2012-10-15T17:15:39-07:00 2011-12-31 391336685 Rural Wisconsin Health Cooperative 880 Independence Lane Sauk CIty WI 53583 990 2011-01-01 390926284 Prairie du Chien Memorial Hospital Inc PRAI 6083572000 705 East Taylor Street Prairie du Chien WI 538212196 William P Sexton 6083572000 2012-10-15 0 Richard Donkle P01349576 6086432343 2012-10-15 2011 2016-02-24 21:20:13Z William P Sexton 705 East Taylor Street Prairie du Chien WI 538212196 33177106 0 X http://www.pdcmh.org/ X 1957 WI Prairie du hien Memorial Hospital will deliver high quality, personalized healthcare and education, in a freindly safe environment, to educate people in every stage of life through partnerships with other regional health care providers. 9 8 341 277 0 0 158490 632988 16845815 31308643 292524 523184 287437 547319 17584266 33012134 1060 8390 0 9570363 19416672 0 84896 5497040 10677412 15068463 30102474 2515803 2909660 37592794 40717408 3207288 3360849 34385506 37356559 Prairie du Chien Memorial Hospital will deliver high quality, personalized healthcare and education, in a friendly safe environment, to educate people in every stage of life through partnerships with other regional health care providers. 0 0 23437470 28905117 Routine services: Inpatient/acute services-2748 days, Hospice acute services-188 days, Skilled Swing Bed services-1196 days, Intermediate Care Serices-375 days. Outpatient services: Outpatient visits-17117 visits. Ancillary Inpatient and Outpatient services are provided to the local community who would otherwise be required to travel outside their community to obtain their health care services. In addition to the services already mentioned, Prairie du Chien Memorial provides Birthing Center, Diagnostics, 24 hour Emergency Services, Urgent Care, Extended Care, Home Oxygen, Home Medical Equipment, Lifeline, Palliative Care, Pulmonology, Podiatry, Sleep Study, Wound Care/Ostomy/Continance Care, Respite Care, Infusion Services, Outpatient Care, Laboratory Services, Medical Imaging, Rehabilitation Services, Sleep Center, Speech & Audiology, and Surgical Services. 969882 483138 Prairie du Chien Memorial Hospital's Home Health Care Agency provides health care services to patients throughout their life span, in their place of residence under the orders of a licensed physician. A registered nurse completes an initial comprehensive assessment of the patient, family and living environment. The nurse (and if required, therapist and medical social worker) and physician develop a plan of care to meet the mutual goals as established with the patient, family, physician and other health care teammembers. As the plan is implemented, referrals are made as appropriate to the other team members and support systems. Inaddition to the above mentioned staff, the Certified Home Health Aide is able to provide assistance with needed personal care, prescribed exercise programs and other duties as directed by the nurse. In-home health services: Registered Nurses, Home Health Aides, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker, Home Health visits-4381; admissions-211. 1444606 1152594 Hospice provides specially trained health care professionals working together with you, your family, and your own primary physician. Your Hospice Team consists of medical directors, registered nurses, medical social workers, home health aides, dietitians, pharmacists, pastoral care services, volunteers, therapists, and bereavement coordinators. Hospice focuses on the patient and their family: To promote a source of continuous physical, emotional, and spiritual care to the dying patient and family. To provide encouragement to live their remaining life to the fullest with dignity and obtain the highest quality of life. To support the family during and after the death of the patient's loved ones. Hospice consists of the following services: Home Care: The family is supported by the Hospice team and attending physician to care for their loved one at home. Regular visits are made by staff to assure patient and family needs are being met. Hospice is also available in nursing homes and assisted living facilities contracted with our agency within our service area. Continuous Care: In times of crisis when intense nursing care is needed for symptom management, staff will be accessible for extended periods as available. Inpatient Care: If the need arises for more acute care and/or symptom management, a patient may be admitted into their local hospital. Hospice has contracts with several hospitals in our service area. Respite Care: This type of care is available to offer caregivers relief. The