2012-11-12T13:08:58-06:00 2011-12-31 420714325 MCGLADREY LLP PO BOX 5946 MADISON WI 537050946 990 2011-01-01 390871113 RIVERSIDE MEDICAL CENTER INC RIVE 7152581000 800 RIVERSIDE DRIVE WAUPACA WI 54981 CRAIG KANTOS 7152581000 2012-11-08 1 JAMES G GRAHAM P00006111 6088332612 2011 2016-02-24 21:20:13Z CRAIG KANTOS 800 RIVERSIDE DRIVE WAUPACA WI 54981 48005957 0 X WWW.THEDACARE.ORG X 1955 WI RIVERSIDE MEDICAL CENTER, IN PARTNERSHIP WITH THE MEDICAL STAFF AND OTHER HEALTH CARE PROVIDERS, SHALL PROVIDE ACCESS TO HEALTH CARE SERVICES FOR WAUPACA AND THE SURROUNDING AREAS THROUGH A STRATEGY EMPHASIZING THE VALUE OF HEALTHCARE ON THE WELLNESS CONTINUUM.RIVERSIDE MEDICAL CENTER SHALL PROVIDE QUALITY, CARING, AND COST EFFECTIVE SERVICES TO ADJUST OR IMPROVE THEIR HEALH STATUS WHILE RECOGNIZING THE INDIVIDUAL PATIENT'S RIGHTS AND RESPONSIBILITIES.WAUPACA WILL HAVE A MEDICAL COMMUNITY THAT FUNCTIONS AS A RESOURCE FOR THE HEALTH CARE DELIVERY SYSTEM. RIVERSIDE MEDICAL CENTER WILL PROVIDE LEADERSHIP FOR THE HEALTH CARE DELIVERY SYSTEM IN OUR COMMUNITY. 9 6 0 175 3862 0 54606 329010 36078948 35579409 402759 862724 -213312 88040 36323001 36859183 0 0 0 0 19317531 19950777 0 0 0 13169704 13304026 32487235 33254803 3835766 3604380 59633154 62211853 7977012 7602627 51656142 54609226 X TO PROVIDE THE HIGHEST QUALITY HEALTH CARE, DELIVERED IN THE MOST EFFICIENT AND COST-EFFECTIVE WAYS, AND ACCESIBLE TO ALL MEMBERS OF THE COMMUNITY. 0 0 31886530 35660616 RIVERSIDE MEDICAL CENTER PROVIDED MEDICAL CARE TO THE CITY OF WAUPACA AND ITS SURROUNDING COMMUNITIES AS A CRITICAL ACCESS FACILITY. INPATIENT ADMISSIONS WERE 1109 FOR THE PERIOD.THE AVERAGE LENGTH OF STAY (ALOS) WAS 2.9 DAYS PER STAY FOR THE PERIOD, COMPARED TO 3.0 DAYS PER STAY FOR THE PRIOR YEAR. THE MEDICAL CENTERS CASE MANAGEMENT PROGRAM CONTINUES T0 PLAY A MAJOR ROLE IN KEEPING RMC'S ALOS BELOW INDUSTRY LEVELS.THE PERIOD AVERAGE DAILY CENSUS WAS 8.9, OR 1.8 PATIENT PER DAY LOWER THAN LAST YEAR.RIVERSIDE MEDICAL CENTERS FINANCIAL SUCCESS CONTINUES TO RELY HEAVILY ON ITS OUTPATIENT BUSINESS. QUTPATIENT VISITS FOR PERIOD TOTALED 52,148 VISITS. THIS IS AN AVERAGE OF 142.87 PER DAY, UP 4.8% FROM 136.72 VISITS PER DAY LAST YEAR. THE OVERALL EMERGENCY ROOM/URGENT PATIENT VOLUMES TOTALED 12,585. THIS IS AN AVERAGE OF 34.5 PER DAY, COMPARED TO AN AVERAGE OF 32.6 LAST YEAR. TOTAL SURGERIES DURING THE PERIOD WERE 2,570. THIS IS AN AVERAGE OF 7.04 PER DAY COMPARED TO A TOTAL OF 2,731 DURING THE SAME PERIOD LAST YEAR.LABORATORY BILLED TESTS WERE 352,274 FOR THE PERIOD. THIS IS AN AVERAGE OF 965.13 PER DAY, COMPARED TO THE PREVIOUS YEARS DAILY AVERAGE OF 1,018.10 PER DAY.RIVERSIDE MEDICAL CENTER ALSO CONTINUES TO PROVIDE X-RAY, NUCLEAR MEDICINE, MRI, CT SCAN, ULTRASOUND, CARDIO SERVICES, CARDIAC REHAB, BONE DENSITY, VASCULAR ULTRASOUND AND REHABIITATION SERVICES.THE MEDICAL CENTER CONTINUED TO OFFER A VARIETY OF EDUCATIONAL PROGRAMS TO THE COMMUNITY. 