TOMAH MEMORIAL HOSPITAL INC: Form 990, tax year 2010
View the entire original 990 at ProPublica ↗
- Organization
- TOMAH MEMORIAL HOSPITAL INC (EIN 39-0799566)
- Tax period
- 2010-10-01 to 2011-09-30
- Filed
- 2012-05-10
- IRS object ID
- 201221319349301847
- Schema version
- 2010v3.4
- 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 D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule M
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2012-05-10T13:27:10-05:00 | Timestamp |
| Tax Period End Date | 2011-09-30 | TaxPeriodEndDate |
Preparer Firm PreparerFirm
Preparer Firm Business Name PreparerFirmBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | EIDE BAILLY LLP | BusinessNameLine1 |
Preparer Firm US Address PreparerFirmUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 NICOLLET MALL STE 1300 | AddressLine1 |
| City | MINNEAPOLIS | City |
| State | MN | State |
| ZIP Code | 554027033 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2010-10-01 | TaxPeriodBeginDate |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390799566 | EIN |
Name Name
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TOMAH MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Control | TOMA | NameControl |
| Phone | 6083722181 | Phone |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
Officer Officer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | JOSEPH ZEPS | Name |
| Title | CFO | Title |
| Phone | 6083722181 | Phone |
| Date Signed | 2012-05-09 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | KIM HUNWARDSEN CPA | Name |
| Phone | 6122536500 | Phone |
| Date Prepared | 2012-05-09 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2010 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | PHILIP J STUART | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 43443931 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c3 | X | Organization501c3 |
| Web Site | WWW.TOMAHHOSPITAL.ORG | WebSite |
| Type Of Organization Corporation | X | TypeOfOrganizationCorporation |
| Year Formation | 1948 | YearFormation |
| State Legal Domicile | WI | StateLegalDomicile |
| Activity Or Mission Description | TO PROMOTE AND PROVIDE QUALITY HEALTH CARE TO PATIENTS IN A HOSPITAL SETTING | ActivityOrMissionDescription |
| Nbr Voting Members Governing Body | 10 | NbrVotingMembersGoverningBody |
| Nbr Independent Voting Members | 8 | NbrIndependentVotingMembers |
| Total Nbr Employees | 319 | TotalNbrEmployees |
| Total Nbr Volunteers | 62 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 203993 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 190406 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 32879769 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 34307234 | ProgramServiceRevenueCY |
| Investment Income Prior Year | 614226 | InvestmentIncomePriorYear |
| Investment Income Current Year | 950411 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -20020 | OtherRevenuePriorYear |
| Other Revenue Current Year | -9787 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 33677968 | TotalRevenuePriorYear |
| Total Revenue Current Year | 35438264 | 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 | 16275654 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 16637378 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp Prior Year | 0 | TotalProfFundrsngExpPriorYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 24053 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 14822487 | OtherExpensePriorYear |
| Other Expenses Current Year | 16192821 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 31098141 | TotalExpensesPriorYear |
| Total Expenses Current Year | 32830199 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 2579827 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 2608065 | RevenuesLessExpensesCY |
| Total Assets BOY | 39730220 | TotalAssetsBOY |
| Total Assets EOY | 42438239 | TotalAssetsEOY |
| Total Liabilities BOY | 11619049 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 12921768 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 28111171 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 29516471 | NetAssetsOrFundBalancesEOY |
| Info In Schedule O Part III | X | InfoInScheduleOPartIII |
| Mission Description | THE MISSION OF TOMAH MEMORIAL HOSPITAL, INC. IS TO PROMOTE AND PROVIDE QUALITY HEALTH CARE BASED ON CUSTOMER NEED AND EXPECTATIONS. IN FULFILLMENT OF ITS MISSION, TOMAH MEMORIAL HOSPITAL IS COMMITTED TO VIEW ITS CUSTOMERS AND EMPLOYEES THROUGH A HOLISTIC APPROACH WITHOUT CONSIDERATION TO ECONOMIC STATUS, GENDER, ETHNIC ORIGIN OR PERSONAL LIMITATIONS. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 25159776 | Expense |
| Revenue | 32093805 | Revenue |
| Description | TOMAH MEMORIAL HOSPITAL HAS PROVIDED FOR THE HEALTH AND WELL BEING OF THE RESIDENTS OF TOMAH AND THE SURROUNDING COMMUNITIES FOR NEARLY SIXTY YEARS. THE HOSPITAL PROVIDES A BROAD SPECTRUM OF HEALTH AND WELLNESS SERVICES TO THE COMMUNITY, INCLUDING GENERAL MEDICAL/SURGICAL AND SWING BED INPATIENT CARE, DIAGNOSTIC LABORATORY AND RADIOLOGY SERVICES, GENERAL AND SPECIALTY SURGICAL SERVICES, 24 HOUR EMERGENCY CARE SERVICES, OBSTETRIC SERVICES, REHABILITATIVE SERVICES, OCCUPATIONAL HEALTH AND WELLNESS PROGRAMS, AND A COMMUNITY OUTREACH PROGRAM. KEY VOLUME INDICATORS FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2011 ARE AS FOLLOWS:* 1,327 INPATIENT DISCHARGES* 3,595 INPATIENT DAYS* 13,935 EMERGENCY ROOM AND URGENT CARE VISITS* 1,276 SURGICAL AND ENDOSCOPIC PROCEDURES* 11,895 RADIOLOGY PROCEDURES (INCLUDING CT AND MRI)* 68,196 LABORATORY TESTS* 32,425 REHABILITATIVE SERVICES PROCEDURESIN FURTHERANCE OF ITS CHARITABLE MISSION, THE HOSPITAL PROVIDED APPROXIMATELY $724,000 OF FREE AND DISCOUNTED CARE TO AREA RESIDENTS (COST OF CARE EQUAL TO $420,000), AND WROTE OFF $1.87 MILLION OF UNCOLLECTIBLE ACCOUNTS (COST EQUAL TO $1.08 MILLION). ADDITIONALLY, BASED ON IT'S MOST RECENTLY COMPLETED COMMUNITY BENEFITS SURVEY, THE HOSPITAL INCURRED APPROXIMATELY $952,000 IN NET LOSSES RELATED TO PROVIDING CARE FOR INDIVIDUALS WITH HEALTH INSURANCE PROVIDED BY EITHER THE MEDICAID PROGRAM OR OTHER GOVERNMENTAL INSURANCE PROGRAMS. THE HOSPITAL SUBSIDIZES SEVERAL PROGRAMS THAT ARE DEEMED VITAL SERVICES FOR THE COMMUNITY, INCLUDING IN-HOME HOSPICE AND PALLIATIVE CARE