2022-05-12T12:46:00-05:00 2021-06-30 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-07-01 390806250 DIVINE SAVIOR HEALTHCARE INC DIVI 6087424131 PO BOX 387 2817 NEW PINERY ROAD PORTAGE WI 53901 SIDNEY C SCZYGELSKI CFO/SENIOR VP OF FINANCE 6087424131 2022-05-06 1 SIDNEY SCZYGELSKI 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2022-04-30 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z ASPIRUS DIVINE SAVIOR HOSPITAL & CLINICS INC SIDNEY C SCZYGELSKI 2200 WESTWOOD DRIVE WAUSAU WI 54401 132629897 0 X ASPIRUS.ORG X 1917 WI WE HEAL PEOPLE, PROMOTE HEALTH, AND STRENGTHEN COMMUNITIES. 13 9 1054 10 0 0 6886934 532314 92114615 93624074 1131604 5247216 276595 144559 100409748 99548163 6000 0 0 0 60132487 56203421 0 0 0 41157871 43709075 101296358 99912496 -886610 -364333 144456917 146404206 60885613 60304271 83571304 86099935 X WE HEAL PEOPLE, PROMOTE HEALTH, AND STRENGTHEN COMMUNITIES. 0 0 38208209 0 72233262 ADS IS AN ACUTE CARE 73-BED HOSPITAL LOCATED IN PORTAGE, WI. INPATIENT SERVICES INCLUDED ADMISSIONS OF ADULTS AND PEDIATRIC PATIENTS WHICH TOTALED 4,730 PATIENT DAYS IN FISCAL YEAR 2021. ADS ALSO OFFERS A WIDE ARRAY OF OUTPATIENT SERVICES TO MEET THE HEALTHCARE NEEDS OF THE COMMUNITY. EMERGENCY ROOM, URGENT CARE, SURGERY, AMBULANCE, RENAL DIALYSIS, AND REHABILITATION SERVICES ARE AMONG MANY OF THE OUTPATIENT SERVICES PROVIDED. KEY OUTPATIENT SERVICE STATISTICS IN FISCAL YEAR 2021 INCLUDED 12,460 EMERGENCY ROOM VISITS, 3,265 URGENT CARE VISITS (CLOSED FOR A PORTION OF YEAR DUE TO COVID), 20,601 X-RAYS AND 3,007 INFUSION THERAPY VISITS WERE AMONG MANY OF THE PATIENT SERVICES AS NOTED. ADS ALSO PROVIDES SPECIALIZED HOME CARE SERVICES TO INDIVIDUALS WHO NEED CARE WITHIN THEIR OWN HOME. THESE PERSONALIZED SERVICES INCLUDE SKILLED NURSING SERVICES, HOME HEALTH AIDES, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, IV THERAPY, AND PALLIATIVE CARE FOR TERMINAL ILLNESS.ADS PROMISES TO THE COMMUNITY TO PROVIDE HEALTHCARE SERVICES TO THOSE IN NEED REGARDLESS OF THEIR ABILITY TO PAY AS DEFINED IN THE HOSPITAL'S CHARITY AND COMMUNITY CARE POLICIES AND PROGRAMS. DURING FISCAL YEAR 2021, ADS'S CHARITY CARE PROGRAM AWARDED APPROXIMATELY $1,036,189 IN GROSS CHARGES FOR FINANCIAL ASSISTANCE TO PATIENTS WHO COULD NOT OTHERWISE AFFORD CARE.IN ADDITION TO INPATIENT AND OUTPATIENT HOSPITAL SERVICES, ADS ALSO PROVIDES EDUCATIONAL AND PREVENTATIVE SERVICES AT FREE OR REDUCED COSTS TO COMMUNITY MEMBERS. SOME OF THESE EVENTS OFFERED TO THE PUBLIC INCLUDE:LOW COST EXERCISE CLASSES, FREE BLOOD PRESSURE SCREENINGS, LOW COST CHOLESTEROL SCREENINGS, LOW COST CHILDBIRTH EDUCATION CLASSES, BLOOD DRIVES, FREE BREASTFEEDING WORKSHOPS, SUPPORT GROUPS, AND LOW-COST CPR AND FIRST AID CLASSES.IN FISCAL YEAR 2016, ADS OPENED A MEDICALLY INTEGRATED FITNESS CENTER IN RESPONSE TO THE COMMUNITY NEEDS ASSESSMENT PERFORMED. 14744859 0 13861315 ADS OWNS AND OPERATES PHYSICIAN PRACTICES IN PORTAGE, OXFORD AND PARDEEVILLE, WI (CLOSED SINCE 2020 DUE TO COVID). TOTAL CLINIC VISITS FOR FISCAL YEAR 2021 WERE 64,804. THESE CLINICS PROVIDE FAMILY PRACTICE, INTERNAL MEDICINE, PHYSIATRY, OB, ORTHOPEDICS AND SURGICAL SERVICES, AMONG MANY OTHER CLINICAL SERVICES OFFERED TO PATIENTS IN THE COMMUNITY, AND WORK TOGETHER WITH THE HOSPITAL SERVICES OF ADS IN AN EFFORT TO COORDINATE HOSPITAL AND CLINICAL CARE TO PROVIDE CONVENIENT, COST-EFFECTIVE CARE TO MEMBERS OF THE COMMUNITY. THE RURAL OXFORD CLINIC IS IN A HEALTH SHORTAGE AREA TO BETTER MEET THE RESIDENTS OF THIS COMMUNITY CLOSER TO THEIR HOMES.THE CLINICS SERVICE A LARGE PORTION OF ELDERLY, DISABLED, AND LOW-INCOME PATIENTS WHO ARE COVERED UNDER THE MEDICARE AND WISCONSIN MEDICAL ASSISTANCE PROGRAMS. THE CLINICS ARE OFTEN REIMBURSED FROM THESE PROGRAMS AT RATES WELL BELOW THE COST OF CARING FOR THESE PATIENTS, HOWEVER, IT IS ADS'S MISSION IN THE COMMUNITY TO PROVIDE CARE TO THESE PATIENTS.PATIENTS OF THE ADS CLINICS ARE ALSO ELIGIBLE FOR THE ORGANIZATION'S CHARITY AND COMMUNITY CARE PROGRAMS WHICH PROVIDE FREE OR REDUCED CARE TO INDIVIDUALS AND FAMILIES BASED ON INCOME AND ASSET GUIDELINES. THE FIGURES PRESENTED IN STATEMENT 4A OF THE HOSPITAL PROGRAM SERVICE ACCOMPLISHMENTS INCLUDE CHARITY CARE AMOUNTS PROVIDED TO CLINIC PATIENTS AS WELL. ADDITIONAL INFORMATION ON THE CHARITY CARE POLICIES CAN ALSO BE FOUND IN SCHEDULE H (HOSPITALS) OF THE FORM 990. 