Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
SUPPORTIVE CARE SERVICES OF MICHIGAN INC
Employer identification number
38-3197374
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
58,242
95,555
153,797
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
92,626
351,592
383,225
459,090
1,286,533
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4,916
4,916
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
0
150,868
447,147
383,225
464,006
1,445,246
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
0
c
Add lines 7a and 7b..
0
0
0
0
0
0
8
Public Support (Subtract line 7c from line 6.)
1,445,246
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
0
150,868
447,147
383,225
464,006
1,445,246
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
0
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
0
0
0
0
0
0
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
207
207
13
Total support (Add lines 9, 10c, 11 and 12.).
0
150,868
447,147
383,225
464,213
1,445,453
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
99.99 %
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
100.0 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
0 %
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
OTHER INCOME, SCHEDULE A, PART III, SECTION B, LINE 12, MISCELLANEOUS INCOME RECEIVED IN FURTHERANCE OF THE ORGANIZATION'S TAX-EXEMPT PURPOSE: 2010 - $207,
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
10000128
Software Version:
v2010.1.0
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
SUPPORTIVE CARE SERVICES OF MICHIGAN INC
Employer identification number
38-3197374
Identifier
Return Reference
Explanation
PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
(CONTINUED FROM PART III) @HOME SUPPORT SERVICES CONSIST OF HOME VISITS AND INDIVIDUALIZED TREATMENT PLANS BY A NURSE AND COUNSELOR WITH THE AIDE OF PATIENT FAMILY ASSISTANTS AND VOLUNTEERS. @HOME SUPPORT WORKS CLOSELY WITH PRIMARY CARE PHYSICIANS TO RELIEVE SYMPTOMS OF PAIN, COORDINATE CARE, ASSIST WITH TREATMENT DECISIONS, AND PROVIDE A SUPPORT SYSTEM TO CAREGIVERS. AVAILABLE 24 HOURS A DAY, 7 DAYS A WEEK, THE @HOME SUPPORT TEAM INCLUDES A DOCTOR THAT SPECIALIZES IN RECOMMENDING MEDICATIONS OR TREATMENTS TO RELIEVE PAIN AND SYMPTOMS CAUSED BY ILLNESS, NURSES WITH ADVANCED TRAINING IN CHRONIC ILLNESS AND HOME BASED CARE, A COUNSELOR THAT ASSISTS IN ADDRESSING INTERPERSONAL ISSUES AND LIFESTYLE CHANGES AND ASSISTS WITH COORDINATING COMMUNITY RESOURCES, AND PATIENT FAMILY ASSISTANTS THAT ASSIST WITH PERSONAL CARE AND PROVIDING SUPPORT TO CAREGIVERS. BY DEVELOPING PARTNERSHIPS WITH HEALTH CARE ORGANIZATIONS AND COMMUNITY BASED PROGRAMS, @HOME SUPPORT STRIVES TO CREATE A SERVICE MODEL THAT IS OUTCOME DRIVEN AND THAT CAN FLEX TO MEET INDIVIDUAL CONTRACTS, CREATE PRIVATE PAY OPTIONS FOR PATIENTS AND FAMILIES THAT WISH CUSTOMIZED SERVICES, AND DEVELOP NEW SERVICES FOR THE FUTURE NEEDS OF PATIENTS AND FAMILIES WITH ADVANCED CHRONIC ILLNESSES. FOR THE YEAR ENDED DECEMBER 31, 2010, @HOME SUPPORT PROVIDED $41,142 IN CHARITY CARE. ADDITIONAL 2010 SERVICE ACCOMPLISHMENTS INCLUDE: - THE ORGANIZATION DOUBLED THE NUMBER OF PATIENTS SERVED FROM PREVIOUS YEARS WITH EXISTING CARRIERS; AND - THE ORGANIZATION WAS AWARDED A GRANT THAT ALLOWED US TO BEGIN A RESEARCH STUDY TO DETERMINE THE EFFECT OF PALLIATIVE CASE MANAGEMENT USING A TEAM-BASED APPROACH ON PATIENT SYMPTOM MANAGEMENT, QUALITY OF LIFE, AND COST. THE DATA COLLECTION PROCESS STARTED IN 2010 WITH COMPLETION DATE IN 3RD QUARTER OF 2011.
