2011-05-03T11:01:38-05:00 2010-09-30 WIPFLI LLP 7601 FRANCE AVENUE SOUTH SUITE 400 MINNEAPOLIS MN 55435 990 2009-10-01 410706115 Madison Lutheran Home MADI 3205987536 900 Second Avenue Madison MN 56256 Scott Larson 3205987536 2011-04-28 1 Richard Ruvelson 9525483400 2011-04-28 2009 2016-02-24 21:20:13Z Scott Larson 900 Second Avenue Madison MN 56256 15892682 0 9386 X www.mlhmn.org X 1945 MN Madison Lutheran Home, which includes the Madison Hospital, Lac qui Parle Clinic and subsidiaries, exists as a non-profit Christian organization called by God to affirm the worth of all people, to provide health care, residential and community service in a competent and caring manner. 9 9 315 500 1300 0 517504 1032707 13735158 14389388 82324 103157 204671 363297 14539657 15888549 709 4139 0 7656442 7978803 0 0 5593871 6370572 13251022 14353514 1288635 1535035 17119858 18619443 2537067 2094609 14582791 16524834 Madison Lutheran Home, which includes the Madison Hospital, Lac qui Parle Clinic and subsidiaries, exists as a non-profit Christian organization called by God to affirm the worth of all people, to provide health care, residential and community service in a competent and caring manner. 0 0 12877088 4139 14368781 Madison Lutheran Home is a 12-bed hospital, 87 bed nursing facility and clinic located in Madison, Minnesota. The organization also operated a clinic in Marietta, Minnesota.The organization provides home health services. During the year home health had 3,039 skilled nursing visits and 4,768 aide visits, with an average clientele of 43 clients. Home Health also provides Assisted Living services to an average of 29 residents.The hospital provides service to the community in the area of acute inpatient care and skilled swing bed rehabilitation. The nursing home provides quality care of the residents by assisting the residents to achieve their highest level of function.The organization also provides social services by providing emotional, social, and economic support/referral to residents and families, obstetrics, pediatrics, surgery, emergency care, cardiac rehab, outreach and inpatient care. The hospital provided care to 448 inpatients, 2969 outpatient visits, 747 emergency room patients, 9 newborn admits, 48 skilled swing bed admits, and 8 hospice/respite admits.The organization maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges foregone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, was $19,237.41 for the year ended September 30, 2010. 238956 20607 The Meals on Wheels program began in the Madison, MN community in 1972. Our goal is service to our community. We provide meals to the town of Madison, and it is a cooperative service with the area churches. The churches provide the volunteer drivers and the Madison Lutheran Home provides the meals. Meals are delivered 5 days a week, including holidays. We send 2 meals, if requested, on Thursdays and Fridays to provide meals through the weekend. The meals include meat, potato, vegetable, dessert, fruit sauce, bread and milk or juice. Our program receives no State of Federal funding. Donations are given to the Meals on Wheels program through area churches, Madison Community Fund, area individuals and other area organizations. These donations help keep the cost reasonable for the participants.Besides the meals we provide, one of the benefits of the program is that someone is checking on the clients daily when the meal is delivered. If a client does not answer the door to accept the meal, we call the client, clients family or proper authorities to check on the safety of the client This program has found community members that have fallen or are in some other difficulty and have helped to obtain needed assistance. This program has been a valuable piece of the services in our community that enable people to stay in their homes. 13116044 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 4 0 315 1 1 1 0 0 0 0 0 0 9 9 0 0 0 0 1 1 0 1 1 0 0 1 1 1 0 1 1 1 1 0 MN X Carol Borgerson 3205987536 900 Second Avenue Madison MN 56256 Pam Weber 1.00 X 0 0 0 Brent Zupan 1.00 X 0 0 0 Gene Koosmann 1.00 X 0 0 0 Robert Wittnebel 1.00 X 0 0 0 Tom Miller 1.00 X 0 0 0 Eunice Mork 1.00 X X 0 0 0 Patty Schuelke 1.00 X 0 0 0 Tom Daline 1.00 X 0 0 0 Jeff Kallhoff 1.00 X X 0 0 0 Scott Larson 40.00 X 111350 0 8703 Laura Hong 40.00 X 168568 0 24668 Brant Hacker 40.00 X 258375 0 18491 Larry Grong 40.00 X 262259 0 18161 Michael Deyo 40.00 X 108985 0 10456 909537 0 80479 5 0 1 0 Doom & Cuypers 331 Burlington Cir Marshall MN 56258 general Contractor 664651 Healthland 625 South Lakeshore Drive Glenwood MN 56334 