TOMAH MEMORIAL HOSPITAL INC: Form 990, tax year 2009
View the entire original 990 at ProPublica ↗
- Organization
- TOMAH MEMORIAL HOSPITAL INC (EIN 39-0799566)
- Tax period
- 2009-10-01 to 2010-09-30
- Filed
- 2011-03-14
- IRS object ID
- 201120739349300507
- Schema version
- 2009v1.7
- 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 G
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Timestamp | 2011-03-14T12:16:45-05:00 | Timestamp |
| Tax Period End Date | 2010-09-30 | 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 | 5601 Green Valley Drive Ste 700 | AddressLine1 |
| City | Minneapolis | City |
| State | MN | State |
| ZIP Code | 554371145 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnType |
| Tax Period Begin Date | 2009-10-01 | 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 Ave | 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 | 2011-03-09 | DateSigned |
| Authorize Third Party | 1 | AuthorizeThirdParty |
Preparer Preparer
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name | Kim Hunwardsen CPA | Name |
| Phone | 9529446166 | Phone |
| Date Prepared | 2011-03-09 | DatePrepared |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax Year | 2009 | TaxYear |
| Build TS | 2016-02-24 21:20:13Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Principal Officer Person | Joseph Zeps | NameOfPrincipalOfficerPerson |
Address Principal Officer US AddressPrincipalOfficerUS
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Ave | AddressLine1 |
| City | Tomah | City |
| State | WI | State |
| ZIP Code | 54660 | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | 35742356 | GrossReceipts |
| Group Return For Affiliates | 0 | GroupReturnForAffiliates |
| Organization501c | X | Organization501c |
| 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 | 10 | NbrIndependentVotingMembers |
| Total Nbr Employees | 301 | TotalNbrEmployees |
| Total Nbr Volunteers | 64 | TotalNbrVolunteers |
| Total Gross UBI | 0 | TotalGrossUBI |
| Net Unrelated Business Txbl Income | 0 | NetUnrelatedBusinessTxblIncome |
| Contributions Grants Prior Year | 183733 | ContributionsGrantsPriorYear |
| Contributions Grants Current Year | 203993 | ContributionsGrantsCurrentYear |
| Program Service Revenue Prior Year | 31391331 | ProgramServiceRevenuePriorYear |
| Program Service Revenue CY | 32879769 | ProgramServiceRevenueCY |
| Investment Income Prior Year | -410503 | InvestmentIncomePriorYear |
| Investment Income Current Year | 614226 | InvestmentIncomeCurrentYear |
| Other Revenue Prior Year | -5933 | OtherRevenuePriorYear |
| Other Revenue Current Year | -20020 | OtherRevenueCurrentYear |
| Total Revenue Prior Year | 31158628 | TotalRevenuePriorYear |
| Total Revenue Current Year | 33677968 | TotalRevenueCurrentYear |
| Grants And Similar Amnts CY | 0 | GrantsAndSimilarAmntsCY |
| Benefits Paid To Members CY | 0 | BenefitsPaidToMembersCY |
| Salaries Etc Prior Year | 15129341 | SalariesEtcPriorYear |
| Salaries Etc Current Year | 16275654 | SalariesEtcCurrentYear |
| Total Prof Fundrsng Exp CY | 0 | TotalProfFundrsngExpCY |
| Total Fundrsng Exp Current Year | 0 | TotalFundrsngExpCurrentYear |
| Other Expense Prior Year | 15329568 | OtherExpensePriorYear |
| Other Expenses Current Year | 14822487 | OtherExpensesCurrentYear |
| Total Expenses Prior Year | 30458909 | TotalExpensesPriorYear |
| Total Expenses Current Year | 31098141 | TotalExpensesCurrentYear |
| Revenues Less Expenses Prior Year | 699719 | RevenuesLessExpensesPriorYear |
| Revenues Less Expenses CY | 2579827 | RevenuesLessExpensesCY |
| Total Assets BOY | 37465093 | TotalAssetsBOY |
| Total Assets EOY | 39730220 | TotalAssetsEOY |
| Total Liabilities BOY | 12510431 | TotalLiabilitiesBOY |
| Total Liabilities EOY | 11619049 | TotalLiabilitiesEOY |
| Net Assets Or Fund Balances BOY | 24954662 | NetAssetsOrFundBalancesBOY |
| Net Assets Or Fund Balances EOY | 28111171 | NetAssetsOrFundBalancesEOY |
| Mission Description | Our mission is to provide high quality health care for you at Tomah Memorial Hospital. | MissionDescription |
| Significant New Program Services | 0 | SignificantNewProgramServices |
| Significant Change | 0 | SignificantChange |
| Expense | 24822131 | Expense |
| Revenue | 30910244 | 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, 2010 are as follows:- 1,434 inpatient discharges- 4,015 inpatient days- 13,374 emergency room and urgent care visits- 1,269 surgical and endoscopic procedures- 12,328 radiology procedures (including CT and MRI)- 68,069 laboratory tests- 34,513 rehabilitative services proceduresIn furtherance of its charitable mission, the Hospital provided approximately $954 thousand of free and discounted care to area residents (cost of care equal to $528 thousand), and wrote off $1.64 million of uncollectible accounts (cost equal to $906 thousand). Additionally, based on it's most recently completed community benefits survey, the Hospital incurred approximately $1.54 million 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 2010 approximated $1.66 million. Additional details regarding the hospice program and the Warrens Walk-In Clinic can be found below. 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 | 2226869 | Expense |
