2012-11-13T16:23:16-06:00 2011-12-31 390758449 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2011-01-01 390808498 THE RICHLAND HOSPITAL INC RICH 6086476321 333 EAST SECOND STREET RICHLAND CENTER WI 53581 KAREN TRAYNOR 6086476321 2012-11-13 1 HOLLY POKRANDT P00449155 7158323407 2012-11-13 2011 2016-02-24 21:20:13Z MICHAEL DELFS 333 EAST SECOND STREET RICHLAND CENTER WI 53581 39211761 0 X WWW.RICHLANDHOSPITAL.COM X 1937 WI THE RICHLAND HOSPITAL IS DEDICATED TO CARING, EDUCATING, AND HEALING - TO BE THE COMMUNITY'S "FIRST CHOICE FOR BETTER HEALTH." 10 9 349 169 149442 -466387 60625 594253 34234923 34415151 487453 411710 -328705 -316519 34454296 35104595 16563 13313 0 0 19353871 19835483 0 0 105747 13917671 14907029 33288105 34755825 1166191 348770 64341789 64146616 21461921 20980864 42879868 43165752 X THE RICHLAND HOSPITAL IS DEDICATED TO CARING, EDUCATING, AND HEALING - TO BE THE COMMUNITY'S "FIRST CHOICE FOR BETTER HEALTH." 0 0 29477172 13313 31981615 THE RICHLAND HOSPITAL, INC. (THE HOSPITAL) OPERATES A 25-BED CRITICAL ACCESS HOSPITAL AND A DAY-CARE CENTER IN RICHLAND CENTER, WI. OUR MISSION IS, "THE RICHLAND HOSPITAL IS DEDICATED TO CARING, EDUCATING, AND HEALING - TO BE THE COMMUNITY'S FIRST CHOICE FOR BETTER HEALTH."PATIENTS SERVED BY THE RICHLAND HOSPITAL IN 2011 INCLUDED 3,898 ADULTS AND PEDIATRICS INPATIENT DAYS, 193 SWING BED PATIENT DAYS, 269 NEWBORN PATIENT DAYS, 31,249 TOTAL OUTPATIENT VISITS, AND 5,620 EMERGENCY ROOM VISITS.AS A PART OF THE HOSPITAL'S MISSION AS A NOT-FOR-PROFIT HEALTHCARE ORGANIZATION IN THE COMMUNITIES SERVED, THE RICHLAND HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS COMMUNITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN ITS ESTABLISHED RATES. THE RICHLAND HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. IN THE CURRENT YEAR, CARE PROVIDED UNDER THE COMMUNITY CARE POLICY AGGREGATED $1,071,000 IN TOTAL CHARGES. THE ESTIMATED COST OF PROVIDING CARE TO PATIENTS UNDER THE COMMUNITY CARE POLICY WAS $616,000. IN ADDITION, THE RICHLAND HOSPITAL IS A PROVIDER UNDER THE WISCONSIN MEDICAL ASSISTANCE PROGRAM. UNDER THIS PROGRAM, THE HOSPITAL IS LEGALLY BOUND TO ACCEPT THE AMOUNT DETERMINED BY THE STATE OF WISCONSIN AS PAYMENT IN FULL FOR EACH PATIENT'S CHARGES. THE CHARGE REDUCTIONS POSTED BY THE HOSPITAL IN ACCEPTANCE OF LOWER PAYMENTS BY THE MEDICAL ASSISTANCE PROGRAM IN FISCAL YEAR 2011 AGGREGATED $4,963,968. (FOR ADDITIONAL INFORMATION ON THE HOSPITAL'S CHARITY CARE PROGRAM AND PRACTICES AND PARTICIPATION IN THE WISCONSIN MEDICAL ASSISTANCE PROGRAM, PLEASE REFER TO SCHEDULE H OF THE FORM 990.)IN 2011, THE RICHLAND HOSPITAL PARTICIPATED IN SEVERAL WELLNESS EVENTS, INCLUDING AREA HEALTH FAIRS. IN ADDITION, THE HOSPITAL SPONSORED A WOMEN'S AND MEN'S HEALTH FAIR AT THE RICHLAND HOSPITAL AND A WELLNESS EVENT IN SPRING GREEN, WI. THESE EVENTS WERE OPEN TO THE PUBLIC AND DREW MORE THAN 50 PEOPLE EACH. ITEMS DONATED INCLUDED: STAFF TIME, MATERIALS, GIVEAWAYS, AND EQUIPMENT. SCREENINGS WERE OFFERED FREE OF CHARGE AND INCLUDED: BLOOD PRESSURE, PULSE OXIMETRY, PEAK FLOW ANALYSIS, BALANCE ASSESSMENT, GLUCOSE SCREENINGS, AND MORE. EDUCATIONAL MATERIALS WERE PROVIDED FREE OF CHARGE AND COVERED A WIDE RANGE OF HEALTHCARE TOPICS INDLUDING: CANCER, DIABETES, HEART DISEASE, LUNG DISEASE, ARTHRITIS, JOINT AND MUSCLE DEGENERATION, MAMMOGRAPHY, SMOKING CESSATION, COLONOSCOPIES, ADVANCE DIRECTIVES, AND MORE. HEALTHCARE PROFESSIONALS PROVIDED INDIVIDUAL COUNSELING TO PARTICIPANTS REGARDING MANY HEALTHCARE ISSUES AND THE PRODUCTS AND SERVICES AVAILABLE LOCALLY AND REGIONALLY.CORONARY RISK ASSESSMENT SERVICES WERE MADE AVAILABLE IN RICHLAND CENTER AT NO COST. MORE THAN 300 PEOPLE TOOK ADVANTAGE OF THIS OFFER.THE BLOOD CENTER OF WISCONSIN HELD MULTIPLE DRIVES IN THE LOWER LEVEL OF THE RICHLAND HOSPITAL IN 2011 AT NO COST TO THEM. EMPLOYEES WHO COULD DONATE WHILE ON WORK TIME DID NOT HAVE TO PUNCH OUT TO DONATE.PROVIDING WELLNESS INFORMATION AND EXPERTISE IS SOMETHING THE HOSPITAL FEELS VERY STRONGLY ABOUT AND IS COMMITTED TO CONTINUE SUPPORTING. 