4686231 0 7529497 ADS OWNS AND OPERATES AN 83-BED EXTENDED CARE FACILITY AND 40-BED ASSISTED LIVING FACILITY. THE EXTENDED CARE FACILITY OFFERS SKILLED AND INTERMEDIATE CARE NURSING FOR RESIDENTS WHO REQUIRE SHORT-TERM REHABILITATION PROGRAMS OR LONG-TERM CARE. THE FACILITY ALSO OFFERS MEDICATION MANAGEMENT, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, IV THERAPY, AND NUTRITION SERVICES, AS WELL AS ACCESS TO OTHER HEALTHCARE AND HOSPITAL SERVICES OFFERED BY ADS'S HOSPITAL PROGRAMS. IN 2021, 20,627 RESIDENT DAYS OF CARE AND 10,893 ASSISTED LIVING DAYS WERE PROVIDED BY THE EXTENDED CARE FACILITY. A MAJORITY OF THE RESIDENTS RECEIVE CARE UNDER THE WISCONSIN MEDICAL ASSISTANCE OR FAMILY CARE PROGRAMS. ADS RECOGNIZES THAT THE COST OF CARING FOR THESE INDIVIDUALS OFTEN EXTENDS BEYOND THE AMOUNT THAT IS PAID TO THE FACILITY BY THE MEDICAL ASSISTANCE PROGRAM. RESIDENTS OF THE EXTENDED CARE FACILITY AT ADS WHO HAVE EXHAUSTED ALL OTHER PROGRAMS SUCH AS MEDICAL ASSISTANCE OR THE WISCONSIN FAMILY CARE PROGRAM ARE ALSO ABLE TO APPLY FOR DISCOUNTED OR FREE CARE FOR HOSPITAL OR CLINICAL SERVICES UNDER THE ORGANIZATION'S CHARITY AND COMMUNITY CARE PROGRAMS AS DESCRIBED EARLIER NOTING THE HOSPITAL AND CLINIC PROGRAM SERVICE ACCOMPLISHMENTS. SINCE MOST EXTENDED CARE CHARGES ARE COVERED UNDER WISCONSIN MEDICAL ASSISTANCE PROGRAMS WHEN INCOME LEVELS ARE BELOW ESTABLISHED GOVERNMENT STANDARDS, THESE PROGRAMS ARE MOST OFTEN UTILIZED AS A SOURCE OF PAYMENTS FOR MANY RESIDENTS. IF THESE MEDICAL ASSISTANCE PROGRAMS ARE NOT AVAILABLE DUE TO A UNIQUE CIRCUMSTANCE, THE RESIDENT'S STAY MAY BE EVALUATED FOR CHARITY OR COMMUNITY CARE ON A CASE BY CASE BASIS BY ADMINISTRATION OF THE ORGANIZATION. 57639299 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 90 0 1054 1 0 0 0 0 0 0 0 0 0 0 0 0 X 13 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X SIDNEY C SCZYGELSKI 7158472250 2200 WESTWOOD DRIVE WAUSAU WI 54401 JOSHUA POGORELEC PHYSICIAN 40.00 X 713862 0 54686 JOHN HEISLER BOARD MEMBER/CHIEF HR OFFICER 1.00 40.00 X X 0 571823 43247 JESSE TISCHER BOARD MEMBER/SVP & PRESIDENT 1.00 40.00 X X 0 551417 54420 TRAVIS HAMELE CHAIRPERSON 3.00 X X 0 0 0 JUDY WARMUTH PHD VICE CHAIRPERSON 2.50 X X 0 0 0 LOUIS HEITKE DDS SECRETARY 2.50 X X 0 0 0 PETE WELSH TREASURER 2.50 X X 0 0 0 BOB CRAWFORD BOARD MEMBER 1.00 X 0 0 0 ROBIN KVALO BOARD MEMBER 1.00 X 0 0 0 KRISTEN SKOLARZ BOARD MEMBER 1.00 X 0 0 0 CHAD STEVENSON BOARD MEMBER 1.00 X 0 0 0 LYNN VOGT BOARD MEMBER 1.00 1.00 X 0 0 0 SUSAN KRECKMAN BOARD MEMBER/PHYSICIAN 40.00 X 365900 0 53443 MATTHEW HEYWOOD PRESIDENT & CEO ASPIRUS 1.00 50.00 X 0 1316596 71205 SIDNEY SCZYGELSKI SR. VP OF FINANCE/CFO 1.00 50.00 X 0 861658 62993 MICHAEL DECKER CEO 40.00 X 658019 0 102851 NANCY ROTH-MALLEK VP FINANCE 40.00 X 0 221008 45855 MARLIN NELSON VP FINANCE (THRU JULY) 40.00 X 353494 0 60934 RENEE SMITH EXECUTIVE DIRECTOR ANI 1.00 50.00 X 0 506661 49619 ERIC ANDERSON SVP- SERVICE LINE & PATIENT EXP. 1.00 50.00 X 0 475604 56304 JENNIFER REDMAN-SCHELL SVP & PRESIDENT- ASPIRUS CLINICS 1.00 50.00 X 0 481240 39357 TODD RICHARDSON SVP & CHIEF INFORMATION OFFICER 1.00 50.00 X 0 455671 52263 RUTH RISLEY-GRAY SVP & SYSTEM CHIEF NURSING OFFICER 1.00 50.00 X 0 419745 45966 MICHAEL MCGRAIL SVP & SYSTEM CHIEF MEDICAL OFFICER 1.00 50.00 X 0 426022 0 RICK NEVERS SVP- REGIONAL OPERATIONS SIO 1.00 50.00 X 0 371883 30050 MICHAEL WALTERS VP PHYSICIAN & CLINICAL SERVICES 40.00 X 502475 0 55063 DOUGLAS ARNOLD PHYSICIAN 40.00 X 724838 0 54619 BRAD ROGOWSKI PHYSICIAN 40.00 X 517406 0 51104 ANGELA MOREAU PHYSICIAN 40.00 X 463088 0 36803 BRENDA JENKIN PHYSICIAN 40.00 X 417652 0 17319 JAMES SELF ORTHOPEDIC SURGEON 40.00 X 396643 0 26676 CARI LOGEMANN SVP & GEN. COUNSEL (THRU JUNE) 1.00 50.00 X 0 437354 22668 5113377 7096682 1087445 71 1 1 0 JACKSON & COKER LOCUMTENENS 3000 OLD ALABAMA RD STE 119-608 ALPHARETTA GA 30022 JOB SEARCH/STAFF 124958 FRANK WALTER S4202 WHISPERING PINES DR BARABOO WI 53913 PHYSICIAN SERVICES 117513 ADP LLC PO BOX 842875 BOSTON MA 00284 PAYROLL SERVICES 104341 3 529175 3139 532314 PATIENT SERVICE REVENUE 621990 70824528 70824528 CLINIC REVENUE 623000 13861315 13861315 EXTENDED CARE FACILITY REVENUE 621110 7529497 7529497 1408734 1408734 93624074 1033732 1033732 43395 0 43395 43395 43395 37295218 33002833 78901 4292385 -78901 4213484 4213484 CAFETERIA REVENUE 722514 101164 101164 101164 99548163 93624074 0 5391775 661128 661128 44864342 36546142 8318200 1684226 1071404 612822 6049626 2309666 3739960 2944099 2314616 629483 291736 291736 18400 18400 400 400 1329 1329 6126368 4645626 1480742 160542 295 160247 390833 14746 376087 223134 55190 167944 1574965 2158 1572807 194417 145760 48657 711380 711380 5336027 262070 5073957 186666 56183 130483 MEDICAL SUPPLIES 11078507 7796044 3282463 CORPORATE ALLOCATIONS 7199393 854 7198539 BAD DEBT EXPENSE 5151683 449425 4702258 REPAIRS AND MAINTENANCE 2569703 1495718 1073985 2493592 181666 2311926 99912496 57639299 42273197 0 4720124 2645741 10003254 9225742 10544595 12178537 1850158 1727368 1896983 530955 140018584 68325254 68343634 