2013-05-14T08:01:57-05:00 2012-06-30 861065772 DELOITTE TAX LLP 111 MONUMENT CIRCLE SUITE 2000 INDIANAPOLIS IN 462045108 990 2011-07-01 351899560 ST MARY'S AT HOME INC STMA 8124854178 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 KIM HODGKINSON 8124854178 2013-05-14 1 SHAWNA M JIMENEZ P01222873 3174648600 2013-05-09 2011 2016-03-07 17:11:31Z TIMOTHY A FLESCH 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 6487328 0 X WWW.STMARYS.ORG X 1993 IN PROVIDES HOME HEALTH CARE SERVICES AND DURABLE MEDICAL EQUIPMENT FOR PATIENTS IN THE COMMUNITY. 7 0 0 0 0 0 0 0 5805021 6433221 56290 53978 25 66 5861336 6487265 0 0 0 0 3586388 3993760 0 0 0 2357689 2243294 5944077 6237054 -82741 250211 2582528 3054070 905992 1168729 1676536 1885341 PROVIDES HOME HEALTH CARE SERVICES AND DURABLE MEDICAL EQUIPMENT FOR PATIENTS IN THE COMMUNITY. 0 0 5024678 6433287 PROGRAM SERVICES ARE DEVOTED TO SUPPORTING ST. MARY'S MEDICAL CENTER OF EVANSVILLE, INC. BY PROVIDING HOME HEALTH CARE SERVICES AND DURABLE MEDICAL EQUIPMENT TO PERSONS IN THE EVANSVILLE AREA. NO INDIVIDUALS ARE REFUSED NEEDED MEDICAL CARE AT HOME DUE TO INABILITY TO PAY FOR SERVICES. ST. MARY'S AT HOME IS PART OF ASCENSION HEALTH AND FOLLOWS THE CHARITY CARE POLICIES OF ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. SEE SCHEDULE O FOR ADDITIONAL DETAILS. 5024678 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 0 0 X 7 0 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 IN X KIMBERLY A HODGKINSON 8124854178 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 X GWEN SANDEFUR 65.00 X X 0 372781 48407 DARCY ELLISON 65.00 X 0 349902 85631 DOUG KNIES 65.00 X 0 168989 58758 JANET RAISOR 60.00 X 0 147984 51760 JANICE K ERNEST 60.00 X 0 228659 96993 JOHN RODRIGUES MD 60.00 X 0 386048 10037 DEBBIE POOLE 60.00 X 0 10075 644 MARK MARCHINO 65.00 X 0 130895 8845 0 1795333 361075 0 0 1 0 BKD LLP 910 E ST LOUIS STREET SUITE 200 SPRINGFIELD MO 658011190 PATIENT BILLING RECOVERY 180523 1 NET PATIENT REVENUE 621610 6433221 6433221 6433221 54041 54041 63 -63 -63 -63 PURCHASE DISCOUNTS 900099 66 66 66 6487265 6433287 0 53978 3129893 2380619 749274 635481 483351 152130 228386 173712 54674 135969 103419 32550 7035 5351 1684 186300 141701 44599 168870 128444 40426 5036 3830 1206 24282 18469 5813 27840 27840 COST OF GOODS SOLD 1144910 1144910 SUPPLIES 221559 168519 53040 OTHER PURCHASED SERVICE 108277 82356 25921 REPAIRS AND MAINTENANCE 37868 28802 9066 175348 133355 41993 6237054 5024678 1212376 0 77319 87834 1124917 1317504 1025054 1118185 272744 468311 8085 702851 652787 74409 50064 12172 2582528 3054070 653087 892552 117581 141911 135324 134266 905992 1168729 X 1676536 1885341 1676536 1885341 2582528 3054070 X 250211 -41406 X 0 1 1 X 0 X X X X 0 0 0 ST MARY'S MEDICAL CENTER OF EVANSVILLE 350869065 3 1 0 1 0 139260 98115 41145 563591 554672 8919 50064 INTERCOMPANY DEBT WITH ASCENSION HEALTH ALLIANCE 134266 134266 0 1 0 0 0 0 0 0 0 GWEN SANDEFUR 0 318830 0 48877 0 5074 0 19559 0 28848 0 421188 0 0 DARCY ELLISON 0 234660 0 41424 0 73818 0 62096 0 23535 0 435533 0 0 DOUG KNIES 0 124689 0 26493 0 17807 0 53911 0 4847 0 227747 0 0 JANET RAISOR 0 127730 0 11695 0 8559 0 33596 0 18164 0 199744 0 0 JANICE K ERNEST 0 173139 0 29489 0 