| Revenue | 1802314 | 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, 2010, the Hospice program experienced 9,273 program days and 1,222 hospice residence days. | Description |
Activity3 Activity3
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | 471199 | Expense |
| Revenue | 167211 | 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, 2010, the clinic experienced 2,462 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 of approximately $207,000 during 2010, 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 | 27520199 | 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 |
| Balance Sheet Amounts Reported | 1 | BalanceSheetAmountsReported |
| 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 | 1 | FundraisingActivities |
| Gaming | 0 | Gaming |
| Hospital | 1 | Hospital |
| 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 | 1 | GrantToRelatedPerson |
| Bsnss Rltnshp With Organization | 0 | BsnssRltnshpWithOrganization |
| Bsnss Rltnshp Thru Family Member | 1 | BsnssRltnshpThruFamilyMember |
| Officer Entity With Bsnss Rltnshp | 0 | OfficerEntityWithBsnssRltnshp |
| Deductible Non Cash Contributions | 0 | DeductibleNonCashContributions |
| Deductible Contributions Of Art | 0 | DeductibleContributionsOfArt |
| Terminated | 0 | Terminated |
| Partial Liquidation | 0 | PartialLiquidation |
| Disregarded Entity | 0 | DisregardedEntity |
| Related Entity | 1 | RelatedEntity |
| Related Org Controlled Entity | 1 | RelatedOrgControlledEntity |
| Transfers To Exempt Non Chrtbl Org | 0 | TransfersToExemptNonChrtblOrg |
| Activities Conducted Partnership | 0 | ActivitiesConductedPartnership |
| Schedule O Required | 1 | ScheduleORequired |
| Number Forms Transmitted With1096 | 7 | NumberFormsTransmittedWith1096 |
| Number W2 G Included | 0 | NumberW2GIncluded |
| Compliance With Backup Witholding | 1 | ComplianceWithBackupWitholding |
| Number Of Employees | 301 | 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 |
| Nbr Voting Governing Body Members | 10 | NbrVotingGoverningBodyMembers |
| Number Independent Voting Members | 10 | NumberIndependentVotingMembers |
| Family Or Business Relationship | 1 | FamilyOrBusinessRelationship |
| Delegation Of Management Duties | 1 | DelegationOfManagementDuties |
| Changes To Organizing Docs | 0 | ChangesToOrganizingDocs |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuse |
| Members Or Stockholders | 0 | MembersOrStockholders |
| Election Of Board Members | 0 | ElectionOfBoardMembers |
| Decisions Subject To Approval | 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 |
Form990 Part VII Section A Form990PartVIISectionA (17 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 | 1.00 | X | X | 0 | 0 | 0 | |
| Oak Moser | |||||||
| Vice Chair | 1.00 | X | X | 0 | 0 | 0 | |
| Jeff Holthaus | |||||||
| Secretary | 1.00 | X | X | 0 | 0 | 0 | |
| Phil Yahnke | |||||||
| Treasurer | 1.00 | X | X | 0 | 0 | 0 | |
| Steve Austin | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Robb Kline MD | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Jerry Molnar | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Ralph Knudson MD | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Nodji Van Wychen | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Penny Precour-Berry | |||||||
| Director | 1.00 | X | 0 | 0 | 0 | ||
| Joseph Zeps | |||||||
| Chief Financial Officer | 40.00 | X | 115880 | 0 | 20183 | ||
| Philip J Stuart | |||||||
| Administrator | 40.00 | X | 241358 | 0 | 0 | ||
| Evelyn Chapman | |||||||
| Chief Nursing Officer | 40.00 | 107205 | 0 | 16440 | X | ||
| Darla Wilson | |||||||
| Dir of Pharmacy | 40.00 | 136765 | 0 | 12044 | X | ||
| Todd Chapman | |||||||
| Pharmacist | 40.00 | 119455 | 0 | 4778 | X | ||
| Gerald Fushianes | |||||||
| Physician Assistant | 40.00 | 107392 | 0 | 20234 | X | ||
| Laura J Miller | |||||||
| Nurse Practitioner | 40.00 | 107984 | 0 | 10931 | X | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | 936039 | TotalReportableCompFromOrg |
| Total Reportable Comp Frm Rltd Orgs | 0 | TotalReportableCompFrmRltdOrgs |
| Total Other Compensation | 84610 | TotalOtherCompensation |
| Number Individuals GT100 K | 6 | NumberIndividualsGT100K |
| Formers Listed | 0 | FormersListed |
| Total Comp GT150 K | 1 | TotalCompGT150K |