Review of form 990 by governing body
Form 990, Part VI, Section B, Line 11b
A FINAL DRAFT OF THE FULL FORM 990 IS REVIEWED WITH OUR TAX ADVISORS AND APPROVED BY AN EXECUTIVE COMMITTEE OF THE BOARD, AND THEN A COPY OF THE FULL FORM 990 DRAFT IS SENT OUT TO EACH VOTING MEMBER OF THE GOVERNING BODY.
Conflict of interest policy
Form 990, Part VI, Section B, Line 12c
PROCEDURE: EMPLOYEES, BOTH PAID AND UNPAID (FROM HERE FORWARD REFERRED TO AS "EMPLOYEE"), AND BOARD MEMBERS, HAVE A FUNDAMENTAL OBLIGATION TO ACT IN THE BEST INTEREST OF PATIENT CARE AND SUPPORTIVE CARE SERVICES OF MICHIGAN D/B/A @HOME SUPPORT. EVERY BOARD MEMBER AND EMPLOYEE IS RESPONSIBLE FOR ACTING CONSISTENT WITH THIS OBLIGATION WHEN ENGAGING IN ACTIVITIES, AND SHOULD NOT LET OTHER PERSONAL AND FINANCIAL INTERESTS INTERFERE WITH THIS OBLIGATION. GENERAL PRACTICE GUIDELINES: (1) @HOME SUPPORT REQUIRES THAT ALL MEMBERS OF ITS BOARDS OF TRUSTEES AND EMPLOYEES DISCLOSE INTERESTS THAT COULD RESULT IN A CONFLICT. ANNUALLY, ALL BOARD MEMBERS SIGN OFF ON A CONFLICT OF INTEREST POLICY AND DISCLOSE ANY SITUATION WHICH MAY REPRESENT A CONFLICT. THE CORPORATE COMPLIANCE OFFICER (CCO) ALSO HAS ACCESS TO THE BOARD AT LEAST ANNUALLY. THE ORGANIZATION ALSO UTILIZES C-TRAC (CROWE TAX RISK ASSESSMENT AND CONTROL), A TOOL PROVIDED BY OUR TAX ADVISORS, TO SEND CONFLICT OF INTEREST SURVEYS TO ALL VOTING BOARD MEMBERS, EXECUTIVES, AND THE HIGHEST PAID STAFF. (2) ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO SUBMIT A DISCLOSURE STATEMENT, IF THERE IS A CONFLICT OF INTEREST THAT MEETS THE STATED DEFINITION, AT THE BEGINNING OF EMPLOYMENT OR TERM. (3) IF A MATTER ARISES IN WHICH A MEMBER OF THE BOARD OR EMPLOYEE HAS A CONFLICT OF INTEREST, THE INDIVIDUAL SHALL PROMPTLY DISCLOSE IT TO THE CEO, OR THE CASE OF THE CEO, THE BOARD CHAIRPERSON. (4) AN INDIVIDUAL WITH A POTENTIAL CONFLICT OF INTEREST SHALL NOT PROCEED TO MAKE ANY DECISION OR TAKE ANY ACTION ON BEHALF OF THE ORGANIZATION WITHOUT APPROVAL OF THE BOARD OF TRUSTEES. (5) @HOME SUPPORT EMPLOYEES ARE PRECLUDED FROM ENGAGING IN ACTIVITIES WITH ANY "VENDOR OR SUPPLIER BUSINESS" (AS THAT TERM IS DEFINED IN THE POLICY) THAT DOES OR SEEKS BUSINESS WITH @HOME SUPPORT WHICH MAY RESULT IN A PERSONAL BENEFIT TO THE EMPLOYEE AT THE EXPENSE OF @HOME SUPPORT OR MAY INFLUENCE THE EMPLOYEE'S DECISIONS ON MATTERS INVOLVING @HOME SUPPORT AND A VENDOR OR SUPPLIER BUSINESS.
