2016-11-02T12:49:30-05:00 2016-03-31 420714325 RSM US LLP 227 W FIRST ST STE 700 DULUTH MN 558021926 990 2015-04-01 391536207 MEDICAL SERVICES INC D/B/A HAYWARD AREA MEMORIAL HOSPITAL MEDI 7156348911 11040 N STATE ROAD 77 HAYWARD WI 548436391 TIM GULLINGSRUD CHIEF EXECUTIVE OFFICER 7156348911 2016-10-27 1 MARY BETH SANTORI P00023783 2187275025 2015 2017-02-10 21:41:12Z HAYWARD AREA MEMORIAL HOSPITAL & WATER'S EDGE TIM GULLINGSRUD 11040 N STATE ROAD 77 HAYWARD WI 548436391 44573947 0 X HTTP://HAYWARDMEMORIALHOSPITAL.COM X 1986 WI TO PROVIDE QUALITY HEALTH CARE TO THE PEOPLE OF HAYWARD, WI AND THE SURROUNDING AREAS 11 9 334 115 0 0 110803 55511 42093421 42950813 398779 468521 407771 232430 43010774 43707275 0 0 0 0 17620581 18291755 0 0 0 18615974 19856894 36236555 38148649 6774219 5558626 59879724 63113666 16061160 14173204 43818564 48940462 X CONTINUOUSLY IMPROVE THE HEALTH STATUS OF THE PEOPLE OF THE HAYWARD AREA 0 0 31180741 43052662 HAYWARD AREA MEMORIAL HOSPITAL & WATER'S EDGE IS A 25 BED CRITICAL ACCESS HOSPITAL, 50 BED NURSING HOME, AND 20 APARTMENT RCAC FACILITY. THE HOSPITAL CAMPUS ALSO CONTAINS TWO ATTACHED CLINICS THAT ARE OWNED AND OPERATED BY ESSENTIA HEALTH AND NORTHLAKES COMMUNITY HEALTH CENTER. THESE CLINICS EMPLOY APPROXIMATELY 18 FULL-TIME PHYSICIANS, AND ADDITIONAL PART-TIME SPECIALTY CARE PHYSICIANS WHO DO ROUNDS AND SEE PATIENTS AT THE HOSPITAL THROUGHOUT THE MONTH. THE HOSPITAL, NURSING HOME AND ASSISTED LIVING EMPLOY CLOSE TO 320 EMPLOYEES. IN FY '15-'16 THE HOSPITAL HAD 675 IN PATIENT ADMISSIONS AND 2106 IP DAYS, 462 OBSERVATION ADMISSIONS WITH 11,682 HOURS OF CARE, AND 86 TCU ADMISSIONS WITH 770 CENSUS DAYS OF CARE. THE NURSING HOME HAD 80 ADMISSIONS WITH 17,628 CENSUS DAYS, AND THE ASSISTED LIVING HAD 7,225 RESIDENT DAYS WITH AN AVERAGE MONTHLY CENSUS OF 19.74 FOR THE FISCAL YEAR WITH 20 TOTAL APARTMENTS. THE EMERGENCY ROOM IS STAFFED BY A PHYSICIAN 24/7/365 SEEING AROUND 9,500 PATIENTS. AIR AND GROUND AMBULANCES ARE AVAILABLE FOR THOSE REQUIRING A HIGHER LEVEL OF TRAUMA CARE. THE OPERATING ROOM PERFORMED 715 CASES AND ENDOSCOPY PERFORMED 947 PROCEDURES. RADIOLOGY EXAMS TOTAL 19,400, AND LAB EXAMS TOTAL 48,000 PER YEAR. HAYWARD HOSPITAL PERFORMED 160 DELIVERIES LAST YEAR WITH 343 NEWBORN DAYS.HAYWARD IS A POPULAR VACATION HOME DESTINATION AND ATTRACTS TOURISTS THROUGHOUT THE YEAR. HAYWARD IS ALSO A POPULAR RECREATIONAL AREA ATTRACTING MOUNTAIN BIKERS, SKIERS, BOATING, FISHING, AND GENERAL OUTDOOR ACTIVITIES. MEDICAL PROFESSIONALS ARE ATTRACTED TO THIS POPULAR RECREATIONAL AREA BY THE QUALITY OF LIFE THEY FIND HERE. 31180741 1 0 0 1 0 0 0 0 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 24 0 1 334 1 0 0 0 0 0 0 0 0 0 0 X 11 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X BRAD ZELLER 7159344245 11040 N STATE ROAD 77 HAYWARD WI 54843 X STEVE GILLIS FORMER VICE CHAIR - RESIGNED 4/29/15 1.00 1.00 X X 0 0 0 KAREN GUSTAFSON TREASURER 1.00 1.00 X X 0 0 0 HEIDI HABEL DIRECTOR 1.00 0.00 X 0 0 0 BRENT KELLEY DO DIRECTOR 1.00 0.00 X 0 0 0 BARBARA KOERPEL-DUFFY CHAIR 1.00 2.00 X X 0 0 0 HARRY MALCOLM MD SECRETARY 1.00 1.00 X X 0 0 0 TIM GULLINGSRUD DIRECTOR/CEO - MSI 38.00 2.00 X X 223315 0 40661 JULIE KAHL MD DIRECTOR 1.00 0.00 X 0 0 0 GARY NATHAN DIRECTOR 1.00 0.00 X 0 0 0 JASON DOUGLAS DIRECTOR/PRESIDENT - REI 1.00 39.00 X 0 359333 42504 JAMES MILLER VICE CHAIR 1.00 1.00 X X 0 0 0 AMY BEILKE DIRECTOR 1.00 0.00 X 0 0 0 BRAD ZELLER VICE PRESIDENT - MSI 39.00 1.00 X 144095 0 34992 KENT DUMONSEAU CFO - REI 14.00 26.00 X 0 212602 38990 HEATHER SHEEHAN VICE PRESIDENT - MSI 39.00 1.00 X 145492 0 36440 SUSAN BAUER CRNA 40.00 0.00 X 183478 0 30312 BRADLEY KRASEAN PHYSICAL THERAPIST 40.00 0.00 X 131256 0 32341 MICHAEL LAIRD PHARMACIST 40.00 0.00 X 135368 0 19573 ALLISON FARLEY PHARMACIST/DIRECTOR OF PHARMACY 40.00 0.00 X 141084 0 28150 STEVEN KRASEAN PHYSICAL THERAPIST 40.00 0.00 X 127381 0 26449 1231469 571935 330412 20 0 1 0 REGIONAL ENTERPRISES INC 1615 MAPLE LANE ASHLAND WI 54806 PROFESSIONAL FEES/RENT 3765082 WAPITI MEDICAL GROUP 107 FLYNN DRIVE SUITE 600 MILBANK SD 57252 ER SERVICES 1525135 ESSENTIA-HAYWARD 11134 N STATE RD 77 HAYWARD WI 54843 ER ON-CALL SERVICES 256211 SHARED MEDICAL TECHNOLOGY 202 W NEWTON ST RICE LAKE WI 54868 PROFESSIONAL FEES 131944 NORTHLAND TRANSCRIPTION PO BOX 39 HAYWARD WI 54843 TRANSCRIPTION SERVICES 110542 5 55511 55511 HOSPITAL 621500 38363602 38363602 NURSING HOME 621500 3194155 3194155 ASSISTED LIVING 621500 855944 855944 ELECTRONIC HEALTH RECORD INCENTIV 621500 510040 510040 DIABETES 621500 27072 27072 42950813 359311 359311 186616 56035 130581 130581 130581 911422 8425 810637 0 100785 8425 109210 109210 CAFETERIA 900099 67753 67753 MISCELLANEOUS 900099 34096 34096 101849 43707275 42984909 0 666855 655415 655415 13108473 12006894 1101579 493582 453363 40219 3059831 2764112 295719 974454 854166 120288 76283 76283 131540 131540 161505 161505 616115 616115 2966271 2966271 444836 355708 89128 3034858 2426788 608070 88624 88624 HOSPITAL SUPPLIES & OTH 6862753 6862753 PROVISION FOR DOUBTFUL 2192845 2192845 NURSING SUPPLIES & OTHE 1891320 1891320 OTHER GENERAL SERVICE S 1372792 1372792 17152 17152 38148649 31180741 6967908 0 22210829 20714271 7115333 10713111 951828 1114955 355537 137981 43259468 20545434 23510843 22714034 4518077 5903321 1217277 1815993 59879724 63113666 3585688 3070237 12475472 11102967 16061160 14173204 X 43818564 48940462 43818564 48940462 59879724 63113666 5558626 -436728 0 X 0 1 X 1 0 X 0 0 0 0 0 0 0 0 1 2935 2935 0 PART II-B, LINE 1: HAYWARD AREA MEMORIAL HOSPITAL AND WATER'S EDGE PAY DUES TO CERTAIN ORGANIZATIONS RELATED TO THE INDUSTRY WHICH HAVE LOBBYING EXPENSES. THE AMOUNT LISTED IS THE PERCENTAGE OF THE DUES PAID THAT WERE USED FOR LOBBYING. 