2020-04-10T10:23:24-05:00 2019-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2018-07-01 390806324 DOOR COUNTY MEMORIAL HOSPITAL DOOR 9207435566 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 ANDREW LALUZERNE CFO 9207435566 2020-04-06 1 TERRI REXRODE CPA MST P00096513 9206620016 2020-02-20 74.87.127.216 2020-04-06 13:11:05 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2018 2021-01-29 14:40:06Z BRIAN STEPHENS 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 118471606 0 X WWW.DCMEDICAL.ORG X 1944 WI TO IMPROVE THE HEALTH AND WELL-BEING OF ALL PEOPLE IN THE COMMUNITIES WE SERVE. 17 14 758 134 0 0 616449 3131593 82735849 90411915 1154044 1227447 -17589 -2149 84488753 94768806 32850 32650 0 0 54742418 57699476 0 0 0 28860330 32283193 83635598 90015319 853155 4753487 107896460 114733211 18201199 18712777 89695261 96020434 X OUR MISSION AS A HEALTH CARE SYSTEM IS TO FURTHER THE HEALING MINISTRY OF JESUS CHRIST BY IMPROVING THE HEALTH AND WELL-BEING OF OUR COMMUNITY, ESPECIALLY THE POOR. 0 0 78198113 32650 90143202 DOOR COUNTY MEMORIAL HOSPITAL ("THE HOSPITAL") IS A FULLY ACCREDITED, ACUTE-CARE HOSPITAL AND OUTPATIENT MEDICAL CENTER, WITH 25 LICENSED BEDS. THE HOSPITAL OFFERS A FULL RANGE OF SERVICES AND SPECIALTIES, INCLUDING HOME HEALTH, A SKILLED NURSING FACILITY FOR LONG-TERM CARE AND REHABILITATION SERVICES, A REHAB SERVICES DEPARTMENT AND NORTH SHORE MEDICAL CLINIC. DURING FISCAL 2019, THE HOSPITAL COUNTED 3,845 INPATIENT DAYS, INCLUDING SWING BED. THE HOSPITAL'S OUTPATIENT FACILITIES, WHICH INCLUDE ITS REHABILITATION AGENCY, 30 BED EXTENDED CARE FACILITY, EMERGENCY ROOM, NORTH SHORE MEDICAL CLINIC SERVED 150,176 VISITS, AND THE NORTH SHORE MEDICAL CLINIC, INCLUDING ITS URGENT CARE FACILITY SERVED 76,330 VISITS. SEE SCHEDULE H FOR FURTHER DETAILS REGARDING THE COMMUNITY BENEFITS DOOR COUNTY MEMORIAL HOSPITAL PROVIDES. 78198113 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 103 0 758 1 0 0 0 0 0 0 0 0 0 0 0 0 X 17 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X ANDREW LALUZERNE 9207435566 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 PATRICK O'HERN BOARD MEMBER 1.00 1.00 X 0 0 0 WILLIAM MUNDY CHAIRMAN 1.00 1.00 X X 0 0 0 CORWIN DAHL SECRETARY 1.00 1.00 X X 0 0 0 KELTON REITZ MD BOARD MEMBER/PHYSICIAN 41.00 1.00 X 391996 0 50725 G HOWARD PHIPPS TREASURER 1.00 1.00 X X 0 0 0 RICHARD HOGAN MD BOARD MEMBER/PHYSICIAN 41.00 1.00 X 356586 0 54553 SCOTT WEDERQUIST BOARD MEMBER 1.00 1.00 X 0 0 0 THERESE PANDL BOARD MEMBER 1.00 X 0 0 0 GREG SIMIA BOARD MEMBER 1.00 X 0 0 0 MIKE FELHOFER VICE CHAIR 1.00 1.00 X X 0 0 0 DREW RICHMOND BOARD MEMBER 1.00 1.00 X 0 0 0 SANDY SEKADLO BOARD MEMBER 1.00 1.00 X 0 0 0 PATRICIA VICKMAN BOARD MEMBER 1.00 1.00 X 0 0 0 REVEREND CARL SCHMITT BOARD MEMBER 1.00 1.00 X 0 0 0 MITCH GROESSL BOARD MEMBER 1.00 1.00 X 0 0 0 PARVINDER JANDU BOARD MEMBER 1.00 1.00 X 0 0 0 DORENE DEMPSTER MD MEDICAL STAFF PRESIDENT 40.00 1.00 X X 366304 0 51144 PAUL BOARD MD MEDICAL STAFF PRESIDENT ELECT 41.00 X 265287 0 61837 BRIAN MATYSIAK FORMER MEDICAL STAFF PRESIDENT 40.00 1.00 X 437776 0 52412 GERALD WORRICK CEO - RETIRED 41.00 0.30 X 374531 0 45079 BRIAN STEPHENS CHIEF EXECUTIVE OFFICER 40.00 1.00 X 149749 0 43438 ANDREW LALUZERNE CHIEF FINANCIAL OFFICER 40.00 X 93694 0 14468 DANIEL TOMASZEWSKI MD PHYSICIAN 40.00 X 1347022 0 56813 JAMES HEISE MD PHYSICIAN 40.00 X 453423 0 53744 MICHAEL BRUNO MD PHYSICIAN 40.00 X 