2019-03-19T10:49:47-05:00 2018-06-30 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2017-07-01 390806324 DOOR COUNTY MEMORIAL HOSPITAL DOOR 9207435566 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 BRIAN STEPHENS CHIEF ADMINISTRATIVE OFFICER 9207435566 2019-03-11 1 TERRI REXRODE CPA MST P00096513 9206620016 2019-01-26 74.87.127.216 2019-03-11 12:58:27 CD P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 A43ECD1EE6AF4781A69F6BFA161A98BDE8FA2C07 2017 2019-02-21 02:37:17Z GERALD WORRICK 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 111180710 0 X WWW.DCMEDICAL.ORG X 1944 WI TO IMPROVE THE HEALTH AND WELL-BEING OF ALL PEOPLE IN THE COMMUNITIES WE SERVE. 18 14 754 115 0 0 651518 616449 84540228 82735849 528203 1154044 121937 -17589 85841886 84488753 0 32850 0 0 53221076 54742418 0 0 0 30603219 28860330 83824295 83635598 2017591 853155 102562760 107896460 15875765 18201199 86686995 89695261 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 72158839 32850 82490546 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 2018, THE HOSPITAL COUNTED 4,073 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 147,691 VISITS, AND THE NORTH SHORE MEDICAL CLINIC, INCLUDING ITS URGENT CARE FACILITY SERVED 93,282 VISITS. SEE SCHEDULE H FOR FURTHER DETAILS REGARDING THE COMMUNITY BENEFITS DOOR COUNTY MEMORIAL HOSPITAL PROVIDES. 72158839 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 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 0 0 0 1 117 0 754 1 0 0 0 0 0 0 0 0 0 0 X 18 14 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X BRIAN STEPHENS 9207435566 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 PATRICK O'HERN - TERMED CHAIRPERSON 1.00 1.00 X X 0 0 0 BARTH GUILETTE CHAIRPERSON 1.00 1.00 X X 0 0 0 WILLIAM MUNDY VICE CHAIR 1.00 1.00 X X 0 0 0 CATHY WIESE - TERMED SECRETARY 1.00 1.00 X X 0 0 0 GERALD WORRICK CEO/BOARD MEMBER 41.00 1.00 X X 358538 0 45162 ANDRZEJ KUREK MD - TERMED MEDICAL STAFF PRES/BOARD M 41.00 1.00 X X 391368 0 49180 BRIAN MATYSIAK MD MEDICAL STAFF PRES/BOARD M 41.00 1.00 X X 435495 0 51110 JOSEPH MCMAHON - TERMED BOARD MEMBER 1.00 1.00 X 0 0 0 CORWIN DAHL BOARD MEMBER 1.00 1.00 X 0 0 0 ERIC PAULSEN - TERMED BOARD MEMBER 1.00 1.00 X 0 0 0 JEFF RABAS SECRETARY 1.00 1.00 X X 0 0 0 KELTON REITZ MD BOARD MEMBER/PHYSICIAN 41.00 1.00 X 424143 0 51577 GRACE ROSSMAN - TERMED BOARD MEMBER 1.00 1.00 X 0 0 0 DAVID WARD TREASURER 1.00 1.00 X X 0 0 0 RICHARD HOGAN MD BOARD MEMBER/PHYSICIAN 41.00 1.00 X 378101 0 51886 JAMES SARKIS - TERMED BOARD MEMBER 1.00 1.00 X 0 0 0 SCOTT WEDERQUIST BOARD MEMBER 1.00 1.00 X 0 0 0 THERESE PANDL BOARD MEMBER 1.00 1.00 X 0 0 0 GREG SIMIA BOARD MEMBER 1.00 1.00 X 0 0 0 SALLY PFEIFER BOARD MEMBER 1.00 1.00 X 0 0 0 MIKE FELHOFER BOARD MEMBER 1.00 1.00 X 0 0 0 HOWARD PHIPPS BOARD MEMBER 1.00 1.00 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 BRIAN STEPHENS CHIEF ADMINISTRATIVE OFFIC 40.00 X 151808 0 37035 ADAM GINGERY CHIEF FINANCIAL OFFICER 40.00 X 126093 0 34631 DANIEL TOMASZEWSKI MD PHYSICIAN 40.00 X 1010564 0 58412 STEVEN DAVIS MD PHYSICIAN 40.00 X 487810 0 63983 MICHAEL BRUNO MD PHYSICIAN 