45799 45799 32229330 14382183 17847147 9094858 5407946 3686912 1889481 755305 1134176 22714034 MUTUAL FUNDS 5903321 F 5903321 X 41125312 -436728 56035 -380693 41506005 2201270 2201270 43707275 36003414 47610 47610 35955804 2192845 2192845 38148649 PART X, LINE 2: THE COMPANY IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL AND STATE INCOME TAXES. NOT-FOR-PROFIT ORGANIZATIONS MAY BECOME SUBJECT TO INCOME TAXES IF QUALIFICATION AS A TAX-EXEMPT ENTITY CHANGES, IF UNRELATED BUSINESS INCOME IS GENERATED AND IN CERTAIN OTHER INSTANCES. NOT-FOR-PROFIT ORGANIZATIONS ARE REQUIRED TO ASSESS THE CERTAINTY OF THEIR TAX POSITIONS RELATED TO THESE MATTERS AND, IN SOME CASES, RECORD LIABILITIES FOR POTENTIAL TAXES, INTEREST AND PENALTIES ACCOMPANIED BY FOOTNOTE DISCLOSURES. THE COMPANY HAS NOT IDENTIFIED ANY UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE THE ACCRUAL OF AN INCOME TAX PROVISION. GENERALLY, THE COMPANY IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL OR STATE TAX AUTHORITIES FOR YEARS BEFORE 2013. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 56,035. PART XI, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL RECEIVABLES 2,192,845. GAIN ON SALE OF EQUIPMENT 8,425. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES 56,035. GAIN ON SALE OF EQUIPMENT -8,425. PART XII, LINE 4B - OTHER ADJUSTMENTS: PROVISION FOR DOUBTFUL RECEIVABLES 2,192,845. 1 1 1 X 1 X 1 1 0 1 1 206499 206499 0.00570 6941811 5272303 1669508 0.04640 7148310 5272303 1876007 0.05210 178322 16825 161497 0.00450 11425430 7915701 3509729 0.09760 28202 28202 0.00080 11631954 7932526 3699428 0.10290 18780264 13204829 5575435 0.15500 1 2192845 0 12165091 12201370 -36279 X 1 1 1 NONE 1 1 HAYWARD AREA MEMORIAL HOSPITAL 11040 N STATE ROAD 77 HAYWARD WI 54843 X X X X HAYWARD AREA MEMORIAL HOSPITAL 1 0 0 1 X X X X X X X X 15 1 0 1 1 X HTTP://HAYWARDMEMORIALHOSPITAL.COM/ABOUT-US/COMMUNITY-COMMITMENT/ X X 1 15 1 HTTP://HAYWARDMEMORIALHOSPITAL.COM/ABOUT-US/COMMUNITY-COMMITMENT/ 0 0 1 X 100.000000000000 200.000000000000 X X X 1 1 X X X 1 X HTTP://HAYWARDMEMORIALHOSPITAL.COM X HTTP://HAYWARDMEMORIALHOSPITAL.COM X HTTP://HAYWARDMEMORIALHOSPITAL.COM X X X 1 0 X X X X 1 X 0 0 HAYWARD AREA MEMORIAL HOSPITAL PART V, SECTION B, LINE 5: HAYWARD AREA MEMORIAL HOSPITAL (HAMH) WORKED WITH THE NATIONAL RURAL HEALTH RESOURCE CENTER (THE CENTER) OF DULUTH, MINNESOTA TO ADMINISTER THEIR COMMUNITY HEALTH ASSESSMENT PROCESS.IN THE SUMMER OF 2015, THE CENTER CONFERRED WITH LEADERS FROM THE HOSPITAL TO DISCUSS THE OBJECTIVES OF A REGIONAL HEALTH NEEDS ASSESSMENT MAILED SURVEY. A SURVEY INSTRUMENT WAS DEVELOPED TO ASSESS THE HEALTH CARE NEEDS AND PREFERENCES IN THE SERVICE AREA. THE SURVEY INSTRUMENT WAS DESIGNED TO BE EASILY COMPLETED BY RESPONDENTS. RESPONSES WERE ELECTRONICALLY SCANNED TO MAXIMIZE ACCURACY. THE SURVEY WAS DESIGNED TO ASSEMBLE INFORMATION FROM LOCAL RESIDENTS REGARDING DEMOGRAPHICS OF RESPONDENTS, UTILIZATION AND PERCEPTION OF LOCAL HEALTH SERVICES, PERCEPTION OF COMMUNITY HEALTH. HAMH PROVIDED THE CENTER WITH A LIST OF INPATIENT HOSPITAL ADMISSIONS. ZIP CODES WITH THE GREATEST NUMBER OF ADMISSIONS WERE STRATIFIED IN THE INITIAL SAMPLE SELECTION. EACH AREA WOULD BE REPRESENTED IN THE SAMPLING PROPORTIONATE TO BOTH THE OVERALL SERVED POPULATION AND THE NUMBER OF PAST ADMISSIONS. EIGHT HUNDRED RESIDENTS WERE SELECTED RANDOMLY FROM PRIME NET DATA SOURCE, A MARKETING ORGANIZATION. ALTHOUGH THE SURVEY SAMPLES WERE, PROPORTIONATELY SELECTED, ACTUAL SURVEYS RETURNED FROM EACH POPULATION AREA VARIED. MEMBERS OF THE HOSPITAL AND HOSPITAL PARTNERS WERE ASSEMBLED TO IDENTIFY THE TOP COMMUNITY HEALTH NEEDS BASED ON THE COMMUNITY HEALTH ASSESSMENT FINDINGS. TEAM MEMBERS FROM HAMH INCLUDE: CEO - TIM GULLINGSRUD, VICE PRESIDENT OF ADMINISTRATION - BRAD ZELLER, VICE PRESIDENT OF SENIOR SERVICES - HEATHER SHEEHAN, BOARD OF DIRECTOR PRESIDENT - BARB KOERPEL DUFFY, HOSPITAL DIRECTOR OF NURSING, RN - SANDY HARM, QUALITY DIRECTOR, RN - PATTI PATEFIELD, PATIENT FINANCIAL SERVICES DIRECTOR - ANN GLEICHERT, MARKETING/COMMUNICATIONS DIRECTOR - CHERIE MORGAN, INFECTION PREVENTION/EDUCATION DIRECTOR, RN - MELODY RUEHL, EMERGENCY DEPARTMENT NURSE MANAGER, RN - LISA ANDERSON. TEAM MEMBERS FROM THE COMMUNITY INCLUDE: NORTHLAKES COMMUNITY CLINIC MANAGER - STACY KOLKIND, ESSENTIA HEALTH-HAYWARD CLINIC MANAGER - LINDA PARKER, SAWYER COUNTY DIRECTOR OF PUBLIC HEALTH, RN - EILEEN SIMAK, HAYWARD COMMUNITY SCHOOLS SUPERINTENDENT - CRAIG OLSON, LAC COURTE OREILLES HEALTH CENTER DIRECTOR - GREGG DUFFEK, NORTHWEST FAMILY CONNECTION RESOURCES, EXECUTIVE DIRECTOR - JACQUELINE