71693330 43161984 43285229 3936185 5117304 144456917 146404206 8229795 9033497 435646 1240856 39728898 37324876 12491274 12705042 60885613 60304271 X 83537524 86067056 33780 32879 83571304 86099935 144456917 146404206 X -364333 -549662 3442626 X X 0 1 X 1 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 8076 8076 0 PART II-B, LINE 1: ADS PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY TO ACCESS EDUCATIONAL MATERIALS AND FOR STAFF TRAINING AND MATERIALS. THE WHA HAS NOTIFIED ADS THAT APPROXIMATELY $2,540 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. ADS IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, ADS PAYS MEMBERSHIP FEES TO THE RWHC. THE RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN FINDING GRANT FUNDING FOR NEW PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST AND EMERGENCY ROOM PATIENT CARE COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, THE RWHC ALSO DOES PROVIDE ANALYSIS ON CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON THE PART OF THE MEMBER ORGANIZATIONS. RWHC DETERMINED THAT APPROXIMATELY $2,217 OF THE FEES PAID BY DIVINE SAVIOR HEALTHCARE IN FISCAL YEAR 2021 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. ADS PAID AHA DUES OF $12,963 OF WHICH 25.6% IS FOR LOBBYING OR $3,319. 5041760 5041760 94930083 42846868 52083215 32192142 25478386 6713756 7854599 7854599 71693330 LONG TERM INSURANCE 1001601 MEDICARE ACCELERATED PAYMENTS 7771862 RELATED PARTY PAYABLES 1976 ESTIMATED THIRD-PARTY PAYOR SETTLEMENTS 1480000 DEFERRED COMPENSATION 905604 LONG TERM FICA 1543999 12705042 1 1 X 1 X 1 X 1 1 1 0 1 1 423630 64708 358922 0.00380 12232129 6915689 5316440 0.05610 12655759 6980397 5675362 0.05990 260 260 0.00000 51808 51808 0.00050 52068 52068 0.00050 12707827 6980397 5727430 0.06040 2105124 0 11633618 17323926 -5690308 X 1 1 1 1 DIVINE SAVIOR HEALTHCARE INC 2817 NEW PINERY ROAD PORTAGE WI 53901 WWW.ASPIRUS.ORG 80 X X X DIVINE SAVIOR HEALTHCARE INC 1 0 0 1 X X X X X X X X X 18 1 0 0 1 X SEE PART V, SECTION C, LINE 7D X 1 18 1 SEE PART V, SECTION C, LINE 7D 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X 1 X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X WWW.ASPIRUS.ORG/FINANCIAL-ASSISTANCE X X X X X X 1 X 0 X X X X X 1 X 0 0 DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 5: AS PART OF THE CHNA PROCESS, ADS'S BOARD OF DIRECTORS APPOINTED A TASK FORCE CONSISTING OF REPRESENTATIVES FROM ADS'S BOARD OF DIRECTORS, EMPLOYEES AND MANAGEMENT OF ADS, AND COMMUNITY MEMBERS AND LEADERS IN ORDER TO HAVE A WIDE PERSPECTIVE OF NEEDS AND INFORMATION BEING REPRESENTED IN THE COMMUNITY TO ACHIEVE BENEFICIAL RESULTS FOR THE CHNA FOR THE HOSPITAL IN PLANNING FOR THE FUTURE. QUANTITATIVE DATA INCLUDING STATISTICS AND DEMOGRAPHIC INFORMATION WERE OBTAINED FROM COUNTY HEALTH STUDIES OF COMMUNITY HEALTH NEEDS BY THE TWO COUNTIES IN ADS'S PRIMARY SERVICE AREA (COLUMBIA AND MARQUETTE COUNTIES) AS WELL AS PATIENT STATISTICS AND TRENDS FROM ADS'S OWN INTERNAL RECORDS. OTHER PUBLISHED SOURCES OF INFORMATION WERE ALSO REFERENCED FOR STATISTICAL AND INFORMATIONAL PURPOSES WHEN NEEDED THROUGHOUT THE PROCESS.INTERVIEWS WERE CONDUCTED WITH COMMUNITY MEMBERS AND INDIVIDUALS WHO WERE REGARDED AS HAVING EXPERTISE IN PUBLIC HEALTH, INDIVIDUALS EMPLOYED WITH GOVERNMENT AGENCIES WITH COMMUNITY HEALTH NEEDS INFORMATION, INDIVIDUALS REPRESENTING COMMUNITY EMPLOYERS, AND INDIVIDUALS WHO WOULD BE ABLE TO ACCESS HEALTH NEEDS INFORMATION FROM A WIDE DEMOGRAPHIC MAKE-UP OF THE POPULATION. DURING INTERVIEWS, PARTICIPANTS FROM THE COMMUNITY WERE ASKED FOR THEIR INPUT REGARDING BOTH HEALTH NEEDS AND POSSIBLE SOLUTIONS TO IDENTIFIED NEEDS. THIS INFORMATION WAS GATHERED, ALONG WITH THE QUANTITATIVE INFORMATION NOTED ABOVE, AND WAS SUMMARIZED FOR THE BOARD OF DIRECTORS OF THE ORGANIZATION TO REVIEW AND SUMMARIZE IN TERMS OF A PRIORITY SETTING EXERCISE. FROM THIS EXERCISE, KEY OR PRIORITY NEEDS WERE IDENTIFIED TO BE ADDRESSED AS A RESULT OF THE INFORMATION GATHERED ON HEALTH NEEDS IN THE COMMUNITY AND PRIMARY SERVICE AREA OF ADS. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 7D: PART V, SECTION B, LINES 7A & 10A:WWW.ASPIRUS.ORG/COMMUNITY-RESOURCES DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 11: TOP IDENTIFIED HEALTH NEEDS BEING ADDRESSED:1. ACCESSIBILITY TO HEALTHCARE SERVICES 2. MANAGEMENT OF OBESITY AND OTHER CHRONIC CONDITIONS THESE STEPS HAVE BEEN TAKEN TO ADDRESSES ACCESS TO CARE:- CONTINUED TO PRIORITIZE ACCESS AND RECRUITMENT AS A KEY INITIATIVE AND HAVE SUCCESSFULLY RECRUITED IN THE AREAS OF OB/GYN, CARDIOLOGY, ORTHOPEDICS, PAIN MANAGEMENT AND ENDOCRINOLOGY- PEDIATRICS AND ORTHOPEDICS HAVE EXPANDED THEIR REACH TO SEE PATIENTS AT THE OXFORD CLINIC- TELEHEALTH VISITS & VIRTUAL CARE WERE OFFERED AS AN OPTION - PROVIDED ATHLETIC TRAINERS TO AREA SCHOOLS- PROVIDED TRAVEL VOUCHERS- UTILIZED INTERPRETER/TRANSLATION SERVICES- UTILIZED SPANISH SPEAKING PEDIATRICIAN TO IMPROVE COMMUNICATION WITH SPANISH SPEAKING PATIENTS - OFFERED WALK-IN ORTHOPEDIC VISITS- UTILIZED THE RESPIRATORY CARE CLINIC FOR COVID-19 RELATED NEEDS - STAFF CONDUCTED EDUCATIONAL PRESENTATIONS AT ORGANIZATIONS THROUGHOUT THE SERVICE AREA FOR FREE- PARTICIPATED IN HEALTH LITERACY INITIATIVES- UTILIZED THE ED2RECOVERY PROGRAM TO PROVIDE SUPPORT FOR DRUG AND ALCOHOL ADDICTION TO ADDRESS THE MANAGEMENT OF OBESITY AND CHRONIC CONDITIONS, THE FOLLOWING STEPS HAVE BEEN TAKEN:-INCREASED ACCESSIBILITY TO PERSONAL WELLNESS SERVICES THROUGH LA VITA, THE MEDICALLY INTEGRATED FITNESS FACILITY. OFFERED PAVE THE WEIGH AND OTHER TRANSITION PROGRAMS AT LA VITA, WITH REDUCED OR FREE MEMBERSHIP FEES. INCREASED HOURS AVAILABLE TO ACCESS THE FACILITY. - EXPANDED THE REACH OF THE MENTAL HEALTH NURSE PRACTITIONER BY OFFERING TELEHEALTH VISITS - OFFERED A FREE PROGRAM ON DIABETES PREVENTION & MANAGEMENT- FREE PRESENTATIONS OFFERED ON A VARIETY OF TOPICS RELATED TO OBESITY & CHRONIC CONDITIONS- OFFERED A FREE BREAST CANCER SUPPORT GROUP- STARTED A VERTICAL GARDEN AT THE ASSISTED LIVING FACILITY - SUPPORTED THE BOYS & GIRLS CLUB BY JOINING THE PLANNING COMMITTEE TO BRING A LOCAL CHAPTER TO THE AREA, AND OFFERING FINANCIAL SUPPORT- PROVIDED SUPPORT FOR THE DRUG AND ALCOHOL ABUSE PREVENTION COALITIONS AND RECOVERY CENTERS DUE TO COVID-19 RELATED ISSUES, SOME OF THE HOSPITAL'S OUTREACH ACTIVITIES AND SUPPORT GROUPS FOR CHRONIC CONDITIONS DID NOT OCCUR THIS YEAR. SEVERAL OF THE NEEDS IDENTIFIED WERE NOT ADDRESSED DUE TO THE FINANCIAL CONSTRAINT OF PROVIDING A NEW SERVICE FOR A LIMITED POPULATION OF PEOPLE WITHIN THE PRIMARY SERVICE AREA, OR AT THE PRESENT TIME IT WAS DETERMINED THAT A PARTNER ORGANIZATION MAY BE NEEDED TO MAKE A NEW HEALTH SERVICE A FINANCIALLY VIABLE OPTION IN THE LOCAL COMMUNITY. TWO EXAMPLES OF THESE ITEMS WHICH WERE NOTED IN THE CHNA PROCESS WERE ACCESS TO CANCER CARE AND MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES. IT WAS DETERMINED THAT ASPIRUS DIVINE SAVIOR DOES NOT HAVE THE POPULATION BASE TO PROVIDE RADIATION ONCOLOGY SERVICES AS THIS WAS MOST EFFECTIVELY AND EFFICIENTLY PROVIDED IN THE MADISON, WISCONSIN AREA WHICH IS WITHIN 30 MINUTES OF THE HOSPITAL. SOME ONCOLOGY SERVICES, INCLUDING CHEMOTHERAPY AND FOLLOW-UP VISITS, ARE PROVIDED BY ASPIRUS DIVINE SAVIOR'S PRIMARY CARE PROVIDERS AS WELL AS VISITING SPECIALISTS, SO IT WAS DETERMINED THAT THE CANCER CARE IN THIS AREA WAS ADEQUATE AT THE CURRENT TIME FOR THE POPULATION. MENTAL HEALTH SERVICES AND ACCESSIBILITY OF ALCOHOL AND SUBSTANCE USE SERVICES WERE IDENTIFIED AS IMPORTANT ISSUES IN THE COMMUNITY. GIVEN ASPIRUS DIVINE SAVIOR'S RESOURCE CONSTRAINTS, AND THE EXISTENCE OF OTHER ORGANIZATIONS FOCUSED ON RESPONDING TO THOSE NEEDS, ASPIRUS DIVINE SAVIOR WILL SUPPORT THEIR EFFORTS THROUGH CONTINUED COLLABORATION WITH OTHER ORGANIZATIONS IN THE COMMUNITY WHO ARE CURRENTLY WORKING TO ADDRESS MENTAL HEALTH AND SUBSTANCE ABUSE ISSUES. IT WAS IDENTIFIED THAT THERE IS A SIGNIFICANT GAP IN FUNDING AVAILABLE FOR MANY PATIENTS IN NEED OF THESE SERVICES; HOWEVER, THERE IS A PRIMARY CARE MENTAL HEALTH CLINIC IN THE COMMUNITY WHICH PROVIDES A SIGNIFICANT AMOUNT OF MENTAL HEALTH SERVICES TO AREA RESIDENTS. ASPIRUS DIVINE SAVIOR DETERMINED THAT DUE TO THE VAST FINANCIAL AND SOCIAL NEEDS OF MANY OF THE PATIENTS IN NEED OF THE MENTAL HEALTH AND SUBSTANCE ABUSE PROGRAMS, THAT MANY GROUPS MAY NEED TO PARTNER TOGETHER IN THE FUTURE TO WORK ON PLANNING EFFORTS FOR THESE SERVICES IN THE FUTURE AS THIS IS A VERY COMPLEX ISSUE.SEVERAL OTHER NEEDS WERE NOT ADDRESSED AS ANOTHER ORGANIZATION WITHIN THE COMMUNITY ALREADY PROVIDES THESE SERVICES WHICH ARE NOT IN ASPIRUS DIVINE SAVIOR'S PRIMARY AREA OF HEALTHCARE EXPERTISE. ONE EXAMPLE OF THESE TYPES OF SERVICES IS A FREE DENTAL CLINIC TO PROVIDE ACCESS TO PATIENTS WHO ARE OTHERWISE UNABLE TO AFFORD PROPER DENTAL CARE. IN RECENT YEARS, A COMMUNITY GROUP HAS ORGANIZED A FREE DENTAL CLINIC TO PROCESS ACCESS TO DENTAL CARE FOR INDIVIDUALS WITH FINANCIAL NEEDS THAT LIMIT THEIR ACCESS TO DENTAL SERVICES. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 13H: THE CHARITABLE CARE POLICY OF ADS ALSO ALLOWS FOR AN ADMINISTRATIVE DETERMINATION FOR A PATIENT THAT MAY UNDERGO A CATASTROPHIC EVENT OR UNIQUE CIRCUMSTANCE. THIS ADDITIONAL PROVISION ALLOWS FOR ADMINISTRATION TO MAKE A DETERMINATION THAT MAY ASSIST A PATIENT IN A UNIQUE TIME OF FINANCIAL NEED. DIVINE SAVIOR HEALTHCARE, INC. PART V, SECTION B, LINE 20E: THE FINANCIAL ASSISTANCE POLICY IS POSTED IN EACH OF THE HOSPITAL'S PHYSICIAN CLINICS. FINANCIAL ASSISTANCE INFORMATIONAL CARDS ARE ALSO GIVEN TO ANYONE INDICATING FINANCIAL HARDSHIP, AND THEY ARE ENCOURAGED TO CONTACT A FINANCIAL COUNSELOR FOR FURTHER INFORMATION ON THE FINANCIAL ASSISTANCE POLICY. 