2011-02-15T10:43:47-07:00 2010-06-30 Rural Wisconsin Health Cooperative 880 Independence Lane Sauk CIty WI 53583 990 2009-07-01 390926284 Prairie du Chien Memorial Hospital Inc PRAI 6083572000 705 East Taylor Street Prairie du Chien WI 538212110 William P Sexton 6083572400 2011-02-15 1 Richard Donkle 6086432343 2011-02-15 2009 2016-02-24 21:20:13Z William P Sexton 705East Taylor Street Prairie du Chien WI 538212110 31495400 0 X http://www.pdcmemorialhospital.org X 1957 WI To meet the health care and wellness needs of our health care community. The most significant activities are inpatient acute care, long term care and diversified outpatient services. 9 7 318 150 0 0 334884 413606 26664406 28063363 334108 488658 531300 501085 27864698 29466712 17500 7550 0 0 16802980 18031392 0 0 0 8386870 9218714 25207350 27257656 2657348 2209056 32178027 35249344 3208211 3643690 28969816 31605654 Prairie du Chien Memorial Hospital will deliver high quality, personalized healthcare and education, in a friendly safe environment, to educate people in every stage of life through partnerships with other regional health care providers. 0 0 21730687 25725816 Routine services: Inpatient/acute services - 2699 days Hospice Acute services -178 days Skilled Swing Bed services - 1175 days Intermediate Care Services - 2065 days. Outpatient services: Outpatient visits - 16,735 visits Ancillary Inpatient and outpatient services are provided to the local community who would otherwise be required to travel outside their community to obtain their health care services. In addition to the services already mentioned Prairie du Chien Memorial provides Birthing Center, Diagnostics, 24 hour Emergency Services, Urgent Care, Extended Care, Home Health Care, Hospice, Home Oxygen, Home Medical Equipment, Personal Home services, Lifeline, Palliative Care, Pulmonology, Podiatry, Sleep Study, Wound Care/Ostomy/Continence Care, Respite Care, Infusion Services, Outpatient Care, Laboratory Services, Medical Imaging, Rehabilitation Services, Sleep Center, Speech and Audiology, Surgical Services, and Telehealth The Hospice program combines emotional, physical, and spiritual help for people dealing with a terminal illness. The Hospice philosophy stresses quality of life, enabling the dying patient and family to make personal choices which lead to a fuller, more meaningful life. 1001479 633766 Prairie du Chien Memorial Hospital's Home Health Care Agency provides health care services to patients throughout the life span, in their place of residence under the orders of a licensed physician. A registered nurse completes an initial comprehensive assessment of the patient, family and living environment. The nurse (and if required, therapist and medical social worker) and physician develop a plan of care to meet the mutual goals as established with the patient, family, physician and other health care team members. As the plan is implemented, referrals are made as appropriate to the other team members and support systems. In addition to the above mentioned staff, the Certified Home Health Aide is able to provide assistance with needed personal cares, prescribed exercise programs and other duties as directed by the nurse. In-home health services: * Registered Nurses * Home Health Aides * Physical Therapy * Occupational Therapy * Speech Therapy * Medical Social Worker Home Health visits - 4,746 admissions - 250 1117746 864613 Hospice provides specially trained health care professionals working together with you, your family, and your own primary physician. Your Hospice Team consists of medical directors, registered nurses, medical social workers, home health aides, dietitians, pharmacists, pastoral care services, volunteers, therapists, and bereavement coordinators. Hospice focuses on the patient and their family: To promote a source of continuous physical, emotional, and spiritual care to the dying patient and family. To provide encouragement to live their remaining life to the fullest with dignity and obtain the highest quality of life. To support the family during and after the death of the patient's loved ones. Hospice consists of the following services: Home Care: The family is supported by the Hospice team and attending physician to care for their loved one at home. Regular visits are made by staff to assure patient and family needs are being met. Hospice is also available in nursing homes and assisted living facilities contracted with our agency within our service area. Continuous Care: In times of crisis when intense nursing care is needed for symptom management, staff will be