2012-07-05T13:47:13-05:00 2011-09-30 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2010-10-01 390806404 VERNON MEMORIAL HEALTHCARE INC VERN 6086372101 507 SOUTH MAIN STREET VIROQUA WI WI 54665 MARY KOENIG 6086372101 2012-06-19 1 HOLLY POKRANDT CPA 7158323407 2012-06-19 2010 2016-02-24 21:20:13Z MARY KOENIG 507 SOUTH MAIN STREET VIROQUA WI WI 54665 70442120 0 X WWW.VMH.ORG X 1946 WI VERNON MEMORIAL HEALTHCARE HAS BEEN COMMITTED TO PROVIDING THE HIGHEST QUALITY CARE AND TREATMENT TO THE INJURED, AFFLICTED AND WELL PEOPLE WHO NEED THE RESOURCES WE HAVE AT OUR COMMAND, WITHOUT REGARD TO RACE, CREED, COLOR, SEX, HANDICAP, NATIONAL ORIGIN, OR ABILITY TO PAY. IT IS OUR INTENTION TO INSURE THAT IN EACH AND EVERY CASE OUR PATIENTS SHALL BE TREATED WITH COMPASSION, UNDERSTANDING AND DIGNITY. FURTHER, THE RIGHTS AND PRIVILEGES OF THE PEOPLE WE SERVE SHALL ALWAYS BE HELD IN THE HIGHEST REGARD, AND THEIR WELL-BEING MUST ALWAYS HAVE FIRST CONSIDERATION. VERNON MEMORIAL HEALTHCARE IS COMMITTED TO PROVIDING MODERN FACILITIES AND EQUIPMENT CONSISTENT WITH NEW AND CONTEMPORARY MEDICAL TECHNOLOGY. WE WILL FOSTER, STIMULATE, ENCOURAGE AND PROMOTE CONTINUING HEALTHCARE EDUCATION FOR EMPLOYEES AND THE COMMUNITY WE SERVE. ALL THIS, WE MOST SOLEMNLY AND SINCERELY PLEDGE TO THE PEOPLE WHO NEED US, RECOGNIZING FULLY, THAT SERVICE TO HUMANITY IS THE GREATEST SERVICE OF ALL. 11 11 564 155 5599156 -207452 96235 620264 64672978 66426192 556618 619418 236480 239971 65562311 67905845 157238 257963 0 0 31403220 31893997 0 0 0 29178727 28899693 60739185 61051653 4823126 6854192 72396251 78875894 31548662 32113444 40847589 46762450 X VERNON MEMORIAL HEALTHCARE, INC. WILL STRIVE TO HAVE THE VISION TO CONTINUALLY PROVIDE THE HIGHEST STANDARD OF CARE TO OUR PATIENTS AND THEIR FAMILIES WHILE BEING 'CLOSE TO HOME.' OUR MISSION IS TO PROVIDE COST-EFFECTIVE, ACCESSIBLE CARE AND SERVICE USING PROFESSIONALLY EDUCATED STAFF AND SUPERIOR TECHNOLOGY TO MEET THE HEALTH CARE NEEDS OF OUR COMMUNITY. OUR CARING AND COMMITMENT TO THE COMMUNITY WILL BE DEMONSTRATED BY OUR EMPHASIS ON HEALTH PROMOTION AND DISEASE PREVENTION THROUGH EDUCATION. 0 0 41554993 257963 49333828 WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HEALTHCARE ORGANIZATION'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR ORGANIZATION PROVIDES SIGNIFICANT CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH CANNOT BE QUANTIFIED. OUR ORGANIZATION WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE CARE LOCALLY-CARE THAT WITHOUT THE PRESENCE OF OUR ORGANIZATION, WOULD NOT BE AVAILABLE TO THE PEOPLE IN OUR SERVICE AREA.BEYOND MEDICAL, OBSTETRICAL, NEWBORN AND SURGICAL INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO MANY OTHER HEALTH SERVICES INCLUDING A BIRTHING CENTER, A DIALYSIS CENTER, DIAGNOSTIC SERVICES-LABORATORY, IMAGING AND CARDIAC TESTING, 24-HOUR EMERGENCY SERVICES, URGENT CARE SERVICES, INFUSION SERVICES, GASTROINTESTINAL SERVICES, HOME HEALTH CARE, HOSPICE, INPATIENT AND OUTPATIENT CARE, REHABILITATION SERVICES-PHYSICAL, OCCUPATIONAL, RESPIRATORY AND SPEECH THERAPY, SPECIALTY MEDICINE, AND PRIMARY CARE CLINICS.IN 2011, HOSPITAL INPATIENT SERVICES INCLUDED 3,815 ACUTE CARE PATIENT DAYS, 50 SWING BED PATIENT DAYS, AND 291 NEWBORN PATIENT DAYS. THERE WERE 1,487 SURGERY CASES, 6,414 EMERGENCY ROOM VISITS, AND 1,137 VISITS TO THE AFTER HOURS CLINIC. 