5 1 - ASPIRUS PORTAGE CLINIC 2817 NEW PINERY ROAD PORTAGE WI 53901 PHYSICIAN CLINIC 2 - ASPIRUS TIVOLI COMMUNITY 2805 HUNTERS TRAIL PORTAGE WI 53901 SKILLED NURSING FACILITY, ASSISTED LIVING FACILITY, AND HOME HEALTH PROGRAM 3 - ASPIRUS OXFORD CLINIC N4390 CROSSROADS CLINIC ROAD OXFORD WI 53952 PHYSICIAN CLINIC 4 - ASPIRUS DIVINE SAVIOR WELLNESS CENTER 2815 NEW PINERY ROAD PORTAGE WI 53901 WELLNESS CENTER 5 - ASPIRUS PARDEEVILLE CLINIC 102 GILLETTE STREET PARDEEVILLE WI 53954 PHYSICIAN CLINIC PART I, LINE 6A: DIVINE SAVIOR HEALTHCARE, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON WHA'S WEBSITE. PART I, LINE 7: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 5,151,682. PART II, COMMUNITY BUILDING ACTIVITIES: ADS PROVIDES SERVICES AND EDUCATIONAL OPPORTUNITIES EITHER FREE OF CHARGE OR AT A NOMINAL FEE IN AN ATTEMPT TO PROVIDE THESE OPPORTUNITIES TO THOSE MEMBERS OF THE COMMUNITIES WHO OTHERWISE MAY NOT BE ABLE TO AFFORD OR HAVE ACCESS TO THESE PROGRAMS. THESE EFFORTS ARE PROVIDED THROUGH A VARIETY OF EDUCATIONAL SPEAKER FORUMS, SUPPORT GROUPS, HEALTH SCREENINGS, HEALTH EDUCATION FORUMS, AND OTHER EDUCATIONAL OPPORTUNITIES FOR STUDENTS. PART III, LINE 2: THE COSTING METHODOLOGY USED ON FORM 990 IS BASED ON A COST TO CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES, EXCLUDING THE PROVISION FOR BAD DEBTS, DIVIDED BY GROSS PATIENT SERVICE REVENUE. THIS COST TO CHARGE RATIO IS APPLIED AGAINST THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. THE HOSPITAL ALSO PROVIDES DISCOUNTS TO ELIGIBLE UNINSURED OR UNDERINSURED PATIENTS UNDER ITS CHARITABLE CARE POLICY. THESE AMOUNTS ARE INCLUDED IN THE CONTRACTUAL ADJUSTMENTS ON THE FINANCIAL STATEMENTS AND ARE NOT INCLUDED IN THE RATIO AS DESCRIBED ABOVE AND APPROVED BY THE IRS FOR USE ON FORM 990. IF CONSIDERED, THESE ADDITIONAL WRITE-OFF AMOUNTS TO UNINSURED OR UNDERINSURED ACCOUNTS WOULD ALSO INCREASE THE ESTIMATED BAD DEBT EXPENSE AMOUNT ASSOCIATED WITH THESE UNCOLLECTIBLE ACCOUNTS TO THE HOSPITAL. PART III, LINE 3: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO AN ALLOWANCE FOR DOUBTFUL ACCOUNTS BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL PATIENT ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. MANY TIMES, PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE ORGANIZATION PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY: IN EVALUATING THE COLLECTIBILITY OF PATIENT ACCOUNTS RECEIVABLE, THE ORGANIZATION ANALYZES PAST RESULTS AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. SPECIFICALLY, FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE ORGANIZATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS AND PATIENTS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE ORGANIZATION RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE FOR. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE. PART III, LINE 8: THE TOTAL MEDICARE REVENUE SHOWN IN SCHEDULE H TO THE FORM 990 IS BASED ON THE IRS 990 INSTRUCTIONS AND INCLUDES ONLY A PORTION OF THE GROSS MEDICARE REVENUE OF THE HOSPITAL AND ALSO DOES NOT CONSIDER CONTRACTUAL ADJUSTMENTS FOR THE REIMBURSEMENT THAT IS ACTUALLY RECEIVED FROM THE MEDICARE PROGRAM. AMOUNTS LISTED FOR MEDICARE REVENUES DO NOT INCLUDE SIGNIFICANT PORTIONS OF LABORATORY, RADIOLOGY, AMBULANCE, AND REHABILITATION SERVICES PROVIDED TO MEDICARE BENEFICIARIES AS WELL AS PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT, ANESTHESIA PROFESSIONAL SERVICES, CLINICAL PHYSICIAN PROFESSIONAL SERVICES, SURGICAL PHYSICIAN PROFESSIONAL SERVICES, HOSPITALIST PHYSICIAN PROFESSIONAL SERVICES, AND REVENUES FOR ANY PATIENTS COVERED UNDER MEDICARE ADVANTAGE PLAN PROGRAMS. PHYSICIAN SERVICES ARE REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY, SURGICAL, AND CLINICAL SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT DIVINE SAVIOR HEALTHCARE, INC. PROVIDES TO THE COMMUNITY AND SURROUNDING AREAS. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON THE FILED MEDICARE COST REPORT FOR THE YEAR ENDED JUNE 30, 2021 AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE).WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHICH ARE TYPICALLY ELDERLY OR DISABLED MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. PART III, LINE 9B: UPON A PATIENT'S APPROVAL FOR FINANCIAL ASSISTANCE, THIS IS LOADED AS AN INSURANCE COVERAGE TO THE PATIENT'S ACCOUNT WITH AN EFFECTIVE AND TERMINATION DATE TO ASSURE CAPTURING ALL CHARGES FOR THE PATIENT FOR ADJUSTMENT IN A WORK QUEUE PRIOR TO ANY REMAINING BALANCE BEING MOVED TO PATIENT LIABILITY AND THEREFORE PREVENTING UNDISCOUNTED SERVICES FROM BEING BILLED TO A PATIENT. PART VI, LINE 2: ADS PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS AND IN ADDITION, THE ORGANIZATION BELIEVES THAT IT PROVIDES A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. ADS, LIKE MOST COMMUNITY HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY WHICH WITHOUT THE HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. BEYOND INPATIENT HOSPITALIZATIONS, THE HOSPITAL PROVIDES LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES, URGENT CARE, HOME CARE, RENAL DIALYSIS, INFUSION SERVICES, SWING BED SERVICES, NURSING HOME SERVICES, ASSISTED LIVING SERVICES, CLINICAL SERVICES, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH PATHOLOGY, SURGICAL SERVICES, WOMEN'S SERVICES, AND AMBULANCE SERVICES, TO NAME SOME OF THE MAJOR SERVICES PROVIDED. PART VI, LINE 3: UNINSURED AND UNDER INSURED PATIENTS ARE ASKED TO MEET WITH ONE OF THE ORGANIZATION'S FINANCIAL COUNSELORS EITHER AT THE TIME SERVICE IS PROVIDED OR WHEN THE PATIENT'S BILL IS GENERATED. THE FINANCIAL COUNSELOR EXPLAINS THE VARIOUS PAYMENT OPTIONS AVAILABLE TO THE PATIENT AS WELL AS THE HOSPITAL'S CHARITY AND COMMUNITY CARE PROGRAM AND OFFERS THE CHARITY CARE APPLICATION WHEN APPROPRIATE. IF OTHER PROGRAMS ARE AVAILABLE TO THE PATIENT, SUCH AS THE WISCONSIN MEDICAL ASSISTANCE OR BADGERCARE PROGRAMS, THESE PATIENTS ARE REFERRED TO THE APPROPRIATE GOVERNMENT AGENCY FOR FURTHER ASSISTANCE. PART VI, LINE 4: THE PRIMARY SERVICE AREA FOR ADS ENCOMPASSES ALL PERSONS LIVING WITHIN A 20 TO 30-MILE RADIUS OF THE HOSPITAL. SOME OF THE COMMUNITIES INCLUDED IN THIS AREA ARE PORTAGE, PARDEEVILLE, WISCONSIN DELLS, LAKE DELTON, BRIGGSVILLE, WYOCENA, POYNETTE, AND ARLINGTON, WISCONSIN, AMONG MANY OTHERS. THE HOSPITAL PROVIDES A SIGNIFICANT PORTION OF ITS PATIENT CARE SERVICES TO BENEFICIARIES OF THE MEDICARE AND MEDICAID PROGRAMS ESPECIALLY THOSE BENEFICIARIES WHO RESIDE IN THE ORGANIZATION'S EXTENDED AND LONG-TERM CARE FACILITIES OR PATIENTS WHO RECEIVE HOME HEALTH SERVICES FROM THE ORGANIZATION. PART VI, LINE 6: ADS IS AN AFFILIATE OF ASPIRUS, INC. ASPIRUS IS AN INTEGRATED, COMMUNITY-GOVERNED HEALTH CARE SYSTEM, WHICH LEADS BY ADVANCING INITIATIVES DEDICATED TO IMPROVING THE HEALTH OF ALL WE SERVE. WE WORK COLLABORATIVELY WITH OTHERS WHO SHARE OUR PASSION FOR EXCELLENCE AND COMPASSION FOR PEOPLE. PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 X X X X 0 1 0 0 0 0 0 0 0 MATTHEW HEYWOOD PRESIDENT & CEO ASPIRUS 0 992466 0 321290 0 2840 0 17196 0 54009 0 1387801 0 0 SIDNEY SCZYGELSKI SR. VP OF FINANCE/CFO 0 571336 0 102719 0 187603 0 20046 0 42947 0 924651 0 174000 DOUGLAS ARNOLD PHYSICIAN 642364 0 54270 0 28204 0 14000 0 40619 0 779457 0 0 0 JOSHUA POGORELEC PHYSICIAN 557554 0 108867 0 47441 0 14000 0 40686 0 768548 0 0 0 MICHAEL DECKER CEO 644962 0 0 0 13057 0 72707 0 30144 0 760870 0 64118 0 JOHN HEISLER BOARD MEMBER/CHIEF HR OFFICER 0 339009 0 66240 0 166574 0 17196 0 26051 0 615070 0 152214 JESSE TISCHER BOARD MEMBER/SVP & PRESIDENT 0 458373 0 92613 0 431 0 11473 0 42947 0 605837 0 0 BRAD ROGOWSKI PHYSICIAN 427753 0 18750 0 70903 0 9760 0 41344 0 568510 0 0 0 MICHAEL WALTERS VP PHYSICIAN & CLINICAL SERVICES 435611 0 44202 0 22662 0 12002 0 43061 0 557538 0 0 0 RENEE SMITH EXECUTIVE DIRECTOR ANI 0 381673 0 68268 0 56720 0 17196 0 32423 0 556280 0 55911 ERIC ANDERSON SVP- SERVICE LINE & PATIENT EXP. 0 399509 0 67809 0 8286 0 17196 0 39108 0 531908 0 0 JENNIFER REDMAN-SCHELL SVP & PRESIDENT- ASPIRUS CLINICS 0 411201 0 69616 0 423 0 17196 0 22161 0 520597 0 0 TODD RICHARDSON SVP & CHIEF INFORMATION OFFICER 0 341475 0 67414 0 46782 0 17196 0 35067 0 507934 0 43823 ANGELA MOREAU PHYSICIAN 391628 0 17188 0 54272 0 14000 0 22803 0 499891 0 0 0 RUTH RISLEY-GRAY SVP & SYSTEM CHIEF NURSING OFFICER 0 309508 0 60518 0 49719 0 20046 0 25920 0 465711 0 41695 CARI LOGEMANN SVP & GEN. COUNSEL (THRU JUNE) 0 228246 0 78456 0 130652 0 15527 0 7141 0 460022 0 129488 BRENDA JENKIN PHYSICIAN 332619 0 65336 0 19697 0 6206 0 11113 0 434971 0 0 0 MICHAEL MCGRAIL SVP & SYSTEM CHIEF MEDICAL OFFICER 0 0 0 0 0 426022 0 0 0 0 0 426022 0 425671 JAMES SELF ORTHOPEDIC SURGEON 384173 0 0 0 12470 0 0 0 26676 0 423319 0 0 0 SUSAN KRECKMAN BOARD MEMBER/PHYSICIAN 263606 0 84974 0 17320 0 14000 0 39443 0 419343 0 0 0 MARLIN NELSON VP FINANCE (THRU JULY) 318821 0 0 0 34673 0 46146 0 14788 0 414428 0 32594 0 RICK NEVERS SVP- REGIONAL OPERATIONS SIO 0 263896 0 64103 0 43884 0 17172 0 12878 0 401933 0 39905 NANCY ROTH-MALLEK VP FINANCE 0 190697 0 29403 0 908 0 12895 0 32960 0 266863 0 0 PART I, LINE 