STRAND. HAYWARD AREA MEMORIAL HOSPITAL PART V, SECTION B, LINE 6B: TEAM MEMBERS FROM THE COMMUNITY INCLUDE: NORTHLAKES COMMUNITY CLINIC MANAGER - STACY KOLKIND, ESSENTIA HEALTH-HAYWARD CLINIC MANAGER - LINDA PARKER, SAWYER COUNTY DIRECTOR OF PUBLIC HEALTH, RN - EILEEN SIMAK, HAYWARD COMMUNITY SCHOOLS SUPERINTENDENT - CRAIG OLSON, LAC COURTE OREILLES HEALTH CENTER DIRECTOR - GREGG DUFFEK, NORTHWEST FAMILY CONNECTION RESOURCES, EXECUTIVE DIRECTOR - JACQUELINE STRAND. HAYWARD AREA MEMORIAL HOSPITAL PART V, SECTION B, LINE 7D: HAMH DISTRIBUTED A PRESS RELEASE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT FINDINGS AND IMPLEMENTATION STRATEGY IN THE LOCAL NEWSPAPER. HAYWARD AREA MEMORIAL HOSPITAL PART V, SECTION B, LINE 11: IN SUPPORT OF THE FY 2017 - FY 2019 COMMUNITY HEALTH NEEDS ASSESSMENT, AND ONGOING COMMUNITY BENEFITS INITIATIVES, HAYWARD AREA MEMORIAL HOSPITAL AND WATER'S EDGE PLANS TO IMPLEMENT THE FOLLOWING STRATEGIES TO IMPACT AND MEASURE COMMUNITY HEALTH IMPROVEMENT.ADDRESS ACCESS TO URGENT CARE SERVICESHAYWARD AREA MEMORIAL HOSPITAL RECOGNIZES THE NEED FOR ACCESS TO HEALTH CARE SERVICES DURING TIMES THAT THE PRIMARY CLINICS ARE NOT PRESENTLY OPEN. CURRENTLY, THE ONLY OPTIONS AVAILABLE TO PATIENTS NEEDING CARE DURING THE TIME THAT THE PRIMARY CARE CLINICS ARE NOT OPEN ARE TO: 1) SEEK CARE IN THE EMERGENCY ROOM WHICH HAS A MUCH HIGHER ASSOCIATED COST AND CAN RESULT IN SIGNIFICANT DELAYS IN RECEIVING CARE DUE TO THE UNPREDICTABLE DEMAND OF EMERGENCY SERVICES; 2) TRAVEL TO AN URGENT CARE SERVICE LOCATED IN ANOTHER COMMUNITY THE CLOSEST OF WHICH IS OVER 50 MILES AWAY; 3) WAIT TO SEEK CARE UNTIL THE PRIMARY PHYSICIAN CLINIC IS OPEN WHICH COULD DELAY TREATMENT FOR SEVERAL DAYS.GOAL: TO PROMOTE TIMELY AND CARE/COST LEVEL APPROPRIATE OPTIONS FOR RECEIVING CARE DURING TIMES WHEN THE PRIMARY CARE CLINICS ARE NOT OPEN.OBJECTIVES: PROVIDE AN OPTION FOR THE APPROPRIATE LEVEL OF CARE DURING TIMES THE PRIMARY CARE CLINIC IS NOT TRADITIONALLY OPEN, OFFER A LOWER COST ALTERNATIVE TO CARE THAN THE MUCH HIGHER COST OF CARE THAT IS FOUND IN AN EMERGENCY ROOM SETTING, DECREASE THE NEED TO TRAVEL TO FIND URGENT CARE SERVICES.CREATE AWARENESS OF SPECIALTY CARE SERVICES AVAILABLE LOCALLYMANY RESIDENTS LIVING IN AND AROUND HAYWARD FIND IT DIFFICULT TO TRAVEL A MINIMUM OF 50 MILES TO OTHER COMMUNITIES TO RECEIVE SPECIALTY CARE. MANY SPECIALISTS PROVIDE SERVICES IN HAYWARD, HOWEVER; COMMUNITY MEMBERS NEEDING THESE SERVICES ARE UNAWARE THAT THEY ARE AVAILABLE LOCALLY.GOAL: TO RAISE COMMUNITY AWARENESS OF SPECIALTY CARE SERVICES AVAILABLE IN HAYWARDOBJECTIVES: INCREASE AWARENESS OF SPECIALTY SERVICES AVAILABLE LOCALLY, REDUCE THE NEED TO TRAVEL TO RECEIVE SPECIALTY SERVICES, INCREASE IN SCOPE AND FREQUENCY THE NUMBER OF SPECIALTY SERVICES TRAVELING TO THE HAYWARD AREA.ENGAGE THE COMMUNITY IN PREVENTION/WELLNESS ACTIVITIES AND ROLE MODEL WELLNESSHAYWARD AREA MEMORIAL HOSPITAL AND WATER'S EDGE RECOGNIZES THE CONNECTION BETWEEN LIFESTYLE BEHAVIORS AND CHRONIC DISEASES. BY FOCUSING ON EDUCATION AND PREVENTION, WE BELIEVE WE CAN IMPROVE THE QUALITY OF LIFE FOR THE MEMBERS OF OUR COMMUNITY WHILE ALSO REDUCING THE OVERALL LIFETIME COST OF HEALTHCARE. WE ALSO ACKNOWLEDGE OUR ROLE IN THE HEALTH OF OUR COMMUNITY AND THE NEED FOR US TO BE ROLE MODELS OF HEALTHY BEHAVIORS.GOAL: TO PROMOTE AND ROLE MODEL HEALTHY BEHAVIORS TO OUR COMMUNITY WHICH WILL RESULT IN AN IMPROVED QUALITY OF LIFE.OBJECTIVES: IMPROVE AWARENESS OF HEALTHY BEHAVIORS, INCREASE AWARENESS OF HEALTH ACTIVITIES AVAILABLE IN OUR AREA, OFFER HEALTHY ACTIVITIES ON OUR CAMPUS THAT ALLOW RESIDENTS OF ALL AGES AN OPPORTUNITY TO INCREASE THEIR LEVEL OF EXERCISEEXPAND COMMUNITY COLLABORATIONSPARTNERSHIPS AND COLLABORATIONS ARE IMPORTANT IN ALLOWING HAYWARD AREA MEMORIAL HOSPITAL AND WATER'S EDGE TO ACHIEVE ITS MISSION OF IMPROVING THE HEALTH STATUS OF THE PEOPLE OF THE HAYWARD AREA. BY WORKING WITH OTHER ENTITIES, WE WILL BE ABLE TO POOL OUR COLLECTIVE RESOURCES AND ACHIEVE MORE ON BEHALF OF OUR COMMUNITY THEN ANY ENTITY COULD ACCOMPLISH ON ITS OWN.GOAL: TO PARTNER AND COLLABORATE WITH OTHER ENTITIES TO CREATE OR ENHANCE HEALTH RELATED SERVICES TO OUR COMMUNITY.OBJECTIVES: SEEK OPPORTUNITIES TO COLLABORATE WITH OTHER HEALTH CARE AND GOVERNMENTAL ORGANIZATIONS, LEVERAGE THESE RELATIONSHIPS TO ENHANCE THE SERVICES PROVIDED TO OUR COMMUNITYCOMMUNITY HEALTH NEEDS NOT ADDRESSEDHAYWARD AREA MEMORIAL HOSPITAL HAS CHOSEN NOT TO FOCUS ON THE FOLLOWING NEEDS THAT WERE IDENTIFIED THROUGH THE COMMUNITY HEALTH NEEDS ASSESSMENT AND PRIORITIZATION PROCESS:INTEGRATE BEHAVIORAL HEALTH SERVICES INTO PRIMARY CARE - HAYWARD AREA MEMORIAL HOSPITAL DOES NOT EMPLOY BEHAVIORAL HEALTH PROVIDERS AND OUR SOCIAL SERVICES DEPARTMENT WILL WORK WITH THESE PATIENTS TO REFER THEM TO THE SPECIFIC SERVICES NEEDED.MAINTAIN CUSTOMER LOYALTY - CUSTOMER LOYALTY IS MORE A BUSINESS AND OPERATIONAL FUNCTION AND DOES NOT SEEM TO FIT INTO THE SPIRIT OF A COMMUNITY HEALTH NEED. HAYWARD AREA MEMORIAL HOSPITAL AND WATER'S EDGE IS DEDICATED TO MAINTAINING AND IMPROVING CUSTOMER LOYALTY AND WILL DO SO OUTSIDE OF THE COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS. HAYWARD