11511571 10770548 A TOTAL OF 44,973 CLINIC VISITS OCCURRED IN FYE 2011 AT THE FOUR CLINICS LOCATED IN VIROQUA, LAFARGE, SOLDIERS GROVE, AND WESTBY. 1312387 722660 DURING FYE 2011, 2,108 HOME HEALTH VISITS WERE MADE TO 117 INDIVIDUALS. HOSPICE CARE WAS PROVIDED TO 78 INDIVIDUALS FOR A TOTAL OF 2,819 DAYS. 54378951 1 1 0 1 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 38 0 1 564 1 1 1 0 0 0 0 0 0 0 0 0 X 11 11 0 0 0 0 1 1 1 1 1 0 0 1 1 0 0 1 1 1 1 0 WI X MARY KOENIG 6086372101 507 SOUTH MAIN STREET VIROQUA WI WI 54665 PHYLLIS MALIN 1.00 X 0 0 0 TIM GASKELL 1.00 X 0 0 0 ENID NEUBAUER 1.00 X 0 0 0 JAMES LARSON 1.00 X X 0 0 0 CHET LEE 1.00 X X 0 0 0 RON MOILIEN 1.50 X X 0 0 0 JERRY MORAN 1.00 X 0 0 0 JUDY SCHMIRLER 1.00 X 0 0 0 BRAD STEINMETZ 2.00 X X 0 0 0 ROGER JOHNSON 1.00 X 0 0 0 ROBERT KNADLE 1.00 X 0 0 0 GARITH STEINER 40.00 X 277740 0 292779 MARY KOENIG 40.00 X 184257 0 66969 KYLE BAKKUM 40.00 X 205082 0 39119 DR JEFFREY MENN 40.00 X 485195 0 27790 DR ANTHONY MACASAET 40.00 X 226646 0 15898 DR DUANE KOONS 40.00 X 267168 0 33402 DR DEBORAH PRIOR 40.00 X 243610 0 31784 BRIAN MILLER 40.00 X 317363 0 28596 2207061 0 536337 34 0 1 0 GUNDERSEN LUTHERAN 1900 SOUTH AVE LA CROSSE WI 54601 LAB/RADIOLOGY 1797639 ARNOLD NOMANN E7332 SKYLINE DRIVE VIROQUA WI 54655 ANESTHESIA SERVICES 407208 GPS ANESTHESIA SERVICES N2685 POTATO RIDGE ROAD LA CROSSE WI 54601 ANESTHESIA SERVICES 399105 SHARED MEDICAL SERVICES PO BOX 330 COTTAGE GROVE WI 53527 MRI 237990 CLINICAL ULTRASOUND SERVICES PO BOX 7 POSTVILLE WI 52162 ULTRASOUND 221590 5 620264 620264 HOSPITAL 621990 49231587 49231587 CLINIC 621110 10770548 10770548 RETAIL PHARMACY 446110 5527548 5527548 HOME HEALTH & HOSPICE 621610 722660 722660 MEALS AND DIETARY 722210 173849 102241 71608 66426192 495204 495204 239971 239971 239971 239971 2602039 58450 2509581 26694 92458 31756 124214 124214 67905845 60827036 5599156 859389 257963 257963 1310986 1310986 22512245 20498789 2013456 901128 820533 80595 5627632 5124306 503326 1542006 1359783 182223 84814 84814 68460 68460 4749448 3960249 789199 73589 73589 15977325 15683435 293890 94310 94310 2510265 2510265 67618 47553 20065 2605060 1886591 718469 258227 258227 BAD DEBT EXPENSE 1972276 1972276 DUES AND SUBSCRIPTIONS 348014 216164 131850 MISCELLANEOUS 90287 41044 49243 61051653 54378951 6672702 0 1605297 1646574 11976720 13531553 496745 6681155 6166143 2174541 2289229 207820 289245 58669974 23645804 35112024 35024170 9726866 15811265 12180 12180 2218284 2115883 649257 616452 2032107 876455 72396251 78875894 5097957 7088121 24315848 23611292 12830 90728 2122027 1323303 31548662 32113444 X 40730886 46169672 116703 592778 40847589 46762450 72396251 78875894 X 6854192 -939331 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4518 4518 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: VERNON MEMORIAL HEALTHCARE, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIPS TO THE WISCONSIN HOSPITAL ASSOCIATION AND RURAL WISCONSIN HEALTH COOPERATIVE. THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. A SMALL PORTION OF THE ANNUAL DUES WERE USED IN CONJUCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. 