2019-07-30T13:25:02-05:00 2018-09-30 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2017-10-01 390799566 Tomah Memorial Hospital TOMA 6083722181 321 Butts Avenue Tomah WI 54660 Joseph Zeps Chief Financial Officer 6083722181 2019-07-29 1 Kim Hunwardsen CPA P00484560 6122536500 2019-07-29 199.247.44.58 2019-07-29 14:12:54 CD P D8A1E5117AA53286D53F57459EBB2DE5C7CA50FC F9BEE9501A3B4F00F190E63700B8BF2BC70C7B96 2017 2019-02-21 02:37:17Z Philip J Stuart 321 Butts Avenue Tomah WI 54660 110630595 0 X www.tomahhospital.org X 1948 WI To promote and provide quality health care to patients in a hospital setting 10 9 422 70 0 0 341949 858518 53812460 59186341 878802 2762298 -27190 -36449 55006021 62770708 0 0 0 0 25884355 28660797 0 116400 116400 25851107 29486948 51735462 58264145 3270559 4506563 68749924 111844534 10154800 50166608 58595124 61677926 X The mission of Tomah Memorial Hospital, Inc. is to promote and provide quality health care based on customer needs and expectations. In fulfillment of its mission, Tomah Memorial Hospital is committed to view its customers and employees through a holistic approach without consideration to economic status, gender, ethnic origin or personal limitations. 0 0 43765103 56172576 Tomah Memorial Hospital has provided for the health and well-being of the residents of Tomah and the surrounding communities for nearly sixty five years. The Hospital provides a broad spectrum of health and wellness services to the community, including general medical/surgical and swing bed inpatient care, diagnostic laboratory and radiology services, general and specialty surgical services, 24 hour emergency care services, obstetric services, rehabilitative services, occupational health and wellness programs, and a community outreach program. Key volume indicators for the fiscal year ended September 30, 2018 are as follows:(Continued on Schedule O)* 1,276 inpatient discharges* 3,935 inpatient days* 17,652 emergency room and urgent care visits* 1,505 surgical and endoscopic procedures* 14,807 radiology procedures (including CT and MRI)* 70,701 laboratory tests* 37,371 rehabilitative services proceduresIn furtherance of its charitable mission, the Hospital provided approximately $738,826 of free and discounted care to area residents (cost of care approximately $350,000), and wrote off $3.49 million of uncollectible accounts (cost equal to approximately $1.67 million). Additionally, based on its most recently completed community benefits survey, the Hospital incurred approximately $2.03 million in net losses related to providing care for individuals with health insurance provided by either the Medicaid program or other governmental insurance programs. The Hospital subsidizes several programs that are deemed vital services for the community, including in-home hospice and palliative care services, a hospice residence, a walk-in clinic located in the rural community of Warrens, WI, and a dedicated community outreach department that provides health and wellness services to area employers and the Tomah community.Subsidies for these programs for fiscal 2018 approximated $2.54 million. Additional details regarding the hospice program and the Warrens Walk-In Clinic can be found below. In addition to providing high quality healthcare services, the Hospital encourages employees to become actively involved in community organizations and projects that provide other benefits to local communities. The Hospital provides many free services to the community, including health and wellness presentations to area school children, CPR and AED training to various organizations, wellness fairs devoted to women and senior citizens, and meeting space to various non-profit and civic organizations. 3934267 2116613 The Hospital provides in-home, inpatient, and residential hospice care to residents of Tomah and the surrounding communities. Residential care is provided via the operation of an eight bed hospice house located off campus. Despite subsidizing the financial losses incurred by the program, the services are deemed vital to the community and represent a necessary component of patient care. For the year ended September 30, 2018, the Hospice program experienced 9,839 program days and 1,706 hospice residence days. 794440 897152 The Hospital began operating an off-site walk-in care clinic several years ago to better serve the needs of the residents of Warrens, Wisconsin. For the fiscal year ended September 30, 2018, the clinic accommodated 4,799 patient visits. The clinic provides residents with a close-to-home, low-cost option for healthcare services (including basic laboratory tests and x-ray capabilities) related to minor injuries and illnesses, and all services provided are supported by the Hospital's Emergency Department. Despite incurring a negative gross contribution margin during 2018, the Hospital's Board of Directors believes the clinic is an important asset to the residents of Warrens and remains committed to supporting it until it achieves a sustainable level of financial performance. 