31886530 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 9 6 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X KRISTEN COGSWELL 9207386471 122 E COLLEGE AVENUE APPLETON WI 54911 ROSE CROW TERM EXP 2012 2.00 X 99128 396511 18653 ROBERT DENT MD TERM EXP 2012 2.00 X 0 217441 22171 GREGORY LONGMD TERM EXP 2012 2.00 X 68561 388508 100460 MARY ELLEN BOARIOTERM EX 2011 2.00 X X 0 0 0 TOM JOHNSON TERM EXP 2013 2.00 X X 0 0 0 JIM LARSON TERM EXP 2014 2.00 X X 0 0 0 GARY JANSSEN TERM EXP 2014 2.00 X X 0 0 0 DAVID POESCHL TERM EXP 2012 2.00 X 0 0 0 JERRY SALANRESIGNED 2011 2.00 X 0 0 0 CRAIG KANTOS 40.00 X 252790 0 20212 KERRY LEE BLANKE 40.00 X 147838 0 18124 DEAN GRUNER 40.00 X 136493 773461 165240 TIM OLSON 40.00 X 65042 368576 99753 KEITH LIVINGSTON 40.00 X 56648 321003 80840 MAUREEN PISTONE 40.00 X 44702 253313 72532 KATHRYN CORREIA 40.00 X 52167 469506 96773 GREGORY DEVINE 40.00 X 69788 395462 81701 WILLIAM HUNTER 40.00 X 59063 334690 75698 JOHN POOLE 40.00 X 56115 317983 78249 ROBERT PETERSON MD 40.00 X 315417 0 15307 1423752 4236454 945713 19 0 1 0 RICHARD VEIGA MD SC E2409 PEBBLE RUN RD WAUPACA WI 54981 PATHOLOGY 373681 AMER DIAGNOSTIC MEDICINE INC 167 OSWALT BATAVIA IL 60510 DIAGNOSTIC 153674 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 PATIENT SCREENING SERVICES 110046 3 23974 305036 329010 OUTPATIENT REVENUE 621400 26488132 26488132 INPATIENT REVENUE 621990 8452006 8452006 OTHER MISC REVENUE 621990 563916 563916 HERITAGE REVENUE 621990 71493 71493 MEDICAL CARE 900099 3862 3862 35579409 325851 325851 2935 0 2935 2935 2935 11683647 11146738 36 536909 -36 536873 -36 536909 CAFETERIA REVENUE 722210 85105 85105 85105 36859183 35660616 3862 865695 900973 900973 14965400 14965400 675807 675807 2444721 2444721 963876 963876 467266 467266 34 34 772062 772062 30141 30141 903631 903631 52531 52531 71005 71005 309147 309147 2823383 2823383 134464 134464 SUPPLIES 3387590 3387590 BAD DEBT EXPENSE 1768961 1768961 PURCHASED SERVICES 1603867 1603867 EQUIPMENT MAINTENANCE 614872 614872 365072 365072 33254803 31886530 1368273 0 920 796 12187371 13099772 3939353 4848270 177907 180612 170665 0 53759542 22222309 33012723 31537233 5332457 11905035 4762001 49757 640135 59633154 62211853 636797 590 7340215 6454102 0 1147935 7977012 7602627 X 51656142 54590615 0 18611 51656142 54609226 59633154 62211853 X 3604380 -651296 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 17999 17999 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: PORTION OF WHA DUES = $17,999 2102028 2102028 37597104 13682294 23914810 1025200 612253 412947 13035210 7927762 5107448 31537233 DUE TO AFFILIATES 1147935 1147935 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FOOTNOTE FROM CONSOLIDATED FINANCIAL STATEMENTS: THEDACARE FOLLOWS FASB GUIDANCE ON INCOME TAXES, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, WHICH ADDRESSES THE DETERMINATION OF WHETHER TAX BENEFITS CLAIMED OR EXPECTED TO BE CLAIMED ON A TAX RETURN SHOULD BE RECORDED IN THE FINANCIAL STATEMENTS. UNDER THIS GUIDANCE, THEDACARE MAY RECOGNIZE