SERVICES, A HOSPICE RESIDENCE, A WALK-IN CLINIC LOCATED IN THE RURAL COMMUNITY OF WARRENS, WI, AND A DEDICATED COMMUNITY OUTREACH DEPARTMENT THAT PROVIDES HEALTH AND WELLNESS SERVICES TO AREA EMPLOYERS AND THE TOMAH COMMUNITY. SUBSIDIES FOR THESE PROGRAMS FOR FISCAL 2011 APPROXIMATED $1.62 MILLION. ADDITIONAL DETAILS REGARDING THE HOSPICE PROGRAM AND THE WARRENS WALK-IN CLINIC CAN BE FOUND BELOW. THE HOSPITAL ALSO INVESTED $1.4 MILLION IN A NEW HOSPICE RESIDENCE FACILITY DURING 2011 IN ORDER TO EXPAND CAPACITY AND CONTINUE MEETING THE NEEDS OF AREA RESIDENTS REQUIRING END-OF-LIFE CARE. IN ADDITION TO PROVIDING HIGH QUALITY HEALTHCARE SERVICES, THE HOSPITAL ENCOURAGES EMPLOYEES TO BECOME ACTIVELY INVOLVED IN COMMUNITY ORGANIZATIONS AND PROJECTS THAT PROVIDE OTHER BENEFITS TO LOCAL COMMUNITIES. THE HOSPITAL PROVIDES MANY FREE SERVICES TO THE COMMUNITY, INCLUDING HEALTH AND WELLNESS PRESENTATIONS TO AREA SCHOOL CHILDREN, CPR AND AED TRAINING TO VARIOUS ORGANIZATIONS, WELLNESS FAIRS DEVOTED TO WOMEN AND SENIOR CITIZENS, AND MEETING SPACE TO VARIOUS NON-PROFIT AND CIVIC ORGANIZATIONS. | Description |
Activity2 Activity2
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 3328463 | Expense |
| Revenue | 1941982 | Revenue |
| Description | THE HOSPITAL PROVIDES IN-HOME, INPATIENT, AND RESIDENTIAL HOSPICE CARE TO RESIDENTS OF TOMAH AND THE SURROUNDING COMMUNITIES. RESIDENTIAL CARE IS PROVIDED VIA THE OPERATION OF A FOUR BED HOSPICE HOUSE LOCATED ADJACENT TO THE MAIN HOSPITAL CAMPUS. DESPITE SUBSIDIZING THE FINANCIAL LOSSES INCURRED BY THE PROGRAM, THE SERVICES ARE DEEMED VITAL TO THE COMMUNITY AND REPRESENT A NECESSARY COMPONENT OF PATIENT CARE. FOR THE YEAR ENDED SEPTEMBER 30, 2011, THE HOSPICE PROGRAM EXPERIENCED 9,782 PROGRAM DAYS AND 1,006 HOSPICE RESIDENCE DAYS. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 503969 | Expense |
| Revenue | 271447 | Revenue |
| Description | THE HOSPITAL BEGAN OPERATING AN OFF-SITE WALK-IN CARE CLINIC DURING 2008 TO BETTER SERVE THE NEEDS OF THE RESIDENTS OF WARRENS, WISCONSIN. FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2011, THE CLINIC EXPERIENCED 3,500 PATIENT VISITS. THE CLINIC PROVIDES RESIDENTS WITH A CLOSE-TO-HOME, LOW-COST OPTION FOR HEALTHCARE SERVICES (INCLUDING BASIC LABORATORY TESTS AND X-RAY CAPABILITIES) RELATED TO MINOR INJURIES AND ILLNESSES, AND ALL SERVICES PROVIDED ARE SUPPORTED BY THE HOSPITAL'S EMERGENCY DEPARTMENT. DESPITE INCURRING A NEGATIVE GROSS CONTRIBUTION MARGIN DURING 2011, THE HOSPITAL'S BOARD OF DIRECTORS BELIEVES THE CLINIC IS AN IMPORTANT ASSET TO THE RESIDENTS OF WARRENS AND REMAINS COMMITTED TO SUPPORTING IT UNTIL IT ACHIEVES A SUSTAINABLE LEVEL OF FINANCIAL PERFORMANCE. | Description |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expense | 28992208 | TotalProgramServiceExpense |
| Described In501 C3 | 1 | DescribedIn501C3 |
| Schedule B Required | 1 | ScheduleBRequired |
| Political Activities | 0 | PoliticalActivities |
| Lobbying Activities | 0 | LobbyingActivities |
| Donor Advised Funds | 0 | DonorAdvisedFunds |
| Conservation Easements | 0 | ConservationEasements |
| Collections Of Art | 0 | CollectionsOfArt |
| Credit Counseling | 0 | CreditCounseling |
| Term Or Permanent Endowments | 1 | 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 | 0 | IndependentAuditFinancialStmt |
| Consolidated Audit Financial Stmt | 1 | 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 | 1 | TaxExemptBonds |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBonds |
| Escrow Account | 0 | EscrowAccount |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| 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 | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 1 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 1 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 1 | 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 | 1 | 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 | 16 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 319 | 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 | 1 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 0 | 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 | 1 | 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 | 1 | CompensationProcessCEO |
| Compensation Process Other | 1 | 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
Name Business NameBusiness
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | JOSEPH ZEPS | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Telephone Number | 6083740307 | TelephoneNumber |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part VII | X | InfoInScheduleOPartVII |
Form990 Part VII Section A Form990PartVIISectionA (22 entries)
| TitleTitle | Average Hours Per WeekAverageHoursPerWeek | Individual Trustee Or DirectorIndividualTrusteeOrDirector | OfficerOfficer | Reportable Comp From OrganizationReportableCompFromOrganization | Reportable Comp From Related OrgsReportableCompFromRelatedOrgs | Other CompensationOtherCompensation | Highest Compensated EmployeeHighestCompensatedEmployee |
|---|---|---|---|---|---|---|---|
| ROBERT FASBENDER | |||||||
| CHAIR UNTIL 1/18/11 | 1.00 | X | X | 0 | 0 | 0 | |
| OAKLEY MOSER | |||||||
| CHAIR - CURRENT | 1.00 | X | X | 0 | 0 | 0 | |
| STEVE AUSTIN | |||||||
| VICE CHAIRMAN | 1.00 | X | X | 0 | 0 | 0 | |
| PHIL YAHNKE | |||||||
| SECRETARY | 1.00 | X | X | 0 | 0 | 0 | |
| JEFF HOLTHAUS | |||||||
| TREASURER | 1.00 | X | X | 0 | 0 | 0 | |
| CYNTHIA ERDMAN | |||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| WES REVELS | |||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| WILL SCHANHOFER MD | |||||||
| PRESIDENT OF MEDICAL STAFF/DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| JAMES QUARTEMONT | |||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| MICHAEL SAUNDERS MD | |||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| NODJI VAN WYCHEN | |||||||
| DIRECTOR | 1.00 | X | 0 | 0 | 0 | ||
| ROBB KLINE MD | |||||||
| DIRECTOR UNTIL 1/18/11 | 1.00 | X | 0 | 0 | 0 | ||
| JERRY MOLNAR | |||||||
| DIRECTOR UNTIL 1/18/11 | 1.00 | X | 0 | 0 | 0 | ||
| RALPH KNUDSON MD | |||||||
| DIRECTOR UNTIL 1/18/11 | 1.00 | X | 0 | 0 | 0 | ||
| PENNY PRECOUR-BERRY | |||||||
| DIRECTOR UNTIL 1/18/11 | 1.00 | X | 0 | 0 | 0 | ||
| JOSEPH ZEPS | |||||||