1188135 1188135 43709846 14492130 29217716 12846700 9153674 3693026 925293 925293 35024170 DEFERRED COMPENSATION PLAN LIABILITY - FUNDED 1027670 POSTRETIREMENT BENEFIT OBLIGATION 295633 1323303 67905845 61051653 6854192 -1082351 143020 -939331 5914861 66539559 -1082351 -1082351 67621910 283935 283935 67905845 60767718 0 60767718 283935 283935 61051653 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: INCOME TAXES THE ORGANIZATION IS A NONPROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE ORGANIZATION IS ALSO EXEMPT FROM STATE INCOME TAXES, PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE ORGANIZATION DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE LIKELY THAN NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE ORGANIZATION IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES WHICH THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE ORGANIZATION'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE ORGANIZATION DOES NOT PRESENTLY ANTICIPATE THAT A TAX BENEFIT FROM THESE NET OPERATING LOSSES WILL BE REALIZED IN THE FUTURE. ACCORDINGLY, ANY POTENTIAL DEFERRED TAX ASSET RESULTING FROM THE AVAILABILITY OF NET OPERATING LOSS CARRYFORWARDS IS OFFSET BY A VALUATION ALLOWANCE OF EQUAL AMOUNT. NO DEFERRED TAX ASSETS AND LIABILITIES HAVE BEEN RECOGNIZED SINCE NO OTHER DIFFERENCES EXIST BETWEEN THE FINANCIAL AND TAX BASES OF REPORTING THE ORGANIZATION'S ASSETS AND LIABILITIES. THE ORGANIZATION'S POLICY IS TO RECOGNIZE INTEREST AND PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF SEPTEMBER 31, 2011 AND 2010, THERE WERE NO MATERIAL TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES, RECORDED BY THE ORGANIZATION IN THE FINANCIAL STATEMENTS. THE ORGANIZATION RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS OR UNRECOGNIZED TAX BENEFITS IN 2011 OR 2010. FEDERAL RETURNS FOR THE YEARS ENDED SEPTEMBER 30, 2008, AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTION FOR OPERATIONS -25,541. POSTRETIREMENT BENEFIT OBLIGATION ADJUSTMENT 168,561. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON THE AUDITED FINANCIALS 283,935. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON THE AUDITED FINANCIALS 283,935. 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 647342 647342 0.01100 7162737 4535245 2627492 0.04450 7810079 4535245 3274834 0.05550 160843 11840 149003 0.00250 180530 180530 0.00310 468986 600 468386 0.00790 810359 12440 797919 0.01350 8620438 4547685 4072753 0.06900 1168 1168 0.00000 706 565 141 0.00000 4441 4441 0.00010 6315 565 5750 0.00010 0 1116858 893486 9587194 9793217 -206023 X 1 0 1 1 VERNON MEMORIAL HOSPITAL INC