THE TAX BENEFIT FROM AN UNCERTAIN TAX POSITION ONLY IF IT IS MORE LIKELY THAN NOT THAT THE TAX POSITION WILL BE SUSTAINED ON EXAMINATION BY TAXING AUTHORITIES, BASED ON THE TECHNICAL MERITS OF THE POSITION. EXAMPLES OF TAX POSITIONS INCLUDE THE TAX-EXEMPT STATUS OF THEDACARE, AND VARIOUS POSITIONS RELATED TO THE POTENTIAL SOURCES OF UNRELATED BUSINESS TAXABLE INCOME (UBIT). THE TAX BENEFITS RECOGNIZED IN THE FINANCIAL STATEMENTS FROM SUCH A POSITION ARE MEASURED BASED ON THE LARGEST BENEFIT THAT HAS A GREATER THAN 50 PERCENT LIKELIHOOD OF BEING REALIZED UPON ULTIMATE SETTLEMENT. AT DECEMBER 31, 2011 AND 2010, THERE WERE NO UNRECOGNIZED TAX BENEFITS IDENTIFIED OR RECORDED AS LIABILITIES. THEDACARE FILES FORM 990 IN THE U.S. FEDERAL JURISDICTION. TAX RETURNS FILED BY THEDACARE ARE GENERALLY OPEN FOR EXAMINATION FOR THE YEARS 2008 THROUGH 2011. 1 1 1 X 300.000000000000 1 X 1 0 1 1 589 161462 161462 0.00510 5351 3722829 3133993 588836 0.01870 5940 3884291 3133993 750298 0.02380 25 477777 597407 5317 592090 0.01880 4 601 280985 280985 0.00890 4 3046 2692658 695867 1996791 0.06340 1 30 1970 1970 0.00010 6 9618 278083 278083 0.00880 40 491072 3851103 701184 3149919 0.10000 40 497012 7735394 3835177 3900217 0.12380 1 0 929 929 0.00000 1 0 102 102 0.00000 1 37 5 5 0.00000 1 300 4841 4841 0.00020 1 19 835 835 0.00000 1 15036 30436 30436 0.00100 1 0 205 205 0.00000 1 750 19027 19027 0.00060 1 1306 19043 19043 0.00060 9 17448 75423 75423 0.00240 0 996604 164493 8715203 8633325 81878 X 1 1 1 1 RIVERSIDE MEDICAL CENTER INC

800 RIVERSIDE DRIVE WAUPACA WI 54981

X X RIVERSIDE MEDICAL CENTER INC 1 1 1 300.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 X X 0 1 X 0 0 PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGES AND ACTUAL COSTS OF SUPPLIES, WAGES AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE BASED ON ACTUAL COSTS. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. 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 $ 1768961. PART II: THE HEALTH OF THE COMMUNITY RIVERSIDE MEDICAL CENTER SERVES IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW. -RIVERSIDE MEDICAL CENTER STAFF WORK WITH THE AREA CHAMBER OF COMMERCE AND LOCAL HIGH SCHOOLS AND COLLEGES TO INFORM YOUTH ABOUT MEDICAL CAREER OPPORTUNITIES AND TO HELP PREPARE OUR EDUCATIONAL FACILITIES TO MEET THE HEALTHCARE STAFFING NEEDS FOR THE COMMUNITIES WE SERVE. -RIVERSIDE MEDICAL CENTER STAFF WERE HEAVILY INVOLVED IN H1N1 COMMUNITY EDUCATION AND SET UP OF IMMUNIZATION CLINICS THAT HELPED PREVENT THE PANDEMIC FROM SPREADING. WE HAD REGIONAL INVOLVEMENT IN PLANNING AS WELL. -RIVERSIDE MEDICAL CENTER STAFF ARE INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS. -RIVERSIDE MEDICAL CENTER STAFF PARTICIPATED IN A THEDACARE-WIDE REBUILDING TOGETHER EVENT WHERE STAFF SPENT THE DAY FIXING UP THE HOME OF A LOCAL FAMILY IN NEED. -THEDA CARE PRESIDENT AND CEO IS ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. PART III, LINE 4: A COST TO CHARGE RATIO WAS