| CHIEF FINANCIAL OFFICER | 40.00 | X | 115898 | 0 | 21015 | ||
| PHILIP J STUART | |||||||
| ADMINISTRATOR | 40.00 | X | 0 | 0 | 0 | ||
| EVELYN CHAPMAN | |||||||
| CHIEF NURSING OFFICER | 40.00 | 116322 | 0 | 18236 | X | ||
| DARLA WILSON | |||||||
| DIRECTOR OF PHARMACY | 40.00 | 146670 | 0 | 13190 | X | ||
| TODD CHAPMAN | |||||||
| PHARMACIST | 40.00 | 125733 | 0 | 5029 | X | ||
| GERALD FUSHIANES | |||||||
| PHYSICIAN ASSISTANT | 40.00 | 114248 | 0 | 20949 | X | ||
| LAURA J MILLER | |||||||
| NURSE PRACTITIONER | 40.00 | 125571 | 0 | 12346 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 744442 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 90765 | TotalOtherCompensation |
| Number Individuals GT100 K | 7 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 0 | CompensationFromOtherSources |
Contractor Compensation ContractorCompensation (5 entries)
| Address Line1AddressOfContractor/AddressUS/AddressLine1 | CityAddressOfContractor/AddressUS/City | StateAddressOfContractor/AddressUS/State | ZIP CodeAddressOfContractor/AddressUS/ZIPCode | Description Of ServicesDescriptionOfServices | CompensationCompensation |
|---|---|---|---|---|---|
| EMCARE INC | |||||
| 7032 COLLECTIONS CTR DR | CHICAGO | IL | 60693 | CONTRACTED ER PHYSICIANS | 1258048 |
| TOMAH ORTHOPEDICS | |||||
| 321 BUTTS AVENUE | TOMAH | WI | 54660 | CONTRACTED ORTHOPEDIC SURGEONS | 1126719 |
| PHILIPS MEDICAL CAPITAL | |||||
| 1111 OLD EAGLE SCHOOL ROAD | WAYNE | PA | 19087 | CT/MRI LEASE | 603183 |
| MAYO CLINIC HEALTH SYSTEM | |||||
| 325 BUTTS AVENUE | TOMAH | WI | 54660 | RADIOLOGY, PATHOLOGY, & CONTRACTED LABOR | 557070 |
| HEALTHTECH MANAGEMENT SERVICES INC | |||||
| PO BOX 636426 | CINCINNATI | OH | 452636426 | MANAGEMENT SERVICES | 467857 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 13 | NumberOfContractorsGT100K |
| Related Organizations | 7419 | RelatedOrganizations |
| All Other Contributions | 182987 | AllOtherContributions |
| Noncash Contributions | 21500 | NoncashContributions |
| Total Contributions | 190406 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| PATIENT SERVICE REVENU | 622110 | 34098184 | 34098184 |
| SUPPORTING REVENUE | 621990 | 209050 | 209050 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 34307234 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 706376 | TotalRevenueColumn |
| Exclusion | $706,376 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 41511 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 51298 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -9787 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -9787 | TotalRevenueColumn |
| Exclusion | -$9,787 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 8190703 | Securities |
| Other | 7701 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 7954369 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 236334 | Securities |
| Other | 7701 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 244035 | TotalRevenueColumn |
| Exclusion | $244,035 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 35438264 | TotalRevenueColumn |
| Related Or Exempt Function Income | 34307234 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $940,624 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 149909 | Total |
| Management And General | 149909 | ManagementAndGeneral |
Comp Disqual Persons CompDisqualPersons
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 77646 | Total |
| Program Services | 77646 | ProgramServices |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 12838530 | Total |
| Program Services | 11152640 | ProgramServices |
| Management And General | 1662812 | ManagementAndGeneral |
| Fundraising | 23078 | Fundraising |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 314146 | Total |
| Program Services | 275124 | ProgramServices |
| Management And General | 39022 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2298280 | Total |
| Program Services | 1993245 | ProgramServices |
| Management And General | 305035 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 958867 | Total |
| Program Services | 827031 | ProgramServices |
| Management And General | 131836 | ManagementAndGeneral |
Fees For Services Management FeesForServicesManagement
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 235032 | Total |
| Management And General | 235032 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 14528 | Total |
| Management And General | 14528 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 83668 | Total |
| Management And General | 83668 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 6055497 | Total |
| Program Services | 5680219 | ProgramServices |
| Management And General | 375278 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 197687 | Total |
| Program Services | 870 | ProgramServices |
| Management And General | 196817 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 3988626 | Total |
| Program Services | 3820195 | ProgramServices |
| Management And General | 167456 | ManagementAndGeneral |
| Fundraising | 975 | Fundraising |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 347093 | Total |
| Program Services | 340152 | ProgramServices |
| Management And General | 6941 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 162043 | Total |
| Program Services | 139473 | ProgramServices |
| Management And General | 22570 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 85510 | Total |
| Program Services | 74092 | ProgramServices |
| Management And General | 11418 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 572296 | Total |
| Program Services | 572296 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1945154 | Total |
| Program Services | 1945154 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 128605 | Total |
| Program Services | 128605 | ProgramServices |
Other Expenses OtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Description | PROVISION FOR BAD DEBTS | Description |
| Total | 1867267 | Total |
| Program Services | 1867267 | ProgramServices |
All Other Expenses AllOtherExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 509815 | Total |
| Program Services | 98199 | ProgramServices |
| Management And General | 411616 | ManagementAndGeneral |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 32830199 | Total |