EMR/Software/Training/Maintenance 626683 Big Stone Therapy 820 Roy Street Ortonville MN 56278 Contract Therapy 507418 Cardinal Health 7000 Cardinal Place Dublin OH 43017 Pharmacy 430274 Dallas Hanson 700 US Highway 75 Ortonville MN 56278 Construction Contractor 233025 12 1032707 1032707 Net patient and reside 621400 14257004 14257004 Other Operating Revenu 900099 80268 80268 Management Fee Revenue 531310 31509 31509 Co-pay fee revenue 621610 20607 20607 14389388 103157 103157 3225 4133 -908 -908 -908 Employee and Guest Mea 900099 207639 207639 Miscellaneous revenue 900099 152447 1300 151147 Hospital Supply Revenu 900099 2977 2977 1142 1142 364205 15888549 14389388 1300 465154 4139 4139 125893 125893 6613863 6287493 326370 110342 104897 5445 481691 457921 23770 647014 605352 41662 2527 2527 30247 30247 1432237 1403509 28728 44930 44930 1142317 945261 197056 23417 23417 301788 301788 36254 36254 67603 67603 45424 45424 900331 900331 56033 12560 43473 Pharmacy Drugs 674025 674025 Lab/XRay/Other Testing 389197 389197 Surcharge and MN Care T 371682 13534 358148 Patient Service Costs 294143 294143 Provision for Bad Debt 217464 217464 340953 286802 54151 14353514 13116044 1237470 0 1240 1240 514135 622789 2319074 2493197 230035 182417 136473 146597 15764247 9112218 6821665 6652029 7007919 8392475 66059 128699 23258 0 17119858 18619443 1182133 832303 1024125 996640 330809 265666 2537067 2094609 X 14563458 15515690 19333 1009144 14582791 16524834 17119858 18619443 X 0 1 1 X 0 X 529229 86102 37082 519562 42707 1214682 11330296 12488712 12173456 14005888 14753593 64751945 11859525 12574814 12210538 14525450 14796300 65966627 492508 492508 0 492508 492508 65474119 215951 256608 230470 82324 103157 888510 215951 256608 230470 82324 103157 888510 12075476 12831422 12441008 14607774 14899457 66855137 0.97930 0.97770 0.01330 0.01460 X Schedule A, Part IV, List of Unusual Grants: Trust Grant Date: 09/30/10 Amount: 990000. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4769 4769 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Madison Lutheran Home is a member of the Minnesota Hospital Association and Aging Services of Minnesota. A portion of their dues are for lobbying expenses. 6522 6522 12012367 6367351 5645016 3739132 2744867 994265 6226 6226 6652029 Deferred Compensation Plan 265666 265666 Part X: Description of Uncertain Tax Positions Under FIN 48: The Organization recorded no assets or liabilities for uncertain tax positions or unrecognized tax benefits. Federal and state informational returns for 2007 and subsequent years remain subject to examination by major tax jurisdictions. 1 1 1 X 250.000000000000 1 X 1 1 1 0 1 1 48539 48539 0.00340 193228 109708 83520 0.00590 241767 109708 132059 0.00930 11 1894 17118 2125 14993 0.00110 4139 4139 0.00030 11 1894 21257 2125 19132 0.00140 11 1894 263024 111833 151191 0.01070 0 40576 26494 2750340 3377136 -626796 X 1 1 Madison Hospital

820 Third Avenue Madison MN 56256

X X X X Part I, Line 7: The costing methodology is the cost to charge ratio per worksheet 2 of the instructions. Part III, Line 4: The actual accounts written off is $40,576 for Madison Hospital and does not include Medicare bad debt accounts. This amount is adjusted using the cost to charge ratio. Management provides for probable uncollectible amounts, primarily from uninsured patients and residents and amounts patients and residents are personally responsible for, through a charge to operations and a credit to a valuation allowance based on its assessment of historical collection likelihood and the current status of individual accounts. Balances that are still outstanding after management has used reasonable collection efforts are written off through a charge to the valuation allowance and a credit to patient and resident accounts receivable. Part III, Line 8: The costing methodology used to determine the Medicare allowable cost reported in the Medicare cost report is the cost to charge ratio. Part III, Line 9b: If patients have completed all paperwork and qualify for charity care, the patient is not billed for any balance and account is written off. If patient has medical assistance, that program is billed for charges and that payment is payment in full unless Medical Assistance notifies us that the patient has responsibility for spend down or co-pay payments. Part I, Line 7, Column FAs allowed, the denominator has been reduced by $217,464, the amount of bad debt reported in Part IX, Line 25 of Form 990. Part VI, Line 2: We work with the Countryside Health to assess the needs of the community, along with various other church organizations. We also have