS $100, MATERIALS STAFF PROVIDES LIST OF PRODUCTS AND ASSOCIATED COSTS (WITHOUT MARK UPS) IN AN E-MAIL TO CFO AND COPY OF EMAIL TO FINANCE & MATERIALS DIRECTORS. - CFO WILL RESPOND BACK TO THE E-MAIL (VIA REPLY TO ALL) INDICATING WHETHER THE REQUEST SHOULD BE BILLABLE OR A CHARITABLE CONTRIBUTION. - MATERIALS STAFF PULLS CENTRAL STORES PRODUCTS AND FORWARDS TO GNC. - IF REQUIRED, PURCHASE ORDER WILL BE CUT FOR NON-STOCK PRODUCTS. - FINANCE USES THE REPLY TO ALL FROM CFO AS INFORMATION REQUIRED FOR BILLING GNC FOR THE PRODUCTS IF REQUIRED. - FINANCE CAN FIND GENERAL LEDGER BREAKDOWNS FOR PRODUCTS VIA A GENERAL LEDGER DISTRIBUTION REPORT FOR GOOD NEIGHBOR CLINIC AS REQUIRED. IF THE REQUEST IS UNDER $100, THE REQUESTS WILL BE PROCESSED THROUGH AND WILL BE CONSIDERED A CHARITABLE CONTRIBUTION. SAUK PRAIRIE MEMORIAL HOSPITAL ALSO PROVIDES A SIGNIFICANT AMOUNT OF MEDICAL SERVICES TO PATIENTS OF THE GOOD NEIGHBOR CLINIC. THE HOSPITAL RELIES UPON THE INCOME REQUIREMENTS SCREENING PROCESS BY THE GOOD NEIGHBOR CLINIC TO REFER PATIENTS IN NEED OF FREE CARE FOR SERVICES. X 1 1 X X X X X 0 1 0 0 0 1 0 0 0 CAROL MAY 166178 0 12002 0 573 0 8638 0 9622 0 197013 0 0 0 LARRY SCHROEDER 251733 0 23150 0 9712 0 12250 0 11059 0 307904 0 0 0 KEN CARLSON 140752 0 10048 0 155 0 7267 0 8520 0 166742 0 0 0 MARGARET SHEEKS 129534 0 6037 0 6360 0 6812 0 8052 0 156795 0 0 0 MARK STARR 219735 0 980 0 11303 0 10889 0 8801 0 251708 0 0 0 MILES MORGAN 261488 0 0 0 0 0 12250 0 -1975 0 271763 0 0 0 THOMAS MURPHY 222797 0 6162 0 1354 0 11328 0 2316 0 243957 0 0 0 ERIC WARBASSE 226913 0 0 0 0 0 9254 0 9219 0 245386 0 0 0 ROLLAND TAYLOR 217669 0 0 0 0 0 10766 0 218 0 228653 0 0 0 PART I, LINE 1A IN 2011, THE BOARD APPROVED A POLICY TO COMPENSATE THE CEO FOR THE TRAVEL OF HIS/HER SPOUSE FOR SPMHC RELATED BUSINESS ACTIVITY. THE CEO WILL BE COMPENSATED FOR REASONABLE TRAVEL EXPENSES INCURRED BY HIS SPOUSE. BOARD APPROVAL NEEDS TO BE RECEIVED PRIOR TO MAKING THE TRAVEL ARRANGEMENTS. THE COST OF ANY SUCH TRAVEL REIMBURSEMENTS ARE ADDED TO THE CEO'S W-2 FOR TAX REPORTING PURPOSES ALSO. PART I, LINE 4B THE FOLLOWING OFFICERS, DIRECTORS, AND EMPLOYEES PARTICIPATE IN THE HOSPITALS 457B DEFERRED COMPENSATION PLAN: CAROL MAY, LARRY SCHROEDER, AND MARK STARR. PART I, LINE 6 SPMHC HAS AN INCENTIVE PAYMENT PLAN THAT ONLY GOES INTO EFFECT IF NET EARNINGS (OPERATING INCOME) IS WITHIN 98% OF BUDGET. THEN, DEPENDING ON WHETHER QUALITY, SAFETY, AND MANAGEMENT GOALS ARE MET, INCENTIVE PAY MAY BE AWARDED. MAXIMUM INCENTIVE IS $30,000 FOR THE CEO, $15,000 FOR VPS, AND $7,500 FOR DIRECTOR LEVEL EMPLOYEES AND MANAGERS. SURGICAL ASSOCIATES OF SAUK PRAIRIE LLP DR. DEGIOVANNI IS A BOARD MEMBER OF SPMHC AND ALSO A GREATER THAN 5% OWNER. 38421 LEASE OF HOSPITAL SPACE FOR OPERATION OF PHYSICIAN CLINIC. 