40.00 X 493044 0 62303 MARC BINARD MD PHYSICIAN 40.00 X 539347 0 45673 REYNALDO PALINES MD PHYSICIAN 40.00 X 487512 0 22548 5283823 0 573500 67 0 1 0 INFINITY HEALTHCARE INC 111 E WISCONSIN AVE SUITE 2000 MILWAUKEE WI 54302 ER PHYSICIANS 3058636 MEDICAL STAFFING SOLUTIONS INC PO BOX 101 RICE LAKE WI 54868 CONTRACTED LABOR 948572 MINISTRY HEALTHCARE INC 11925 W LAKE PARK DR SUITE 100 MILWAUKEE WI 53224 SUPPORT SERVICES 754881 CLOUDWAVE DEPT CH 19800 PALATINE IL 600559800 COMPUTER SUPPORT 657183 NAVIN HAFFTY & ASSOCIATES LLC 1900 W PARK DR SUITE 180 WESTBOROUGH MA 01581 COMPUTER SUPPORT 554593 21 231131 135000 250318 616449 NET PATIENT SERVICE REVENUE 622110 80840109 80840109 MISCELLANEOUS REVENUES 909999 707620 707620 OCCUPATIONAL HEALTH AND WELLNESS 909999 324231 324231 MOB RENTAL INCOME 909999 322620 322620 THERAPY OTHER REVENUES 909999 295966 295966 245303 245303 82735849 1043524 1043524 8742 26331 -17589 -17589 -17589 26776146 26665626 110520 110520 110520 84488753 82490546 0 1381758 32850 32850 2586128 1832860 753268 40804449 37265945 3538504 1916845 1754810 162035 7378946 6725656 653290 2056050 1856749 199301 279435 279435 113628 113628 157618 157618 7470577 5649376 1821201 780961 780961 9417514 8932758 484756 2435065 1788546 646519 1364856 1292537 72319 633877 454884 178993 270955 270955 3639144 2552451 1086693 343009 140427 202582 BAD DEBT EXPENSE 1365028 1365028 DUES AND SUBSCRIPTIONS 220692 145991 74701 EQUIPMENT RENTAL 109387 109387 258584 258584 83635598 72158839 11476759 0 3228 3128 7897748 6368661 15289281 12813738 192222 129167 367623 233614 1244241 1482613 859037 1401372 51593211 19504652 29808019 32088559 44096909 46212577 2804452 7163031 102562760 107896460 6629838 6593169 7687258 7223938 1050178 4384092 508491 0 15875765 18201199 X 85236119 87307352 1450876 2387909 86686995 89695261 102562760 107896460 X 853155 1218078 937033 X X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 10689 10689 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 20305932 9470006 10835926 25658485 10034646 15623839 1425254 1425254 32088559 CASH SURRENDER VALUE OF LIFE INSURANCE 1458705 INTEREST IN NET ASSETS OF DOOR COUNTY MEMORIAL HOSPITAL FOUNDATION, INC. 2376780 DUE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 3327546 7163031 84210516 1218078 -1365028 -146950 84357466 157618 -26331 131287 84488753 82139283 26331 26331 82112952 157618 1365028 1522646 83635598 PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -1,365,028. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES -26,331. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 26,331. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,365,028. 