AREA MEMORIAL HOSPITAL PART V, SECTION B, LINE 22D: FOLLOWING A DETERMINATION OF FINANCIAL-ASSISTANCE ELIGIBILITY, THE ELIGIBLE INDIVIDUAL WILL NOT BE CHARGED MORE FOR EMERGENCY OR MEDICALLY NECESSARY CARE THAN THE AMOUNTS GENERALLY BILLED (AGB) TO INDIVIDUALS WITH INSURANCE COVERING SUCH CARE. AT HAMH THE AGB IS DETERMINED THROUGH THE "LOOK-BACK METHOD" WHICH IS CALCULATED AS FOLLOWS: FOR 2017, HAMH IS USING THE "LOOK-BACK METHOD" TO CALCULATE THE AGB. THIS METHOD BASED AGB ON FULLY ALLOWED PAYMENTS AMOUNTS FOR HOSPITAL CLAIMS WITH A PRIMARY PAYER OF EITHER MEDICARE FEE FOR SERVICE OR A COMMERCIAL PAYER DURING THE PERIOD 12/1/14-11/30/15. HAMH DIVIDES THE SUM OF TOTAL PAYMENTS ALLOWED BY THOSE PAYERS (INCLUDING COINSURANCE, COPAYMENTS, AND DEDUCTIBLES) BY THE SUM OF TOTAL HOSPITAL CHARGES FOR THOSE CLAIMS TO IDENTIFY THE "AGB PERCENTAGE". HAMH WILL NOT CHARGE PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE MORE THAN BELOW-NOTED AGB PERCENTAGE FOR EMERGENCY OR MEDICALLY NECESSARY SERVICES IN 2016-2017. AGB FOR THE PERIOD 4/1/16-3/31/2017 (UNLESS EARLIER UPDATED) WILL BE 56 PERCENT OF TOTAL HOSPITAL CHARGES. HAMH WILL RE-CALCULATE ITS AGB AT LEAST ANNUALLY. THE CURRENT DISCOUNT RATES OFFERED TO ELIGIBLE INDIVIDUALS ARE: 55% FOR INDIVIDUALS AT OR BELOW 100% OF THE FEDERAL POVERTY GUIDELINE 45% FOR INDIVIDUALS AT OR BELOW 200% OF THE FEDERAL POVERTY GUIDELINE 2 1 - WATER'S EDGE 11040 N STATE ROAD 77 HAYWARD WI 54843 NURSING HOME 2 - WATER'S EDGE 11040 N STATE ROAD 77 HAYWARD WI 54843 ASSISTED LIVING FACILITY PART I, LINE 7: COSTS ARE CALCULATED USING FINANCIAL DATA AND THE COST TO CHARGE RATIO FROM THE AS FILED MEDICARE COST REPORT. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES INCLUDE PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH PATHOLOGY, DIABETES EDUCATION, EMERGENCY, OBSERVATION BEDS, NURSING HOME, AND ASSISTED LIVING. PART I, LN 7 COL(F): BAD DEBT EXPENSE FROM FINANCIAL STATEMENTS IS $2,192,845. PART II, COMMUNITY BUILDING ACTIVITIES: MANY PROGRAMS HAVE BEEN DESIGNED TO HELP PATIENTS OF THE COMMUNITY SUCH AS BREASTFEEDING EDUCATION, BLOOD DRIVES, CHILD BIRTH CLASSES, DISASTER READINESS, DIABETES EDUCATION, HEALTH FAIRS, HABITAT FOR HUMANITY, MORE ENERGY, IN KIND DONATIONS AND CASH DONATIONS AS EXAMPLES OF THE COMMUNITY ACTIVITIES HAYWARD HOSPITAL IS CURRENTLY INVOLVED IN. THE ACTIVITIES HAVE BEEN REPORTED ON SCHEDULE H, PART I, LINE 7E. PART III, LINE 2: PATIENT AND RESIDENT ACCOUNTS RECEIVABLE ARE REDUCED BY AN ALLOWANCE FOR DOUBTFUL ACCOUNTS. IN EVALUATING THE COLLECTABILITY OF ACCOUNTS RECEIVABLE, THE COMPANY ANALYZES ITS PAST HISTORY AND IDENTIFIES TRENDS FOR EACH OF ITS MAJOR PAYOR SOURCES OF REVENUE TO ESTIMATE THE APPROPRIATE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND PROVISION FOR BAD DEBTS. MANAGEMENT REGULARLY REVIEWS DATA ABOUT THESE MAJOR PAYOR SOURCES OF REVENUE IN EVALUATING THE SUFFICIENCY OF THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE COMPANY ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND A PROVISION FOR BAD DEBTS, IF NECESSARY (FOR EXAMPLE, FOR EXPECTED UNCOLLECTIBLE DEDUCTIBLES AND COPAYMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID, OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY). FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR PART OF THE BILL), THE COMPANY RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS PAST EXPERIENCE, WHICH INDICATES THAT MANY PATIENTS ARE UNABLE OR UNWILLING TO PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE STANDARD RATES (OR THE DISCOUNTED RATES IF NEGOTIATED) AND THE AMOUNTS ACTUALLY COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED OFF AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS AS A PERCENTAGE OF SELF-PAY RECEIVABLE HAS INCREASED FROM 61.8 PERCENT FOR THE YEAR ENDED MARCH 31, 2015, TO 67.0 PERCENT FOR THE YEAR ENDED MARCH 31, 2016.THE COMPANY HAS NOT CHANGED ITS CHARITY CARE OR UNINSURED DISCOUNT POLICIES DURING FISCAL YEARS 2016 OR 2015. THE COMPANY DOES NOT MAINTAIN A MATERIAL ALLOWANCE FOR DOUBTFUL ACCOUNTS FROM THIRD-PARTY PAYORS NOR DID IT HAVE SIGNIFICANT WRITE-OFFS FROM THIRD PARTY PAYORS. PART III, LINE 3: AT HAYWARD AREA MEMORIAL HOSPITAL BAD DEBT IS CONSIDERED THE UNWILLINGNESS TO PAY, WHILE CHARITY CARE AND FREE CARE ARE INABILITY TO PAY. PART III, LINE 4: SEE FOOTNOTE 1 ON PAGE 6 OF THE AUDITED FINANCIAL STATEMENTS PART III, LINE 8: HAYWARD AREA MEMORIAL HOSPITAL IS A CRITICAL ACCESS HOSPITAL THAT IS REIMBURSED AT 101% OF COST, LESS 2% SEQUESTRATION. THE MEDICARE FEES FOR REIMBURSED SERVICES AND MEDICARE ADVANTAGE SERVICES RESULTED IN NET REVENUE OF $820,511 AND ALLOWABLE COSTS OF $1,157,590 RESULTING IN A SHORTFALL OF $337,080. THE SHORTFALL IS THE RESULT OF UNREIMBURSED PROFESSIONAL CARE.THE HOSPITAL FOLLOWED MEDICARE'S PRESCRIBED METHODS OF DETERMINING COSTS PAYABLE UNDER TITLE XVIII (MEDICARE) IN COMPLETING ITS ANNUAL MEDICARE COST REPORT (COST REPORT) USING DATA AVAILABLE FROM THE INSTITUTION'S BASIC ACCOUNTS, AS USUALLY MAINTAINED, TO ARRIVE AT EQUITABLE AND PROPER PAYMENT FOR SERVICES. THE COST REPORT WAS COMPLETED USING THE HOSPITAL'S TRIAL BALANCE OF EXPENSES, AS WELL AS