TOMAH MEMORIAL HOSPITAL INC: Form 990, tax year 2015
View the entire original 990 at ProPublica ↗
- Organization
- TOMAH MEMORIAL HOSPITAL INC (EIN 39-0799566)
- Tax period
- 2015-10-01 to 2016-09-30
- Filed
- 2017-05-15
- IRS object ID
- 201711359349304221
- Schema version
- 2015v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
- Return header
- Form 990
- Schedule A
- Schedule B
- Schedule D
- Schedule H
- Schedule J
- Schedule K
- Schedule L
- Schedule O
- Schedule R
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-05-15T10:51:18-05:00 | ReturnTs |
| Tax Period End | 2016-09-30 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 450250958 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Eide Bailly LLP | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 800 Nicollet Mall Ste 1300 | AddressLine1Txt |
| City | Minneapolis | CityNm |
| State Abbreviation | MN | StateAbbreviationCd |
| ZIP | 554027033 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-10-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 390799566 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tomah Memorial Hospital | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | TOMA | BusinessNameControlTxt |
| Phone | 6083722181 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Joseph Zeps | PersonNm |
| Person Title | Chief Financial Officer | PersonTitleTxt |
| Phone | 6083722181 | PhoneNum |
| Signature | 2017-05-12 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | Kim Hunwardsen CPA | PreparerPersonNm |
| PTIN | P00484560 | PTIN |
| Phone | 6122536500 | PhoneNum |
| Preparation | 2017-05-12 | PreparationDt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | Philip J Stuart | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $55,823,024 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c3 | Yes (X) | Organization501c3Ind |
| Website Address | www.tomahhospital.org | WebsiteAddressTxt |
| Type Of Organization Corp | Yes (X) | TypeOfOrganizationCorpInd |
| Formation | 1948 | FormationYr |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Activity Or Mission | To promote and provide quality health care to patients in a hospital setting | ActivityOrMissionDesc |
| Voting Members Governing Body | 10 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 10 | VotingMembersIndependentCnt |
| Total Employee | 371 | TotalEmployeeCnt |
| Total Volunteers | 45 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $168,838 | PYContributionsGrantsAmt |
| CY Contributions Grants | $105,888 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $47,063,633 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $48,780,483 | CYProgramServiceRevenueAmt |
| PY Investment Income | $1,229,776 | PYInvestmentIncomeAmt |
| CY Investment Income | $366,064 | CYInvestmentIncomeAmt |
| PY Other Revenue | -$2,056 | PYOtherRevenueAmt |
| CY Other Revenue | $18,874 | CYOtherRevenueAmt |
| PY Total Revenue | $48,460,191 | PYTotalRevenueAmt |
| CY Total Revenue | $49,271,309 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $0 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $0 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $21,416,317 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $22,945,034 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $20,849,253 | PYOtherExpensesAmt |
| CY Other Expenses | $22,404,472 | CYOtherExpensesAmt |
| PY Total Expenses | $42,265,570 | PYTotalExpensesAmt |
| CY Total Expenses | $45,349,506 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $6,194,621 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | $3,921,803 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $57,907,603 | TotalAssetsBOYAmt |
| Total Assets EOY | $62,359,385 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $9,688,435 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $8,366,956 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $48,219,168 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $53,992,429 | NetAssetsOrFundBalancesEOYAmt |
| Info In Schedule O Part III | Yes (X) | InfoInScheduleOPartIIIInd |
| Mission | 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. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $33,568,179 | ExpenseAmt |
| Revenue | $46,283,530 | RevenueAmt |
| Desc | 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, 2016 are as follows:* 1,286 inpatient discharges* 3,539 inpatient days* 16,767 emergency room and urgent care visits* 1,669 surgical and endoscopic procedures* 13,560 radiology procedures (including CT and MRI)* 69,452 laboratory tests* 34,198 rehabilitative services proceduresIn furtherance of its charitable mission, the Hospital provided approximately $1,104,500 of free and discounted care to area residents (cost of care approximately $569,500), and wrote off $1.80 million of uncollectible accounts (cost equal to approximately $930,000). Additionally, based on its most recently completed community benefits survey, the Hospital incurred approximately $2.08 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 2016 approximated $2.51 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. | Desc |
Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $3,603,878 | ExpenseAmt |
| Revenue | $1,860,622 | RevenueAmt |
| Desc | 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, 2016, the Hospice program experienced 9,974 program days and 1,132 hospice residence days. | Desc |
Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Expense | $891,999 | ExpenseAmt |
| Revenue | $636,331 | RevenueAmt |
| Desc | 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, 2016, the clinic accommodated 4,375 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 2016, 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. | Desc |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Expenses | $38,064,056 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | Yes (1) | DescribedInSection501c3Ind |
| Schedule B Required | Yes (1) | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Lobbying Activities | 0 | LobbyingActivitiesInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | Yes (1) | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | Yes (1) | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | Yes (1) | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | 0 | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | Yes (1) | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | Yes (1) | OperateHospitalInd |