0 NEW PROGRAM SERVICES FORM 990, PART III, LINE 2 SAUK PRAIRIE MEMORIAL HOSPITAL, INC. ADDED OUTPATIENT PULMONARY REHABILITATION SERVICE. THIS SERVICE ASSISTS COPD PATIENTS IN MAINTAINING AND IMPROVING THE QUALITY OF LIFE. FORM 990, PART VI, SECTION A, LINE 4 SAUK PRAIRIE MEMORIAL HOSPITAL ASSOCIATION, ON RECOMMENDATION OF THE BOARD OF DIRECTORS, APPROVED CHANGES TO THE CORPORATE BYLAWS IN 2011. THE MOST SIGNIFICANT CHANGE WAS TO ELIMINATE A CAP ON THE NUMBER OF TERMS MEMBERS OF THE BOARD OF DIRECTORS CAN SERVE. FORM 990, PART VI, SECTION A, LINE 6 ANNUAL MEMBERSHIP WILL BE CONFERRED FOR ONE YEAR UPON PERSONS CONTRIBUTING THE SUM OF TEN DOLLARS TO THE CORPORATION AND/OR THE SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. LIFE MEMBERSHIP WILL BE CONFERRED UPON PERSONS CONTRIBUTING THE SUM OF ONE HUNDRED DOLLARS TO THE CORPORATION AND/OR SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. TWO LIFE MEMBERSHIPS WILL BE CONFERRED UPON TWO PERSONS CONTRIBUTING THE SUM OF TWO HUNDRED DOLLARS OR MORE TO THE CORPORATION AND/OR SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION. FORM 990, PART VI, SECTION A, LINE 7A AN ANNUAL AND LIFE MEMBERSHIP SHALL BE ENTITLED TO ONE VOTE AT THE ANNUAL MEETING OR AT ANY SPECIAL MEETINGS OF THE MEMBERSHIP. THOSE WITH LIFE MEMBERSHIPS MAY ALSO HOLD OFFICE AS A DIRECTOR OF THE CORPORATION OR SERVE ON A COMMITTEE. MEMBERS MAY VOTE ON ELECTIONS OF BOARD MEMBERS, CHANGES TO THE BYLAWS, AND OTHER BUSINESS ALLOWED BY LAW. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD OF DIRECTORS REVIEWS THE 990 AT ITS MONTHLY MEETING PRIOR TO SUBMISSION. IN THE EVENT MEETING AND DUE DATES ARE SUCH THAT THIS IS NOT POSSIBLE, THE BOD WILL REVIEW AT THE FIRST MEETING AFTER SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12C SINCE SAUK PRAIRIE MEMORIAL HOSPITAL IS A PART OF A SMALL COMMUNITY, CONFLICTS ARE GENERALLY KNOWN, IF NOT DISCLOSED THROUGH THE ANNUAL PROCESS CONDUCTED BY HUMAN RESOURCES. THE ANNUAL PROCESS INCLUDES ALL DIRECTOR LEVEL EMPLOYEES AND ABOVE OF THE HOSPITAL. THE BOARD OF DIRECTORS HAS A CONFLICT OF INTEREST POLICY AND MUST ANNUALLY SIGN A DISCLOSURE FORM STATING ANY POTENTIAL CONFLICTS OF INTEREST. THE BOARD PRESIDENT THEN DISCLOSES ANY CONFLICTS TO THE FULL BOARD OF DIRECTORS. CONFLICT OF INTEREST STATEMENTS COMPLETED BY BOARD MEMBERS ARE REVIEWED BY THE BOARD PRESIDENT AND EMPLOYEE'S CONFLICT OF INTEREST STATEMENTS ARE REVIEWED BY STAFF LEADERSHIP AND/OR ADMINISTRATION. THESE INDIVIDUALS ARE CHARGED WITH THE RESPONSIBILITY OF ENSURING THAT BUSINESS IS CONDUCTED IN A MANNER THAT ADHERES TO THE ORGANIZATION'S FORMALLY APPROVED CONFLICT OF INTEREST POLICY. FORM 990, PART VI, SECTION B, LINE 15 THE BOARD OF DIRECTORS HAS ESTABLISHED POLICY BSR-14 TO ESTABLISH ITS COMPENSATION PHILOSOPHY WITH RESPECT TO EXECUTIVE COMPENSATION AND TO DEFINE PRACTICES ASSOCIATED IN ACCORDANCE WITH IRC 4958. SPMHC EXECUTIVE SALARY IS SET