| Program Services | 28992208 | ProgramServices |
| Management And General | 3813938 | ManagementAndGeneral |
| Fundraising | 24053 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2538784 | BOY |
| EOY | 3124420 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4575955 | BOY |
| EOY | 5042146 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 479604 | BOY |
| EOY | 461584 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 242991 | BOY |
| EOY | 191902 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 31864920 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 16066681 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12924562 | BOY |
| EOY | 15798239 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 18484868 | BOY |
| EOY | 17347561 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 281786 | BOY |
| EOY | 282026 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 201670 | BOY |
| EOY | 190361 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 39730220 | BOY |
| EOY | 42438239 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2154879 | BOY |
| EOY | 2391918 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8486702 | BOY |
| EOY | 8220258 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 977468 | BOY |
| EOY | 2309592 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 11619049 | BOY |
| EOY | 12921768 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 27421030 | BOY |
| EOY | 28973582 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 157662 | BOY |
| EOY | 3685 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 532479 | BOY |
| EOY | 539204 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 28111171 | BOY |
| EOY | 29516471 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 39730220 | BOY |
| EOY | 42438239 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | X | InfoInScheduleOPartXI |
| Reconcilation Revenue Expenses | 2608065 | ReconcilationRevenueExpenses |
| Reconcilation Other Changes | -1202765 | ReconcilationOtherChanges |
| Method Of Accounting Accrual | X | MethodOfAccountingAccrual |
| Accountant Compile Or Review | 0 | AccountantCompileOrReview |
| FS Audited | 1 | FSAudited |
| Audit Committee | 1 | AuditCommittee |
| Financial Statement Consolidated | X | FinancialStatementConsolidated |
| 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 D IRS990ScheduleD
Current Year CurrentYear
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 535663 | BeginningOfYearBalance |
| Contributions | 185 | Contributions |
| Investment Earnings Or Losses | 13959 | InvestmentEarningsOrLosses |
| Other Expenditures | 10603 | OtherExpenditures |
| End Of Year Balance | 539204 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 483734 | BeginningOfYearBalance |
| Contributions | 36960 | Contributions |
| Investment Earnings Or Losses | 22725 | InvestmentEarningsOrLosses |
| Other Expenditures | 7756 | OtherExpenditures |
| End Of Year Balance | 535663 | EndOfYearBalance |
Current Year Minus2 Years CurrentYearMinus2Years
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Of Year Balance | 410683 | BeginningOfYearBalance |
| Contributions | 88020 | Contributions |
| Investment Earnings Or Losses | -6375 | InvestmentEarningsOrLosses |
| Other Expenditures | 8594 | OtherExpenditures |
| End Of Year Balance | 483734 | EndOfYearBalance |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Permanent Endowment EOY Balance | 1.00000 | PermanentEndowmentEOYBalance |
| Endowments Held By Unrelated Orgs | 0 | EndowmentsHeldByUnrelatedOrgs |
| Endowments Held By Related Orgs | 0 | EndowmentsHeldByRelatedOrgs |
Land Land
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 34500 | OtherCostOrOtherBasis |
| Book Value | 34500 | BookValue |
Buildings Buildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 22210704 | OtherCostOrOtherBasis |
| Depreciation | 10816540 | Depreciation |
| Book Value | 11394164 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 8824967 | OtherCostOrOtherBasis |
| Depreciation | 5005103 | Depreciation |
| Book Value | 3819864 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 794749 | OtherCostOrOtherBasis |
| Depreciation | 245038 | Depreciation |
| Book Value | 549711 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 15798239 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| CAPITAL LEASE OBLIGATIONS | $1,494,592 |
| ESTIMATED THIRD PARTY PAYOR SETTLEMENTS | $815,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 2309592 | TotalOfAmounts |
| Total Revenue | 35438264 | TotalRevenue |
| Total Expenses | 32830199 | TotalExpenses |
| Excess Or Deficit For Year | 2608065 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | -1200716 | NetUnrealizedGLOnInvestments |
| Other | -$2,049 | OtherAmount |
| Total Adjustments | -1202765 | TotalAdjustments |
| Excess Or Deficit Per FS | 1405300 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 35276611 | TotRevenueEtcAuditedFinclStmt |
| Other Revenues | -194654 | OtherRevenues |
| Revenue Not Rptd F990 | -194654 | RevenueNotRptdF990 |
| Revenue Subtotal | 35471265 | RevenueSubtotal |
| Other Revenues Not Included | -33001 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | -33001 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 35438264 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 32881497 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 51298 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 51298 | ExpensesNotRptdF990 |
| Expenses Subtotal | 32830199 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 32830199 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (6 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: | PART V, LINE 4: | PERMANENTLY RESTRICTED NET ASSETS ARE RESTRICTED TO THE HOSPICE ENDOWMENT FUND AND THE BENEFICIAL INTEREST IN A PERPETUAL TRUST. THE INTEREST EARNED CAN BE USED FOR HOSPICE EXPENDITURES. |
| DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: | PART X: | THE HOSPITAL BELIEVES THAT IT HAS APPROPRIATE SUPPORT FOR ANY TAX POSITIONS TAKEN AFFECTING ITS ANNUAL FILING REQUIREMENTS, AND, AS SUCH, DOES NOT HAVE ANY UNCERTAIN TAX POSITIONS THAT ARE MATERIAL TO THE CONSOLIDATED FINANCIAL STATEMENTS. THE HOSPITAL WOULD RECOGNIZE FUTURE ACCRUED INTEREST AND PENALTIES RELATED TO UNRECOGNIZED TAX BENEFITS AND LIABILITIES IN INCOME TAX EXPENSE, IF SUCH INTEREST AND PENALTIES ARE INCURRED. |