USED TO DETERMINE THE AMOUNTS REPORTED IN PART III LINES 2 AND 3. PATIENT PAYMENTS OR DISCOUNTS ARE APPLIED PRIOR TO DETERMINING BAD DEBT EXPENSE AND ARE NOT INCLUDED IN THE BAD DEBT WRITE-OFF REPORTED ON THE AUDITED FINANCIAL STATEMENTS. DEDUCTIBLES AND CONINSURANCE AMOUNTS THAT ARE DEEMED UNCOLLECTIBLE ARE WRITTEN OFF EITHER TO BAD DEBT EXPENSE OR, IF APPLICABLE, TO CHARITY CARE IF THE PATIENT SO QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE BUT THEY ACCOUNT FOR BAD DEBTS BASED ON GROSS CHARGES TO PATIENTS AFTER REFLECTING ANY PAYMENTS OR DISCOUNTS, OR AMOUNTS DETERMINED TO BE ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE. PART III, LINE 8: WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART V, LINE 12 PATIENTS ARE SENT AN OVERVIEW LETTER EXPLAINING THE PROCESS FOR APPLYING FOR OUR ASSISTANCE PROGRAM OR OUR STAFF WALKS THEM THROUGH THE PROCESS. THEY ARE ASKED TO COMPLETE AN APPLICATION THAT INCLUDES REQUESTS FOR INFORMATION THAT WE NEED TO MAKE A DECISION AS TO WHETHER THE PATIENT MEETS THE CRITERIA FOR ACCEPTANCE AND THEN TO WHAT LEVEL. ONCE THE DECISION IS MADE, WE WILL NOTIFY THE PATIENT AND IF ACCEPTABLE, WRITE OFF THE BALANCE AS DETERMINED. PART VI, LINE 2: THEDACARE SERVES AN 8 COUNTY PRIMARY SERVICE AREA. FIVE THEDACARE HOSPITALS PROVIDE SERVICE IN THIS AREA. THEDACARE CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY TWO YEARS FOR THE ENTIRE SYSTEM GATHERING DATA PERTINENT TO EACH COMMUNITY. INFORMATION COLLECTED INCLUDES DATA FROM THE WISCONSIN COUNTY HEALTH RANKINGS, FOX CITIES LIFE STUDY (LOCAL INDICATORS FOR EXCELLENCE), THE BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY, AND INSIGHTS GATHERED FROM MONTHLY MEETINGS OF THE THEDACARE-LED CHAT TEAM (COMMUNITY HEALTH ACTION TEAM) COMPRISED OF 25 COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, HEALTHCARE, UNITED WAY AND THE LOCAL COMMUNITY FOUNDATION. THE WISCONSIN STATE HEALTH PLAN IS ALSO TAKEN INTO CONSIDERATION. PART VI, LINE 3: THERE ARE SEVERAL WAYS THIS OCCURS - THE MOST PROMINENT OF THOSE BEING THROUGH OUR PATIENT HANDBOOK THAT IS PROVIDED TO ALL PATIENTS, THROUGH CONVERSATION WITH OUR CARE MANAGEMENT/DISCHARGE PLANNERS AFTER ADMISSION TO OUR HOSPITALS, AND THROUGH CONVERSATION WITH OUR COLLECTION STAFF. PART VI, LINE 4: THEDACARE'S SERVICE AREA CONSISTS OF 8 COUNTIES INCLUDING OUTAGAMIE, WINNEBAGO, CALUMET, SHAWANO, WAUPACA, WAUSHARA, MENOMINEE AND GREEN LAKE. RIVERSIDE MEDICAL CENTER PROVIDES SERVICES PRIMARILY TO PEOPLE IN WAUPACA COUNTY. HIGHLIGHTS REGARDING THE COMMUNITIES WE SERVE INCLUDE: -TOTAL POPULATION OF THE THEDACARE SERVICE AREA IS 518,000. RIVERSIDE MEDICAL CENTER'S SERVICE AREA TOTALS APPROXIMATELY 50,000. -POPULATION OF THE SERVICE AREA CONTINUES TO GROW BUT THE RATE OF GROWTH IS DECLINING -THE AVERAGE AGE OF THE POPULATION IS INCREASING; THE WORKING-AGE POPULATION IS DECLINING -THERE IS A TREND TOWARD SUBURBANIZATION; CORE CITIES AND TOWNS STAY FLAT WHILE CITIES SPRAWL INTO THE SUBURBS -THE NORTHEAST