2019-11-15T15:13:41-06:00 2018-12-31 390758449 WIPFLI LLP 4890 OWEN AYRES COURT SUITE 200 EAU CLAIRE WI 54701 990 2018-01-01 390944012 MOUNDVIEW MEMORIAL HOSPITAL & CLINICS MOUN 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 FRANK PEREZ-GUERRA CEO 6083393331 2019-11-13 1 PAUL M TRACZEK CPA P01368830 7158323407 2019-11-13 74.87.127.216 2019-11-13 13:58:12 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 1C219CDDF15C8270F05DB4B8B867D1BB5680077B 2018 2020-03-31 21:24:44Z GUNDERSEN MOUNDVIEW HOSPITAL AND CLINICS FRANK PEREZ-GUERRA 402 WEST LAKE STREET FRIENDSHIP WI 53934 18309516 0 X HTTP://WWW.GUNDERSENHEALTH.ORG/MOUNDVIEW/ X 1959 WI WE WILL ENHANCE THE HEALTH AND WELL-BEING OF OUR COMMUNITIES WHILE ENRICHING EVERY LIFE WE TOUCH, INCLUDING PATIENTS, FAMILIES AND STAFF. 11 4 182 60 0 1603 46379 179418 10845952 18037066 23485 50264 42200 28028 10958016 18294776 0 0 0 0 5151876 9686974 0 0 0 5765359 9110087 10917235 18797061 40781 -502285 15376510 14211453 6162341 5541149 9214169 8670304 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 15278325 17963663 THE HOSPITAL IS A GENERAL MEDICAL CRITICAL ACCESS HOSPITAL LICENSED FOR 25 BEDS. DURING FISCAL YEAR 12-2018 (12 MONTHS), THE HOSPITAL HAD 440 ACUTE INPATIENT DAYS AND 280 MEDICARE SKILL NURSING DAYS (SWING BED). THE HOSPITAL ALSO HAD 5,020 EMERGENCY ROOM VISITS, 1,109 URGENT CARE VISITS AND 35,313 OUTPATIENT CLINIC AND OTHER OUTPATIENT ANCILLARY VISITS. 15278325 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 230 0 182 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 11 4 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 WI X CURT DOWDY CFO 6083393331 402 WEST LAKE STREET FRIENDSHIP WI 53934 RICHARD STERNHAGEN- TERMED CHAIR 2.50 X X 0 0 0 RENEE SCHINDLBECK TREASURER 2.50 X X 0 0 0 BARBARA ALBRECHT BOARD MEMBER 2.50 X 0 0 0 PAUL FISCH VICE-CHAIR 2.50 X X 0 109248 37164 ROXANNE POTTS BOARD MEMBER 2.50 X 0 0 0 MICHAEL CUMMINGS BOARD MEMBER 2.50 X 0 0 0 GARITH STEINER BOARD MEMBER 2.50 X 0 278260 39305 FRANK PEREZ GUERRA CEO 40.00 X X 0 171498 47083 MICHAEL O'NEILL BOARD MEMBER 2.50 X 0 175870 45977 BRYAN ERDMANN BOARD MEMBER 2.50 X 0 261182 61694 SARAH ROSSMAN SECRETARY 2.50 X X 0 112941 23074 MARILU BINTZ BOARD MEMBER 2.50 X 0 635394 41041 DONALD HEINZ- TERMED CEO 40.00 X 174081 0 22452 ALICIA FERNANDEZ PHYSICIAN 40.00 X 194083 0 7938 SHERYL OBERNBERGER NURSE PRACTITIONER 40.00 X 163868 0 30007 HEATHER CLARSON NURSE PRACTITIONER 40.00 X 128581 0 31020 BRONWYN DILLEY NURSE PRACTITIONER 40.00 X 138751 0 27275 DAVID SHAPIRO PHARMACY DIRECTOR 40.00 X 136324 0 14679 935688 1744393 428709 17 0 1 0 EMCARE PHYSICIAN SERVICES INC 7032 COLLECTION