| Audited Financial Stmt Att | Yes (1) | AuditedFinancialStmtAttInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | Yes (1) | TaxExemptBondsInd |
| Invest Tax Exempt Bonds | 0 | InvestTaxExemptBondsInd |
| Escrow Account | 0 | EscrowAccountInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Engaged In Excess Benefit Trans | 0 | EngagedInExcessBenefitTransInd |
| PY Excess Benefit Trans | 0 | PYExcessBenefitTransInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | Yes (1) | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | Yes (1) | RelatedOrganizationCtrlEntInd |
| Transaction With Control Ent | 0 | TransactionWithControlEntInd |
| Trnsfr Exmpt Non Chrtbl Rltd Org | 0 | TrnsfrExmptNonChrtblRltdOrgInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 14 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Backup Wthld Compliance | Yes (1) | BackupWthldComplianceInd |
| Employee | 371 | EmployeeCnt |
| Employment Tax Returns Filed | 0 | EmploymentTaxReturnsFiledInd |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Rcv Fnds To Pay Prsnl Bnft Cntrct | 0 | RcvFndsToPayPrsnlBnftCntrctInd |
| Pay Premiums Prsnl Bnft Cntrct | 0 | PayPremiumsPrsnlBnftCntrctInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 10 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 10 | IndependentVotingMemberCnt |
| Family Or Business Rln | 0 | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | Yes (1) | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | Yes (1) | MinutesOfGoverningBodyInd |
| Minutes Of Committees | Yes (1) | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | Yes (1) | ConflictOfInterestPolicyInd |
| Annual Disclosure Covered Prsn | Yes (1) | AnnualDisclosureCoveredPrsnInd |
| Regular Monitoring Enfrc | Yes (1) | RegularMonitoringEnfrcInd |
| Whistleblower Policy | Yes (1) | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | Yes (1) | CompensationProcessCEOInd |
| Compensation Process Other | Yes (1) | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| States Where Copy Of Return Is Fld | WI | StatesWhereCopyOfReturnIsFldCd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Joseph Zeps | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 6083740307 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (17 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | OfficerOfficerInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt | Highest Compensated EmployeeHighestCompensatedEmployeeInd |
|---|---|---|---|---|---|---|---|---|
| Wes Revels | ||||||||
| Chair | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Cynthia Erdman | ||||||||
| Vice Chair | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| James Quartemont | ||||||||
| Secretary | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Paul Potter | ||||||||
| Treasurer | 1.00 | 0.00 | Yes (X) | Yes (X) | $0 | $0 | $0 | |
| Michael Saunders MD | ||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Jill Boulden MD | ||||||||
| President of Medical Staff | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Kurt Olson | ||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Terrie Gaarder | ||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Patty Clark | ||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Tom Bramwell | ||||||||
| Director | 1.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Philip J Stuart | ||||||||
| Administrator | 40.00 | 0.00 | Yes (X) | $0 | $0 | $0 | ||
| Joseph Zeps | ||||||||
| Chief Financial Officer | 40.00 | 0.00 | Yes (X) | $148,289 | $0 | $36,511 | ||
| Lily Liu MD | ||||||||
| Geriatric & Family Medicine | 40.00 | 0.00 | $306,250 | $0 | $7,385 | Yes (X) | ||
| Darla Wilson | ||||||||
| Director of Pharmacy | 40.00 | 0.00 | $173,450 | $0 | $18,209 | Yes (X) | ||
| Todd Chapman | ||||||||
| Pharmacist | 40.00 | 0.00 | $157,941 | $0 | $6,309 | Yes (X) | ||
| Gerald Fushianes PA-C | ||||||||
| Physician Assistant | 40.00 | 0.00 | $151,917 | $0 | $36,759 | Yes (X) | ||
| Laura J Miller FNP | ||||||||
| Nurse Practitioner | 40.00 | 0.00 | $134,369 | $0 | $16,666 | Yes (X) | ||
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $1,072,216 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $0 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $121,839 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 20 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp (5 entries)
| Address Line1ContractorAddress/USAddress/AddressLine1Txt | CityContractorAddress/USAddress/CityNm | State AbbreviationContractorAddress/USAddress/StateAbbreviationCd | ZIPContractorAddress/USAddress/ZIPCd | ServicesServicesDesc | CompensationCompensationAmt |
|---|---|---|---|---|---|
| Gundersen Lutheran Health Systems | |||||
| 1900 South Ave | LaCrosse | WI | 54601 | Contracted ER physicians/dietician | $1,677,886 |
| Tomah Orthopedics | |||||
| 321 Butts Avenue | Tomah | WI | 54660 | Contracted orthopedic surgeon services | $1,212,021 |
| Mayo Clinic Health System | |||||
| 201 W Center St | Rochester | MN | 55902 | Contracted hospitalist/pathology service | $1,035,131 |
| Medical X-Ray Consultants | |||||
| 900 W Clairemont Avenue | Eau Claire | WI | 54701 | Contracted radiologist services | $891,932 |
| Rural Wisconsin Health Cooperative Infor | |||||
| 880 Independence Lane | Sauk City | WI | 53583 | HIS software licensing/service/support/h | $666,021 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 16 | CntrctRcvdGreaterThan100KCnt |
| Related Organizations | $10,083 | RelatedOrganizationsAmt |
| Government Grants | $18,609 | GovernmentGrantsAmt |
| All Other Contributions | $77,196 | AllOtherContributionsAmt |
| Total Contributions | $105,888 | TotalContributionsAmt |
Program Service Revenue ProgramServiceRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Patient service revenue | Desc |
| Business | 622110 | BusinessCd |
| Total Revenue Column | $48,479,454 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $48,479,454 | RelatedOrExemptFuncIncomeAmt |
Total Oth Program Service Rev TotalOthProgramServiceRevGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $301,029 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $301,029 | RelatedOrExemptFuncIncomeAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $48,780,483 | TotalProgramServiceRevenueAmt |
Investment Income InvestmentIncomeGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $978,742 | TotalRevenueColumnAmt |
| Exclusion | $978,742 | ExclusionAmt |
Gross Rents GrossRentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $71,749 | RealAmt |