WISCONSIN WILL GROW SLIGHTLY SLOWER THAN THE FOX CITIES. -THE NUMBER OF UNINSURED IN RIVERSIDES SERVICE AREA IS SLIGHTLY HIGHER THAN THE FOX CITIES AT 10%. -98% OF SERVICE AREA IS CAUCASIAN WITH PRESENCE OF HISPANIC POPULATION. -THE POVERTY RATE IN RIVERSIDE MEDICAL CENTERS SERVICE AREA IS APPROXIMATELY 9%. PART VI, LINE 5: EACH YEAR, RIVERSIDE MEDICAL CENTER'S PARENT ORGANIZATION THEDACARE SETS ASIDE A PERCENTAGE OF EXCESS NET BUDGETED INCOME TO FUND AN EFFORT CALLED CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF 25 COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THROUGH CHAT, SUCH EFFORTS AS THE SHAWANO COUNTY RURAL HEALTH INITIATIVE HAVE BEEN DEVELOPED. THIS INITIATIVE TAKES BASIC HEALTH CARE AND SCREENING SERVICES TO THE FARM. EACH YEAR HUNDREDS OF FARM FAMILIES LIVING WITHOUT INSURANCE OR ONLY CATASTROPHIC COVERAGE RECEIVE CRITICAL ASSISTANCE. ANOTHER INITIATIVE DEVELOPED THROUGH CHAT IS MAKING THE RIDE HAPPEN WHICH PROVIDES TRANSPORTATION TO OLDER ADULTS WHO OTHERWISE WOULD STAY COOPED UP IN APARTMENTS AND FIGHT DEPRESSION AND ISOLATION. PROJECT PROMISE IS A POVERTY INITIATIVE DEVELOPED THROUGH CHAT THAT BROUGHT TOGETHER MANY LOCAL AGENCIES AND BUSINESSES TO WORK TO ADDRESS POVERTY IN A COLLABORATIVE FASHION. VOICES OF MEN WAS LAUCHED WITH SUPPORT FROM CHAT TO RAISE AWARENESS OF EVERYDAY BEHAVIORS OF MEN THAT CAN LEAD TO AN ACCEPTANCE OF VIOLENCE TOWARD WOMEN. MOST RECENT INITIATIVES INCLUDE WORK AROUND HISPANIC TEEN PREGNANCY AND PREVENTING SUICIDE AMONG THE GAY, LESBIAN, BISEXUAL, TRANSGENDER POPULATION. THE PROJECTS ARISING FROM CHAT ARE MANY. THE LIVES TOUCHED ARE NUMEROUS. THEDACARE PROVIDES FUNDING AND STAFF SUPPORT TO MAKE CHAT AND THESE COMMUNITY HEALTH EFFORTS POSSIBLE. OTHER WAYS THAT THEDACARE HOSPITALS IMPROVE THE HEALTH OF THE COMMUNITY INCLUDE: -THEDACARE SHARED ITS CUTTING EDGE APPLICATION OF LEAN PRODUCTION IMPROVEMENTS WITH VISITORS ALMOST WEEKLY IN 2011. HUNDREDS OF HEALTHCARE AND NON-HEALTHCARE VISITORS CAME FROM AROUND THE COUNTRY. MOST VISITORS WERE FROM HOSPITALS AND HEALTH SYSTEMS IN THE UNITED STATES LOOKING TO IMPROVE QUALITY AND REDUCE COSTS. -THEDACARE HOSPITALS PROVIDED FUNDING TO THE THEDACARE CENTER FOR HEALTHCARE VALUE WHICH IS COORDINATING EFFORTS ACROSS THE COUNTRY TO SHARE QUALITY IMPROVEMENT AND COST REDUCTION LEARNINGS. -THEDACARE PARTNERS WITH THE FOX CITIES/UW RESIDENCY CENTER TO PROVIDE HANDS ON EXPERIENCE FOR MEDICAL STUDENTS. -THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE TEACHERS FOR THEIR NURSING PROGRAMS AND PROVIDES VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS. -THEDACARE HOSPITALS LEADERSHIP PROVIDED MORE THAN $40,000 WORTH OF STAFF TIME PROVIDING LEADERSHIP TO LOCAL NON-PROFIT ORGANIZATIONS. -THEDACARE HOSPITALS PROVIDED FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA CLINICS PROVIDING MEDICAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA. -THEDACARE HOSPITAL EMPLOYEES TAKE PART IN HELPING HEARTS, AN EMPLOYEE VOLUNTEERISM