2011-03-14T12:16:45-05:00 2010-09-30 Eide Bailly LLP 5601 Green Valley Drive Ste 700 Minneapolis MN 554371145 990 2009-10-01 390799566 Tomah Memorial Hospital TOMA 6083722181 321 Butts Ave Tomah WI 54660 Joseph Zeps 6083722181 2011-03-09 1 Kim Hunwardsen CPA 9529446166 2011-03-09 2009 2016-02-24 21:20:13Z Joseph Zeps 321 Butts Ave Tomah WI 54660 35742356 0 X WWW.TOMAHHOSPITAL.ORG X 1948 WI To promote and provide quality health care to patients in a hospital setting. 10 10 301 64 0 0 183733 203993 31391331 32879769 -410503 614226 -5933 -20020 31158628 33677968 0 0 15129341 16275654 0 0 15329568 14822487 30458909 31098141 699719 2579827 37465093 39730220 12510431 11619049 24954662 28111171 Our mission is to provide high quality health care for you at Tomah Memorial Hospital. 0 0 24822131 30910244 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. 2226869 1802314 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. 471199 167211 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. 27520199 1 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 1 0 0 1 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 1 0 0 1 7 0 1 301 1 0 0 0 0 0 0 0 0 0 10 10 1 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Joseph Zeps 6083740307 321 Butts Avenue Tomah WI 54660 Robert Fasbender 1.00 X X 0 0 0 Oak Moser 1.00 X X 0 0 0 Jeff Holthaus 1.00 X X 0 0 0 Phil Yahnke 1.00 X X 0 0 0 Steve Austin 1.00 X 0 0 0 Robb Kline MD 1.00 X 0 0 0 Jerry Molnar 1.00 X 0 0 0 Ralph Knudson MD 1.00 X 0 0 0 Nodji Van Wychen 1.00 X 0 0 0 Penny Precour-Berry 1.00 X 0 0 0 Joseph Zeps 40.00 X 115880 0 20183 Philip J Stuart 40.00 X 241358 0 0 Evelyn Chapman 40.00 X 107205 0 16440 Darla Wilson 40.00 X 136765 0 12044 Todd Chapman 40.00 X 119455 0 4778 Gerald Fushianes 40.00 X 107392 0 20234 Laura J Miller 40.00 X 107984 0 10931 936039 0 84610 6 0 1 1 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 10 112263 91730 203993 Patient Service Revenu 621990 32728049 32728049 Other Revenue 621990 151720 151720 32879769 485074 485074 35416 50825 -15409 -15409 -15409 2119640 3250 1993738 125902 3250 129152 129152 15214 112263 19825 -4611 -4611 33677968 32879769 0 594206 387141 387141 12387409 10795416 1591993 291755 256108 35647 2300740 1999951 300789 908609 784223 124386 39308 39308 70879 70879 5592141 5249610 342531 216098 1174 214924 1705937 1611241 94696 351886 344900 6986 146335 132980 13355 72366 59480 12886 611318 611318 1866805 1866805 116317 116317 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 31098141 27520199 3577942 0 4743231 2538784 4862976 4575955 425386 479604 237299 242991 29158829 16234267 12809464 12924562 13900574 18484868 8816 8816 477347 474640 37465093 39730220 2090294 2154879 8743146 8486702 1676991 977468 12510431 11619049 X 24426782 27421030 44146 157662 483734 532479 24954662 28111171 37465093 39730220 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 483734 36960 22725 7756 535663 410683 88020 -6375 8594 483734 0.99410 0.00590 0 0 34500 34500 18983738 10095285 8888453 8751167 5909636 2841531 1389424 229346 1160078 12924562 Capital Lease obligations 536468 Estimated third party payor settlements 441000 977468 33677968 31098141 2579827 569372 7310 576682 3156509 33585911 0 33585911 92057 92057 33677968 31168791 70650 70650 31098141 0 31098141 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. Hospice House Capital Campaign 109813 109813 17625 Hearts for Hospice 17664 2450 15214 2200 127477 112263 15214 19825 19825 -4611 1 1 X 1 X 50.000000000000 1 X 1 1 1 0 1 1 163 527941 527941 0.01790 6726 4384930 3644213 740717 0.02510 2873 2758272 1963766 794506 0.02700 9762 7671143 5607979 2063164 0.07000 284522 193023 91499 0.00310 9 21125 21125 0.00070 3079 3536120 1969525 1566595 0.05320 3088 3841767 2162548 1679219 0.05700 12850 11512910 7770527 3742383 0.12700 1 906126 14226 6593804 6482299 111505 X 1 1 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 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 benefits report. 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. 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%. 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. 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). 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. 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. 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. 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. Part VI, Line 5: 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. WI X X X 0 0 0 0 0 0 0 0 0 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 Supplemental Information Part III 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. WI Health and Educational Facilities Authority 391337855 2003-07-15 10470000 Building Expansion 0 0 10416049 913589 1229698 272762 8000000 2004 1 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 1 0 0 0 0 0 Joseph Zeps Officer education assistance Amount $ 5000. 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 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. Pederson Trust Fund for the Benefit of Tomah Memorial Hospital 321 Butts Avenue Tomah WI 54660 396173790 support Tomah Memorial Hospital WI 501(c)(3) 509(a)(3), Type II N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Pederson Trust Fund for the Benefit of Tomah Memorial Hospital C 7756