Less Rental Expenses LessRentalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $52,875 | RealAmt |
Rental Income Or Loss RentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Real | $18,874 | RealAmt |
Net Rental Income Or Loss NetRentalIncomeOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $18,874 | TotalRevenueColumnAmt |
| Exclusion | $18,874 | ExclusionAmt |
Gross Amount Sales Assets GrossAmountSalesAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $5,886,162 | SecuritiesAmt |
Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | $6,498,840 | SecuritiesAmt |
Gain Or Loss GainOrLossGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Securities | -$612,678 | SecuritiesAmt |
Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | -$612,678 | TotalRevenueColumnAmt |
| Exclusion | -$612,678 | ExclusionAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $49,271,309 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $48,780,483 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $384,938 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Comp Current Ofcr Directors CompCurrentOfcrDirectorsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $191,673 | TotalAmt |
| Management And General | $191,673 | ManagementAndGeneralAmt |
Comp Disqual Persons CompDisqualPersonsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $41,094 | TotalAmt |
| Program Services | $41,094 | ProgramServicesAmt |
Other Salaries And Wages OtherSalariesAndWagesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $17,615,405 | TotalAmt |
| Program Services | $15,087,333 | ProgramServicesAmt |
| Management And General | $2,528,072 | ManagementAndGeneralAmt |
Pension Plan Contributions PensionPlanContributionsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $509,170 | TotalAmt |
| Program Services | $437,590 | ProgramServicesAmt |
| Management And General | $71,580 | ManagementAndGeneralAmt |
Other Employee Benefits OtherEmployeeBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $3,272,738 | TotalAmt |
| Program Services | $2,807,691 | ProgramServicesAmt |
| Management And General | $465,047 | ManagementAndGeneralAmt |
Payroll Taxes PayrollTaxesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,314,954 | TotalAmt |
| Program Services | $1,125,541 | ProgramServicesAmt |
| Management And General | $189,413 | ManagementAndGeneralAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $571,136 | TotalAmt |
| Management And General | $571,136 | ManagementAndGeneralAmt |
Fees For Services Legal FeesForServicesLegalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $38,869 | TotalAmt |
| Management And General | $38,869 | ManagementAndGeneralAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $55,446 | TotalAmt |
| Management And General | $55,446 | ManagementAndGeneralAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $8,400,689 | TotalAmt |
| Program Services | $7,220,283 | ProgramServicesAmt |
| Management And General | $1,180,406 | ManagementAndGeneralAmt |
Advertising AdvertisingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $216,107 | TotalAmt |
| Management And General | $216,107 | ManagementAndGeneralAmt |
Office Expenses OfficeExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,989,567 | TotalAmt |
| Program Services | $1,117,970 | ProgramServicesAmt |
| Management And General | $871,597 | ManagementAndGeneralAmt |
Occupancy OccupancyGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $412,903 | TotalAmt |
| Program Services | $401,910 | ProgramServicesAmt |
| Management And General | $10,993 | ManagementAndGeneralAmt |
Travel TravelGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $150,349 | TotalAmt |
| Program Services | $120,946 | ProgramServicesAmt |
| Management And General | $29,403 | ManagementAndGeneralAmt |
Conferences Meetings ConferencesMeetingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $119,932 | TotalAmt |
| Program Services | $92,455 | ProgramServicesAmt |
| Management And General | $27,477 | ManagementAndGeneralAmt |
Interest InterestGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $239,053 | TotalAmt |
| Program Services | $239,053 | ProgramServicesAmt |
Depreciation Depletion DepreciationDepletionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,571,947 | TotalAmt |
| Program Services | $2,571,947 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $123,758 | TotalAmt |
| Management And General | $123,758 | ManagementAndGeneralAmt |
Other Expenses OtherExpensesGrp (3 entries)
| DescDesc | TotalTotalAmt | Program ServicesProgramServicesAmt | Management And GeneralManagementAndGeneralAmt |
|---|---|---|---|
| Medical supplies | $4,185,069 | $4,185,069 | |
| Bad debt expense | $1,803,040 | $1,803,040 | |
| Repairs and Maintenance | $903,091 | $678,199 | $224,892 |
All Other Expenses AllOtherExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $623,516 | TotalAmt |
| Program Services | $133,935 | ProgramServicesAmt |
| Management And General | $489,581 | ManagementAndGeneralAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $45,349,506 | TotalAmt |
| Program Services | $38,064,056 | ProgramServicesAmt |
| Management And General | $7,285,450 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Savings And Temp Cash Invst SavingsAndTempCashInvstGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,699,801 | BOYAmt |
| EOY | $7,439,130 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $5,849,705 | BOYAmt |
| EOY | $6,440,054 | EOYAmt |
Inventories For Sale Or Use InventoriesForSaleOrUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $607,411 | BOYAmt |
| EOY | $710,767 | EOYAmt |
Prepaid Expenses Defrd Charges PrepaidExpensesDefrdChargesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $159,023 | BOYAmt |
| EOY | $985,480 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Land Bldg Equip Cost Or Other Bss | $37,609,732 | LandBldgEquipCostOrOtherBssAmt |
| Land Bldg Equip Accum Deprec | $23,655,134 | LandBldgEquipAccumDeprecAmt |
Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $13,925,705 | BOYAmt |
| EOY | $13,954,598 | EOYAmt |
Investments Pub Traded Sec InvestmentsPubTradedSecGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $30,114,145 | BOYAmt |
| EOY | $32,229,364 | EOYAmt |
Investments Other Securities InvestmentsOtherSecuritiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $8,816 | BOYAmt |
| EOY | $8,816 | EOYAmt |
