2022-11-14T13:34:48-06:00 2021-12-31 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2021-01-01 410837659 MINNESOTA VALLEY HEALTH CENTER INC MINN 5076653375 621 SOUTH 4TH STREET LE SUEUR MN 56058 AARON BLOOMQUIST CFO 5076653375 2022-11-11 1 AARON BLOOMQUIST XXX-XX-XXXX DARRYN MCGARVEY P00958683 6123764500 2022-11-11 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z RIDGEVIEW LE SUEUR MEDICAL CENTER MICHAEL PHELPS 621 SOUTH 4TH STREET LE SUEUR MN 56058 15775964 0 X WWW.RIDGEVIEWMEDICAL.ORG X 1959 MN PROVIDE COMMUNITY-BASED HEALTH CARE IN AN ENVIRONMENT THAT FOSTERS DIGNITY, RESPECT & EXCELLENCE. 9 8 165 7 0 0 1464228 2059652 12555037 13235751 14816 66552 474737 414009 14508818 15775964 0 0 0 0 6301032 6849731 0 0 0 6842663 6351498 13143695 13201229 1365123 2574735 20560454 20327367 12891415 10056374 7669039 10270993 OUR MISSION IS TO PROVIDE COMMUNITY-BASED HEALTHCARE IN AN ENVIRONMENT THAT FOSTERS DIGNITY, RESPECT, AND EXCELLENCE. 0 0 8487838 0 13235751 RIDGEVIEW LE SUEUR MEDICAL CENTER IS CREATED & ORGANIZED EXCLUSIVELY FOR CHARITABLE PURPOSES. RIDGEVIEW LE SUEUR MEDICAL CENTER IS CREATED AND ORGANIZED TO OWN, MAINTAIN, OPERATE AND CONDUCT, DIRECTLY OR INDIRECTLY, AND TO ASSIST AND COORDINATE ACTIVITIES OF FACILITIES FOR HEALTH CARE, EDUCATION, CARE FOR THE AGED AND SOCIAL SERVICES. RIDGEVIEW LE SUEUR MEDICAL CENTER INCLUDES A HOSPITAL, OUTPATIENT SPECIALTY CLINICS, COMPLETE LAB AND RADIOLOGY DEPARTMENTS, A COMPREHENSIVE PHYSICAL OCCUPATIONAL AND SPEECH THERAPY DEPARTMENT, EXTENDED CARE NURSING FACILITIES, AND INDEPENDENT LIVING SENIOR HOUSING. 8487838 1 1 0 1 0 0 0 0 1 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 13 0 165 1 0 0 0 0 0 0 0 0 0 0 0 0 X 9 8 0 0 0 0 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 MN X AARON BLOOMQUIST 9524422191 500 S MAPLE STREET WACONIA MN 55387 MICHAEL PHELPS CEO 0.50 49.50 X 0 1197762 68637 GORDON GABLENZ CIO 0.50 49.50 X 0 801951 87436 AARON BLOOMQUIST CFO 0.50 49.50 X 0 276340 59127 BENJAMIN NIELSEN COO & BOARD DIRECTOR 0.50 49.50 X X 0 298901 14170 PAMELA WILLIAMS VICE PRESIDENT (THROUGH JULY 2021) 0.50 49.50 X 0 262574 27326 WAYNE HUBIN BOARD DIRECTOR 2.00 2.40 X 0 7400 0 IRENE MANKE BOARD PRESIDENT 10.00 0.00 X X 0 0 0 STEVE SMITH BOARD VICE PRESIDENT 2.00 0.00 X X 0 0 0 ROBERT BROEDER BOARD SECRETARY/TREASURER 5.00 0.00 X X 0 0 0 MARK AMUNDSON BOARD DIRECTOR 2.00 0.00 X 0 0 0 DAVID BRAUN BOARD DIRECTOR 2.00 0.00 X 0 0 0 KAY KING BOARD DIRECTOR 2.00 0.00 X 0 0 0 SHAWN KIRBY BOARD DIRECTOR 3.00 0.00 X 0 0 0 0 2844928 256696 0 0 1 0 PREMIER STAFFING INC 243 WINKLER WAY COLOGNE MN 55322 ED PHYSICIAN SERVICES 665669 AEGIS THERAPIES INC PO BOX 8103 FORT SMITH AR 72902 THERAPY SERVICES 538689 EMPAC 500 S MAPLE STREET WACONIA MN 55387 ED PHYSICIAN SERVICES 515206 SCHWICKERTS TECTA AMERICA LLC 330 POPLAR STEET MANKATO MN 56001 CONSTRUCTION 228692 ESSENTIA HEALTH 632 EAST FIRST STREET DULUTH MN 55805 I.T. SUPPORT 198707 9 47789 2011863 2059652 PATIENT/RESIDENT REVEN 621110 12872207 12872207 APARTMENT PROJECT REVE 623000 318228 318228 PHARMACY 621110 45316 45316 13235751 14392 14392 305832 0 305832 305832 305832 52160 0 52160 52160 52160 MISCELLANEOUS INCOME 900099 108177 108177 108177 15775964 13235751 0 480561 X 5714008 4050872 1663136 162191 114983 