patient can be admitted into their local hospital and be cared for by the nursing staff. Medicare/Medicaid covers five consecutive days of Respite Care on a non-routine basis. Hospice Home Care Days-6292 1352214 767795 Prairie du Chien Memorial Hospital provides significant charity care and other community benefits as defined by the IRS. But in addition, we believe that we provide a critically important community benefit which is not quantified. Our hospital, like most rural hospitals, was created and is maintained in order to provide care locally-care that without our hospital, would not be available locally. Beyond inpatient hospitalizations, we provide local access to many health services: Birthing Center, Dialysis Center, Diagnostics, 24 hour Emergency Services, Urgent Care, Extended Care, Home Health Care, Hospice, Home Oxygen, Home Medical Equipment, Personal Home services, Lifeline, Palliative Care, Home delivered meals, Pulmonology, Podiatry, Sleep Study, Wound Care/Ostomy/Continence Care, Respite Care, Infusion Services, Outpatient Care, Laboratory Services, Medical Imaging, Rehabilitation Services, Sleep Center, Speech and Audiology, Surgical Services, Family Resource Center, Crawford Abuse Resistance Effort, Independent Living, and Telehealth. Prairie du Chien Memorial Hospital provides quality medical health care regardless of race, color, age, national origin, sex, gender identity, sexual orientation, disability or ability to pay. In keeping with this hospital's commitment to serve all members of the community: Memorial Hospital provided free care and/or subsidized care. Memorial Hospital provides care to persons covered by governmental programs at below cost. Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. To the extent reimbursement is below charges, Memorial Hospital recognizes these amounts as contractual allowances in meeting its mission to the entire community. Memorial Hospital's health activities and programs help support the community. Consideration is also given where the need and/or individual's inability to pay coexists. These activities include wellness programs, community education programs, special programs for the elderly, medically underserved, screening programs and a variety of broad community support activities. Preparing and delivering 24,401 Meals on Wheels during the year December 31, 2011 to community residents who are unable to prepare a meal for themselves due to their medical condition. These meals were provided at a minimal subsidized fee. Diet counseling is provided. During the year December 31, 2011, 363 people received diet counseling. Sponsoring a weight loss program and a variety of other wellness type programs at subsidized cost. Offering a series of seminars on topics such as Parenting, Women & Heart Disease, Osteoporosis, Stress Management, Advanced Directives, and Survivors of Sexual Abuse. In addition, we provide Lamaze classes for prenatal education and an "I Can Cope Program" for cancer patients. These classes are all free or subsidized by the Hospital. Interactive video presentations were also provided for the community. Providing bereavement counseling for about 430 families of Hospice patients during the year December 31, 2011. Also offering grief support program and newsletters for families in local communities. Support groups for parents who have lost a child through miscarriage or stillbirth. Providing free newborn hearing testing. Providing community education center which coordinates clinical rotation and provides assistance to educators through our work with student nurses, unit clerk students, physical therapy students, radiology tech students, health information students, and residents. Providing CPR classes for the community. First Aid classes were provided for community members. Participation in Farm & Home Show and the Senior Expo.. Health brochures and screenings were done. We performed free oximeter screenings for the community and offere for free or reduced cost blood pressure, glucose, and cholesterol screenings. Collaborating with local school systems to provide educational programs on issues such as sex education, breast health, and providing tours of the hospital for health classes, child development classes, and others. Community benefits are also achieved through many reduced price services and free programs offered throughout the year based upon activities and services which Memorial Hospital believes will serve a bona fide community health need. These include: A variety of brochures on health and wellness are available free of charge in several