2011-08-04T12:55:35-05:00 2010-09-30 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2009-10-01 390806324 DOOR COUNTY MEMORIAL HOSPITAL DOOR 9207435566 323 SOUTH 18TH AVENUE Sturgeon Bay WI 54235 Robert Scieszinski 9207435566 2011-07-12 1 Terri Rexrode CPA MST 9206620016 2011-07-12 2009 2016-02-24 21:20:13Z MINISTRY DOOR COUNTY MEDICAL CENTER Robert Scieszinski 323 s 18th ave Sturgeon Bay WI 54235 64690735 0 X www.ministryhealth.org/DCMH/home.nws X 1944 WI Door County Memorial Hospital, Inc. is a fully accredited, acute-care hospital and outpatient medical center. The hospital offers a full range of services and specialties, including home health, a skilled nursing facility for long-term care and rehabilitation services, a rehab services department and North Shore Medical Clinic. 16 12 661 135 0 0 133939 164367 59415187 64035420 155940 -151082 113521 138803 59818587 64187508 14002 22375 0 35626681 38638502 0 0 20031058 21695788 55671741 60356665 4146846 3830843 59785687 74283847 12955373 22828722 46830314 51455125 Our Mission as a Catholic health care system is to further the healing ministry of Jesus by continually improving the health and well being of all people, especially the poor, in the communities we serve. 0 0 48848838 22375 63695734 DOOR COUNTY MEMORIAL HOSPITAL PROVIDES THE FOLLOWING HEALTH CARE PROGRAMS: HOSPITAL INPATIENT WITH DAYS TOTALING 5,290, OUTPATIENT SERVICES THAT SERVED 77,387 VISITS, 30 BED EXTENDED CARE FACILITY, CLINIC THAT SERVED 58,995 VISITS, AND A REHABILITATION AGENCY THAT HAD 40,795 VISITS. 48848838 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 86 0 661 1 0 0 0 0 0 0 0 0 0 16 12 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 WI X ROBERT SCIENSZINSKI 9207435566 323 SOUTH 18TH PLACE STURGEON BAY WI 542351495 CHARLES BRANN 1.00 X X 0 0 0 gregory CASPERSON 1.00 X 0 0 0 barth guilette 1.00 X 0 0 0 toM HERLACHE 1.00 X 0 0 0 DR JAMES LEWIS 1.00 X X 9350 0 374 josEph MCMAHON 1.00 X X 0 0 0 pATRICK O'HERN 1.00 X X 0 0 0 eric Paulsen 1.00 X 0 0 0 sally pfeifer 1.00 X 0 0 0 jeff rabas 1.00 X 0 0 0 dr george roenning 1.00 X 189433 0 35264 grace Rossman 1.00 X 0 0 0 dr kelton reitz 40.00 X 293061 0 25377 david ward 1.00 X 0 0 0 cathy wiese 1.00 X 0 0 0 GERALD WORRICK 40.00 X X 0 379309 49116 ROBERT SCIESZINSKI 40.00 X 0 205603 53019 JODY BOES 40.00 X 0 180866 39036 SANDRA MCKUEN 40.00 X 0 23430 1815 STEVEN QUADE 40.00 X 0 131461 41891 STEVEN DAVIS 40.00 X 441312 0 42637 Dorene Dempster 40.00 X 299190 0 40137 Richard Hogan 40.00 X 348182 0 37637 MICHAEL S BRUNO 40.00 X 329736 0 42137 RICHARD L HECKER 40.00 X 312725 0 14047 2222989 920669 422487 33 0 1 0 THE BOLDT COMPANY po box 419 appleton WI 54912 construction services 1119371 BERNER SCHOBER ASSOCIATES 