a survey that is sent out by the Rural Health Coop. Part VI, Line 3: Inpatients are given a packet with all of our billing information as well as the charity policy and where to obtain one. We do have the billing information posted in the entry. If a patient is admitted that has no insurance the Accounting manager does meet with them prior to discharge to discuss options for payment that may be available to them, including an application for Medical Assistance. The staff has charity applications available in the admissions office, along with the Accounting Manager. Part VI, Line 4: The area being served by the Madison Hospital and Lac qui Parle Clinic is primarily rural. The patient base is made up of both working class and farmers. The counties that we serve are Lac qui Parle, Big Stone and some border counties of South Dakota. The closest facility is 25 miles away, being Canby, Dawson, Appleton or Ortonville. The average individual income is approximately $24,000.00 gross. On average the poverty level in the county is at about 30 to 35% with many people being laid off, and families of 3 or more. The percentage of families on Medicaid would probably be approximately 35%, receiving some type of medical assistance or county assistance. Part VI, Line 5: N/A Part VI, Line 6: Madison Lutheran Home consists of a hospital, clinic and nursing home. The Charity Care percentage on Part I line 7(k) column f appears low however excluding the nursing home gross patient charges(39% of gross patient charges) increases this percentage to 1.50%. Madison Hospital is constantly striving to add new services, including outreach services to better serve the needs of our community. A leadership team has been formed to meet the community needs, continue to look at adding new services, continue to look at updating our current facility, and asking for community involvement in final decision making. With our aging population, we strive to bring the services to the patients, rather than the patients having to drive hours from home to get the services.One of the services Madison Hospital provides is a Caregiver Support Group. This is a community support group lead by the Madison Hospital Home Care Department. This group meets monthly on the third Wednesday of the month. This is a confidential group meeting, where members can voice frustrations and concerns being a caregiver with other who are going through the same ordeal. We as a Home Care agency also provide education to this group on various topics from daily cares to disease process and positive encouragement.Madison Hospital provided health care screenings at reduced rates to the community. Part VI, Line 7: N/A X 0 0 0 1 0 0 0 0 0 Laura Hong 168568 0 0 0 0 0 15285 0 9383 0 193236 0 0 0 Brant Hacker 258375 0 0 0 0 0 7471 0 11020 0 276866 0 0 0 Larry Grong 262259 0 0 0 0 0 7398 0 10763 0 280420 0 0 0 Part I, Line 5 Physicians are able to receive a bonus based on revenue generated. Dr Brant Hacker Compensation package X 0 1 1 Form 990, Part VI, Section A, line 6 The organization's members are The Lutheran congregations that were members of Lac Qui Parle Health Care Services on the date of Merger with Madison Lutheran Home on July 10, 1992. Form 990, Part VI, Section A, line 7a The members of the Lutheran congregations elect the Board members of Madison Lutheran Home. Form 990, Part VI, Section B, line 11 The Form 990 is presented to the Board of Directors for approval prior to submission. Form 990, Part VI, Section B, line 12 The organization monitors the conflict of interest policy as conflicts arise. Form 990, Part VI, Section B, line 15 The organization uses comparability data from surveys of other organizations of similar size in the surrounding areas to determine compensation of top management and officers of the organization. Form 990, Part VI, Section C, line 19 The organization does not make its governing documents, conflict of interest polciy, or financial statements available to the public. Form 990, Part XI, Line 2c The board of directors assumes oversight of the audit of its financial statements and selection of an independent accountant. Hilltop Residence Inc 900 Second Avenue Madison MN 56256 411376605 Housing for handicapped and elderly MN 501(c)(3) 509(a)(2) Madison Lutheran Home Madison Hospital Inc 900 Second Avenue madison MN 56256 411653496 Assist injured and sick individuals MN 501(c)(7) Madison Lutheran Home Lac Qui Parle Clinic Inc 900 Second Avenue madison MN 56256 411702606 Assist injured and sick individuals MN 501(c)(7) madison Lutheran Home 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0