497188 0 57639 MARC BINARD MD PHYSICIAN 40.00 X 581906 0 47644 REYNALDO PALINES MD PHYSICIAN 40.00 X 502281 0 23218 5817743 0 612714 70 0 1 0 INFINITY HEALTHCARE INC 111 E WISCONSIN AVE SUITE 2000 MILWAUKEE WI 54302 ER PHYSICIANS 3096376 ST VINCENT HOSPITAL PO BOX 13508 GREEN BAY WI 54307 LAB SERVICES AND CONTRACT LABOR 695746 NORTHERN XRAY COMPANY 2118 4TH AVE SOUTH MINNEAPOLIS MN 55404 RADIOLOGY EQUIP SERVICE CONTRACTS 663042 MEDICAL STAFFING SOLUTIONS INC PO BOX 101 RICE LAKE WI 54868 CONTRACTED LABOR 636163 BERNERS SCHOBER ASSOCIATES 310 PINE STREET GREEN BAY WI 54301 CONTRACTED LABOR 615138 17 2962993 135000 33600 3131593 NET PATIENT SERVICE REVENUE 622110 87652678 87652678 MOB RENTAL INCOME 909999 362582 362582 THERAPY OTHER REVENUES 909999 325895 325895 CAFETERIA REVENUES 622100 268713 268713 OCCUPATIONAL HEALTH AND WELLNESS 909999 176280 176280 1625767 1625767 90411915 1157710 1157710 10908 13057 -2149 -2149 -2149 23739480 20000 23662440 27303 77040 -7303 69737 69737 94768806 90143202 0 1494011 32650 32650 2380983 1548664 832319 41853849 38115795 3738054 1990994 1812294 178700 8806732 7964738 841994 2666918 2400596 266322 262006 223162 38844 91605 91605 162378 162378 8332963 6874935 1458028 833606 2298 831308 11610380 11204587 405793 2164900 337068 1827832 1460864 1337679 123185 681164 506688 174476 327557 306966 20591 3823605 3583131 240474 334270 108693 225577 BAD DEBT EXPENSE 1613761 1613761 DUES AND SUBSCRIPTIONS 218184 111278 106906 EQUIPMENT RENTAL 113130 113130 252820 252820 90015319 78198113 11817206 0 3128 3128 6368661 5571880 12813738 13549115 129167 72500 233614 164431 1482613 1512645 1401372 1319069 52690511 12819278 32088559 39871233 46212577 50522704 7163031 2146506 107896460 114733211 6593169 7475446 7223938 6762068 4384092 3583909 0 891354 18201199 18712777 X 87307352 95389491 2387909 630943 89695261 96020434 107896460 114733211 X 4753487 3328652 -1756966 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 12581 12581 0 PART II-B, LINE 1: LOBBYING EXPENSES REPRESENT THE PORTION OF DUES PAID TO NATIONAL AND STATE HOSPITAL ASSOCIATIONS THAT ARE SPECIFICALLY ALLOCABLE TO LOBBYING. DOOR COUNTY MEMORIAL HOSPITAL DOES NOT PARTICIPATE IN OR INTERVENE IN (INCLUDING THE PUBLISHING OR DISTRIBUTING OF STATEMENTS) ANY POLITICAL CAMPAIGN ON BEHALF OF (OR IN OPPOSITION TO) ANY CANDIDATE FOR PUBLIC OFFICE. 4203540 4203540 21453631 7248831 14204800 6354 6354 0 17070548 5564093 11506455 9956438 9956438 39871233 DUE TO 3RD-PARTY REIMBURSEMENT PROGRAMS 891354 891354 96334376 3328652 -1613761 1714891 94619485 162378 -13057 149321 94768806 88252237 13057 13057 88239180 162378 1613761 1776139 90015319 PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -1,613,761. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -13,057. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 13,057. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,613,761. 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 1224655 1224655 0.01390 6707128 5005621 1701507 0.01920 7931783 5005621 2926162 0.03310 18 236 1167685 98351 1069334 0.01210 6 99 524297 524297 0.00590 4 3412 1797457 169326 1628131 0.01840 7 2172 445400 445400 0.00500 35 5919 3934839 267677 3667162 0.04140 35 5919 11866622 5273298 6593324 0.07450 1 149 149 0.00000 1 912 912 0.00000 1 13953 13953 0.00020 1 141 35989 35989 0.00040 1 1781 1781 0.00000 3 158987 158987 0.00180 8 141 211771 211771 0.00240 1 1613761 