2012-10-28T23:37:57-05:00 2011-12-31 861065772 Deloitte Tax LLP 111 South Wacker Drive Chicago IL 60606 990 2011-01-01 621136742 Alexian Village of Tennessee ALEX 4238860100 437 Alexian Way Signal Mountain TN 373771860 Matthew Fox 4238860100 2012-10-26 1 Laura Gillespie P00855604 3124861000 2011 2016-02-24 21:20:13Z Robin Baschnagel 437 Alexian Way Signal Mountain TN 373771860 22857875 0 0928 X www.alexianbrothershealth.org X 1983 TN AVT carries out the healing mission of the Catholic Church (See Schedule O) as an Alexian Brothers ministry by identifying and developing effective responses to the health and housing needs of those we are called to serve. 6 5 479 100 0 0 342321 78402 22074021 22598336 354270 181137 0 0 22770612 22857875 6000 0 0 0 10280921 10949069 0 0 0 10881861 11309924 21168782 22258993 1601830 598882 52778663 53155611 48172788 48206876 4605875 4948735 X Alexian Village of Tennessee ("AVT") carries out the healing mission of the Catholic Church as an Alexian Brothers ministry by identifying and developing effective responses to the health and housing needs of those we are called to serve. 0 0 15472239 20010848 Alexian Village of Tennessee ("AVT") provides a continuum of services to residents of AVT (101,483 resident days served), assisted living services to residents of Alexian Inn (8,187 days served) and residents of the health care center (37,307 days served) that maximizes dignity and independence. Although reimbursement for services rendered is critical to the operation and stability for the continuum of services, as a charitable organization, it is recognized that not all persons served possess the ability to purchase essential services needed for care and our mission is to serve the community with respect to providing health care services. In 2011, over $65,000 was provided in charitable care. AVT also serves the communities of Signal Mountain and Chattanooga by providing programs throughout the year. Meeting rooms are provided at no costs to local charitable organizations and community groups. As a religious organization, AVT also employs staff to provide chaplaincy services. There are multiple chapels at AVT, which have daily interdenominational services & programs. 1836930 1578122 Alexian Brothers Valley Residence ("ABVR") is a separate and distinct division of AVT. It exists to provide a secure environment to those suffering from dementia or Alzheimer's disease. On average, 32 residents were served each day of 2011. Such services include nursing assistance with activities of daily living, recreational activities, meal preparation and dining, and spiritual wellness. In addition, ABVR provides short term respite care and an adult day care program, also to serve those suffering from dementia or Alzheimer's disease. 742467 1009366 Alexian Grove is a separate and distinct division of the AVT organization. It exists to provide independent, residential retirement living while promoting the well-being of all those served through a delivery of quality services. Alexian Grove is home to almost 35 senior citizens in independent apartments (on average 32 persons served each day). In keeping with our commitment to serve all members of Chattanooga and the surrounding community, free or subsidized care and other activities and programs to support the community at large are considered and provided when appropriate. 18051636 1 1 0 0 0 0 0 0 0 1 1 1 0 1 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 38 0 1 479 1 0 0 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 TN X Kelli Payne 4238860100 250 East 10th Street Signal Mountain TN 37421 X Sue D Culpepper 1.00 X 0 0 0 Brother Andrew Thome CFA 1.00 X 0 0 0 Kathleen Puri RN MSN 1.00 X X 0 0 0 Robert Main 1.00 X X 0 0 0 Linda Bennett 1.00 X X 0 0 0 John Turongian 1.00 X X 0 240368 43828 Matthew Fox 40.00 X 0 182240 41143 Virginia Golembiewski 1.00 X 0 69801 16144 Jim Lewandowski 1.00 X 0 372210 66995 Homer Sanders 40.00 X 120806 0 4263 Tim Booth 40.00 X 0 104940 5648 120806 969559 178021 1 0 1 0 Reese Lower Patrick & Scott 1910 Harrington Drive Lancaster PA 17601 Architect/Engineering 729110 Morgan Construction PO Box 4404 Chattanooga TN 37405 Renovation Contractor 631194 Tennessee Lawn Care LLC PO Box 264 Signal Mountain TN 37377 Grounds & Landscaping Contractor 533405 Mountain City Electric Inc PO Box 5319 Chattanooga TN 347060319 Electrician Contractor 358237 Jolley Building 243 Signal Mountain Road Chattanooga TN 37405 Contractor 118000 6 78402 78402 Lifecare & Independent 623000 11889074 11889074 Skilled Nursing 623000 4471990 4471990 Medicare & Medicaid 623000 3346373 3346373 Assisted Living 623000 2094197 2094197 Adult Day Care 624100 35126 35126 761576 761576 22598336 181137 181137 22857875 22598336 0 181137 8307957 7555543 752414 169235 154112 15123 1870988 1686610 184378 600889 560411 40478 147450 850 146600 16775 16775 1142796 767536 375260 70664 2320 68344 499902 434609 65293 43181 326 42855 1569149 1569149 27765 10654 17111 14283 13946 337 82642 82642 2787460 2729050 58410 237506 237506 Food 1643080 1643080 Property & Bed Taxes 805909 805909 Management Fees - ABHS 667024 667024 Medical Supplies 414532 414532 1139806 508908 630898 22258993 18051636 