Other Assets Total OtherAssetsTotalGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $542,997 | BOYAmt |
| EOY | $591,176 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $57,907,603 | BOYAmt |
| EOY | $62,359,385 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $2,787,685 | BOYAmt |
| EOY | $2,247,516 | EOYAmt |
Tax Exempt Bond Liabilities TaxExemptBondLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $6,509,678 | BOYAmt |
| EOY | $6,059,440 | EOYAmt |
Mortg Notes Pybl Scrd Invst Prop MortgNotesPyblScrdInvstPropGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $261,072 | BOYAmt |
| EOY | $0 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $130,000 | BOYAmt |
| EOY | $60,000 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $9,688,435 | BOYAmt |
| EOY | $8,366,956 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Organization Follows SFAS117 | Yes (X) | OrganizationFollowsSFAS117Ind |
Unrestricted Net Assets UnrestrictedNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $47,263,033 | BOYAmt |
| EOY | $52,940,455 | EOYAmt |
Temporarily Rstr Net Assets TemporarilyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $3,685 | BOYAmt |
| EOY | $3,685 | EOYAmt |
Permanently Rstr Net Assets PermanentlyRstrNetAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $952,450 | BOYAmt |
| EOY | $1,048,289 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $48,219,168 | BOYAmt |
| EOY | $53,992,429 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $57,907,603 | BOYAmt |
| EOY | $62,359,385 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part XI | Yes (X) | InfoInScheduleOPartXIInd |
| Reconcilation Revenue Expnss | $3,921,803 | ReconcilationRevenueExpnssAmt |
| Net Unrlzd Gains Losses Invst | $1,796,574 | NetUnrlzdGainsLossesInvstAmt |
| Other Changes In Net Assets | $54,884 | OtherChangesInNetAssetsAmt |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Consolidated Basis Fincl Stmt | Yes (X) | ConsolidatedBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | Yes (1) | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule A IRS990ScheduleA
| Field | Value | IRS element (for citing) |
|---|---|---|
| Hospital | Yes (X) | HospitalInd |
Schedule B IRS990ScheduleB
Contributor Information ContributorInformationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Contributor | RESTRICTED | ContributorNum |
Contributor Business Name ContributorBusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | RESTRICTED | BusinessNameLine1 |
Contributor US Address ContributorUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | RESTRICTED | AddressLine1 |
| Address Line2 | RESTRICTED | AddressLine2 |
| City | RESTRICTED | City |
| State | RESTRICTED | State |
| ZIP Code | RESTRICTED | ZIPCode |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Contributions | RESTRICTED | TotalContributionsAmt |
Schedule D IRS990ScheduleD
CY Endwmt Fund CYEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $952,450 | BeginningYearBalanceAmt |
| Contributions | $34,130 | ContributionsAmt |
| Investment Earnings Or Losses | $72,113 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $10,404 | OtherExpendituresAmt |
| End Year Balance | $1,048,289 | EndYearBalanceAmt |
CY Minus1 Yr Endwmt Fund CYMinus1YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $869,600 | BeginningYearBalanceAmt |
| Contributions | $102,541 | ContributionsAmt |
| Investment Earnings Or Losses | -$9,919 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $9,772 | OtherExpendituresAmt |
| End Year Balance | $952,450 | EndYearBalanceAmt |
CY Minus2 Yr Endwmt Fund CYMinus2YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $756,737 | BeginningYearBalanceAmt |
| Contributions | $45,853 | ContributionsAmt |
| Investment Earnings Or Losses | $78,568 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $11,558 | OtherExpendituresAmt |
| End Year Balance | $869,600 | EndYearBalanceAmt |
CY Minus3 Yr Endwmt Fund CYMinus3YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $655,732 | BeginningYearBalanceAmt |
| Contributions | $55,282 | ContributionsAmt |
| Investment Earnings Or Losses | $56,609 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $10,886 | OtherExpendituresAmt |
| End Year Balance | $756,737 | EndYearBalanceAmt |
CY Minus4 Yr Endwmt Fund CYMinus4YrEndwmtFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Beginning Year Balance | $539,204 | BeginningYearBalanceAmt |
| Contributions | $39,504 | ContributionsAmt |
| Investment Earnings Or Losses | $86,657 | InvestmentEarningsOrLossesAmt |
| Other Expenditures | $9,633 | OtherExpendituresAmt |
| End Year Balance | $655,732 | EndYearBalanceAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Board Designated Balance EOY | 0.00000 | BoardDesignatedBalanceEOYPct |
| Prmnnt Endowment Balance EOY | 1.00000 | PrmnntEndowmentBalanceEOYPct |
| Term Endowment Balance EOY | 0.00000 | TermEndowmentBalanceEOYPct |
| Endowments Held Unrelated Org | 0 | EndowmentsHeldUnrelatedOrgInd |
| Endowments Held Related Org | 0 | EndowmentsHeldRelatedOrgInd |
Land LandGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $1,706,459 | OtherCostOrOtherBasisAmt |
| Book Value | $1,706,459 | BookValueAmt |
Buildings BuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $22,151,071 | OtherCostOrOtherBasisAmt |
| Depreciation | $14,437,021 | DepreciationAmt |
| Book Value | $7,714,050 | BookValueAmt |
Equipment EquipmentGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $13,091,391 | OtherCostOrOtherBasisAmt |
| Depreciation | $8,951,941 | DepreciationAmt |
| Book Value | $4,139,450 | BookValueAmt |
Other Land Buildings OtherLandBuildingsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other Cost Or Other Basis | $660,811 | OtherCostOrOtherBasisAmt |
| Depreciation | $266,172 | DepreciationAmt |
| Book Value | $394,639 | BookValueAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $13,954,598 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | Estimated Third-Party Payor Settlements | Desc |
| Amt | $60,000 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $60,000 | TotalLiabilityAmt |
| Footnote Text | Yes (X) | FootnoteTextInd |
| Total Rev Etc Audited Fincl Stmt | $49,266,359 | TotalRevEtcAuditedFinclStmtAmt |
| Net Unrealized Gains Invst | $1,796,574 | NetUnrealizedGainsInvstAmt |
| Other Revenue | -$1,803,040 | OtherRevenueAmt |
| Revenue Not Reported | -$6,466 | RevenueNotReportedAmt |
| Revenue Subtotal | $49,272,825 | RevenueSubtotalAmt |
| Other Revenues Not Included | -$1,516 | OtherRevenuesNotIncludedAmt |