PROGRAM ENCOURAGING STAFF TO GIVE OF THEIR TIME IN THE COMMUNITY. THEDACARE PROVIDES PAID STAFF TO COORDINATE THE PROGRAM AND IDENTIFY AND PROMOTE VOLUNTEERISM OPPORTUNITIES. -ALL THEDACARE HOSPITALS PROVIDE HEALTH EDUCATION PROGRAMMING FOR THEIR RESPECTIVE COMMUNITIES FOCUSING ON SUCH CRITICAL TOPICS AS PROPER NUTRITION, DIABETES IDENTIFICATION, AND STRESS MANAGEMENT. -THEDACARE SPONSORS PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE YOUTH ON THE PERILS OF RISKY BEHAVIOR AND DRIVING. HOSTED AT OUR PERFORMING ARTS CENTER, LIVE DRAMATIZATIONS ALONG WITH STORIES OF YOUTH DISABLED DUE TO DRIVING AND RISKY BEHAVIOR ENCOURAGE TEENS TO THINK TWICE BEFORE DRINKING OR TEXTING AND DRIVING. -RIVERSIDE MEDICAL CENTER STAFF ARE ENGAGED IN WAUPACA COUNTY NUACT COALITION, A COMMUNITY-WIDE MULTI-DISCIPLINARY TEAM ADDRESSING COMMUNITY HEALTH AND WELLNESS NEEDS -RIVERSIDE MEDICAL CENTER STAFF WORK WITH THE AREA CHAMBER OF COMMERCE AND LOCAL HIGH SCHOOLS AND COLLEGES TO INFORM YOUTH ABOUT MEDICAL CAREER OPPORTUNITIES AND TO HELP PREPARE OUR EDUCATIONAL FACILITIES TO MEET THE HEALTHCARE STAFFING NEEDS FOR THE COMMUNITIES WE SERVE. -RIVERSIDE MEDICAL CENTER REACHES OUT TO THE COMMUNITY TO HOST SCREENINGS AND HEALTH FAIRS. -RIVERSIDE MEDICAL CENTER HOSTS A FUN RUN FOR THE COMMUNITY TO ENCOURAGE FITNESS AND ACTIVITY. -RIVERSIDE MEDICAL CENTER STAFF PROVIDE FREE ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOL ATHLETIC EVENTS. -RIVERSIDE MEDICAL CENTER STAFF ARE INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS. -RIVERSIDE MEDICAL CENTER STAFF PARTICIPATED IN A THEDACARE-WIDE REBUILDING TOGETHER EVENT WHERE STAFF SPENT THE DAY FIXING UP THE HOME OF A LOCAL FAMILY IN NEED. -THEDA CARE PRESIDENT AND CEO IS ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY NEEDS ASSESSMENT FOR ALL HOSPITALS AND MARKETS WITH ITS SERVICE AREA. EACH THEDACARE HOSPITAL DETERMINES HOW BEST TO MEET LOCAL NEEDS. IMPLEMENTATION OF COMMUNITY PROGRAMMING OCCURS AT THE HOSPITAL LEVEL. REPORTS FILED WITH STATES PART VI, LINE 7 WI X X 1 1 0 1 0 0 0 0 0 1 0 ROSE CROW TERM EXP 2012 62358 249431 11870 47480 24900 99600 2576 10304 1155 4618 102859 411433 0 0 ROBERT DENT MD TERM EXP 2012 0 213895 0 356 0 3190 0 8428 0 13743 0 239612 0 0 GREGORY LONGMD TERM EXP 2012 54725 310106 10216 57890 3620 20512 12922 73227 2147 12164 83630 473899 0 0 CRAIG KANTOS 214606 0 20425 0 17759 0 7350 0 12862 0 273002 0 0 0 KERRY LEE BLANKE 139945 0 6705 0 1188 0 4400 0 13724 0 165962 0 0 0 DEAN GRUNER 100050 566950 35291 199985 1152 6526 22732 128817 2054 11637 161279 913915 0 0 TIM OLSON 51697 292952 9381 53160 3964 22464 12983 73568 1980 11222 80005 453366 0 0 KEITH LIVINGSTON 45374 257119 8234 46658 3040 17226 10162 57587 1964 11127 68774 389717 0 0 MAUREEN PISTONE 36463 206622 6616 37492 1623 9199 8939 50656 1941 10996 55582 314965 0 0 KATHRYN CORREIA 39934 359409 10869 97825 1364 12272 8237 74135 1440 12961 61844 556602 0 0 GREGORY DEVINE 57095 323536 10868 61587 1825 10339 10102 