| Compensation From Other Sources | 1 | 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 | 1203186 |
| Tomah Orthopedics | |||||
| 321 Butts Ave | Tomah | WI | 54660 | Contracted Orthopedic surgeons | 1111893 |
| David DeMask CRNA | |||||
| 21591 Glasgow Ave | Tomah | WI | 54660 | Anesthesiology | 902721 |
| Franciscan Skemp Medical Center | |||||
| PO Box 4102 | La Crosse | WI | 54602 | Radiology/Pathology | 724846 |
| Cardinal Health | |||||
| 2353 Prospect Drive | Aurora | IL | 60502 | Medical Supplies | 570127 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Number Of Contractors GT100 K | 10 | NumberOfContractorsGT100K |
| Fundraising Events | 112263 | FundraisingEvents |
| All Other Contributions | 91730 | AllOtherContributions |
| Total Contributions | 203993 | TotalContributions |
Program Service Revenue ProgramServiceRevenue (2 entries)
| DescriptionDescription | Business CodeBusinessCode | Total Revenue ColumnTotalRevenueColumn | Related Or Exempt Function IncomeRelatedOrExemptFunctionIncome |
|---|---|---|---|
| Patient Service Revenu | 621990 | 32728049 | 32728049 |
| Other Revenue | 621990 | 151720 | 151720 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | 32879769 | TotalProgramServiceRevenue |
Investment Income InvestmentIncome
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 485074 | TotalRevenueColumn |
| Exclusion | $485,074 | ExclusionAmount |
Gross Rents GrossRents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 35416 | Real |
Less Rental Expenses LessRentalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | 50825 | Real |
Rental Income Or Loss RentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | -15409 | Real |
Net Rental Income Or Loss NetRentalIncomeOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -15409 | TotalRevenueColumn |
| Exclusion | -$15,409 | ExclusionAmount |
Gross Amount Sales Assets GrossAmountSalesAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 2119640 | Securities |
| Other | 3250 | Other |
Less Cost Oth Basis Sales Expenses LessCostOthBasisSalesExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 1993738 | Securities |
Gain Or Loss GainOrLoss
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | 125902 | Securities |
| Other | 3250 | Other |
Net Gain Or Loss Investments NetGainOrLossInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 129152 | TotalRevenueColumn |
| Exclusion | $129,152 | ExclusionAmount |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Income Fundraising Events | 15214 | GrossIncomeFundraisingEvents |
| Cntrbtns Rprtd Fundraising Events | 112263 | CntrbtnsRprtdFundraisingEvents |
| Fundraising Direct Expenses | 19825 | FundraisingDirectExpenses |
Net Income From Fundraising Events NetIncomeFromFundraisingEvents
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -4611 | TotalRevenueColumn |
| Exclusion | -$4,611 | ExclusionAmount |
Total Revenue TotalRevenue
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | 33677968 | TotalRevenueColumn |
| Related Or Exempt Function Income | 32879769 | RelatedOrExemptFunctionIncome |
| Unrelated Business Revenue | 0 | UnrelatedBusinessRevenue |
| Exclusion | $594,206 | ExclusionAmount |
Comp Current Officers Directors CompCurrentOfficersDirectors
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 387141 | Total |
| Management And General | 387141 | ManagementAndGeneral |
Other Salaries And Wages OtherSalariesAndWages
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 12387409 | Total |
| Program Services | 10795416 | ProgramServices |
| Management And General | 1591993 | ManagementAndGeneral |
Pension Plan Contributions PensionPlanContributions
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 291755 | Total |
| Program Services | 256108 | ProgramServices |
| Management And General | 35647 | ManagementAndGeneral |
Other Employee Benefits OtherEmployeeBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 2300740 | Total |
| Program Services | 1999951 | ProgramServices |
| Management And General | 300789 | ManagementAndGeneral |
Payroll Taxes PayrollTaxes
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 908609 | Total |
| Program Services | 784223 | ProgramServices |
| Management And General | 124386 | ManagementAndGeneral |
Fees For Services Legal FeesForServicesLegal
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 39308 | Total |
| Management And General | 39308 | ManagementAndGeneral |
Fees For Services Accounting FeesForServicesAccounting
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 70879 | Total |
| Management And General | 70879 | ManagementAndGeneral |
Fees For Services Other FeesForServicesOther
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 5592141 | Total |