| Revenue Not Reported Fincl Stmt | -$1,516 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $49,271,309 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $43,599,341 | TotExpnsEtcAuditedFinclStmtAmt |
| Other Expenses Included | $52,875 | OtherExpensesIncludedAmt |
| Expenses Not Reported | $52,875 | ExpensesNotReportedAmt |
| Expenses Subtotal | $43,546,466 | ExpensesSubtotalAmt |
| Other Expenses Not Included | $1,803,040 | OtherExpensesNotIncludedAmt |
| Expenses Not Rpt Fincl Stmt | $1,803,040 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $45,349,506 | TotalExpensesPerForm990Amt |
Supplemental Information Detail SupplementalInformationDetail (6 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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: | Tomah Memorial Hospital 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). Tomah Memorial Hospital and the Auxiliary are annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, Tomah Memorial Hospital 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 -1,803,040. |
| Part XI, Line 4b - Other Adjustments: | Temporarily restricted interest income included in fund balance 10,404. Rental expenses recorded in expenses for financial statements -52,875. Permanently restricted interest income included in fund balance 6,825. Permanently restricted contributions included in fund balance 34,130. |
| Part XII, Line 2d - Other Adjustments: | Rental expenses recorded in expenses for Financial Statements 52,875. |
| Part XII, Line 4b - Other Adjustments: | Provision for bad debts in revenue for financial statements 1,803,040. |
Schedule H IRS990ScheduleH
| Field | Value | IRS element (for citing) |
|---|---|---|
| Financial Assistance Policy | Yes (1) | FinancialAssistancePolicyInd |
| Written Policy | Yes (1) | WrittenPolicyInd |
| All Hospitals Policy | Yes (X) | AllHospitalsPolicyInd |
| FPG Reference Free Care | Yes (1) | FPGReferenceFreeCareInd |
| Percent100 | Yes (X) | Percent100Ind |
| FPG Reference Discounted Care | Yes (1) | FPGReferenceDiscountedCareInd |
| Percent400 | Yes (X) | Percent400Ind |
| Free Care Medically Indigent | Yes (1) | FreeCareMedicallyIndigentInd |
| Financial Assistance Budget | Yes (1) | FinancialAssistanceBudgetInd |
| Expenses Exceed Budget | Yes (1) | ExpensesExceedBudgetInd |
| Unable To Provide Care | 0 | UnableToProvideCareInd |
| Annual Community Bnft Report | Yes (1) | AnnualCommunityBnftReportInd |
| Report Publically Available | Yes (1) | ReportPublicallyAvailableInd |
Financial Assistance At Cost Typ FinancialAssistanceAtCostTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 1044 | PersonsServedCnt |
| Total Community Benefit Expns | $578,000 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $578,000 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.01330 | TotalExpensePct |
Unreimbursed Medicaid UnreimbursedMedicaidGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 8524 | PersonsServedCnt |
| Total Community Benefit Expns | $14,836,196 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $12,945,782 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $1,890,414 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.04340 | TotalExpensePct |
Unreimbursed Costs UnreimbursedCostsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 1 | ActivitiesOrProgramsCnt |
| Persons Served | 2299 | PersonsServedCnt |
| Total Community Benefit Expns | $5,328,877 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $5,135,861 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $193,016 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00440 | TotalExpensePct |
Total Financial Assistance Typ TotalFinancialAssistanceTyp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Persons Served | 11867 | PersonsServedCnt |
| Total Community Benefit Expns | $20,743,073 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $18,081,643 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,661,430 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.06110 | TotalExpensePct |
Community Health Services CommunityHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $512,910 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $295,219 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $217,691 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00500 | TotalExpensePct |
Health Professions Education HealthProfessionsEducationGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 15 | PersonsServedCnt |
| Total Community Benefit Expns | $38,469 | TotalCommunityBenefitExpnsAmt |
| Net Community Benefit Expns | $38,469 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.00090 | TotalExpensePct |
Subsidized Health Services SubsidizedHealthServicesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Community Benefit Expns | $4,785,295 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,496,953 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,288,342 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05250 | TotalExpensePct |
Total Other Benefits TotalOtherBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Persons Served | 15 | PersonsServedCnt |
| Total Community Benefit Expns | $5,336,674 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $2,792,172 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $2,544,502 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.05840 | TotalExpensePct |
Total Community Benefits TotalCommunityBenefitsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Activities Or Programs | 2 | ActivitiesOrProgramsCnt |
| Persons Served | 11882 | PersonsServedCnt |
| Total Community Benefit Expns | $26,079,747 | TotalCommunityBenefitExpnsAmt |
| Direct Offsetting Revenue | $20,873,815 | DirectOffsettingRevenueAmt |
| Net Community Benefit Expns | $5,205,932 | NetCommunityBenefitExpnsAmt |
| Total Expense | 0.11950 | TotalExpensePct |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bad Debt Expense Reported | 0 | BadDebtExpenseReportedInd |
| Bad Debt Expense | $1,803,040 | BadDebtExpenseAmt |
| Bad Debt Expense Attributable | $274,062 | BadDebtExpenseAttributableAmt |
| Reimbursed By Medicare | $9,389,282 | ReimbursedByMedicareAmt |
| Cost Of Care Reimbursed By Medcr | $9,433,706 | CostOfCareReimbursedByMedcrAmt |
| Medicare Surplus Or Shortfall | -$44,424 | MedicareSurplusOrShortfallAmt |
Costing Methodology Used CostingMethodologyUsedGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Other | Yes (X) | OtherInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Written Debt Collection Policy | Yes (1) | WrittenDebtCollectionPolicyInd |