4207357 0 -236276 -619152 50000 2242285 3830660 79397 100524 56403 72034 81845946 39224549 38592205 42621397 8773203 4370983 3221446 2779165 52778663 53155611 2200512 2520288 14600000 14000000 973928 938197 30398348 30748391 48172788 48206876 X 1822532 2511550 2271421 1972954 511922 464231 4605875 4948735 52778663 53155611 X 598882 -256022 X 0 1 1 X 0 X 182963 221577 244922 169787 78402 897651 19566986 21594608 21471012 22074021 22598336 107304963 19749949 21816185 21715934 22243808 22676738 108202614 0 0 0 108202614 411498 -358336 128476 277269 181137 640044 411498 -358336 128476 277269 181137 640044 20161447 21457849 21844410 22521077 22857875 108842658 0.99410 0.99480 0.00590 0.00770 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 511922 2309 50000 464231 517303 14232 19613 511922 504858 12445 517303 1.00000 0 1 1 975034 975034 62702505 26606083 36096422 14542736 10571966 3970770 3625671 2046500 1579171 42621397 Beneficial Interest in Alexian Brothers Health System, Inc. Investment Trust 4370983 F 4370983 Due from Affiliates 24706 Deferred Finance Charges 364207 Land for Future Development 1310000 Restricted Assets 1080252 2779165 Unamortized Life Entry Fees 30578436 Resident Security Deposits 100644 Reserve for Outstanding Ins Losses 48653 Annuity Payables 17865 Resident Personal Funds 2793 30748391 Description of Uncertain Tax Positions Under FIN 48: Part X: Alexian Village of Tennessee does not file a separate audit report, but is part of the Alexian Brothers Health System consolidated audit report. There were no uncertain tax positions, and as a result there was no disclosure related to FIN 48 (ASC740) in the December 31, 2011 audit report. 0 1 0 0 0 0 0 0 0 John Turongian 0 213212 0 27156 0 0 0 22190 0 21638 0 284196 0 0 Matthew Fox 0 163209 0 10829 0 8202 0 13300 0 27843 0 223383 0 0 Jim Lewandowski 0 280338 0 56701 0 35171 0 35309 0 31686 0 439205 0 12354 Part I, Line 3 Alexian Village of Tennessee follows the requirements set forth in the IRS rebuttable presumption of reasonableness in determining compensation of the CEO and other officers and executives of the Corporation. This function is performed by the Compensation Committee of the Board of Governors of Alexian Brothers Health System, which is comprised of independent board members. The process includes review of comparability data, retention of an outside compensation consultant, and contemporaneous substantiation of the deliberation and decision through detailed minutes of the Compensation Committee. All of the items in Schedule J, Part I, Line 3 are used by the Committee to establish compensation for the CEO of the organization. Supplemental Information Part III Part I, Line 4b: Alexian Brothers Health System offers a Supplemental Employee Retirement Plan to all employees who participate in the executive benefits program and whose compensation exceeds the IRS allowable limit for a qualified pension plan. The amount accrued in 2011 was included in income in Schedule J for the following individual: Jim Lewandowski - $5,297. Form 990, Part VI, Section A, line 6 The Organization has two classes of members, Alexian Brothers Health System (the "National Member") and Alexian Brothers Senior Ministries (the "Area Member"). Form 990, Part VI, Section A, line 7a Alexian Brothers Health System has the authority to appoint and remove Directors and Executive Officers of Alexian Village of Tennessee. Form 990, Part VI, Section A, line 7b Alexian Brothers Health System has principal authority with respect to the following matters: - Adoption or amendment of the Articles of Incorporation; - Amendment of the Bylaws as provided by Statute; - Appointment and removal of Directors and Executive Officers; - Adoption, amendment and repeal of fundamental statements of mission, philosophy, spirit, vision, values, charity policy, and the sponsorship of apostolic activities; - Any plan of merger, consolidation, dissolution, sale or lease of all or substantially all of the assets of Alexian Village of Tennessee; - The annual capital and operating budget and the Strategic Plan of Alexian Village of Tennessee; - Other certain reserved powers which Alexian Brothers Health System may designate. Form 990, Part VI, Section B, line 11 Alexian Village of Tennessee is an affiliate of Alexian Brothers Health System ("ABHS" or "the System"), which is a Catholic health system. Alexian Brothers Health System is the National Member and ultimate parent for each entity within the System. Alexian Village of Tennessee's Form 990 goes through an intensive review process at the System's Corporate level prior to being filed with the IRS. The entire Form 990 is reviewed by Alexian Village of Tennessee's financial officer and the CEO. The Form 990 is also reviewed at the System Corporate level by the Chief Accounting Officer for the System. The Vice President and General Counsel for the System reviews all sections of the Form 990 with the exception of the compensation section. The Vice President of Human Resources for Alexian Brothers Health System reviews all compensation disclosures for each entity in Alexian Brothers Health System. These reviews were conducted before the Form 990 was signed and filed