1469861 2205811 THE RICHLAND HOSPITAL, INC. ALSO OPERATES TWO RURAL HEALTH CLINICS LOCATED IN SPRING GREEN AND MUSCODA, WI. DURING 2011 THESE TWO CLINICS PROVIDED A TOTAL OF 8,527 VISITS TO PATIENTS IN BOTH COMMUNITIES. THE CLINICS ARE DESIGNATED RURAL HEALTH CLINICS BY THE MEDICARE AND MEDICAID PROGRAMS AND AS SUCH BY DEFINITION ARE LOCATED IN DESIGNATED RURAL OR UNDERSERVED AREAS OF THE COUNTRY BY HEALTH CARE PRACTITIONERS. THESE CLINICS PROVIDE CARE TO A LARGE PORTION OF MEDICARE AND MEDICAID BENEFICIARIES WHO WITHOUT ACCESS TO CARE LOCALLY WOULD BE REQUIRED TO TRAVEL FARTHER DISTANCES FOR QUALITY HEALTHCARE. 30947033 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 54 0 1 349 1 1 1 0 0 0 0 0 0 0 0 0 X 10 9 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 WI X KAREN TRAYNOR 6086476321 333 EAST SECOND STREET RICHLAND CENTER WI 53581 V CHARLES GOCHENAUR 0.50 X X 0 0 0 DENNIS HAMILTON 0.50 X X 0 0 0 BRYAN MYERS MD 10.00 X X 12000 0 0 DOTTIE BEHLING 0.50 X X 0 0 0 DWAYNE HILTBRAND 0.50 X X 0 0 0 RICHARD W EDWARDS MD 0.50 X 0 0 0 DEB ZOREA 0.50 X 0 0 0 KEVIN WHITNEY MD 0.50 X 0 0 0 RICHARD MARSHALL 0.50 X 0 0 0 DEB LIEGEL 0.50 X 0 0 0 ROBERT NUGENT 0.50 X 0 0 0 MELISSA SPRECHER 0.50 X 0 0 0 STEVEN NOCKERTS 40.00 X 239645 0 20118 KAREN TRAYNOR 40.00 X 139340 0 10679 JEREL BERRES MD 36.00 X 282326 0 37633 E RACHEL SHANNON-GOODRICH CRNA 40.00 X 300046 0 36039 MARK KAMM CRNA 40.00 X 240345 0 35860 BRUCE MOTHS MD 37.00 X 245063 0 36472 MUHAMMAD S KHAN MD 46.00 X 310558 0 36592 1769323 0 213393 20 0 1 0 RICHLAND MEDICAL CENTER LTD 301 EAST SECOND STREET RICHLAND CENTER WI 53581 PHYSICIANS/CLINIC MGMT SERVICES 994316 SHARED IMAGING SERVICES PO BOX 44719 MADISON WI 53744 NUCLEAR MEDICINE 472659 BLOODCENTER OF WISCONSIN INC PO BOX 78961 MILWAUKEE WI 53278 BLOOD PROCESSING 295533 RURAL WI HOSPITAL COOPERATIVE 880 INDEPENDENCE LANE SAUK CITY WI 53583 SPEECH THERAPISTS / LEGAL 268380 MERITER LABORATORIES 36 SOUTH BROOKS ST MILWAUKEE WI 53288 LAB SERVICES 152683 7 563905 28236 2112 594253 PATIENT SERVICE REVENU 621990 33260409 33260409 CONTRACTED THERAPY 621990 265065 265065 MEDICAL RECORDS 621990 213770 141505 72265 MEALS 722320 147760 86318 61442 DAY CARE REVENUE 624410 94018 14675 79343 434129 434129 34415151 354455 354455 810972 1127491 -316519 -316519 1060 -317579 3023630 13300 2965062 14613 58568 -1313 57255 57255 35104595 34187426 149442 173474 13313 13313 421782 421782 14489204 12999045 1417587 72572 720832 646698 70524 3610 3176147 2849493 310746 15908 1027518 897620 124887 5011 119635 119635 112207 112207 3026684 2554875 464309 7500 168247 27726 140521 382315 238943 142226 1146 149043 149043 1636413 1602346 34067 45997 41079 4918 41871 35132 6739 2943327 2943327 99520 99520 SUPPLIES 4566813 4502584 64229 PROVISION FOR BAD DEBT 1578068 1578068 EQUIPMENT RENTAL & MAIN 641045 620940 20105 STATE HOSPITAL ASSESSME 287425 287425 -891581 -891581 34755825 30947033 3703045 105747 1503 1915 7964593 8376015 7833871 8120848 307996 268816 961730 1134625 259611 327248 55009459 22747488 33757488 32261971 5887930 6175717 3624569 3783460 3742498 3696001 64341789 64146616 3290980 3456972 17840000 17190000 330941 333892 21461921 20980864 X 42234909 42432991 584959 672761 60000 60000 42879868 43165752 64341789 64146616 X 348770 -62886 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 4122 4122 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: THE RICHLAND HOSPITAL, INC. PAYS ANNUAL ASSOCIATION MEMBERSHIP DUES TO THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THESE DUES ARE PRIMARILY FOR ACCESS TO EDUCATIONAL MATERIALS AND STAFF TRAINING AND DEVELOPMENT. WHA HAD NOTIFIED THE RICHLAND HOSPITAL THAT APPROXIMATELY $1,538 OF THE ANNUAL DUES WERE USED IN CONJUNCTION WITH LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE OVERALL HEALTHCARE ENVIRONMENT. THE RICHLAND HOSPITAL IS ALSO A MEMBER OF THE RURAL WISCONSIN HEALTH COOPERATIVE (RWHC). EACH YEAR, THE RICHLAND HOSPITAL PAYS MEMBERSHIP FEES TO RWHC. RWHC PROVIDES SUPPORT SERVICES FOR A NUMBER OF ITS MEMBER HOSPITALS THROUGHOUT THE STATE OF WISCONSIN. SOME OF THE MANY SERVICES PROVIDED TO MEMBER HOSPITALS INCLUDE