2014-08-08T11:34:08-05:00 2013-12-31 450250958 Eide Bailly LLP 800 Nicollet Mall Ste 1300 Minneapolis MN 554027033 990 2013-01-01 390819992 Edgerton Hospital and Health Services Inc EDGE 6088843441 11101 North Sherman Road Edgerton WI 53534 Charles Roeder CFO 6088843441 2014-08-07 1 Kim Hunwardsen CPA P00484560 6122536500 2014-08-07 2013 2015-11-30 17:44:51Z James Pernau 11101 North Sherman Road Edgerton WI 53534 19483140 0 X www.edgertonhospital.com X 1968 WI Serve area communities with exceptional quality and innovative health services 7 6 225 108 0 0 492253 158654 18729089 19300282 13397 9737 -20058 10575 19214681 19479248 174587 140717 0 0 9607677 9611551 0 0 0 10629668 11438506 20411932 21190774 -1197251 -1711526 32899272 30903747 27855769 27567603 5043503 3336144 X To provide exceptional healthcare for our communities 0 0 18511680 140717 19300282 Edgerton Hospital and Health Services, Inc. is an 18-bed acute care hospital located in Edgerton, Wisconsin.There were 383 total adult admissions in 2013. Total patient days were 2,823 with an average daily census of 7.8 patients. Emergency room and urgent care visits for 2013 were 5,499.Preventive Care Services:Edgerton Hospital and Health Services (Edgerton Hospital) provides several types of free health screenings during the year. These include: blood pressure, dietary counseling and education, diabetes, and cancer screenings.Emergency Room:Edgerton Hospital's Emergency Room is fully staffed 24 hours a day, seven days a week. Edgerton Hospital is affiliated with "Life Flight," a helicopter service that delivers patients to area tertiary care centers. Edgerton Hospital's Urgent Care Center provides another level of walk-in care when appropriate.Community Outreach:Edgerton Hospital works closely with the community to provide hospital and hospital-related services responsive to the specific needs of Edgerton and surrounding farming communities. Edgerton Hospital partners with other city services (such as the police and fire departments) to provide emergency equipment and training necessary to enhance area emergency services. Edgerton Hospital also participates in cooperative emergency response training (with the county and other community services) in preparation for local or area disasters. Community Education:Events are held at the Hospital or conducted by Hospital staff several times a year. In addition, Edgerton Hospital provides targeted outreach to the transient recreational communities within the service area. Charity Care:The Hospital provides care to patients who meet certain criteria under its charity care policy without charge or at amounts less than established rates. Because the Hospital does not pursue collection of amounts determined to qualify as charity care, they are not reported as revenue. The amount of charges foregone for services provided under the Hospital's charity care policy was approximately $464,000 for the year ended December 31, 2013. The estimated costs of the charges foregone, based upon an overall cost-to-charge ratio calculation, for the year ended December 31, 2013, was $282,000. 18511680 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 0 1 23 0 1 225 1 0 0 0 0 0 0 0 0 0 0 X 7 6 0 0 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X Charles Roeder 6088841656 11101 North Sherman Road Edgerton WI 53534 James Schultz Chair 0.30 0.30 X X 0 0 0 Jay Peterson DC Vice Chair 0.30 0.00 X X 0 0 0 Donald Bice Treasurer 0.30 0.00 X X 0 0 0 Melva Sue Larson Treasurer until July 2013 0.30 0.00 X X 0 0 0 Steve Thompson Secretary 0.30 0.00 X X 0 0 0 Kamal Muzaffar MD Chief of Staff 0.30 0.00 X 0 0 0 Dennis Litsheim MD Trustee 0.30 0.00 X 0 0 0 Terry Johnson DVM Trustee 0.30 0.00 X 0 0 0 Lawanna Schieldt Trustee until July 2013 0.30 0.00 X 0 0 0 Sara Karman Trustee until July 2013 0.30 0.00 X 0 0 0 Matthew Roethe Trustee until July 2013 0.30 0.00 X 0 0 0 Fred Falk Trustee until July 2013 0.30 0.30 X 0 0 0 Charlie Johnson Trustee until July 2013 0.30 0.00 X 0 0 0 Linda Taplin Statz Trustee until July 2013 0.30 0.00 X 0 0 0 James Pernau CEO 40.00 0.30 X 184712 0 22250 Charles Roeder CFO 40.00 0.00 X 140121 0 14380 Todd Crowley Pharmacist 40.00 0.00 X 141415 0 12655 Sharon Adrian Nurse Supervisor 40.00 0.00 X 102665 0 15635 Laurie Drewson Occupational Therapy 40.00 0.00 X 