48493810 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 1 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 14 0 1 422 1 0 0 0 0 0 0 0 0 0 0 X 10 9 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Joseph Zeps 6083740307 321 Butts Avenue Tomah WI 54660 Paul Potter Chair - until 1/16/18 1.00 X X 0 0 0 Oak Moser Chair - as of 1/16/18 1.00 X X 0 0 0 Tom Bramwell Vice Chair 1.00 X X 0 0 0 Spencer Stephens Secretary 1.00 X X 0 0 0 Patty Clark Treasurer 1.00 X X 0 0 0 Terrie Gaarder Director 1.00 X 0 0 0 Penny Precour-Berry Director 1.00 X 0 0 0 John Laufenberg Director 1.00 X 0 0 0 Jill McMullen MD Pres of Medical Staff 1.00 X 0 0 0 John Robertson III MD Director 1.00 X 471723 0 0 Keith Laugen Director - as of 1/16/18 1.00 X 0 0 0 Philip J Stuart Administrator 40.00 X 0 0 0 Joseph Zeps Chief Financial Officer 40.00 X 173967 0 40062 James Piper CRNA Certified Registered Nurse Anesthetist 40.00 X 247771 0 33652 Michelle Masters APNP Emergency Medicine 40.00 X 164090 0 39782 Todd Chapman Pharmacist 40.00 X 175443 0 7006 Gerald Fushianes PA-C Physician Assistant 40.00 X 179719 0 40293 Darla Wilson Pharmacist 40.00 X 175756 0 18830 1588469 0 179625 32 0 1 0 BWBR Architects 1241 John Q Hammons Dr 503 Madison WI 53717 Architect services 2269357 Gundersen Lutheran Health Systems 1900 South Ave LaCrosse WI 54601 Contracted ER physicians/dietician 1756000 Tomah Orthopedics 321 Butts Avenue Tomah WI 54660 Contracted orthopedic surgeon services 1330988 Mayo Clinic Health System 201 W Center St Rochester MN 55902 Contracted hospitalist/pathology service 1009649 Medical X-Ray Consultants 900 W Clairemont Avenue Eau Claire WI 54701 Contracted radiologist services 995087 22 11302 2000 845216 858518 Patient service revenue 622110 59007071 59007071 179270 179270 59186341 617609 617609 43648 80097 -36449 -36449 -36449 49924479 47709165 70625 2215314 -70625 2144689 2144689 62770708 59186341 0 2725849 X 706370 479478 226892 51114 51114 21374622 18258085 3116537 527147 445116 82031 4462262 3773317 688945 1539282 1308360 230922 339301 339301 114769 114769 63294 63294 116400 116400 9218649 6946286 2272363 191813 25 191788 2302737 1123448 1179289 452871 441770 11101 146571 112178 34393 180554 138780 41774 198354 198354 3993579 3993579 122884 122884 Medical supplies 6871347 6871347 Bad debt expense 3492341 3492341 Repairs and Maintenance 958756 720567 238189 839128 139665 699463 58264145 48493810 9653935 116400 8434913 5604296 268209 665606 6178029 9168612 804456 940410 295352 467479 63889151 28562382 17876732 35326769 34342766 59042846 8816 8816 540651 619700 68749924 111844534 4545471 4039870 5489329 39189554 120000 6937184 10154800 50166608 X 57168627 59315737 275535 1096887 1150962 1265302 58595124 61677926 68749924 111844534 X 4506563 -1498562 74801 X 0 1 X 1 0 X 1150962 31647 93995 11302 1265302 1048289 38192 75358 10877 1150962 952450 34130 72113 10404 1048289 869600 102541 -9919 9772 952450 756737 45853 78568 11558 869600 0.00000 1.00000 0.00000 0 0 1821831 1821831 22249037 18030578 4218459 15013645 10176502 4837143 24804638 355302 24449336 35326769 Estimated Third-Party Payor Settlements 230000 Construction accounts payable 6707184 6937184 X 57934703 -1498562 -3417540 -4916102 62850805 -80097 -80097 62770708 54851901 80097 80097 54771804 3492341 3492341 58264145 Part V, Line 4: Permanently restricted net assets are restricted to the Hospice endowment fund and the beneficial interest in a perpetual trust. The interest earned can be used for hospice expenditures. Part X, Line 2: TMH and the Auxiliary are organized as a Wisconsin nonprofit corporations and have been recognized by the IRS as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). TMH and the Auxiliary are annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, TMH and the Auxiliary are subject to income tax on net income that is derived from business activities that are unrelated to their exempt purpose. The Hospital believes that it has appropriate support for any tax positions taken affecting its annual filing requirements, and, as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Hospital would recognize future accrued interest and penalties related to unrecognized tax benefits and liabilities in income tax expense, if such interest and penalties are incurred. Part XI, Line 2d - Other Adjustments: Provision for bad debts in revenue for financial statements -3,492,341. Net change in fair value of beneficial interest in a