OTHER STATISTICAL AND FINANCIAL RECORDS MAINTAINED BY THE HOSPITAL. AS REQUIRED BY MEDICARE REGULATIONS, CERTAIN RECLASSIFICATIONS AND ADJUSTMENTS TO COSTS WERE INCLUDED IN THE COST REPORT TO DETERMINE MEDICARE ALLOWABLE COSTS.AFTER MEDICARE ALLOWABLE COSTS ARE DETERMINED, THE COST REPORT PROVIDES FOR THE STEP DOWN METHOD OF COST FINDING. THIS METHOD PROVIDES FOR ALLOCATING THE COST OF SERVICES RENDERED BY EACH GENERAL SERVICE COST CENTER TO OTHER COST CENTERS, WHICH UTILIZE THE SERVICES. ONCE THE COSTS OF A GENERAL SERVICE COST CENTER HAVE BEEN ALLOCATED, THAT COST CENTER IS CONSIDERED CLOSED. ONCE CLOSED, IT DOES NOT RECEIVE ANY OF THE COSTS SUBSEQUENTLY ALLOCATED FROM THE REMAINING GENERAL SERVICE COST CENTERS. AFTER ALL COSTS OF THE GENERAL SERVICE COST CENTERS HAVE BEEN ALLOCATED TO THE REMAINING COST CENTERS, THE TOTAL COSTS OF THESE REMAINING COST CENTERS ARE FURTHER DISTRIBUTED TO THE DEPARTMENTAL CLASSIFICATION TO WHICH THEY PERTAIN, E.G., HOSPITAL GENERAL INPATIENT ROUTINE, SUBPROVIDER, ANCILLARY, ETC.AFTER THE STEP-DOWN PROCESS, THE COST REPORT PROVIDES FOR THE APPORTIONMENT OF COSTS TO THE MEDICARE PROGRAM BASED ON A NUMBER OF DIFFERENT METHODOLOGIES INCLUDING PER PATIENT DAY, PER VISIT, AND PERCENTAGE OF CHARGES, AS MOST PREVALENT. MEDICARE COSTS AS DETERMINED BY THE COST REPORT METHODOLOGIES DESCRIBED PREVIOUSLY WERE UTILIZED TO COMPLETE THE APPLICABLE MEDICARE ALLOWABLE COSTS OF CARE FOR SCHEDULE H (FORM 990) PART III SECTION B LINE 6. PART III, LINE 9B: HAYWARD AREA MEMORIAL HOSPITAL'S BILLING AND COLLECTION POLICY STATES:A. SUBJECT TO COMPLIANCE WITH THE PROVISIONS OF THIS POLICY, HAMH MAY TAKE ANY AND ALL LEGAL ACTIONS, INCLUDING EXTRAORDINARY COLLECTION ACTIONS (ECAS), TO OBTAIN PAYMENT FOR MEDICAL SERVICES PROVIDED.B. ALL PATIENTS WILL BE OFFERED A PLAIN LANGUAGE SUMMARY (APPENDIX A) AND AN APPLICATION FORM (APPENDIX B) FOR FINANCIAL ASSISTANCE UNDER THE FINANCIAL ASSISTANCE POLICY (FAP) AS PART OF THE DISCHARGE OR INTAKE PROCESS FROM A HOSPITAL.C. AT LEAST THREE SEPARATE STATEMENTS FOR COLLECTION OF SELF-PAY ACCOUNTS SHALL BE MAILED OR EMAILED TO THE LAST KNOWN ADDRESS OF EACH RESPONSIBLE INDIVIDUAL(S); PROVIDED, HOWEVER, THAT NO ADDITIONAL STATEMENTS NEED BE SENT AFTER A RESPONSIBLE INDIVIDUAL(S) SUBMITS A COMPLETE APPLICATION FOR FINANCIAL ASSISTANCE UNDER THE FAP OR HAS PAID IN-FULL. AT LEAST 60 DAYS SHALL HAVE ELAPSED BETWEEN THE FIRST AND LAST OF THE REQUIRED THREE MAILINGS. IT IS THE RESPONSIBLE INDIVIDUAL(S) OBLIGATION TO PROVIDE A CORRECT MAILING ADDRESS AT THE TIME OF SERVICE OR UPON MOVING. IF AN ACCOUNT DOES NOT HAVE A VALID ADDRESS, THE DETERMINATION FOR "REASONABLE EFFORT" WILL HAVE BEEN MADE. ALL SINGLE PATIENT ACCOUNT STATEMENTS OF SELF-PAY ACCOUNTS WILL INCLUDE BUT NOT LIMITED TO:1. AN ACCURATE SUMMARY OF THE HOSPITAL SERVICES COVERED BY THE STATEMENT;2. THE CHARGES FOR SUCH SERVICES;3. THE AMOUNT REQUIRED TO BE PAID BY THE RESPONSIBLE INDIVIDUAL(S) (OR, IF SUCH AMOUNT IS NOT KNOWN, A GOOD FAITH ESTIMATE OF SUCH AMOUNT AS OF THE DATE OF THE INITIAL STATEMENT); AND4. A CONSPICUOUS WRITTEN NOTICE THAT NOTIFIES AND INFORMS THE RESPONSIBLE INDIVIDUAL(S) ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER THE HOSPITAL FAP INCLUDING THE TELEPHONE NUMBER OF THE DEPARTMENT AND DIRECT WEBSITE ADDRESS WHERE COPIES OF DOCUMENTS MAY BE OBTAINED.D. AT LEAST ONE OF THE STATEMENTS MAILED OR EMAILED WILL INCLUDE WRITTEN NOTICE THAT INFORMS THE RESPONSIBLE INDIVIDUAL(S) ABOUT THE ECAS THAT ARE INTENDED TO BE TAKEN IF THE RESPONSIBLE INDIVIDUAL(S) DOES NOT APPLY FOR FINANCIAL ASSISTANCE UNDER THE FAP OR PAY THE AMOUNT DUE BY THE BILLING DEADLINE. SUCH STATEMENT MUST BE PROVIDED TO THE RESPONSIBLE INDIVIDUAL(S) AT LEAST 30 DAYS BEFORE THE DEADLINE SPECIFIED IN THE STATEMENT. A PLAIN LANGUAGE SUMMARY WILL ACCOMPANY THIS STATEMENT. IT IS THE RESPONSIBLE INDIVIDUAL(S) OBLIGATION TO PROVIDE A CORRECT MAILING ADDRESS AT THE TIME OF SERVICE OR UPON MOVING. IF AN ACCOUNT DOES NOT HAVE A VALID ADDRESS, THE DETERMINATION FOR "REASONABLE EFFORT" WILL HAVE BEEN MADE.E. RESPONSIBLE INDIVIDUAL(S) PROPENSITY TO PAY WILL BE SCORED BASED ON THAT ASSESSMENT OF THE RESPONSIBLE INDIVIDUAL(S) LIKELIHOOD TO PAY AND DOLLAR AMOUNT OF THE SELF-PAY ACCOUNT.F. HAMH OFFERS PAYMENT PLANS THAT BEAR NO INTEREST. GENERALLY, BALANCE REQUIRE A MINIMUM PAYMENT OF $25.00 PER MONTH AND MUST BE PAID IN FULL WITHIN 24 MONTHS.G. PRIOR TO INITIATION OF ANY ECAS, AN ORAL ATTEMPT WILL BE MADE TO CONTACT RESPONSIBLE INDIVIDUAL(S) BY TELEPHONE AT THE LAST KNOWN TELEPHONE NUMBER, IF ANY, AT LEAST ONCE DURING THE SERIES OF MAILED OR EMAILED STATEMENTS IF THE ACCOUNT REMAINS UNPAID. DURING ALL CONVERSATIONS, THE PATIENT OR RESPONSIBLE INDIVIDUAL(S) WILL BE INFORMED ABOUT THE FINANCIAL ASSISTANCE THAT MAY BE AVAILABLE UNDER THE FAP.H. ECAS MAY BE COMMENCED AS FOLLOWS:1. IF ANY RESPONSIBLE INDIVIDUAL(S) FAIL TO APPLY FOR FINANCIAL ASSISTANCE UNDER THE FAP BY 120 DAYS AFTER THE FIRST POST DISCHARGE STATEMENT, AND THE RESPONSIBLE PARTIES HAVE RECEIVED A STATEMENT WITH A BILLING DEADLINE DESCRIBED IN SECTION III.E ABOVE, THEN HAMH OR COLLECTION AGENCY MAY INITIATE ECAS.2. IF ANY RESPONSIBLE