2011-10-06T08:23:56-05:00 2010-12-31 Deloitte Tax LLP 111 South Wacker Chicago IL 60606 990 2010-01-01 621136742 Alexian Village of Tennessee ALEX 4238860100 437 Alexian Way Signal Mountain TN 373771860 Matthew Fox 4238860100 2011-10-03 1 3124861000 2010 2016-03-07 17:11:31Z Matthew Fox 437 Alexian Way Signal Mountain TN 37377 22770612 0 0928 X www.alexianbrothershealth.org X 1983 TN Alexian Village of Tennessee ("AVT") carries out the healing mission of the Catholic Church 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. 6 4 417 100 0 0 213054 342321 21471012 22074021 128476 354270 22425 0 21834967 22770612 0 6000 0 0 10178769 10280921 0 0 0 10291142 10881861 20469911 21168782 1365056 1601830 51262418 52778663 48484275 48172788 2778143 4605875 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 14946818 19321372 Alexian Village of Tennessee ("AVT") provides a continuum of services to residents of AVT (137,453 resident days served), assisted living services to residents of Alexian Inn (7,779 days served) and residents of the health care center (36,563 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 2010, over $88,000 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. AVT also participated in Adopt-A-School program by providing donations of $6,000 to four Signal Mountain schools. As a religious organization, AVT also employs staff to provide chaplaincy services. There are multiple chapels at AVT, which have daily interdenominational services & programs. 1944038 1603548 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, 36 residents were served each day of 2010. 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. 804212 1149101 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 40 senior citizens in independent apartments (on average 38 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. 17695068 1 1 0 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 28 0 1 417 1 0 0 0 0 0 0 0 0 0 0 1 0 X 6 4 0 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 TN X Tim Booth 4238860100 437 Alexian Way Signal Mountain TN 37421 X 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 Sue Culpepper 1.00 X 0 0 0 Brother Andrew Thome CFA 1.00 X 0 0 0 John Turongian 1.00 X 0 225222 36461 Kevin Mulhearn 40.00 X 0 287117 178935 Matthew Fox 40.00 X 0 193407 26606 Virginia Golembiewski 1.00 X 0 67752 15425 Jim Lewandowski 1.00 X 0 358777 63762 Homer Sanders 40.00 X 113662 0 10061 Dennis Burtnett 40.00 X 103183 0 14820 Timothy Booth 40.00 X 3215 99826 16712 220060 1232101 362782 2 0 1 0 TN Lawn Care LLC PO Box 264 Signal Mountain TN 37377 Grounds & Landscaping Contractor 682886 Siskin Hospital One Siskin Plaza Chattanooga TN 37403 Rehab services 206142 SFCS Inc 305 South Jefferson Street Roanoke VA 24011 Architect/Engineering 114226 Zion Carpet Mills Inc PO Box 789 Rossville GA 30741 Carpet contractor 107405 Aaron Sheppard 193 Spring Street Signal Mountain TN 37377 Renovation contractor 105900 5 342321 342321 Lifecare & Independent 623000 11832132 11832132 Skilled Nursing 623000 4829646 4829646 Medicare & Medicaid 623000 2470970 2470970 Assisted Living 623000 2258269 2258269 Adult Day Care 624100 47839 47839 635165 635165 22074021 354270 354270 22770612 22074021 0 354270 6000 6000 7656692 7122201 534491 187621 175041 12580 1878502 1736526 141976 558106 524862 33244 10737 10737 16697 16697 720777 618812 101965 89324 2318 87006 504906 424003 80903 138443 2444 135999 1718154 1718154 35480 17011 18469 8768 8618 150 106644 106644 2760335 2703623 56712 215383 215383 Food 1597901 1597901 Property & Bed Taxes 792318 792318 Management Fees-ABHS 649200 649200 Medical Supplies 508470 508470 Purchased Services 505783 176398 329385 502541 352686 149855 21168782 17695068 3473714 0 132991 -236276 50000 50000 1622699 2242285 72801 79397 50094 56403 75029294 36437089 39830936 38592205 5996104 8773203 3506793 3221446 51262418 52778663 2023475 2200512 15100000 14600000 1007920 973928 30352880 30398348 48484275 48172788 X -156745 1822532 2417585 2271421 517303 511922 2778143 4605875 51262418 52778663 X 1601830 225903 X 0 1 1 X 0 X 92601 182963 221577 244922 169787 911850 16890753 19566986 21594608 21471012 22074021 101597380 16983354 19749949 21816185 21715934 22243808 102509230 0 0 0 102509230 78378 411498 -358336 128476 277269 537285 78378 411498 -358336 128476 277269 537285 17061732 20161447 21457849 21844410 22521077 103046515 0.99480 0.99230 0.00520 0.00770 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 517303 14232 19613 511922 504858 12445 517303 1.00000 0 1 1 975034 975034 57462153 24639807 32822346 13647328 9909693 3737635 2944779 1887589 1057190 38592205 Beneficial Interest in Alexian Brothers Health System, Inc. Investment Trust 8773203 F 8773203 Due to Affiliates 24894 Deferred Finance Charges 537772 Land for Future Development 1310000 Restricted Assets 1348780 3221446 Unamortized Life Entry Fees 30181072 Resident Security Deposits 130074 Reserve for Outstanding Ins Losses 48653 Annuity Payables 35928 Resident Personal Funds 2621 30398348 PART X Line 2 FIN48 Footnote: AVT does not file a separate audit report, but is part of the Alexian Brothers Health System consolidated audit report. The text of the FIN48 (ASC740) footnote in this audit report is as follows: On January 1, 2008, the Corporations adopted Interpretation No. 48, Accounting for Uncertainty in Income Taxes, included in FASB ASC Subtopic 740 10, Income Taxes Overall. ASC