perpetual trust 74,801. Part XI, Line 4b - Other Adjustments: Rental expenses recorded in expenses for financial statements -80,097. Part XII, Line 2d - Other Adjustments: Rental expenses recorded in expenses for Financial Statements 80,097. Part XII, Line 4b - Other Adjustments: Provision for bad debts in revenue for financial statements 3,492,341. X X 1 McDonald Schaefer 2810 Crossroads Dr Suite 4000 Madison WI 53718 Professional fundraising services 0 0 116400 0 116400 WI Schedule G, Part I, column (iv): The organization is not reporting gross receipts as the fundraising did not begin in this fiscal year. 1 1 X 1 X 1 X 1 1 1 0 1 1 409 350000 350000 0.00640 1 8635 17323290 15141048 2182242 0.03980 1 9044 17673290 15141048 2532242 0.04620 926624 539589 387035 0.00710 15 78500 78500 0.00140 3 5008 5163765 3013765 2150000 0.03930 3 5023 6168889 3553354 2615535 0.04780 4 14067 23842179 18694402 5147777 0.09400 0 3492341 408604 14575339 14649871 -74532 X 1 1 1 1 Tomah Memorial Hospital 321 Butts Avenue Tomah WI 54660 www.tomahhospital.org 1023 X X X Warrens Walk-In Clinic - provider based Tomah Memorial Hospital 1 0 0 1 X X X X X X X X X 15 1 1 0 1 X See Part V, Page 8 X 1 15 1 See Part V, Page 8 0 1 X 100.000000000000 400.000000000000 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 1 X 0 X X X 1 X 0 0 Tomah Memorial Hospital Part V, Section B, Line 5: The Hospital participated in a collaboration of several area non-profit healthcare providers and various community organizations (e.g. local United Way organizations, county health departments, etc.) to conduct a comprehensive community health needs assessment of Tomah, WI, and the surrounding communities. Input for the assessment was solicited via random household surveys and focus group discussions with community members. Leadership for the assessment was provided by representatives from Gundersen Health System and the Great Rivers United Way, with additional representation from healthcare facilities in Hillsboro, Sparta, LaCrosse, Viroqua, and Tomah, WI, as well as county health departments located in Vernon, LaCrosse, Monroe, Trempeleau, and Houston Counties. Tomah Memorial Hospital Part V, Section B, Line 6a: Gundersen Health SystemGundersen St. Joseph's Hospital and ClinicsGundersen Tri County Hospital and ClinicsMayo Clinic Health System - LaCrosse and SpartaVernon Memorial Healthcare Tomah Memorial Hospital Part V, Section B, Line 11: Fiscal year 2018 accomplishments for the Community Health Needs Assessment completed June 30, 2016 include the following:Adverse Childhood Experiences (ACEs) Current Action1. Tomah Memorial and the Monroe County CHIP Mental Health Workgroup received a grant to host a presentation by Gundersen National Child Protection Training Center. This training focused on Adverse Childhood Experiences and increasing the community's collective ability to support individuals who have experienced traumatic events. Healthcare personal, teachers, social workers, and public health workers were present at the training. 2. The Hospital is the co-chair of the Monroe County CHIP Mental Health Committee and the topic of ACEs is addressed throughout the year at monthly meetings. The committee continues to look for opportunities and partnerships to increase the number of community members trained in ACEs and trauma informed care. 3. The Monroe County CHIP Mental Health Committee has been providing an introduction to ACEs presentation and what it means to be a Trauma Informed Care community. The presentations have been done at the hospitals and schools in our area.Workforce Readiness Current Action: 1. Tomah Memorial Hospital has partnered with the Tomah High School to support the Healthcare Careers Class, the Certified Nursing Assistant (CNA) Class and the Building Trades Class.2. Tomah Memorial donates the American Heart Association Healthcare Provider CPR/AED and First Aid Certification Courses to the Healthcare Careers the CNA class and the Building Trades class.3. Hospital Tours4. School visits from Tomah Memorial workers to the Healthcare Careers class to discuss certain healthcare professions, ex. Occupational health, Physical Therapy. 5. Job Shadows for high school students. We have worked with both Tomah High School and West Salem High School to coordinate job shadows in departments students are interested in pursuing a career in. 6. CNA Clinical Rotations 7. HIPPA Training 8. Junior Achievement Classes 9. Reality Check at Tomah High SchoolYouth Resilience Current Action 1. The hospital has a presence on the Tomah Boys and Girls Club Executive Board and is currently working on programming to increase students' abilities to manage stress and prepare for adulthood. 