507 SOUTH MAIN ST VIROQUA WI 54665

X X X X VERNON MEMORIAL HOSPITAL INC 1 8 HIRSCH CLINIC

407 S MAIN ST SUITE 400 VIROQUA WI 54665

PROVIDER BASED RURAL HEALTH CLINIC VERNON MEMORIAL HEALTHCARE PHARMACY

407 S MAIN ST SUITE 400 VIROQUA WI 54665

PHARMACY LAFARGE MEDICAL CLINIC

111 W SNOW ST LAFARGE WI 54639

PROVIDER BASED RURAL HEALTH CLINIC SOLAR TOWN PHARMACY

104 SUNSET AVE SOLDIERS GROVE WI 54655

PHARMACY BLAND CLINIC

100 MELBY ST WESTBY WI 54667

PROVIDER BASED RURAL HEALTH CLINIC KICKAPOO VALLEY MEDICAL CLINIC

102 SUNSET AVE SOLDIERS GROVE WI 54655

PROVIDER BASED RURAL HEALTH CLINIC VERNON MEMORIAL HEALTHCARE INC

507 S MAIN ST VIROQUA WI 54665

HOSPICE VERNON MEMORIAL HEALTHCARE INC

507 S MAIN ST VIROQUA WI 54665

HOME HEALTH AGENCY PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 1972276. PART I, LINE 7: THE COSTING METHOD USED ON FORM 990 IS BASED ON A COST-TO-CHARGE RATIO WHICH IS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUES. THIS COST-TO-CHARGE RATIO IS APPLIED AGAINST VARIOUS REVENUE AND EXPENSE CATEGORIES TO COMPUTE THE ESTIMATED COMMUNITY BENEFIT EXPENSE UNDER IRS COSTING METHODS FOR THE FORM 990. THE COST OF COMMUNITY HEALTH IMPROVEMENT AND HEALTH PROFESSIONALS EDUCATION REFLECT THE DIRECT AND INDIRECT COSTS AS DETERMINED BY THE HOSPITAL.PART II, WHILE THERE IS A GROWING AGREEMENT IN THE UNITED STATES ABOUT WHAT CONSTITUTES A NON-PROFIT HOSPITAL'S COMMUNITY BENEFIT, THIS IS A WORK IN PROGRESS. OUR HOSPITAL PROVIDES CHARITY CARE AND OTHER COMMUNITY BENEFITS AS DEFINED BY THE IRS. BUT IN ADDITION, WE BELIEVE THAT WE PROVIDE A CRITICALLY IMPORTANT COMMUNITY BENEFIT WHICH IS NOT QUANTIFIED. OUR HOSPITAL, LIKE MOST RURAL HOSPITALS, WAS CREATED AND IS MAINTAINED IN ORDER TO PROVIDE LOCAL ACCESS TO MANY HEALTH SERVICES: BIRTHING CENTER, DIAGNOSTICS, EMERGENCY SERVICES AND URGENT CARE, HOME CARE, HOSPICE, INFUSION SERVICES, INPATIENT CARE, LABORATORY SERVICES, OCCUPATIONAL HEALTH, REHABILITATION SERVICES, SPECIALTY MEDICINE, SPEECH AND AUDIOLOGY, SURGICAL SERVICES, AND WOMENS HEALTH.PART III, LINE 4: ACCOUNTS RECEIVABLE AND CREDIT POLICY THE COSTING METHOD USED IS BASED ON A COST-TO-CHARGE RATIO WHICH WAS DEVELOPED BASED ON THE HOSPITAL'S TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBTS DIVIDED BY GROSS PATIENT SERVICE REVENUE. THE COST OF BAD DEBT AMOUNTS IS CONSIDERED A COMMUNITY BENEFIT BECAUSE IT REFLECTS THE COST OF SERVICES PROVIDED TO UNINSURED COMMUNITY MEMBERS AND DEDUCTIBLES OR COINSURANCE AMOUNTS FOR UNINSURED PATIENTS WHO ARE UNABLE TO PAY FOR A PORTION OF SERVICES.ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT FROM OUTSTANDING BALANCES. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYER AGREEMENTS. THE ORGANIZATION BILLS THIRD-PARTY PAYERS ON EACH PATIENT'S BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYER, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR CO-PAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENT. THE ORGANIZATION DOES NOT HAVE A POLICY TO CHARGE INTEREST ON PAST DUE ACCOUNTS. THE CARRYING AMOUNTS OF ACCOUNTS RECEIVABLE ARE REDUCED BY ALLOWANCES THAT REFLECT MANAGEMENT'S BEST ESTIMATE OF THE AMOUNTS THAT WILL NOT BE COLLECTED. MANAGEMENT PROVIDES FOR CONTRACTUAL ADJUSTMENTS UNDER TERMS OF THIRD-PARTY REIMBURSEMENT AGREEMENTS THROUGH CHARGE TO GROSS PATIENT SERVICE REVENUE AND A CREDIT TO THE ACCOUNTS RECEIVABLE. IN ADDITION, MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY RESPONSIBLE FOR, THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO A VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF HISTORICAL COLLECTION LIKELIHOOD AND THE CURRENT STATUS OF INDIVIDUAL ACCOUNTS. BALANCES THAT ARE STILL OUTSTANDING AFTER MANAGEMENT HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. ACCOUNTS RECEIVABLE ARE RECORDED IN THE ACCOMPANYING BALANCE SHEETS NET OF CONTRACTUAL ADJUSTMENTS AND ALLOWANCE FOR DOUBTFUL ACCOUNTS. THE AUDITED FINANCIAL STATEMENTS DO NOT INCLUDE A SEPARATE FOOTNOTE REGARDING BAD DEBT EXPENSE.PART III, LINE 8: THE SHORTFALL SHOULD BE TREATED AS A COMMUNITY BENEFIT EXPENSE BECAUSE THE HOSPITAL PROFESSIONALS OFFER CLASSES TO THE COMMUNITY AIMED AT MAINTAINING AND IMPROVING THE GENERAL HEALTH OF THE POPULATION. ALSO A SIGNIFICANT PORTION OF THE PEOPLE RECEIVING SERVICES FROM THE HOSPITAL ARE COVERED BY EITHER MEDICARE OR MEDICAL ASSISTANCE PROGRAMS AND ARE RESIDENTS OF THE LOCAL COMMUNITY. THE COST TO CHARGE RATIO WAS CALCULATED USING THE MEDICARE COST REPORT.PART III, LINE 9B: PATIENTS RECEIVE OUR COMMUNITY CARE APPLICATION WHEN THEY PRESENT FOR SERVICES. THEY ARE ENCOURAGED TO REVIEW THE APPLICATION AND SUBMIT THE REQUIRED INFORMATION TO APPLY FOR POTENTIAL COVERAGE. IF THEY HAVE QUESTIONS OR NEED HELP WITH THE APPLICATION THEY MAY MEET WITH OUR PATIENT ACCOUNTS STAFF. ONCE A PATIENT APPLIES AND IS APPROVED FOR COMMUNITY CARE, THE APPLICATION IS CONSIDERED CURRENT AND VALID FOR THE FOLLOWING 12-MONTH PERIOD.PART VI, LINE 2 : VERNON MEMORIAL HEALTHCARE'S COMMUNITY HEALTH EDUCATION STAFF ACTIVELY WORKS WITH A VARIETY OF BUSINESSES IN THE SERVICE AREA TO EDUCATE EMPLOYEES AND ASSESS NEEDS FOR PROGRAMS AND SERVICES THAT WE COULD ASSIST WITH. VMH STAFF FROM MANY DEPARTMENTS SPEAK TO COMMUNITY GROUPS ON A VARIETY OF HEALTH-RELATED TOPICS. NEEDS ARE INFORMALLY ASSESSED AT THESE AND OTHER EVENTS SPONSORED BY VMH. IN 2011 VMH CONTRACTED WITH THE UNITED WAY TO PARTICIPATE IN A FORMAL COMMUNITY NEEDS ASSESSMENT PROJECT THAT WAS COMPLETED IN EARLY 2012. STARTING IN 2012, VMH WILL BE DEVELOPING AN ACTION PLAN TO ADDRESS THE NEEDS ADDRESSED IN THE COMMUNITY NEEDS ASSESSMENT PROJECT. PART VI, LINE 3: SIGNS ARE POSTED AT ALL REGISTRATION LOCATIONS INFORMING PATIENTS OF OUR