PROVIDING ASSISTANCE TO ORGANIZATIONS IN SECURING GRANT FUNDING FOR NEW OR EXISTING HEALTHCARE PROGRAMS, LEGAL SERVICES, REIMBURSEMENT REVIEW SERVICES, ACCOUNTING ASSISTANCE, CONTRACTING FOR THERAPIST COVERAGE, AND ADMINISTRATIVE CONSULTING SERVICES. AS A PART OF THESE SERVICES, RWHC ALSO DOES PROVIDE ANALYSIS OF CURRENT HEALTHCARE ISSUES IN AN EFFORT TO PROMOTE AND BETTER HEALTHCARE FOR HOSPITALS IN RURAL COMMUNITIES THROUGHOUT WISCONSIN. ONE OF THESE EFFORTS ALSO INCLUDES SOME LOBBYING ON BEHALF OF THE MEMBER ORGANIZATIONS. IT WAS DETERMINED THAT APPROXIMATELY $2,584 OF THE FEES PAID BY THE RICHLAND HOSPITAL IN 2011 RELATED TO LOBBYING ACTIVITIES WITH THE GOAL OF IMPROVING THE HEALTHCARE ENVIRONMENT IN THE STATE OF WISCONSIN. 69549 122 69671 69400 149 69549 69240 160 69400 68099 1141 69240 0.86120 0.13880 0 0 941726 941726 40012480 14019139 25993341 695605 175381 520224 12271830 8350245 3921585 1087818 202723 885095 32261971 UNDER BOND INDENTURE AGREEMENT 2609105 F FUNDED DEPRECIATION 836554 F UNEMPLOYMENT RESERVE 148520 F RESTRICTED INVESTMENTS 87240 F LONG TERM CD INVESTMENTS 102041 F 3783460 BOND INSURANCE PREMIUM 503756 BOND ISSUANCE COST 105561 INTEREST IN NET ASSETS OF FOUNDATION 1778460 DEFERRED COMPENSATION PLAN ASSETS 333892 MEDICAL CLAIMS RECEIVABLE 134675 AMOUNTS RECEIVABLE FROM THIRD-PARTY REIMBURSEMENT PROGRAMS 599500 UNAMORTIZED BOND DISCOUNT AND PREMIUM 240157 3696001 DEFERRED COMPENSATION PLAN LIABILITY 333892 333892 35104595 34755825 348770 -33172 -29714 -62886 285884 35668181 1127491 1127491 34540690 563905 563905 35104595 35870003 1127491 1127491 34742512 13313 13313 34755825 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ENDOWMENT FUNDS MAINTAINED BY THE RICHLAND HOSPITAL, INC. HAVE BEEN RESTRICTED BY DONORS TO BE MAINTAINED IN PERPETUITY, THE INCOME OF WHICH IS EXPENDABLE TO SUPPORT SCHOLARSHIP PROGRAMS OF THE HOSPITAL. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL IS A TAX-EXEMPT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE "CODE") AND IS EXEMPT FROM FEDERAL TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS ALSO EXEMPT FROM STATE INCOME TAXES ON RELATED INCOME PURSUANT TO SIMILAR STATE OF WISCONSIN TAX LAWS. IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THE HOSPITAL 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 THE TAX POSITION IS NOT RECOGNIZED IN THE FINANCIAL STATEMENTS. THE HOSPITAL IS ALSO ENGAGED, TO A LIMITED EXTENT, IN ACTIVITIES THAT THE INTERNAL REVENUE SERVICE CONSIDERS UNRELATED TO THE HOSPITAL'S EXEMPT PURPOSE AND, THEREFORE, TAXABLE. THESE ACTIVITIES, HOWEVER, ANNUALLY RESULT IN NET OPERATING LOSSES FOR INCOME TAX PURPOSES. THE HOSPITAL 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 HOSPITAL'S ASSETS AND LIABILITIES. THE HOSPITAL'S POLICY IS TO RECOGNIZE INTEREST AND ANY PENALTIES RELATED TO INCOME TAX MATTERS IN INCOME TAX EXPENSE WHEN INCURRED. AS OF AND FOR THE YEARS ENDED DECEMBER 31, 2011 AND 2010, THERE WAS NO INCOME TAX EXPENSE, TAX PENALTIES, OR INTEREST RELATED TO TAX PENALTIES RECORDED BY THE HOSPITAL IN THE FINANCIAL STATEMENTS. THE HOSPITAL RECORDED NO ASSETS OR LIABILITIES FOR UNCERTAIN TAX POSITIONS IN 2011 AND 2010. FEDERAL TAX RETURNS FOR TAX YEARS 2008 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. PART XI, LINE 8 - OTHER ADJUSTMENTS: NET CHANGE IN UNRESTRICTED NET ASSETS OF FOUNDATION: 81,929. NET CHANGE IN TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION: 438,949. DISTRIBUTIONS FROM SCHOLARSHIP FUNDS INCLUDED IN CHANGE IN NET ASSETS: 13,313. CONTRIBUTIONS FROM RELATED ORGANIZATIONS: -563,905. TOTAL TO SCHEDULE D, PART XI, LINE 8: -29,714. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH EXPENSES ON FINANCIAL STATEMENTS 1,127,491. PART XII, LINE 4B - OTHER ADJUSTMENTS: CONTRIBUTIONS FROM RELATED ORGANIZATIONS 563,905. PART XIII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES INCLUDED WITH EXPENSES ON FINANCIAL STATEMENTS 1,127,491. PART XIII, LINE 4B - OTHER ADJUSTMENTS: DISTRIBUTIONS FROM SCHOLARSHIP FUNDS 13,313. 1 1 1 X 1 X 1 1 1 0 1 1 616025 616025 0.01860 3779181 1539692 2239489 0.06750 38952 33846 5106 0.00020 4434158 1573538 2860620 0.08630 126805 28412 98393 0.00300 2136981 1903278 233703 0.00700 90557 90557 0.00270 2354343 1931690 422653 0.01270 6788501 3505228 3283273 0.09900 2774 2774 0.00010 1100 1100 0.00000 30336 30336 0.00090 34210 34210 0.00100 0 908067 454033 13308476 13191046 117430 X 0 1 1 THE RICHLAND HOSPITAL INC