28226491 28507954 -281463 X 1 1 1 1 DOOR COUNTY MEMORIAL HOSPITAL 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 WWW.DCMEDICAL.ORG 1054 X X X X DOOR COUNTY MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X HTTP://WWW.DCMEDICAL.ORG/ABOUT US X 1 18 1 HTTP://WWW.DCMEDICAL.ORG/ABOUT US 0 1 X 250.000000000000 400.000000000000 X X X X X 1 1 X X X 1 X HTTPS://WWW.DCMEDICAL.ORG/DCMEDICAL.ORG/MEDIA/FILES/BILLING-AND-INSURANCE/F X HTTPS://WWW.DCMEDICAL.ORG/DCMEDICAL.ORG/MEDIA/FILES/BILLING-AND-INSURANCE/C X HTTPS://WWW.DCMEDICAL.ORG/DCMEDICAL.ORG/MEDIA/FILES/BILLING-AND-INSURANCE/F X X X X X X 1 X 0 X X X X 1 X 0 0 DOOR COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE CHNA PROCESS LISTED BELOW HAPPENS EVERY THREE YEARS. DOOR COUNTY MEDICAL CENTER'S CHNA PROCESS SOUGHT INPUT FROM COMMUNITY MEMBERS, INCLUDING MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS AND FROM ORGANIZATIONS THAT SERVE THOSE POPULATIONS. IN JANUARY 2019, A COMMUNITY STAKEHOLDER MEETING WAS HELD. DOOR COUNTY MEDICAL CENTER INTENTIONALLY INVITED ORGANIZATIONS THAT REPRESENT MEMBERS OF MEDICALLY UNDERSERVED, LOW-INCOME AND MINORITY POPULATIONS. THE STAKEHOLDER MEETING ATTENDEES PARTICIPATED IN A FACILITATED DISCUSSION ABOUT THE COMMUNITY HEALTH DATA, PROGRESS ON THE PREVIOUS PRIORITY AREAS, AND ANY EMERGING NEEDS. THE LIST OF ORGANIZATIONS PARTICIPATING IN THE JANUARY 2019 STAKEHOLDER MEETING IS BELOW. DOOR COUNTY DEPARTMENT OF PUBLIC HEALTH STAFF* DOOR COUNTY MEDICAL CENTER UNITED WAY OF DOOR COUNTY* THE AGING & DISABILITY RESOURCE CENTER OF DOOR COUNTY BOYS AND GIRLS CLUB OF DOOR COUNTY* DOOR COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: A CORE GROUP OF REPRESENTATIVES FROM BOTH THE DOOR COUNTY PUBLIC HEALTH DEPARTMENT AND DOOR COUNTY MEDICAL CENTER WORKED TOGETHER TO IDENTIFY THE DATA TO BE USED AND DISTRIBUTE THAT DATA IN ORDER TO GATHER FEEDBACK FROM KEY STAKEHOLDERS. DOOR COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: PRIORITY NEED #1. MENTAL HEALTH AND WELL-BEINGDCMC IS A MAJOR SPONSOR AND PARTICIPANT OF THE "LEARNING TO EMPOWER AND APPRECIATE ALL PEOPLE" (LEAP) PROJECT. LEAP IS A COMMUNITY PRODUCTION FEATURING OVER 50 DOOR COUNTY HIGH SCHOOL STUDENTS EACH YEAR IN AN EFFORT TO REACH OUT TO SCHOOLS, FAMILIES, AND YOUTH TO PROMOTE PHYSICAL AND MENTAL WELLNESS. IN 2018 LEAP PROJECT'S THEME WAS "INCLUSION IS THE SOLUTION". IN APRIL 2019 THE PRODUCTION WAS PRESENTED TO HIGH SCHOOL PEERS AND COMMUNITY SERVING OVER 1,500 HIGH SCHOOL STUDENTS AND 800 ADULTS. BARB JOHNSON-GIESE WAS THERE TO ANSWER QUESTIONS ABOUT MENTAL HEALTH AND ISSUES SUCH AS SUICIDE.JANUARY 2019 DCMC, ALONG WITH UNITED WAY OF DOOR COUNTY, STARTED THE DOOR COUNTY COLLABORATIVE SCHOOL MENTAL HEALTH PROJECT (STRIDE). THIS PROGRAM ALLOWS MENTAL HEALTH PROVIDERS FROM DCMC TO HAVE COUNSELING SESSIONS WITH STUDENTS AND FAMILIES AT STURGEON BAY SCHOOL. THE PROGRAM ALSO INCLUDES TIME FOR DCMC MENTAL HEALTH PROVIDERS TO EDUCATE AND TRAIN SCHOOL STAFF REGARDING SCHOOL-BASED MENTAL HEALTH. JANUARY THRU MAY 2019, THERE WERE A TOTAL OF 24 HOURS LOGGED BY PROVIDERS WITH THIS PROGRAM. PRIORITY NEED #2. FOOD, NUTRITION, AND EXERCISEDCMC OFFERS SPACE FOR A COMMUNITY GARDEN WHICH IS A WAY TO HELP LOCAL, LOW-INCOME FAMILIES ENJOY NOT ONLY THE HEALTH BENEFITS ASSOCIATED WITH GROWING THEIR OWN FOOD, BUT THE FINANCIAL BENEFITS AS WELL. AT THE COMMUNITY GARDEN, THE $40 RENTAL FEE FOR A 20' X 20' PLOT IS WAIVED