2021-11-10T07:41:20-06:00 2020-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2020-01-01 390773970 LADD MEMORIAL HOSPITAL INC LADD 7152942111 2600 65TH AVENUE PO BOX 218 OSCEOLA WI 54020 MATTHEW FORGE CEO 7152942111 2021-11-09 1 MATTHEW FORGE 999009999 MICHAEL J PETERSON CPA P01833529 2187224705 2021-11-09 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z OSCEOLA MEDICAL CENTER MATTHEW FORGE 2600 65TH AVENUE PO BOX 218 OSCEOLA WI 54020 42476734 0 X WWW.MYOMC.ORG X 1947 WI TO INSPIRE AND IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY THROUGH HOME-TOWN CUSTOMER SERVICE, QUALITY AND STRATEGIC PARTNERSHIPS. 10 10 316 34 2005246 0 326033 599075 38185765 40651408 113567 48956 519011 399903 39144376 41699342 0 0 0 0 16282762 16727677 0 0 170596 22416270 24220887 38699032 40948564 445344 750778 38495361 46005640 17934790 24701894 20560571 21303746 TO INSPIRE AND IMPROVE THE HEALTH AND WELL-BEING OF OUR COMMUNITY THROUGH HOME-TOWN CUSTOMER SERVICE, QUALITY AND STRATEGIC PARTNERSHIPS. 0 0 33350588 0 38646162 DURING 2020, LADD MEMORIAL HOSPITAL PROVIDED INPATIENT, OUTPATIENT, AND CLINICAL CARE SERVICES TO THE RESIDENTS OF THE GREATER OSCEOLA AREA, REGARDLESS OF ABILITY TO PAY.INPATIENT SERVICES WERE PROVIDED TO 434 PATIENTS AND TOTALED 1463 DAYS OF SERVICE. INPATIENT SERVICES INCLUDED GENERAL MEDICINE, SURGERY, PEDIATRIC, AND OBSTETRIC.OUTPATIENT SERVICES INCLUDED 2830 EMERGENCY ROOM VISITS, AND 1294 OP SURGERIES. CLINICAL CARE SERVICES INCLUDED 21,512 CLINIC VISITS, 7,281 WALK IN VISITS, TOTALING 28,793. 33350588 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 0 0 0 1 22 0 316 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 10 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI MN X KIM ERICSON 7152942111 2600 65TH AVENUE PO BOX 218 OSCEOLA WI 54020 MARYBETH GUSTAFSON PHARMACIST 40.00 X 159594 0 33795 COBY SOMSEN NURSE PRACTITONER 36.00 X 138248 0 5745 NATALIA CROPPER NURSE PRACTITONER 36.00 X 104528 0 28952 TOM HECHT EXECUTIVE OF FOUNDATION 40.00 X 101390 0 23828 RACHEL JOHNSON-HIMES PHARMACIST 40.00 X 114166 0 4298 MATT FORGE CEO 40.00 X 246155 0 18670 KIM ERICSON CFO 40.00 X 180205 0 18897 MISTY CHARLIER CAO 40.00 X 153851 0 36794 RACHEL ZIMMER CNO 40.00 X 128576 0 5331 ANNE MARIE PUESHNER CHAIRPERSON 1.00 X X 0 0 0 PETER MANSHIP VICE-CHAIRPERSON 1.00 X X 0 0 0 DEBORAH PETERS SECRETARY 1.00 X X 0 0 0 JOHN CLARK BOARD MEMBER 1.00 X 0 0 0 MARK ERICKSON BOARD MEMBER 1.00 X 0 0 0 KIERSTEN JUSTINGER BOARD MEMBER 1.00 0.50 X 0 0 0 GREG KUMLIEN DC BOARD MEMBER 1.00 X 0 0 0 TYLER SCHMIDTZ BOARD MEMBER 1.00 X 0 0 0 ERIK SEVERSON MD BOARD MEMBER 1.00 X 0 0 0 AMANDA TREMBREULL MD BOARD MEMBER 1.00 X 0 0 0 1326713 0 176310 10 0 1 0 HEALTHPARTNERS MAIL STOP 21109A ST PAUL MN 55164 PHYSICIANS 5194111 NATIONAL GOVERNMENT SERVICES PO BOX 809199 CHICAGO IL 606809199 CONTRACTED