| Financial Assistance Prvsn | Yes (1) | FinancialAssistancePrvsnInd |
| Hospital Facilities | 1 | HospitalFacilitiesCnt |
Hospital Facilities HospitalFacilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tomah Memorial Hospital | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Website Address | www.tomahhospital.org | WebsiteAddressTxt |
| State License | 1023 | StateLicenseNum |
| Licensed Hospital | Yes (X) | LicensedHospitalInd |
| Critical Access Hospital | Yes (X) | CriticalAccessHospitalInd |
| Emergency Room24 Hrs | Yes (X) | EmergencyRoom24HrsInd |
| Other | Warrens Walk-In Clinic - provider based | OtherDesc |
Hospital Fclty Policies Prctc HospitalFcltyPoliciesPrctcGrp
Hospital Facility Name HospitalFacilityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tomah Memorial Hospital | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
| First Licensed CY Or PY | 0 | FirstLicensedCYOrPYInd |
| Tax Exempt Hospital CY Or PY | 0 | TaxExemptHospitalCYOrPYInd |
| CHNA Conducted | Yes (1) | CHNAConductedInd |
| Community Definition | Yes (X) | CommunityDefinitionInd |
| Community Demographics | Yes (X) | CommunityDemographicsInd |
| Existing Resources | Yes (X) | ExistingResourcesInd |
| How Data Obtained | Yes (X) | HowDataObtainedInd |
| Community Health Needs | Yes (X) | CommunityHealthNeedsInd |
| Other Health Issues | Yes (X) | OtherHealthIssuesInd |
| Community Hlth Needs Id Process | Yes (X) | CommunityHlthNeedsIdProcessInd |
| Consulting Process | Yes (X) | ConsultingProcessInd |
| Information Gaps | Yes (X) | InformationGapsInd |
| CHNA Conducted | 15 | CHNAConductedYr |
| Take Into Account Others Input | Yes (1) | TakeIntoAccountOthersInputInd |
| CHNA Conducted With Other Fclts | Yes (1) | CHNAConductedWithOtherFcltsInd |
| CHNA Conducted With Non Fclts | 0 | CHNAConductedWithNonFcltsInd |
| CHNA Report Widely Available | Yes (1) | CHNAReportWidelyAvailableInd |
| Rpt Available On Own Website | Yes (X) | RptAvailableOnOwnWebsiteInd |
| Own Website URL | www.tomahhospital.org | OwnWebsiteURLTxt |
| Paper Copy Public Inspection | Yes (X) | PaperCopyPublicInspectionInd |
| Implementation Strategy Adopt | Yes (1) | ImplementationStrategyAdoptInd |
| Implementation Strategy Adpt | 15 | ImplementationStrategyAdptYr |
| Strategy Posted Website | Yes (1) | StrategyPostedWebsiteInd |
| Strategy Website URL | http://www.tomahhospital.org/content/detail.cfm?pageid=205 | StrategyWebsiteURLTxt |
| Strategy Attached | 0 | StrategyAttachedInd |
| Organization Incur Excise Tax | 0 | OrganizationIncurExciseTaxInd |
| Elig Criteria Explained | Yes (1) | EligCriteriaExplainedInd |
| FPG Family Incm Lmt Free Dscnt | Yes (X) | FPGFamilyIncmLmtFreeDscntInd |
| FPG Family Incm Lmt Free Care | 100.000000000000 | FPGFamilyIncmLmtFreeCarePct |
| FPG Family Incm Lmt Dscnt Care | 400.000000000000 | FPGFamilyIncmLmtDscntCarePct |
| Asset Level Criteria | Yes (X) | AssetLevelCriteriaInd |
| Medical Indigency Criteria | Yes (X) | MedicalIndigencyCriteriaInd |
| Insurance Status Criteria | Yes (X) | InsuranceStatusCriteriaInd |
| Underinsurance Stat Criteria | Yes (X) | UnderinsuranceStatCriteriaInd |
| Explained Basis | Yes (1) | ExplainedBasisInd |
| App Financial Asst Expln | Yes (1) | AppFinancialAsstExplnInd |
| Described Info | Yes (X) | DescribedInfoInd |
| Described Suprt Doc | Yes (X) | DescribedSuprtDocInd |
| Provided Hospital Contact | Yes (X) | ProvidedHospitalContactInd |
| Provided Nonprofit Contact | Yes (X) | ProvidedNonprofitContactInd |
| Includes Publicity Measures | Yes (1) | IncludesPublicityMeasuresInd |
| FAP Available On Website | Yes (X) | FAPAvailableOnWebsiteInd |
| FAP Available On Website URL | www.tomahhospital.org | FAPAvailableOnWebsiteURLTxt |
| FAP App Available On Website | Yes (X) | FAPAppAvailableOnWebsiteInd |
| FAP App Available On Website URL | www.tomahhospital.org | FAPAppAvailableOnWebsiteURLTxt |
| FAP Summary On Website | Yes (X) | FAPSummaryOnWebsiteInd |
| FAP Summary On Website URL | www.tomahhospital.org | FAPSummaryOnWebsiteURLTxt |
| FAP Avlbl On Request No Charge | Yes (X) | FAPAvlblOnRequestNoChargeInd |
| FAP App Avlbl On Request No Chrg | Yes (X) | FAPAppAvlblOnRequestNoChrgInd |
| FAP Sum Avlbl On Request No Chrg | Yes (X) | FAPSumAvlblOnRequestNoChrgInd |
| FAP Notice Displayed | Yes (X) | FAPNoticeDisplayedInd |
| Other Publicity | Yes (X) | OtherPublicityInd |
| FAP Actions On Nonpayment | Yes (1) | FAPActionsOnNonpaymentInd |
| Permit No Actions | Yes (X) | PermitNoActionsInd |
| Collection Activities | 0 | CollectionActivitiesInd |
| FAP Notified Upon Admission | Yes (X) | FAPNotifiedUponAdmissionInd |
| FAP Notified All Patients | Yes (X) | FAPNotifiedAllPatientsInd |
| Documented Elig Determination | Yes (X) | DocumentedEligDeterminationInd |
| Nondis Emergency Care Policy | Yes (1) | NondisEmergencyCarePolicyInd |
| Other Method Used | Yes (X) | OtherMethodUsedInd |
| Amounts Generally Billed | 0 | AmountsGenerallyBilledInd |
| Gross Charges | 0 | GrossChargesInd |
Supplemental Information SupplementalInformationGrp (5 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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: The Community Health Needs Assessment completed by June 30, 2016 included the following significant needs.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. Workforce ReadinessCurrent Action1. Tomah Memorial Hospital has partnered with the Tomah High School to support the Healthcare Careers Class and the Certified Nursing Assistant (CNA) Certification Class.2. Tomah Memorial donates to the American Heart Association Healthcare Provider CPR/AED and First Aid Certification Courses to the Healthcare Careers and the CNA classes. 3. Hospital Tours - to show students the diversity of the healthcare field 4. CNA Clinical Rotation5. HIPAA Training6. Junior Achievement Classes7. Reality Check at Tomah High SchoolFuture ActionThe hospital is working with the Tomah Area School district to continue developing the opportunities and trainings available for the CNA and Healthcare Careers classes. Youth Resilience Current Action1. 