26031 0 73586 0 23407 0 325652 0 0 JOHN RODRIGUES MD 0 371480 0 0 0 14568 0 4550 0 5487 0 396085 0 0 SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. A RELATED ORGANIZATION OF ST. MARY'S AT HOME, INC., USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE SUPPLEMENTAL INFORMATION PART III PART I, LINE 4B: ALL EMPLOYEES AND AMOUNTS LISTED ARE VOLUNTARY DEFERRALS OR COMPANY CONTRIBUTIONS TO VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS ORGANIZED UNDER CODE SECTION 457 (F). THE EXACT PURPOSE OF EACH PLAN VARIES BUT THEY INCLUDE: COMPENSATION LIMITATION MAKE-UP PLANS, VOLUNTARY DEFERRAL PLANS, DEFERRAL OF A PORTION OF INCENTIVE BONUS TYPE PLANS, ETC. NO PAYMENTS WERE MADE TO LISTED PERSONS IN PART VII UNDER THE VARIOUS NON-QUALIFIED DEFERRED COMPENSATION PLANS DURING THE YEAR. FORM 990, PART VI, SECTION A, LINE 6 ST. MARY'S AT HOME, INC. HAS A SINGLE CORPORATE MEMBER, SETON HEALTH CORPORATION OF SOUTHERN INDIANA, INC. FORM 990, PART VI, SECTION A, LINE 7A ST. MARY'S AT HOME, INC. HAS A SINGLE CORPORATE MEMBER, SETON HEALTH CORPORATION OF SOUTHERN INDIANA, INC., WHO HAS THE ABILITY TO ELECT MEMBERS TO THE GOVERNING BODY OF ST. MARY'S AT HOME, INC. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO ST. MARY'S AT HOME, INC. FINANCIAL INFORMATION OR CORPORATION AS A WHOLE ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, SETON HEALTH CORPORATION OF SOUTHERN INDIANA, INC. FORM 990, PART VI, SECTION B, LINE 11 ST. MARY'S HEALTH SYSTEM OF AMERICA, INC.'S FINANCE COMMITTEE REVIEWS THE FORM 990 IN MARCH UPON RECEIVING DIRECTION FROM ITS TAX PREPARER. THE FORM 990 IS THEN SENT TO THE GOVERNING BODY IN APRIL TO ALLOW FOR A THOROUGH REVIEW BY THE GOVERNING BODY PRIOR TO THE FILING DATE OF MAY 15TH. THE GOVERNING BODY WILL REVIEW THE FORM 990 VIA A SECURE WEB-BASED PORTAL AND ASK ANY QUESTIONS REGARDING THE FORM 990. ANY QUESTIONS AND RESPONSES WILL BE POSTED TO THE WEB-BASED PORTAL BEFORE THE RETURN IS FILED. ALL QUESTIONS AND RESPONSES WILL BE REVIEWED AND DISCLOSED IN THE MEETING MINUTES OF THE NEXT BOARD MEETING FOLLOWING THE REVIEW OF THE FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY IN THAT ANY DIRECTOR, PRINCIPAL OFFICER, OR MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS, WHO HAS A DIRECT OR INDIRECT FINANCIAL INTEREST, MUST DISCLOSE THE EXISTENCE OF THE FINANCIAL INTEREST AND BE GIVEN THE OPPORTUNITY TO DISCLOSE ALL MATERIAL FACTS TO THE DIRECTORS AND MEMBERS OF THE COMMITTEES WITH GOVERNING BOARD DELEGATED POWERS CONSIDERING THE PROPOSED TRANSACTION OR ARRANGEMENT. THE REMAINING INDIVIDUALS ON THE GOVERNING BOARD OR COMMITTEE MEETING WILL DECIDE IF CONFLICTS OF INTEREST EXIST. EACH DIRECTOR, PRINCIPAL OFFICER AND MEMBER OF A COMMITTEE WITH GOVERNING BOARD DELEGATED POWERS ANNUALLY SIGNS A STATEMENT WHICH AFFIRMS SUCH PERSON HAS RECEIVED A COPY OF THE CONFLICTS OF INTEREST POLICY, HAS READ AND UNDERSTANDS THE POLICY, HAS AGREED TO COMPLY WITH THE POLICY, AND UNDERSTANDS THAT THE ORGANIZATION IS CHARITABLE AND IN ORDER TO MAINTAIN ITS FEDERAL TAX EXEMPTION IT MUST ENGAGE PRIMARILY IN ACTIVITIES WHICH ACCOMPLISH ITS TAX-EXEMPT PURPOSE. COMPENSATION DETERMINATIONS OF ST. MARY'S AT HOME, INC.'