| PART XI, LINE 8 - OTHER ADJUSTMENTS: | DECREASE IN FAIR VALUE OF BENEFICIAL INTEREST IN PERPETUAL TRUST -2,049. | |
| PART XII, LINE 2D - OTHER ADJUSTMENTS: | RECLASSIFICATION UNREALIZED LOSSES ON INVESTMENTS INCLUDED IN REVENUE -194,654. | |
| PART XII, LINE 4B - OTHER ADJUSTMENTS: | TEMPORARILY RESTRICTED INTEREST INCOME INCLUDED IN FUND BALANCE 9,523. RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS -51,298. PERMANENTLY RESTRICTED INTEREST INCOME INCLUDED IN FUND BALANCE 8,589. PERMANENTLY RESTRICTED CONTRIBUTIONS INCLUDED IN FUND BALANCE 185. | |
| PART XIII, LINE 2D - OTHER ADJUSTMENTS: | RENTAL EXPENSES RECORDED IN EXPENSES FOR FINANCIAL STATEMENTS 51,298. |
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 |
Other Percentage OtherPercentage
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| Free Other Percentage | 50.000000000000 | FreeOtherPercentage |
| Field | Value | IRS element (for citing) |
|---|---|---|
| FPG Reference Discounted Care | 1 | FPGReferenceDiscountedCare |
| Pcent400 | X | Pcent400 |
| 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) |
|---|---|---|
| Persons Served | 163 | PersonsServed |
| Total Community Benefit Expense | 420148 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 420148 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01360 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 6726 | PersonsServed |
| Total Community Benefit Expense | 4569606 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 4399914 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 169692 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00550 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 2873 | PersonsServed |
| Total Community Benefit Expense | 2374256 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1591849 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 782407 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02530 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 9762 | PersonsServed |
| Total Community Benefit Expense | 7364010 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 5991763 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1372247 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.04440 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 94060 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 94060 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00300 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 4499 | PersonsServed |
| Total Community Benefit Expense | 3832432 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2213429 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1619003 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05230 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 4499 | PersonsServed |
| Total Community Benefit Expense | 3926492 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2213429 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1713063 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05530 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 14261 | PersonsServed |
| Total Community Benefit Expense | 11290502 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 8205192 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3085310 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.09970 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReported |
| Bad Debt Expense | $1,083,626 | BadDebtExpenseAmount |
| Amount Attributable To | 14087 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 6761878 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 6694928 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 66950 | MedicareSurplusOrShortfall |
Costing Methodology Used CostingMethodologyUsed
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | X | Other |
| 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 | TOMAH MEMORIAL HOSPITAL | BusinessNameLine1 |
Address Address
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Licensed Hospital | X | LicensedHospital |
| 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 | NOT REQUIRED | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital Facility Number | 1 | HospitalFacilityNumber |
Form990 Schedule H Part V Section C Form990ScheduleHPartVSectionC
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Other Facilities | 2 | NumberOfOtherFacilities |
Other Facilities OtherFacilities (2 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Facility TypeFacilityType |
|---|---|---|---|---|
| HOSPICE TOUCH SERENITY HOUSE | ||||
| 330 BUTTS AVENUE | TOMAH | WI | 54660 | HOSPICE RESIDENCE |
| WARRENS WALK IN CLINIC | ||||
| 101 UNITY DRIVE | WARRENS | WI | 54666 | WALK-IN CARE CLINIC |
Form990 Schedule H Part VI Form990ScheduleHPartVI (11 entries)
| ExplanationExplanation | IdentifierIdentifier | Return ReferenceReturnReference |
|---|---|---|
| PART I, LINE 6A: THE ORGANIZATION PARTICIPATES IN THE WISCONSIN HOSPITAL ASSOCIATION (WHA) ANNUAL COMMUNITY BENEFIT REPORTING PROCESS, WHICH IS RELEASED TO THE PUBLIC VIA A WRITTEN REPORT DISTRIBUTED TO MEMBER HOSPITALS AS WELL AS THE WHA'S WEBSITE. THIS REPORTING INITIATIVE ATTEMPTS TO QUANTIFY THE AMOUNT OF COMMUNITY BENEFITS PROVIDED BY THE HOSPITAL, AND INCLUDES FIGURES RELATED TO COMMUNITY CARE WRITE-OFFS, BAD DEBT WRITE-OFFS, MEDICARE AND MEDICAID SHORTFALLS, AND PROGRAMS OPERATED AT A LOSS.THE ORGANIZATION ALSO PREPARES A QUARTERLY NEWSLETTER THAT IS DISTRIBUTED TO THE PUBLIC VIA A MASS-MAILING. THE QUARTERLY NEWSLETTER IS INTENDED TO PROVIDE THE COMMUNITIES THE HOSPITAL SERVES INFORMATION REGARDING HOSPITAL OPERATIONS, FINANCIAL RESULTS, AND PROGRAMS/INITIATIVES INTENDED TO FULFILL THE HOSPITAL'S COMMITMENT TO COMMUNITY. THE NEWSLETTER ALSO CONTAINS FINANCIAL HIGHLIGHTS FROM THE WHA COMMUNITY BENEFIT REPORT. CURRENT AND PRIOR EDITIONS OF THE NEWSLETTER ARE AVAILABLE ON THE HOSPITAL'S WEBSITE. | ||