47208 557740 395403 162337 415792 294770 121022 6370 6370 85806 85806 1841854 1001677 840177 21175 21175 22661 11132 11529 20272 8939 11333 530460 296541 233919 5492 3070 2422 9296 5197 4099 97723 97723 890248 342598 547650 44692 24984 19708 REPAIRS AND MAINTENANCE 1102884 616540 486344 SUPPLIES 1065617 1053568 12049 DUES AND SUBSCRIPTIONS 253966 141973 111993 TAXES AND LICENSES 147325 82358 64967 205657 43233 162424 13201229 8487838 4713391 0 266630 268511 9117994 7681376 3031354 3646404 147046 175317 63051 142783 19497064 12067080 6978606 7429984 955773 982992 20560454 20327367 2162946 829236 2958066 627920 20571 16381 6513010 5789589 1236822 2793248 12891415 10056374 X 6713266 9288001 955773 982992 7669039 10270993 20560454 20327367 X 2574735 27219 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 209 209 0 PART II-B, LINE 1: RIDGEVIEW LE SUEUR MEDICAL CENTER PAY DUES TO A CERTAIN ORGANIZATION RELATED TO THE INDUSTRY WHICH HAS LOBBYING EXPENSES. THE AMOUNT LISTED IS THE PERCENTAGE OF THE DUES PAID THAT WERE USED FOR LOBBYING. 0 1 X 955773 27219 982992 793116 162657 955773 722130 111628 30050 10592 793116 794693 -32850 29405 10308 722130 711289 5050 115650 27879 9417 794693 0.00000 1.00000 0.00000 1 0 46482 46482 6108189 4802729 1305460 253994 362248 -108254 12077247 6902103 5175144 1011152 1011152 7429984 DUE TO RIDGEVIEW 2793248 2793248 X 15688263 0 15688263 87701 87701 15775964 13175709 0 13175709 25520 25520 13201229 PART IV, LINE 2B: RIDGEVIEW LE SUEUR MEDICAL CENTER, INC ACTS AS A CUSTODIAN FOR THE FUNDS OF THE RESIDENTS. RESIDENT TRUST FUNDS TOTALED $4,705 AT DECEMBER 31, 2021. DURING THAT SAME TIME RIDGEVIEW LE SUEUR MEDICAL CENTER, INC HOLDS $4,705 IN A SEPARATE ACCOUNT FOR TENANT SECURITY DEPOSITS. THE ORGANIZATION HOLDS SECURITY DEPOSITS FOR TENANTS LEASING SPACE WITHIN OUR FACILITIES. EACH SECURITY DEPOSIT WILL BE REFUNDED, LESS ANY REPAIRS FOR DAMAGES, WHEN THE LEASE IS TERMINATED. PART V, LINE 4: RIDGEVIEW LE SUEUR MEDICAL CENTER'S INTENDED USE OF ITS ENDOWMENT FUNDS IS FOR CAPITAL AND OTHER IMPROVEMENTS THAT FURTHER RIDGEVIEW LE SUEUR MEDICAL CENTER'S MISSION. PART X, LINE 2: THE HEALTH CENTER IS OPERATED AS A TAX-EXEMPT CORPORATION UNDER SECTION 501(C)(3) OF THE IRC AND IS NOT SUBJECT TO FEDERAL OR STATE INCOME TAX RELATED TO BUSINESS INCOME. THE HEALTH CENTER FOLLOWS THE ACCOUNTING STANDARD FOR RECOGNITION AND MEASUREMENT OF UNCERTAIN TAX POSITIONS. THE HEALTH CENTER'S TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 14,392. FOUNDATION CONTRIBUTION 47,789. BAD DEBT EXPENSE 25,520. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 25,520. 1 1 X 1 X 1 X 1 1 0 1 1 30617 30617 0.00230 1714985 970320 744665 0.05650 1745602 970320 775282 0.05880 2 9772 9772 0.00070 2 9772 9772 0.00070 2 1755374 970320 785054 0.05950 1 25520 6380 4740111 4760799 -20688 X 1 1 1 1 RIDGEVIEW LE SUEUR MEDICAL CENTER 621 SOUTH 4TH STREET LE SUEUR MN 56058 WWW.RIDGEVIEWMEDICAL.ORG HFID-00336 X X X X RIDGEVIEW LE SUEUR MEDICAL CENTER 1 0 0 1 X X X X X X X X X 19 1 1 1 1 X WWW.RIDGEVIEWMEDICAL.ORG/ABOUT-US/ X 1 19 1 WWW.RIDGEVEIWMEDICAL.ORG/ABOUT-US/ 0 1 X 200.000000000000 250.000000000000 X X X X X 1 1 X X X X 1 X SEE LINE 16J X SEE LINE 16J X SEE LINE 16J X X X X X X X 1 X 0 X X X X 1 X 0 0 RIDGEVIEW