accessible for extended periods as available. Inpatient Care: If the need arises for more acute care and/or symptom management, a patient may be admitted into their local hospital. Hospice has contracts with several hospitals in our service area. Respite Care: This type of care is available to offer caregivers relief. The patient can be admitted into their local hospital and be cared for by the nursing staff. Medicare/Medicaid covers five consecutive days of Respite Care on a non-routine basis. Hospice Home Care Days - 4,931 1078647 839168 Prairie du Chien Memorial Hospital 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 is not quantified. Our hospital, like most rural hospitals, was created and is maintained in order to provide care locally-care that without our hospital, would not be available locally. Beyond inpatient hospitalizations, we provide local access to many health services: Birthing Center, Dialysis Center, Diagnostics, 24 hour Emergency Services, Urgent Care, Extended Care, Home Health Care, Hospice, Home Oxygen, Home Medical Equipment, Personal Home services, Lifeline, Palliative Care, Home delivered meals, Pulmonology, Podiatry, Sleep Study, Wound Care/Ostomy/Continence Care, Respite Care, Infusion Services, Outpatient Care, Laboratory Services, Medical Imaging, Rehabilitation Services, Sleep Center, Speech and Audiology, Surgical Services, Family Resource Center, Crawford Abuse Resistance Effort, Independent Living, and Telehealth. Prairie du Chien Memorial Hospital provides quality medical health care regardless of race, creed, sex, national origin, handicap, age or ability to pay. In keeping with this hospital's commitment to serve all members of the community: Memorial Hospital provided free care and/or subsidized care. Memorial Hospital provides care to persons covered by governmental programs at below cost. Recognizing its mission to the community, services are provided to both Medicare and Medicaid patients. To the extent reimbursement is below charges, Memorial Hospital recognizes these amounts as contractual allowances in meeting its mission to the entire community. Memorial Hospital's health activities and programs help support the community. Consideration is also given where the need and/or individual's inability to pay coexists. These activities include wellness programs, community education programs, special programs for the elderly, medically under served, screening programs and a variety of broad community support activities. Preparing and providing 6,104 meals for the congregate meal site as well as preparing and delivering 29,725 meals on wheels during the fiscal year June 30, 2010 to community residents who are unable to prepare a meal for themselves due to their medical condition. These meals were provided at a minimal subsidized fee. Diet counseling is provided. During fiscal year June 30, 2010, 435 people received diet counseling. Sponsoring a weight loss program and a variety of other wellness type programs at subsidized cost. Offering a series of seminars on topics such as Parenting, Women & Heart Disease, Osteoporosis, Stress Management, Advanced Directives, and Survivors of Sexual Abuse. In addition, we provide Lamaze classes for prenatal education and an "I Can Cope Program" for cancer patients. These classes are all free or subsidized by the Hospital. Interactive video presentations were also provided for the community. Providing bereavement counseling for about 196 families of Hospice patients during the fiscal year June 30, 2010. Also offering grief support program and newsletters for families in local communities. support groups for parents who have lost a child through miscarriage or stillbirth. Provide free newborn hearing testing. Providing community education center which coordinates clinical rotation and provides assistance to educators through our work with student nurses, unit clerk students, physical therapy students, radiology tech students, health information students, and residents. Providing CPR classes for the community. Two hundred twenty six (236) people become certified in CPR. First Aid classes were provided for community members. Participation in Farm & Home Show, the Senior Expo, and Family & Children's Expo. Health brochures and screenings were done. We performed free oximeter screenings for the community and offered for free or reduced cost blood pressure, glucose, and cholesterol screenings. Collaborating with local school systems to provide educational programs on issues such as sex education, breast health, and providing tours of the hospital for