locations within the hospital. A variety of brochures to educate Medicare patients, with respect to their benefits under the Medicare program. Participation in two county fairs during the year December 31, 2011 in order to foster health education in the community. Services provided include glucose, oximeter, blood pressure and cholesterol screenings. Being available to speak before community organizations on a variety of health care topics, in 2011. The Family Resource Center provides a variety of services and resources including a Toy Resource & Lending Library; a three-week "Music, Movement & Memories" series; parent education for jail inmates; babysitter training; phone consultations; family coaching; family drop-ins; family support groups; car seat installation & instruction; new parent education; CPR training; and a variety of other family focused services. FRC also tours MFL Mar MAC schools yearly to educate about the services and programs for new parents. FRC strives to pursue its goal of empowering parents to face the challenges of family life in a caring and positive way. Through education and support along with resources the ultimate goal of FRC is the prevention of child abuse and neglect. Crawford Abuse Resistance Effort (C.A.R.E.) as Sponsored by Prairie du Chien Memorial Hospital provided the following services for the year ending December 31, 2011. The goal of C.A.R.E. is to reduce and/or prevent alcohol, tobacco, and other drug use/abuse among Crawford County youth and adults using comprehensive prevention and health promotion strategies. To achieve this goal, C.A.R.E. collaborates with schools, law enforcement and community agencies to provide substance abuse prevention education and training programs for youth and adults. In 2011, 1,149 adults contributed 2,991 hours and 2,293 youth contributed 8,511 hours to planning, implementation, evaluation and/or participation in prevention and youth development programs. Additionally, approximately 380 adults and 825 youth were impacted by C.A.R.E. through some level of direct service. C.A.R.E. focuses their efforts on the implementation of environmental strategies designed to create positive community change. These strategies include alcohol/tobacco compliance checks, local policy/ordinance change and saturation/party patrols. 1352214 0 767795 27204172 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 25 0 1 341 1 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X David Breitbach 6083572405 705 East Taylor Street Prairie du Chien WI 538212196 Paul Ginkel 4 X 0 0 0 Charlie Connell 2 X 0 0 0 Patrick Mulhern 2 X 0 0 0 Lisa Esser 2 X 0 0 0 Gayette Grimm 2 X 0 0 0 Rory Meisner 2 X 0 0 0 Mattie Rademacher 2 X 0 0 0 Alice Staples 2 X 0 0 0 Roy C George 2 X 0 0 0 William Sexton 40 X 425056 0 37946 David Beitbach 40 X 160975 0 36708 M C Achenbach 40 X 177739 0 26064 James Gariti 47.75 X 290305 0 41037 R Timothy Fitzner 49.25 X 292150 0 39181 Khalid Ali 48.25 X 263276 0 40005 Christopher Burrows 47.50 X 278155 0 32600 Tom Wilkes 40 X 136029 0 30758 Harold W Brown 0 X 182487 0 0 2206172 0 284299 13 1 1 0 Gundersen Clinic 1836 South Avenue LaCrosse WI 54601 Medical Services 749333 Prairie Anesthesia Service 36681 Wildernest Prairie du Chien WI 53821 Anesthesia Services 612289 Shared Medical Services PO Box 330 Cottage Grove WI 53527 Medical Services 177570 Monona Pharmacy 1118 West Center St Monona IA 52159 Pharmacy Services 106060 4 0 0 0 0 204847 428141 0 632988 Inpatient & Outpatient Services 622000 28905116 28905116 0 0 Home Health Services 621610 483138 483138 0 0 Hospice Services 624100 1152594 1152594 0 0 767795 767795 0 0 31308643 505270 0 0 505270 0 0 0 0 0 0 0 0 16544 0 19566 0 -3022 0 -3022 -3022 0 0 35151 128169 16778 128628 18373 -459 17914 17914 0 0 0 WEE Care 624100 267777 267777 0 0 Meal Income 622000 95848 95848 0 0 186716 186716 0 0 550341 33012134 31873876 0 505270 8390 8390 586031 586031 13501338 12498515 951721 51102 590220 523651 64428 2141 3777997 3351893 412399 13705 961086 852689 104911 3486 34143 4035 24981 5127 44733 44733 85899 85899 2950050 2827052 122998 380980 361730 19250 252951 245677 3798 3476 1235202 1235202 105588 40586 65002 Contracted Expenses 2111682 2056117 55565 0 Bad Debts 535951 535951 0 0 Payments to Hospitals & Nursing Homes 294175 294175 0 0 Equipment Expenses 1161373 1149898 11475 0 1484685 1218611 260215 5859 30102474 27204172 2813406 84896 250 250 16103118 18577911 6215189 6525118 835642 839336 975184 980311 126894 178855 23642233 14631645 8907268 9010588 4400516 4578923 8816 8816 19917 17300 37592794 40717408 2622798 2959236 