SERVICES 2717208 MARSHFIELD LABS 1000 NORTH OAK AVENUE MARSHFIELD WI 54449 LABORATORY SERVICES 944104 JOHNSON & JOHNSON 5972 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 SURGICAL IMPLANTS 877427 CMDI PO BOX 158 MILACA MN 56353 DIAGNOSTIC IMAGING 751892 22 131468 350133 117474 599075 NET PATIENT SERVICE REV 621990 40497075 38491829 2005246 FITNESS CENTER 713940 154333 154333 40651408 42095 42095 784253 750027 27365 34226 -27365 6861 6861 GIFT SHOP 900099 46736 46736 353167 353167 399903 41699342 38646162 2005246 448859 X 788479 788479 12784408 9670343 2991092 122973 264234 201606 60064 2564 2013509 1487927 506661 18921 877047 628565 240489 7993 18426 18426 36500 36500 10870352 10617283 253069 4001 4001 367915 199221 168020 674 1277278 81013 1196265 569175 410747 158428 10291 8437 1813 41 360985 288736 69415 2834 1836289 1468767 353105 14417 47885 47885 DRUGS 3893696 3893106 590 MEDICAL SUPPLIES 2825221 2499734 325487 BAD DEBT EXPENSE 890969 890969 EQUIPMENT RENTAL AND MA 665132 637289 27843 546772 366845 179748 179 40948564 33350588 7427380 170596 5024270 10757933 976058 1879189 4307524 5548871 901489 1090998 99705 257621 37380861 19468512 19253443 17912349 6489454 5661944 812240 810688 631178 561047 0 1525000 38495361 46005640 3464974 4183345 1192 2192 12952968 11910863 1325656 1147898 190000 7457596 17934790 24701894 X 20560571 21303746 20560571 21303746 38495361 46005640 750778 -7603 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 1095 1095 0 PART II-B, LINE 1: LADD MEMORIAL HOSPITAL PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. THE WHA HAS NOTIFIED LADD MEMORIAL HOSPITAL THAT $1,095 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 1545900 1545900 27483282 12395323 15087959 8280042 7073189 1206853 71637 71637 17912349 PAYROLL PROTECTION PROGAM LOAN 3183300 DEFERRED PROVIDER RELIEF FUNDS 4274296 7457596 1 1 X 1 X 1 X 1 1 0 1 1 142268 142268 0.00350 3075784 2024534 1051250 0.02570 3218052 2024534 1193518 0.02920 15258 1000 14258 0.00030 33337 33337 0.00080 4416630 1754539 2662091 0.06500 99884 99884 0.00240 4565109 1755539 2809570 0.06850 7783161 3780073 4003088 0.09770 0 442964 221482 11306538 11180385 126153 X 1 1 1 1 LADD MEMORIAL HOSPITAL INC DBA OSCEOLA MED 2600 65TH AVENUE OSCEOLA WI 54020 WWW.MYOMC.ORG 1021 X X X X OSCEOLA MEDICAL CENTER 1 0 0 1 X X X X X X X X 19 1 1 1 1 X SEE SUPPLEMENTAL INFORMATION X SEE SUPPLEMENTAL INFORMATION X X 1 19 1 SEE SUPPLEMENTAL INFORMATION 0 1 X 200.000000000000 300.000000000000 X X X X X 1 1 X X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 5: THE COMMUNITY HEALTH NEEDS ASSESSMENT LEADERSHIP TEAM COLLECTED BOTH QUANTITATIVE AND QUALITATIVE SATA TO IDENTIFY THE TOP HEALTH PRIORITIES IN POLK COUNTY. METHODS USED INCLUDED A SURVEY, COMMUNITY FORUMS, A KEY PARTNER MEETING AND COMPREHENSIVE COLLECTION AND REVIEW OF SECONDARY