4B SCHEDULE J, PART I, LINE 4A - SEVERANCE PAY MICHAEL MCGRAIL RECEIVED SEVERANCE PAY TOTALING $426,022 FOR CALENDAR YEAR 2020. THE FOLLOWING OFFICERS AND HIGHEST COMPENSATED EMPLOYEES PARTICIPATED IN A NON-QUALIFIED 457(F) RETIREMENT PLAN AND REPORTED THE FOLLOWING INCREASE IN THEIR RESPECTIVE PLANS: MIKE DECKER: $64,118 MARLIN NELSON: $32,146 SCHEDULE J, PART I, LINE 4B RELATED PARTY INFORMATION - SUPPLEMENTAL NONQUALIFIED RETIREMENT 457(F) DISTRIBUTION: S. SCZYGELSKI $174,000 J. HEISLER $152,214 C. LOGEMANN $129,488 M. MCGRAIL $425,671 R. NEVERS $39,905 T. RICHARDSON $43,823 R. RISLEY-GRAY $41,695 R. SMITH $55,911 M. NELSON $32,594 M. DECKER $64,118 KEY EMPLOYEES OF THE RELATED ORGANIZATION OR A PARTICIPATING AFFILIATE ARE ELIGIBLE TO PARTICIPATE IN THE PLAN. THE PLAN YEAR IS JANUARY 1 TO DECEMBER 31ST. EMPLOYER CONTRIBUTIONS: THE CONTRIBUTION MADE BY THE EMPLOYER IS A THREE-TIERED STRUCTURE DEPENDING UPON THE EXECUTIVE'S POSITION, WHICH ARE AS FOLLOWS: 9% FOR VICE PRESIDENT, 13% FOR SENIOR LEADERSHIP COUNCIL, AND 15% FOR THE CEO. IF A PARTICIPANT TERMINATES DURING THE YEAR, THE PARTICIPANT'S EXECUTIVE ALLOWANCE IS PRORATED BASED ON THE NUMBER OF FULL CALENDAR MONTHS FROM THE BEGINNING OF THE PLAN YEAR TO THE BEGINNING OF THE CALENDAR YEAR MONTH CLOSEST TO THE CHANGE OR TERMINATION OF EMPLOYMENT. DISTRIBUTIONS: CONTINUATION OF EMPLOYMENT THROUGH THE DEFERRED VESTING DATE; THE DATE ON WHICH THE PARTICIPANT'S EMPLOYMENT IS TERMINATED AS A RESULT OF DEATH OR DISABILITY; THE DATE ON WHICH THE PARTICIPANT INCURS AN INVOLUNTARY SEPARATION FROM SERVICE WITHOUT REASONABLE CAUSE; OR THE DATE THAT IS 24 MONTHS FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE, BUT ONLY IF THE PARTICIPANT'S INTEREST HAS NOT BEEN FORFEITED FOR COMPETITION DURING SUCH 24 MONTH PERIOD AND THE PARTICIPANT HAS NOT ENGAGED IN COMPETITION AFTER HIS OR HER SEPARATION FROM SERVICE AND PRIOR TO HIS OR HER DEATH, THE PARTICIPANT SHALL BE VESTED AT HIS OR HER DATE OF DEATH. A WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 2020-06-29 39808745 REFINANCE OF 2006, 2009, 2012, 2014, 2016, 2019 REVENUE BONDS 0 0 0 A 2354291 39808745 139675 39808745 2020 0 1 1 1 A 0 0 0 0 0 0 1 A 0 1 0 0 0 0 0 0 1 A 1 PART III, LINES 2, 3A, AND 3B: ASPIRUS, INC., THE PARENT ORGANIZATION OF DIVINE SAVIOR HEALTHCARE, INC., HAS POLICIES AND PROCEDURES IN PLACE TO REVIEW LEASE AGREEMENTS, MANAGEMENT, AND SERVICE CONTRACTS TO IDENTIFY AGREEMENTS THAT MAY RESULT IN PRIVATE BUSINESS USE OF BOND-FINANCED PROPERTY. ON A CONTRACT BY CONTRACT BASIS, ASPIRUS, INC. WILL SEEK HELP FROM BOND COUNSEL AS MANAGEMENT DEEMS NECESSARY. PART III, LINE 9: SUPPLEMENTAL INFORMATION ON TAX EXEMPT BONDS: POLICY STATES WE WILL SEEK BOND COUNSEL OPINION ON ALL REMEDIAL ACTIONS. PART VI: THE PROCEEDS OF THE WISCONSIN HEALTH AND EDUCATION FACILITIES AUTHORITY REVENUE BONDS, SERIES 2020 BONDS (ASPIRUS, INC. OBLIGATED GROUP) WERE BORROWED BY DIVINE SAVIOR HEALTHCARE, INC. (EIN 39-0806250). THE PROCEEDS OF THE SERIES 2020 BONDS WERE USED TO REFINANCE THE DIVINE SAVIOR HEALTHCARE, INC., SERIES 2016 BONDS (REFINANCING OF SERIES 2006 BONDS) AND SERIES 2019 BONDS (REFINANCING OF SERIES 2009, 2012, 2014 BONDS). INFORMATION REGARDING THE SERIES 2020 BONDS IS REPORTED IN SCHEDULE K FOR THAT ORGANIZATION. FOR THE ENTITY THAT BORROWED FUNDS, THE INFORMATION REPORTED IN PART I, PART II AND PART III OF SCHEDULE K RELATES ONLY TO THE PORTION OF THE SERIES 2020 BONDS LOANED TO THE ORGANIZATION. FOR THE ENTITY THAT BORROWED FUNDS, THE INFORMATION REPORTED IN PART IV OF SCHEDULE K RELATES TO THE ENTIRE ISSUE OF THE SERIES 2020 BONDS. FORM 990, PART VI, SECTION A, LINE 2 BOARD MEMBERS TRAVIS HAMELE AND CHAD STEVENSON HAVE A FAMILY RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 6 THE PARENT ORGANIZATION, ASPIRUS, INC., IS THE SOLE CORPORATE MEMBER OF THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A ASPIRUS, INC. HAS THE ABILITY TO ELECT AT LEAST 10 OF THE 11 BOARD MEMBERS AS DESCRIBED IN THE BYLAWS. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING ACTIONS MUST BE APPROVED BY THE SOLE MEMBER OF THE ORGANIZATION, ASPIRUS, INC.: 1) CHANGE OR AMEND THE ARTICLES OF INCORPORATION OR BYLAWS; 2) CHANGE THE MISSION, PURPOSE, OR SCOPE OF THE CORPORATION; 3) RATIFICATION OR REMOVAL OF DIRECTORS OR OFFICER; 4) CHANGE THE FORMULA OR METHODOLOGY FOR DETERMINING PHYSICIAN COMPENSATION; 5) APPROVAL OF ANNUAL OPERATING AND CAPITAL EXPENDITURE BUDGETS, STRATEGIC AND LONG-RANGE PLANS. FORM 990, PART VI, SECTION B, LINE 11B THE ACCOUNTING DEPARTMENT ACCUMULATES ALL 990 INFORMATION, INCLUDING THE UBI CALCULATIONS. THESE DOCUMENTS ARE REVIEWED BY THE CFO. THE 990 AND THE 990-T ARE REVIEWED BY OTHER SENIOR MANAGEMENT