310 PINE STREET GREEN BAY WI 54301 ARCHITECTURAL AND DESIGN SERVICES 859041 infinity healthcare inc 111 e wisconsin ave milwaukee WI 54302 ER PHYSICIANS 495000 MARSHFIELD LABORATORIES 1000 N OAK AVE MARSHFIELD WI 54449 LABORATORY TEST 464059 ARAMARK SERVICES 2300 WARRENVILLE ROAD DOWNERS GROVE IL 60515 MANAGEMENT OF DIETARY, HOUSEKEEPING AND 369951 16 164367 164367 net PATIENT SERVICE R 624100 62917051 62917051 oncology clinic revenu 624100 600637 600637 cafeteria sales 624100 213630 213630 WASHINGTON ISLAND SUB 624100 135000 135000 lifeline revenue 624100 108179 108179 60923 43046 17877 64035420 104406 104406 341097 202294 138803 138803 138803 45445 300933 -255488 -255488 -255488 64187508 63695734 0 327407 22375 22375 1672559 1672559 28816887 24684385 4132502 1427533 1199147 228386 4881558 3977498 904060 1839965 1542107 297858 353489 353489 309920 309920 1542 1542 3941719 3406464 535255 654975 3407 651568 8094427 7610443 483984 760310 150209 610101 1075108 919756 155352 369042 265564 103478 320398 320398 3107929 2424746 683183 254399 279323 -24924 PROVISION FOR BAD DEBTS 1501836 1501836 Recruitment 422039 376702 45337 Dues & Subscriptions 137259 60266 76993 Planning, Research, and 104035 104035 Permits & Licenses 103359 95609 7750 184002 8603 175399 60356665 48848838 11507827 0 23251 22218 8804395 7180719 8093902 8714090 1107977 1367938 667076 913762 1166218 1288649 68988679 30249962 22837550 38738717 2210701 2409008 14874617 13648746 59785687 74283847 5639029 7026271 7316344 15802451 12955373 22828722 X 46595671 51221755 234643 233370 46830314 51455125 59785687 74283847 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 5003 5003 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: LOBBYING PORTION OF DUES PAID TO WHA - $2,055 LOBBYING PORTION OF DUES PAID TO RHWC - $2,948 598339 598339 44239343 13766983 30472360 668425 479427 188998 23304655 15870408 7434247 177917 133144 44773 38738717 Third Party Settlement 2440671 Other A/R 589065 Foundation 230743 LSHS Investment 8290941 Due from affiliate 2097326 13648746 64187508 60356665 3830843 944730 -150762 793968 4624811 Part XI, Line 8 - Other Adjustments: NET TRANSFER FROM AFFILIATE: -38446. Ministry Home Care Loss Funding: -140299. Restricted Fund Activity for Katies's Fund: 27983. 1 1 1 X 1 X 1 1 0 1 1 1545471 1545471 0.02630 6300808 4303529 1997279 0.03390 7846279 4303529 3542750 0.06020 1468063 258273 1209790 0.02060 73295 73295 0.00120 181485 181485 0.00310 1722843 258273 1464570 0.02490 9569122 4561802 5007320 0.08510 1653 1653 0.00000 580 580 0.00000 3501 3501 0.00010 131711 131711 0.00220 2474 2474 0.00000 159842 159842 0.00270 299761 299761 0.00500 1 853923 0 16147609 20715270 -4567661 X 1 1 Door County Memorial Hospital