HEALTH DATA. DATA FROM THE COMMUNITY SURVEY AND SECONDARY REVIEW WAS PRESENTED AND DICUSSED AT BOTH THE COMMUNITY FORUMS AND KEY PARTNER MEETINGS WITH VOTING CONDUCTED FOR THE TOP HEALTH PRIORITIES. PARTICIPANTS IDENTIFIED THE TOP FOUR HEALTH PRIORITIES IN POLK COUNTY AS:1. MENTAL HEALTH2. SUBSTANCE USE AND ABUSE3. NUTRITION AND PHYSICAL ACTIVITY4. ACCESS TO CARE OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 6A: THE CHNA WAS CONDUCTED AND A COMMUNITY HEALTH IMPROVEMENT PROCESS ("CHIP") WAS DEVELOPED IN JOINT EFFORT WITH THE FOLLOWING OTHER HOSPITALS:1. AMERY REGIONAL MEDICAL CENTER2. ST. CROIX REGIONAL MEDICAL CENTER OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 6B: THE CHNA WAS CONDUCTED AND CHIP DEVELOPED IN JOINT EFFORT WITH THE POLK COUNTY HEALTH DEPARTMENT. OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 7D: POLK COUNTY HEALTH DEPARTMENT OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 11: THE HOSPITAL'S WORK TOWARD MEETING STATED GOALS WERE GREATLY IMPACTED BY THE COVID-19 PANDEMIC. SOME ACTIVITIES DID OCCUR AND PANDEMIC-RELATED ACTIVITIES WERE ADDED. MENTAL HEALTH- ONGOING SCREENINGS DURING CLINIC VISITS.- PROVIDED MENTAL HEALTH TOPICS THROUGH SOCIAL MEDIA. ADDED PANDEMIC-RELATED TOPICS AND RESOURCES.- PARTNERED WITH LOCAL SCHOOL DISTRICT TO PREVENT A MENTAL HEALTH "COMMUNITY CONVERSATION".- CONTINUED DEVOTING STAFF TIME TO COUNTY AND AREA MENTAL HEALTH COMMITTEES.- PROVIDED FUNDS FOR A "SUICIDE AWARENESS WALK"- PARTNERED WITH LOCAL SCHOOL DISTRICT ON STRATEGIC PLANNING THAT WOULD, IN PART, INCLUDE MENTAL HEALTH.- PROVIDED FUNDS TO LOCAL CHAMBER FOR PANDEMIC DISASTER RELIEF.- THROUGH OUR FOUNDATION, PROVIDED FUNDS INTO THE COMMUNITY FOR MENTAL HEALTH ACTIVITIES.- WORKED ON "GET FIT FOR LIFE" WEIGHT MANAGEMENT PROGRAM FOR MENTAL HEALTH AND NUTRITION.OBESITY/NUTRITION- PROVIDED VOLUNTEERS TO FOR UNITED WAY FREE FOOD DISTRIBUTION.- THROUGH OUR FOUNDATION, PROVIDED FUNDS INTO THE COMMUNITY FOR OBESITY ACTIVITIES.- THROUGH OUR FOUNDATION, PROVIDED FUNDS CREATE FREE VIRTUAL FITNESS CLASSES.- WORKED WITH LOCAL NONPROFIT ON "PLAY AND LEARN" PROGRAM ABOUT HEALTHY EATING FOR TODDLERS.- WORKED ON "GET FIT FOR LIFE" WEIGHT MANAGEMENT PROGRAM FOR MENTAL HEALTH AND NUTRITION.- CONTINUED DEVOTING STAFF TIME TO COUNTY PUBLIC HEALTH NUTRITION AND PHYSICAL ACTIVITY COMMITTEES.- PROVIDED RESOURCES FOR FREE FRUITS AND VEGETABLES FOR CHILDREN THROUGH A POWER OF PRODUCE PROGRAM AT LOCAL FARMERS MARKET.SUBSTANCE ABUSE- THROUGH OUR FOUNDATION, PROVIDED FUNDS INTO THE COMMUNITY FOR ALCOHOL AND DRUG TREATMENT ACTIVITIES.ACCESS TO CARE- CONTINUED OFFERING AND PROMOTING WALK-IN CLINIC TO SEE PATIENTS.- HOSTED "BETTER BREATHERS CLUB" TO PROVIDE SUPPORT AND INFORMATION TO THOSE WITH BREATHING PROBLEMS.