LE SUEUR MEDICAL CENTER PART V, SECTION B, LINE 5: RIDGEVIEW PARTNERED WITH CARVER COUNTY PUBLIC HEALTH TO COMPLETE THE PRIMARY DATA COLLECTION FOR THE 2019 CHNA. THIS INCLUDED PRIMARY RESEARCH, DATA ANALYSIS, VALIDATION AND PRIORITIZATION, AND ANALYSIS OF DOCUMENTED HEALTH AND SOCIOECONOMIC FACTORS WITH COMMUNITY INPUT.THE COMMUNITY INPUT INCLUDED SURVEYS FROM RESIDENTS OF CARVER COUNTY PLUS ACROSS THE SIX OTHER COUNTIES IN RIDGEVIEW'S SERVICE AREA. THIS PRIMARY DATA WAS SUPPLEMENTED WITH SECONDARY DATA* COLLECTED FROM THE FOLLOWING SOURCES (BUT NOT LIMITED TO): RIDGEVIEW'S ELECTRONIC MEDICAL RECORD AND FINANCIAL SYSTEMS, US CENSUS BUREAU, COUNTY HEALTH RANKINGS, MINNESOTA HOSPITAL ASSOCIATION. RIDGEVIEW LE SUEUR MEDICAL CENTER PART V, SECTION B, LINE 6A: THE 2019 COMMUNITY HEALTH NEEDS ASSESSMENT WAS CONDUCTED WITH RIDGEVIEW MEDICAL CENTER AND RIDGEVIEW SIBLEY MEDICAL CENTER. RIDGEVIEW LE SUEUR MEDICAL CENTER PART V, SECTION B, LINE 6B: CARVER COUNTY PUBLIC HEALTH RIDGEVIEW LE SUEUR MEDICAL CENTER PART V, SECTION B, LINE 11: RIDGEVIEW WILL CONTINUE TO IMPLEMENT SYSTEM-WIDE INITIATIVES THAT SUPPORT AND IMPACT THE HEALTH OF ITS GROWING SERVICE AREA AS WELL AS TARGETED RESOURCES TO ADDRESS SPECIFIC NEEDS OF ITS DIVERSE POPULATIONS. COMMUNITY HEALTH NEEDS THAT THE HOSPITAL DOES NOT PLAN TO ADDRESS ARE:-PREVENTION, CLINICAL CARE AND DISEASE MANAGEMENT: PREVENTIVE SCREENINGS, ACCESS TO CARE, SPECIFICALLY IN RURAL AREAS. RIDGEVIEW LE SUEUR MEDICAL CENTER PART V, SECTION B, LINE 16J: THE FINANCIAL ASSISTANCE POLICY, PLAIN LANGUAGE SUMMARY, AND APPLICATION ARE AVAILABLE AT WWW.RIDGEVIEWMEDICAL.ORG/PATIENTS-VISITORS/FINANCIAL/. 2 1 - RIDGEVIEW LE SUEUR LONG-TERM CARE 621 SOUTH 4TH STREET LE SUEUR MN 56058 SKILLED NURSING FACILITY 2 - SUNRIZE PLAZA 600 SOUTH 5TH STREET LE SUEUR MN 56058 SENIOR APARTMENTS PART I, LINE 3C: TO QUALIFY FOR FINANCIAL ASSISTANCE, THE FOLLOWING CONDITIONS MUST BE MET:(A) THE MEDICAL CARE PROVIDED BY RIDGEVIEW LE SUEUR MEDICAL CENTER IS MEDICALLY NECESSARY;(B) THE INDIVIDUAL SUBMITS A COMPLETED APPLICATION;(C) THE INDIVIDUAL COOPERATES WITH THE HOSPITAL TO EXPLORE ALTERNATIVE MEANS OF ASSISTANCE, IF NECESSARY (INCLUDING SSI, DISABILITY, MEDICARE AND MEDICAID); AND(D) THE INDIVIDUAL'S FAMILY INCOME IS LESS THAN 250% OF FEDERAL POVERTY GUIDELINES ("FPG"). FREE CARE IS OFFERED FOR FEDERAL ADJUSTED GROSS INCOME UP TO 200% OF FPG. 75% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME BETWEEN 200% AND 225% FPG. 56% OF A PATIENT'S CHARGES ARE FORGIVEN FOR FEDERAL ADJUSTED GROSS INCOME BETWEEN 225% AND 250% OF FPG.IN ADDITION, PATIENTS SEEKING FINANCIAL ASSISTANCE MAY BE ASKED FIRST TO APLY FOR OTHER EXTERNAL PROGRAMS (SUCH AS MEDICAID OR INSURANCE THROUGH THE PUBLIC MARKETPLACE).RIDGEVIEW MAY RELY ON EXTERNAL SOURCES TO DETERMINE ELIGIBILITY WHEN:(A) THE PATIENT IS HOMELESS;(B) THE PATIENT IS ELIGIBLE FOR OTHER UNFUNDED STATE OR LOCAL ASSISTANCE PROGRAMS;(C) THE PATIENT IS ELIGIBLE FOR FOOD STAMPS OR SUBSIDIZED SCHOOL LUNCH;(D) THE PATIENT IS ELIGIBLE FOR STATE-FUNDED PRESCRIPTION MEDICATION;(E) THE PATIENTS VALID ADDRESS IS CONSIDERED LOW-INCOME OR SUBSIDIZED HOUSING; OR(F) THE PATIENT RECEIVEDS FREE CARE FROM A COMMUNITY CLINIC AND IS REFERRED TO THE HOSPITAL FOR FURTHER TREATMENT.RIDGEVIEW