100568 0 6608 Brenda Nolen Family Nurse Practitioner 40.00 0.00 X 100517 0 16494 Heather Prestil Registered Pharmacist 40.00 0.00 X 119957 0 1228 889955 0 89250 7 0 1 0 Southern Wisconsin Emergency Physicians PO Box 793 Traverse City MI 49685 ER Physicians 1250132 Wisconsin Integrated Information 1808 W Beltline Hwy Madison WI 53713 Epic and other application 290035 Stoughton Hospital PO Box 78216 Milwaukee WI 53278 Certified Registered Nurse Anesthetists 289701 Rock Valley Radiologists PO Box 2103 Janesville WI 53546 Radiology physicians 257000 Aviand's 1751 W Cty Rd B Roseville MN 55113 Food services management 131491 8 139015 18807 832 158654 Patient service revenue 622110 18824678 18824678 MEHR Incentive payment 900099 330681 330681 Other supporting revenue 900099 144923 144923 19300282 13129 13129 10575 0 10575 10575 10575 500 3892 -3392 -3392 -3392 19479248 19300282 0 20312 X 140717 140717 364244 364244 7281823 6329867 951956 38731 16148 22583 1366277 1273557 92720 560476 462802 97674 88054 88054 43895 43895 4535162 3946800 588362 143017 1301 141716 753768 517465 236303 376036 372890 3146 41581 18967 22614 71407 47046 24361 1687987 1687987 1748229 1748229 65736 65736 Provision for bad debts 1170260 1170260 Medical supplies 558900 558900 Medicaid Provider Tax 92162 92162 Food costs 57422 57422 4890 3424 1466 21190774 18511680 2679094 0 2651923 1780205 4527 5886 2791041 2516599 326426 340723 149892 154776 28510751 6078445 23549309 22432306 1885721 2199929 14069 18236 456577 456577 1069787 998510 32899272 30903747 1993747 2097148 724760 483173 24545077 24927282 592185 60000 27855769 27567603 X 5029434 3317783 14069 18361 5043503 3336144 32899272 30903747 X -1711526 4167 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 50000 562849 612849 485524 20196546 2688883 17993187 97208 90784 6424 5648657 3112730 2535927 21618 1448349 186048 1283919 22432306 Estimated third party payor settlements 60000 60000 X Part X, Line 2: The Hospital is organized as a Wisconsin non-profit corporation and has been recognized by the Internal Revenue Service (IRS) as exempt from federal income taxes under Internal Revenue Code Section 501(c)(3). The Hospital is annually required to file a Return of Organization Exempt from Income Tax (Form 990) with the IRS. In addition, they are also subject to income tax on net income that is derived from business activities that are unrelated to its exempt purpose, if applicable. The Organization believes it has appropriate support for any tax positions taken affecting its annual filing requirments, and as such, does not have any uncertain tax positions that are material to the consolidated financial statements. The Organization 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. 1 1 X 1 X 125.000000000000 1 X 225.000000000000 1 1 0 1 1 282000 282000 0.01410 282000 282000 0.01410 5390542 3826870 1563672 0.07810 5390542 3826870 1563672 0.07810 5672542 3826870 1845672 0.09220 0 1170260 390048 7584855 7614238 -29383 X 1 1 1 1 Edgerton Hospital and Health Services 11101 North Sherman Road Edgerton WI 53534 www.edgertonhospital.com 1022 X X X X Provider based clinic - Milton Clinic Edgerton Hospital and Health Services 1 1 X X X X X X X X X 13 1 0 1 X www.edgertonhospital.com X X X X X X X X X X 0 0 1 1 125.000000000000 1 225.000000000000 1 X X X X X X X 1 1 X X 1 0 X X X X 1 X 0 0 Edgerton Hospital and Health Services Part V, Section B, Line 3: Interviews regarding health needs in the community served by Edgerton Hospital were conducted with 17 key informants, including external stakeholders (those not affiliated with Edgerton Hospital - such as religious leaders, community leaders, representative from the local media, Hispanic population representative, school officials, local health department, EMS, etc.) and internal Edgerton Hospital staff. The interviews provided input on a wide range of community health issues, including barriers to access to health services, changes in community population, prevalence of certain health conditions, social determinants of health, health disparities, and other topics. The interviews were guided by a structured interview guide, and interviewees were encouraged to identify and discuss current and emerging issues affecting community health. Edgerton Hospital and Health Services Part V, Section