584490 401613 3207288 3360849 X 34385506 37173827 0 182732 0 0 34385506 37356559 37592794 40717408 X 2909660 61393 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 755250 755250 0 9945659 5924461 4021198 0 0 0 0 0 8838890 5994031 2844859 0 4102434 2713153 1389281 9010588 0 Severance Pay 401613 401613 33012134 30102474 2909660 46796 0 0 0 14597 61393 2971053 33031700 0 0 0 19566 19566 33012134 0 0 0 33012134 30122040 0 0 0 19566 19566 30102474 0 0 0 30102474 SchD_P11_S00_L08 Schedule D, Part XI, Line 8 Net change in restricted contributions. SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Rental expenses included in Part VIII, Line 6b SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Rental expenses included on Part VIII, Line 6b X X X 0 1 1 1 X 1 X 1 1 1 0 1 1 527458 0 527458 0.0178 2420462 1706096 714366 0.0242 89916 66978 22938 0.0008 0 0 3037836 1773074 1264762 0.0428 471809 168256 303553 0.0103 6173898 4097883 2076015 0.0702 1060 1060 0 0 6646767 4266139 2380628 0.0805 0 0 9684603 6039213 3645390 0.1233 1 535954 80393 10577605 10734197 -156592 X 1 1 1 1 Prairie du Chien Memorial Hospital

705 East Taylor Street Prairie du Chien WI 53821

X X X X Prairie du Chien Memorial Hospital 1 1 1 1 100 1 300 1 X X X X X 1 1 X X 0 1 X X X X X X 1 X 0 1 SchH_P01_S00_L06a Schedule H, Part I, Line 6a The Hospital prepares an annual report that includes community benefits, and that report is made available to the public. SchH_P01_S00_L07 Schedule H, Part I, Line 7 In computing the costs for line 7a through c the cost to charge ratio derived from Worksheet 2 was utilized. In computing the costs for Line 7e through g the costs were obtained from the Medicare cost report. For Line 7i actual costs were used. SchH_P03_S0A_L04 Schedule H, Part III, Section A, Line 4 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. Management also reviews accounts to determine if classification as charity care is appropriate. Our rough estimate is based on an estimate of the amount of bad debt claims returned to us by our third party collection agency due to inability to collect or bankruptcy. SchH_P03_S0B_L08 Schedule H, Part III, Section B, Line 8 The Medicare allowable costs on Line 6 were taken from the Medicare cost report, Worksheets E, Part B, E-2, and E-3, Part V. Also included was the estimated cost of Medicare Fee for Service services. These costs were estimated based on the Medicare inpatient and outpatient cost to charge ratio. Cost related to subsidized health services reported in Part I, Line 7g were not included. Any shortfalls in Medicare reimbursement should be included as community benefit because of the additional cost the Hospital incurred as a result of onerous Medicare requirements. SchH_P03_S0C_L09b Schedule H, Part III, Section C, Line 9b All accounts are subject to mamagement reivew prior to being turned over for outside collection. SchH_P05_S0B_L13 Schedule H, Part V, Section B, Line 13 Applications available on hospital website and notification of the availability of discounted care is posted within patient care areas of the hospital. SchH_P05_S0B_L19 Schedule H, Part V, Section B, Line 19 These patients were offered interest free repayment plans and where applicable were referred to the Hospital's charity care program. SchH_P05_S0B_L21 Schedule H, Part V, Section B, Line 21 Gross charges are billed to all patients unless they meet charity care guidelines or have another contractual arrangement. A discount is given for FAP eligible patients according to the Hospital's policy and these discounts are removed from gross charges. SchH_P06_S00_L02 Schedule H, Part VI, Line 2 In October of 2010 the Board of Directors, Hospital administration and staff met with community leaders in an open forum to discuss the heath care needs of our community. As part of this discussion we asked these community leaders to identify any unmet health care needs. In May 2011 the Hospital started a community health assessment in cooperation with Crawford and Grant Counties and Grant Regional Health Center and Soutwest Health Center. SchH_P06_S00_L03 Schedule H, Part VI, Line 3 Patients who do not have the ability to pay all or any portion of their hospital bill are informed about family services, nursing, or patient financial services. The patient or family member is given an application for Charity Care. The patient is also directed to contact their county Department of Human Services to apply for assistance under federal, state, or local government programs. If the patient is not eligible for Medical Assistance or any other government program, they are instructed to complete and return the Hospital's Charity Care application. SchH_P06_S00_L04 Schedule H, Part VI, Line 4 Prairie du Chien Memorial Hospital provides healthcare services to the general public in southwestern Wisconsin and northeastern Iowa. Demographically Prairie du Chien Memorial Hospital serves a rural population with an average household income in the low to median range. Prairie du Chien Memorial Hospital serves all ages but is experiencing an increase in geriatric patients. 