health classes, child development classes, and others. Community benefits are also achieved through many reduced price services and free programs offered throughout the year based upon activities and services which Memorial Hospital believes will serve a bona fide community health need. These include: A variety of brochures on health and wellness are available free of charge in several locations within the hospital. A variety of brochures to educate Medicare patients, with respect to their benefits under the Medicare program. Participation in two county fairs during the fiscal year June 30, 2010 in order to foster health education in the community. Services provided include glucose, oximeter, blood pressure and cholesterol screenings. Being called upon to speak before community organizations on a variety of health care topics, during the fiscal year June 30, 2010. The Family Resource Center provides a variety of services and resources including a Toy Resource & Lending Library; a three-week "Music, Movement & Memories" series; parent education for jail inmates; babysitter training; phone consultations; family coaching; family drop-ins; family support groups; car seat installation & instruction; new parent education; CPR training; and a variety of other family focused services. FRC strives to pursue its goal of empowering parents to face the challenges of family life in a caring and positive way. Through education and support along with resources the ultimate goal of FRC is the prevention of child abuse and neglect. Crawford Abuse Resistance Effort (C.A.R.E.) as Sponsored by Prairie du Chien Memorial Hospital provided the following services for the year ending June 30, 2010 The goal of C.A.R.E. is to reduce and/or prevent alcohol, tobacco, and other drug use/abuse (ATOD) among Crawford County youth and adults using comprehensive prevention and health promotion strategies. To achieve this goal, C.A.R.E. collaborates with the community to provide substance abuse prevention education and training programs for youth and adults. C.A.R.E. provided an extensive list of education and events, often in collaboration with other organizations, to promote education and awareness of ATOD issues and prevention. 364 adults contributed 1,985 hours and 633 youth contributed 7,668 hours to planning, implementation, participation in, and/or evaluation of prevention programs. In addition, approximately 1,750 adults and 2,300 youth were either actively involved in planning or implementation of C.A.R.E. programming and/or received some level of direct service. C.A.R.E. staff and local law enforcement attended training targeting law enforcement and their role in the implementation of environmental strategies including compliance checks, the development of social host ordinances, saturation and party patrols. Staff and members also attended the Wisconsin State Prevention Conference (June 2010) gaining knowledge on tobacco, alcohol and other drug use and abuse trends in Wisconsin. 1078647 0 839168 24928559 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 5 0 1 318 1 0 0 0 0 0 0 0 0 0 1 1 9 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X David Breitbach 6083572405 705 East Taylor Street Prairie du Chien WI 538212110 Paul Ginkel 4 X X 0 0 0 Joesph Faust 2 X X 0 0 0 Patrick Mulhern 2 X X 0 0 0 Lisa Esser 2 X X 0 0 0 Charlie Connell 2 X 0 0 0 Gayette Grimm 2 X 0 0 0 Rory Meisner 2 X 0 0 0 Mattie Rademacher 2 X 0 0 0 Alice Staples 2 X 0 0 0 William Sexton 40 X X X 295085 0 0 David Breitbach 40 X X X 145092 0 0 M C Achenbach 40 X X 150693 0 0 R Timothy Fitzner 49.25 X 253513 0 0 Khalid Ali 48.25 X 248998 0 0 Christopher Burrows 47.50 X 248275 0 0 James Gariti 47.75 X 284469 0 0 Tom Wilkes 40 X 123408 0 0 Harold W Brown 0 X 343776 0 0 2093309 0 0 13 1 1 0 Prairie Anesthesia Services 36681 Wildernest Rd Prairie du Chien WI 53821 Anesthesia Services 345379 Sidley Austin LLP One South Dearborn Chicago IL 60603 Legal Services 115060 2 5312 0 0 0 291754 116540 0 413606 Inpatient & Outpatient Hospital Services 622000 25725816 25725816 0 0 Home Health Services 621610 633766 633766 0 0 Hospice Services 624100 864613 864613 0 0 839168 839168 0 0 28063363 494314 494314 0 0 0 0 0 0 0 0 0 0 16550 0 4356 0 12194 0 12194 12194 0 0 2016981 1695 1986098 38234 30883 -36539 -5656 -5656 0 0 0 Wee Care 624100 198179 198179 0 0 Meal Income 622000 91708 91708 0 0 199004 199004 0 0 488891 29466712 29053106 0 0 7550 7550 606798 606798 12664192 11949647 714545 579096 521438 57658 3318288 2987898 330390 863018 777089 85929 50732 5029 45703 22600 22600 52378 52378 2462563 