- THROUGH OUR FOUNDATION, PROVIDED EQUIPMENT FUNDS FOR LOCAL SCHOOL NURSES. - THROUGH OUR FOUNDATION, PROVIDED TECHNOLOGY FUNDS FOR VIRTUAL CLINIC VISITS. OSCEOLA MEDICAL CENTER PART V, SECTION B, LINE 13B: IN A CASE BY CASE REVIEW, OSCEOLA MEDICAL CENTER HOLDS THE RIGHT TO MAKE EXCEPTIONS TO THE GUIDELINES LISTED IN THE COMMUNITY CARE POLICY (SUCH AS BUT NOT LIMITED TO PRESUMPTIVE GRANTING) WHEN IT IS FOUND TO BE IN THE BEST INTEREST OF THE PATIENT. PART V, SECTION B, LINE 7A HTTPS://MYOMC.ORG/ABOUT/COMMUNITY PART V, SECTION B, LINE 7B HTTP://POLKUNITED.ORG/WHAT_IS_CHACHIP/CHA PART V, SECTION B, LINE 10 HTTP://POLKUNITED.ORG/WHAT_IS_CHACHIP/COMMUNITY_HEALTH_IMPROVEMENT_PLAN_CHIP PART V, SECTION B, LINE 16A HTTPS://MYOMC.ORG/INFO/PATIENTS/FINANCIAL-POLICIES PART V, SECTION B, LINE 16B HTTPS://WWW.MYOMC.ORG/INFO/PATIENTS/BILLING/137-POLICIES PART V, SECTION B, LINE 16C HTTPS://WWW.MYOMC.ORG/INFO/PATIENTS/BILLING/137-POLICIES#PLS 4 1 - OSCEOLA CLINIC 2600 65TH AVENUE OSCEOLA WI 54020 PROVIDER BASED CLINIC 2 - CLINIC PHARMACY 2600 65TH AVENUE OSCEOLA WI 54020 RETAIL PHARMACY 3 - SCANDIA CLINIC 21150 OZARK COURT NORTH SCANDIA MN 55073 FREE STANDING CLINIC (CLOSED DURING 2020) 4 - WILD RIVER FITNESS CENTER 2630 65TH AVENUE OSCEOLA WI 54020 FITNESS CENTER PART I, LINE 6A: THE COMMUNITY BENEFIT REPORT IS AVAILABLE UPON REQUEST. PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS 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 COSTING METHODS FOR THE FORM 990. THE COST OF COMMUNITY HEALTH IMPROVEMENT, HEALTH PROFESSIONALS EDUCATION, AND IN-KIND CONTRIBUTIONS REFLECTS THE DIRECT AND INDIRECT COSTS AS DETERMINED BY THE HOSPITAL. PART I, LINE 7G: THE COST OF SUBSIDIZED HEALTH SERVICES IS BASED ON COST ALLOCATIONS FROM THE MEDICARE COST REPORT. SERVICES INCLUDE NURSERY, OCCUPATIONAL HEALTH, CLINIC SERVICES, EMERGENCY ROOM, AND PHYSICIAN SERVICES. PART II, COMMUNITY BUILDING ACTIVITIES: OUR HOSPITAL PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY THAT WITHOUT OUR HOSPITAL, WOULD NOT BE AVAILABLE TODAY.BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES INCLUDING: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES, WALK-IN CLINIC, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SLEEP CENTER, SPEECH AND SURGICAL SERVICES. PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICY: IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, OSCEOLA MEDICAL CENTER 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, OSCEOLA MEDICAL CENTER ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS 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), OSCEOLA MEDICAL CENTER RECORDS A PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF THEIR PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE TO OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. 