FOR FAMILIES THAT RECEIVE WIC OR SNAP BENEFITS THROUGH FOODSHARE, WI. ALL OF THE START-UP COSTS ASSOCIATED WITH A NEW FOOD GARDEN ARE NON-EXISTENT DUE TO ALL TOOLS AND TILLING PROVIDED AND DONE BY DCMC AND THE CITY OF STURGEON BAY. THIS YEAR, 43 GARDENERS ARE HARVESTING 42 PLOTS, ROUNDING OUT ANOTHER SUCCESSFUL GROWING SEASON.DCMC SPONSORS A FOOD VOUCHER PROGRAM AT THE STURGEON BAY FARMER'S MARKET. THE DOUBLE YOUR FOODSHARE DOLLARS PROGRAM AIMS TO INCENTIVIZE HEALTHY EATING BY DOUBLING AVAILABLE FUNDS. THE VOUCHER IS BOUGHT FOR $10 ON A QUEST CARD AND IS WORTH $20 IN FOODSHARE TOKENS TO BE USED AT THE FARMERS MARKET.OVER THE PAST SEVERAL YEARS, DCMH HAS ALSO ASSISTED CROSSROADS OF BIG CREEK WITH THE CREATING OF WALKING PATHS AND CROSS-COUNTRY SKI AND SNOW-SHOE TRAILS. THESE EFFORTS ALSO ENCOURAGE PHYSICAL EXERCISE AND THE APPRECIATION OF BEING OUTDOORS DURING ALL FOUR SEASONS.COMMUNITY HEALTH FAIRS ARE HELD SEVERAL TIMES DURING THE YEAR, WITH DIFFERENT HEALTH AND WELLNESS PARTNERS SUCH AS THE YMCA OF DOOR COUNTY, AND KEWAUNEE COUNTY AGING HEALTH SERVICES. THESE HEALTH FAIRS INCLUDE FREE HEALTH CARE SERVICES FOR THE PUBLIC SUCH AS CHOLESTEROL AND BLOOD PRESSURE SCREENINGS, AS WELL AS SEMINARS FACILITATED BY OUR CLINICAL STAFF AND PHYSICIANS.PRIORITY NEED #3. ORAL HEALTHDCMC HAS A DENTAL CLINIC, WHICH CURRENTLY OPERATES 5 DAYS A WEEK, 8 HOURS A DAY. EACH YEAR WE INCREASE THE AMOUNT OF PATIENT VISITS WE SEE; IN 2018 MORE THAN 400 PATIENTS RECEIVED DENTAL CARE. THIS CLINIC IS UNIQUE IN THAT IT IS THE ONLY ORAL HEALTH CLINIC OF ITS KIND IN THE AREA. THE PATIENTS SERVED ARE ON MEDICAID AND/OR ARE LOW INCOME WITH NO DENTAL INSURANCE AND WOULD HAVE NO OTHER PLACE TO TURN FOR DENTAL CARE. THE SEAL A SMILE PROGRAM IS AN OUTREACH PROGRAM WHERE A HYGIENST FROM THE DENTAL CLINIC BRINGS PORTABLE DENTAL EQUIPMENT INTO THE AREA SCHOOLS AND PROVIDE FLUORIDE VARNISH AND SEALENTS TO 2ND AND 3RD GRADERS, WITH THE CONSENT OF THEIR PARENTS. IN 2018 WE PLACED SEALANTS AND PROVIDED ORAL HEALTH EDUCATION TO 225 STUDENTS. WITH THE HELP OF THE ORAL HEALTH COALITION TEAM OF DOOR COUNTY WE ALSO WENT TO HEADSTART AND WASHINGTON ISLAND WHERE WE PROVIDED FLUORIDE VARNISH TO 200 CHILDREN.ANOTHER SERVICE THE DENTAL CLINIC PROVIDES IS FLUORIDE VARNISH AND EXAMS TO OUR SKILLIED NURSING FACILITY (SNF) RESIDENTS. ON A QUARTERLY BASIS ONE OF OUR DENTISTS VISITS OUR SNF AND DOES EXAMS ON THE RESIDENTS. WHILE THERE, ONE OF OUR HYGIENISTS GOES TO EACH OF THE RESIDENTS AND APPLIES FLUORIDE VARNISH. THE VARNISH HELPS WITH DRY MOUTH SYNDROME THAT IS A REACTION FROM MANY TYPES OF PRESCRIPTION DRUGS. THIS ALSO HELPS PREVENT CAVITIES, SINCE MOST OF THESE RESIDENTS DO NOT SEE A DENTIST ON A REGULAR BASIS FOR TEETH CLEANING. 7 1 - DCMC - STURGEON BAY CLINIC 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 OP PHYSICIAN CLINIC 2 - DCMC - FISH CREEK CLINIC 3711 HIGHWAY 42 FISH CREEK WI 54212 OP PHYSICIAN CLINIC 3 - DCMC - ALGOMA CLINIC 815 JEFFERSON STREET ALGOMA WI 54201 OP PHYSICIAN CLINIC 4 - DCMC - WASHINGTON ISLAND CLINIC 910 MAIN ROAD WASHINGTON ISLAND WI 54246 OP PHYSICIAN CLINIC 5 - STURGEON BAY REHAB SERVICES 1300 EGG HARBOR ROAD STURGEON BAY WI 54235 REHAB SERVICES 6 - SISTER BAY REHAB SERVICES 2311 MEADOW WOOD DRIVE SISTER BAY WI 54234 REHAB SERVICES 7 - ALGOMA REHAB SERVICES 1510 FREMONT STREET ALGOMA WI 54201 REHAB SERVICES PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS FOR SCHEDULE