2011-05-09T09:53:42-05:00 2010-09-30 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2009-10-01 390938661 Burnett Medical Center Inc BURN 7154635353 257 West Saint George Avenue/PO Box 99 Grantsburg WI 54840 CHARLIE FAUGHT 7154635353 2011-05-06 1 HOLLY POKRANDT CPA 7158323407 2011-05-06 2009 2016-02-24 21:20:13Z CHARLIE FAUGHT 257 West Saint George Avenue/PO Box 99 Grantsburg WI 54840 19879623 0 X burnettmedicalcenter.org X 1957 WI THE MISSION OF BURNETT MEDICAL CENTER IS TO PROVIDE COMPASSIONATE, COMPREHENSIVE, COMMUNITY HEALTHCARE THAT EXCEEDS OUR CUSTOMER'S EXPECTATIONS. OUR MISSION, AS WELL AS OUR VISION AND VALUES, SERVES AS A GUIDELINE FOR DAILY DECISION MAKING AND REPRESENTS THE PRINCIPLES AND PRACTICES THAT WE CONSTANTLY APPLY. THE COMFORT AND CARE OF OUR PATIENTS IS A MAJOR FOCUS OF OURS. WE WANT TO BE THE HEALTHCARE PROVIDER OF "CHOICE" - PROVIDING EXPERT AND COST EFFECTIVE CARE IN A "HOMETOWN" ATMOSPHERE. ANOTHER OBJECTIVE OF OURS IS TO PROVIDE EDUCATION THAT WILL INCREASE HEALTH AWARENESS. PART OF OUR MISSION IS TO CONTINUALLY PUT THE "CARE" IN HEALTHCARE. MORE HEALTHCARE INFORMATION IS NOW AVAILABLE FROM OUR WEB SITe, which also provides patient education resources for those we serve. 7 7 265 18 0 0 26503 34261 18485403 19808573 31025 35319 0 18542931 19878153 0 0 10630603 10574825 0 0 8640741 9729163 19271344 20303988 -728413 -425835 26296201 25646452 18259524 18023884 8036677 7622568 The mission of Burnett Medical Center is to provide compassionate, comprehensive community healthcare. 0 0 11758634 12032078 Burnett Medical Center, located in rural northwest Wisconsin is a 17 bed critical access hospital that provides the following services throughout a three county region:Acute Care has 40+ employees who also work in obstetrics, the operating room, the emergency room, and post anesthesia recovery. We provide general inpatient medical and surgical care, as well as a large volume of outpatient services which include: OP surgery, chemotherapy, blood transfusion, IV therapy as examples. All of the RN staff is ACLS accredited and the entire staff is certified in CPR. The goal of the nursing staff is to provide excellent patient care, close to home, near family and friends.We also provide a full range of services from a 24/7 ER to cardiac rehab, and we provide other therapeutic and diagnostic services via Radiology, Lab, Physical Therapy, and Occupational Therapy.During FY 2010 in a total of 2,000 patient days we served 517 patients in our inpatient and swing bed programs and also had 46 births. We performed 826 surgical procedures, saw 5,054 patients in emergency and urgent care, and provided services for over 12,270 other outpatient visits. Gross hospital revenue of $157,280 was provided as charity care to 51 different patients for 195 episodes of care.Since June of 2004, Burnett Medical Center has been participating in the level 1 heart attack program developed by Abbott Northwestern Hospital and the Minneapolis Heart Institute. The Level 1 Heart Attack Program is an innovative approach to treating patients suffering from a heart attack. The key ingredient for success is speed in treatment. The goal is to treat and transport patients within 120 minutes, meaning 120 minutes from the time a patient enters the emergency room at Burnett Medical Center until the first balloon is inflated or stent placed at Abbott Northwestern Hospital (ABNW).Because rural hospitals do not have the capability to do angioplasty, it is important to move a heart attack patient to the nearest hospital that has a heart catheterization lab. The Level 1 Program has a definite protocol to move these patients quickly during that 'golden hour' when angioplasty is the most successful.Burnett Medical Center is one of 30 hospitals in Minnesota and Wisconsin participating in the Level 1 Program. Clearly, the Level 1 Program is advantageous to residents of Burnett County, knowing that cardiovascular disease is the leading cause of death for men and women in the United States. This team approach gives patients the advantage of time which translates to better outcomes and decreased mortality. Burnett Medical Center's medical and nursing staff have been trained for this program and are prepared and pleased to provide quick access to efficient cardiac care through the Level 1 Heart Attack Program. 3211236 3218993 The Continuing Care Center of Burnett Medical Center offers 46 semi-private and 4 private room accommodations and a full range of health and personal care services. Physical, occupational, and speech therapy are available, as well as nutritional services, recreational activities, and social services. Additionally, adult day care and respite care is available. The goal of the Continuing Care Center's staff is to provide necessary health services while maintaining an atmosphere of hope, harmony, humor, and a 'home' away from home.We strive to enhance the quality of residents' life via a venue for community-based volunteers sharing their time and talent with our residents, such as musical bands, Rotary Club sponsored functions, etc.During FY2010 we had over 18,400 resident days serving about 120 different residents. 