| Program Services | 5249610 | ProgramServices |
| Management And General | 342531 | ManagementAndGeneral |
Advertising Advertising
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 216098 | Total |
| Program Services | 1174 | ProgramServices |
| Management And General | 214924 | ManagementAndGeneral |
Office Expenses OfficeExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1705937 | Total |
| Program Services | 1611241 | ProgramServices |
| Management And General | 94696 | ManagementAndGeneral |
Occupancy Occupancy
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 351886 | Total |
| Program Services | 344900 | ProgramServices |
| Management And General | 6986 | ManagementAndGeneral |
Travel Travel
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 146335 | Total |
| Program Services | 132980 | ProgramServices |
| Management And General | 13355 | ManagementAndGeneral |
Conferences Meetings ConferencesMeetings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 72366 | Total |
| Program Services | 59480 | ProgramServices |
| Management And General | 12886 | ManagementAndGeneral |
Interest Interest
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 611318 | Total |
| Program Services | 611318 | ProgramServices |
Depreciation Depletion DepreciationDepletion
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 1866805 | Total |
| Program Services | 1866805 | ProgramServices |
Insurance Insurance
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 116317 | Total |
| Program Services | 116317 | ProgramServices |
Other Expenses OtherExpenses (5 entries)
| DescriptionDescription | TotalTotal | Program ServicesProgramServices | Management And GeneralManagementAndGeneral |
|---|---|---|---|
| Provision for Bad Debts | 1638922 | 1638922 | |
| Drugs and Medical Suppl | 1590101 | 1590101 | |
| Dues and Subscriptions | 423851 | 357087 | 66764 |
| Other Expenses | 262891 | 104566 | 158325 |
| Collection Fees | 117332 | 117332 |
Total Functional Expenses TotalFunctionalExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | 31098141 | Total |
| Program Services | 27520199 | ProgramServices |
| Management And General | 3577942 | ManagementAndGeneral |
| Fundraising | 0 | Fundraising |
Savings And Temp Cash Investments SavingsAndTempCashInvestments
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4743231 | BOY |
| EOY | 2538784 | EOY |
Accounts Receivable AccountsReceivable
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 4862976 | BOY |
| EOY | 4575955 | EOY |
Inventories For Sale Or Use InventoriesForSaleOrUse
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 425386 | BOY |
| EOY | 479604 | EOY |
Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 237299 | BOY |
| EOY | 242991 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Buildings Equipment Basis | 29158829 | LandBuildingsEquipmentBasis |
| Land Bldg Equipment Accum Deprec | 16234267 | LandBldgEquipmentAccumDeprec |
Land Buildings Equipment Basis Net LandBuildingsEquipmentBasisNet
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12809464 | BOY |
| EOY | 12924562 | EOY |
Investments Pub Traded Securities InvestmentsPubTradedSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 13900574 | BOY |
| EOY | 18484868 | EOY |
Investments Other Securities InvestmentsOtherSecurities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8816 | BOY |
| EOY | 8816 | EOY |
Other Assets Total OtherAssetsTotal
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 477347 | BOY |
| EOY | 474640 | EOY |
Total Assets TotalAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 37465093 | BOY |
| EOY | 39730220 | EOY |
Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 2090294 | BOY |
| EOY | 2154879 | EOY |
Tax Exempt Bond Liabilities TaxExemptBondLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 8743146 | BOY |
| EOY | 8486702 | EOY |
Other Liabilities OtherLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 1676991 | BOY |
| EOY | 977468 | EOY |
Total Liabilities TotalLiabilities
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 12510431 | BOY |
| EOY | 11619049 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Follow SFAS117 | X | FollowSFAS117 |
Unrestricted Net Assets UnrestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24426782 | BOY |
| EOY | 27421030 | EOY |
Temporarily Restricted Net Assets TemporarilyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 44146 | BOY |
| EOY | 157662 | EOY |
Permanently Restricted Net Assets PermanentlyRestrictedNetAssets
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 483734 | BOY |
| EOY | 532479 | EOY |
Total Net Assets Fund Balances TotalNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 24954662 | BOY |
| EOY | 28111171 | EOY |
Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | 37465093 | BOY |
| EOY | 39730220 | EOY |
| Field | Value | IRS element (for citing) |
|---|---|---|
| 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 | 483734 | BeginningOfYearBalance |
| Contributions | 36960 | Contributions |
| Investment Earnings Or Losses | 22725 | InvestmentEarningsOrLosses |
| Other Expenditures | 7756 | OtherExpenditures |
| End Of Year Balance | 535663 | EndOfYearBalance |
Current Year Minus1 Year CurrentYearMinus1Year
| 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 | 0.99410 | PermanentEndowmentEOYBalance |
| Term Endowment EOY Balance | 0.00590 | TermEndowmentEOYBalance |
| 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 | 18983738 | OtherCostOrOtherBasis |
| Depreciation | 10095285 | Depreciation |
| Book Value | 8888453 | BookValue |
Equipment Equipment
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 8751167 | OtherCostOrOtherBasis |
| Depreciation | 5909636 | Depreciation |
| Book Value | 2841531 | BookValue |
Other Land Buildings OtherLandBuildings
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | 1389424 | OtherCostOrOtherBasis |
| Depreciation | 229346 | Depreciation |
| Book Value | 1160078 | BookValue |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Book Value Land Buildings | 12924562 | TotalOfBookValueLandBuildings |
Other Liabilities OtherLiabilities (2 entries)
| DescriptionDescription | AmountAmount |
|---|---|
| Capital Lease obligations | $536,468 |
| Estimated third party payor settlements | $441,000 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Of Amounts | 977468 | TotalOfAmounts |
| Total Revenue | 33677968 | TotalRevenue |
| Total Expenses | 31098141 | TotalExpenses |
| Excess Or Deficit For Year | 2579827 | ExcessOrDeficitForYear |
| Net Unrealized GL On Investments | 569372 | NetUnrealizedGLOnInvestments |
| Other | $7,310 | OtherAmount |
| Total Adjustments | 576682 | TotalAdjustments |
| Excess Or Deficit Per FS | 3156509 | ExcessOrDeficitPerFS |
| Tot Revenue Etc Audited Fincl Stmt | 33585911 | TotRevenueEtcAuditedFinclStmt |
| Revenue Not Rptd F990 | 0 | RevenueNotRptdF990 |
| Revenue Subtotal | 33585911 | RevenueSubtotal |
| Other Revenues Not Included | 92057 | OtherRevenuesNotIncluded |
| Revenue Not Rptd On Fin Stmt | 92057 | RevenueNotRptdOnFinStmt |
| Total Revenue Per Form990 | 33677968 | TotalRevenuePerForm990 |
| Tot Expenses Etc Audited Fincl Stmt | 31168791 | TotExpensesEtcAuditedFinclStmt |
| Other Expenses Included | 70650 | OtherExpensesIncluded |
| Expenses Not Rptd F990 | 70650 | ExpensesNotRptdF990 |
| Expenses Subtotal | 31098141 | ExpensesSubtotal |
| Expenses Not Rptd On Fin Stmt | 0 | ExpensesNotRptdOnFinStmt |
| Total Expenses Per Form990 | 31098141 | TotalExpensesPerForm990 |
Form990 Schedule D Part XIV Form990ScheduleDPartXIV (5 entries)
| IdentifierIdentifier | Return ReferenceReturnReference | ExplanationExplanation |
|---|---|---|
| Part V, Line 4: | Description of Intended Use of Endowment Funds: | 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. |
| Part X: | Description of Uncertain Tax Positions Under FIN 48: | The Hospital undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities, as defined by Financial accounting Standards Board (FASB) Accounting Standards Codification Topic ASC 740-10 (previously Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes). As of September 30, 2010, no amounts were recorded as a result of this analysis. The Hospital will recognize future accrued interest and penalties related to unrecognized tax benefits in income tax expense, if incurred. Under normal circumstances, the Hospital is no longer subject to Federal and state tax examinations by tax authorities for years before 2007. |
| Part XI, Line 8 - Other Adjustments: | Increase in fair value of beneficial interest in perpetual trust: 7310. | |
| Part XII, Line 4b - Other Adjustments: | Temporarily Restricted interest income included in fund balance: 11656. Rental expenses recorded in expenses for financial statements: -50825. Permanently Restricted interest income included in fund balance: 4475. Permanently Restricted Contributions for Hospice Endowment Fund: 36960. Special Events Expenses recorded in expenses for financial statements: -19825. Temporarily Restricted contributions included in fund balance: 109616. | |
| Part XIII, Line 2d - Other Adjustments: | Rental expenses recorded in expenses for financial statements: 50825. Special Events Expenses recorded in expenses for financial statements: 19825. |
Schedule G IRS990ScheduleG
Events Information EventsInformation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Event1 | Hospice House Capital Campaign | NameOfEvent1 |
| Gross Receipts Event1 | 109813 | GrossReceiptsEvent1 |