B, Line 6i: Edgerton Hospital and Health Services, Inc. adopted an implementation strategy to address the community health needs identified in its Community Health Needs Assessment. The implementation strategy is posted to their website at www.edgertonhospital.com. Edgerton Hospital and Health Services Part V, Section B, Line 7: The following needs will not be addressed due to lack of hospital resources and funds: Lack of affordable and accessible care, lack of access to dental care, gender/racial/ethnic disparities, mental health, unsafe sex, unemployment and high rates of violent crime and child abuse.The Hospital was unable to address smoking/tobacco use in 2013 due to lack of hospital resources and funds. This will be addressed in the future.Edgerton Hospital has begun to address diet and exercise related issues and alcohol and drug abuse. Edgerton Hospital and Health Services Part V, Section B, Line 12i: Other living expenses and financial obligations relative to household/family size are considered in the calculation for amounts charged to patients. Edgerton Hospital and Health Services Part V, Section B, Line 14g: A summary of the financial assistance policy was made available to the public upon admission, included as a brochure in registration areas, emergency room, and waiting rooms of the Hospital, and is available on our website. Edgerton Hospital and Health Services Part V, Section B, Line 18e: All accounts were reviewed for possible financial assistance prior to sending to a collection agency. Part I, Line 3c: In addition to providing free or discounted care based on Federal Poverty Guidelines, Edgerton Hospital provides certain accommodations to patients who have trouble paying their bills. These practices include offering uninsured patients a cash discount for prompt payment of the estimated or final charges for services provided. Edgerton Hospital provides interest-bearing loans through H.E.L.P. Financial Inc. Payment arrangements are also available for accounts to be paid within 6 months at no interest. Part I, Line 6a: Edgerton Hospital and Health Services makes its community benefit report available to the public by providing it upon request. Part I, Line 7: Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. The cost for subsidized health services reported on line 7g was determined using the Medicare Cost Report. Part I, Ln 7 Col(f): The amount of bad debt expense removed from total expenses to determine the percentage was $1,170,260. Part III, Line 4: All past due accounts are reviewed to determine if a patient qualifies for charity care, or federal, state, or local assistance. Before an account is written off to bad debt all discounts and payments are applied, including contractual allowances. After every attempt is made to collect the unpaid balance, the account is written off to bad debt. Payments on accounts that were written off as bad debt reduces bad debt expense.Bad debt expense on line 2 is reported at charges as presented on the financial statements.A reasonable estimate of the Organization's bad debt expense attributable to patients under the Organization's financial assistance policy is one-third of bad debt expense. This is based on an estimate of incomplete applications.The footnote to the Organization's financial statements can be found on page 9 of the attached audited financial statements. Part III, Line 8: Edgerton Hospital and Health Services, Inc. is a critical access hospital and in prior years has not shown a Medicare shortfall. There was a shortfall for 2013 due to sequestration. Even though Medicare was at a loss, the Hospital provides services to these patients because access to healthcare and individual's health is important to the Hospital. Therefore, the Medicare shortfall is considered a community benefit. Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by the Centers for Medicare and Medicaid Services. Part III, Line 9b: Edgerton Hospital and Health Services provides a charitable program consisting of partial or total discounts for those patients who are uninsured, underinsured, and/or unable to pay for necessary healthcare services and are determined eligible to receive such care. As part of the debt collection policy patients are given a written notice after 30 days, 45 days, 60 days, and 70 days. This is followed up by a phone call and if there is no response the account is sent to a pre-collection agency and then the collection agency. For patients known to qualify for charity care or financial assistance, this process is followed for the portion they are responsible for. On accounts which have been assigned to outside collection agencies and are later approved for Community Care, the hospital will request such agencies to cancel and return accounts to the hospital, and to reverse any applicable detrimental credit information created against the patient/guarantor. Part VI, Line 2: We use the following tools to assess health care needs of the communities we serve: (1) Patient exit questionnaires; (2) Involvement in community groups such as the Edgerton Coalition for a Healthy Community where we assess health needs based upon discussions and topics brought up by the Coalition members; (3) Analysis of data received from the Wisconsin Hospital Association and the Rock County Department of Health; and (4) Utilization of the Intelimed software program which allows us to analyze data from facilities comparable to ours.The Community Health Needs Assessment (CHNA) and implementation strategy is complete and posted to our website at www.edgertonhospital.com. Part VI, Line 3: A summary of our community care program is listed on our Hospital website and is contained in a brochure that is available to all patients at all registration areas, emergency room, and waiting rooms in the Hospital. The policy is also provided upon admission and upon request. The complete packet of information, along with an application, is given to any patient upon request. Posters which explain our community care program are located in the Emergency Department and inform patients to contact the Business Office for more information. Billing staff discuss the availability of various government benefits, state programs, and assist the patient on how to qualify for such programs where applicable. Part VI, Line 4: Edgerton is located 30 miles south of Madison and 12 Miles north of Janesville on the northern edge of Rock County. Edgerton is in a rural, agricultural area. The 2010 population of Edgerton and Rock County was 5,461 and 160,331 with a projected county growth to 186,331 by 2035. Rock County is dominated by service and manufacturing sectors. The median household income for the county is $49,716, the poverty level is at 12.4% and the population aged 65+ is at 13.8%.There are multiple hospitals within 30 miles of Edgerton including three facilities in Madison, one in Janesville, one in Stoughton and one in Fort Atkinson.Madison Hospitals (30 miles distant)* St.Mary's - 440 bed acute care hospital * Meriter - 448 bed acute care hospital* University of Wisconsin Hospital - 536 bed acute care hospitalOther Hospitals (20 or less miles distant)* Mercy Hospital - Located 12 miles south - 240 bed acute care hospital* Stoughton Hospital - located 12 miles northwest - 35 bed acute care, critical access hospital* Fort Atkinson - Located 17 miles northeast - 82 bed acute care hospital Part VI, Line 5: Edgerton Hospital is an 18-bed critical access hospital located in Edgerton, Wisconsin. Our Board of Trustees is comprised of persons who reside in our primary service area who are not employees of our Organization. The Hospital extends medical staff privileges to all qualified physicians in the community and all surplus funds are reinvested in patient care and plant upgrades. Our Organization is the fiscal agent for the Edgerton Coalition for a Healthy Community and one of our employees is the Project Director of the Coalition. We hold an annual health fair for the community and offer many health related community education classes at little or no cost to the attendees. We provide and staff a First Aid tent at our local community summer festival. Our CEO sits on the Board of Directors of the local Hope Institute of Uganda with meetings held in Janesville, Wisconsin. Part VI, Line 7, Reports Filed With States WI 1 Edgerton Hospital Capital Foundation Inc 11101 North Sherman Road Edgerton WI 53534 203161048 501(c)(3) 137831 Support for operating expenses 1 0 Part I, Line 2: Edgerton Hospital provides support to assist with operating expenses for Edgerton Hospital Capital