H, LINE 7, IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. THE ACTUAL COST OF SUPPLIES USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A RATIO OF ALL BENEFITS RELATED TO THE WAGE CALCULATION. NO COST TO CHARGE RATIO IS USED. PART I, LN 7 COL(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 $1,613,761. PART II, COMMUNITY BUILDING ACTIVITIES: DOOR COUNTY MEDICAL CENTER PARTICIPATES IN COMMUNITY COALITIONS AND OTHER COLLABORATIVE EFFORTS WITH THE COMMUNITY WHOSE PURPOSE IS TO IMPROVE THE HEATLH OF THE COMMUNITY. THESE INCLUDE HABITAT FOR HUMANITY, WI COMMUNITY HEALTH PROGRAM, SOUTHERN DOOR AUDITORIUM COMMITTEE, DOOR COUNTY ELDER AND ADULT-AT-RISK INTERDISCIPLINARY TEAM, DOOR COUNTY COMMUNITY PARTNERSHIP FOR CHILDREN AND FAMILIES, MENTAL HEALTH FOCUS GROUP AND DOOR COUNTY UNITED WAY. BY WORKING TOGETHER WITH OTHER ORGANIZAITONS IN THE COMMUNITY, WE EXPECT TO HAVE A GREATER IMPACT ON HEALTH. ACCORDING TO THE COUNTY HEALTH RANKINGS SITE, WITH A SHARED VISION AND COMMITMENT TO IMPROVED HEALTH, WORKING TOGETHER CAN YIELD BETTER RESULTS THAN WORKING ALONE. LEADERSHIP FROM DOOR COUNTY MEDICAL CENTER ALSO ATTEND LEADERSHIP DOOR COUNTY. FUTURE COMMUNITY LEADERS WHO ARE KNOWLEDGEABLE ABOUT BOTH THE ASSETS AND CHALLENGES OUR COMMUNITY HAS WILL HELP US TO POSITIVELY ADDRESS THE HEALTH ISSUES OF THE FUTURE. THE MEDICAL CENTER ALSO IS A COMMUNITY SHARPS DISPOSAL SITE. BY SAFELY REMOVING SHARPS FROM THE ENVIRONMENT, WE MAKE THE COMMUNITY SAFER IN TERMS OF INJURY AND INFECTION. IN ADDITION, DOOR COUNTY MEDICAL CENTER PROVIDES JOB SHADOWING FOR AREA YOUTH. ACCORDING TO THE COUNTY HEALTH RANKINGS, EMPLOYMENT PROVIDES INCOME AND BENEFITS THAT CAN SUPPORT HEALTHY LIFESTYLE CHOICES. UNEMPLOYMENT AND UNDER EMPLOYMENT LIMIT THESE CHOICES, AND NEGATIVELY AFFECT BOTH QUALITY OF LIFE AND HEALTH OVERALL. PART III, LINE 2: ACCOUNTS ARE WRITTEN OFF TO BAD DEBT AFTER ALL INTERNAL COLLECTION EFFORTS HAVE BEEN EXHAUSTED. ATTEMPTS TO RESOLVE THESE OUTSTANDING BALANCES CAN INCLUDE, BUT ARE NOT LIMITED TO STATEMENTS BEING SENT, PHONE CALLS AND LETTERS BEING SENT. ACCOUNT FOLLOW UP PROTOCOL IS BASED ON PERSONAL PAY BALANCE SIZE OWED. PART III, LINE 3: DOOR COUNTY MEMORIAL HOSPITAL HAS A VERY ROBUST FINANCIAL ASSISTANCE PROGRAM; THEREFORE, NO ESTIMATE IS MADE FOR BAD DEBT ATTRIBUTED TO FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. PART III, LINE 4: PATIENT PAYMENTS OR DISCOUNTS ARE APPLIED PRIOR TO DETERMINING BAD DEBT EXPENSE AND ARE NOT INCLUDED IN THE BAD DEBT WRITE-OFF REPORTED ON THE AUDITED FINANCIAL STATEMENTS. DEDUCTIBLES AND COINSURANCE AMOUNTS THAT ARE DEEMED UNCOLLECTIBLE ARE WRITTEN OFF EITHER TO BAD DEBT EXPENSE OR, IF APPLICABLE, TO CHARITY CARE IF THE PATIENT SO QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE BUT THEY ACCOUNT FOR BAD DEBTS BASED ON GROSS CHARGES TO PATIENTS AFTER REFLECTING ANY PAYMENTS OR DISCOUNTS, OR AMOUNTS DETERMINED TO BE ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE. PART III, LINE 8: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: DOOR COUNTY MEMORIAL HOSPITAL ("DCMH") HAS A DEBT COLLECTION POLICY WHICH SETS FORTH COLLECTION PRACTICES FOR PATIENTS WHO ARE KNOWN TO QUALIFY OR MAY QUALIFY FOR FINANCIAL ASSISTANCE UNDER THE CHARITY CARE PROGRAM. SUFFICIENT FINANCIAL COUNSELING SUPPORT IS MADE AVAILABLE TO PATIENTS SO THEY CAN EASILY ACCESS PATIENT FINANCIAL SERVICE REPRESENTATIVES AND HAVE THEIR QUESTIONS