333 EAST SECOND STREET RICHLAND CENTER WI 53581

X X X X THE RICHLAND HOSPITAL INC 1 1 1 150.000000000000 1 200.000000000000 1 X X X X X 1 1 X X X X 1 X 1 X X X X X 1 X 0 0 2 MUSCODA HEALTH CENTER

125 WEST NEBRASKA STREET MUSCODA WI 53573

RURAL HEALTH CLINIC SPRING GREEN MEDICAL CENTER

150 EAST JEFFERSON STREET SPRING GREEN WI 53588

RURAL HEALTH CLINIC PART I, LINE 6A: THE RICHLAND HOSPITAL, INC. PREPARES A COMMUNITY BENEFIT REPORT ANNUALLY AND FILES IT WITH THE WISCONSIN HOSPITAL ASSOCIATION (WHA). THE REPORT IS AVAILABLE TO THE GENERAL PUBLIC ON WHA'S DATABASE AND WEBSITE. PART I, LINE 7: THE COSTING METHODOLOGY 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 SUGGESTED COSTING METHODS FOR THE FORM 990. PART I, LINE 7G: SUBSIDIZED HEALTH SERVICES AT THE RICHLAND HOSPITAL, INC. INCLUDES THE OPERATION OF THE HOSPITAL EMERGENCY ROOM DEPARTMENT AND THE INTENSIVE CARE INPATIENT UNIT. THESE SERVICES ARE UNAVAILABLE TO MEMBERS OF THE COMMUNITY OTHER THAN THROUGH THE RICHLAND HOSPITAL AND ARE PRIMARILY UTILIZED FOR EMERGENCY SERVICES. THE EMERGENCY ROOM DEPARTMENT OPERATES 24 HOURS PER DAY, SEVEN DAYS PER WEEK AND IS STAFFED BY PRIMARILY BOARD CERTIFIED EMERGENCY ROOM PHYSICIANS. THE HOSPITAL ALSO WORKS IN CONJUNCTION WITH A LOCAL CLINIC ORGANIZATION TO PROVIDE A THIRD YEAR RESIDENT PHYSICIAN AN OPPORTUNITY TO PROVIDE SERVICES TO PATIENTS IN THE EMERGENCY MEDICAL SETTING AS PART OF THEIR PHYSICIAN TRAINING EXPERIENCE. AS PART OF THE PATIENT SERVICES PROVIDED TO THE COMMUNITY, THE HOSPITAL HAS DESIGNATED A PORTION OF ITS INPATIENT UNIT AS A CERTIFIED INTENSIVE CARE UNIT KNOWN AS THE "SPECIAL CARE UNIT." THIS UNIT REQUIRES A HIGHER ACUITY OF NURSING AND HAS DEDICATED STAFF TO PROVIDE THIS CARE TO PATIENTS. A SIGNIFICANT PORTION OF THE ADMISSIONS TO THE UNIT COME FROM EMERGENCY ADMISSIONS TO THE HOSPITAL SO IT IS CONSIDERED A SUBSIDIZED HEALTH SERVICE PROVIDED TO THE COMMUNITY BY THE HOSPITAL. IT IS THE GOAL OF THE RICHLAND HOSPITAL TO PROVIDE THESE SERVICES TO THE COMMUNITY REGARDLESS OF THE PATIENT'S ABILITY TO PAY. 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 $ 1578068. PART II: THE RICHLAND HOSPITAL, INC. ENGAGES IN A VARIETY OF COMMUNITY BUILDING ACTIVITIES THAT WOULD OTHERWISE NOT BE MET OR PROVIDED WITHOUT THE EFFORTS AND SPECIALIZED KNOWLEDGE OF THE LOCAL COMMUNITY HOSPITAL TO THE RESIDENTS OF RICHLAND CENTER, WISCONSIN AND THE SURROUNDING AREAS. SOME OF THE COMMUNITY BUILDING ACTIVITIES THAT THE HOSPITAL PARTICIPATES IN ARE LOCAL HEALTH AND WELLNESS FAIRS, SUPPORT GROUPS, PROVIDING EDUCATIONAL MATERIALS TO COMMUNITY MEMBERS, SAFE SITTER CLASSES, AND LOCAL BLOOD PRESSURE SCREENINGS TO NAME A FEW OF THESE ACTIVITIES. THESE ACTIVITIES WERE DETERMINED BY MEMBERS OF THE COMMUNITY OR ASKED BY COMMUNITY REPRESENTATIVES OF THE RICHLAND HOSPITAL TO PROVIDE THESE SERVICES SINCE THE HOSPITAL HAS THE EXPERTISE IN THESE AREAS. THE HOSPITAL ALSO PARTICIPATES IN HEALTH EDUCATION AWARENESS AND CAREER BUILDING ACTIVITIES SUCH AS CLINICAL TRAINING EXPERIENCE, SPEAKERS AT LOCAL SCHOOLS, AND CAREER FAIRS. THE HOSPITAL RECOGNIZES THAT IT IS IMPORTANT TO EDUCATE LOCAL COMMUNITY MEMBERS ON THESE CAREERS AS A CAREER BUILDING INITIATIVE SO THAT LOCAL PRIMARY CARE AND ACCESS TO CARE WILL BE CONTINUED IN THE FUTURE WITH WELL-TRAINED AND EDUCATED COMMUNITY MEMBERS IN HEALTH CARE RELATED FIELDS. PART III, LINE 4: MANAGEMENT PROVIDES FOR PROBABLE UNCOLLECTIBLE AMOUNTS, PRIMARILY UNINSURED PATIENTS AND AMOUNTS PATIENTS ARE PERSONALLY REPONSIBLE 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 THE ORGANIZATION HAS USED REASONABLE COLLECTION EFFORTS ARE WRITTEN OFF THROUGH A CHARGE TO THE VALUATION ALLOWANCE AND A CREDIT TO ACCOUNTS RECEIVABLE. MANY TIMES PATIENTS ARE UNABLE TO