LE SUEUR MEDICAL CENTER ALSO USES CHANGE HEALTHCARE, AN ELIGIBILITY VENDOR, TO HELP IDENTIFY PATIENTS WHO MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE. PART I, LINE 7: THE COST TO CHARGE RATIO DERIVED FROM WORKSHEET 2 OF THE IRS INSTRUCTIONS, RATIO OF PATIENT CARE COST-TO-CHARGES WAS USED TO CALCULATE THE COSTS FOR THE FOLLOWING COMMUNITY BENEFITS: CHARITY CARE, UNREIMBURSED MEDICAID AND COSTS FROM OTHER MEANS-TESTED GOVERNMENT PROGRAMS. ACTUAL COSTS WERE USED FOR THE REMAINDER OF THE COMMUNITY BENEFITS REPORTED. 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 $ 25,520. PART III, LINE 2: THE AMOUNT OF BAD DEBT EXPENSE INCLUDED IN PART III, LINE 2 IS CALCULATED BY RIDGEVIEW AS FOLLOWS: PAYMENT FOR SERVICES IS REQUIRED WITHIN 30 DAYS OF RECEIPT OF THE INVOICE OR CLAIM SUBMITTED. PATIENT ACCOUNTS THAT ARE MORE THAN 90 DAYS PAST DUE ARE INDIVIDUALLY ANALYZED FOR COLLECTIBILITY. IN ADDITION, AN ALLOWANCE IS ESTIMATED FOR OTHER ACCOUNTS BASED ON HISTORICAL EXPERIENCE OF THE ORGANIZATION. WHEN ALL COLLECTION EFFORTS HAVE BEEN EXHAUSTED, THE ACCOUNT IS WRITTEN OFF AGAINST THE RELATED ALLOWANCE. PART III, LINE 3: MINNESOTA VALLEY HEALTH CENTER, INC. (DBA: RIDGEVIEW LE SUEUR MEDICAL CENTER) ESTIMATES THAT APPROXIMATELY 25% OF ITS TOTAL COST OF CHARITY CARE IS ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR CHARITY CARE BUT DID NOT COMPLETE AN APPLICATION AND WERE ULTIMATELY INCLUDED IN BAD DEBT EXPENSE REPORTED IN PART III, LINE 2. PART III, LINE 4: SEE NOTE 2, "PATIENT AND RESIDENT SERVICE REVENUE", ON PAGES 12-16 OF THE ATTACHED AUDITED FINANCIAL STATEMENTS FOR AN EXPLANATION OF MINNESOTA VALLEY HEALTH CENTER'S BAD DEBT EXPENSE. PART III, LINE 8: MINNESOTA VALLEY HEALTH CENTER, INC. INCORPORATED THE FULL VALUE OF THE MEDICARE SHORTFALL AS A COMMUNITY BENEFIT. THE RATIONALE FOR THE ORGANIZATION'S OPINION IS PROVIDING CARE FOR THE ELDERLY AND SERVING MEDICARE PATIENTS IS AN ESSENTIAL PART OF THE COMMUNITY BENEFIT STANDARD. MEDICARE, LIKE MEDICAID, DOES NOT PAY THE FULL COST OF CARE AND IT IS LIKELY TO GET WORSE. MANY MEDICARE BENEFICIARIES ARE POOR AND ARE ELIGIBLE FOR MEDICAID IN ADDITION TO MEDICARE. MEDICARE UNDERPAYMENT MUST BE SHOULDERED BY THE HOSPITAL AND NURSING HOME IN ORDER TO CONTINUE TREATING THE COMMUNITY'S ELDERLY AND POOR. THESE UNDERPAYMENTS REPRESENT A REAL COST OF SERVING THE COMMUNITY. PART III, LINE 9B: RIDGEVIEW'S CHARITY PROGRAM ALLOWS FOR ACCOUNTS IN BAD DEBT STATUS TO COMPLETE A CHARITY CARE APPLICATION. IF APPROVED, THE ACCOUNT WILL BE RETURNED FROM BAD DEBT AND APPLIED TO OUR CHARITY CARE PROGRAM. ALL PATIENTS ARE ADVISED OF OUR CHARITY CARE PROGRAM THROUGH OUR MONTHLY BILLING PROCESS. RIDGEVIEW MEDICAL CENTER DOES NOT CHARGE INTEREST ON OUTSTANDING PATIENT ACCOUNT BALANCES. PART VI, LINE 2: RIDGEVIEW LE SUEUR MEDICAL CENTER IS A LICENSED 15 BED CRITICAL ACCESS HOSPITAL IN LE SUEUR, MN AND IS THE ONLY HOSPITAL IN LE SUEUR COUNTY. RIDGEVIEW LE SUEUR MEDICAL CENTER ALSO HAS TWO CLINICS. RIDGEVIEW LE SUEUR MEDICAL CENTER WORKS WITH THE ONLY LOCAL PRIMARY CARE PHYSICIAN CLINIC IN LE SUEUR, SIBLEY COUNTY PUBLIC HEALTH, NICOLLET COUNTY PUBLIC HEALTH AND LE SUEUR COUNTY PUBLIC HEALTH AGENCIES FOR ASSESSING THE NEEDS OF THE RURAL COMMUNITIES IN OUR AREA. THESE NEEDS