ANSWERED, AND GAIN AN UNDERSTANDING OF THE REASONS WHY THEY OWE A BALANCE. ACCOUNTS ARE DESIGNATED AS CHARITY CARE IN THE BUSINESS OFFICES SO NO ADDITIONAL TIME IS SPENT ON COLLECTION EFFORTS. PART VI, LINE 2: OTHER THAN THE CHNA PROCESS, WHICH OCCURS EVERY THREE YEARS IN COLLABORATION WITH THE DOOR COUNTY PUBLIC HEALTH DEPARTMENT, THE ORGANIZATION USES MARKET RESEARCH TO GAUGE HEALTH CARE NEEDS. THE ORGANIZATION CONDUCTED A FACEBOOK SURVEY THAT ASSESSED NEEDS IN OUR MARKET/COMMUNITY AND RECEIVED INPUT ON HEALTH CARE NEEDS THAT WILL BE USED IN THE 2019 CHNA. PART VI, LINE 3: THE ORGANIZATION GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THE CHARITY CARE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATION'S WEBSITE. ADMISSIONS AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE CHARITY CARE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE POLICY AND OTHER INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE, THE PATIENT SHALL BE REFERRED TO THE ORGANIZATION'S COMMUNITY CARE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDING FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF COMMUNITY CARE FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITAL'S WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENT'S POTENTIAL NEED FOR COMMUNITY CARE FINANCIAL ASSISTANCE. THE CHARITY CARE POLICY WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE. PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH SCRIPTS TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE CHARITY CARE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: WHILE THERE IS GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S "COMMUNITY BENEFIT", THIS IS A WORK IN PROGRESS. DOOR COUNTY MEMORIAL HOSPITAL ("DCMH") PROVIDED 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 - CARE THAT WITHOUT OUR HOSPITAL, WOULD NOT BE AVAILABLE LOCALLY. THE CITY OF STURGEON BAY IS LOCATED IN DOOR COUNTY. THE POPULATION OF DOOR COUNTY, AS OF THE 2015 CENSUS DATA, IS 24,038. THE POPULATION CONSISTED OF 97% WHITE, 2% HISPANIC, 1% AFRICAN AMERICAN, AND 1% ASIAN. OF THE 24,038 POPULATION, 51% WERE FEMALE AND 49% MALE. THE AGE POPULATION IS WIDELY SPREAD. 17% WERE UNDER 18 AND 24% WERE 65+. THE LARGEST INDUSTRY IN DOOR COUNTY IS EDUCATIONAL, HEALTH AND SOCIAL SERVICES (18.8%). ARTS, ENTERTAINMENT AND RECREATION (16.1%) AND MANUFACTURING (14.0%) ARE THE NEXT LARGEST INDUSTRIES IN DOOR COUNTY. ROUGHLY 6.2% OF FAMILIES AND 11.4% OF THE POPULATION WERE BELOW THE POVERTY LINE. THAT INCLUDES 20.7% OF THOSE UNDER 18 YEARS OLD AND 7.9% OF THOSE 65 AND OLDER. PART VI, LINE 5: THE LOCAL BOARD FOR DOOR COUNTY MEMORIAL HOSPITAL IS MADE UP OF COMMUNITY MEMBERS THAT LIVE IN OUR PRIMARY SERVICE AREA. DOOR COUNTY MEMORIAL HOSPITAL PARTNERS WITH THE LOCAL YMCA ON VARIOUS EVENTS PROMOTING HEALTH AND WELL-BEING IN THE COMMUNITY. DOOR COUNTY MEMORIAL HOSPITAL EXTENDS MEDICAL PRIVILEGES TO ALL QUALIFIED PHYSICIANS IN THE COMMUNITY. DOOR COUNTY MEMORIAL HOSPITAL PARTICIPATES IN MEDICARE, MEDICAID, AND OTHER GOVERNMENT SPONSORED PROGRAMS. PART VI, LINE 6: N/A PART VI, LINE 7, REPORTS FILED WITH STATES WI 1 NORTHEAST WISCONSIN TECHNICAL COLLEGE 2740 W MASON STREET GREEN BAY WI 54307 237069405 501(C)(3) 25000 NURSING & HEALTH CARE PROGRAMS DOOR COUNTY ECONOMIC DEVELOPMENT 185 E WALNUT STREET STURGEION BAY WI 54235 391621905 501(C)(3) 7500 DOOR COUNTY ECONOMIC DEVELOPMENT 2 0 PART I, LINE 2: POLICY STAT ID: 