| Charitable Contributions Event1 | 109813 | CharitableContributionsEvent1 |
| Other Direct Expenses Event1 | 17625 | OtherDirectExpensesEvent1 |
| Name Of Event2 | Hearts for Hospice | NameOfEvent2 |
| Gross Receipts Event2 | 17664 | GrossReceiptsEvent2 |
| Charitable Contributions Event2 | 2450 | CharitableContributionsEvent2 |
| Gross Revenue Event2 | 15214 | GrossRevenueEvent2 |
| Other Direct Expenses Event2 | 2200 | OtherDirectExpensesEvent2 |
| Gross Receipts Total | 127477 | GrossReceiptsTotal |
| Charitable Contributions Total | 112263 | CharitableContributionsTotal |
| Gross Revenue Total Events | 15214 | GrossRevenueTotalEvents |
| Other Direct Expenses Total Events | 19825 | OtherDirectExpensesTotalEvents |
| Direct Expense Summary Events | 19825 | DirectExpenseSummaryEvents |
| Net Income Summary | -4611 | NetIncomeSummary |
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 | 527941 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 527941 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.01790 | PercentOfTotalExpense |
Unreimbursed Medicaid UnreimbursedMedicaid
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 6726 | PersonsServed |
| Total Community Benefit Expense | 4384930 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 3644213 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 740717 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02510 | PercentOfTotalExpense |
Unreimbursed Costs UnreimbursedCosts
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 2873 | PersonsServed |
| Total Community Benefit Expense | 2758272 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1963766 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 794506 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.02700 | PercentOfTotalExpense |
Total Charity Care TotalCharityCare
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 9762 | PersonsServed |
| Total Community Benefit Expense | 7671143 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 5607979 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 2063164 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.07000 | PercentOfTotalExpense |
Community Health Services CommunityHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expense | 284522 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 193023 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 91499 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00310 | PercentOfTotalExpense |
Health Professions Education HealthProfessionsEducation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 9 | PersonsServed |
| Total Community Benefit Expense | 21125 | TotalCommunityBenefitExpense |
| Net Community Benefit Expense | 21125 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.00070 | PercentOfTotalExpense |
Subsidized Health Services SubsidizedHealthServices
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 3079 | PersonsServed |
| Total Community Benefit Expense | 3536120 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 1969525 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1566595 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05320 | PercentOfTotalExpense |
Total Other Benefits TotalOtherBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 3088 | PersonsServed |
| Total Community Benefit Expense | 3841767 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 2162548 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 1679219 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.05700 | PercentOfTotalExpense |
Total Community Benefits TotalCommunityBenefits
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 12850 | PersonsServed |
| Total Community Benefit Expense | 11512910 | TotalCommunityBenefitExpense |
| Direct Offsetting Revenue | 7770527 | DirectOffsettingRevenue |
| Net Community Benefit Expense | 3742383 | NetCommunityBenefitExpense |
| Percent Of Total Expense | 0.12700 | PercentOfTotalExpense |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 1 | BadDebtExpenseReported |
| Bad Debt Expense | $906,126 | BadDebtExpenseAmount |
| Amount Attributable To | 14226 | AmountAttributableTo |
| Amount Reimbursed By Medicare | 6593804 | AmountReimbursedByMedicare |
| Cost Of Care Reimbursed By Medicare | 6482299 | CostOfCareReimbursedByMedicare |
| Medicare Surplus Or Shortfall | 111505 | 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 |
Form990 Schedule H Part V Form990ScheduleHPartV (3 entries)
| Address Line1Address/AddressLine1 | CityAddress/City | StateAddress/State | ZIP CodeAddress/ZIPCode | Critical Access HospitalCriticalAccessHospital | Er24 HoursEr24Hours | OtherOther |
|---|---|---|---|---|---|---|
| Tomah Memorial Hospital | ||||||
| 321 Butts Avenue | Tomah | WI | 54660 | X | X | |