ANNUALLY CONSIDERING COMPENSATION LEVELS AT SIMILARLY SITUATED ORGANIZATIONS (TYPICALLY NOT-FOR-PROFIT HEALTHCARE ORGANIZATIONS IN OUR REVENUE CATEGORY). THE EXECUTIVE COMMITTEE IS RESPONSIBLE FOR SETTING SALARY FOR THE CEO BASED ON THE CEO'S JOB PERFORMANCE. THE COMMITTEE RELIES UPON COMPARABILITY DATA DEVELOPED BY OUTSIDE CONSULTANTS TO SUPPORT ITS DECISION MAKING PROCESS AND TO ENSURE COMPETITIVE SALARY LEVELS. COMPENSATION FOR OTHER KEY EMPLOYEES IS ESTABLISHED BY APPLICATION OF SPMHC'S COMPENSATION PHILOSOPHY, WHEREIN RATES OF PAY ARE COMPARED TO MARKET RATES OBTAINED THROUGH PARTICIPATION IN WAGE AND BENEFIT SURVEYS. PAY RANGES ARE OBTAINED FROM SURVEYS OF SIMILARLY SITUATED HOSPITALS LOCATED WITHIN THE STATE OF WISCONSIN IN TERMS OF SIZE AND REVENUE CATEGORY. SPMHC ADOPTED A "MEET THE MARKET" APPROACH TO COMPENSATION FOR POSITIONS AT THESE LEVELS. THIS MEANS THAT SPMHC TARGETS THE MIDPOINT OF THE PAY RANGE ASSOCIATED WITH EACH POSITION. FORM 990, PART VI, SECTION C, LINE 19 THE ABBREVIATED FINANCIAL STATEMENTS ARE A PART OF THE HOSPITAL'S ANNUAL REPORT PRESENTED TO THE PUBLIC AT THE ANNUAL MEETING AND POSTED ON THE HOSPITAL'S WEBSITE. THE ABBREVIATED FINANCIAL STATEMENTS ARE ALSO MADE PUBLICLY AVAILABLE THROUGH THE WISCONSIN HOSPITAL ASSOCIATION. THE HOSPITAL'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE MADE AVAILABLE TO THE PUBLIC ON A REQUEST BASIS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -411,000. NET ASSETS RELEASED FROM RESTRICTIONS -81,184. CHANGE IN INTEREST IN NET ASSETS OF FOUNDATION 1,210,293. TOTAL TO FORM 990, PART XI, LINE 5: 718,109. SELECTION OF INDEPENDENT ACCOUNTANT THE ORGANIZATION ANSWERED "YES" TO QUESTION 2C UNDER PART XI OF THE 990, INDICATING THAT THE ORGANIZATION DOES HAVE A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THE FULL BOARD OF DIRECTORS REVIEWS THE FINANCIAL STATEMENTS AND HEARS THE AUDIT FIRM PRESENTATION. THE FOLLOWING PROCESS WAS IMPLEMENTED BY THE BOARD FOR REVIEW OF THE AUDIT FIRM. FOR AUDIT FIRM SELECTION, A REQUEST FOR PROPOSAL IS PREPARED, INTERNAL STAFF SELECTS THE TWO OR THREE TOP CANDIDATES, AND THE FINANCE AND AUDIT COMMITTEE RECOMMENDS AN AUDIT FIRM TO THE FULL BOARD. BASED ON THE PROPOSAL RESPONSES AND INTERVIEWS/PRESENTATIONS BY THE AUDIT FIRMS, THE FULL BOARD OF DIRECTORS THEN VOTES BASED ON THIS RECOMMENDATION AND SELECTS THE INDEPENDENT ACCOUNTING FIRM. THERE WAS NO CHANGE TO THIS PROCESS IN 2011. SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION LTD 80 FIRST STREET PRAIRIE DU SAC WI 53578 930841113 FUNDRAISING WI 501(C)3 7 N/A 0 FRIENDS OF SAUK PRAIRIE MEMORIAL HOSPITAL 80 FIRST STREET PRAIRIE DU SAC WI 53578 391453754 VOLUNTEERING WI 501(C)3 11 TYPE 3 N/A 0 0 0 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION LTD C 153184 FAIR MARKET VALUE SAUK PRAIRIE MEMORIAL HOSPITAL FOUNDATION LTD N 76501 COST