323 S 18th Ave Sturgeon Bay WI 54235

X X X X North Shore Medical Clinic

3711 Hwy 42 Fish Creek WI 54212

OP Phys Clinic north Shore Medical Clinic

815 Jefferson St Algoma WI 54201

oP Phys Clinic north Shore Medical Clinic

910 Main Rd Washington Island WI 54246

oP Phys Clinic north Shore Medical Clinic

323 S 18th Ave Sturgeon Bay WI 54235

oP Phys Clinic Part I, Line 6a: As part of Ministry Health Care, Inc., the organization files an annual community benefit report on its webpage. The report can be viewed by visiting www.ministryhealth.org/MinistryHealth/Community.nws. Part I, Line 7: Amounts calculated in Part I, Line 7 are determined both on a cost accounting system and a cost-to-charge ratio. Other benefits are determined based on the direct and indirect costs (where allocated) associated with a program net of earned revenue. Detail for each program/activity is maintained and determined at the department level. Charity care and means tested programs are determined based on a cost-to-charge ratio consistent with Worksheet 2, ratio of Patient Care Cost to Charge. Prior year cost report settlements are excluded from the shortfall calculation in order to get a true fiscal year shortfall amount. Part I, Line 7f: In the calculation of Part I, line 7, column (f), the total expenses from Part IX, line 25 were reduced by bad debt expense of $1,501,836. Part III, Line 4: The calculation above started with the actual patient charges written off to bad debt and contractual reserves multiplied by ratio of patient care cost to charge ratio. These accounts are considered uncollectable. Part III, Line 9b: DCMH has a debt collection policy which sets forth collection practices for patients who are known to qualify or may qualify for financial assistance under the charity care program. Sufficient financial counseling support is made available to patients so they can easily access patient financial service representatives and have their questions answered, and gain an understanding of the reasons why they owe a balance. Accounts are designated as charity care in the business offices so no additional time is spent on collection efforts. Part VI, Line 2: The organization performs community needs assessments as needed. Planning workgroups consisting of community partners are formed to define the community and its needs through review of Health People Initiatives, census documents, and local government health and welfare agencies. Considering other community resources/assets, data collection methods are used to identify particular problems or subgroups and areas known to have high poverty rates and to be underserved. The data is analyzed and priorities are set based on trending information which may target a specific need. When a need is identified, the hospital develops a plan to implement a program either through community collaboration or individually. Outcomes from the programs are measured and considered in subsequent community needs assessments. Community benefit plans are presented to senior leadership and board members to ensure the findings are incorporated into the organization's strategy and policy development. For example, senior leaders are required to provide direct service to the poor hours as part of their performance goals. Part VI, Line 3: The organization goes to great lengths in order to inform and educate patients/persons who may be billed for patient care about their eligibility for assistance under federal, state or local government programs and under the organization's charity care policy. The charity care policy and application is posted on the organization's website. Admissions and other key areas contain summary information of the charity care policy. As part of the intake/discharge process, patients are provided with a copy of the policy and other information for financial assistance. If during the course of the patient registration process, treatment, or upon discharge it becomes evident that a patient may need financial assistance, the patient shall be referred to the organization's community care program. Patients may be identified as needed financial assistance at any time during the course of an encounter. A referral for consideration of community care financial assistance can be initiated by any member of the hospital's workforce, including medical staff members, who become aware of the patient's potential need for community care financial assistance. The charity care policy was also translated into dialects prevalent in the community in order to reach out to those that may speak another language. Patient Registration staff and Financial Counselors are provided with scripts to follow when interacting with patients. As part of the charity care process, patients must register with the county public assistance to see if they may qualify under any other federal or state programs. Part VI, Line 4: While there is growing agreement in the United States about what constitutes a non-profit hospital's "community benefit", this is a work in progress. DCMH provided 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. Part VI, Line 5: Some of the things included in this area are working with community organizations such as Rotary, Leadership of Door County, and Loaves and Fishes. Workforce development includes Health Care Career Presentations and school/community programs that allow job shadowing and mentoring. Support a community garden and work with local emergency agencies regarding disaster readiness. Part VI, Line 6: -The local Board for Door County Memorial Hospital is made up of community members that live in our primary service area.-Door County Memorial Hospital partners with the local YMCA on various events promoting health and well being in the community.