2. Tomah Memorial has a presence on the Tomah Boys and Girls Club Education and Resource Committees, finding volunteers and educational presentations to enrich students in the Tomah area. 3. The hospital partnered with Monroe County Health Department in sponsoring Teen Wellness Day that was geared towards sophomore students in Tomah and Brookwood school districts. The day was centered around education on mental health, distracted driving, substance abuse, learning mindfulness and behavior techniques in stressful situations.Alcohol Use and Illegal Drug UseCurrent Action1. Drug and alcohol abuse presentation/ Reasonable Suspicion training 2. Cancer prevention presentation3. Attendance of the "Wake-Up Call" Room- Monroe County Safe Communities Coalition sponsored an event where interested parties were shown how a child can hide drug or alcohol use within their room. 4. Thiesen's Grant- Tomah Memorial Hospital, Monroe County Safe Communities and the Monroe County Health Department have received a grant to provide presentations on locking up and properly disposing of medication to the public. Personal medication lock boxes will be purchased and given to many of the local daycares in Monroe County who do not have a place to safely lock away medication. The grant will also help purchase a larger medication drop box for the Sparta Police Department to handle the large volume of medications dropped off at the department. Mental HealthCurrent Action1. The hospital is a part of the Monroe County CHIP Mental Health Workgroup in order to discover how we can expand the mental health services available to Monroe County. The workgroup is currently planning a mental health education forum in an effort to break down some of the social stigma surrounding mental health issues. 2. The hospital is also part of the Tomah Veteran's Administration Mental Health Executive Committee, a committee developed to lead, coordinate and encourage coherent principles to improve mental health care and services for Veterans. 3. Stress relief presentation4. Anti-bullying presentation5. National Night Out 6. Teen Wellness Day ObesityCurrent Action1. Women and Men's Health Night and the Senior Health and Safety Expo2. Winnebago Wednesday presentation. 3. CSA (Small Family Farms)- Tomah Memorial Hospital is a drop of site for Small Family Farms. Community members are able to sign up for shares of seasonal vegetables and fruit that are delivered on a weekly or bi-weekly basis.4. Heart Health Presentation 5. Label Reading Presentation 6. Employee Wellness Committee7. Monthly Wellness Presentations at area businesses8. Health Risk Assessments 9. Healthcheck 360 on Lynx 24 10. Health Fair Participation 11. Blood pressure presentation and screeningsChildcareCurrent Actions1. The hospital currently offers a community babysitting class that equips children 11-15 years to handle the responsibility of caring for another child. 2. The hospital offers water birth, prepared childbirth, breastfeeding, sibling, and infant CPR & car safety classes to increase the quality and safety of basic childcare.3. The hospital plans to start offering a Safe at Home course that equips children 11-15 years of age the education and skills to be able to stay at home alone. Tomah Memorial Hospital Part V, Section B, Line 16j: Brochures containing information about financial assistance are available to patients. The Hospital's website contains information regarding community care and financial assistance. Contact information regarding community care and financial assistance is included on billing statements. Summary and contact information is also included in the emergency room, waiting rooms, and business office. The Hospital employs a full-time, dedicated patient benefit specialist who works with uninsured and underinsured patients regarding community care applications and financial assistance. Part V, line 7a, Community Health Needs Assessment website: https://www.tomahhospital.org/about-us/community-health-needs-assessment Part V, line 10a, Implementation Strategy website: https://www.tomahhospital.org/about-us/community-health-needs-assessment Part V, line 16a, FAP website: https://www.tomahhospital.org/patients-guests/general-hospital-and-billing-information Part V, line 16a, FAP Application website: https://www.tomahhospital.org/patients-guests/general-hospital-and-billing-information Part V, line 16a, FAP Plain Language Summary website: https://www.tomahhospital.org/patients-guests/general-hospital-and-billing-information 1 1 - Hospice Touch Serenity House 330 Butts Avenue Tomah WI 54660 Hospice residence Part I, Line 6a: The Organization participates in the Wisconsin Hospital Association (WHA) Annual Community Benefit reporting process, which is released to the public via a written report distributed