2011-07-05T09:18:42-05:00 2010-09-30 WIPFLI LLP 3703 OAKWOOD HILLS PARKWAY EAU CLAIRE WI 54701 990 2009-10-01 390806404 Vernon Memorial Healthcare inc VERN 6086372101 507 South Main Street VIROQUA WI 54665 Mary Koenig 6086372101 2011-07-05 1 Holly Pokrandt CPA 7158323407 2011-06-30 2009 2016-02-24 21:20:13Z Mary Koenig 507 South Main Street VIROQUA WI 54665 66954357 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. 10 10 565 200 5803330 -416711 58661 96235 62763321 64672978 431281 556618 179695 236480 63432958 65562311 174000 157238 0 29036701 31403220 0 0 29780049 29178727 58990750 60739185 4442208 4823126 67975886 72396251 31733375 31548662 36242511 40847589 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 44057335 157238 47915349 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 2010, hospital inpatient services included 4,401 acute care patient days, 46 swing bed patient days, and 358 newborn patient days. There were 1,555 surgery cases, 6,334 emergency room visits, and 1,154 visits to the after hours clinic. 9316310 10120636 A total of 45,446 clinic visits occurred in FYE 2010 at the four clinics located in Viroqua, LaFarge, Soldiers Grove, and Westby. 1178422 833663 During FYE 2010, 1,938 home health visits were made to 82 individuals. Hospice care was provided to 72 individuals for a total of 3,232 days. 54552067 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 43 0 1 565 1 1 1 0 0 0 0 0 0 0 0 10 10 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 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 0 0 0 Ron Moilien 1.00 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 John Young 1.00 X X 0 0 0 Garith Steiner 40.00 X 284356 0 28010 Mary Koenig 40.00 X 187573 0 18952 Kyle Bakkum 40.00 X 186210 0 21888 Dr Jeffrey menn 40.00 X 440544 0 27276 Dr Brian Woody 40.00 X 261531 0 27083 Dr Duane Koons 40.00 X 250454 0 26910 Dr Deborah Prior 40.00 X 239869 0 25483 Brian Miller 40.00 X 304987 0 22848 2155524 0 198450 27 0 1 0 Gundersen Lutheran 1900 South Ave La Crosse WI 54601 Lab/Radiology 985561 Arnold Nomann E7332 Skyline Drive Viroqua WI 54655 Anesthesia 347052 Clinical Ultrasound Services PO Box 7 Postville IA 52162 Ultrasound 222930 RPH on the go PO Box 102640 Atlanta GA 303684640 Pharmacist 214644 Access CRNA Anesthesia Relief Services N2685 Potato Ridge Road La Crosse WI 54601 Anesthesia 207310 8 96235 96235 Hospital 621990 47808448 47808448 Clinic 621110 10120636 10120636 Retail Pharmacy 446110 5708245 5708245 Home Health & hospice 621610 833663 833663 Meals and Dietary 722210 201986 106901 95085 64672978 384358 384358 26 26 236480 236480 236480 236480 1276446 287834 1210561 181485 65885 106349 172234 172234 65562311 58869648 5803330 793098 146238 146238 11000 11000 794907 794907 22606275 20629189 1977086 901629 822775 78854 5538039 5053697 484342 1562370 1387393 174977 68149 68149 70550 70550 4372926 3923995 448931 79763 79763 16746186 16114328 631858 195172 195172 2546127 2546127 80513 63833 16680 2471876 1780282 691594 252928 252928 Bad debt expense 1814227 1814227 Dues and Subscriptions 370228 212441 157787 Miscellaneous 110082 46542 63540 60739185 54552067 6187118 0 1597572 1605297 10223366 11958786 6194236 6681155 2287407 2174541 174817 207820 56245757 21133733 34990566 35112024 7802990 8690342 12180 12180 2322485 2218284 682063 649257 1688204 3086565 67975886 72396251 6174037 5097957 24983680 24315848 26037 12830 549621 2122027 31733375 31548662 X 36149673 40730886 92838 116703 36242511 40847589 67975886 72396251 X 0 1 0 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4885 4885 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: 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. 1176135 1176135 41770403 12864860 28905543 11791913 8268873 3523040 1507306 1507306 35112024 deferred compensation plan liability - funded 1174953 Postretirement Benefit Obligation 302160 Deferred compensation plan liability - unfunded 644914 2122027 65562311 60739185 4823126 601233 -644914 -174367 -218048 4605078 65885524 601233 601233 65284291 278020 278020 65562311 60629726 168561 168561 60461165 278020 278020 60739185 Part X: Description of Uncertain Tax Positions Under FIN 48: 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 RECORDED NO ASSETS OR LIABILITIES FOR UNRECOGNIZED TAX BENEFITS FROM UNCERTAIN TAX POSITIONS IN 2010 OR 2009. FEDERAL RETURNS FOR THE TAX YEARS 2006 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. Part XI, Line 8 - Other Adjustments: Net assets released from restriction for operations: -5806. Postretirement Benefit Obligation Adjustment: -168561. Part XII, Line 4b - Other Adjustments: Expenses netted against revenue on the audited financials: 278020. Part XIII, Line 2d - Other Adjustments: Postretirement Benefit Obligation Adjustment: 168561. Part XIII, Line 4b - Other Adjustments: Expenses netted against revenue on the audited financials: 278020. PART XI, LINE 7 DURING 2010, MANAGEMENT DETERMINED THAT THE DEFERRED COMPENSATION PLAN ASSETS AND RELATED OTHER LONG-TERM LIABILITIES WAS UNDERSTATED IN PRIOR YEARS. TOTAL ASSETS AND TOTAL LIABILITIES WERE UNDERSTATED BY $310,826. IN ADDITION, MANAGEMENT DETERMINED THAT THEY HAVE ANOTHER DEFERRED COMPENSATION PLAN ENTIRELY FUNDED BY THE ORGANIZATION. NET ASSETS AT OCTOBER 1, 2008, WERE UNDERSTATED BY $506,417 AND EMPLOYEE BENEFIT EXPENSE FOR 2009 WAS UNDERSTATED BY $138,497 RELATED TO THIS PLAN. MANAGEMENT CONCLUDED THAT THE FINANCIAL STATEMENTS SHOULD BE RESTATED TO REFLECT THE PROPER PRESENTATION OF THE DEFERRED COMPENSATION PLAN ASSETS, OTHER LONG-TERM LIABILITIES, AND EMPLOYEE BENEFITS EXPENSE. ACCORDINGLY, BEGINNING NET ASSETS DECREASED $506,417 AND REVENUE IN EXCESS OF EXPENSES FOR THE YEAR ENDED SEPTEMBER 30, 2009, DECREASED $138,497 FROM AMOUNTS PREVIOUSLY REPORTED. TOTAL ASSETS INCREASED $310,826 AND TOTAL LONG-TERM LIABILITIES INCREASED $955,740 AT SEPTEMBER 30, 2009. 1 1 1 X 300.000000000000 1 X 1 1 0 1 1 484602 484602 0.00830 6561557 3990062 2571495 0.04380 7046159 3990062 3056097 0.05210 61293 4740 56553 0.00100 178774 178774 0.00300 357137 7450 349687 0.00600 597204 12190 585014 0.01000 7643363 4002252 3641111 0.06210 2762 2762 0.00000 2762 2762 0 1023559 204710 10289601 10440429 -150828 X 1 0 Vernon Memorial Hospital Inc

507 South Main St Viroqua WI 54665

X X X X 4 RURAL HEALTH CLINICS Part I, Line 7: The calculated percent of total expenses excludes bad debt expense of $1,814,227. The expenses recognized in the table were calculated using the cost-to-charge ratio from the medicare cost report. These calculations from worksheet 2 were used to arrive at cost of charity care and unreimbursed Medicaid. The cost of community health improvement and health professionals education reflect the direct and indirect costs as determined by the hospital.Part III, Line 4: Accounts receivable and credit policy The 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. 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. 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 will be conducted in 2011 and 2012. 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: 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 VI, Line 6: 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.Part VI, Line 8: List of states receiving community benefit report: WI 1 Viroqua Area Schools 115 N Education Ave Viroqua WI 54665 396004944 501(c)(3) 22442 General Support Youth Initiative High School 500 East Jefferson St Viroqua WI 54665 391906073 501(c)(3) 12000 General Support Pleasant Ridge Waldorf School 431 E Court St Viroqua WI 54665 391357578 501(c)(3) 10000 General Support Kickapoo Area School District S6520 State Hwy 131 Viola WI 54664 396030294 501(c)(3) 8540 General Support Viroqua Area Foundation PO Box 262 Viroqua WI 54665 391603279 501(c)(3) 60500 General Support DRIFTLESS UNITED ATHLETICS UNITED PO BOX 12 VIRoqua WI 54665 800398975 501(c)(3) 8000 GENERAL SUPPORT NORSEMEN BOOSTER CLUB 206 WEST AVE SOUTH WESTBY WI 54667 392041425 501(c)(3) 11997 GENERAL SUPPORT WESTBY AREA SCHOOL DISTRICT 206 WEST AVE SOUTH WESTBY WI 54667 396005143 501(c)(3) 12759 GENERAL SUPPORT 8 0 BENEFIT FUND CONTRIBUTIONs 1 11000 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 1 0 0 0 Garith Steiner 256837 0 11019 0 16500 0 16528 0 11482 0 312366 0 0 0 Mary Koenig 164885 0 7188 0 15500 0 10139 0 8813 0 206525 0 0 0 Kyle Bakkum 179537 0 6673 0 0 0 10406 0 11482 0 208098 0 0 0 Dr Jeffrey menn 417750 0 6294 0 16500 0 12208 0 15068 0 467820 0 0 0 Dr Brian Woody 254594 0 6937 0 0 0 12015 0 15068 0 288614 0 0 0 Dr Duane Koons 243621 0 6833 0 0 0 11842 0 15068 0 277364 0 0 0 Dr Deborah Prior 218630 0 8239 0 13000 0 13983 0 11500 0 265352 0 0 0 Brian Miller 298694 0 6293 0 0 0 10203 0 12645 0 327835 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 2010 WAS AS FOLLOWS: GARITH STEINER $66,335 MARY KOENIG $29,181 KYLE BAKKUM $24,980 Wisconsin Health and Educational Facilities Authority 391337855 97710VXQ6 2005-05-19 22894672 Finance construction of facility expansion 0 0 22894672 1846325 457893 20590454 2006 0 0 1 1 0 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. Form 990, Part XI, Line 2c Oversight of audit 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 1 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0