1 X SchI_P01_S00_L02 Schedule I, Part I, Line 2 Prairie du Chien Memorial Hospital gave support to various local charitable groups with donations, none of which exceeded $1500, to further their charitable missions. X X 0 1 X X 0 1 0 0 0 1 0 0 0 Harold W Brown 0 0 0 0 0 0 0 0 0 0 0 0 182487 0 William Sexton 392501 0 32555 0 0 0 10500 0 27446 0 463002 0 0 0 M C Achenbach 170052 0 7687 0 0 0 2402 0 23661 0 203802 0 0 0 David Beitbach 145781 0 15194 0 0 0 9122 0 27585 0 197682 0 0 0 James Gariti 260319 0 29986 0 0 0 10500 0 30537 0 331342 0 0 0 R Timothy Fitzner 262892 0 29259 0 0 0 10500 0 28681 0 331332 0 0 0 Khalid Ali 233663 0 29612 0 0 0 10500 0 29505 0 303280 0 0 0 Christopher Burrows 249083 0 29072 0 0 0 10500 0 22100 0 310755 0 0 0 Tom Wilkes 123497 0 12532 0 0 0 7524 0 23233 0 166786 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a A new CEO was hired 10/01/08 and is using a hospital owned residence until his move to the area has been completed in accordance with his employment agreement. CEO compensation was grossed up to allow for the value of this housing and the related income taxes. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b There is no written policy, but was done at the direction of the hospital board of directors. SchJ_P01_S00_L03 Schedule J, Part I, Line 3 Prairie du Chien Memorial Hospital administration utilizes the Rural WIsconsin Health Cooperative and Wisconsin Hospital Association salary surveys when determining compensation. Compensation is approved by the Board of Directors. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Previous CEO receives payments from a nonqualified deferred compensation arrangement. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 Prairie du Chien Memorial Hospital has an historical employee incentive plan. The employee incentive plan has the following stipulations, criteria and guidelines: a.) The plan allows for employee incentive pay if the hospital has generated a gain in excess of 5% based on net patient income less interest and unrestricted contributions. b.) Employee incentive payment will not exceed 2% of gross pay based on each quarter performance. All overtime will not be included in the calculation of incentive pay. c.) Eligible employees are those on the hospital payroll as of the end of each quarter. Employees leaving employment during the quarter will not be eligible to participate. Jane Page Daughter of Board Member 27407 Employment 0 Katy Krueger Daughter of Board Member 63396 Employment 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 Prairie du Chien Memorial is a community hospital which was organized through community membership. Members are required to pay a minimal fee to belong to Prairie du Chien Memorial Hospital Association. F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a Members of the Prairie du Chien Memorial Hospital Association meet annually to vote for new Board members and for bylaw changes. F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Members of the Prairie du Chien Memorial Hospital Association must approve bylaw changes. F990_P06_S0B_L11b Form 990, Part VI, Section B, Line 11b Annual IRS Form 990 is mailed to each individual member of the Board of Directors. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Appropriate staff are notified of potential conflicts of interest and monitor compliance through the year. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Prairie du Chien Memorial Hospital administration utilizes the Rural Wisconsin Health Cooperative and Wisconsin Hospital Association salary surveys when determining compensation. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Prairie du Chien Memorial Hospital uses its wesite to communicate with the public. Prairie du Chien Memorial Hospital also publishes an annual report that presents financial information, mission statement, a review of last year and a look forward. Conflict of interest statements are available on request. F990_P11_S00_L05 Form 990, Part XI, Line 5 Unrealized gains = $46796, Net change in restricted assets = $14597