to member hospitals as well as the WHA's website. This reporting initiative attempts to quantify the amount of community benefits provided by the Hospital, and includes figures related to community care write-offs, bad debt write-offs, Medicare and Medicaid shortfalls, and programs operated at a loss.The Organization also prepares a quarterly newsletter that is distributed to the public via a mass-mailing. The quarterly newsletter is intended to provide the communities the Hospital serves information regarding Hospital operations, financial results, and programs/initiatives intended to fulfill the Hospital's commitment to community. The newsletter also contains financial highlights from the WHA community benefit report. Current and prior editions of the newsletter are available on the Hospital's website. Part I, Line 7: The methodology for determining charity care and Medicaid/Tricare shortfalls at cost was as follows: a cost to charge ratio was computed using totals from the Hospital's audited financial statements; this ratio was applied to charity care charges, and gross Medicaid/Tricare revenue. Actual reimbursement received from Medicaid/Tricare was then compared to the estimated cost (computed by multiplying the CCR by gross charges) to determine the shortfall. All other items were based on actual program expenses. Also worth noting that the methodology used for charity care/Tricare/Medicaid is the same as the methodology used by the Wisconsin Hospital Association in compiling their annual community benefit report. Part I, Ln 7 Col(f): The amount of bad debt removed from total expenses to determine the percentage was $3,492,341. Part III, Line 2: Accounts are not written off to bad debt until all forms of payment have been applied to the account such as insurance, discounts, and contractual allowances, and the remaining balance is the personal portion due. A payment received on an account previously written off to bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements. Part III, Line 3: The estimated amount of the Organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy is determined by using the percentage of residents with income below the poverty level in Tomah, WI. The percentage for 2017 was 11.7%. Part III, Line 4: The footnote to the Organization's financial statements can be found on page 8 and 9 of the attached audited financial statements. Part III, Line 8: Tomah Memorial Hospital follows the CHA guidelines in reporting community benefits and therefore any Medicare shortfall is excluded from our community benefit report. Providing services to Medicare patients is essential to these patients and the community and increases their access to healthcare services, which is a community benefit.Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by The Centers for Medicaid and Medicare services. Part III, Line 9b: Tomah Memorial Hospital attempts to screen all elective/scheduled patients prior to the receipt of service regarding community care eligibility, and works with patient financial services staff to identify emergent/unscheduled patients who may be eligible for community care (generally after receipt of service). Patients without insurance are offered a 15% discount. Patients that express an interest in community care assistance, are in the process of applying for community care assistance, or waiting on a determination of community care assistance will not have collection efforts imposed on their accounts. After a determination of community care assistance is made, any personal portion due by the patient will follow the same collection procedures as other patients. Part VI, Line 2: Tomah Memorial Hospital currently operates on a three-year strategic planning cycle. At the beginning of each cycle, a strategic planning retreat is held during which an analysis is conducted of the services the Hospital currently provides and areas of need that should be addressed by the Hospital. The retreat is open to all Hospital staff, Hospital Board Members, and members of the Hospital's medical staff. The Hospital's medical staff is comprised primarily of physicians employed by other area healthcare providers (e.g. Mayo, Gundersen Lutheran), and as such their input into the strategic planning process allows the Hospital to work collaboratively with other hospitals and health systems in assessing the needs of the community. The strategic planning process is facilitated by a representative of HealthTechS3 (contracted management organization), and the three-year plan that is adopted by the Hospital's governance serves as a blueprint for ensuring the Hospital is addressing the needs of the community.In addition to the formal strategic planning process, the Hospital engages