CENTER DRIVE CHICAGO IL 60693 ER PHYSICIAN COVERAGE 1868009 WEATHERBY HEALTHCARE PO BOX 972633 DALLAS TX 753972633 SPECIALTY PHYSICIAN SERVICES 940845 GUNDERSEN HEALTH SYSTEM 1900 SOUTH AVENUE LA CROSSE WI 54601 ADMINISTRATIVE AND CLINICAL SERVICES 461450 SHARED IMAGING SERVICES PO BOX 88450 MILWAUKEE WI 532880450 NUCLEAR MEDICINE/EKG TESTING SERVICES 307573 CERNER CORPORATION PO BOX 959156 ST LOUIS MO 63195 EHR MAINTENANCE CONTRACTS 236402 7 130650 13584 35184 179418 NET PATIENT SERVICE REVENUE 900099 17885381 17885381 MISCELLANEOUS REVENUE 900099 97421 97421 MEDICAL BUILDING RENT 900099 54264 54264 18037066 50264 50264 18750 14740 4010 4010 4010 EHR INCENTIVE 900099 24018 24018 24018 18294776 17963663 0 151695 X 196533 196533 7543098 6148559 1394539 147875 112390 35485 1264830 882609 382221 534638 413909 120729 24775 24775 30633 30633 5246037 4632986 613051 41454 41454 2072326 1749700 322626 27878 1981 25897 278045 265863 12182 20510 12906 7604 12188 8006 4182 180750 157630 23120 484378 423408 60970 84099 41306 42793 REPAIRS & MAINTENANCE 355103 327954 27149 COLLECTION EXPENSE 111397 111397 EQUIPMENT RENTS & LEASE 47863 47863 92651 51255 41396 18797061 15278325 3518736 0 700 700 4293035 2699910 3193580 3016239 39584 35139 364966 279249 165834 52744 7012482 650307 6151656 6362175 1132016 1800436 15376510 14211453 2572934 2545124 25250 3165000 2715000 141133 60358 283274 195417 6162341 5541149 X 8642153 8139868 572016 530436 9214169 8670304 15376510 14211453 X -502285 -41580 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 1463 1463 0 PART II-B, LINE 1: WHA MEMBERSHIP DUES 76500 76500 5067021 277573 4789448 1196787 285928 910859 672174 86806 585368 6362175 RECEIVABLE FROM POLIVKA TRUST 530436 RECEIVABLE FROM THIRD PARTY PAYORS 1270000 1800436 CAPITAL LEASE OBLIGATIONS 195417 195417 18274954 -34562 -34562 18309516 -14740 -14740 18294776 18811801 14740 14740 18797061 0 18797061 PART XI, LINE 2D - OTHER ADJUSTMENTS: FOUNDATION ACTIVITY -34,562. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -14,740. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 14,740. 1 1 X 1 X 1 X 1 1 1 0 1 1 66698 66698 0.00350 3133890 1452421 1681469 0.08950 3200588 1452421 1748167 0.09300 162562 12323 150239 0.00800 10590 10590 0.00060 173152 12323 160829 0.00860 3373740 1464744 1908996 0.10160 1 541245 43300 7475452 7585054 -109602 X 1 1 1 1 MOUNDVIEW MEMORIAL HOSPITAL 402 WEST LAKE STREET FRIENDSHIP WI 53934 HTTPS://WWW.GUNDERSENHEALTH.ORG/MOUNDV 1014 X X X X MOUNDVIEW MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X X 18 1 0 1 1 X HTTP://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8071/MOUNDVIEW-NEEDS-ASSESS