-Door County Memorial Hospital extends medical privileges to all qualified physicians in the community. -Door County Memorial Hospital participates in Medicare, Medicaid, and other government sponsored programs. Part VI, Line 7: The organization is part of an affiliated health care system called Ministry Health Care, Inc. The mission of Ministry as a Catholic health care system is to further the healing ministry of Jesus by continually improving the health and well being of all people, especially the poor, in the communities served. Ministry supports such non-hospital facilities as the Agape Community Center. As a community center, it has the unique advantage of welcoming youth, adults, families and seniors into the facility through a broad range of educational, social, recreational, cultural, health and life-long learning opportunities in an impoverished portion of Milwaukee. Our Catholic Identity expects leaders to initiate and support efforts to reach out to the poor and vulnerable people, especially where no one else wants to go. Health care can become very bureaucratic and burdened with oversight of finances, regulatory requirements and strategic planning. Our focus on these issues may cause us to lose touch with those for whom we have a primary responsibility, those who are poor and vulnerable. Tithing of time allows us to look into the face of the poor, hear the voice of the poor, and help us better understand the daily challenges and barriers they face. As an affiliated health system, all leaders with direct reports are required to provide service to the poor. This also includes physician leaders and hourly supervisory staff. The organization also participates in the Ministry Health Care Fund which provides monies for special projects within the communities we serve. All organizations sponsored or co-sponsored by Ministry Health Care, Inc. set aside monies each year to assist with the needs of the community and the poor. As the Ministry Health Care Fund, these dollars are funneled back into our communities for a variety of programs and services through a community assets and needs assessment process. WI 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: Our organization did not issue "grants". We did provide assistance to the Community Clinic by providing free lab services up to $12000 for the year. The other type of assistance we provide is community care or charity care for patients who are eligible. Documentation is kept in the patient records and patient financial services office. 1 X X X X 0 0 0 0 0 0 0 0 0 dr george roenning 188128 0 100 0 1205 0 11724 0 23540 0 224697 0 0 0 dr kelton reitz 226402 0 66476 0 183 0 14700 0 10677 0 318438 0 0 0 GERALD WORRICK 0 231019 0 70711 0 77579 0 30480 0 18636 0 428425 0 0 ROBERT SCIESZINSKI 0 149281 0 30666 0 25656 0 31743 0 21276 0 258622 0 0 JODY BOES 0 138154 0 24038 0 18674 0 17952 0 21084 0 219902 0 0 STEVEN QUADE 0 99590 0 16992 0 14879 0 16007 0 25884 0 173352 0 0 STEVEN DAVIS 440892 0 0 0 420 0 14700 0 27937 0 483949 0 0 0 Dorene Dempster 298916 0 0 0 274 0 14700 0 25437 0 339327 0 0 0 Richard Hogan 299382 0 48015 0 785 0 14700 0 22937 0 385819 0 0 0 MICHAEL S BRUNO 281399 0 48063 0 274 0 14700 0 27437 0 371873 0 0 0 RICHARD L HECKER 180491 0 129914 0 2320 0 9800 0 4247 0 326772 0 0 0 Form 990, Part VI, Section A, line 6 Ministry Health Care, Inc. is the corporate member of Door County Memorial Hospital, Inc. Form 990, Part VI, Section A, line 7a Ministry Health Care, Inc. has the power to appoint and remove members of the Board of directors. Form 990, Part VI, Section A, line 7b Ministry Health Care, Inc. has the power to initiate and approve all amendments to the Articles of Incorporation and Bylaws. Form 990, Part VI, Section B, line 11 THE FORM 990 WAS PROVIDED TO THE ORGANIZATION'S Finance committee after It WAS FILED. THE EXECUTIVE COMMITTEE HAS DESIGNATED THE DETAIL REVIEW OF THE FORM 990 TO MANAGEMENT, BUT HAS FINAL APPROVAL OF THE RETURN. Form 990, Part VI, Section B, line 12c Jerry Worrick, CEO, Robert Scieszinski, CFO, and Ron Mohorek watch for proposals that are being voted on at the Board meetings in the event that the particular proposal might be considered a conflict of interest for any of the voting members. Form 990, Part VI, Section B, line 15 Ministry Health Care and Door County Memorial Hospital use Comparability data to determine compensation. The Ministry Board of Directors has a compensation committee that is assisted by an independent outside consulting firm; Sillivan Cotter. Sullivan Cotter, in partnership with the compensation committee of the Board of Directors, reviews market data for compensation and benefits and comparability data on every Ministry Health Care executive. Gerald Worrick, CEO, and Greg Holub, VP Clinic, uses AMGA data by region and specialty to determine compensation for the Physicians. This process is documented with the Ministry Health Care compensation committee. Form 990, Part VI, Section C, line 19 UPON REQUEST Form 990 Part XI line 2b-c and Form 990 Part IV line 12 Audited Financial Statements Door County Memorial Hospital's financial statements are audited as part of Ministry Health Care's consolidated statements. THERE HAS BEEN NO CHANGE IN THE OVERSIGHT OR SELECTION PROCESS BETWEEN THE CURRENT AND PRIOR YEAR. Ministry Health Care 11925 W Lake PArk Drive Milwaukee WI 53224 391490371 Support related Healthcare organizations WI 501(c)(3) 11B-II N/A Door County Memorial Hospital Foundation Inc 1843 Michigan Street Sturgeon Bay WI 54235 391649104 Raise Funds in support of Door County Memorial Hospital, Inc. WI 501(c)(3) 11a-I N/A 0 0 0 1 0 0 0 0 0 0 0 1 1 1 1 1 0 0 Ministry Health Care Inc D 322328 Ministry Health Care Inc L 2076216 Ministry Health Care Inc P 384225 ministry Health Care Inc O 370974