in ongoing discussions with various stakeholders (area businesses, physicians, patients, and community members) regarding the services offered at the Hospital, and Hospital leadership evaluates all suggestions offered for improving the many ways in which the Hospital serves its community.Finally, the Hospital participated in a collaborative community health needs assessment project with other area healthcare providers and county health departments. The final report and the Hospital's implementation plan are published on the Hospital's website at www.tomahhospital.org. Part VI, Line 3: Tomah Memorial Hospital makes available brochures containing information about financial assistance to all patients seen in the emergency room/urgent care areas, and any patient that registers for a non-emergent service is questioned by admissions or nursing staff regarding any concerns they might have about the cost of their Hospital services. The Hospital employs a full-time, dedicated patient benefit specialist who works with uninsured and underinsured patients regarding community care applications and financial assistance. Additionally, a review is conducted of all accounts that become delinquent to ensure that an attempt to contact the patient has been made by Hospital staff. Finally, the Hospital is in the process of adding a community care & financial assistance section to its website. Part VI, Line 4: Tomah Memorial Hospital, Inc. is a 25-bed Critical Access Hospital located in Tomah, Wisconsin. The Hospital's primary service area consists of Tomah, WI, and the outlying communities of Camp Douglas, Warrens, Oakdale, and Wilton. Tomah is located in rural western Wisconsin, and as such a significant portion of the Hospital's patient base is comprised of agricultural workers and members of the Amish community. Additionally, Tomah's proximity to two military installations results in a large portion of services provided to members of the military and their families. The Hospital's payer mix is comprised of approximately 14.7% Medicaid, 42.0% Medicare, 7.7% military, 3.1% self-pay, and 32.5% commercial insurance. The reimbursement challenges associated with providing a high percentage of services to Medicaid/Medicare recipients and the uninsured has required the Hospital to operate at a high level of efficiency, ensuring that all services provided represent an excellent value to area community members. Although the Hospital has benefited from the additional reimbursement afforded through the Critical Access Hospital program, competition for market share with other area healthcare providers requires Hospital leadership to continually reevaluate service offerings and business lines for appropriateness given the healthcare needs of the community. Part VI, Line 5: Tomah Memorial Hospital's Board of Directors is comprised of community members that represent both a cross section of industry expertise (banking, manufacturing, attorneys, physicians, small business, etc.) as well as an appreciation of the healthcare needs of the community. The Hospital generally budgets for a targeted operating margin of between 3% and 5% each year. This target was established by the Hospital's Board of Directors, and is believed to represent an appropriate balance between fulfilling the Hospital's charitable purpose and achieving financial results that allow for continued reinvestment in staff and equipment to remain competitive.The Hospital operates a fully staffed Community Health Initiatives Department dedicated to improving the health of the community through wellness education and preventative healthcare strategies. This Department maintains an active presence in the community, sponsoring such events as an annual Women's Health Night, an annual Senior Health and Safety Expo, and various other educational programs in area schools and businesses. Part VI, Line 7, Reports Filed With States WI X X X X 0 0 0 0 0 0 0 1 0 John Robertson III MD Director 471723 0 0 0 0 0 0 0 0 0 471723 0 0 0 Joseph Zeps Chief Financial Officer 165548 0 3203 0 5216 0 7267 0 33556 0 214790 0 0 0 James Piper CRNA Certified Registered Nurse Anestheti 242919 0 4492 0 360 0 857 0 33714 0 282342 0 0 0 Michelle Masters APNP Emergency Medicine 159145 0 2926 0 2019 0 6987 0 33578 0 204655 0 0 0 Todd Chapman Pharmacist 172277 0 2806 0 360 0 7006 0 426 0 182875 0 0 0 Gerald Fushianes PA-C Physician Assistant 175271 0 3130 0 1318 0 7498 0 33492 0 220709 0 0 0 Darla Wilson Pharmacist 168796 0 3370 0 3590 0 6683 0 13065 0 195504 0 0 0 Part I, Line 7 Bonuses are provided based on production and performance. The Board of Directors has authority to determine if a bonus should be granted or denied. Part I, Question 3: Tomah Memorial Hospital does not pay compensation