X 1 18 1 HTTP://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8916/MOUNDVIEW-IMPLEMENTATI 0 1 X 200.000000000000 200.000000000000 X X 1 1 X X X X 1 X HTTP://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8939/MOUNDVIEW-GL-2555-FINA X HTTP://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8946/FINANCIAL-ASSISTANCE-A X HTTP://WWW.GUNDERSENHEALTH.ORG/APP/FILES/PUBLIC/8936/MOUNDVIEW-PLAIN-LANGUA X X X X X X 1 X 0 X X X X 1 X 0 0 MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: THE HOSPITAL COLLABORATED WITH THE ADAMS COUNTY PUBLIC HEALTH, UW EXTENSION, ADAMS COUNTY GOVERNMENT, ADAMS-FRIENDSHIP SCHOOL DISTRICT AND COMMUNITY MEMBERS TO CREATE AND CONDUCT A HEALTH SURVEY OF THE GENERAL PUBLIC IN MARCH 2016. THERE WERE 602 RESPONDENTS, MAKING IT A STATISTICALLY SIGNIFICANT SAMPLE OF THE COUNTY. THE SURVEY WAS WIDELY DISTRIBUTED VIA A SURVEY LINK SHARED THROUGH ORGANIZATION EMAIL LISTS, ORGANIZATION FACEBOOK PAGES, AREA NEWSLETTERS, NEWSPAPER AND RADIO. INDIVIDUALS WERE LIMITED TO ONE SURVEY PER EMAIL ADDRESS. PAPER SURVEYS WERE DISTRIBUTED THROUGH FOOD PANTRIES, LIBRARY, MEALS ON WHEELS, SENIOR MEAL SITES AND THE LIGHTED SCHOOL HOUSE PROGRAM TO OBTAIN INPUT FROM THOSE WITHOUT COMPUTERS AND OTHER DIFFICULT TO REACH POPULATIONS. SURVEY RESPONDENTS WERE ASKED TO RANK ISSUES THAT MAY IMPACT THEIR COMMUNITY'S HEALTH ON A SEVEN POINT SCALE AND TO NAME THEIR TOP TWO HEALTH CONCERNS. A SIMILAR SURVEY WAS DISTRIBUTED VIA EMAIL TO 43 COMMUNITY STAKEHOLDERS WHO WERE IDENTIFIED AS HAVING A BROAD, VESTED INTEREST IN THE COMMUNITY. THESE INCLUDED MEDICAL PROVIDERS AND PROFESSIONALS, SERVICE AGENCIES (INCLUDING THOSE REPRESENTING LOW INCOME AND DISABILITY POPULATIONS), SCHOOL LEADERS, COUNTY GOVERNMENT, BUSINESS LEADERS AND OTHER OFFICIALS. COMMUNITY STAKEHOLDER AND PATIENT ADVISORY COUNCIL FOCUS GROUPS WERE HELD IN 2018 TO REVIEW AND PRIORITIZE SEVEN IDENTIFIED NEEDS. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: WHILE THE NEEDS ASSESSMENT IS SPECIFIC TO GUNDERSEN MOUNDVIEW, THE HOSPITAL COLLABORATED WITH OTHER ORGANIZATIONS IN OBTAINING AND ANALYZING DATA INCLUDING ADAMS COUNTY HEALTH PUBLIC HEALTH AND THE BE HEALTHY ADAMS COUNTY COALITION WHICH INCLUDED REPRESENTATIVES FROM ADAMS COUNTY HEALTH AND HUMAN SERVICES, ADAMS COUNTY UW EXTENSION, ADAMS COUNTY GOVERNMENT, ADAMS-FRIENDSHIP SCHOOL DISTRIC AND COMMUNITY MEMBERS AT LARGE. MOUNDVIEW MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: GUNDERSEN MOUNDVIEW ESTABLISHED AN IMPLEMENTATION PLAN TO ADDRESS IDENTIFIED HEALTH NEEDS. WE HAVE ADDRESSED "CHRONIC DISEASE AND CONDITIONS" BY CONTINUING TO PARTICIPATE IN NUMEROUS COMMUNITY HEALTH COALITIONS