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: OSCEOLA MEDICAL CENTER HAS BEEN DESIGNATED AS A CRITICAL ACCESS HOSPITAL.THE COST-TO-CHARGE RATIOS USED TO CALCULATE THE COST OF MEDICARE SERVICES WERE TAKEN FROM THE MEDICARE COST REPORT.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: ONCE APPROVED FOR FINANCIAL ASSISTANCE, THAT FINANCIAL ASSISTANCE IS VALID FOR ONE YEAR FROM THE APPROVAL DATE WITH FOLLOW UP VERIFICATION COMPLETED AFTER 6 MONTHS. IT IS THE PATIENT'S RESPONSIBILITY TO NOTIFY OMC IMMEDIATELY SHOULD THERE BE ANY CHANGE IN THE DETERMINING FACTORS WITHIN THE APPROVED YEAR PERIOD. PART VI, LINE 2: THE MEDICAL CENTER ASSESSES THE HEALTHCARE NEEDS OF THE COMMUNITY BY WORKING WITH COUNTY AND STATE OFFICES, COMMUNICATING WITH CIVIC ORGANIZATIONS, INTERPRETING PATIENT TRENDS AND INTERPRETING FEEDBACK FROM ONE-ON-ONE PATIENT CONVERSATIONS.IN ADDITION, A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IS COMPLETED EVERY THREE YEARS. THE CHNA SOUGHT INPUT FROM DIVERSE STAKEHOLDERS, INCLUDING HEALTHCARE PROVIDERS, COMMUNITY LEADERS AND THE PUBLIC. THE ULTIMATE GOAL OF THE ASSESSMENT IS TO IDENTIFY HEALTH ISSUES AND DEVELOP STRATEGIES TO ADDRESS THE COMMUNITY'S HEALTH NEEDS. THE EFFORT INCLUDED A COMPREHENSIVE REVIEW OF HEALTH DATA, AN ANALYSIS OF REAL TIME BODY MASS INDEX DATA FROM LOCAL CLIENT PATIENT ELECTRONIC MEDICAL RECORDS AND HEALTH AND LIFESTYLE DATA FROM COMMUNITY SURVEYS. PART VI, LINE 3: OSCEOLA MEDICAL CENTER HAS INFORMATION REGARDING THE CHARITY CARE POLICY AND OTHER FINANCIAL ASSISTANCE OPTIONS AVAILABLE: 1. A DEDICATED PATIENT ADVOCACY POSITION THAT WORKS ONE ON ONE WITH PATIENTS 2. PLACED IN MAILINGS 3. PAMPHLETS USED BY THE HOSPITAL'S PROVIDERS THAT CAN BE DISTRIBUTED 4. IN PLAIN SIGHT AT EACH POINT OF REGISTRATION 6. THE FAP AND BILLING AND COLLECTION POLICIES ARE AVAILABLE AT THE OSCEOLA PUBLIC LIBRARY 5. ON THEIR WEBSITE THESE RESOURCES ARE AVAILABLE TO ENSURE THAT ALL PATIENTS FULLY UNDERSTAND ALL OPTIONS THAT ARE AVAILABLE FOR ASSISTANCE. PART VI, LINE 4: OSCEOLA MEDICAL CENTER SERVES THE CITY OF OSCEOLA, WISCONSIN, AND NEIGHBORING COMMUNITIES IN WESTERN WISCONSIN AND EASTERN MINNESOTA. THE MEDIAN INCOME IN THE SURROUNDING AREA IS APPROXIMATELY $59,994 PER YEAR. APPROXIMATELY 8.6% OF THE LOCAL POPULATION LIVES AT OR BELOW THE FEDERAL POVERTY GUIDELINES AND APPROXIMATELY 7% OF THE POPULATION DOES NOT HAVE HEALTH INSURANCE. PART VI, LINE 5: A MAJORITY OF OSCEOLA MEDICAL CENTER'S GOVERNING BODY IS COMPRISED OF PERSONS WHO RESIDE IN THE HOSPITAL'S PRIMARY SERVICE AREA WHO ARE NEITHER EMPLOYEES NOR CONTRACTORS OF THE HOSPITAL, NOR FAMILY MEMBERS THEREOF.OSCEOLA MEDICAL CENTER ALSO PROMOTES COMMUNITY HEALTH BY PROVIDING FREE HEALTH SEMINARS, OTHER CLASSES FOR A FEE, SUCH AS ATHLETIC SCREENINGS, AND FREE FITNESS VIDEOS. OSCEOLA MEDICAL CENTER IS A NON-PROFIT ORGANIZATION, AND THEREFORE ALL EARNINGS IN EXCESS OF COST ARE USED BY THE HOSPITAL TO IMPROVE THE HEALTH OF THE