COMPLETE THE REQUIRED CHARITY CARE APPLICATION AND ARE TRANSFERRED TO COLLECTION SERVICES EVEN THOUGH THE ORGANIZATION PROVIDES THIS INFORMATION TO ALL PATIENTS AND ASSISTANCE WITH THE APPLICATIONS. DUE TO NO RESPONSES FROM SOME PATIENTS A SIGNIFICANT AMOUNT OF BAD DEBTS COULD BE CONSIDERED AS CHARITY CARE.THE COSTING METHODOLOGY 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 THE TOTAL CHARGES THAT ARE WRITTEN OFF DURING THE FISCAL YEAR TO ESTIMATE THE COST OF THE CARE OF PATIENTS THAT HAVE ACCOUNTS THAT ARE DEEMED TO BE BAD DEBTS TO THE HOSPITAL. PART III, LINE 8: THE RICHLAND HOSPITAL, INC. IS DESIGNATED AS A CRITICAL ACCESS HOSPITAL AND AS SUCH, A PORTION OF ITS REVENUES ARE PAID UNDER A COST REIMBURSEMENT SYSTEM. THE TOTAL MEDICARE REVENUE SHOWN BASED ON THE IRS 990 INSTRUCTIONS INCLUDES ONLY A PORTION OF THE TOTAL MEDICARE REVENUE OF THE HOSPITAL. THE AMOUNTS LISTED FOR MEDICARE DO NOT INCLUDE PHYSICIAN SERVICES FOR THE COVERAGE OF THE EMERGENCY DEPARTMENT, RADIOLOGIST SERVICES, AND SURGICAL ANESTHESIA SERVICES AT THE RICHLAND HOSPITAL. PHYSICIAN AND MID-LEVEL PRACTITIONER COVERAGE IS REIMBURSED PRIMARILY ON FEE SCHEDULE REIMBURSEMENT AT RATES THAT ARE OFTEN BELOW THE COSTS OF CARING FOR PATIENTS. EMERGENCY SERVICES PROVIDED TO MEDICARE PATIENTS ARE VITAL TO THE WELL-BEING OF THE COMMUNITY, AND AS SUCH THESE COSTS AND SHORTFALLS SHOULD ALSO BE CONSIDERED AS AN ADDITIONAL BENEFIT THAT THE RICHLAND HOSPITAL PROVIDES TO THE COMMUNITY AND SURROUNDING AREA OF RICHLAND COUNTY, WISCONSIN. THE COSTING METHOD USED ABOVE FOR IRS 990 COMPLIANCE REPORTING IS ALSO BASED ON AN OVERALL AVERAGE COST TO CHARGE RATIO AND DOES NOT CONSIDER MEDICARE NON-ALLOWABLE EXPENSES AS IT IS BASED ON TOTAL HOSPITAL PATIENT SERVICE REVENUES (IGNORING CONTRACTUAL ADJUSTMENTS ON FEE SCHEDULE REIMBURSED ITEMS AND NON-ALLOWABLE MEDICARE EXPENSES AS NOTED ABOVE) DIVIDED BY TOTAL OPERATING EXPENSES LESS THE PROVISION FOR BAD DEBT EXPENSE. THIS RATIO IS THEN MULTIPLIED BY THE TOTAL MEDICARE SERVICES WHICH ARE REIMBURSED ON A COST METHODOLOGY EXCLUDING THE FEE SCHEDULE ITEMS LIKE PHYSICIAN SERVICES AND THE HOSPITAL WOULD SHOW A LARGE LOSS ON THESE SERVICES.WHETHER THERE IS A SHORTFALL OR SURPLUS ON SERVICES PROVIDED TO MEDICARE BENEFICIARIES, THESE PEOPLE, WHO ARE TYPICALLY ELDERLY MEMBERS OF THE COMMUNITY, ARE AN UNDERSERVED POPULATION WHO EXPERIENCE ISSUES WITH ACCESS TO HEALTHCARE SERVICES. WITHOUT TAX-EXEMPT HOSPITALS PROVIDING MEDICARE PATIENT SERVICES, THE CENTERS FOR MEDICARE AND MEDICAID (CMS) WOULD BEAR THE BURDEN OF DIRECTLY PROVIDING SERVICES TO THE ELDERLY AND DISABLED MEMBERS OF THE COMMUNITY. THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 13G: THE HOSPITAL ALSO PROVIDED FINANCIAL ASSISTANCE INFORMATION IN BROCHURES LOCATED IN THE CASHIERS OFFICE. BROCHURES CAN ALSO BE FOUND AT BOTH OF THE RURAL HEALTH CLINICS. FURTHER INFORMATION REGARDING THE FINANCIAL ASSISTANCE POLICY IS ALSO AVAILABLE THROUGH PHONE CONVERSATIONS WITH FINANCIAL COUNSELORS AT THE HOSPITAL. THE RICHLAND HOSPITAL, INC. PART V, SECTION B, LINE 19D: THE HOSPITAL FOLLOWS ITS NORMAL PROCEDURES FOR COLLECTION OF THESE ACCOUNTS, INCLUDING DISCOUNTS BASED ON INCOME/ASSET LEVELS, MEDICAL INDIGENCE, INSURANCE STATUS, AND PROMPT PAYMENT. PATIENTS WHO ARE ELIGIBLE UNDER THE FINANCIAL ASSISTANCE POLICY THAT DO NOT COMPLETE THE REQUIRED APPLICATION MAY BE CHARGED THE RATE THAT IS CHARGED TO ALL UNINSURED PATIENTS. AT A MINIMUM, ALL UNINSURED PATIENTS OF THE RICHLAND HOSPITAL, INC. RECEIVE A 10 PERCENT DISCOUNT ON ALL HOSPITAL SERVICES. AN ADDITIONAL 5 PERCENT PROMPT PAY DISCOUNT IS ALSO AVAILABLE TO UNINSURED PATIENTS, AS WELL AS A SLIDING SCALE DISCOUNT PROGRAM BASED ON INCOME AND ASSET LEVELS OF PATIENTS AND COMPLETION AND REVIEW OF AN APPLICATION UNDER THE HOSPITAL'S COMMUNITY CARE POLICY. PART VI, LINE 2: THE RICHLAND HOSPITAL, INC. ASSESSES THE HEALTH CARE NEEDS OF THE COMMUNITY IT SERVES BY LOOKING AT LOCAL AND SURROUNDING COMMUNITY DEMOGRAPHICS TO DETERMINE THE SERVICES THAT ARE MOST NECESSARY IN ORDER TO FULFILL ITS MISSION. THE FACILITY ALSO REVIEWS HOSPITAL