AND PROMOTING/PARTICIPATING IN RELATED PROGRAMMING AND EVENTS. WE ALSO IMPLEMENTED A MENTORING PROGRAM AT THE ELEMENTARY SCHOOL TO HELP MITIGATE THE IMPACT OF ADVERSE CHILDHOOD EXPERIENCES. WE HAVE ADDRESSED "SUBSTANCE ABUSE" THROUGH OUR SUPPORT/COLLABORATION WITH FAMILY HEALTH LA CLININICA ROCHE-A-CRI BEHAVIORAL HEALTH AND RECOVERY CENTER, CONTINUED PARTICIPATION ON DRUG FREE COALITIONS AND PROGRAMS, SPONSORED AN EVENT TO EDUCATE PARENTS/GUARDIANS ON TEEN SUBSTANCE ABUSE SIGNS, AND PROVIDED LAB SUPPORT TO THE COUNTY DRUG TREATMENT COURT. WE HAVE ADDRESSED "HEALTH CARE COST AND ACCESS" BY CONTINUING TO WORK ON PRIMARY AND SPECIALTY PROVIDER RECRUITMENT, FINDING COST CONTAINMENT STRATEGIES THROUGH SHARED RESOURCES VIA OUR AFFILIATION WITH GUNDERSEN, AND ENHANCING MENTAL HEALTH THROUGH THE ROCHE-A-CRI BEHAVIORAL HEALTH AND TREATMENT CENTER. WE HAVE ADDRESSED "WORKFORCE DEVELOPMENT" BY PARTICIPATING ON THE COUNTY ECONOMIC DEVELOPMENT COUNCIL, PROVIDING JOB SHADOWING AND CLINICAL ROTATIONS/INTERNSHIP OPPORTUNITIES, ESTABLISHING A NURSING SCHOLARSHIP THROUGH THE TECHNICAL COLLEGE, AND PROVIDING CONTINUING EDUCATION AND TUITION REIMBURSEMENT PROGRAMS FOR OUR STAFF. 2 1 - GUNDERSEN FRIENDSHIP CLINIC 402 WEST LAKE STREET FRIENDSHIP WI 53934 CLINIC 2 - GUNDERSEN WESTFIELD CLINIC 207 NORTH PIONEER PARK ROAD WESTFIELD WI 53964 CLINIC PART I, LINE 7: UTILIZE THE MEDICARE COST TO CHARGE METHODOLOGY. PART II, COMMUNITY BUILDING ACTIVITIES: THE HOSPITAL'S COMMUNITY BUILDING ACTIVITIES PROMOTES HEALTH OF THE COMMUNITIES IT SERVES THROUGH LOCAL ADVERTISEMENTS, INVOLVEMENT WITH CHAMBER OF COMMERCE, DEPARTMENT OF AGING AND OTHER COMMUNITY ORGANIZATIONS. THE AMOUNT OF SUPPORT IS DIFFICULT TO QUANTIFY. PART III, LINE 2: THE RATIO OF PATIENT COST TO CHARGES WAS CALCULATED BY DIVIDING HOSPITAL EXPENSES NET OF NON-PATIENT REVENUE AND IDENTIFIED COMMUNITY BENEFIT EXPENSE BY GROSS PATIENT REVENUE. THE PERCENTAGE WAS THEN MULTIPLED BY THE GROSS REVENUES ON BAD DEBT ACCOUNTS. PART III, LINE 3: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. PART III, LINE 4: PATIENT ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING CONSOLIDATED BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND AN ALLOWANCE FOR DOUBTFUL ACCOUNTS, THAT REFLECTS MANAGEMENT'S BEST ESTIMATE OF AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH A REDUCTION OF GROSS PATIENT SERVICE REVENUE AND A CREDIT TO PATIENT ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY FROM UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND CURRENT STATUS OF INDIVIDUAL ACCOUNTS.