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. Future ActionThe hospital is working with the Boys and Girls Club to host a "Teen Night" centered on health education and job readiness. This night would be a similar event to the current Hospital Men's Night and Women's Night, just geared toward a younger population.Alcohol Use and Illegal Drug UseCurrent Action1. Reasonable Suspicion Training This presentation covers the physical, mental, and emotional effects of drug and alcohol use (both short and long term) with information specific to Monroe county. Participants are shown what signs to look for in drug abuse and how to help someone who is struggling with substance abuse. 2. Cancer Prevention PresentationsOne of the ways to reduce your risk of developing cancer is to limit the amount of alcohol consumed. These presentations encourage healthy alcohol consumption and cover some of the physical and emotional effects of long term alcohol abuse.3. Attendance of the "Wake-Up Call" RoomMonroe 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 GrantTomah Memorial Hospital, Monroe County Safe Communities Coalition, 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. Future ActionWe're currently working with the Monroe County Health Department, WHEEP Western Healthcare Coalition, and Couleecap, a non?profit organization that fights poverty and promotes self-sufficiency, economic development, and social justice, to host several presentations about the effects of drug & alcohol. The Lybert Family from Your Choice to Live, LLC will be sharing their story of how drug and alcohol use affected their family with High School and Middle Schools students in the Tomah, Cashton, and Sparta School Districts. A presentation from the entire Lybert family will also be held for Monroe County to address the drug and alcohol about issue. Mental HealthCurrent ActionThe 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 focusing on youth in Monroe County.Tomah Memorial has partnered with the Rural Wisconsin Health Cooperative, St. Croix Regional Medical Center, and the Monroe County Health Department to provide 8 hours of psychiatric telehealth services per month to underserved clients within Monroe County. Future ActionIn 2017, we'll provide QPR Suicide Prevention Trainings to students in the Cashton and Tomah Area School Districts and to Emergency Department Staff at Tomah Memorial Hospital to better equip them to deal with people struggling with suicidal thoughts. The Monroe County CHIP Mental Health Committee will work to provide Mental Health First Aid Presentations to Monroe County High School health classes. ObesityCurrent Action1. Women and Men's Health Night and the Senior Health and Safety Expo2. Winnebago Wednesday - Tomah Memorial has an interactive booth every year where kids are shown different fun ways to stay active throughout the year. 3. Healthy Eating and Quick Cooking Presentations4. Heart Health Presentations5. Whitney's Healthcheck on Lynxx 24 network6. Label Reading Presentations7. Employee Wellness Committee8. Health Fair Participation9. Monthly Wellness Presenations10. Health Risk Assessments11. Impact Tomah Future ActionWe're in the process of fostering further relations with the Tomah Area School District to explore how the hospital can help promote exercise and a healthy lifestyle.ChildcareCurrent ActionsThe hospital currently offers a community babysitting class that equips children 11-15 years to handle the responsibility of caring for another child. The hospital offers water birth, prepared childbirth, breastfeeding, sibling, and infant CPR & car safety classes to increase the quality and safety of basic childcare. |
| Tomah Memorial Hospital | Part V, Section B, Line 16i: 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. |
| Tomah Memorial Hospital | Part V, Section B, Line 22d: Tomah Memorial Hospital uses the Look Back Method to determine the maximum amounts charged to patients eligible for financial assistance. The aggregate discount percentage is computed based on the Hospital's most recent audit report, and is calculated by dividing total contractual adjustments by total patient service revenue. Total patient service revenue is comprised of all charges for all departments of the Hospital. Individual charges are reviewed annually for reasonableness, and charges are set based on the costs incurred to provide the service, industry benchmark data, and Medicare reimbursement levels. |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | 1 | FacilityNum |
Oth Hlth Care Fclts Not Hospital OthHlthCareFcltsNotHospitalGrp
Oth Hlth Care Fclts OthHlthCareFcltsGrp
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | 1 - Hospice Touch Serenity House | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 330 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Facility | Hospice residence | FacilityTxt |
Supplemental Information Detail SupplementalInformationDetail (13 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 $1,803,040. |
| 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 individuals living below the poverty level in Tomah, WI. |
| Part III, Line 4: | The footnote to the Organization's financial statements can be found on page 8 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 HealthTech Management Services, Inc. (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 16.4% Medicaid, 33.2% Medicare, 6.5% military, 3.7% self-pay, and 40.2% 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 |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Form990 Of Other Organizations | Yes (X) | Form990OfOtherOrganizationsInd |
| Written Employment Contract | Yes (X) | WrittenEmploymentContractInd |
| Compensation Survey | Yes (X) | CompensationSurveyInd |
| Board Or Committee Approval | Yes (X) | BoardOrCommitteeApprovalInd |
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
| Comp Based On Revenue Of Flng Org | 0 | CompBasedOnRevenueOfFlngOrgInd |
| Comp Bsd On Rev Related Orgs | 0 | CompBsdOnRevRelatedOrgsInd |
| Comp Bsd Net Earns Flng Org | 0 | CompBsdNetEarnsFlngOrgInd |
| Comp Bsd Net Earns Rltd Orgs | 0 | CompBsdNetEarnsRltdOrgsInd |
| Any Non Fixed Payments | Yes (1) | AnyNonFixedPaymentsInd |
| Initial Contract Exception | 0 | InitialContractExceptionInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (6 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Joseph Zeps | ||||||||||||||
| Chief Financial Officer | $133,841 | $0 | $2,717 | $0 | $11,731 | $0 | $6,231 | $0 | $32,554 | $0 | $187,074 | $0 | $0 | $0 |
| Lily Liu MD | ||||||||||||||
| Geriatric & Family Medicine | $300,000 | $0 | $5,000 | $0 | $1,250 | $0 | $7,385 | $0 | $0 | $0 | $313,635 | $0 | $0 | $0 |
| Darla Wilson | ||||||||||||||