1 1 X 1 X 250.000000000000 1 X 1 1 0 1 1 831784 831784 0.01010 7931082 6715808 1215274 0.01480 8762866 6715808 2047058 0.02490 18 872 1359641 430864 928777 0.01130 7 280 377091 377091 0.00460 3 5024 1719709 383497 1336212 0.01620 7 1343 474037 474037 0.00580 35 7519 3930478 814361 3116117 0.03790 35 7519 12693344 7530169 5163175 0.06280 1 108 108 0.00000 1 876 876 0.00000 1 17146 17146 0.00020 1 292 49489 49489 0.00060 1 1217 1217 0.00000 3 1 120537 120537 0.00150 8 293 189373 189373 0.00230 1 1365028 25741282 25990731 -249449 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 15 1 0 1 1 X HTTP://WWW.DCMEDICAL.ORG/HOSPITAL-INFORMATION/ABOUT/COMMUNITY-HEALTH-NEEDS X 1 15 1 HTTP://WWW.DCMEDICAL.ORG/HOSPITAL-INFORMATION/ABOUT/COMMUNITY-HEALTH-NEEDS 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 2016, 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 2016 STAKEHOLDER MEETING IS BELOW. DOOR COUNTY DEPARTMENT OF PUBLIC HEALTH STAFF* MINISTRY DOOR COUNTY MEDICAL CENTER UNITED WAY OF DOOR COUNTY* DOOR COUNTY PUBLIC LIBRARY MINISTRY DENTAL CLINIC* UW-EXTENSION, DOOR COUNTY UW-GREEN BAY DOOR COUNTY PUBLIC SCHOOLS* BOYS AND GIRLS CLUB OF DOOR COUNTY* DOOR COUNTY YMCA SENIOR RESOURCE CENTER* MINISTRY HOME CARE STURGEON BAY FIRE DEPARTMENT NORTHEAST WISCONSIN TECHNICAL COLLEGE (NWTC) DOOR COUNTY BOARD OF HEALTH BELLIN COLLEGE GOOD SAMARITAN- SCANDIA VILLAGE LAKESHORE CAP FOOD PANTRY* DOOR COUNTY SHERIFF'S DEPARTMENT**DENOTES ORGANIZATIONS OR PROGRAMS DOOR COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: DOOR COUNTY PUBLIC HEALTH DEPARTMENT DOOR COUNTY MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: USING THE CHNA COMPLETED IN JANUARY 2016, THE HOSPITAL DEVELOPED, ADOPTED, AND WORKED ON EXECUTING A THREE-YEAR IMPLEMENTATION STRATEGY TO ADDRESS PRIORITY COMMUNITY HEALTH NEEDS. IN FISCAL YEAR 2016 (TAX YEAR 2015), THE HOSPITAL IMPLEMENTED A PLAN TO ADDRESS THE PRIORITY NEEDS. BELOW IS AN UPDATE ON THE PROGRESS OF THE IMPLEMENATION.PRIORITY NEED #1. 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 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.DCMC SPONSORS A FOOD VOUCHER PROGRAM AT THE STURGEON BAY FARMER'S MARKET. THE DOUBLE YOU 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.IN 2017, CONSTRUCTION OF A SIDEWALK AROUND THE PERIMETER OF OUR CAMPUS WAS COMPLETED TO ENCOURAGE EMPLOYEE AND PUBLIC HEALTH AND WELLNESS AS WELL AS CALMING EFFECTS OF NATURE.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 #2. 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 2017 LEAP PROJECT'S THEME WAS ABOUT BUILDING A POSITIVE COMMUNITY. IN LATE APRIL 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.PRIORITY NEED #3. ORAL HEALTHDCMC HAS A DENTAL CLINIC THAT CURRENTLY OPERATES 5 DAYS A WEEK, 8 HOURS A DAY. EACH YEAR WE INCREASE THE AMOUNT OF PATIENT VISITS WE SEE; IN 2017 WE REACHED OUR ALL-TIME HIGH OF 5,274 PATIENT VISITS. 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. IF CALCULATED IN PRODUCTION OF WORK, THE DENTAL CLINIC HAS PROVIDED $1,352,633 WORTH OF DENTAL SERVICES TO THE DOOR AND KEWAUNEE COUNTY LOW INCOME RESIDENTS.THE SEAL A SMILE PROGRAM IS AN OUTREACH PROGRAM WHERE A HYGIENIST FROM THE DENTAL CLINIC BRINGS PORTABLE DENTAL EQUIPMENT INTO THE AREA SCHOOLS AND PROVIDE FLUORIDE VARNISH AND SEALANTS TO 2ND AND 3RD GRADERS, WITH THE CONSENT OF THEIR PARENTS. IN 2017 WE PLACED SEALANTS AND PROVIDED ORAL HEALTH EDUCATION TO 220 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 175 CHILDREN.ANOTHER SERVICE THE DENTAL CLINIC PROVIDES IS FLUORIDE VARNISH AND EXAMS TO OUR SKILLED 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 CLEANINGS. 