6244784 POLICY STATEMENT: IT IS THE POLICY OF DOOR COUNTY MEDICAL CENTER THAT ANY GRANT OR OTHER ASSISTANCE OF $5,000 OR MORE FROM DOOR COUNTY MEDICAL CENTER WILL REQUIRE ADMINISTRATIVE APPROVAL. THE CONTRIBUTIONS ADDRESSED IN THIS POLICY ARE CONSIDERED GRANT DONATIONS AND ARE NOT SPONSORSHIPS OR MARKETING EVENTS. PROCEDURE: A REQUEST FOR DONATIONS OF $5,000 OR MORE WILL NEED TO BE WRITTEN IN LETTER FORMAT ADDRESSED TO THE DOOR COUNTY MEDICAL CENTER ADMINISTRATIVE TEAM. THE CHECK REQUEST TO BE PROCESSED BY ACCOUNTS PAYABLE SHOULD BE SIGNED BY THE CHIEF EXECUTIVE OFFICER OF THE HOSPITAL. THE ADMINISTRATIVE TEAM WILL DISCUSS AND APPROVE OR REJECT THE REQUEST DURING ITS WEEKLY TEAM MEETING. DEPARTMENT DIRECTORS DO NOT HAVE THE AUTHORITY TO APPROVE ANY DONATION REQUEST. WHEN A REQUEST IS APPROVED BY THE ADMINISTRATIVE TEAM, A "GRANT AGREEMENT" FORM (COPY ATTACHED) WILL BE ISSUED AND WILL BE SIGNED BY THE ORGANIZATION RECEIVING THE CONTRIBUTION. THE ADMINISTRATIVE TEAM, WHEN MAKING DECISIONS ON REQUESTS FOR DONATIONS, MUST DETERMINE THAT THERE IS A DIRECT BENEFIT TO THE WELFARE OF DCMC OR TO THE PATIENTS AND COMMUNITY IT SERVES. AT THE COMPLETION OF THE GRANT PERIOD NOTED ON THE "GRANT AGREEMENT" FORM, THE ORGANIZATION THAT RECEIVED THE CONTRIBUTION WILL NEED TO COMPLETE A "GRANT FINAL REPORT" FORM. X 1 1 X X X X 0 0 0 0 0 0 0 0 0 KELTON REITZ MD BOARD MEMBER/PHYSICIAN 277937 0 113407 0 652 0 16500 0 34225 0 442721 0 0 0 RICHARD HOGAN MD BOARD MEMBER/PHYSICIAN 346000 0 0 0 10586 0 16500 0 38053 0 411139 0 0 0 DORENE DEMPSTER MD MEDICAL STAFF PRESIDENT 351714 0 0 0 14590 0 16500 0 34644 0 417448 0 0 0 PAUL BOARD MD MEDICAL STAFF PRESIDENT ELECT 261635 0 0 0 3652 0 16500 0 45337 0 327124 0 0 0 BRIAN MATYSIAK FORMER MEDICAL STAFF PRESIDENT 417695 0 0 0 20081 0 16500 0 35912 0 490188 0 0 0 GERALD WORRICK CEO - RETIRED 355260 0 0 0 19271 0 16500 0 28579 0 419610 0 0 0 BRIAN STEPHENS CHIEF EXECUTIVE OFFICER 149158 0 0 0 591 0 9584 0 33854 0 193187 0 0 0 DANIEL TOMASZEWSKI MD PHYSICIAN 1019085 0 264340 0 63597 0 15827 0 40986 0 1403835 0 0 0 JAMES HEISE MD PHYSICIAN 439039 0 0 0 14384 0 16500 0 37244 0 507167 0 0 0 MICHAEL BRUNO MD PHYSICIAN 494399 0 0 0 2789 0 16500 0 41139 0 554827 0 0 0 MARC BINARD MD PHYSICIAN 573647 0 0 0 8259 0 16500 0 31144 0 629550 0 0 0 REYNALDO PALINES MD PHYSICIAN 490270 0 0 0 12011 0 16500 0 6718 0 525499 0 0 0 PART I, LINE 1A PHYSICIANS ARE ALLOWED UP TO $1,000 FOR SPOUSE TRAVEL TO CONFERENCES. SUPPORTING DOCUMENTATION OF THE EXPENSES IS MAINTAINED AND TRACKED BY THE PHYSICIANS. SPOUSE TRAVEL AMOUNTS ARE INCLUDED IN TAXABLE COMPENSATION. A WISCONSIN HEALTH & EDUCATION FACILITIES AUTHORITY 391337855 2014-08-15 10000000 REFUND DEBT ISSUED 10/21/09 0 0 0 A 461870 10000000 10000000 1 0 1 1 A 0 0 1 1 0 0 0 1 A 0 1 0 0 1 0 0 1 A 1 DANIEL TOMASZWESKI MD HIGHEST COMPENSATED/PHYSICIAN EMPLOYEE RETENTION LOAN X 150000 45833 0 1 1 JAMES HEISE MD HIGHEST COMPENSATED/PHYSICIAN EDUCATION LOAN X 50000 26667 0 1 1 72500 FORM 990, PART VI, SECTION A, LINE 6 THERE ARE TWO CLASSES OF MEMBERS. CLASS H MEMBERS ARE REPRESENTATIVES FROM HSHS. TWO CLASS H MEMBERS ARE REQUIRED PER THE PARTNERSHIP AGREEMENT WITH HSHS. CLASS D MEMBERS ARE REPRESENTATIVES FROM DOOR COUNTY MEDICAL CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A CLASS H DIRECTORS OF THE GOVERNING BODY OF DOOR COUNTY MEMORIAL HOSPITAL SHALL BE APPOINTED BY ST. VINCENT HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS PROVIDED THAT THE CLASS D DIRECTORS SHALL RECEIVE ADVANCE NOTICE OF AND THE RIGHT TO ATTEND AND PARTICIPATE IN DISCUSSION AT SVGB MEETINGS DURING WHICH SVGB DISCUSSES POTENTIAL CANDIDATES TO THE CLASS H DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B STARTING 11/1/16 DOOR COUNTY MEMORIAL HOSPITAL ENTERED INTO AN AFFILIATION AGREEMENT WITH HOSPITAL SISTERS HEALTH SYSTEM, HOSPITAL SISTERS SERVICES, INC. AND ST. VINCENT HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS. THERE ARE SOME DECISIONS THAT REQUIRE AFFIRMATIVE APPROVAL OF THE CLASS H DIRECTORS, VOTING A SINGLE VOTE AS A CLASS, AND THE AFFIRMATIVE APPROVAL OF THE CLASS D DIRECTORS, VOTING A SINGLE VOTE AS A CLASS. FORM 990, PART VI, SECTION B, LINE 11B MANAGEMENT, INCLUDING CERTAIN OFFICER, WORKS DILIGENTLY TO COMPLETE THE FORM 990 AND ATTACHED SCHEDULES IN A THOROUGH MANNER. PRIOR TO FILING THE RETURN, ALL BOARD MEMBERS ARE PROVIDED THE FORM 990 AND MANAGEMENT TEAM MEMBERS ARE AVAILABLE TO ANSWER ANY BOARD MEMBERS' QUESTIONS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY IN THAT ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF THE COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING INDIVIDUALS OF THE GOVERNING BOARD OR COMMITTEE WILL DECIDE IF CONFLICTS ON INTEREST EXIST. EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICT OF INTEREST POLICY, HAS READ AND UNDERSTAND THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX-EXEMPT PURPOSE. FORM 990, PART VI, SECTION B, LINE 15 IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, THE PROCESS PERFORMED BY DOOR COUNTY MEMORIAL HOSPITAL, INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE, WHICH IS ASSISTED BY AN INDEPENDENT CONSULTING FIRM, REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO, WAS COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. INDIVIDUAL WAS NOT PRESENT WHEN HIS COMPENSATION WAS DECIDED. IN DETERMINING COMPENSATION OF OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS PERFORMED BY DOOR COUNTY MEMORIAL HOSPITAL, INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE COMPENSATION COMMITTEE, ASSISTED BY AN INDEPENDENT CONSULTING FIRM, REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OTHER OFFICERS AND KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO INDIVIDUALS AT OTHER ORGANIZATIONS IN THE AREA WHO HOLD THE SAME TITLE. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE DOOR COUNTY MEMORIAL HOSPITAL WEB PAGE IS AVAILABLE TO THE PUBLIC FOR INSPECTION WITH A GOOD DEAL OF INFORMATION REGARDING WHO DOOR COUNTY MEMORIAL HOSPITAL IS ALONG WITH OUR MISSION. THE ARTICLES OF INCORPORATION, BYLAWS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE NOT INCLUDED ON ANY WEB PAGE. HOWEVER, IF ANY INQUIRY IS MADE FOR ANY DOCUMENTS THEY ARE SHARED AS APPROPRIATE. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS IN DOOR COUNTY HOSPITAL FOUNDATION -1,756,966. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. DOOR COUNTY MEDICAL CORPORATION 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 814221171 SUPPORTING ORGANIZATION WI 501(C)(3) LINE 12B, II 0 DOOR COUNTY MEMORIAL HOSPITAL FOUNDATION INC 1843 MICHIGAN STREET STURGEON BAY WI 54235 391649104 CHARITABLE FOUNDATION WI 501(C)(3) LINE 7 DOOR COUNTY MEDICAL CORPORATION 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1 1 0 DOOR COUNTY MEMORIAL HOSPITAL FOUNDATION INC C 2962993 ACTUAL