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 UNCOLLECTIBLE 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 UNCOLLECTIBLE 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 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 SIGNIFICANT 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. 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 UNCOLLECTIBLE ACCOUNTS. PART III, LINE 8: IT IS CONSIDERED COMMUNITY BENEFIT AS THE HOSPITAL IS REIMBURSED ON MEDICARE ALLOWABLE COSTS. MEDICARE ALLOWABLE COSTS ARE DEFINED BY MEDICARE. THEY DO NOT NECESSARILY CAPTURE ALL COSTS OF THE HOSPITAL PROVIDING SERVICES TO THE COMMUNITY. CONSEQUENTLY, THERE ARE COSTS NOT REIMBURSED BY EITHER PATIENT OR THE PROGRAM. THE COST METHODOLOGY USED TO DETERMINE MEDICARE ALLOWABLE COSTS IS A STEP-DOWN ALLOCATION OF COSTS FROM NON-REVENUE AREAS TO REVENUE AREAS. THIS ALLOCATION IS DONE FOLLOWING MEDICARE RULES AND REGULATIONS. PART III, LINE 9B: PATIENTS UPON REGISTRATION ARE GIVEN THE POLICY AND REQUIREMENTS TO BE ELIGIBLE FOR CHARITY CARE. THEY ARE ENCOURAGED BY A FINANCIAL ADVISOR TO REVIEW THEIR SITUATION FOR ELIGIBILITY. PART VI, LINE 2: THE HOSPITAL COLLECTS, REVIEWS AND ANALYZES LOCAL, REGIONAL AND STATE DATA SOURCES IN CONJUNCTION WITH THE LOCAL PUBLIC HEALTH DEPARTMENT TO ASSESS SPECIFIC UNMET COMMUNITY NEEDS. THIS DATA INCLUDES SURVEYS OF THE GENERAL COMMUNITY AS WELL AS COMMUNITY STAKEHOLDERS WITH A BROAD, VESTED INTEREST IN THE COMMUNITY. IT ALSO INCLUDES TWO FOCUS GROUP SESSIONS OF COMMUNITY STAKEHOLDERS AND THE HOSPITAL'S PATIENT ADVISORY COUNCIL TO REVIEW AND HELP PRIORITIZE HEALTH NEEDS. THE HOSPITAL ANNUALLY REVIEWS THE COUNTY HEALTH RANKINGS AS WELL AS INFECTION CONTROL/COMMUNICABLE DISEASE REPORTS WITH THE PUBLIC HEALTH OFFICE. PART VI, LINE 3: THE HOSPITAL ANNUALLY UPDATES THE AVAILABILITY OF ITS CHARITY PLAN AND QUALIFYING INCOME NEEDS TO QUALIFY ON THE HOSPITAL WEBSITE. THE EXISTENCE OF A CHARITY PLAN IS POSTED IN THE ADMITTING AREA. UPON REGISTRATION, THE PATIENT IS INFORMED OF THE HOSPITAL'S CHARITY PLAN, ELIGIBILITY AND METHODS FOR APPLYING. ANYONE INTERESTED IN FURTHER INFORMATION IS REFERRED TO THE PATIENT ACCOUNT COORDINATOR FOR QUESTIONS AND ELIGIBILITY. THIS PERSON WORKS WITH THE PATIENT IN APPLICATION AS WELL AS EXPLORING THE POSSIBLE ELIGIBILITY OF ANY OTHER GOVERNMENT PROGRAM THAT MAY BE APPLICABLE. IE MEDICAID, BADGER CARE. PART VI, LINE 4: THE ORGANIZATION SERVES ALL OF ADAMS COUNTY WISCONSIN (POPULATION APPROXIMATELY 19,973). ITS PRIMARY SERVICE AREA IS WITHIN THE CENTER OF THE COUNTY, BORDERED BY HWY 82 SOUTH, COUNTY C NORTH. THE COUNTY'S POVERTY RATE IS 13.9% HIGHER THAN THE STATE AVERAGE. OVER 70% OF STUDENTS ENROLLED IN THE SCHOOL DISTRICT ARE ELIGIBLE FOR FREE