3086881 4557502 Burnett Medical Center Clinic is located just off Highway 70 in Grantsburg and is now part of our new expanded facility. The clinic is staffed by 23 employees including (5) Physicians, (1) Physician Assistant, (2) Certified Nurse Practitioners, and (1) Certified Nurse Midwife.We are pleased to offer our patients a range of services including: Physicals (Including Well Child Checks, Pre-operative, DOT, etc.), obstetrical exams, health status assessments, diagnosis and treatment of common, acute and chronic health conditions, immunizations, family planning, diabetic education, women's health, colonoscopy procedures, fracture care, vasectomies, routine laboratory testing, EKG's, and Holter monitoring. Additionally, the clinic laboratory is a certified collection site for urine drug screening.Hours of operation have been expanded to allow people increased access, including working families with school-age children, people that work varying shifts, etc. Our providers have collaborative relationships with area industries, including the local school systems. This allows Burnett Medical Center to provide educational opportunities to employees of these industries, including bloodborne pathogens training, health education to school children, and participation in employee health fairs. BMC providers participate in the local Rotary group and in County Coalitions to reduce prescription drug abuse and improve awareness of wellness activities in the area. We also sponsor an annual 5K event that raises funds for a local charity while promoting healthy lifestyles-this year is our 6th annual!Over 20,000 primary care clinic visits were provided during FY 2010. Clinic gross revenue of $27,040 was provided as charity care to 47 different patients in 206 visits. 18056751 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 7 0 1 265 1 0 0 0 0 0 0 0 0 0 7 7 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 WI X Charlie Faught 7154635353 257 WEST SAINT GEORGE AVE GRANTSBURG WI 54840 jim richison 0.50 X 0 0 0 JOHN SAUERBERG 0.50 X X 0 0 0 ADAM BENSON 0.50 X X 0 0 0 William Hunt 0.50 X 0 0 0 CRAIG SELANDER 0.50 X X 0 0 0 JoLouise McNally 0.50 X 0 0 0 Marilyn Kooiker 0.50 X 0 0 0 CHARLIE FAUGHT 40.00 X 128700 0 25814 Gordon Lewis 40.00 X 162660 0 34566 Timothy Novick 36.00 X 268590 0 18959 James franzel 34.00 X 206389 0 16653 Adeola Jolayemi 40.00 X 213201 0 4406 Vesna Radivojevic 40.00 X 170864 0 11370 julie Andersson 0.40 X 120131 0 13487 1270535 0 125255 8 0 1 0 Dr Blaise Vitale 257 West Saint george Avenue Grantsburg WI 54840 Clinic and ER Services 316112 BNB Enterprises 27165 John Stone Road webster WI 54893 CRNA Services 288025 Anton Mentele 257 West Saint george Avenue grantsburg WI 54840 crNA Services 233235 3 34261 34261 Hospital patient servi 621990 12032078 12032078 Clinic patient service 621110 4557502 4557502 Nursing home resident 623000 3218993 3218993 19808573 36039 36039 750 1470 -720 -720 -720 19878153 19808573 0 35319 356395 356395 8351747 7463038 888709 49885 42330 7555 1239465 1104648 134817 577333 509879 67454 222499 222499 23546 23546 53025 53025 2845067 2746013 99054 74675 74675 2190430 2056214 134216 36315 36315 1137987 1137987 71270 56146 15124 1323026 1323026 96346 96346 Bad debt Expense 982196 982196 Repairs & Maintenance 463394 454390 9004 Nursing Home Bed Assess 115985 115985 Dues & Subscriptions 53910 25407 28503 Minor Equipment 39492 39492 20303988 18056751 2247237 0 -14742 -45408 2509105 2743488 2886383 2860043 470703 463828 277018 350446 25164322 8322501 17286608 16841821 1524601 1559471 558012 130232 241758 231013 556755 511518 26296201 25646452 1659914 1814883 16486265 16069837 113345 139164 18259524 18023884 X 8036677 7622568 8036677 7622568 26296201 25646452 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 2177 2177 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Burnett Medical Center, Inc. pays annual association memberships to the american hospital association and wisconsin hospital association. These dues are primarily for access to educational materials and staff training and development. A small portion of the annual dues were used in conjunction with lobbying activities with the goal of improving the overall healthcare environment. 