INDIVIDUAL(S) SUBMITS AN INCOMPLETE APPLICATION FOR FINANCIAL ASSISTANCE UNDER THE FAP PRIOR TO THE APPLICATION DEADLINE, THEN ECAS MAY NOT BE INITIATED UNTIL AFTER EACH OF THE FOLLOWING STEPS HAS BEEN COMPLETED:A. PFS PROVIDES THE RESPONSIBLE INDIVIDUAL(S) WITH A WRITTEN NOTICE THAT DESCRIBES THE ADDITIONAL INFORMATION OR DOCUMENTATION REQUIRED UNDER THE FAP IN ORDER TO COMPLETE THE APPLICATION FOR FINANCIAL ASSISTANCE, WHICH NOTICE WILL INCLUDE A COPY OF THE PLAIN LANGUAGE SUMMARY.B. PFS PROVIDES THE RESPONSIBLE INDIVIDUAL(S) WITH AT LEAST 30 DAYS' PRIOR WRITTEN NOTICE OF THE ECAS THAT HAMH OR COLLECTION AGENCY MAY INITIATE AGAINST THE RESPONSIBLE INDIVIDUAL(S) IF THE FAP APPLICATION IS NOT COMPLETED OR PAYMENT IS NOT MADE; PROVIDED, HOWEVER, THAT THE COMPLETION DEADLINE FOR PAYMENT MAY NOT BE SET PRIOR TO 120 DAYS AFTER THE FIRST POST DISCHARGE STATEMENT.C. IF THE RESPONSIBLE INDIVIDUAL(S) WHO HAS SUBMITTED THE INCOMPLETE APPLICATION COMPLETES THE APPLICATION FOR FINANCIAL ASSISTANCE, AND PFS DETERMINES DEFINITIVELY THAT THE RESPONSIBLE INDIVIDUAL(S) IS INELIGIBLE FOR ANY FINANCIAL ASSISTANCE UNDER THE FAP, HAMH WILL INFORM THE RESPONSIBLE INDIVIDUAL(S) IN WRITING THE DENIAL AND INCLUDE A 30 DAYS' PRIOR WRITTEN NOTICE OF THE ECAS THAT HAMH OR COLLECTION AGENCY MAY INITIATE AGAINST THE RESPONSIBLE INDIVIDUAL(S); PROVIDED, HOWEVER, THAT THE BILLING DEADLINE MAY NOT BE SET PRIOR TO 120 DAYS AFTER THE FIRST POST DISCHARGE STATEMENT.D. IF THE RESPONSIBLE INDIVIDUAL(S) WHO HAS SUBMITTED THE INCOMPLETE APPLICATION FAILS TO COMPLETE THE APPLICATION BY THE COMPLETION DEADLINE SET IN THE NOTICE PROVIDED PURSUANT TO SECTION III.G.3.B ABOVE, THEN ECAS MAY BE INITIATED.E. IF AN APPLICATION, COMPLETE OR INCOMPLETE, FOR FINANCIAL ASSISTANCE UNDER THE FAP IS SUBMITTED BY A RESPONSIBLE INDIVIDUAL(S), AT ANY TIME PRIOR TO THE APPLICATION DEADLINE, HAMH WILL SUSPEND ECAS WHILE SUCH FINANCIAL ASSISTANCE APPLICATION IS PENDING.I. AFTER THE COMMENCEMENT OF ECAS IS PERMITTED UNDER SECTION III.G ABOVE, COLLECTION AGENCIES SHALL BE AUTHORIZED TO REPORT UNPAID ACCOUNTS TO CREDIT AGENCIES, AND TO FILE JUDICIAL OR LEGAL ACTION, GARNISHMENT, OBTAIN JUDGMENT LIENS AND EXECUTE UPON SUCH JUDGMENT LIENS USING LAWFUL MEANS OF COLLECTION; PROVIDED, HOWEVER, THAT PRIOR APPROVAL OF PFS SHALL BE REQUIRED BEFORE INITIAL LAWSUITS MAY BE INITIATED. HAMH AND EXTERNAL COLLECTION AGENCIES MAY ALSO TAKE ANY AND ALL LEGAL OTHER ACTIONS INCLUDING BUT NOT LIMITED TO TELEPHONE CALLS, EMAILS, TEXTS, MAILING NOTICES, AND SKIP TRACING TO OBTAIN PAYMENT FOR MEDICAL SERVICES PROVIDED.IV. POLICY AVAILABILITYCONTACT OUR BUSINESS OFFICE AT 715-934-4267 FOR INFORMATION REGARDING ELIGIBILITY OR THE PROGRAMS THAT MAY BE AVAILABLE TO YOU, TO REQUEST A COPY OF THE FAP, FAP APPLICATION FORM, OR COLLECTION POLICY TO BE MAILED TO YOU, OR IF YOU NEED A COPY OF THE FAP, FAP APPLICATION FORM, OR COLLECTION POLICY TRANSLATED TO SPANISH. FULL DISCLOSURE OF THE FAP, FAP APPLICATION FORM, OR COLLECTION POLICY MAY BE FOUND AT WWW.HAYWARDMEMORIALHOSPITAL.COM/FINANCIAL-SERVICES/ . A PAPER COPY OF OUR FAP, FAP APPLICATION FORM, OR COLLECTION POLICY CAN BE OBTAINED AT OUR FACILITY LOCATED AT 11040N STATE RD. 77, HAYWARD, WI 54843 AT THE REGISTRATION DESK. PART VI, LINE 2: FACILITY STAFF PARTICIPATE IN THE COMMUNITY NEEDS ASSESSMENT PROCESS WITH THE SAWYER COUNTY HEALTH DEPARTMENT, COMMUNITY HEALTH CLINICS, ASSISTED LIVING FACILITY, AND PHYSICIANS FROM THE COMMUNITY. FOLLOWING THE COMPLETION OF THE ASSESSMENT, VARIOUS WORK GROUPS ARE CONVENED. APPROPRIATE STAFF MEMBERS FROM THE FACILITY THEN WORK WITH COMMUNITY MEMBERS TO DEVELOP PROGRAMS AND APPROACHES TO ADDRESS THE IDENTIFIED HEALTH ISSUES. SOME EXAMPLES INCLUDE ABUSE OF PRESCRIPTION DRUGS, SEXUAL ABUSE PREVENTION PROGRAMS, UNDERAGE ALCOHOL USE, TRANSPORT ISSUES, TELEHEALTH, PATIENT ADVOCACY PROGRAM, AND REDUCED COST CLINIC. PART VI, LINE 3: ALL PATIENTS ARE BILLED THE SAME, HOWEVER, IF A PATIENT BECOMES DELINQUENT ON A BILL, A LETTER IS SENT TO THE PATIENT ASKING THAT THE PATIENT CONTACT THE BUSINESS OFFICE FOR ASSISTANCE. PATIENTS HAVE THE OPTION TO DISCUSS PAYMENT OPTIONS WITH THE BUSINESS OFFICE AND POSSIBLE ELIGIBILITY FOR CHARITY CARE. PART VI, LINE 4: HAYWARD WISCONSIN IS LOCATED IN NORTHERN WISCONSIN AND CONSISTS OF A HIGH MEDICAID POPULATION. HAYWARD SERVES A HIGH MEDICAID AND HIGH MEDICARE POPULATION WITH THE TWO ACCOUNTING FOR 69% OF GROSS REVENUES AND 50% OF NET PATIENT SERVICES REVENUES. HAYWARD IS CONSIDERED A SUMMER VACATION DESTINATION THAT BRINGS LARGE CROWDS DURING THE SUMMER MONTHS. THE EMERGENCY DEPARTMENT SERVES A LARGE NUMBER OF PATIENTS THAT RANGE FROM COMMERCIAL INSURANCE, MEDICARE, MEDICAID, IHS (INDIAN HEALTH SERVICES), ETC. HAYWARD HOSPITAL IS FOCUSED ON PROVIDING HIGH QUALITY HEALTHCARE IN A RURAL LOCATION. MANY SERVICES ARE PROVIDED BY HAYWARD HOSPITAL, ALLOWING LESS PATIENT TRAVEL AT A TIME WHEN THE PATIENT IS LIKELY NOT FEELING WELL. THE HAYWARD COMMUNITY IS AN AGING POPULATION AND WE RECOGNIZE THAT NEED AND HAVE COMMITTED MILLIONS OF DOLLARS INTO SERVICES FOR THE OLDER POPULATION. WE BELIEVE HAYWARD HOSPITAL PROVIDES EXCEPTIONAL CARE IN A RURAL LOCATION. PART