LUNCH. THE PERCENTAGE OF THOSE AGED 65 YEARS AND OVER IS 28% IS SIGNIFICANTLY HIGHER THAN THE STATE AND IS PROJECTED TO STEADILY INCREASE TO GREATER THAN 35% BY 2040. THERE IS A LOWER LEVEL OF COLLEGE EDUCATED RESIDENTS THAN STATE AVERAGES. PART VI, LINE 5: THE HOSPITAL WORKS WITH LOCAL PUBLIC HEALTH AND COMMUNITY SERVICE ORGANIZATIONS TO COORDINATE AND/OR PROVIDE SPONSORSHIP FUNDS TO SUPPORT COMMUNITY HEALTH PROGRAMS TO MEET THE NEEDS OF THE LOCAL COMMUNITY. THE HOSPITAL PROVIDES INKIND SUPPORT INCLUDING THE USE OF OUR MEETING ROOMS BY NONPROFIT GROUPS, DONATION OF EQUIPMENT/FURNITURE TO HABITAT FOR HUMANITY AND STAFF WHO SERVE ON NUMEROUS COMMUNITY COALITIONS AND HEALTH BOARDS. THE HOSPITAL BOARD INCLUDES COMMUNITY MEMBERS WHO ARE UNPAID. THE HOSPITAL ALSO PROVIDES SPONSORSHIPS OF EVENTS/PROGRAMS THAT HAVE HEALTH/WELLNESS EDUCATION BUILT INTO THEM. PART VI, LINE 6: THE ORGANIZATION IS PART OF GUNDERSEN HEALTH SYSTEM. EACH AFFILIATE DEVELOPS ITS OWN NEEDS ASSESSMENT AND IMPLEMENTATION PLAN, WITH SUPPORT FROM THE SYSTEM AS NEEDED. THE SYSTEM HOLDS QUARTERLY COMMUNITY BENEFIT MEETINGS AMONG THE AFFILIATES TO REVIEW PROGRESS ON GOALS. PART VI, LINE 7, REPORTS FILED WITH STATES WI X 0 0 0 0 0 0 0 0 0 GARITH STEINER BOARD MEMBER 0 277750 0 0 0 510 0 35751 0 3554 0 317565 0 0 FRANK PEREZ GUERRA CEO 0 161506 0 500 0 9492 0 25272 0 21811 0 218581 0 0 MICHAEL O'NEILL BOARD MEMBER 0 174104 0 500 0 1266 0 25904 0 20073 0 221847 0 0 BRYAN ERDMANN BOARD MEMBER 0 258757 0 500 0 1925 0 38134 0 23560 0 322876 0 0 MARILU BINTZ BOARD MEMBER 0 630610 0 500 0 4284 0 29875 0 11166 0 676435 0 0 DONALD HEINZ- TERMED CEO 164655 0 0 0 9426 0 4950 0 17502 0 196533 0 0 0 ALICIA FERNANDEZ PHYSICIAN 3603 0 184 0 190296 0 0 0 7938 0 202021 0 0 0 SHERYL OBERNBERGER NURSE PRACTITIONER 162997 0 0 0 871 0 5170 0 24837 0 193875 0 0 0 HEATHER CLARSON NURSE PRACTITIONER 103482 0 25000 0 99 0 0 0 31020 0 159601 0 0 0 BRONWYN DILLEY NURSE PRACTITIONER 127582 0 10702 0 467 0 3939 0 23336 0 166026 0 0 0 DAVID SHAPIRO PHARMACY DIRECTOR 134879 0 0 0 1445 0 4095 0 10584 0 151003 0 0 0 A VILLAGE OF FRIENDSHIP REVENUE BONDS 396006271 2003-11-01 5000000 WI HOSPITAL DEVELOPMENT REVENUE BONDS 0 0 0 A 450000 5000000 110000 4890000 2005 0 0 1 1 A 0 0 0 0 1 0 1 A 0 1 0 0 0 0 0 0 0 A 0 FORM 990, SCHEDULE K, PART III, LINE 7 MANAGEMENT CALCULATES AND REVIEWS BOND COVENANTS ON A MONTHLY BASIS. THE BOND COVENANTS ARE REPORTED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF MOUNDVIEW MEMORIAL HOSPITAL IS GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., HAS THE RIGHT TO APPOINT, ELECT, AND REMOVE DIRECTORS OF THE BOARD. FORM 990, PART VI, SECTION A, LINE 7B GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., THE SOLE MEMBER, MUST APPROVE OF THE FOLLOWING ACTIONS: BYLAW CHANGES, INCURRENCE OF DEBT IN EXCESS OF A CERTAIN AMOUNT, ANNUAL OPERATING BUDGET, CAPITAL EXPENDITURES, STRATEGIC PLANS, NEW PROGRAMS OR PROJECTS, ANY PLAN TO DISSOLVE, REORGANIZE, MERGE OR CONSOLIDATE, THE APPOINTMENT AND EVALUATION OF THE CHIEF EXECUTIVE OFFICER, PHYSICIAN COMPENSATION, AND THE PAYOR CONTRACTING STRATEGY. FORM 990, PART VI, SECTION B, LINE 11B THE 990 IS REVIEWED BY THE PRESIDENT, TREASURER, CEO AND DIRECTOR OF FINANCE PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY IS REVIEWED EVERY YEAR BY THE POLICY AND PROCEDURE COMMITTEE AND BY THE CEO. OFFICERS AND DIRECTORS ARE REQUIRED TO REVIEW THE POLICY AND DISCLOSE CONFLICTS. THE CEO REVIEWS THE SIGNED STATEMENTS. IF THERE IS A CONFLICT, THE CONFLICT WOULD BE DECLARED AND THE MEMBER WOULD ABSTAIN FROM VOTING. FORM 990, PART VI, SECTION B, LINE 15A CEO COMPENSATION IS BASED ON DIRECT NEGOTIATIONS BETWEEN THE BOARD MEMBERS WITHOUT CONFLICT AND THE INDIVIDUAL UTILIZING CURRENT RELEVANT MARKET SURVEYS AS A GUIDE WITH THE LANGUAGE OF CONTRACT GIVEN TO MMC ATTORNEYS FOR REVIEW AND COMMENTS. SUBSEQUENT MODIFICATIONS ARE PERFORMANCE BASED AND MARKET DRIVEN. FOR OTHER OFFICERS AND KEY EMPLOYEES THE CEO DETERMINES SALARY BASED ON THE MARKET, EXPERIENCE AND INDUSTRY SURVEY GUIDES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION BELIEVES THE GOVERNING DOCUMENTS, AND POLICIES ARE THE PROPERTY OF THE ORGANIZATION AND ARE NOT AVAILABLE FOR PUBLIC INSPECTION. THE AUDITED FINANCIAL STATEMENTS ARE NOW REQUIRED TO BE ATTACHED TO FORM 990. AUDITED FINANCIAL INFORMATION IS POSTED ANNUALLY ON THE HOSPITAL'S WEBSITE. FORM 990, PART IX, LINE 11G EMERGENCY ROOM CONTRACT LABOR: PROGRAM SERVICE EXPENSES 1,651,279. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,651,279. CLINIC CONTRACT LABOR: PROGRAM SERVICE EXPENSES 999,442. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 999,442. OTHER PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 630,355. MANAGEMENT AND GENERAL EXPENSES 446,378. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,076,733. OTHER CONTRACT LABOR: PROGRAM SERVICE EXPENSES 787,815. MANAGEMENT AND GENERAL EXPENSES 166,673. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 954,488. OTHER MEDICAL SERVICES: PROGRAM SERVICE EXPENSES 564,095. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 564,095. FORM 990, PART XI, LINE 9: CHANGE IN ASSETS HELD IN POLIVKA TRUST -41,580. FORM 990, PART XII, LINE 2C: THIS PROCESS HAS NOT CHANGED FROM THE PRIOR YEARS. 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