ARE DETERMINED BY SEVERAL DIFFERENT MENTHODS, BUT MOSTLY BASED ON WHAT THESE AGENCIES ARE ACTUALLY SEEING WHEN THEY ARE WORKING WITH THEIR CLIENTS. THIS COMMUNICATION IS ONGOING THROUGHOUT THE YEAR. RIDGEVIEW LE SUEUR MEDICAL CENTER IS A MEMBER OF A LOCAL NON-PROFIT GROUP CALLED COMMUNITY WELLNESS COLLABORATION. THE MISSION OF THIS GROUP IS TO ADDRESS DEPRESSION, BULLYING AND SUICIDE PREVENTION IN OUR COMMUNITY. OTHER MEMBERS OF THIS COLLABORATION ARE LE SUEUR COUNTY PUBLIC HEALTH AND SOCIAL SERVICES, A LOCAL FAMILY PRACTICE CLINIC, LAW ENFORCEMENT AGENCIES AND A LOCAL SCHOOL. THE COLLABORATION WAS FORMED IN THE LAST THREE YEARS AND IS BASED ON WHAT THESE AGENCIES WERE SEEING EITHER IN THE EMERGENCY ROOM, CLINIC VISITS, AMBULANCE CALLS, INCIDENTS AT SCHOOL AND CALLS TO LAW ENFORCEMENT. THE COLLABORATION WAS DEEMED NECESSARY AS THE NUMBER OF THESE EVENTS HAVE BEEN INCREASING. PART VI, LINE 3: RIDGEVIEW LE SUEUR MEDICAL CENTER MAKES INFORMATION ON ITS FINANCIAL ASSISTANCE POLICY (FAP) READILY AVAILABLE TO THE PATIENT. INFORMATION ABOUT FINANCIAL ASSISTANCE PROGRAM IS AVAILABLE ON THE WEB SITE WWW.RIDGEVIEWLESUEUR.ORG WHERE THE INFORMATION AND APPLICATION WERE EASILY ACCESSIBLE TO BE VIEWED, DOWNLOADED AND PRINTED AT NO CHARGE TO THE PATIENT. NOTICES ON THE AVAILABILITY OF FINANCIAL ASSISTANCE ARE CONSPICUOUSLY POSTED IN EMERGENCY ROOM DEPARTMENTS AND IN WAITING ROOMS. FINANCIAL ASSISTANCE INFORMATION IS AVAILABLE DURING THE PRE-ADMISSION FINANCIAL SCREENING, AT THE TIME OF REGISTRATION AND PRIOR TO A HOSPITAL DISCHARGE. INFORMATION ABOUT THE FAP IS IN ALL COLLECTION LETTERS AND PATIENT STATEMENTS. RIDGEVIEW LE SUEUR MEDICAL CENTER EDUCATES STAFF MEMBERS WHO WORK CLOSELY WITH PATIENTS PROVIDING DIRECT PATIENT TREATMENT AND WHO WORK IN ADMISSIONS, BILLING AND COLLECTIONS, ABOUT THE EXISTENCE OF THE FAP AND HOW A PATIENT MAY OBTAIN MORE INFORMATION. ANNUAL EDUCATION/AWARENESS OF THE FAP IS PROVIDED TO ENSURE ALL EMPLOYEES WITH PATIENT CONTACT ARE AWARE OF THE PROGRAM AND HOW PATIENTS CAN OBTAIN ADDITIONAL INFORMATION. CLINICAL AND HOSPITAL STAFF WHO PROVIDE DIRECT PATIENT CARE HAVE KNOWLEDGE OF THE FAP AND KNOW TO DIRECT PATIENTS TO A REGISTRATION INTERVIEWER OR BUSINESS OFFICE REPRESENTATIVE. REGISTRATION STAFF HAVE AN UNDERSTANDING OF THE POLICY, KNOWLEDGE OF WHERE THE RELATED DOCUMENTS ARE LOCATED AND WHERE TO DIRECT THE PATIENT FOR MORE INFORMATION ON THE FAP. DESIGNATED EMPLOYEES HAVE A THOROUGH UNDERSTANDING OF THE FAP AND OFFER THE INFORMATION ON THE FAP TO THOSE PATIENTS WHO MAKE AN INQUIRY ABOUT THE PROGRAM OR ARE DETERMINED THROUGH A FINANCIAL SCREENING THAT THE PATIENT MAY BE ELIGIBLE FOR THIS PROGRAM. A REQUEST FOR FINANCIAL ASSISTANCE MAY BE MADE BY THE PATIENT, A PATIENT'S GUARANTOR, A FAMILY MEMBER, CLOSE FRIEND, OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. RIDGEVIEW LE SUEUR MEDICAL CENTER RESPONDS TO ANY ORAL OR WRITTEN REQUESTS FOR MORE GENERAL INFORMATION ON THE FAP MADE BY A PATIENT OR ANY INTERESTED PARTY. PART VI, LINE 4: MINNESOTA VALLEY HEALTH CENTER, INC. (DBA: RIDGEVIEW LE SUEUR) IS LOCATED IN LE SUEUR, MN. MINNESOTA VALLEY HEALTH CENTER, INC. OPERATES A CRITICAL ACCESS HOSPITAL, A LONG-TERM CARE FACILITY, AND A 37 UNIT HUD-SUBSIDIZED LOW INCOME HOUSING FOR SENIORS THAT