VI, LINE 5: OPEN MEDICAL STAFF. COMMUNITY CALL PROGRAM FOR MEDICAL STAFF. LOCAL COMMUNITY BOARD WITH 12 VOTING MEMBERS. NONPROFIT STATUS WITH PROFITS (IF ANY) USED FOR ADDITIONAL SERVICES, CAPITAL PURCHASES SUCH AS A CT SCANNER, LAB EQUIPMENT, ELECTRONIC HEALTH RECORD, IMPROVED INPATIENT SERVICES, OB PROGRAM, CONTINUED EDUCATION FOR ALL STAFF, GROWING SENIOR SERVICES PROGRAM AND A FOCUS ON THE NEEDS OF THE COMMUNITY. PART VI, LINE 7, REPORTS FILED WITH STATES WI X X 0 0 0 0 0 0 0 0 0 TIM GULLINGSRUD DIRECTOR/CEO - MSI 190213 0 19802 0 13300 0 9977 0 30684 0 263976 0 0 0 JASON DOUGLAS DIRECTOR/PRESIDENT - REI 0 318149 0 23184 0 18000 0 13250 0 29254 0 401837 0 0 BRAD ZELLER VICE PRESIDENT - MSI 115656 0 18639 0 9800 0 6318 0 28674 0 179087 0 0 0 KENT DUMONSEAU CFO - REI 0 197118 0 15484 0 0 0 9848 0 29142 0 251592 0 0 HEATHER SHEEHAN VICE PRESIDENT - MSI 108922 0 18570 0 18000 0 6270 0 30170 0 181932 0 0 0 SUSAN BAUER CRNA 183478 0 0 0 0 0 9451 0 20861 0 213790 0 0 0 BRADLEY KRASEAN PHYSICAL THERAPIST 131256 0 0 0 0 0 6609 0 25732 0 163597 0 0 0 MICHAEL LAIRD PHARMACIST 135368 0 0 0 0 0 6969 0 12604 0 154941 0 0 0 ALLISON FARLEY PHARMACIST/DIRECTOR OF PHARMACY 141084 0 0 0 0 0 7434 0 20716 0 169234 0 0 0 STEVEN KRASEAN PHYSICAL THERAPIST 127381 0 0 0 0 0 6630 0 19819 0 153830 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 REGIONAL ENTERPRISES, INC. IS THE SOLE CORPORATE MEMBER OF MEDICAL SERVICES, INC. FORM 990, PART VI, SECTION A, LINE 7A THE PRESIDENT OF REI SHALL BE AN EX OFFICIO MEMBER OF THE MSI BOARD WITH FULL VOTING PRIVILEGES. FORM 990, PART VI, SECTION A, LINE 7B AS THE SOLE MEMBER OF MEDICAL SERVICES, INC., REGIONAL ENTERPRISES, INC. HAS THE FOLLOWING RESERVE POWERS: A. TO MAKE, AMEND, OR REPEAL MSI'S BYLAWS AND ARTICLES OF INCORPORATION. B. TO APPROVE ANY CHANGE IN MSI'S PHILOSOPHY, MISSION OR VISION STATEMENTS, AND APPROVE THE LONG-RANGE GOALS AND STRATEGIC PLAN FOR MSI. C. TO APPROVE THE ANNUAL OPERATING AND CAPITAL BUDGET. D. TO APPROVE ALL BUILDING PROGRAMS THAT EXCEED $500,000 IN VALUE. E. TO SELECT AND RETAIN AN INDEPENDENT AUDITING FIRM. F. TO APPOVE THE PURCHASE, SALE, LEASE, DISPOSITION, OR ALIENATION OF ANY REAL PROPERTY OWNED BY MSI. ANY SUCH ACTION SHALL BE JOINTLY APPROVED BY THE BOARD OF DIRECTORS OF MEMORIAL MEDICAL CENTER OF ASHLAND, WISCONSIN. G. TO APPROVE ANY PLAN OF DISSOLUTION OR MERGER, CONSOLIDATION, ACQUISITION OR DISPOSITION OF REAL PROPERTY OR RELOCATION OF THE FACILITIES OF MSI. ANY SUCH ACTION SHALL BE JOINTLY APPROVED BY THE BOARD OF DIRECTORS OF MEMORIAL MEDICAL CENTER OF ASHLAND, WISCONSIN. H. TO AUTHORIZE THE PRESIDENT OF REI TO RECOMMEND TO THE BOARD OF MSI, THE INDIVIDUAL WHO WILL SERVE AS THE CHIEF ADMINISTRATIVE OFFICER FOR MSI, SUBJECT TO RATIFICATION BY THE MSI BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 11 THE FINANCE AND ACCOUNTING TEAM REVIEW THE 990 PRIOR TO FILING TO CONFIRM ACCURACY OF INFORMATION. THE 990 IS REVIEWED BY THE BOARD OF DIRECTORS BEFORE IT IS FILED. IF ANY CHANGES ARE MADE, A FINAL COPY OF THE 990 IS PROVIDED TO THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C EACH DIRECTOR AND OFFICER SHALL DISCLOSE TO THE BOARD OF DIRECTORS, OR TO THE OTHER MEMBERS OF ANY COMMITTEE CONSIDERING A PROPOSED BUSINESS TRANSACTION OR ARRANGEMENT, THE EXISTENCE AND NATURE OF ANY FINANCIAL INTEREST SUCH PERSON OR A MEMBER OF SUCH PERSON'S FAMILY MAY HAVE WITH RESPECT TO SUCH PROPOSED TRANSACTION OR ARRANGEMENT. EACH DIRECTOR AND PRINCIPAL OFFICER SHALL PROMPTLY MAKE DISCLOSURES AS MAY BE NECESSARY TO KEEP THE BOARD OR COMMITTEE FULLY APPRISED OF SUCH PERSON'S FINANCIAL INTERESTS. DISCLOSURE SHALL ALSO BE ACCOMPLISHED ON AN ANNUAL BASIS BY HAVING EACH DIRECTOR AND PRINCIPAL OFFICER EXECUTE AND DELIVER TO MSI A CERTIFICATE REGARDING CONFLICTS OF INTEREST. IF ANY DIRECTOR OR PRINCIPAL OFFICER DISCLOSES A POTENTIAL FINANCIAL INTEREST TO THE BOARD OF DIRECTORS OR ANY COMMITTEE REGARDING A PROPOSED TRANSACTION OR ARRANGEMENT, THE BOARD OR COMMITTEE SHALL FIRST DETERMINE WHETHER THE PROPOSED TRANSACTION OR ARRANGEMENT COULD BE CONSIDERED AN INSIDER TRANSACTION. IF THE BOARD OR COMMITTEE IS CERTAIN THAT THE TRANSACTION OR ARRANGEMENT WILL NOT INVOLVE AN INSIDER, THE INTERESTED PERSON SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE FINANCIAL INTEREST IS DISCUSSED. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE IF A CONFLICT OF INTEREST EXISTS. IF IT IS DETERMINED NO CONFLICT EXISTS, THE INTERESTED PERSON MAY REJOIN THE MEETING AND PARTICIPATE IN THE DISCUSSIONS AND ACTIONS REGARDING THIS AGENDA ITEM. THE BOARD OR COMMITTEE SHALL DETERMINE WHETHER MSI CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE, THE BOARD OR COMMITTEE SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN MSI'S BEST INTEREST AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO MSI. IF THE BOARD OR COMMITTEE BELIEVES AN ALTERNATE TRANSACTION COULD BE CONSIDERED THAT WOULD BE MORE ADVANTAGEOUS TO MSI, THE CHAIRPERSON OF THE BOARD OR COMMITTEE SHALL APPOINT A DISINTERESTED PERSON OR COMMITTEE TO INVESTIGATE ALTERNATIVES TO THE PROPOSED TRANSACTION. FURTHER ACTION BY THE BOARD OR COMMITTEE SHALL BE TABLED UNTIL