PEOPLE THEY SERVE THROUGH THE PURPOSE OR UPGRADE OF FACILITIES AND EQUIPMENT, OR THE ADDITION OR EXPANSION OF NEEDED SERVICES. WE ALSO PROVIDED COVID TESTING AND COVID VACCINES TO THE COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X X X X 0 0 0 0 0 0 0 0 0 MARYBETH GUSTAFSON PHARMACIST 159594 0 0 0 0 0 5123 0 28672 0 193389 0 0 0 MATT FORGE CEO 246155 0 0 0 0 0 5440 0 13230 0 264825 0 0 0 KIM ERICSON CFO 180205 0 0 0 0 0 3255 0 15642 0 199102 0 0 0 MISTY CHARLIER CAO 153851 0 0 0 0 0 4504 0 32290 0 190645 0 0 0 A VILLAGE OF OSCEOLA HOSPITAL FACILITIES REVENUE BOND 396006338 2007-06-13 8000000 REFINANCE EXISTING BONDS & CONSTRUCT NEW HOSPITAL BUILDING 0 0 0 B TOWN OF OSCEOLA HOSPITAL FACILITIES REVENUE BOND 396006044 2007-06-28 7040000 CONSTRUCT NEW HOSPITAL BUILDING 0 0 0 C TOWN OF FARMINGTON HOSPITAL FACILITIES REVENUE BOND 390990620 2007-07-13 6040000 CONSTRUCT NEW HOSPITAL BUILDING 0 0 0 A 3295121 8000000 138545 4581314 3280141 2008 1 0 1 1 B 2934249 7040000 80850 6959150 2008 0 0 1 1 C 2771887 6040000 65800 5974200 2008 0 0 1 1 A 0 0 0 0 0.01270 0.01270 0 0 0 B 0 0 0 0 0.01270 0.01270 0 0 0 C 0 0 0 0 0.01270 0.01270 0 0 0 A 0 0 0 1 0 0 0 0 0 B 0 0 0 1 0 0 0 0 0 C 0 0 0 1 0 0 0 0 0 A 0 B 0 C 0 SCHEDULE K, PART II, LINE 11, COLUMN A: THE AMOUNT LISTED WAS USED TO REFINANCE EXISTING DEBT. SCHEDULE K, PART IV, LINE 2: THERE IS NO REBATE BECAUSE THERE ARE NO PROCEEDS AVAILABLE FOR INVESTMENT. ALL PROCEEDS HAVE BEEN USED FOR CAPITAL EXPENDITURES. FORM 990, PART III, LINE 3, CHANGES IN PROGRAM SERVICES OMC WAS SIGNIFICANTLY IMPACTED BY COVID 19 AND SERVICES WERE REDUCED IN SOME AREAS DUE TO CONSERVING PPE OR LACK OF VOLUME. THE SCANDIA CLINIC SHIFTED SERVICES TO THE OSCEOLA CAMPUS FROM MARCH THROUGH SEPTEMBER AND SUBSEQUENTLY THE DECISION TO CLOSE THAT LOCATION AT THE END OF 2020. FORM 990, PART VI, SECTION B, LINE 11B THE COMPLETED FORM WAS REVIEWED AND APPROVED BY THE ADMINISTRATOR AND CHIEF FINANCIAL OFFICER BEFORE THE FORM WAS FILED. THE BOARD OF DIRECTORS FINANCE COMMITTEE MEETING AND THE FULL BOARD OF DIRECTORS RECEIVED A COPY AFTER THE RETURN WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICT OF INTEREST POLICY THAT IS MONITORED THROUGHOUT THE YEAR. ANNUALLY THE BOARD OF DIRECTORS MUST ATTEST TO ANY KNOWN CONFLICTS AS DEFINED BY THE POLICY. IF AT THAT TIME, OR DURING THE YEAR, A MEMBER BELIEVES THERE TO BE A CONFLICT THEY MUST DISCLOSE SUCH EXISTENCE TO THE BOARD OR COMMITTEE THAT THE OPPORTUNITY PERTAINS TO. THE REMAINING BOARD OR COMMITTEE THEN MUST DETERMINE IF A CONFLICT ACTUALLY EXISTS. IF SO, THE CONFLICTED BOARD MEMBER HAS THE ABILITY TO PRESENT TO THE BOARD ON THE MATTER BUT THEN MUST ABSTAIN FROM FURTHER DISCUSSION OR VOTING ON THE MATTER. FORM 990, PART VI, SECTION B, LINE 15 IN SETTING THE COMPENSATION OF THE CEO AND CFO, THE EXECUTIVE COMMITTEE SHALL COMPLY WITH