COMMUNITY CARE PROGRAM. IF PATIENTS INQUIRE ABOUT THE PROGRAM, THEY ARE ALSO PROVIDED WITH INFORMATION ABOUT GOVERNMENT PROGRAMS THAT THEY MAY QUALIFY FOR. REGISTRATION STAFF ALSO INFORM PATIENTS WITH NO INSURANCE ABOUT COMMUNITY CARE OR OTHER PROGRAMS THAT THEY MAY QUALIFY FOR. STAFF IN THE PATIENT ACCOUNTING DEPARTMENT ARE READILY AVAILABLE TO ASSIST PATIENTS IN COMPLETING THE APPLICATION FORM AND TO ANSWER QUESTIONS. PART VI, LINE 4: VERNON MEMORIAL HEALTHCARE'S PRIMARY SERVICE AREA IS THE AREA WITHIN APPROXIMATELY A 25-MILE RADIUS OF VIROQUA, WI. THIS IS PRIMARILY A RURAL AREA WITH SEVERAL SMALL COMMUNITIES. THE LARGEST CITY IN THE SERVICE AREA IS VIROQUA, A TOWN OF APPROXIMATELY 4,500. THE NEAREST HOSPITALS ARE APPROXIMATELY 35 MILES AWAY IN LACROSSE, SPARTA, RICHLAND CENTER, AND BOSCOBEL. VERNON MEMORIAL HEALTHCARE IS LOCATED IN VERNON COUNTY WISCONSIN. IN 2009, THE AVERAGE HOUSEHOLD INCOME IN VERNON COUNTY WAS $37,876, THE UNEMPLOYMENT RATE WAS 7.9%, AND 14% OF THE RESIDENTS LIVED BELOW THE POVERTY GUIDELINES.PART VI, LINE 5: ALL MEMBERS OF THE ORGANIZATION'S GOVERNING BODY RESIDE IN THE SERVICE AREA AND SERVE ON A VOLUNTARY BASIS. NONE OF THE MEMBERS ARE EMPLOYEES OR CONTRACTORS OF THE ORGANIZATION. MEDICAL STAFF PRIVILEGES ARE EXTENDED TO ALL QUALIFIED PHYSICIANS WHO APPLY. VERNON MEMORIAL HEALTHCARE IS A NON-PROFIT ORGANIZATION, SO ALL EARNINGS IN EXCESS OF COST ARE USED BY THE ORGANIZATION TO IMPROVE THE HEALTHCARE OF THE PEOPLE WE SERVE THROUGH THE PURCHASE OR UPGRADE OF FACILITIES AND EQUIPMENT, OR THE ADDITION OR EXPANSION OF NEEDED SERVICES. REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 VIROQUA AREA SCHOOLS 115 N EDUCATION AVE VIROQUA WI 54665 396004944 GOV'T ORGANIZATION 70740 GENERAL SUPPORT YOUTH INITIATIVE HIGH SCHOOL 500 EAST JEFFERSON ST VIROQUA WI 54665 391906073 501(C)(3) 10000 GENERAL SUPPORT PLEASANT RIDGE WALDORF SCHOOL 431 E COURT ST VIROQUA WI 54665 391357578 501(C)(3) 10000 GENERAL SUPPORT VIROQUA AREA FOUNDATION PO BOX 262 VIROQUA WI 54665 391603279 501(C)(3) 30000 GENERAL SUPPORT NORSEMEN BOOSTER CLUB W2693 COUNTY ROAD N COON VALLEY WI 54623 392041425 501(C)(3) 6950 GENERAL SUPPORT WESTBY AREA SCHOOL DISTRICT 206 WEST AVE SOUTH WESTBY WI 54667 396005143 GOV'T ORGANIZATION 47734 GENERAL SUPPORT FAMILY AND CHILDREN'S CENTER 1707 MAIN STREET LA CROSSE WI 54601 390821863 501(C)(3) 30000 GENERAL SUPPORT VERNON ECONOMIC DEVELOPMENT ASSOCIATION INC 100 N MAIN STREET WESTBY WI 54667 371520081 501(C)(3) 5000 GENERAL SUPPORT VIROQUA CHAMBER MAIN STREET 220 SOUTH MAIN STREET VIROQUA WI 54665 390920449 501(C)(3) 30039 GENERAL SUPPORT WTC CASHIER'S OFFICE 400 7TH STREET NORTH LA CROSSE WI 54602 396002842 501(C)(3) 17500 GENERAL SUPPORT 10 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: ALL DONEES ARE REQUIRED TO SUBMIT THEIR DONATION REQUESTS TO THE CEO OR MARKETING