SUCH TIME AS THE DISINTERESTED PERSON HAS BEEN ABLE TO REPORT HIS OR HER FINDINGS TO THE APPROPRIATE GOVERNING BODY. THE BOARD OR COMMITTEE SHALL NOT APPROVE ANY TRANSACTION OR ARRANGEMENT THAT IS NOT IN THE BEST INTERESTS OF MSI AND THAT IS NOT FAIR AND REASONABLE TO MSI. ONCE DISCUSSION AND/OR ACTION REGARDING THE AGENDA ITEM RELATING TO THE DIRECTOR'S FINANCIAL INTEREST HAS BEEN COMPLETED, THE INTERESTED PERSON MAY REJOIN THE BOARD OR COMMITTEE MEETING. IF THE TRANSACTION OR ARRANGEMENT INVOLVES OR MAY INVOLVE AN INSIDER, THE BOARD OR COMMITTEE SHALL FOLLOW THE PROCEDURES ABOVE AND THE INSIDER SHALL LEAVE THE BOARD OR COMMITTEE MEETING WHILE THE INSIDER TRANSACTION IS DISCUSSED. THE REMAINING BOARD OR COMMITTEE MEMBERS SHALL DECIDE WHETHER THE TRANSACTION OR ARRANGEMENT UNDER CONSIDERATION COULD CONSTITUTE AN INSIDER TRANSACTION. AS PART OF THIS CONSIDERATION, THE BOARD OR COMMITTEE SHALL ALSO CONSIDER WHETHER THEIR ACTION COULD BE CONSTRUED TO BE AN EXCESS BENEFIT TRANSACTION SUBJECT TO INTERMEDIATE SANCTIONS. IN DETERMINING WHETHER A TRANSACTION OR ARRANGEMENT IS AN EXCESS BENEFIT TRANSACTION, THE BOARD OR COMMITTEE CONSIDERING THE TRANSACTION OR ARRANGEMENT SHOULD REVIEW APPROPRIATE DATA AS TO COMPARABILITY (SUCH AS COMPENSATION LEVELS PAID BY SIMILARLY SITUATED ORGANIZATIONS IN THE REGION, NATIONAL COMPENSATION STUDIES, COMPETING OFFERS RECEIVED BY THE INSIDER, ASSET APPRAISALS OR RENTAL ANALYSES BY QUALIFIED APPRAISERS AND OTHER INFORMATION THAT MAY BE OBTAINED ABOUT COMPARABLE AGREEMENTS, PURCHASES, SALES AND LEASES). THE BOARD OR COMMITTEE MAY RELY ON SUCH INFORMATION OR DATA PROVIDED BY MSI'S MANAGEMENT. THE BOARD OR COMMITTEE SHALL NOT APPROVE ANY TRANSACTION OR ARRANGEMENT THAT IS AN EXCESS BENEFIT TRANSACTION. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT A DIRECTOR OR PRINCIPAL OFFICER HAS FAILED TO DISCLOSE A FINANCIAL INTEREST, IT SHALL INFORM THE DIRECTOR OR PRINCIPAL OFFICER OF THE BASIS FOR SUCH BELIEF AND AFFORD THE DIRECTOR OR PRINCIPAL OFFICER AN OPPORTUNITY TO EXPLAIN WHY DISCLOSURE WAS NOT MADE. IF, AFTER HEARING THE RESPONSE OF THE DIRECTOR OR PRINCIPAL OFFICER AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT THE DIRECTOR HAS IN FACT FAILED TO DISCLOSE A FINANCIAL INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND/OR CORRECTIVE ACTION, WHICH MAY INCLUDE, BUT NOT BE LIMITED TO: SUSPENSION OF VOTING RIGHTS, RECISION OF ANY AGREEMENTS, AND TERMINATION OF DIRECTOR OR OFFICER STATUS. FORM 990, PART VI, SECTION B, LINE 15 HR WILL RESEARCH SALARY DATA FOR OUR REGION AND PROVIDE ADMINISTRATION WITH A TYPICAL COMPENSATION RANGE. DIFFICULT POSITIONS TO FILL, DEMANDS OF THE POSITION, EXPERIENCE, EDUCATION, PAST WORK HISTORY, AND REFERENCES ARE ALL TAKEN INTO CONSIDERATION WHEN DETERMINING COMPENSATION. UPDATES TO THE RANGES ARE PUT INTO PLACE AROUND APRIL OR MAY EACH YEAR, IF CHANGES OCCURRED. FORM 990, PART VI, SECTION C, LINE 19 THE CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE BY REQUEST FROM THE PUBLIC RELATIONS DIRECTOR FOR THE SAME PERIOD OF DISCLOSURE SET FORTH IN SECTION 6104(D). THE GOVERNING DOCUMENTS ARE CONFIDENTIAL AND NOT AVAILABLE TO THE PUBLIC. FORM 990, PART VII TIMOTHY GULLINGSRUD: TIME ALLOCATION: REI MEDICAL CLINICS, INC: 1 HOUR PER WEEK REGIONAL ENTERPRISES, INC: 1 HOUR PER WEEK MEDICAL SERVICES, INC: 38 HOURS PER WEEK COMPENSATION RELATED TO REI MEDICAL CLINICS, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO REGIONAL ENTERPRISES, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO MEDICAL SERVICES, INC: REPORTABLE COMPENSATION = $223,315 OTHER COMPENSATION = $ 40,661 JASON DOUGLAS: TIME ALLOCATION: REI MEDICAL CLINICS, INC: 1 HOUR PER WEEK REGIONAL ENTERPRISES, INC: 1 HOUR PER WEEK MEDICAL SERVICES, INC: 1 HOUR PER WEEK MEMORIAL MEDICAL CENTER: 37 HOURS PER WEEK COMPENSATION RELATED TO REI MEDICAL CLINICS, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO REGIONAL ENTERPRISES, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO MEDICAL SERVICES, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO MEMORIAL MEDICAL CENTER: REPORTABLE COMPENSATION = $359,333 OTHER COMPENSATION = $ 42,504 KENT DUMONSEAU: TIME ALLOCATION: REI MEDICAL CLINICS, INC: 1 HOUR PER WEEK REGIONAL ENTERPRISES, INC: 1 HOUR PER WEEK MEDICAL SERVICES, INC: 14 HOURS PER WEEK MEMORIAL MEDICAL CENTER: 24 HOURS PER WEEK COMPENSATION RELATED TO REI MEDICAL CLINICS, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO REGIONAL ENTERPRISES, INC: REPORTABLE COMPENSATION = $212,602 OTHER COMPENSATION = $ 38,990 COMPENSATION RELATED TO MEDICAL SERVICES, INC: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 COMPENSATION RELATED TO MEMORIAL MEDICAL CENTER: REPORTABLE COMPENSATION = $0 OTHER COMPENSATION = $0 MEMORIAL MEDICAL CENTER INC 1615 MAPLE LANE ASHLAND WI 54806 237013497 MEDICAL SERVICES WI 501(C)(3) LINE 3 REGIONAL ENTERPRISES INC 1 REGIONAL ENTERPRISES INC 1615 MAPLE LANE ASHLAND WI 54806 391555837 SUPPORT WI 501(C)(3) LINE 11B, II N/A 0 REI MEDICAL CLINICS INC 1615 MAPLE LANE ASHLAND WI 54806 391701306 SUPPORT WI 501(C)(3) LINE 11B, II REGIONAL ENTERPRISES INC 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0