Subtopic 740 addresses the determination of how tax benefits claimed or expected to be claimed on a tax return should be recorded in the consolidated financial statements. Under ASC Subtopic 740 10, the Corporations must recognize the tax benefit from an uncertain tax position only if it is more likely than not that the tax position will be sustained on examination by the taxing authorities, based on the technical merits of the position. The tax benefits recognized in the consolidated financial statements from such a position are measured based on the largest benefit that has a greater than 50% likelihood of being realized upon ultimate settlement. ASC Subtopic 740 10 also provides guidance on derecognition, classification, interest and penalties on income taxes, and accounting in interim periods and requires increased disclosures. As of December 31, 2010 and 2009, the Corporations do not have a liability for unrecognized tax benefits. PART V Line 4: AVT's primary use of the endowment funds is to provide charity care and continuing health education. 1 X 3 0 1 0 0 0 0 0 0 0 0 John Turongian 0 207284 0 17938 0 0 0 17636 0 18825 0 261683 0 0 Kevin Mulhearn 0 215278 0 26812 0 45027 0 152365 0 26570 0 466052 0 31632 Matthew Fox 0 124260 0 0 0 69147 0 10182 0 16424 0 220013 0 0 Jim Lewandowski 0 272185 0 50985 0 35607 0 32953 0 30810 0 422540 0 12292 Part I, Line 4a The following individuals listed in Schedule J were paid the referenced amount of severance in 2010: Kevin Mulhearn $13,395 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 2010 was included in income in Schedule J for the following individuals: Jim Lewandowski $4,547. Supplemental Information Part III Part I Line 3: AVT 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 ABHS, which is composed 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. Form 990, Part VI, Section A, line 6 Alexian Village of Tennessee 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: -Amendment of the Articles of Incorporation and 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 and 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; and -Other certain reserved powers which Alexian Brothers Health System may designate. Form 990, Part VI, Section B, line 11 AVT is an affiliate of Alexian Brothers Health System ("ABHS" or "the System"), which is a Catholic health system. ABHS is the National Member and ultimate parent for each entity within the System. AVT'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 AVT'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 ABHS reviews all compensation disclosures for each entity in ABHS. 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 ABHS Board of Governors. This Committee reviews the Compensation disclosures for all entities in the System. AVT's board reports to the ABHS Board of Governors, which has ultimate oversight of the activities of all entities within the System. The Audit Committee of the ABHS 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 a rotating basis. It then reports back to the ABHS 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 2010 Form 990 for AVT. Form 990, Part VI, Section B, line 12c AVT collects annual attestations from board members, officers, directors and key employees. The attestations are reviewed by the AVT compliance officer and any conflicts are shared with the AVT Chief Executive Officer. The conflicts are also reviewed by the System's Vice President of Compliance and Internal Audit. The Audit Committee of the ABHS Board of Governors monitors and receives reports on the completion of this process. Form 990, Part VI, Section B, line 15 AVT 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 ABHS, which is composed 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 AVT's financial statements are available through the National Reporting Municipal Services Information Repository (NRMSR). Conflicts of Interest and AVT's governing documents are not made available to the public. Form 990, Part VII - Column E Payroll records are kept that identify which officers/key employees are paid by a related entity. These documents also show the organization being charged for the officer/key employee's services. Form 990, Part VII Disclosure for estimated hours per week devoted to related organization for which compensation was reported: John Turongian, Kevin Mulhearn, 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 VIII, Line 3; Schedule D, Part VII The amount reflected as dividends and interest reflects AVT's share of interest, dividends and realized gains/losses 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. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized gains on investments: 225,903. Alexian Brothers of America Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 362606768 Religious order of Roman Catholic men TX 501(c)(3) 1 N/A 0 Brothers of St Alexius Health and Welfare Fund Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 362976617 Provides for health & welfare payments for religious sponsor TX 501(c)(3) 1 Alexian Brothers of America Inc 1 Alexian Brothers Bonaventure House 825 Wellington Avenue Chicago IL 60657 363527899 Housing & supportive care services for persons with HIV/AIDS IL 501(c)(3) 9 Alexian Brothers of America Inc 1 Alexian Brothers Health System 3040 W Salt Creek Lane Arlington Heights IL 60005 363260495 Supports the provision of healthcare services for related corporations IL 501(c)(3) 11 III FI Alexian Brothers of America Inc 1 Alexian Brothers Health System Inc Investment Trust 3040 W Salt Creek Lane Arlington Heights IL 60005 363801585 Manages pooled investments of related not-for-profit entities IL 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 60005 364390471 Manages pooled investments of related not-for-profit entities IL 501(c)(3) 11 III FI Alexian Brothers of America Inc 1 The Alexian Brothers Hospital School of Nurses 3040 W Salt Creek Lane Arlington Heights IL 60005 Inactive Corporation IL 501(c)(3) 9 Alexian Brothers of America Inc 1 Alexian Brothers of Chicago 3040 W Salt Creek Lane Arlington Heights IL 60005 Inactive Corporation IL 501(c)(3) 9 Alexian Brothers of America Inc 1 Alexian Brothers of San Jose Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 941530037 Acute care hospital (sold 1998) TX 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Services Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 431295333 HUD housing MO 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 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Community Services 425 Cumberland Street Suite 110 Chattanooga TN 37404 364344423 Provides comprehensive and coordinated community based services IL 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 501(c)(3) 7 Alexian Brothers Health System 1 Alexian Brothers Senior Ministries 3040 W Salt Creek Lane Arlington Heights IL 60005 364484290 Supports the provision of healthcare for related corporations IL 501(c)(3) 11 III FI Alexian Brothers Health System 1 Alexian Elderly Services Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 392039667 Community outreach WI 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Lansdowne Village 4624 Lansdowne St Louis MO 63116 431470362 Skilled nursing facility MO 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 501(c)(3) 9 Alexian Brothers Health System 1 Alexian Brothers Hospital Network 3040 W Salt Creek Lane Arlington Heights IL 60005 363276552 Supports the provision of healthcare services for related corporations IL 501(c)(3) 11 III FI Alexian Brothers Health System 1 Alexian Brothers Medical Center 800 Biesterfield Road Elk Grove Village IL 60007 362596381 Acute care hospital TX 501(c)(3) 3 Alexian Brothers Health System 1 Savelli Properties Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 363308965 Owns or leases properties where healthcare services are delivered IL 501(c)(2) NA Alexian Brothers Health System 1 Alexian Brothers Center for Mental Health 3350 W Salt Creek Lane Arlington Heights IL 60005 363045007 Outpatient community mental health services IL 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 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 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Brothers Ambulatory Group 3040 W Salt Creek Lane Arlington Heights IL 60005 364336931 Physician services IL 501(c)(3) 3 Alexian Brothers Health System 1 Chicago Catholic Healthcare System Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 363693486 Inactive Corporation IL 501(c)(3) 9 Alexian Brothers Hospital Network 1 Alexian Brothers of St Louis Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 430653236 Acute care hospital (sponsorship transferred in 1997) MO 501(c)(3) 3 Alexian Brothers Health System 1 Alexian Rehabilitation Services LLC 935 Beisner Elk Grove Village IL 60007 300221481 Rehabilitation hospital IL N/A N/A 0 0 Illinois NeuroMeg Center LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 870783164 Provision of NeuroMeg services IL N/A N/A 0 0 Elk Grove MOB Limited Partnership 3040 W Salt Creek Lane Arlington Heights IL 60005 363853289 Medical Office Building IL N/A N/A 0 0 Workplace Solutions LLC 1100 East Woodfield Rd Schaumburg IL 60173 364095007 Provision of EAP services IL N/A N/A 0 0 Bonaventure Medical Foundation LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 363978153 Managers managed care contracts DE N/A N/A 0 0 Neurosciences Equipment LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 861115516 Ownership of Gamma Knife IL N/A N/A 0 0 Alexian Cardiovascular Institute Equipment LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 300307978 Lease and sub lease of 64-slice CT equipment IL N/A N/A 0 0 St Alexius Center for Sleep Health LLC 665 W North Ave Lombard IL 60148 205876371 Operation of sleep labs IL N/A N/A 0 0 Thelen Corporation 3040 W Salt Creek Lane Arlington Heights IL 60005 363266316 Owns/leases property; joint venture partner IL N/A C Edessa Insurance Company Ltd 3040 W Salt Creek Lane Arlington Heights IL 60005 Captive insurer located in Bermuda BD N/A C Alexian Brothers Health Providers Association Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 363853286 Messenger model IPA IL N/A C Alexian Village of Elk Grove 3040 W Salt Creek Lane Arlington Heights IL 60005 352211303 Tax credit financed housing IL N/A C Alexian Brothers Corpus Christi Housing Project LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 943465394 Tax credit financed housing IL N/A C 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 Alexian Brothers Health System O 649200 Alexian Brothers Health System P 549309 Alexian Brothers Senior Ministries O 443724 Alexian Brothers Community Services K 1894883 Alexian Brothers Health System Inc Investment Trust Q 1732174 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.