2434731 27832 413409 392525 20884 206008 184817 21191 1296227 1296227 91939 21644 70295 Contractual Expenses 938958 890235 48723 0 Bad Debts 1095912 1095912 0 0 Payment to NH 198856 198856 0 0 Equipment Rent & Maintenance 898753 867087 31666 0 Departmental Expenses 1379255 1246153 133102 0 111124 29121 82003 27257656 24928559 2329097 0 250 250 10570801 14987433 5166751 5135774 846220 834110 635293 956225 166789 208389 21991161 12971884 8671222 9019277 5986865 4080130 8816 8816 125020 18940 32178027 35249344 2426939 2986513 781272 657177 3208211 3643690 X 28815032 31443240 154784 162414 0 0 28969816 31605654 32178027 35249344 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 365853 365853 0 9748225 5547927 4200298 0 395777 162872 232905 0 11354876 7261085 4093791 0 126430 0 126430 9019277 0 8816 C 8816 Interest Receivable 18940 18940 Severeance Pay 657177 657177 29466712 27257656 2209056 419152 0 0 0 4 419156 2628212 29471076 0 0 0 4364 4364 29466712 0 0 0 29466712 27262016 0 0 0 4360 4360 27257656 0 0 0 27257656 SchD_P10_S00_L00 Schedule D, Part X None SchD_P11_S00_L08 Schedule D, Part XI, Line 8 Rounding SchD_P12_S00_L02d Schedule D, Part XII, Line 2d Rental Expense (4356) and Rounding (8) SchD_P13_S00_L02d Schedule D, Part XIII, Line 2d Rental Expense (4356) & rounding (4) 1 1 1 X 1 X 1 1 0 1 1 0 0 192904 0 192904 0.0074 0 0 2181218 1282853 898365 0.0343 0 0 45053 25324 19729 0.0008 0 0 2419175 1308177 1110998 0.0425 0 0 500326 244355 255971 0.0098 0 0 0 0 0 0 0 0 5209620 3455728 1753891 0.067 0 0 0 0 0 0 0 0 8390 0 8390 0.0003 0 0 5718336 3700083 2018252 0.0771 0 0 8137511 5008260 3129250 0.1196 9174 9174 0.0004 0 0 9174 0 9174 0.0004 1 550186 82500 8978962 8953699 25263 X 1 1 Prairie du Chien Memorial Hospital

705 East Taylor Street Prairie du Chien WI 53821

X X X X In computing the costs for line 7 a through c the cost to charge ratio derived from worksheet 2 was utilized. In computing the costs for line 7 e through g the costs were obtained from the Medicare cost report. For line 7i actual cost were used. The subsidized health services do not include costs attributed to a physician clinic. When computing the percentages on Schedule H, Part I, line 7, Col (f) total bad debts expense of $1,095,912 was excluded from total expense, FORM 990, PT IX, LINE 25, COL A. The carrying amount of patient receivables is reduced by a valuation allowance that reflects management's estimate of amounts that will not be collected from patients and third-party payors. Management reviews patient receivables by payor class and applies percentages to determine estimated amounts that will not be collected from third parties under contractual agreements and amounts that will not be collected from patients due to bad debts. Management considers historical write off and recovery information in determining the estimated bad debt provision. Management also reviews accounts to determine if classification as charity care is appropriate. Our rough estimate is based on an estimate of the amount of bad debt claims returned to us by our third party collection agency due to inability to collect and bankruptcy. The Medicare allowable costs on line 6 were taken from the Medicare cost report, worksheets F Pt B, E-2, and E-3. Also included was the estimated cost off the Medicare Fee For Service services. These costs were estimated based on the Medicare inpatient and outpatient cost to charge ratio. Cost related to related to subsidized health services reported In Part I, line 7g were not included. Any shortfall to our Medicare reimburse should be included as community benefit because of the additional cost the Hospital incurred as a result of onerous Medicare requirements. All accounts are subject to management review prior to being turned over for outside collection. the year ended 6/30/10 the Board of Directors, Hospital administration and staff met with community leaders in an open forum to discuss the heath care needs of our community. As part of this discussion we asked these community leaders to identify any unmet health care needs . Patients who do not have the ability to pay all or any portion of their hospital bill are informed about Prairie du Chien Memorial Hospital's Charity Care program by hospital employees in the areas of registration, patient family services, nursing, or patient financial services. The patient or family member is given an application for Charity Care. The patient is also directed to contact their county Department of Human Services to apply for assistance under federal, state, or local government programs. If the patient is not eligible for Medical Assistance or any other government program, they are instructed to complete and return the Hospital's Charity Care application. Prairie du Chien Memorial Hospital provides healthcare services to the general public in southwestern Wisconsin and northeastern Iowa. Demographically Prairie du Chien Memorial Hospital serves a rural population with an average household income in the low to median range. Prairie du Chien Memorial Hospital serves all ages but is experiencing an increase in geriatric patients. The hospital works with local government agencies regarding readiness planning, disaster recovery and public health issues. 