SERVE THE COMMUNITIES OF LE SUEUR, NICOLLET AND SIBLEY COUNTIES. THE OVERALL COMMUNITY IS CLASSIFIED AS RURAL. MINNESOTA VALLEY HEALTH CENTER, INC. AND ITS RELATED FACILITIES COVER A SERVICE REGION OF APPROXIMATELY 29,000 PEOPLE. THE SERVICE REGION AGE DISTRIBUTION IS 29% UNDER THE AGE OF 18, 52% BETWEEN THE AGES OF 18 AND 65, AND 19% OVER THE AGE OF 65. THE RACIAL MAKEUP OF THE SERVICE REGION IS 90% WHITE, NON-HISPANIC, 7% HISPANIC OR LATINO, 1% BLACK OR AFRICAN AMERICAN, 1% AMERICAN INDIAN AND 1% ASIAN. THE GENDER SPLIT RATIO IS 49% WOMEN AND 51% MEN. THE AVERAGE INCOME FOR THE SERVICE AREA IS APPROXIMATELY $75,925. APPROXIMATELY 6.7% OF THE POPULATION FALLS BELOW THE FEDREAL POVERTY GUIDELINES. MINNESOTA VALLEY HEALTH CENTER, INC. IS COMMITTED TO SERVE PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. MINNESOTA VALLEY HEALTH CENTER HAS AN OUTREACH PROGRAM THAT BRINGS SPECIALISTS LIKE CARDIOLOGISTS, GASTROENTEROLOGY, ORTHOPAEDICS AND OTHERS INTO ITS SMALLER COMMUNITY. THIS ELIMINATES BARRIERS TO CARE FOR MANY PATIENTS, PARTICULARLY THOSE WHO ARE EDERLY, LIVING ON LOW INCOMES, OR ARE FACED WITH OTHER CHALLENGES THAT MAKE IT DIFFICULT TO TRAVEL LONG DISTANCES FOR CARE. RIDGEVIEW LE SUEUR IS PART OF THE RIDGEVIEW HEALTH SYSTEM WHICH SERVES APPROXIMATELY 350,000 PEOPLE IN THE COUNTIES OF CARVER, SIBLEY, MCLEOD, LE SUEUR, SCOTT AND WRIGHT COUNTIES IN MN. PART VI, LINE 5: MINNESOTA VALLEY HEALTH CENTER, INC'S DBA RIDGEVIEW LE SUEUR, BOARD OF DIRECTORS IS A BOARD CONSISTING OF LOCAL COMMUNITY MEMBERS WITH A CROSS SECTION OF OCCUPATIONS. ONE OF THE REPRESENTATIVES IS APPOINTED BY THE LE SUEUR CITY COUNCIL AND ANOTHER BOARD MEMBER IS FROM RIDGEVIEW'S CORPORATE BOARD. NONE OF THE BOARD MEMBERS ARE EMPLOYEES, RELATED TO EMPLOYEES OR ARE INDEPENDENT CONTRACTORS OF THE ORGANIZATION. GIVEN THAT WE ARE A SMALL COMMUNITY IF A VOTE COMES UP FOR SOMETHING THAT COULD APPEAR TO BE A CONFLICT OF INTEREST THE BOARD MEMBER WILL ABSTAIN FROM VOTING. ANY SURPLUS CASH IS USED TO UPDATE MEDICAL EQUIPMENT FOR BOTH THE HOSPITAL AND NURSING HOME. ANY AND ALL EMERGENCY REPAIRS OR EQUIPMENT NEEDS THAT ARISE ARE TAKEN CARE OF IMMEDIATLEY. RIDGEVIEW LE SUEUR OFFERS A MEALS ON WHEELS PROGRAM FOR HOME BOUND RESIDENTS AND MOST OF THOSE MEALS ARE PAID FOR THROUGH AN ELDERLY WAIVER PGORAM THROUGH THE COUNTY, WHICH JUST COVERS THE COST OF THE FOOD. VOLUNTEERS DELIVER MEALS TO HOME BOUND CLIENTS MONDAYS - FRIDAYS, THIS PAST YEAR 2,594_ MEALS WERE PREPARED AND DELIVERED. WITH THE IMPLEMENTATION OF COVID SAFETY PRECAUTIONS, WE WERE ABLE TO CONTINUE TAKING NURSING HOME RESIDENTS. THE OUTPATIENT CLINIC WING PROVIDES SPACE FOR VISITING SPECIALISTS (CARDIOLOGY, ORTHOPEDICS, UROLOGY, GENERAL SURGERY) FROM OTHER HEALTH CARE SYSTEMS TO SEE PATIENTS LOCALLY AND TO PERFORM OUTPATIENT PROCEDURES LOCALLY. MOST OF OUR POPULATION IS ELDERLY AND ARE UNABLE TO DRIVE GREAT DISTANCES SO THEY ARE ABLE TO RECEIVE CARE FROM SPECIALISTS LOCALLY. WE STRIVE TO PROVIDE HIGH-QUALITY, PATIENT-CENTERED CARE CLOSE TO HOME FOR THE COMMUNITIES WE SERVE. WE CONTINUE TO UPGRADE FACILITIES AND TECHNOLOGY TO ENSURE PATIENTS IN RURAL COMMUNITIES HAVE NEARBY ACCESS TO THESE SERVICES. WE ALSO WERE ABLE TO IMPLEMENT TELE VISITS FOR OUR PATIENTS WITH THE SPECIALISTS DURING 