50000 50000 19594998 5618872 13976126 5244152 2703629 2540523 275172 275172 16841821 457(B) Plan Payable 131702 Flexible Spending acocunt Liability 7462 139164 19878153 20303988 -425835 5112 6614 11726 -414109 19878153 0 19878153 0 19878153 20303988 0 20303988 0 20303988 Part X: Description of Uncertain Tax Positions Under FIN 48: Schedule D Part XIV: Income Taxes The Medical Center and Foundation are nonprofit corporations as described in Section 501(c)(3) of the Internal Revenue Code (the "Code") and are exempt from federal taxes on related income pursuant to Section 501(a) of the Code. The Medical Center and Foundation are also exempt from state taxes on related income. The Medical Center adopted ASC Topic 740-10, Accounting for uncertainty in income taxes, during 2010. ASC Topic 740-10 requires companies to determine 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 Medical Center recorded no assets or liabilities for uncertain tax positions or unrecognized tax benefits in 2010 and 2009. Federal returns for the years ended September 30, 2009, 2008, and 2007, remain subject to examination by the Internal Revenue Service. The return for the year ended September 30, 2010, is not yet due and has not yet been filed as of the report date. Part XI, Line 8 - Other Adjustments: Change in Interest in net assets of Foundation: 6614. 1 1 1 X 1 X 1 1 0 1 1 108064 108064 0.00560 4758811 4043306 715505 0.03700 4866875 4043306 823569 0.04260 17474 5531 11943 0.00060 17474 5531 11943 0.00060 4884349 4048837 835512 0.04320 575845 230340 5742532 5702144 40388 X 1 1 Burnett Medical Center Inc

257 West Saint George Avenue Grantsburg WI 54840

X X X X Nursing Home, Rural Health Clinic Part I, Line 7: The calculated percent of total expenses excluded bad debt expense of $982,196. The expenses recognized in the table were calculated using the cost-to-charge ratio from the medicare cost report. Part I, Line 7f: The calculated percent of total expenses excluded bad debt expense. Part III, Line 4: Accounts Receivable and Credit PolicyThe cost-to-charge ratio was calculated using the medicare cost report.Accounts receivable are uncollateralized patient obligations that are stated at the amount management expects to collect from outstanding balances. The obligations are primarily from local residents, most of whom are insured under third-party payer agreements. The Medical Center bills third-party payers on the patients' 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 copay 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 Medical Center 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 a reduction of gross revenue and a credit to 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 an allowance for uncollectible accounts. The audited financial statements do not include a separate footnote regarding bad debt expense. Part III, Line 8: The Medical Center has been designated as a Critical Access Hospital and therefore did not recognize a shortfall from the Medicare program. 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 Financial Counselor and/or our Business Office Manager. Part VI, Line 2: We have used marketing and demographic data for both our Primary and Secondary Service Areas as supplied by proprietary sources from both Thomson Reuters Market Expert and the Minnesota Hospital Association. Such market-based analysis provides estimates and projections for the medical needs of those that live within our service area. We then look at the availability of existing healthcare providers and services to determine what gaps may exist, and how we can best be a part of addressing unmet need in partnership with both public and private providers of healthcare services. The results of this review and analysis become a fundamental basis for the development of goals and objectives in our Strategic Plan. Part VI, Line 3: A sign is posted near registration areas informing patients of our community care program. Patients are also told about the program by registration staff and our financial counselor. If the patient feels they will need assistance they are encouraged to submit the community care application. Patients are also informed of the program during the collection process and encouraged to apply if their situation qualifies. Part VI, Line 4: Based on 2009 estimates, Burnett County has a population of 15,884, which represents our primary service area. Burnett Medical Center, a 17 bed federally designated Critical Access Hospital, is the sole hospital in Burnett County. Located in rural Northwest Wisconsin, Burnett County covers over 820 square miles, or 19.1 persons per square mile (compared to Wisconsin's 98.8 per square mile). Burnett County is one of Wisconsin's poorer counties as 14.1% live below the poverty level compared to a state average of 10.5% with a median income of $41,276 which is about 21% below the state median income of $52,103. Demographically