| PART I, LINE 7: THE METHODOLOGY FOR DETERMINING CHARITY CARE AND MEDICAID/TRICARE SHORTFALLS AT COST WAS AS FOLLOWS: A COST TO CHARGE RATIO WAS COMPUTED USING TOTALS FROM THE HOSPITAL'S AUDITED FINANCIAL STATEMENTS; THIS RATIO WAS APPLIED TO CHARITY CARE CHARGES, AND GROSS MEDICAID/TRICARE REVENUE. ACTUAL REIMBURSEMENT RECEIVED FROM MEDICAID/TRICARE WAS THEN COMPARED TO THE ESTIMATED COST (COMPUTED BY MULTIPLYING THE CCR BY GROSS CHARGES) TO DETERMINE THE SHORTFALL. ALL OTHER ITEMS WERE BASED ON ACTUAL PROGRAM EXPENSES. ALSO WORTH NOTING THAT THE METHODOLOGY USED FOR CHARITY CARE/TRICARE/MEDICAID IS THE SAME AS THE METHODOLOGY USED BY THE WISCONSIN HOSPITAL ASSOCIATION IN COMPILING THEIR ANNUAL COMMUNITY BENEFIT REPORT. | ||
| PART I, L7 COL(F): BAD DEBT EXPENSE REPORTED ON FORM 990, PART IX, LINE 25, COLUMN (A) OF $1,867,267 WAS REMOVED FROM THE DENOMINATOR PRIOR TO THE CALCULATION. | ||
| PART III, LINE 4: BAD DEBT EXPENSE AT COST WAS CONVERTED TO COST USING EXPENSES AND REVENUES FROM THE FINANCIAL STATEMENTS AND APPLYING AN OVERALL COST-TO-CHARGE RATIO.ACCOUNTS ARE NOT WRITTEN OFF TO BAD DEBT UNTIL ALL FORMS OF PAYMENT HAVE BEEN APPLIED TO THE ACCOUNT SUCH AS INSURANCE, DISCOUNTS, AND CONTRACTUAL ALLOWANCES, AND THE REMAINING BALANCE IS THE PERSONAL PORTION DUE. A PAYMENT RECEIVED ON AN ACCOUNT PREVIOUSLY WRITTEN OFF TO BAD DEBT REDUCES BAD DEBT EXPENSE.THE ESTIMATED AMOUNT OF THE ORGANIZATION'S BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY IS CALCULATED BASED ON AN ESTIMATE OF CHARGES FOREGONE TO GROSS PATIENT CHARGES.FINANCIAL STATEMENT FOOTNOTE: THE CARRYING AMOUNT OF PATIENT RECEIVABLES IS REDUCED BY A VALUATION ALLOWANCE THAT REFLECTS MANAGEMENT'S ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS AND THIRD-PARTY PAYORS. MANAGEMENT REVIEWS PATIENT RECEIVABLES BY PAYOR CLASS AND APPLIES PERCENTAGES TO DETERMINE ESTIMATED AMOUNTS THAT WILL NOT BE COLLECTED FROM THIRD PARTIES UNDER CONTRACTUAL AGREEMENTS AND AMOUNTS THAT WILL NOT BE COLLECTED FROM PATIENTS DUE TO BAD DEBTS. MANAGEMENT CONSIDERS HISTORICAL WRITE OFF AND RECOVERY INFORMATION IN DETERMINING THE ESTIMATED BAD DEBT PROVISION. | ||
| PART III, LINE 8: MEDICARE ALLOWABLE COSTS OF CARE ARE BASED ON THE MEDICARE COST REPORT. THE MEDICARE COST REPORT IS COMPLETED BASED ON THE RULES AND REGULATIONS SET FORTH BY CMS. TOMAH MEMORIAL HOSPITAL FOLLOWS THE CHA GUIDELINES IN REPORTING COMMUNITY BENEFITS AND THEREFORE ANY MEDICARE SHORTFALL IS EXCLUDED FROM OUR COMMUNITY BENEFIT REPORT. PROVIDING SERVICES TO MEDICARE PATIENTS IS ESSENTIAL TO THESE PATIENTS AND THE COMMUNITY AND INCREASES THEIR ACCESS TO HEALTHCARE SERVICES, WHICH IS A COMMUNITY BENEFIT. | ||
| PART III, LINE 9B: TOMAH MEMORIAL HOSPITAL ATTEMPTS TO SCREEN ALL ELECTIVE/SCHEDULED PATIENTS PRIOR TO THE RECEIPT OF SERVICE REGARDING COMMUNITY CARE ELIGIBILITY, AND WORKS WITH PATIENT FINANCIAL SERVICES STAFF TO IDENTIFY EMERGENT/UNSCHEDULED PATIENTS WHO MAY BE ELIGIBLE FOR COMMUNITY CARE (GENERALLY AFTER RECEIPT OF SERVICE). PATIENTS WITHOUT INSURANCE ARE OFFERED A 15% DISCOUNT. PATIENTS THAT EXPRESS AN INTEREST IN COMMUNITY CARE ASSISTANCE, ARE IN THE PROCESS OF APPLYING FOR COMMUNITY CARE ASSISTANCE, OR WAITING ON A DETERMINATION OF COMMUNITY CARE ASSISTANCE WILL NOT HAVE COLLECTION EFFORTS IMPOSED ON THEIR ACCOUNTS. AFTER A DETERMINATION OF COMMUNITY CARE ASSISTANCE IS MADE, ANY PERSONAL PORTION DUE BY THE PATIENT WILL FOLLOW THE SAME COLLECTION PROCEDURES AS OTHER PATIENTS. | ||
| PART VI, LINE 2: TOMAH MEMORIAL HOSPITAL CURRENTLY OPERATES ON A THREE-YEAR STRATEGIC PLANNING CYCLE. AT THE BEGINNING OF EACH CYCLE, A STRATEGIC PLANNING RETREAT IS HELD DURING WHICH AN ANALYSIS IS CONDUCTED OF THE SERVICES THE HOSPITAL CURRENTLY PROVIDES AND AREAS OF NEED THAT SHOULD BE ADDRESSED BY THE HOSPITAL. THE RETREAT IS OPEN TO ALL HOSPITAL STAFF, HOSPITAL BOARD MEMBERS, AND MEMBERS OF THE HOSPITAL'S MEDICAL STAFF. THE HOSPITAL'S MEDICAL STAFF IS COMPRISED PRIMARILY OF PHYSICIANS EMPLOYED BY OTHER AREA HEALTHCARE PROVIDERS (E.G. MAYO, GUNDERSEN LUTHERAN), AND AS SUCH THEIR INPUT INTO THE STRATEGIC PLANNING PROCESS ALLOWS THE HOSPITAL TO WORK COLLABORATIVELY WITH OTHER HOSPITALS AND HEALTH SYSTEMS IN ASSESSING THE NEEDS OF THE COMMUNITY. THE STRATEGIC PLANNING PROCESS IS FACILITATED BY A REPRESENTATIVE OF HEALTHTECH MANAGEMENT SERVICES, INC. (CONTRACTED MANAGEMENT ORGANIZATION), AND THE THREE YEAR PLAN THAT IS ADOPTED BY THE HOSPITAL'S GOVERNANCE SERVES AS A BLUEPRINT FOR ENSURING THE HOSPITAL IS ADDRESSING THE NEEDS OF THE COMMUNITY.IN ADDITION TO THE FORMAL STRATEGIC PLANNING PROCESS, THE HOSPITAL ENGAGES IN ONGOING DISCUSSIONS WITH VARIOUS STAKEHOLDERS (AREA BUSINESSES, PHYSICIANS, PATIENTS, AND COMMUNITY MEMBERS) REGARDING THE SERVICES OFFERED AT THE HOSPITAL, AND HOSPITAL LEADERSHIP EVALUATES ALL SUGGESTIONS OFFERED FOR IMPROVING THE MANY WAYS IN WHICH THE HOSPITAL SERVES ITS COMMUNITY. | ||
| PART VI, LINE 3: TOMAH MEMORIAL HOSPITAL MAKES AVAILABLE BROCHURES CONTAINING INFORMATION ABOUT FINANCIAL ASSISTANCE TO ALL PATIENTS SEEN IN THE EMERGENCY ROOM/URGENT CARE AREAS, AND ANY PATIENT THAT REGISTERS FOR A NON-EMERGENT SERVICE IS QUESTIONED BY ADMISSIONS OR NURSING STAFF REGARDING ANY CONCERNS THEY MIGHT HAVE ABOUT THE COST OF THEIR HOSPITAL SERVICES. THE HOSPITAL EMPLOYS A FULL-TIME, DEDICATED PATIENT BENEFIT SPECIALIST WHO WORKS WITH UNINSURED AND UNDERINSURED PATIENTS REGARDING COMMUNITY CARE APPLICATIONS AND FINANCIAL ASSISTANCE. ADDITIONALLY, A REVIEW IS CONDUCTED OF ALL ACCOUNTS THAT BECOME DELINQUENT TO ENSURE THAT AN ATTEMPT TO CONTACT THE PATIENT HAS BEEN MADE BY HOSPITAL STAFF. FINALLY, THE HOSPITAL IS IN THE PROCESS OF ADDING A COMMUNITY CARE & FINANCIAL ASSISTANCE SECTION TO ITS WEBSITE. | ||
| PART VI, LINE 4: TOMAH MEMORIAL HOSPITAL, INC. IS A 25-BED CRITICAL ACCESS HOSPITAL LOCATED IN TOMAH, WISCONSIN. THE HOSPITAL'S PRIMARY SERVICE AREA CONSISTS OF TOMAH, WI, AND THE OUTLYING COMMUNITIES OF CAMP DOUGLAS, WARRENS, OAKDALE, AND WILTON. TOMAH IS LOCATED IN RURAL WESTERN WISCONSIN, AND AS SUCH A SIGNIFICANT PORTION OF THE HOSPITAL'S PATIENT BASE IS COMPRISED OF AGRICULTURAL WORKERS AND MEMBERS OF THE AMISH COMMUNITY. ADDITIONALLY, TOMAH'S PROXIMITY TO TWO MILITARY INSTALLATIONS RESULTS IN A LARGE PORTION OF SERVICES PROVIDED TO MEMBERS OF THE MILITARY AND THEIR FAMILIES. THE HOSPITAL'S PAYER MIX IS COMPRISED OF APPROXIMATELY 15% MEDICAID, 37% MEDICARE, 7% MILITARY, 5% SELF-PAY, AND 36% COMMERCIAL INSURANCE. THE REIMBURSEMENT CHALLENGES ASSOCIATED WITH PROVIDING A HIGH PERCENTAGE OF SERVICES TO MEDICAID/MEDICARE RECIPIENTS AND THE UNINSURED HAS REQUIRED THE HOSPITAL TO OPERATE AT A HIGH LEVEL OF EFFICIENCY, ENSURING THAT ALL SERVICES PROVIDED REPRESENT AN EXCELLENT VALUE TO AREA COMMUNITY MEMBERS. ALTHOUGH THE HOSPITAL HAS BENEFITED FROM THE ADDITIONAL REIMBURSEMENT AFFORDED THROUGH THE CRITICAL ACCESS HOSPITAL PROGRAM, COMPETITION FOR MARKET SHARE WITH OTHER AREA HEALTHCARE PROVIDERS REQUIRES HOSPITAL LEADERSHIP TO CONTINUALLY REEVALUATE SERVICE OFFERINGS AND BUSINESS LINES FOR APPROPRIATENESS GIVEN THE HEALTHCARE NEEDS OF THE COMMUNITY. | ||