2020. PART VI, LINE 6: MINNESOTA VALLEY HEALTH CENTER IS A SUBSIDIARY OF RIDGEVIEW MEDICAL CENTER. RIDGEVIEW MEDICAL CENTER IS A 109-BED ACUTE CARE HOSPITAL IN WACONIA, MINNESOTA THAT PROVIDES HEALTHCARE SERVICES TO THE RESIDENTS OF THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MN. RIDGEVIEW MEDICAL CENTER'S SUBSIDIARIES INCLUDE:RIDGEVIEW CLINICS, WHICH PROVIDES OUTPATIENT HEALTHCARE SERVICES FROM VARIOUS CLINIC LOCATIONS THROUGHOUT THE WEST SUBURBAN METROPOLITAN AREA OF MINNEAPOLIS AND ST. PAUL AND ADJACENT RURAL AREAS OF MINNESOTA.SIBLEY MEDICAL CENTER OPERATES AN AMBULATORY SURGICAL CENTER. CHASKA PLAZA SURGERY CENTER IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER OWNS A 51% INTEREST.MINNEAPOLIS HEART INSTITUTE AT RIDGEVIEW HEART CENTER PROVIDES CARDIOLOGY SERVICES. THE HEART INSTITUTE IS A PARTNERSHIP IN WHICH RIDGEVIEW MEDICAL CENTER HOLDS A 50% INTEREST.WACONIA BUILDING INVESTMENTS OWNS A MEDICAL OFFICE BUILDING ON RIDGEVIEW MEDICAL CENTER'S CAMPUS.RIDGEVIEW REAL ESTATE LLC HOLDS THE LAND LEASE FOR WACONIA BUILDING INVESTMENTS.RIDGEVIEW COMMUNITY NETWORK OPERATES A AN ACCOUNTABLE CARE ORGANIZATION.RIDGEVIEW INSURANCE COMPANY OPERATES A CAPTIVE INSURANCE COMPANY FOR THE BENEFIT OF RIDGEVIEW MEDICAL CENTER.RIDGEVIEW FOUNDATION OPERATE FOR THE EXCLUSIVE BENEFIT OF RIDGEVIEW MEDICAL CENTER. PART VI, LINE 7, REPORTS FILED WITH STATES MN 0 1 0 0 0 1 1 0 0 MICHAEL PHELPS CEO 0 530661 0 0 0 667101 0 28337 0 40300 0 1266399 0 0 GORDON GABLENZ CIO 0 313342 0 0 0 488609 0 25560 0 61876 0 889387 0 0 AARON BLOOMQUIST CFO 0 275606 0 0 0 734 0 13627 0 45500 0 335467 0 0 BENJAMIN NIELSEN COO & BOARD DIRECTOR 0 274784 0 0 0 24117 0 13416 0 754 0 313071 0 0 PAMELA WILLIAMS VICE PRESIDENT (THROUGH JULY 2021) 0 247423 0 0 0 15151 0 9772 0 17554 0 289900 0 0 PART I, LINE 3 THE CEO IS COMPENSATED BY RIDGEVIEW MEDICAL CENTER, THE SOLE MEMBER. THE FOLLOWING WERE USED BY RIDGEVIEW MEDICIAL CENTER TO DETERMINE THE CEO'S COMPENSATION: 1) COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) 2) INDEPENDENT COMPENSATION CONSULTANT 3) FORM 990 OF OTHER ORGANIZATIONS 4) WRITTEN EMPLOYEMENT CONTRACT 5) COMPENSATION SURVEY OR STUDY 6) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE (EXECUTIVE COMMITTEE) PART I, LINE 4B MICHAEL PHELPS PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2021, $621,440 WAS CONTRIBUTED TO THE PLAN, $42,739 WAS ACCRUED WITHIN THE PLAN, AND $0 WAS PAID OUT OF THE PLAN. GORDON GABLENZ PARTICIPATED IN A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. DURING 2021, $434,954 WAS CONTRIBUTED TO THE PLAN, $50,027 ACCRUED WITHIN THE PLAN, AND $0 WAS PAID OUT OF THE PLAN. THESE DEFERRED COMPENSATION AMOUNTS ARE REPORTED ON A PRO-RATA BASIS WITHOUT REGARD TO THE INDIVIDUAL'S VESTING SCHEDULE. CURRENTLY, THE MAJORITY OF DEFERRED COMPENSATION IS NOT VESTED. PART I, LINE 6 THE OFFICERS OF RIDGEVIEW MEDICAL CENTER AND AFFILIATES RECEIVE BONUSES CONTINGENT ON THE NET EARNINGS OF THE CONSOLIDATED ENTITY AND GOALS ACHIEVED. BONUSES WERE EARNED IN 2021 AND PAID IN 2022. FORM 990, PART VI, SECTION A, LINE 6 RIDGEVIEW MEDICAL CENTER IS THE SOLE MEMBER OF THE FILING ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A THE FILING ORGANIZATION'S BOARD SHALL CONSIST TWO PERSONS APPOINTED