PRIOR TO SUBMISSION TO THE INTERNAL REVENUE SERVICE AND ARE MADE AVAILABLE TO THE BOARD OF DIRECTORS THROUGH DIRECTOR'S DESK OR OTHER MEANS OF ELECTRONIC RETRIEVAL. FORM 990, PART VI, SECTION B, LINE 12C BOARD MEMBERS AND KEY EMPLOYEES ARE REQUIRED TO SIGN ANNUAL CONFLICT OF INTEREST STATEMENTS AND ALL MANAGERS ARE REQUIRED TO SIGN BIANNUAL CONFLICT OF INTEREST STATEMENTS. THE ORGANIZATION'S CEO AND BOARD CHAIR REVIEW THE STATEMENTS AND HIGHLIGHT POTENTIAL CONFLICTS. THE BOARD DETERMINES ON A CASE BY CASE BASIS ANY ACTIONS REQUIRED. INDIVIDUALS ARE NOT PERMITTED TO VOTE ON ANY TRANSACTION WHERE A CONFLICT HAS BEEN DETERMINED TO EXIST. ALL CONFLICTS AND PROCEEDINGS ARE NOTED IN THE MEETING MINUTES. FORM 990, PART VI, SECTION B, LINE 15 FOR PURPOSES OF DETERMINING COMPENSATION, DIVINE SAVIOR HEALTHCARE, INC. RELIES ON RELATED ORGANIZATIONS TO ESTABLISH THE COMPENSATION OF THE CEO, OTHER OFFICERS, AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. FORM 990, PART VI, SECTION C, LINE 19 THE AUDITED FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE 9: UNRESTRICTED NET ASSET TRANSFERS - AWH 6,689,889. UNRESTRICTED NET ASSET TRANSFERS - AI -3,481,531. UNRESTRICTED NET ASSET TRANSFERS - ACI 211,929. UNRESTRICTED NET ASSET TRANSFERS - AOH 7. UNRESTRICTED NET ASSET TRANSFERS - VNA 928. UNRESTRICTED NET ASSET TRANSFERS - AIR -125. UNRESTRICTED NET ASSET TRANSFERS - ARH 21,809. UNRESTRICTED NET ASSET TRANSFERS - AKH -280. FORM 990, PART XII, LINE 3B THE ORGANIZATION IS REQUIRED TO BE INCLUDED IN A SINGLE AUDIT FOR THE YEAR ENDED 06/30/2021. THE DEADLINE FOR THIS FILING FALLS AFTER THE DEADLINE FOR THE 990 FOR THE SAME FISCAL YEAR END. THE SINGLE AUDIT WILL NOT BE FINALIZED AT THE TIME OF THIS SUBMISSION. ASPIRUS INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391328331 HEALTH CARE SYSTEM MANAGEMENT WI 501(C)(3) LINE 12B, II N/A 0 ASPIRUS WAUSAU HOSPITAL INC 333 PINE RIDGE BLVD WAUSAU WI 54401 391138241 HOSPITAL WI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS BUILDINGS INC 333 PINE RIDGE BLVD WAUSAU WI 54401 391406537 PROPERTY LEASING WI 501(C)(3) LINE 10 ASPIRUS INC 1 ASPIRUS EXTENDED SERVICES INC 425 PINE RIDGE BLVD WAUSAU WI 54401 390782130 NURSING HOME SERVICES WI 501(C)(3) LINE 10 ASPIRUS INC 0 ASPIRUS MEDICAL GROUP INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391670223 MEDICAL SERVICES WI 501(C)(3) LINE 10 ASPIRUS INC 1 ASPIRUS ONTONAGON HOSPITAL INC 601 SEVENTH STREET ONTONAGON MI 49953 260806477 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS VNA HOME HEALTH INC 520 N 32ND AVENUE WAUSAU WI 54401 390808511 HOME HEALTHCARE SERVICES WI 501(C)(3) LINE 10 ASPIRUS INC 1 ASPIRUS VNA EXTENDED CARE INC 520 N 32ND AVENUE WAUSAU WI 54401 391597350 PERSONAL CARE SERVICES WI 501(C)(3) LINE 10 ASPIRUS VNA HOME HEALTH INC 1 ASPIRUS IRON RIVER HOSPITAL & CLINICS INC 1400 W ICE LAKE RD IRON RIVER MI 49935 383236977 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS HEALTH FOUNDATION INC 425 PINE RIDGE BLVD WAUSAU WI 54401 391256656 CHARITABLE FOUNDATION WI 501(C)(3) LINE 7 ASPIRUS INC 1 ASPIRUS RIVERVIEW HOSPITAL & CLINICS INC 410 DEWEY STREET WISCONSIN RAPIDS WI 54494 390868982 HOSPITAL WI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS KEWEENAW HOSPITAL 205 OSCEOLA STREET LAURIUM MI 49913 381443361 HOSPITAL MI 501(C)(3) LINE 3 ASPIRUS INC 1 ASPIRUS IRONWOOD HOSPITAL & CLINICS INC N10561 GRAND VIEW LANE IRONWOOD MI 49938 382908586 HOSPITAL WI 501(C)(3) LINE 3 ASPIRUS INC 1 THE WESTWOOD CONFERENCE CENTER LLC 333 PINE RIDGE BLVD WAUSAU WI 54401 571184256 CONFERENCE CENTER WI N/A 0 0 WESTERN UPPER MICHIGAN EYE CARE LLC 131 W GENESEE STREET IRON RIVER MI 49935 272324957 EYE CARE SERVICES MI N/A 0 0 ASPIRUS NETWORK INC 3000 WESTHILL DRIVE 202 WAUSAU WI 54401 391931679 HEALTH CARE NETWORK WI N/A C 0 ASPIRUS KEWEENAW ENTERPRISES 205 OSCEOLA STREET LAURIUM MI 49913 383390273 PHARMACY MI N/A C 0 ASPIRUS HEALTH VENTURES 3000 WESTHILL DRIVE 303 WAUSAU WI 54401 474925640 HEALTH INSURANCE PLAN WI N/A C 0 ASPIRUS ARISE HEALTH PLAN OF WI INC 3000 WESTHILL DRIVE 303 WAUSAU WI 54401 364832569 HEALTH INSURANCE PLAN WI N/A C 0 ASPIRUS ARISE HEALTH PLAN OF MI INC 3000 WESTHILL DRIVE 303 WAUSAU WI 54401 475448266 HEALTH INSURANCE PLAN MI N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 ASPIRUS INC M 5486849 COST ASPIRUS INC O 24542351 COST ASPIRUS INC P 4264512 COST ASPIRUS INC Q 569677 COST ASPIRUS VNA O 93034 COST ASPIRUS WAUSAU HOSPITAL INC M 122288 COST ASPIRUS WAUSAU HOSPITAL INC O 289013 COST ASPIRUS WAUSAU HOSPITAL INC P 169124 COST ASPIRUS WAUSAU HOSPITAL INC Q 338996 COST SCHEDULE R, PART V, LINE 1D: ALL OUTSTANDING OBLIGATED GROUP DEBT IS GUARANTEED BY ALL MEMBERS OF THE OBLIGATED GROUP.