LADD MEMORIAL HOSPITAL, INC.'S CONFLICT OF INTEREST POLICY AND, WITHOUT LIMITING THAT COMPLIANCE, WILL: (A) ACT ONLY WITH THE PARTICIPATION OF EXECUTIVE COMMITTEE MEMBERS WHO DO NOT HAVE A CONFLICT OF INTEREST CONCERNING THE MATTER, (B) WILL OBTAIN AND RELY UPON APPROPRIATE DATA AS TO COMPARABILITY, AND (C) WILL ADEQUATELY AND TIMELY DOCUMENT THE BASIS FOR ITS DETERMINATION, CONCURRENTLY WITH MAKING THAT DETERMINATION. APPROPRIATE DATA AS TO COMPARABILITY CAN INCLUDE, BUT IS NOT NECESSARILY LIMITED TO: COMPENSATION LEVELS PAID BY SIMILARLY SITUATED ORGANIZATIONS, BOTH TAXABLE AND TAX-EXEMPT, FOR FUNCTIONALLY COMPARABLE POSITIONS; THE AVAILABILITY OF SIMILAR SERVICES IN THE GEOGRAPHIC AREA OF THE CORPORATION; CURRENT COMPENSATION SURVEYS COMPILED BY INDEPENDENT FIRMS; OR ACTUAL WRITTEN OFFERS FROM SIMILAR INSTITUTIONS COMPETING FOR THE SERVICES OF THE SAME INDIVIDUAL. ADEQUATE AND TIMELY DOCUMENTATION WILL GENERALLY BE MINUTES OR OTHER RECORDS OF THE EXECUTIVE COMMITTEE MEETING THAT STATE: THE COMPENSATION AND WHEN IT WAS APPROVED; THE EXECUTIVE COMMITTEE MEMBERS WHO WERE PRESENT AND HOW EACH VOTED; THE COMPARABILITY DATA OBTAINED AND RELIED UPON BY THE EXECUTIVE COMMITTEE AND A SUMMARY OF HOW THE DATA WAS OBTAINED, AND ANY ACTION TAKEN IN SPECIFIC COMPLIANCE WITH THE MEDICAL CENTER'S CONFLICT OF INTEREST POLICY. IF THE EXECUTIVE COMMITTEE APPROVES A COMPENSATION PACKAGE FOR THE CEO OR CFO THAT IS HIGHER OR LOWER THAN THE RANGE OF COMPARABILITY DATA OBTAINED, THE BASIS FOR THE DETERMINATION OUTSIDE THE RANGE MUST BE RECORDED. MINUTES OR OTHER RECORDS OF THE EXECUTIVE COMMITTEE THAT DOCUMENT A DECISION ON CEO OR CFO COMPENSATION MUST BE PREPARED BEFORE THE LATER OF THE NEXT MEETING OF THE EXECUTIVE COMMITTEE OR 60 DAYS AFTER THE DECISION, AND MUST BE REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE WITHIN A REASONABLE PERIOD THEREAFTER. FORM 990, PART VI, SECTION C, LINE 19 LADD MEMORIAL HOSPITAL, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G PHYSICIAN SERVICES: PROGRAM SERVICE EXPENSES 7,687,163. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,687,163. ANESTHESIA SERVICES: PROGRAM SERVICE EXPENSES 724,936. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 724,936. LAB SERVICES: PROGRAM SERVICE EXPENSES 1,023,482. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,023,482. RADIOLOGY SERVICES: PROGRAM SERVICE EXPENSES 951,474. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 951,474. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 230,228. MANAGEMENT AND GENERAL EXPENSES 253,069. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 483,297. OSCEOLA COMMUNITY HEALTH FOUNDATION INC 2600 65TH AVENUE OSCEOLA WI 54020 392029106 FOUNDATION WI 501(C)(3) LINE 12B, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 OSCEOLA COMMUNITY HEALTH FOUNDATION C 131468 ACTUAL