our over 65 year old population represents over one in five, or 22.1% of the population, compared to the state average of 13.5%. According to the US Census, while the county population is comprised of predominately white persons at 92.5%, our next largest population is American Indian at 5.0% (compared to 1% overall for the state). In our secondary service areas in the neighboring counties of Polk County in Wisconsin and Pine County in Minnesota, we see similarities. Based on Census bureau data, their comparisons show them to have far fewer persons per square mile, and are relatively lower than their respective state averages for median household income, the 65+ years of age population, and greater than state average of both white persons and American Indians.Despite our rural location in Northwest Wisconsin, we are in a relatively competitive market as residents from both our primary and secondary service areas have access to ten hospitals (in either Wisconsin or Minnesota) within 50 miles of Burnett Medical Center's geographic location in Grantsburg, Wisconsin Finally, we take our role in providing a health care safety net seriously for all, including the uninsured, as evidenced by our 24/7 emergency department which provides emergent, urgent, and primary care to all that present to the emergency department. Part VI, Line 5: In response to the growing trend of illegal use of prescription drugs by the youth of our nation and community, Burnett Medical Center partnered with the Burnett County Coalition for Healthy Living in sponsoring prescription drug disposal as part of the National Take Back Day in Burnett County. The Coalition will be hosting five drop-off sites throughout Burnett County: Burnett County Government Center Grantsburg Village Hall St. Croix Tribal Clinic in Hertel St. Croix Tribal Hall in Danbury A & H Senior Citizen's CenterThis effort will bring awareness to the need for proper disposal of prescription drugs, and will inform the community that a pill drop box is located and accessible for the proper disposal of drugs at the Burnett County Sheriff's Department entrance 24/7. We have provided information on this initiative at our website, to highlight this growing national healthcare concern for adolescents and it is intended to advance the general knowledge of the issue. Part VI, Line 6: As a sole community rural hospital we take pride in being close to those we serve. We benefit from the community in its involvement in knowing of our services and in promoting our mission throughout the communities served. For example our governing body is composed of seven community volunteers from throughout Burnett County, that reside in our primary service area, none of which are employees, contractors, nor family members.We enjoy the continued support of our community with the establishment of a healthcare Foundation which provides philanthropic support to fulfilling the hospital's mission.In order to ensure continued and ready access to qualified healthcare providers, we take pride in having an open medical staff model that extends medical staff privileges to all qualified providers in our community.When we have surplus funds, those funds are used for improvements in patient care and quality, as evidenced by our recent $15M renovation and early adoption of the electronic medical record.Advocacy of the communities healthcare needs are done locally by members of the Board speaking with local officials on relevant issues that may affect the hospital. Additionally, the organization's CEO serves as a member of the Wisconsin Hospital Association's Board of Directors which advocates for initiatives for community, state and national efforts for improving the overall health of the population and continued ready access to quality healthcare for all.Mindful of the need for support of various methods of insurance, we are proud of our participation in such governmentally-sponsored healthcare programs such as Medicare, Medicaid and TRICARE. WI X X X 0 0 0 0 0 0 0 0 0 CHARLIE FAUGHT 115500 0 13200 0 0 0 4620 0 21194 0 154514 0 0 0 Gordon Lewis 154660 0 8000 0 0 0 6186 0 28380 0 197226 0 0 0 Timothy Novick 253021 0 0 0 15569 0 7350 0 11609 0 287549 0 0 0 James franzel 206151 0 0 0 238 0 6579 0 10074 0 223042 0 0 0 Adeola Jolayemi 213079 0 0 0 122 0 1494 0 2912 0 217607 0 0 0 Vesna Radivojevic 170864 0 0 0 0 0 0 0 11370 0 182234 0 0 0 Burnett County 396005675 2007-03-23 7000000 To refinance and provide funds for building renovation and expansion 0 0 Village of Grantsburg 396006277 2007-04-10 5000000 To provide funds for building renovation and expansion 0 0 Village of Siren 396008452 2007-04-25 4850000 to provide funds for building renovation and expansion 0 0 7000000 126304 140000 5338460 2008 1 0 0 1 5000000 100000 