with the IRS. In addition, there is also a Compensation Committee that reports to the Alexian Brothers Health System Board of Governors. This Committee reviews the Compensation disclosures for all entities in the System. Alexian Village of Tennessee's board reports to the Alexian Brothers Health System Board of Governors, which has ultimate oversight of the activities of all entities within the System. The Audit Committee of the Alexian Brothers Health System Board of Governors has responsibility for and oversight of the Tax Compliance process. The Audit Committee provides oversight for the Form 990 process for the entire System and reviews detailed Forms 990 for the System on an as requested basis. It then reports back to the Alexian Brothers Health System Board of Governors on the results of these activities. The Forms 990 not reviewed by the Audit Committee are available to the Audit Committee members upon request. The Audit Committee did not review the 2011 Form 990 for Alexian Village of Tennessee. Form 990, Part VI, Section B, line 12c Alexian Village of Tennessee collects annual attestations from board members, officers, directors and key employees. The attestations are reviewed by the Alexian Village of Tennessee compliance officer and any conflicts are shared with the Alexian Village of Tennessee Chief Executive Officer. The conflicts are also reviewed by the System's Vice President, Corporate Responsibility Officer. The Audit Committee of the Alexian Brothers Health System Board of Governors monitors and receives reports on the completion of this process. Form 990, Part VI, Section B, line 15 Alexian Village of Tennessee follows the requirements set forth in the IRS rebuttable presumption of reasonableness in determining compensation of the CEO and other officers and executives of the Corporation. This function is performed by the Compensation Committee of the Board of Governors of Alexian Brothers Health System, which is comprised of independent board members. The process includes review of comparability data, retention of an outside compensation consultant, and contemporaneous substantiation of the deliberation and decision through detailed minutes of the Compensation Committee. Form 990, Part VI, Section C, line 19 Alexian Village of Tennessee's financial statements are available through the National Reporting Municipal Services Information Repository (NRMSR). Conflicts of Interest and Alexian Village of Tennessee's governing documents are not made available to the public. Form 990, Part VII: Average hours devoted to related organizations when related compensation is reported: - John Turongian, Jim Lewandowski and Virginia Golembiewski each worked 40 hours per week for Alexian Brothers Health System. - Matt Fox worked 40 hours per week for the filing organization. Form 990, Part VII, Column E: Description of reasonable effort made to obtain compensation from related organization: Payroll records are kept that identify which officers/key employees are paid by a related entity. These documents also identify the organization being charged for the officer's/key employee's services. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -14,739. Donation 30. Transfers for Operating Purposes -199,644. Investment Income 8,331. Pledge Discounts -50,000. Total to Form 990, Part XI, Line 5: -256,022. Part VIII, Line 3; Schedule D, Part VII: The amount reflected as dividends and interest reflects AVT's share of interest, dividends and realized gains from AVT's beneficial share in the Alexian Brothers Health System, Inc. Investment Trust (ABHSIT). ABHSIT is a related entity whose purpose is to pool the investments of the not-for-profit entities in ABHS and acts as an internal mutual fund. Details of gains and losses are shown on the Form 990 of ABHSIT. Alexian Brothers of America Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 362606768 Religious order of Roman Catholic men TX Section 501(c)(3) 1 N/A 0 Brothers of St Alexius Health and Welfare Fund Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 362976617 Provides for health & welfare payments for religious sponsor TX Section 501(c)(3) 1 Alexian Brothers of America Inc 1 Alexian Brothers Bonaventure House 825 Wellington Avenue Chicago IL 60657 363527899 Housing and supportive care services for persons with HIV/AIDS IL Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Health System 3040 W Salt Creek Lane Arlington Heights IL 600051069 363260495 Supports provision of healthcare services for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers of America Inc 1 Alexian Brothers Health System Inc Inv Trust 3040 W Salt Creek Lane Arlington Heights IL 600051069 363801585 Manages pooled investments of related not-for-profit entities IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Alexian Brothers of America Investment Trust 3040 W Salt Creek Lane Arlington Heights IL 600051069 364390471 Manages pooled investments of related not-for-profit entities IL Section 501(c)(3) 11, III-FI Alexian Brothers of America Inc 1 Alexian Brothers Specialty Group 3040 W Salt Creek Lane Arlington Heights IL 600051069 800710751 Specialty physician practice group IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers of Chicago 3040 W Salt Creek Lane Arlington Heights IL 600051069 Inactive Corporation IL Section 501(c)(3) 9 Alexian Brothers of America Inc 1 Alexian Brothers of San Jose Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 941530037 Acute care hospital (sold in 1998) TX Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Services Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 431295333 HUD housing MO Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Village of Milwaukee Inc 9301 N 76th Street Milwaukee WI 53223 391351584 Continuing care retirement community WI Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Community Services 425 Cumberland Street Suite 110 Chattanooga TN 37404 364344423 Provides comprehensive & coordinated community based services IL Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Senior Neighbors 250 East 10th Street Chattanooga TN 37402 620646376 Supports the provision of community services for senior citizens TN Section 501(c)(3) 7 Alexian Brothers Health System 1 Alexian Brothers Senior Ministries 3040 W Salt Creek Lane Arlington Heights IL 600051069 364484290 Supports the provision of healthcare for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Alexian Elderly Services Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 392039667 Community outreach WI Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Lansdowne Village 4624 Lansdowne St Louis MO 63116 431470362 Skilled nursing facility MO Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Sherbrooke Village 4005 Ripa Avenue St Louis MO 63125 431592502 Skilled nursing facility MO Section 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers of St Louis Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 430653236 Acute care hospital (sponsorship transferred in 1997) MO Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Hospital Network 3040 W Salt Creek Lane Arlington Heights IL 600051069 363276552 Supports the provision of healthcare services for related corporations IL Section 501(c)(3) 11, III-FI Alexian Brothers Health System 1 Savelli Properties Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 363308965 Owns or leases properties where healthcare services are delivered IL Section 501(c)(2) N/A Alexian Brothers Health System 1 Alexian Brothers Center for Mental Health 3436 N Kennicott Avenue Arlington Heights IL 60004 363045007 Outpatient community mental health services IL Section 501(c)(3) 7 Alexian Brothers Health System 1 Alexian Brothers Behavioral Health Hospital 1650 Moon Lake Blvd Hoffman Estates IL 60194 364251848 Behavioral health hospital IL Section 501(c)(3) 3 Alexian Brothers Health System 1 St Alexius Medical Center 1555 Barrington Road Hoffman Estates IL 60194 364251846 Acute care hospital IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Ambulatory Group 3040 W Salt Creek Lane Arlington Heights IL 600051069 364336931 Physician services IL Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Medical Center 800 Biesterfield Road Elk Grove Village IL 60007 362596381 Acute care hospital TX Section 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Rehabilitation Services LLC 935 Beisner Road Elk Grove Village IL 60007 300221481 Rehabilitation hospital IL N/A Illinois NeuroMeg Center LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 870783164 Provision of NeuroMeg services IL N/A Elk Grove MOB Limited Partnership 3040 W Salt Creek Lane Arlington Heights IL 600051069 363853289 Medical office building IL N/A Workplace Solutions LLC 1100 East Woodfield Road Schaumburg IL 60173 364095007 Provision of EAP services IL N/A Bonaventure Medical Foundation LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 363978153 Manages managed care contracts DE N/A Neurosciences Equipment LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 861115516 Ownership of Gamma Knife IL N/A St Alexius Center for Sleep Health LLC 665 W North Avenue Lombard IL 60148 205876371 Operation of sleep lab IL N/A Thelen Corporation 3040 W Salt Creek Lane Arlington Heights IL 600051069 363266316 Owns/leases property; joint venture partner IL N/A C Edessa Insurance Company Ltd 3040 W Salt Creek Lane Arlington Heights IL 600051069 Captive insurer located in Bermuda BD N/A C Alexian Brothers Health Providers Association Inc 3040 W Salt Creek Lane Arlington Heights IL 600051069 363853286 Messenger model IPA IL N/A C Alexian Brothers Corpus Christi Housing Project LLC 3040 W Salt Creek Lane Arlington Heights IL 600051069 943465394 Tax credit financed housing IL N/A C Alexian Village of Elk Grove 3040 W Salt Creek Lane Arlington Heights IL 600051069 352211303 Tax credit financed housing IL N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 1 Alexian Brothers Health System O 722452 FMV Alexian Brothers Senior Ministries O 561132 FMV Alexian Brothers Community Services K 1505011 FMV Alexian Brothers Health System Inc Investment Trust R 3784925 FMV Alexian Brothers Health System P 559808 FMV Schedule R, Part V, Line 2: AVT tracks all transactions with related organizations in the general ledger or subsidiary schedules to the general ledger. Amounts are valued based on the fair market value of the transaction.