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. IN DETERMINING COMPENSATION OF THE ORGANIZATION'S CEO, EXECUTIVE DIRECTOR, OR TOP MANAGEMENT OFFICIAL, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMMITTEE OF THE ST MARY'S HEALTH SYSTEM BOARD REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE CEO, EXECUTIVE DIRECTOR, AND TOP MANAGEMENT WERE COMPARED TO OTHER HOSPITALS IN THE AREA THAT HOLD THE SAME POSITION. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. INDIVIDUALS WERE NOT PRESENT WHEN THEIR COMPENSATION WAS DECIDED. COMPENSATION DETERMINATIONS OF ST. MARY'S AT HOME, INC.'S OTHER OFFICERS OR KEY EMPLOYEES ARE MADE BY A COMPENSATION COMMITTEE OF ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. IN DETERMINING COMPENSATION OF OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION, THE PROCESS INCLUDED A REVIEW AND APPROVAL BY INDEPENDENT PERSONS, COMPARABILITY DATA, AND CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. THE EXECUTIVE COMMITTEE OF THE ST MARY'S HEALTH SYSTEM BOARD REVIEWED AND APPROVED THE COMPENSATION. IN THE REVIEW OF THE COMPENSATION, THE OTHER OFFICERS OR KEY EMPLOYEES OF THE ORGANIZATION WERE COMPARED TO OTHER HOSPITALS' EMPLOYEES IN THE AREA THAT HOLD THE SAME POSITION. DURING THE REVIEW AND APPROVAL OF THE COMPENSATION, DOCUMENTATION OF THE DECISION WAS RECORDED IN THE BOARD MINUTES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION WILL PROVIDE ANY DOCUMENTS OPEN TO PUBLIC INSPECTION UPON REQUEST. FORM 990, PART VII, LINE 1A, COLUMN B: OFFICERS, DIRECTORS, AND KEY EMPLOYEES OF ST. MARY'S AT HOME, INC. PROVIDE SERVICES TO ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND AFFILIATES. HOURS WORKED ARE NOT TRACKED SEPARATELY FOR EACH ENTITY. THEREFORE, HOURS FOR ALL INDIVIDUALS REPORTED ON FORM 990, PART VII, COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, HIGHEST COMPENSATED EMPLOYEES, AND INDEPENDENT CONTRACTORS REPRESENT AGGREGATE HOURS WORKED PER WEEK FOR ALL ENTITIES. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -41,406. FORM 990, PART IV, LINE 24A: ST MARY'S AT HOME, INC. IS A HEALTH FACILITY THAT IS PART OF THE ASCENSION HEALTH SYSTEM. ASCENSION HEALTH IS THE BORROWER FOR TAX-EXEMPT HOSPITAL REVENUE BONDS. ST. MARY'S AT HOME, INC. HOLDS AN INTERCOMPANY NOTE PAYABLE WITH ASCENSION HEALTH, AND THIS INFORMATION IS REPORTED ON THE BALANCE SHEET. FORM 990, PART VII, LINE 1A, COLUMNS D, E, AND F: OFFICERS OF ST. MARY'S AT HOME, INC. PROVIDE SERVICES TO ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND ITS AFFILIATES. COMPENSATION IS NOT REPORTED SEPARATELY BY ENTITY. THEREFORE, COMPENSATION AMOUNTS REPORTED ON FORM 990, PART VII, COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, AND KEY EMPLOYEES REPRESENT COMPENSATION PAID FOR MANAGING ST. MARY'S HEALTH SYSTEM OF AMERICA, INC. AND ALL RELATED ENTITIES. CHARITY CARE SUMMARY FOR FISCAL PERIOD JULY 1, 2011 TO JUNE 30, 2012 FORM 990, PART III, LINE 4A: CATEGORY 1 CARE OF THE POOR CHARITY - $134,242 CATEGORY 2 CARE OF THE POOR MEDICAID - $721 CATEGORY 5 BAD DEBTS ATTRIBUTABLE TO CHARITY - $58,711 ST MARY'S BREAST CENTER LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 351935526 MAMMOGRAPHY IN 919860 1477316 SETON PHYSICIANS' HEALTH GROUP LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 043679294 DISSOLVED IN 0 0 SMMC ST MARY'S PHYSICIANS' HEALTH GROUP LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 261356310 PHYSICIAN PRACTICE IN -3093234 2385048 SMMC ST MARY'S AT WORK LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 272085003 DORMANT IN 0 0 SETON ST MARY'S MEDICAL GROUP LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 261356310 DORMANT IN 0 0 SMMC ST MARY'S BUILDING CORPORATION 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 237248362 REAL ESTATE IN 501(C)(2) SETON 1 ST MARY'S WARRICK EMS INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 205342518 EMS IN 501(C)(4) SMHS 1 MEDICAL MANAGEMENT INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 351831570 DORMANT IN 501(C)(3) 11C, III-FI SMHS 1 ST MARY'S HEALTH SYSTEM OF AMERICA INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 352057801 HEALTH MINISTRY PARENT IN 501(C)(3) 11C, III-FI ASCENSION HEALTH 0 ST MARY'S PHYSICIAN NETWORK LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 205023387 PHYSICIAN PRACTICE IN 501(C)(3) 9 SMMC 1 PRIMARY PHYSICIAN NETWORK LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 208775914 PHYSICIAN PRACTICE IN 501(C)(3) 9 SMMC 1 SETON HEALTH CORPORATION OF SOUTHERN INDIANA INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 351679526 INVESTMENT IN 501(C)(3) 11C, III-FI SMHS 1 ST MARY'S HOME HEALTH CARE SERVICES INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 351899562 DORMANT IN 501(C)(3) 11A, I SETON 1 ST MARY'S MEDICAL CENTER FOUNDATION INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 237045370 FUNDRAISING IN 501(C)(3) 11A, I SMMC 1 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC 3700 WASHINGTON AVENUE EVANSVILLE IN 47750 350869065 HOSPITAL IN 501(C)(3) 3 SMHS 1 ST MARY'S WARRICK HOSPITAL FOUNDATION INC 1116 MILLIS AVENUE BOONVILLE IN 47601 351961890 FUNDRAISING IN 501(C)(3) 11A, I SMW 1 ST MARY'S WARRICK HOSPITAL INC 1116 MILLIS AVENUE BOONVILLE IN 47601 351343019 HOSPITAL IN 501(C)(3) 3 SMHS 1 ST MARY'S OHIO VALLEY HEARTCARE LLC 901 ST MARYS DRIVE EVANSVILLE IN 47714 273474697 CARDIOLOGIST SERVICES IN 501(C)(3) 11A, I SMMC 1 SVSM INC 2001 W 86TH STREET INDIANAPOLIS IN 46260 810607827 HOLDING COMPANY IN 501(C)(3) 11A, I SVH 1 ASCENSION HEALTH PO BOX 45998 ST LOUIS MO 63145 311662309 NATIONAL HEALTH SYSTEM MO 501(C)(3) 11A, I N/A 0 AMBULATORY CARE CENTER LLC 1125 PROFESSIONAL BLVD EVANSVILLE IN 47714 352006018 OP SURGERY IN SETON RELATED 3892985 4257562 0 0 0.50000 ST MARY'S ACUTE DIALYSIS SERVICES LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 271346179 MANAGEMENT IN SETON RELATED 618570 119625 0 0 0.50000 SETON HEALTH SERVICES LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 270451316 EQUIP RENTAL IN SETON RELATED 28967 140493 0 0 0.50000 ST MARY'S PERIPHERAL VASCULAR SERVICES MANAGEMENT COMPANY LLC 3700 WASHINGTON AVE EVANSVILLE IN 47750 205062635 MANAGEMENT IN SMOVHC RELATED -12633 40241 0 0 0.50000 ST MARY'S MEDICAL GROUP INC AND SUB 3700 WASHINGTON AVE EVANSVILLE IN 47750 352076827 INVESTMENT IN SMHS C -611983 641965 1.00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 ST MARY'S MEDICAL CENTER OF EVANSVILLE INC O 5778180 FMV OR SERVICES OR CASH