| 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
| Field | Value | IRS element (for citing) |
|---|---|---|
| Annual Community Benefit Expln | 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. | AnnualCommunityBenefitExpln |
| Costing Method Used | 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 benefits report. | CostingMethodUsed |
| Percent Of Total Expense Expln | Part I, Line 7f: Bad debt expense reported on Form 990, Part IX, Line 25, column (A) of $1,638,922 was removed from the denominator prior to the calculation. | PercentOfTotalExpenseExpln |
| Bad Debt Footnote | Part III, Line 4: 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.Line 2: Bad debt expense at cost is calculated by applying the ratio of cost to charges to the bad debt attributable to patient accounts. Cost to charges was calculated as described in Part I, Line 7. Bad debts are net of discounts and amounts collected.Line 3: The estimated amount of bad debt expense attributable to patients eligible under the organization's charity care policy was determined by taking charity care (at cost) as a percentage of total revenues and applying that percentage to the bad debt expense (at cost). The percentage applied was 1.57%. | BadDebtFootnote |
| Shortfall As Community Benefit | Part III, Line 8: The hospital does not have a shortfall in the current year. If they did, the entire shortfall should be treated as a community benefit. The organization provides services to medicare patients understanding there will be write-offs and knowing the organization will not recover all the costs of the services provided. Providing these services is essential to these patients and the community and increases their access to healthcare serices, which is a community benefit. | ShortfallAsCommunityBenefit |
| Debt Collection Policy | Part III, Line 9b: The Hospital's billing and collections guidelines are set forth in two policies: "Management of Accounts Receivable" and "Community Care". The "Management of Accounts Receivable" policy provides guidance regarding submitting claims to third party payers, establishing payment guidelines for individuals without insurance or with a balance resulting from a copay or deductible, and when an account should be reviewed for community care qualification. The "Community Care" policy addresses the qualifications for community care, the application process, and provides a grid of discount amounts (based on family size, income level, and medical debt amounts). The 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). | DebtCollectionPolicy |
| Number Of Facility Type Expln | Part V: 1 Critical access hospital, 1 hospice residence, and 1 walk-in clinic. Additionally, the hospital operates a hospice program that provides in-home hospice care. The hospice program has a main office located adjacent to the hospital campus, as well as two outlying offices (Mauston, WI and Adams, WI). No patient care is provided at any of the hospice office locations. | NumberOfFacilityTypeExpln |
| Needs Assessment | Part VI, Line 2: The 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 Solutions (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. | NeedsAssessment |
| Patient Education Assistance | Part VI, Line 3: The 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. | PatientEducationAssistance |
| Community Information | Part VI, Line 4: 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. | CommunityInformation |
| Community Building Activities | Part VI, Line 5: | CommunityBuildingActivities |
| Other Information | Part VI, Line 6: 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. The 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. | OtherInformation |
| Reports Filed With States | WI | ReportsFiledWithStates |
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 (2 entries)
| Base Compensation Filing OrgBaseCompensationFilingOrg | Comp Based On Related OrgsCompBasedOnRelatedOrgs | Bonus Filing OrgBonusFilingOrg | Bonus Related OrgsBonusRelatedOrgs | Other Compensation Filing OrgOtherCompensationFilingOrg | Other Compensation Related OrgsOtherCompensationRelatedOrgs | Deferred Comp Filing OrgDeferredCompFilingOrg | Deferred Comp Related OrgsDeferredCompRelatedOrgs | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrg | Nontaxable Benefits Related OrgsNontaxableBenefitsRelatedOrgs | Total Compensation Filing OrgTotalCompensationFilingOrg | Total Compensation Related OrgsTotalCompensationRelatedOrgs | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrg | Comp Report Prior990 Related OrgsCompReportPrior990RelatedOrgs |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Philip J Stuart | |||||||||||||
| 241358 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 241358 | 0 | 0 | 0 |