STATISTICS OF PATIENT VISITS TO DETERMINE WHAT TYPES OF SERVICES OFFERED BY THE FACILITY ARE BEING UTILIZED. A FEW EXAMPLES OF PROJECTS THAT THE HOSPITAL HAS COMPLETED RECENTLY OR IS CURRENTLY WORKING ON INCLUDE A LARGE RENNOVATION PROJECT AND ELECTRONIC HEALTH RECORDS. STARTING IN 2009 AND CONTINUING INTO 2011, THE HOSPITAL BEGAN IMPLEMENTATION AND INSTALLATION OF AN ELECTRONIC HEALTH RECORD SYSTEM. ONE OF THE MAIN GOALS OF THIS SYSTEM IS TO PROVIDE ACCESS TO PATIENT MEDICAL HISTORIES IN A MORE UP TO DATE MANNER, WHICH WILL PROVIDE FOR A MORE EFFICIENT AND EFFECTIVE PATIENT EXPERIENCE BOTH WHEN PATIENTS ARE SEEN AT THE RICHLAND HOSPITAL AND ALSO WHEN THEIR INFORMATION IS NEEDED FOR TREATMENT AT OTHER HEALTHCARE FACILITIES. BEGINNING IN 2011, THE HOSPITAL ALSO STARTED PRELIMINARY DESIGN AND CONSTRUCTION OF A REPLACEMENT CLINIC FACILITY IN MUSCODA, WISCONSIN TO BETTER SERVE THE NEEDS OF PATIENTS IN THE COMMUNITY OF MUSCODA. PART VI, LINE 3: CONSISTENT WITH THE MISSION OF THE RICHLAND HOSPITAL, INC., HEALTH-RELATED SERVICES ARE PROVIDED TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY, INCLUDING PROVIDING SERVICES TO THOSE PERSONS WHO CANNOT AFFORD HEALTH INSURANCE BECAUSE OF INADEQUATE RESOURCES OR THOSE WHO ARE UNDERINSURED. WHEN A PATIENT'S INCOME IS LESS THAN 150 TO 200% OF THE FEDERAL POVERTY LEVEL, THEY ARE PROVIDED CARE WITHOUT CHARGE OR AT A REDUCED RATE. THIS IS DETERMINED UPON APPROVAL BY THE BUSINESS OFFICE MANAGER AND THE CHIEF FINANCIAL OFFICER AT THE FACILITY AFTER THE PATIENT HAS MET WITH A PATIENT FINANCIAL COUNSELOR AT THE FACILITY AND HAS COMPLETED A FINANCIAL APPLICATION, AND SUPPLIED THE NECESSARY DOCUMENTATION TO SUPPORT A FINANCIAL NEED FOR CARE UNDER THE HOSPITAL'S COMMUNITY CARE POLICY. FREE RADIOLOGY, LABORATORY, AND OTHER DIAGNOSTIC ANCILLARY SERVICES ARE ALSO PROVIDED TO PATIENTS WHO ARE REFERRED TO THE HOSPITAL BY THE RICHLAND CENTER FREE CLINIC.INFORMATION ON THE HOSPITAL'S CHARITY CARE POLICIES IS POSTED AT THE HOSPITAL PATIENT REGISTRATION DESK AS WELL AS ON THE HOSPITAL WEBSITE. REGISTRATION CLERKS AT THE HOSPITAL ARE TRAINED TO INQUIRE WITH SELF PAY PATIENTS UPON REGISTRATION IF THEY WOULD LIKE FURTHER INFORMATION ON THESE POLICIES OR WOULD LIKE TO MEET WITH A MEMBER OF THE BUSINESS OFFICE STAFF. DURING THE COLLECTION PROCESS, THE RICHLAND HOSPITAL MAKES AN EFFORT TO ALSO PROVIDE INFORMATION AND SEND CHARITY CARE APPLICATION INFORMATION TO THE MAJORITY OF PRIVATE PAY OR SELF-PAY PATIENTS THAT DO NOT RESPOND WITH PAYMENT ON THE SECOND OR THIRD PATIENT STATEMENT THAT IS SENT ITEMIZING THE BALANCE OF THEIR HOSPITAL BILL. SOCIAL SERVICES AND BUSINESS OFFICE STAFF AT THE HOSPITAL ARE ALSO AVAILABLE TO PROVIDE INFORMATION TO PATIENTS ON OTHER GOVERNMENT PROGRAMS SUCH AS THE MEDICAL ASSISTANCE PROGRAM OR TO REFER PATIENTS TO PERSONNEL AT RICHLAND COUNTY OR OTHER STATE OF WISCONSIN OR COUNTY AGENCIES THAT MAY PROVIDE ACCESS TO CARE FOR ELIGIBLE PATIENTS OR PROVIDE OTHER INFORMATION TO PATIENTS. PART VI, LINE 4: THE RICHLAND HOSPITAL, INC. IS LOCATED IN RICHLAND CENTER, WISCONSIN, WHICH IS A COMMUNITY OF ABOUT 5,000 PEOPLE. RICHLAND CENTER IS LOCATED 50 MINUTES FROM MADISON, WISCONSIN. THE FACILITY OPERATES A 25-BED, ACUTE CARE CRITICAL ACCESS HOSPITAL AND TWO RURAL HEALTH CLINICS LOCATED IN NEIGHBORING COMMUNITIES. THE RICHLAND HOSPITAL OFFERS A WIDE VARIETY OF SERVICES IN ORDER TO FULFILL MANY OF THE NEEDS OF THE INDIVIDUALS IN THE LOCAL COMMUNITY. AMONG SERVICES PROVIDED ARE: DIAGNOSTIC CARE, 24-HOUR EMERGENCY ROOM, OBSTETRICS, REHABILITATION, SURGICAL CARE, AND DIABETES SELF-CARE PROGRAMS, ALONG WITH OTHER SPECIALITY SERVICES, WHICH INCLUDES, AUDIOLOGY, CARDIOLOGY, ORTHOPEDICS, CHEMOTHERAPY, CLINICAL SERVICES, AMONG OTHERS. CARE IS OFFERED TO PATIENTS REGARDLESS OF PAY SOURCE AND REGARDLESS OF A PATIENT'S ABILITY TO PAY. DURING 2011, MEDICARE AND MEDICARE ADVANTAGE PLAN BENEFICIARIES ACCOUNTED FOR APPROXIMATELY 50 PERCENT OF ALL GROSS PATIENT SERVICE REVENUE AT THE RICHLAND HOSPITAL AND MEDICAID BENEFICIARIES ACCOUNTED FOR APPROXIMATELY 14 PERCENT OF ALL GROSS PATIENT SERVICE REVENUE. MEDICARE