57247 2153 12199 82043 464908 0 0 WILLIAM HUNTER 48738 276184 9278 52573 1047 5933 9382 53167 1972 11177 70417 399034 0 0 JOHN POOLE 45749 259242 8708 49346 1658 9395 9773 55378 1965 11133 67853 384494 0 0 ROBERT PETERSON MD 311105 0 302 0 4010 0 9350 0 5957 0 330724 0 0 0 PART I, LINE 1A EXECUTIVES RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT AN AMOUNT GROSSED-UP FOR TAXES. ALL EXECUTIVES IN THE SENIOR MANAGEMENT BENEFIT CATEGORY ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES PAID DIRECTLY TO THE CLUB, OR REIMBURSED TO THEM ON EVIDENCE OF PAYMENT. SENIOR EXECUTIVES WHOSE DUTIES INCLUDE MEETING WITH PEOPLE OUTSIDE THE COMPANY FOR PURPOSED OF DEVELOPING BUSINESS RELATIONSHIPS HAVE COMPANY PAID MEMBERSHIPS AT A LOCAL COUNTRY CLUB. 32 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 19 EMPLOYEES RECEIVED CLUB DUES REIMBURSEMENTS. PART I, LINE 3 THE ORGANIZATION RELIES ON THEDACARE, INC., A RELATED 501(C)(3) ORGANIZATION, TO ESTABLISH THE COMPENSATION FOR ITS EXECUTIVE DIRECTOR. THEDACARE, INC. USES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE, AS ITS METHODS FOR ESTABLISHING THE COMPENSATION FOR RIVERSIDE MEDICAL CENTER'S EXECUTIVE DIRECTOR. PART I, LINE 4B SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVESTED IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. PART I, LINE 7 EXECUTIVE AT-RISK COMPENSATION PLAN THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG KEY EXECUTIVES, IMPROVE THEDACARE INC'S ABILITY TO COMPETE WITH OTHER EMPLOYERS FOR HIGH TALENT EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE AT-RISK COMPENSATION AMOUNTS THAT THE EXECUTIVES WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2011 TO DECEMBER 31, 2011) TO RECEIVE THEIR 2011 AT-RISK COMPENSATION. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS ELIGIBLE UNDER THE AT-RISK COMPENSATION PLAN OR MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE AT-RISK COMPENSATION PLAN OR DIES THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN AT-RISK COMPENSATION EARNED WILL BE FORFEITED. CARING FOR SUCCESS THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FULFILLMENT OF THEDACARE'S MISSION. THE ORGANIZATIONAL MEASURE IS THEDACARE'S OPERATING PERFORMANCE AND EMPLOYES HEALTH ASSESSMENT TOOL SCORE IMPROVEMENTS. ALL ELIGIBLE EMPLOYEES (ON THE PAYROLL AS OF JULY 1, 2011 AND STILL BE ON THE PAYROLL AS OF MARCH 15, 2012) SHARE IN THE GAIN. THE PAYOUT AMOUNT IS DETERMINED BASED ON THEDACARE'S OPERATING MARGIN AND REDUCTION IN OSHA RECORDABLE STRAINS AND SPRAINS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN. FORM 990, PART VI, SECTION B, LINE 11 THE COMPLETE FORM 990 WAS MADE AVAILABLE TO THE BOARD MEMBERS AT A MONTHLY BOARD MEETING PRIOR TO ITS FILING. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS ALL RIVERSIDE MEDICAL CENTER EMPLOYEES ARE REQUIRED TO COMPLETE A COMPUTER BASED CORPORATE COMPLIANCE MODULE. WITHIN THIS MODULE, CONFLICT OF INTEREST IS ADDRESSED. AS PART OF COMPLETION OF THIS MODULE THE EMPLOYEE INDICATES THAT NO CONFLICT OF INTEREST EXISTS, OR DISCLOSES THE CONFLICT OF INTEREST. ANY DISCLOSURE OF A CONFLICT OF INTEREST IS INVESTIGATED. BOARD OF DIRECTORS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST STATEMENT ANNUALLY. AT THE TIME OF COMPLETION, THE BOARD MEMBER INDICATES IF NO CONFLICT OF INTEREST EXISTS, OR DISCLOSES THE CONFLICT OF INTEREST. ANY DISCLOSURE OF A CONFLICT OF INTEREST IS INVESTIGATED. IF INFORMATION IS RECEIVED AT ANY TIME DURING THE YEAR SUGGESTING THAT A CONFLICT OF INTEREST COULD POTENTIALLY EXIST WITH AN EMPLOYEE OR BOARD MEMBER, THIS IS IMMEDIATELY INVESTIGATED AND RESOLVED. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION IS ESTABLISHED BASED UPON MARKET SALARY SURVEY DATA. ADJUSTMENTS TO SALARY ARE BASED UPON THE SAME DATA AND APPROVED BY THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC BY CONTACTING THE MEDICAL CENTER'S ADMINISTRATIVE ASSISTANT, CFO, OR CEO. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -669,908. NET ASSETS RELEASED FROM RESTRICTIONS 18,612. TOTAL TO FORM 990, PART XI, LINE 5: -651,296. FORM 990, PART XII, LINE 2C NO CHANGE FROM PRIOR YEAR NUMBER OF EMPLOYEES FORM 990, PART I, LINE 5: RIVERSIDE MEDICAL CENTER, INC. REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE ALL PAID BY THEDACARE INC., THEREFORE RIVERSIDE MEDICAL CENTER, INC. DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY RIVERSIDE MEDICAL CENTER, INC. FOR SALARY EXPENSES FOR ALL OF THE EMPLOYEES PERMANENTLY ASSIGNED TO RIVERSIDE MEDICAL CENTER, INC. APPLETON MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 THEDA CLARK MEDICAL CENTER PO BOX 8025 APPLETON WI 54912 390830664 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 APPLETON MEDICAL CENTER FOUNDATION 1818 N MEADE APPLETON WI 54911 391459276 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 THEDA CLARK MEDICAL CENTER FOUNDATION 130 SECOND STREET NEENAH WI 54956 391550056 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 WOLF RIVER AREA HEALTHCARE FOUNDATION 1405 MILL STREET NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 11B, II THEDACARE 0 COMMUNITY HOSPICE FOUNDATION 1818 N MEADE APPLETON WI 54911 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE 0 GEORGE F PEABODY FOUNDATION PO BOX 2553 APPLETON WI 54912 391702534 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE 0 NEW LONDON FAMILY MEDICAL CENTER 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 THEDACARE INC 122 E COLLEGE AVE APPLETON WI 54912 391509362 HEALTHCARE WI 501(C)(3) LINE 11C, III-FI 0 AUXILIARY OF RIVERSIDE MEDICAL CENTER 800 RIVERSIDE DRIVE WAUPACA WI 54981 900328881 SUPPORT OF RIVERSIDE MEDICAL CENTER WI 501(C)(3) LINE 11A, I THEDACARE 0 SHAWANO MEDICAL CENTER FOUNDATION INC 309 N BARTLETTE ST SHAWANO WI 54166 391539117 FOUNDATION WI 501(C)(3) LINE 11D, III-O THEDACARE 0 SHAWANO MEDICAL CENTER INC 309 N BARTLETTE ST SHAWANO WI 54166 390807068 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0