| PART VI, LINE 6: TOMAH MEMORIAL HOSPITAL'S BOARD OF DIRECTORS IS COMPRISED OF COMMUNITY MEMBERS THAT REPRESENT BOTH A CROSS SECTION OF INDUSTRY EXPERTISE (BANKING, MANUFACTURING, ATTORNEYS, PHYSICIANS, SMALL BUSINESS, ETC.) AS WELL AS AN APPRECIATION OF THE HEALTHCARE NEEDS OF THE COMMUNITY. THE HOSPITAL BUDGETS FOR A TARGETED OPERATING MARGIN OF BETWEEN 3% AND 5% EACH YEAR. THIS TARGET WAS ESTABLISHED BY THE HOSPITAL'S BOARD OF DIRECTORS, AND IS BELIEVED TO REPRESENT AN APPROPRIATE BALANCE BETWEEN FULFILLING THE HOSPITAL'S CHARITABLE PURPOSE AND ACHIEVING FINANCIAL RESULTS THAT ALLOW FOR CONTINUED REINVESTMENT IN STAFF AND EQUIPMENT TO REMAIN COMPETITIVE.THE HOSPITAL OPERATES A FULLY STAFFED COMMUNITY HEALTH INITIATIVES DEPARTMENT DEDICATED TO IMPROVING THE HEALTH OF THE COMMUNITY THROUGH WELLNESS EDUCATION AND PREVENTATIVE HEALTHCARE STRATEGIES. THIS DEPARTMENT MAINTAINS AN ACTIVE PRESENCE IN THE COMMUNITY, SPONSORING SUCH EVENTS AS AN ANNUAL WOMEN'S HEALTH NIGHT, AN ANNUAL SENIOR HEALTH AND SAFETY EXPO, AND VARIOUS OTHER EDUCATIONAL PROGRAMS IN AREA SCHOOLS AND BUSINESSES. | ||
| 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 | 0 | 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Person | DARLA WILSON | NamePerson |
| Base Compensation Filing Org | 139835 | BaseCompensationFilingOrg |
| Comp Based On Related Orgs | 0 | CompBasedOnRelatedOrgs |
| Bonus Filing Org | 1917 | BonusFilingOrg |
| Bonus Related Orgs | 0 | BonusRelatedOrgs |
| Other Compensation Filing Org | 4918 | OtherCompensationFilingOrg |
| Other Compensation Related Orgs | 0 | OtherCompensationRelatedOrgs |
| Deferred Comp Filing Org | 5867 | DeferredCompFilingOrg |
| Deferred Comp Related Orgs | 0 | DeferredCompRelatedOrgs |
| Nontaxable Benefits Filing Org | 8798 | NontaxableBenefitsFilingOrg |
| Nontaxable Benefits Related Orgs | 0 | NontaxableBenefitsRelatedOrgs |
| Total Compensation Filing Org | 161335 | TotalCompensationFilingOrg |
| Total Compensation Related Orgs | 0 | TotalCompensationRelatedOrgs |
| Comp Report Prior990 Filing Org | 0 | CompReportPrior990FilingOrg |
| Comp Report Prior990 Related Orgs | 0 | CompReportPrior990RelatedOrgs |
Form990 Schedule J Part III Form990ScheduleJPartIII (2 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| SUPPLEMENTAL INFORMATION | PART III | PART I, QUESTION 3: TOMAH MEMORIAL HOSPITAL DOES NOT PAY COMPENSATION TO THE ADMINISTRATOR DIRECTLY. THE ADMINISTRATOR IS COMPENSATED BY AN UNRELATED MANAGEMENT COMPANY, HEALTHTECH MANAGEMENT SERVICES, INC., AND IS CONSIDERED A COMMON LAW EMPLOYEE OF THE MANAGEMENT COMPANY. THE HOSPITAL BOARD OF DIRECTORS USES THE PROCESSES DESCRIBED IN PART I, QUESTION 3 TO HELP DETERMINE APPROPRIATE COMPENSATION FOR THE ADMINISTRATOR. THE BOARD OF DIRECTORS ALSO APPROVES THE ORGANIZATION'S CONTRACT WITH THE MANAGEMENT COMPANY. |
| SUPPLEMENTAL INFORMATION | PART III | PART II: PHILIP J. STUART, ADMINISTRATOR, IS COMPENSATED BY HEALTHTECH MANAGEMENT SERVICES, INC., AN UNRELATED MANAGEMENT COMPANY, FOR SERVICES RENDERED TO TOMAH MEMORIAL HOSPITAL. THE ADMINISTRATOR IS CONSIDERED A COMMON LAW EMPLOYEE OF HEALTHTECH MANAGEMENT SERVICES AND THEREFORE HIS COMPENSATION IS NOT REPORTED. |
Schedule K IRS990ScheduleK
Form990 Schedule K Part I Form990ScheduleKPartI
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | WI HEALTH AND EDUCATIONAL FACILITIES AUTHORITY | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Issuer EIN | 391337855 | IssuerEIN |
| CUSIP Number | 97710VNC8 | CUSIPNumber |
| Date Issued | 2003-07-15 | DateIssued |
| Issue Price | 10256096 | IssuePrice |
| Description Of Purpose | BLDG EXPANSION AND REFUND 1993 CITY OF TOMAH, WI REV BONDS ISSUED 4/22/1993 | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
| Pool Financing | 0 | PoolFinancing |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Amount Retired | 2105000 | AmountRetired |
| Total Proceeds | 10256096 | TotalProceeds |
| Amount In Reserve Fund | 875300 | AmountInReserveFund |
| Issuance Costs From Proceeds | 205122 | IssuanceCostsFromProceeds |
| Capital Expenditures | 8022515 | CapitalExpenditures |
| Other Spent Proceeds | 1153159 | OtherSpentProceeds |
| Year Of Subst Completion | 2004 | YearOfSubstCompletion |
| Current Refunding | 1 | CurrentRefunding |
| Advance Refunding | 0 | AdvanceRefunding |
| Final Allocation Made | 1 | FinalAllocationMade |
| Adequate Books And Recds Maintaind | 1 | AdequateBooksAndRecdsMaintaind |
Form990 Schedule K Part III Form990ScheduleKPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Owning Bond Financed Property | 0 | OwningBondFinancedProperty |
| Any Lease Arrangements | 0 | AnyLeaseArrangements |
| Mngment Cntrct Bond Financd Prprty | 0 | MngmentCntrctBondFinancdPrprty |
| Any Research Agreements | 0 | AnyResearchAgreements |
| Prcntge Prvt Business Use By Others | 0.00000 | PrcntgePrvtBusinessUseByOthers |
| Percentage Of Prvt Business Re UBI | 0.00000 | PercentageOfPrvtBusinessReUBI |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUse |
| Post Issuance Compliance Procdrs | 1 | PostIssuanceComplianceProcdrs |
Form990 Schedule K Part IV Form990ScheduleKPartIV
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form8038 T Filed | 1 | Form8038TFiled |
| Variable Rate Issue | 0 | VariableRateIssue |
| Hedge Identified In Books And Recds | 0 | HedgeIdentifiedInBooksAndRecds |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGIC |
| Gross Proceeds Invested | 0 | GrossProceedsInvested |
| Exception To Rebate | 0 | ExceptionToRebate |
Schedule L IRS990ScheduleL
Form990 Schedule L Part IV Form990ScheduleLPartIV (3 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| CINDY LAMBERT | |||
| FAMILY MEMBER OF CHIEF FINANCIAL OFFICER | 36311 | COMPENSATION AND BENEFITS AS AN EMPLOYEE | 0 |
| SHANA STEELE | |||