| Darla Wilson | |||||||||||||
| 131943 | 0 | 0 | 0 | 4822 | 0 | 5500 | 0 | 7961 | 0 | 150226 | 0 | 0 | 0 |
Form990 Schedule J Part III Form990ScheduleJPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Identifier | Supplemental Information | Identifier |
| Return Reference | Part III | ReturnReference |
| Explanation | Page 2, Part II: Philip J. Stuart, Administrator, is compensated by HealthTech Management Services, an unrelated management company, for services rendered to Tomah Memorial Hospital. | Explanation |
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 |
| Date Issued | 2003-07-15 | DateIssued |
| Issue Price | 10470000 | IssuePrice |
| Description Of Purpose | Building Expansion | DescriptionOfPurpose |
| Defeased | 0 | Defeased |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuer |
Form990 Schedule K Part II Form990ScheduleKPartII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Proceeds | 10416049 | TotalProceeds |
| Amount In Reserve Fund | 913589 | AmountInReserveFund |
| Amount Defeased | 1229698 | AmountDefeased |
| Issuance Costs From Proceeds | 272762 | IssuanceCostsFromProceeds |
| Capital Expenditures | 8000000 | CapitalExpenditures |
| 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 |
| Bond Counsel Routinely Engaged | 0 | BondCounselRoutinelyEngaged |
| 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 III Form990ScheduleLPartIII
| Field | Value | IRS element (for citing) |
|---|---|---|
| Name Of Interested Person | Joseph Zeps | NameOfInterestedPerson |
| Relationship With Organization | Officer | RelationshipWithOrganization |
| Type Of Assistance | education assistance Amount $ 5000. | TypeOfAssistance |
Form990 Schedule L Part IV Form990ScheduleLPartIV (3 entries)
| RelationshipRelationship | Amount Of TransactionAmountOfTransaction | Description Of TransactionDescriptionOfTransaction | Sharing Of RevenuesSharingOfRevenues |
|---|---|---|---|
| Cindy Lambert | |||
| Family member of a current officer | 19420 | Reportable Compensation paid to a family member of a current officer | 0 |
| Shana Steele | |||
| Family member of a current officer | 22169 | Reportable Compensation paid to a family member of a current officer | 0 |
| Tomah Lumber | |||
| Entity owned by a current director | 20000 | Tomah Memorial Hospital entered into an agreement with Tomah Lumber to construct a new hospice residence (payment for services). | 0 |
Schedule O IRS990ScheduleO
General Explanation GeneralExplanation (8 entries)
| IdentifierIdentifier | ExplanationExplanation |
|---|---|
| Form 990, Part VI, Section A, line 1 | The hospital utilizes an Executive Committee which is comprised of four board members (the President, Vice President, Secretary, and Treasurer). The Committee meets monthly and is briefed on all significant aspects of hospital operations. Any resolutions acted on by the Executive Committee are subsequently forwarded to the full board for action. |
| Form 990, Part VI, Section A, line 2 | Oak 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. |
| Form 990, Part VI, Section B, line 11 | The Administrator, CFO, and Executive/Finance Committee review the draft in detail and provide a copy to the board. |
| Form 990, Part VI, Section B, line 12c | All members of the board and administration team are covered by the conflict of interest policy. The hospital administration reviews annual statements for potential conflicts. If a board member has a conflict they must abstain from voting on any matter related to the conflict. |
| Form 990, Part VI, Section B, line 15 | The Administrator is employed by HealthTech Management Services. 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 just renewed this last year. The Administrator makes recommendations to the Finance/Executive Committee of the Board for other officers and key employees. Comparability data is used during this process and the decisions are documented. This is an annual process. |
| Form 990, Part VI, Section C, line 19 | 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 VII, Section A: Robb Kline, MD and Ralph Knudson, MD, are employees of Emcare and Gundersen Lutheran, respectively. Tomah Memorial Hospital contracts with both of these unrelated organizations for various services. Both individuals receive compensation via their employment relationship with the unrelated organizations and Tomah Memorial Hospital does not have knowledge of their specific compensation arrangement. |
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 | 509(a)(3), Type II | PublicCharityStatus |
| Direct Controlling Entity NA | N/A | DirectControllingEntityNA |
| 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 |
| Amount Involved | 7756 | AmountInvolved |