| Director of Pharmacy | $167,396 | $0 | $3,113 | $0 | $2,941 | $0 | $6,994 | $0 | $13,489 | $0 | $193,933 | $0 | $0 | $0 |
| Todd Chapman | ||||||||||||||
| Pharmacist | $150,212 | $0 | $2,563 | $0 | $5,166 | $0 | $6,309 | $0 | $1,595 | $0 | $165,845 | $0 | $0 | $0 |
| Gerald Fushianes PA-C | ||||||||||||||
| Physician Assistant | $145,261 | $0 | $2,815 | $0 | $3,841 | $0 | $6,479 | $0 | $32,545 | $0 | $190,941 | $0 | $0 | $0 |
| Laura J Miller FNP | ||||||||||||||
| Nurse Practitioner | $128,659 | $0 | $2,438 | $0 | $3,272 | $0 | $5,451 | $0 | $13,459 | $0 | $153,279 | $0 | $0 | $0 |
Supplemental Information Detail SupplementalInformationDetail (2 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 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. |
Schedule K IRS990ScheduleK
Tax Exempt Bonds Issues TaxExemptBondsIssuesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
Issuer Name IssuerName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Wisconsin Health and Educational Facilities Authority | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Issuer EIN | 391337855 | BondIssuerEIN |
| Bond Issued | 2012-08-08 | BondIssuedDt |
| Issue Price | $7,827,337 | IssuePriceAmt |
| Purpose | Refund Revenue Bond Series 2003 issued 7/15/03 | PurposeDesc |
| Defeased | 0 | DefeasedInd |
| On Behalf Of Issuer | 0 | OnBehalfOfIssuerInd |
| Pool Financing | 0 | PoolFinancingInd |
Tax Exempt Bonds Proceeds TaxExemptBondsProceedsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Retired | $1,767,897 | RetiredAmt |
| Total Proceeds | $7,827,337 | TotalProceedsAmt |
| Issuance Costs From Proceeds | $155,074 | IssuanceCostsFromProceedsAmt |
| Other Spent Proceeds | $7,672,263 | OtherSpentProceedsAmt |
| Substantial Completion | 2012 | SubstantialCompletionYr |
| Current Refunding | 0 | CurrentRefundingInd |
| Advance Refunding | Yes (1) | AdvanceRefundingInd |
| Final Allocation Made | Yes (1) | FinalAllocationMadeInd |
| Adequate Books And Rec Maint | Yes (1) | AdequateBooksAndRecMaintInd |
Tax Exempt Bonds Private Bus Use TaxExemptBondsPrivateBusUseGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Owning Bond Financed Property | 0 | OwningBondFinancedPropertyInd |
| Any Lease Arrangements | 0 | AnyLeaseArrangementsInd |
| Mgmt Contract Bond Fincd Prop | 0 | MgmtContractBondFincdPropInd |
| Any Research Agreements | 0 | AnyResearchAgreementsInd |
| Private Bus Use By Others | 0.00000 | PrivateBusUseByOthersPct |
| Private Bus Concerning UBI | 0.00000 | PrivateBusConcerningUBIPct |
| Total Private Business Use | 0.00000 | TotalPrivateBusinessUsePct |
| Bond Iss Meet Prvt Sec Pymt Test | 0 | BondIssMeetPrvtSecPymtTestInd |
| Change In Use Bond Financed Prop | 0 | ChangeInUseBondFinancedPropInd |
| Procs Nonqualified Bond Remdtd | Yes (1) | ProcsNonqualifiedBondRemdtdInd |
Tax Exempt Bonds Arbitrage TaxExemptBondsArbitrageGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Form8038 T Filed | 0 | Form8038TFiledInd |
| Rebate Not Due Yet | 0 | RebateNotDueYetInd |
| Exception To Rebate | 0 | ExceptionToRebateInd |
| No Rebate Due | 0 | NoRebateDueInd |
| Variable Rate Issue | 0 | VariableRateIssueInd |
| Hedge Identified In Bks And Rec | 0 | HedgeIdentifiedInBksAndRecInd |
| Gross Proceeds Invested In GIC | 0 | GrossProceedsInvestedInGICInd |
| Gross Proceeds Invested | 0 | GrossProceedsInvestedInd |
| Written Proc To Monitor Reqs | Yes (1) | WrittenProcToMonitorReqsInd |
Procedures Corrective Action ProceduresCorrectiveActionGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Bond Reference | A | BondReferenceCd |
| Procedures Corrective Action | Yes (1) | ProceduresCorrectiveActionInd |
Schedule L IRS990ScheduleL
Bus Tr Involve Interested Prsn BusTrInvolveInterestedPrsnGrp
Name Of Interested NameOfInterested
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | Cindy Lambert | PersonNm |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Relationship Description | Family member of Chief Financial Officer | RelationshipDescriptionTxt |
| Transaction | $41,094 | TransactionAmt |
| Transaction | Compensation and benefits as an employee | TransactionDesc |
| Sharing Of Revenues | 0 | SharingOfRevenuesInd |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (8 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| 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 HealthTech Management Services, Inc., an unrelated management company. The Administrator has the responsibility of supervising the management, administration and operation of the Organization. Philip was compensated $285,380 for services provided to Tomah Memorial Hospital. |
| Form 990, Part VI, Section B, line 11 | 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 has 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 2016. |
| 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 6,961,244. Management and general expenses 890,330. Fundraising expenses 0. Total expenses 7,851,574. Professional fees: Program service expenses 259,039. Management and general expenses 290,076. Fundraising expenses 0. Total expenses 549,115. |
| Form 990, Part XI, line 9: | Net change in fair value of beneficial interest in perpetual trust 54,884. |
Schedule R IRS990ScheduleR
Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp
Disregarded Entity Name DisregardedEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Pederson Trust Fund for the Benefit of Tomah Memorial Hospital | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 321 Butts Avenue | AddressLine1Txt |
| City | Tomah | CityNm |
| State Abbreviation | WI | StateAbbreviationCd |
| ZIP | 54660 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 396173790 | EIN |
| Primary Activities | Support Tomah Memorial Hospital | PrimaryActivitiesTxt |
| Legal Domicile State | WI | LegalDomicileStateCd |
| Exempt Code Section | 501(c)(3) | ExemptCodeSectionTxt |
| Public Charity Status | Line 11b, II | PublicCharityStatusTxt |
Direct Controlling Entity Name DirectControllingEntityName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | Tomah Memorial Hospital | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Controlled Organization | Yes (1) | ControlledOrganizationInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | Yes (1) | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | 0 | SharingOfFacilitiesInd |
| Paid Employees Sharing | 0 | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | 0 | TransferFromOtherOrgInd |
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