| FAMILY MEMBER OF A CURRENT DIRECTOR OF THE BOARD | 41335 | COMPENSATION AND BENEFITS AS AN EMPLOYEE | 0 |
| TOMAH LUMBER | |||
| ENTITY OWNED BY VICE CHAIRMAN OF BOARD | 1175947 | TOMAH MEMORIAL HOSPITAL ENTERED INTO AN AGREEMENT WITH TOMAH LUMBER TO CONSTRUCT A NEW HOSPICE RESIDENCE (PAYMENT FOR SERVICES). | 0 |
Schedule M IRS990ScheduleM
Real Estate Other RealEstateOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Non Cash Checkbox | X | NonCashCheckbox |
| Number Of Contributions | 1 | NumberOfContributions |
| Noncash Contribs Rptd F990 | 21500 | NoncashContribsRptdF990 |
| Method Of Determining Revenues | FAIR MARKET VALUE | MethodOfDeterminingRevenues |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Any Property That Must Be Held | 0 | AnyPropertyThatMustBeHeld |
| Review Process Unusual NC Gifts | 1 | ReviewProcessUnusualNCGifts |
| Third Parties Used | 0 | ThirdPartiesUsed |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (10 entries)
| IdentifierIdentifier | ExplanationExplanation | Return ReferenceReturnReference |
|---|---|---|
| FORM 990, PART VI, SECTION A, LINE 1 | THE EXECUTIVE COMMITTEE INCLUDES THE CORPORATION'S OFFICERS AND CHAIRMAN OF STANDING COMMITTEES. THE EXECUTIVE COMMITTEE HAS POWER TO TRANSACT ALL REGULAR BUSINESS OF THE CORPORATION DURING THE PERIOD BETWEEN THE MEETINGS OF THE BOARD OF DIRECTORS SUBJECT TO ANY PRIOR LIMITATION IMPOSED BY THE ARTICLES OF INCORPORATION, BYLAWS, OR THE BOARD. ALL MATTERS OF MAJOR IMPORTANCE WILL BE REFERRED TO THE BOARD OF DIRECTORS. | |
| FORM 990, PART VI, SECTION A, LINE 2 | OAKLEY MOSER AND STEVE AUSTIN HAVE A BUSINESS RELATIONSHIP. | |
| FORM 990, PART VI, SECTION A, LINE 3 | THE ADMINISTRATOR OF TOMAH MEMORIAL HOSPITAL IS EMPLOYED BY HEALTHTECH MANAGEMENT SERVICES, INC. | |
| FORM 990, PART VI, SECTION A, LINE 7A | THE NOMINATING COMMITTEE HAS THE DUTY OF PROPOSING TO THE PUBLIC MEMBERSHIP AT THE ANNUAL MEETING AND AT OTHER MEETINGS WHERE VACANCIES ARE TO BE FILLED, THE NAMES OF NOMINEES TO THE BOARD OF DIRECTORS. THE NOMINATING COMMITTEE'S RECOMMENDATIONS ARE ADVISORY AND ADDITIONAL NOMINATIONS MAY BE MADE AT THE MEETING BY ANY MEMBER. | |
| FORM 990, PART VI, SECTION B, LINE 11 | A COPY OF THE FORM 990 IS PROVIDED TO THE BOARD BEFORE IT IS FILED. THE ADMINISTRATOR, CFO, AND EXECUTIVE/FINANCE COMMITTEE REVIEW THE DRAFT IN DETAIL. | |
| ALL MEMBERS OF THE BOARD AND ADMINISTRATION TEAM ARE COVERED BY THE CONFLICT OF INTEREST POLICY. POTENTIAL CONFLICTS ARE CONTRACTS OR TRANSACTIONS BETWEEN THE HOSPITAL AND A DIRECTOR OR ANOTHER CORPORATION, FIRM, ASSOCIATION, OR ENTITY IN WHICH THERE IS A MATERIAL FINANCIAL INTEREST. THE HOSPITAL ADMINISTRATION REVIEWS ANNUAL STATEMENTS FOR POTENTIAL CONFLICTS. IF THE HOSPITAL ADMINISTRATION DETERMINES THERE IS A CONFLICT, THE PERSON INVOLVED MUST ABSTAIN FROM VOTING ON ANY MATTER RELATED TO THE CONFLICT. | FORM 990, PART VI, SECTION B, LINE 12C | |
| THE ADMINISTRATOR IS EMPLOYED BY HEALTHTECH MANAGEMENT SERVICES, INC. THE BOARD APPROVES THE CONTRACT ON A THREE YEAR PERIOD WITH TWO ONE-YEAR RENEWAL CLAUSES. COMPARABILITY DATA IS USED DURING THIS PROCESS AND THE DECISION IS DOCUMENTED. THE CONTRACT WAS RENEWED IN FISCAL YEAR 2010. THE ADMINISTRATOR MAKES RECOMMENDATIONS TO THE FINANCE/EXECUTIVE COMMITTEE OF THE BOARD FOR OTHER OFFICERS. COMPARABILITY DATA IS USED DURING THIS PROCESS AND THE DECISIONS ARE DOCUMENTED. THIS IS AN ANNUAL PROCESS AND WAS LAST COMPLETED IN FISCAL YEAR 2011. | FORM 990, PART VI, SECTION B, LINE 15 | |
| THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY HAVE NOT BEEN AVAILABLE TO THE GENERAL PUBLIC IN THE PAST, ALTHOUGH ADMINISTRATION IS CONSIDERING POSTING THEM ON THE ORGANIZATION'S WEBSITE IN THE FUTURE. FINANCIAL STATEMENTS ARE AVAILABLE THROUGH THE ORGANIZATION'S BOND ISSUER ON THE INTERNET, AND THE ORGANIZATION PRESENTS AN ANNUAL REPORT TO THE COMMUNITY, OPEN TO THE GENERAL PUBLIC, IN WHICH A FINANCIAL REPORT IS PRESENTED. ADDITIONALLY, AN ANNUAL FINANCIAL REPORT IS INCLUDED IN THE QUARTERLY MAILINGS THE ORGANIZATION SENDS TO ALL COMMUNITY MEMBERS. | FORM 990, PART VI, SECTION C, LINE 19 | |
| THE FOLLOWING INDIVIDUALS DEVOTED TIME PROVIDING SERVICES TO PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL, A RELATED EXEMPT ORGANIZATION. ROBER FASBENDER 1 HOUR PER WEEK PHIL YAHNKE 1 HOUR PER WEEK JEFF HOLTHAUS 1 HOUR PER WEEK | FORM 990, PART VII, SECTION A: | |
| CHANGES IN NET ASSETS OR FUND BALANCES: | NET UNREALIZED LOSSES ON INVESTMENTS: -1,200,716. DECREASE IN FAIR VALUE OF BENEFICIAL INTEREST IN PERPETUAL TRUST -2,049. TOTAL TO FORM 990, PART XI, LINE 5: -1,202,765. | FORM 990, PART XI, LINE 5: |
Schedule R IRS990ScheduleR
Form990 Schedule R Part II Form990ScheduleRPartII
Name Of Disregarded Entity NameOfDisregardedEntity
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL | BusinessNameLine1 |
Address US AddressUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 BUTTS AVENUE | AddressLine1 |
| City | TOMAH | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 396173790 | EIN |
| Primary Activities | SUPPORT TOMAH MEMORIAL HOSPITAL | PrimaryActivities |
| Legal Domicile State | WI | LegalDomicileState |
| Exempt Code Section | 501(C)(3) | ExemptCodeSection |
| Public Charity Status | LINE 11B, II | PublicCharityStatus |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | TOMAH MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Org | 1 | ControlledOrg |
| 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 | 1 | GiftGrantOrCapContrFrOtherOrg |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrg |
| Loans Or Guarantees From Other Org | 0 | 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 | 0 | 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 | 0 | SharingOfPaidEmployees |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrg |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrg |
| Other Transfer To Other Org | 0 | OtherTransferToOtherOrg |
| Other Transfer From Other Org | 0 | OtherTransferFromOtherOrg |
Transactions Related Orgs Table TransactionsRelatedOrgsTable
Name Of Other Organization NameOfOtherOrganization
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | PEDERSON TRUST FUND FOR THE BENEFIT OF TOMAH MEMORIAL HOSPITAL | BusinessNameLine1 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Transaction Type | C | TransactionType |