AND MEDICAID BENEFICIARIES MAKE UP THE LARGEST PORTION OF PATIENTS THAT ARE SERVED BY THE RICHLAND HOSPITAL OVER THE PREVIOUS FEW YEARS. PART VI, LINE 5: THE RICHLAND HOSPITAL, INC. IS ACCREDITED THROUGH THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS. THE JOINT COMMISSION IS AN ORGANIZATION THAT EVALUATES HOSPITAL PERFORMANCE STANDARDS, FOCUSING ON THE QUALITY OF HEALTH CARE. ACCREDITATION THROUGH THE JOINT COMMISSION IS RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY, AS IT REQUIRES RIGOROUS PERFORMANCE STANDARDS. TO EARN AND MAINTAIN ACCREDITATION, THE HOSPITAL IS EVALUATED THROUGH AN UNANNOUNCED SURVEY PROCESS COVERING NEARLY 600 STANDARDS RELATED TO QUALITY PATIENT CARE, SAFETY, INFECTION CONTROL, AND ONGOING PERFORMANCE-IMPROVEMENT ACTIVITIES, AMONG OTHERS. ALL HOSPITALS SURVEYED BY THE JOINT COMMISSION ARE EVALUATED AGAINST THE SAME CRITERIA, REGARDLESS OF SIZE OR LOCATION.THE ACTIVITIES OF THE RICHLAND HOSPITAL ARE SUPPORTED LOCALLY BY A VOLUNTEER BOARD OF DIRECTORS WHICH OVERSEE THE OPERATIONS OF THE HOSPITAL. THE BOARD OF DIRECTORS IS MADE UP OF COMMUNITY MEMBERS WHICH RESIDE IN RICHLAND CENTER, WI AND THE SURROUNDING AREA WHICH IS THE HOSPITAL'S PRIMARY PATIENT SERVICE AREA. THE HOSPITAL ALSO EXTENDS MEDICAL STAFF PRIVILEDGES TO A MAJORITY OF ALL QUALIFIED PHYSICIANS IN THE COMMUNITY AND SURROUNDING AREAS WHO WISH TO BETTER SERVE THEIR PATIENTS BY PROVIDING CARE AT THE RICHLAND HOSPITAL.ANY SURPLUSES IN OPERATIONS THAT ARE ACHIEVED BY THE ORGANIZATION OPERATING IN AN EFFECTIVE MANNER AND CONTROLLING THE COST OF HEALTHCARE ARE PRIMARILY RESERVED FOR FUTURE BUILDING AND CAPITAL PURCHASE NEEDS. THE RICHLAND HOSPITAL RECOGNIZES THAT IT IS IMPORTANT TO SAVE THESE RESERVES DURING YEARS OF SURPLUS SO THAT IN TIMES OF ECONOMIC DOWNTURN, IF A LARGE CAPITAL ADDITION IS NEEDED, THE ORGANIZATION WILL NOT HAVE TO PASS HIGHER COSTS ON TO MEMBERS OF THE COMMUNITY. THE HOSPITAL FURTHER ACHIEVES ITS GOAL OF PROVIDING TRUE COMMUNITY SUPPORT BY PROVIDING CHARITY CARE AS DESCRIBED THROUGHOUT SCHEDULE H AND PROVIDING SERVICES TO MEMBERS OF OTHER PROGRAMS WHICH OFTEN REIMBURSE THE HOSPITAL BELOW THE COST OF PROVIDING THIS CARE SUCH AS CHAMPUS, TRICARE, AND THE WISCONSIN HEALTH INSURANCE RISK SHARING PROGRAM OR "HIRSP" (THE HIRSP PROGRAM REIMBURSES THE HOSPITAL AT RATES SIMILAR TO THE MEDICAID PROGRAM AND IS FOR PATIENTS THAT HAVE PRE-EXISTING ILLNESSES WHICH MAKE IT DIFFICULT TO OBTAIN INSURANCE FROM COMMERCIAL INSURANCE CARRIERS IN THE MARKETPLACE). REPORTS FILED WITH STATES PART VI, LINE 7 WI 1 SCHOLARSHIPS FOR HEALTHCARE EDUCATION 26 13313 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THE RICHLAND HOSPITAL, INC. FOLLOWS A STANDARD PROCEDURE ON ISSUANCE OF SCHOLARSHIP FUNDS WHICH IS DETERMINATED BY THE BOARD OF DIRECTORS AND MANAGEMENT OF THE RICHLAND HOSPITAL, THE RICHLAND HOSPITAL FOUNDATION, AND THE PARTNERS OF THE RICHLAND HOSPITAL. THESE THREE SEPARATE ORGANIZATIONS HAVE ESTABLISHED CRITERIA FOR REVIEW OF APPLICATIONS FOR PROSPECTIVE SCHOLARSHIP RECIPIENTS TO ENSURE THAT SCHOLARSHIPS ARE BEING GRANTED FOR HEALTH EDUCATION RELATED PURPOSES AND TO A QUALIFIED STUDENT STUDYING AT AN ACCREDITED TECHNICAL COLLEGE, COLLEGE, OR UNIVERSITY. (A LARGE PORTION OF THE FUNDING FOR SCHOLARSHIPS IS ALSO GOVERNED BY DONOR AGREEMENTS AS NOTED IN SCHEDULE D TO THE FORM 990 RELATED TO ENDOWMENT FUNDS.) X 0 0 X X X X 0 1 0 0 0 0 0 0 0 STEVEN NOCKERTS 222145 0 0 0 17500 0 13376 0 6742 0 259763 0 0 0 KAREN TRAYNOR 139063 0 0 0 277 0 6773 0 3906 0 150019 0 0 0 JEREL BERRES MD 271534 0 0 0 10792 0 14685 0 22948 0 319959 0 0 0 E RACHEL SHANNON-GOODRICH CRNA 296849 0 0 0 3197 0 14700 0 21339 0 336085 0 0 0 MARK KAMM CRNA 238618 0 0 0 1727 0 14479 0 21381 0 276205 0 0 0 BRUCE MOTHS MD 244224 0 0 0 839 0 14700 0 21772 0 281535 0 0 0 MUHAMMAD S KHAN MD 309971 0 0 0 587 0 14761 0 21831 0 347150 0 0 0 PART I, LINE 1A HEALTH CLUB DUE GROSS UPS, WHEN APPLICABLE, WERE ADDED TO THE INDIVIDUAL'S COMPENSATION AT FAIR MARKET VALUE. PART I, LINE 4B PART I, LINE 4B: STEVEN NOCKERTS, 457 PLAN CONTRIBUTION BY THE HOSPITAL: $13,163 JEREL