4900000 2008 0 0 1 1 4850000 97000 4753000 2008 0 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Form 990, Part VI, Section A, line 6 Each person, business, corporation or organization who has contributed and paid one hundred dollars or more to Burnett Medical Center, Inc."the Corporation" shall be a lifetime member of the Corporation. Each person, business, corporation or organization is entitled to hold a maximum of one membership certificate. A husband and wife, or two or more related persons, may hold a membership as joint tenants, however, only one vote per membership shall be permitted. Form 990, Part VI, Section A, line 7a The duties of the members of Burnett Medical Center, Inc. "the Corporation" shall be: the formulation and development of the overall purposes; objectives and philosophy of the Corporation; the election of members of the Board of Directors of the Corporation; the removal of members of the Board of Directors of the Corporation; the changing of the number of directors constituting the Board of Directors; 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 or its merger with another Corporation. Form 990, Part VI, Section B, line 11 The board of directors for Burnett Medical Center, Inc. reviewed and approved the FYE 2010 Form 990 prior to filing. Form 990, Part VI, Section B, line 12c Burnett Medical Center, Inc. has a conflict of interest policy. The purpose of this policy is to protect the interest of BMC when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer or director of BMC. It is expected that such persons shall exercise the utmost good faith in all transactions touching upon their duties at Burnett Medical Center and its property. All members of the board complete a disclosure form upon appointment, and review and sign it annually thereafter. This statement establishes the duty of an interested party to disclose the existence of his or her financial interest and must disclose all material facts. After any such disclosure, he/she shall leave the governing board meeting while the determination of a conflict of interest is discussed and voted upon by the remaining board members. If the Board has reasonable cause to believe that a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis of such belief and afford the member an opportunity to explain the alleged failure to disclose. If members fail to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. Form 990, Part VI, Section B, line 15 Burnett Medical Center Inc.'s Executive Compensation Policy is designed with the goal of providing remuneration that is fair, reasonable and competitive. The hospital board may establish a compensation committee or may act as a committee of the whole in executive session. The committee oversees the total compensation packages to ensure that they are competitive with other healthcare organizations, reflect job responsibilities and requirements and are fair, equitable and consistently managed. The committee meets as often as it deems appropriate to carry out its responsibilities. In general, BMC positions total executive compensation at the median of the market. The board of directors uses contemporaneous data including executive compensation data from the wisconsin hospital association as a guide when approving the compensation of the administrator and chief financial officer. The policy is meant to be flexible so that compensation can be above or below the median based on experience, performance, size and complexity of organization, and business need to attract and retain executive talent. Form 990, Part VI, Section C, line 19 Burnett Medical Center, Inc. makes it financial statements and governing documents available to the public on a per request basis. Form 990, Part XI, Line 2C Oversight of the audit Burnett Medical Center, Inc. does not have a specific committee which assumes the responsibility for oversight of the audit. The entire board of directors is responsible for the selection of the independent accountant. The process has not changed from the prior year. Form 990, Part VI, Section A, Line 3 Management Company Burnett Medical Center, Inc. entered into a five year agreement for management services with Brim Healthcare, Inc. effective February 1, 2007. Both the chief executive officer and chief financial officer of Burnett Medical Center, Inc. are employees of Brim Healthcare, Inc. Form 990, schedule K, Part II, Line 4 The remaining unspent proceeds were spent in fiscal year end 2011 towards the purchase of an electronic medical records system as approved by the lender and bond trustee. Burnett medical Center Foundation Inc 257 West Saint George Avenue Grantsburg WI 54840 263129839 Foundation WI 501(c)(3) 170(b)(1)(A)(vi) N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0