1 X SchI_P01_S00_L02 Schedule I, Part I, Line 2 All grants are made to local municipal or civic organizations for services provided within the community. X X 0 1 X X 0 1 0 0 0 1 0 0 0 Harold W Brown 0 0 0 0 0 0 343776 0 0 0 343776 0 343776 0 William Sexton 254178 0 40906 0 0 0 3379 0 26990 0 325453 0 0 0 M C Achenbach 142403 0 8289 0 0 0 8629 0 6418 0 165739 0 0 0 David Breitbach 137247 0 7845 0 0 0 8318 0 25896 0 179306 0 0 0 James Gariti 274965 0 9504 0 0 0 16013 0 4390 0 304872 0 0 0 R Timothy Fitzner 245296 0 8217 0 0 0 13855 0 11126 0 278494 0 0 0 Khalid Ali 240590 0 8409 0 0 0 11788 0 24706 0 285493 0 0 0 Christopher Burrows 242497 0 5778 0 0 0 10874 0 4130 0 263279 0 0 0 Tom Wilkes 119572 0 3836 0 0 0 7430 0 26286 0 157124 0 0 0 SchJ_P01_S00_L01a Schedule J, Part I, Line 1a A new CEO was hired 10/01/08 and is using a hospital owned residence until his move to the area has been completed in accordance with his employment agreement. CEO compensation was grossed up to allow for the value of this housing and the related income taxes. SchJ_P01_S00_L01b Schedule J, Part I, Line 1b There is no written policy, but was done at the direction of the hospital board of directors. SchJ_P01_S00_L03 Schedule J, Part I, Line 3 Prairie du Chien Memorial Hospital administration utilizes the Rural Wisconsin Health Cooperative and Wisconsin Hospital Association salary surveys when determining compensation. Compensation is approved by the board of directors. SchJ_P01_S00_L04 Schedule J, Part I, Line 4 Previous CEO receives payments from a nonqualfied deferred compensation arrangement. SchJ_P01_S00_L06 Schedule J, Part I, Line 6 Prairie du Chien Memorial Hospital has an historical employee incentive plan. The employee incentive plan has the following stipulations, criteria and guidelines: a.) The plan allows for employee incentive pay if the hospital has generated a gain in excess of 5% based on net patient income less interest and unrestricted contributions. b.) Employee incentive payment will not exceed 2% of gross pay based on each quarter performance. All overtime will not be included in the calculation of incentive pay. c.) Eligible employees are those on the hospital payroll as of the end of each quarter. Employees leaving employment during the quarter will not be eligible to participate. Jane Page Daughter of Board Member 27280 Employment 0 Katy Krueger Daughter of Board Member 62443 Employment 0 F990_P06_S0A_L06 Form 990, Part VI, Section A, Line 6 Prairie du Chien Memorial Hospital is a community hospital which was organized through community membership. Members are required to pay a minimal fee to belong to Prairie du Chien Memorial Hospital Association. F990_P06_S0A_L07a Form 990, Part VI, Section A, Line 7a Members of the Prairie du Chien Memorial Hospital Association meet annually to vote for new Board Members and for bylaw changes. F990_P06_S0A_L07b Form 990, Part VI, Section A, Line 7b Members of the Priaire du Chien Memorial Hospital Association must approve bylaw changes. F990_P06_S0B_L11 Form 990, Part VI, Section B, Line 11 The annual IRS Form 990 is made available to the Board of Directors for their reivew prior to filing. F990_P06_S0B_L12c Form 990, Part VI, Section B, Line 12c Appropriate staff are notified of potential conflicts of interest and monitor compliance through the year. F990_P06_S0B_L15 Form 990, Part VI, Section B, Line 15 Prairie du Chien Memorial Hospital administration utilizes the Rural Wisconsin Health Cooperative and Wisconsin Hospital Association salary surveys when determining compensation. F990_P06_S0C_L19 Form 990, Part VI, Section C, Line 19 Prairie du Chien Memorial Hospital uses it's website to communicate with the public. Prairie du Chien Memorial Hospital also publishes an Annual Report the presents financial information, the mission statement, a review of the last year and a look forward. Conflict of interest statements are available on request.