Foundation, Inc. The Foundation must provide documentation of what the funding was used for. X X X 0 0 0 0 0 0 0 0 0 James Pernau CEO 161712 0 0 0 23000 0 1634 0 22082 0 208428 0 0 0 Charles Roeder CFO 117121 0 0 0 23000 0 1319 0 14376 0 155816 0 0 0 Todd Crowley Pharmacist 134260 0 0 0 7155 0 1311 0 12850 0 155576 0 0 0 Rock Valley Radiologists Officer and 33.3% owner is a member of the Board 257000 Radiology physician services 0 Form 990, Part VI, Section A, line 1 The Executive Committee consists of the Board Chair, Vice Chair, Secretary, and Treasurer of the Corporation. The Executive Committee has power to transact all regular business of the Corporation during the interim between meetings of the Board of Trustees, except the power to: elect officers of the Corporation, fill vacancies in the Board of Trustees or in the Executive Committee, amend or repeal any provisions of these Bylaws, appropriate funds of the Corporation not included in the budget or exceeding an amount for any one purpose in any one fiscal year fixed or authorized by the Board from time to time, or adopt programs which would involve continuing activity or support by the Corporation for more than one fiscal year. Minutes of the Executive Committee summarizing its actions must be submitted to the Board at its next regularly scheduled meeting. Form 990, Part VI, Section A, line 7a The Board of Trustees consists of two classes: Class E Trustees and Class S Trustees. SSM Health Care of Wisconsin, Inc. has the right to appoint and remove the Class S Trustees. SSM Health Care of Wisconsin, Inc. also has the right to appoint an alternate who will serve instead of a Class S Trustee with voting rights if the Class S Trustee is unable to attend a meeting of the Board of Trustees. Class E Trustees are appointed by the Board of Trustees. Class E and Class S Trustees have the same voting rights. Form 990, Part VI, Section B, line 11 The Form 990 is provided to the Trustees of the Board before it is filed. The return is reviewed by the Accounting Manager and CFO. Form 990, Part VI, Section B, line 12c Board members, officers, and employees complete and sign a conflict of interest policy annually. The employee handbook contains a conflict of interest policy. The Board Chair and CEO review the potential conflicts of Board members and the HR department reviews the potential conflicts of employees. Potential conflicts may include but are not limited to ownership or control of an entity that contracts with Edgerton Hospital. Board members with conflicts are restricted from voting on such matters and the conflict is made a matter of record in the minutes. Form 990, Part VI, Section B, line 15a The Board determines compensation for the CEO. It is based on an annual performance review and comparability data. The Board provides substantiation of the deliberation and decision for the compensation process. The process is completed annually and was last completed in 2013. The CEO determines the salary of the CFO based on comparability data. Form 990, Part VI, Section C, line 19 The Organization's governing documents, conflict of interest policy, and financials statements are available to the public upon request. The financial statements are also attached to the Form 990. Form 990, Part IX, line 11g Equipment repair, rental and service agreements: Program service expenses 755,135. Management and general expenses 282,912. Fundraising expenses 0. Total expenses 1,038,047. Physician, consulting & professional fees: Program service expenses 2,484,856. Management and general expenses 280,199. Fundraising expenses 0. Total expenses 2,765,055. Contract fees & purchased services: Program service expenses 706,809. Management and general expenses 25,251. Fundraising expenses 0. Total expenses 732,060. Form 990, Part XI, line 9: Change in net assets of Edgerton Memorial Community Hospital Auxiliary 4,167. Edgerton Hospital Capital Foundation Inc 11101 North Sherman Road Edgerton WI 53534 203161048 Provide financial support for Edgerton Hospital and Health Services, Inc. WI 501(c)(3) Line 11a, I Edgerton Hospital and Health Services Inc 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 Edgerton Hospital Capital Foundation Inc C 139015 General ledger Edgerton Hospital Capital Foundation Inc B 137831 General ledger