8 1 - NORTH SHORE MEDICAL CLINIC 323 SOUTH 18TH AVENUE STURGEON BAY WI 54235 OP PHYSICIAN CLINIC 2 - NORTH SHORE MEDICAL CLINIC 3711 HIGHWAY 42 FISH CREEK WI 54212 OP PHYSICIAN CLINIC 3 - NORTH SHORE MEDICAL CLINIC 815 JEFFERSON STREET ALGOMA WI 54201 OP PHYSICIAN CLINIC 4 - NORTH SHORE MEDICAL CLINIC 910 MAIN ROAD WASHINGTON ISLAND WI 54201 OP PHYSICIAN CLINIC 5 - NORTH SHORE MEDICAL CLINIC 2073 COUNTY ROAD DK BRUSSELS WI 54204 OP PHYSICIAN CLINIC 6 - STURGEON BAY REHAB SERVICES 1300 EGG HARBOR ROAD STURGEON BAY WI 54235 REHAB SERVICES 7 - SISTER BAY REHAB SERVICES 2311 MEADOW WOOD DRIVE SISTER BAY WI 54234 REHAB SERVICES 8 - 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 $1,365,028. 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 HEALTH OF THE COMMUNITY. THESE INCLUDE HABITAT FOR HUMANITY, WISCONSIN 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 ANDDOOR COUNTY UNITED WAY. BY WORKING TOGETHER WITH OTHER ORGANIZATIONS 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, OFTEN, 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 SURVEYED THE COMMUNITY TWICE IN 2018 USING SOCIAL MEDIA AND RECEIVED INPUT ON HEALTH CARE NEEDS THAT WILL BE USED IN THE CHNA FOR 2019. 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 0 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 X 1 1 X X X X 0 0 0 0 0 0 0 0 0 GERALD WORRICK CEO/BOARD MEMBER 343111 0 0 0 15427 0 16200 0 28962 0 403700 0 0 0 ANDRZEJ KUREK MD - TERMED MEDICAL STAFF PRES/BOARD M 191232 0 198116 0 2020 0 16200 0 32980 0 440548 0 0 0 BRIAN MATYSIAK MD MEDICAL STAFF PRES/BOARD M 416107 0 0 0 19388 0 16200 0 34910 0 486605 0 0 0 KELTON REITZ MD BOARD MEMBER/PHYSICIAN 242619 0 128232 0 53292 0 16200 0 35377 0 475720 0 0 0 RICHARD HOGAN MD BOARD MEMBER/PHYSICIAN 335820 0 249 0 42032 0 16200 0 35686 0 429987 0 0 0 BRIAN STEPHENS CHIEF ADMINISTRATIVE OFFIC 151223 0 0 0 585 0 9316 0 27719 0 188843 0 0 0 ADAM GINGERY CHIEF FINANCIAL OFFICER 123624 0 0 0 2469 0 7764 0 26867 0 160724 0 0 0 DANIEL TOMASZEWSKI MD PHYSICIAN 889687 0 20589 0 100288 0 16058 0 42354 0 1068976 0 0 0 STEVEN DAVIS MD PHYSICIAN 483081 0 0 0 4729 0 16200 0 47783 0 551793 0 0 0 MICHAEL BRUNO MD PHYSICIAN 477924 0 0 0 15120 0 16200 0 46103 0 555347 0 0 0 MARC BINARD MD PHYSICIAN 520557 0 0 0 18790 0 16200 0 29473 0 585020 0 0 0 REYNALDO PALINES MD PHYSICIAN 475686 0 0 0 11826 0 16200 0 6348 0 510060 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. SCHEDULE J, PART I FOUR HIGHLY COMPENSATED INDIVIDUALS RECEIVED TRAVEL FOR COMPANIONS WHICH WAS TAXED AS ADDITIONAL COMPENSATION. A WISCONSIN HEALTH & EDUCATION FACILITIES AUTHORITY 391337855 2014-08-15 10000000 REFUND DEBT ISSUED 10/21/09 0 0 0 A 463320 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 95833 0 1 1 BRIAN MATYSIAK MD BOARD MEMBER/PHYSICIAN EMPLOYEE RETENTION LOAN X 85000 26667 0 1 1 REYNALDO PALINES HIGHEST COMPENSATED/PHYSICIAN EMPLOYEE RETENTION LOAN X 30000 6667 0 1 1 129167 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 937,033. 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 231131 ACTUAL