BY THE SOLE MEMBER. OTHER MEMBERS OF THE FILING ORGANIZATION'S BOARD ARE SELECTED BY A NOMINATING COMMITTEE AND MUST BE APPROVED BY THE SOLE MEMBER. FORM 990, PART VI, SECTION A, LINE 7B THE ARTICLES AND BYLAWS PROVIDE THE SOLE MEMBER CERTAIN RESERVED POWERS IN AREAS SUCH AS CAPITAL, BUDGET, DEBT, AMENDMENT OF THE ARTICLES & BYLAWS AND GENERAL OPERATION DECISIONS. FORM 990, PART VI, SECTION A, LINE 8B FILING ORGANIZATION HAS NO EXECUTIVE COMMITTEE OR SIMILAR COMMITTEE WITH BOARD DELEGATED AUTHORITY. FORM 990, PART VI, SECTION B, LINE 11B MANAGEMENT REVIEWED THE FORM 990 AND PROVIDED COPIES TO THE BOARD OF DIRECTORS PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD MEMBERS ANNUALLY REVIEW AND SIGN THE STATEMENTS FOR POTENTIAL CONFLICTES OF INTEREST POLICY. EACH MEMBER IS EXPECTED TO DISCLOSE ANY CONFLICT OF INTEREST THAT MAY ARISE DURING THE YEAR. IF IT IS DETERMINED THAT CONFLICT OF INTEREST EXISTS, THE SITUATION WILL BE EXAMINED AND HANDLED APPROPRIATELY BY THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE CEO & CFO ARE PAID BY RIDGEVIEW MEDICAL CENTER, THE SOLE CORPORATE MEMBER, WHICH PERFORMS THE REVIEW AND APPROVAL OF THE COMPENSATION FOR THE CEO AND CFO. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS, CONFILICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G CONSULTING & OTHER PROFESSIONAL FEE: PROGRAM SERVICE EXPENSES 1,001,677. MANAGEMENT AND GENERAL EXPENSES 790,150. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,791,827. ER MEDICAL DIRECTOR: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 50,027. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 50,027. FORM 990, PART XI, LINE 9: CHANGE IN BENEFICIAL INTEREST IN NET ASSETS OF FOUNDATION 27,219. FORM 990, PART XII, LINE 2C THE PROCESS REGARDING OVERSIGHT OF THE AUDIT OF THE FINANCIAL STATEMENTS AND SELECTION OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR. MINNESOTA VALLEY MEMORIAL HOSPITAL FOUNDATION 621 SOUTH FOURTH STREET LE SUEUR MN 56058 411754182 RAISING FUNDS FOR RIDGEVIEW LE SUEUR MEDICAL CENTER. MN 501(C)(3) LINE 12A, I N/A 0 RIDGEVIEW MEDICAL CENTER 500 S MAPLE ST WACONIA MN 55387 311667875 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 N/A 0 RIDGEVIEW FOUNDATION 500 S MAPLE ST WACONIA MN 55387 411328097 RAISING FUNDS FOR RIDGEVIEW MEDICAL CENTER MN 501(C)(3) LINE 7 RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW CLINICS 500 S MAPLE ST WACONIA MN 55387 411651783 HEALTH CARE SERVICES MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 RIDGEVIEW INSURANCE CO 60 E SOUTH TEMPLE STE 1800 SALT LAKE CITY UT 84111 454109041 CAPTIVE INSURANCE COMPANY UT 501(C)(3) LINE 12A, I RIDGEVIEW MEDICAL CENTER 0 SIBLEY MEDICAL CENTER 601 W CHANDLER ST ARLINGTON MN 55307 411801967 CRITICAL ACCESS HOSPITAL MN 501(C)(3) LINE 3 RIDGEVIEW MEDICAL CENTER 0 MINNEAPOLIS HEART INSTITITUE AT RIDGEVIEW HEART CENTER LLC 500 S MAPLE ST WACONIA MN 55387 205785920 CARDIOLOGY MN N/A 0 0 CHASKA PLAZA SURGERY CENTER 3000 HUNDERTMARK ROAD CHASKA MN 55318 450975783 SURGERY SERVICES MN N/A 0 0 EXECUTIVE HEALTH MANAGEMENT SERVICES 500 SOUTH MAPLE ST WACONIA MN 55387 411760239 MANAGEMENT SERVICES MN N/A C 0 CHARITABLE REMAINDER UNITRUST (1) CHARITABLE TRUST MN N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1