MANAGER OF VERNON MEMORIAL HEALTHCARE, INC. REQUESTS SUBMITTED TO THE MARKETING MANAGER ARE FORWARDED TO THE CEO FOR FINAL APPROVAL. THE REQUESTS MUST INCLUDE A DETAILED DESCRIPTION OF WHAT THE FUNDS WILL BE USED FOR AND HOW THEY WILL BENEFIT THE COMMUNITY. DONEES ARE ASKED TO PROVIDE CONFIRMATION OF RECEIPT AND AN EXPLANATION OF HOW THE FUNDS WERE USED, EITHER VERBALLY OR IN WRITING, TO THE CEO. IF THE REQUESTS ARE DEEMED BENEFICIAL TO THE NEEDS OF THE COMMUNITY, THE FUNDS ARE AWARDED TO THE APPLYING ORGANIZATION. X X X X 0 1 0 0 0 0 0 0 0 GARITH STEINER 261240 0 0 0 16500 0 280721 0 12058 0 570519 0 0 0 MARY KOENIG 167757 0 0 0 16500 0 54610 0 12359 0 251226 0 0 0 KYLE BAKKUM 205082 0 0 0 0 0 27061 0 12058 0 244201 0 0 0 DR JEFFREY MENN 468695 0 0 0 16500 0 13937 0 13853 0 512985 0 0 0 DR ANTHONY MACASAET 226646 0 0 0 0 0 1781 0 14117 0 242544 0 0 0 DR DUANE KOONS 267168 0 0 0 0 0 19549 0 13853 0 300570 0 0 0 DR DEBORAH PRIOR 227110 0 0 0 16500 0 17931 0 13853 0 275394 0 0 0 BRIAN MILLER 317363 0 0 0 0 0 16538 0 12058 0 345959 0 0 0 SUPPLEMENTAL INFORMATION PART III PART III: IN ADDITION TO THE COMPENSATION REPORTED IN PART II, THE ORGANIZATION ACCRUED ADDITIONAL PAID LEAVE TIME THAT IS RECOGNIZED AS UNFUNDED DEFERRED COMPENSATION FOR THREE INDIVIDUALS. THE UNFUNDED DEFERRED COMPENSATION EXPENSED IN FISCAL YEAR 2011 WAS AS FOLLOWS: GARITH STEINER $261,863 MARY KOENIG $42,557 KYLE BAKKUM $12,415 THE ORGANIZATION HAS ALSO INSTITUTED A POLICY WHEREBY THESE EXECUTIVES (GARITH STEINER AND MARY KOENIG) ARE ABLE TO ACCRUE VACATION TIME THAT IS NOT LIMITED BY THE ORGANIZATION'S STANDARD POLICY. WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY 391337855 97710VXQ6 2005-05-19 22894672 FINANCE CONSTRUCTION OF FACILITY EXPANSION 0 0 0 22894672 1846325 457893 20590454 2006 0 0 1 1 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 ANY PERSON WHO IS EIGHTEEN YEARS OF AGE OR OLDER AND A BONA FIDE RESIDENT OF VERNON COUNTY, WISCONSIN, OR THE AREA WITHIN A RADIUS OF TWENTY-FIVE MILES OF THE CITY OF VIROQUA, WISCONSIN, AND WHO HAS THE HERETOFORE OR MAY HEREAFTER CONTRIBUTE TEN DOLLARS OR MORE TO THE CORPORATION SHALL BE A MEMBER THEREOF. ALL MEMBERS OF THE CORPORATION SHALL BE VOTING MEMBERS. EACH MEMBER SHALL HAVE ONE VOTE ON ANY MATTER SUBMITTED TO A VOTE OF THE MEMBERS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE DUTIES OF THE MEMBERS OF THE VERNON MEMORIAL HEALTHCARE, INC ("THE CORPORATION") SHALL BE: THE ELECTION OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION, THE REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS OF THE CORPORATION, AND THE CHANGING OF THE NUMBER OF DIRECTORS CONSTITUTING THE BOARD OF DIRECTORS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE DUTIES OF THE MEMBERS OF THE VERNON MEMORIAL HEALTHCARE, INC ("THE CORPORATION") SHALL ALSO INCLUDE: THE AMENDMENT, RESTATEMENT, OR MODIFICATION OF THE ARTICLES OF INCORPORATION OR BYLAWS OF THE CORPORATION; AND THE APPROVAL OF THE SALE, LEASE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL OF THE ASSETS AND PROPERTY OF THE CORPORATION, THE DISSOLUTION OF THE CORPORATION, OR ITS MERGER WITH ANOTHER CORPORATION. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED AND APPROVED BY A COMMITTEE OF THE BOARD OF DIRECTORS OF VERNON MEMORIAL HEALTHCARE, INC. BEFORE SUBMISSION. FORM 990, PART VI, SECTION B, LINE 12 ALL BOARD MEMBERS OF VERNON MEMORIAL HEALTHCARE, INC. ARE REQUIRED TO DISCLOSE ALL POSSIBLE CONFLICTS OF INTEREST WHEN FIRST ELECTED TO THE BOARD OF DIRECTORS. DURING THEIR TERMS, IF ANY BUSINESS RELATIONSHIPS ARE ENTERED INTO WHICH MAY AFFECT THEIR INDEPENDENCE AS A MEMBER, THE MEMBER MUST IMMEDIATELY DISCLOSE THESE RELATIONSHIPS. FORM 990, PART VI, SECTION B, LINE 15 FOR UPPER MANAGEMENT POSITIONS, VERNON MEMORIAL HOSPITAL, INC. UTILIZES AN INDEPENDENT CONSULTING FIRM THAT PROVIDES SURVEY RESULTS FOR SIMILAR POSITIONS ACROSS THE COUNTRY ANNUALLY. THE 'TRUE MARKET AVERAGE' FOR EACH POSITION IS INCLUDED IN THE INFORMATION RECEIVED. ACCORDING TO THE CONTRACTS FOR THE CEO, CFO AND COO, THESE PEOPLE ARE TO RECEIVE THE 'TRUE MARKET AVERAGE' AS DEFINED IN THE STUDY. DEVIATIONS FROM THIS ARE PERMITTED IF THERE IS MUTUAL CONSENT. THE CEO HAS THE RIGHT TO AMEND THE AMOUNT FOR THE CFO AND COO. THE BOARD HAS THE RIGHT TO AMEND THE AMOUNT FOR THE CEO. THE EXECUTIVE COMMITTEE OF THE BOARD REVIEWS THE DATA FOR THE CEO ANNUALLY TO DETERMINE THE AMOUNT OF HIS COMPENSATION, AND ANY CHANGES IN COMPENSATION ARE MAINTAINED IN THE PERSONNEL FILE. THE CEO REVIEWS THE DATA FOR THE CFO AND COO ANNUALLY TO DETERMINE THE AMOUNT OF COMPENSATION AND ANY CHANGES ARE MAINTAINED IN THE PERSONNEL FILE. FORM 990, PART VI, SECTION C, LINE 19 VERNON MEMORIAL HEALTHCARE, INC. MAKES ITS FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC ON A PER REQUEST BASIS. THE FORM 990 IS ALSO AVAILABLE TO THE PUBLIC ON A THIRD PARTY WEBSITE CALLED GUIDESTAR. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,082,351. NET ASSETS RELEASED FROM RESTRICTION FOR OPERATIONS -25,541. POSTRETIREMENT BENEFIT OBLIGATION ADJUSTMENT 168,561. TOTAL TO FORM 990, PART XI, LINE 5: -939,331. OVERSIGHT OF AUDIT FORM 990, PART XI, LINE 2C VERNON MEMORIAL HEALTHCARE, INC. DOES NOT HAVE A SPECIFIC COMMITTEE WHICH ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. THE ENTIRE BOARD OF DIRECTORS IS RESPONSIBLE FOR SELECTION OF THE INDEPENDENT ACCOUNTANT. NO CHANGES HAVE BEEN MADE IN THE PAST YEAR REGARDING THIS OVERSIGHT FUNCTION OF THE GOVERNING BODY. VERNON MEMORIAL HEALTHCARE FOUNDATION INC 507 SOUTH MAIN STREET VIROQUA WI 54665 391515716 FUNDRAISING WI 501(C)3 509(A)(3) 11 C - III - FI 0 0 0 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0