to the Administrator directly. The Administrator is compensated by an unrelated management company, HealthTechS3, and is considered a common law employee of the management company. The Hospital Board of Directors uses some of the processes described in Part I, Question 3 to help determine appropriate compensation for the Administrator. The Board of Directors also approves the Organization's contract with the Management Company. A Wisconsin Health and Educational Facilities Authority 391337855 2012-08-08 7827337 Refund Revenue Bond Series 2003 issued 7/15/03 0 0 0 B Wisconsin Health and Educational Facilities Authority 391337855 2017-11-09 35000000 Construction of replacement facility 0 0 0 A 2721775 7827337 155074 7672263 2012 0 1 1 1 B 35000000 35000000 0 0 1 1 A 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 B 0 0 0 0 0.00000 0.00000 0.00000 0 0 1 A 0 0 0 0 0 0 0 0 1 B 0 0 0 0 0 0 0 0 1 A 1 B 1 Cindy Lambert Family member of Chief Financial Officer 51114 Compensation and benefits as an employee 0 Form 990, Part VI, Section A, line 1 The Executive Committee includes the Corporation's officers and Chairmen of Standing Committees. The Executive Committee has power to transact all regular business of the Corporation during the period between the meetings of the Board of Directors subject to any prior limitation imposed by the Articles of Incorporation, these Bylaws, or the Board, and with the understanding that all matters of major importance will be referred to the Board of Directors. The Chairman of the Board presides as Chairman of Executive Committee and the Treasurer presides in the Chairman's absence. Actions of the Executive Committee are subjected to approval or disapproval at the next regular Board of Directors meeting except for those actions taken pursuant to delegation by the Board of Directors. Form 990, Part VI, Section A, line 3 Philip J. Stuart, Administrator of Tomah Memorial Hospital, is employed by HealthTechS3, an unrelated management company. The Administrator has the responsibility of supervising the management, administration and operation of the Organization. HealthTechS3 was compensated $326,448 for Philip's services provided to Tomah Memorial Hospital. Form 990, Part VI, Section B, line 11b A copy of the Form 990 is provided to the Board before it is filed. The Administrator, CFO, and Executive/Finance Committee review the draft in detail. Form 990, Part VI, Section B, line 12c All members of the Board and Administration team are covered by the conflict of interest policy. Potential conflicts are contracts or transactions between the Hospital and a Director or another corporation, firm, association, or entity in which there is a material financial interest. The Hospital administration reviews annual statements for potential conflicts. If the Hospital Administration determines there is a conflict, the person involved must abstain from voting on any matter related to the conflict. Form 990, Part VI, Section B, line 15 The Administrator is employed by HealthTechS3. The Board approves the contract on a three-year period with two one-year renewal clauses. Comparability data is used during this process and the decision is documented. The contract was renewed on 6/18/14, with an effective date of 7/1/14. It runs through 6/30/19 and had an opt-out on 6/30/17. The Administrator makes recommendations to the Finance/Executive Committee of the Board for other officers. Comparability data is used during this process and the decisions are documented. This is an annual process and was last completed in fiscal year 2018. Form 990, Part VI, Section C, line 19 The Organization's governing documents and conflict of interest policy are not available to the general public. Financial statements are available through the Organization's bond issuer on the internet, and the Organization presents an annual report to the community, open to the general public, in which a financial report is presented. Additionally, an annual financial report is included in the quarterly mailings the Organization sends to all community members. Form 990, Part IX, line 11g Purchased services: Program service expenses 6,794,993. Management and general expenses 1,610,566. Fundraising expenses 0. Total expenses 8,405,559. Professional fees: Program service expenses 151,293. Management and general expenses 661,797. Fundraising expenses 0. Total expenses 813,090. Form 990, Part XI, line 9: Net change in fair value of beneficial interest in perpetual trust 74,801. Pederson Trust Fund for the Benefit of Tomah Memorial Hospital 321 Butts Avenue Tomah WI 54660 396173790 Support Tomah Memorial Hospital WI 501(c)(3) Line 12b, II Tomah Memorial Hospital 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0