BERRES, 457 PLAN CONTRIBUTION BY THE HOSPITAL: $8,125 FORM 990, PART VI, SECTION B, LINE 11 A COPY OF FORM 990 WAS EMAILED OR MAILED TO ALL MEMBERS OF THE HOSPITAL'S BOARD OF DIRECTORS BEFORE IT WAS FILED. ALL BOARD MEMBERS WERE GIVEN THE OPPORTUNITY TO RESPOND WITH COMMENTS PRIOR TO THE FINAL SUBMISSION OF THE FORM 990 TO THE INTERNAL REVENUE SERVICE. FORM 990, PART VI, SECTION B, LINE 12C THE RICHLAND HOSPITAL, INC. REQUIRES ALL OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, HIGHEST-COMPENSATED EMPLOYEES, AND HIGHEST-COMPENSATED PROFESSIONAL OR INDEPENDENT CONTRACTORS TO COMPLETE ITS ANNUAL DISCLOSURE STATEMENT. THESE QUESTIONNAIRES ARE THEN REVIEWED BY THE BOARD OF DIRECTORS, NOTING ANY RELATIONSHIPS THAT COULD POTENTIALLY CREATE A CONFLICT OF INTEREST. ANY INDIVIDUALS WITH NOTED CONFLICTS ARE ASKED TO ABSTAIN FROM VOTING OR ACTING ON THOSE MATTERS. FORM 990, PART VI, SECTION B, LINE 15A THE BOARD OF DIRECTORS HAS AN ESTABLISHED PROCESS TO ANNUALLY REVIEW THE COMPENSATION FOR THE CHIEF EXECUTIVE OFFICER AND TO DEFINE APPROPRIATE MARKET AND PERFORMANCE BASED ADJUSTMENTS. COMPARATIVE DATA IS OBTAINED FROM EITHER THE WISCONSIN HOSPITAL ASSOCIATION EXECUTIVE COMPENSATION SURVEY OR OTHER REPUTABLE THIRD-PARTY HEALTHCARE DATA SOURCE TO USE IN THE ESTABLISHMENT OF A MARKET FOR THIS KEY POSITION. THE PERSONNEL COMMITTEE OF THE BOARD OF DIRECTORS FULFILLS THIS ROLE. THE BOARD OF DIRECTORS HAS DELEGATED THE AUTHORITY AND RESPONSIBILITY FOR THE ONGOING MAINTENANCE OF THE OVERALL ORGANIZATIONAL COMPENSATION MODEL TO THE CHIEF EXECUTIVE OFFICER. COMPARIATIVE MARKET DATA IS OBTAINED VIA THE RURAL WISCONSIN HEALTH COOPERATIVE AND THE WISCONSIN SOCIETY OF HOSPITAL HUMAN RESOURCE ADMINISTRATORS VIA INDEPENDENT SALARY SURVEYS THAT PROVIDE BENCHMARK INFORMATION FOR HEALTHCARE JOB CLASSES. THIS DATA IS USED TO ESTABLISH SALARY RANGES FOR ALL JOB CLASSES WITHIN THE ORGANIZATION. THE BOARD OF DIRECTORS ANNUALLY AUTHORIZES THE OVERALL INCREASE TO THE SALARY BUDGET FOR THE ORGANIZATION WITH THE CEO MAINTAINING DELEGATED AUTHORITY FOR IMPLEMENTATION WITHIN THE ORGANIZATIONAL COMPENSATION MODEL. DURING THE REVIEW PROCESS, DECISIONS AFFECTING COMPENSATION AND CONTRACTS ARE ONLY REVIEWED AND APPROVED BY INDIVIDUALS WHO DO NOT HAVE NOTED CONFLICTS. FORM 990, PART VI, SECTION C, LINE 19 THE RICHLAND HOSPITAL, INC. MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT ITS HOSPITAL BUSINESS LOCATION DURING NORMAL BUSINESS HOURS. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -33,172. NET CHANGE IN UNRESTRICTED NET ASSETS OF FOUNDATION: 81,929. NET CHANGE IN TEMPORARILY RESTRICTED NET ASSETS OF FOUNDATION: 438,949. DISTRIBUTIONS FROM SCHOLARSHIP FUNDS INCLUDED IN CHANGE IN NET ASSETS: 13,313. CONTRIBUTIONS FROM RELATED ORGANIZATIONS: -563,905. TOTAL TO FORM 990, PART XI, LINE 5: -62,886. SELECTION OF INDEPENDENT ACCOUNTANT FORM 990, PART XI, LINE 2C THE RICHLAND HOSPITAL'S FINANCE COMMITTEE WHICH IS A SUB-COMMITTEE TO THE HOSPITAL'S BOARD OF DIRECTORS REVIEWS THE ANNUAL AUDIT PROCESS WITH THE INDEPENDENT ACCOUNTANTS ANNUALLY. BOARD MEMBERS ARE ALSO GIVEN THE NAMES AND CONTACT INFORMATION OF THE INDEPENDENT ACCOUNTANTS AT THE ANNUAL FINANCE COMMITTEE'S REVIEW MEETING OF THE AUDITED FINANCIAL STATEMENTS SO THAT THEY MAY INQUIRE, IF NEEDED, WITH THE ACCOUNTANTS THROUGHOUT THE YEAR. A BOARD MEMBER IS ALSO SELECTED ANNUALLY FOR REVIEW AND INQUIRY BY THE INDEPENDENT ACCOUNTANTS EACH YEAR FOR SEPARATE AND PRIVATE INTERVIEW AS A PART OF THE AUDIT PROCESS. THESE FUNCTIONS ALLOW A GREATER AMOUNT OF OVERSIGHT BY THE BOARD INTO THE ANNUAL AUDIT PROCESS. THERE HAS BEEN NO CHANGE TO THESE PROCEDURES DURING THE PAST YEAR. RICHLAND HOSPITAL FOUNDATION INC 333 EAST SECOND STREET RICHLAND CENTER WI 53581 391567249 FOUNDATION WI 501 (C) 3 LINE 9 N/A 0 PARTNERS OF RICHLAND HOSPITAL INC 333 EAST SECOND STREET RICHLAND CENTER WI 53581 391693458 AUXILIARY WI 501 (C) 3 LINE 9 N/A 0 0 0 1 0 0 0 0 0 0 0 1 1 1 1 0 1 0 0 THE RICHLAND HOSPITAL FOUNDATION INC C 557401 COST PARTNERS OF RICHLAND HOSPITAL INC C 6504 COST PARTNERS OF RICHLAND HOSPITAL INC P 61442 COST