Process used to establish compensation of top management official
Form 990, Part VI, Section B, Line 15a
THE ORGANIZATION'S PRESIDENT/CEO IS PAID BY HOSPICE OF MICHIGAN, INC. (HOM), A RELATED TAX-EXEMPT ORGANIZATION. HOM'S EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES MEETS ANNUALLY IN MARCH TO REVIEW AND APPROVE AS APPROPRIATE, FUNDS TO BE ALLOCATED FOR TOTAL COMPENSATION FOR THE ORGANIZATION'S PRESIDENT/CEO, INCLUDING BASE SALARY, BONUS, CAR ALLOWANCE, AND OTHER BENEFITS. HOM'S EXECUTIVE COMMITTEE ALSO DETERMINES IF THE PRESIDENT/CEO'S CONTRACT NEEDS TO BE UPDATED OR RENEWED AT THIS TIME. MINUTES ARE TAKEN UP UNTIL THE POINT WHERE DISCUSSION OF COMPENSATION TAKES PLACE AND VOTE/DECISION IS MADE IN REGARDS TO COMPENSATION. THE CEO AND EXECUTIVE ASSISTANT ARE EXCUSED FROM THE MEETING AT THIS POINT WHILE DISCUSSION AND DECISION IS MADE. IN ADDITION, AN EXTERNAL COMPENSATION STUDY IS PERFORMED AT LEAST EVERY THREE YEARS TO ASSESS EXECUTIVE COMPENSATION. THE COMPENSATION STUDY AIMS TO PRICE POSITIONS AT MARKET BY USING LOCAL, NATIONAL, AND INDUSTRY SPECIFIC SURVEY DATA.
Public Disclosure
Form 990, Part VI, Section C, Line 19
CONSOLIDATED FINANCIAL STATEMENTS ARE PROVIDED ANNUALLY IN THE ORGANIZATION'S CONSOLIDATED ANNUAL REPORT THAT IS LOCATED ON THE HOSPICE OF MICHIGAN, INC. (A RELATED TAX EXEMPT ORGANIZATION) EXTERNAL WEBSITE (WWW.HOM.ORG). OTHER SPECIFIC DOCUMENTS CAN BE AVAILABLE UPON REQUEST.
PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES
FORM 990, PART VI, SECTION B, LINE 15B
THE ORGANIZATION'S CHIEF ADMINISTRATIVE OFFICER IS PAID BY HOSPICE OF MICHIGAN, INC. (HOM), A RELATED TAX-EXEMPT ORGANIZATION. ANNUALLY IN MARCH, THE FILING ORGANIZATIONS' PRESIDENT/CEO REVIEWS AND APPROVES AS APPROPRIATE, FUNDS TO BE ALLOCATED FOR TOTAL COMPENSATION, WHICH INCLUDES BASE SALARY, BONUS, CAR ALLOWANCE, AND OTHER BENEFITS, FOR THE OFFICER. IN ADDITION, AN EXTERNAL COMPENSATION STUDY IS PERFORMED AT LEAST EVERY THREE YEARS TO ASSESS COMPENSATION. THE COMPENSATION STUDY AIMS TO PRICE POSITIONS AT MARKET BY USING LOCAL, NATIONAL, AND INDUSTRY SPECIFIC SURVEY DATA.
Average hours worked per week for related organization
Form 990, Part VII, Section A, Column B
DOROTHY E. DEREMO - DEVOTES APPROXIMATELY 40 HOURS PER WEEK TO HOSPICE OF MICHIGAN, INC. AND APPROXIMATELY ONE HOUR PER WEEK TO HOSPICE OF MICHIGAN FOUNDATION , RELATED TAX EXEMPT ORGANIZATIONS. ROBERT CAHILL - DEVOTES APPROXIMATELY 40 HOURS PER WEEK TO HOSPICE OF MICHIGAN, INC. AND APPROXIMATELY ONE HOUR PER WEEK TO HOSPICE OF MICHIGAN FOUNDATION, RELATED TAX EXEMPT ORGANIZATIONS. JANE MCNAMARA - DEVOTES APPROXIMATELY 1 HOUR PER WEEK TO HOSPICE OF MICHIGAN, INC., A RELATED TAX EXEMPT ORGANIZATION. JOHN R. MAURER, MD - DEVOTES APPROXIMATELY 1 HOUR PER WEEK TO HOSPICE OF MICHIGAN, INC., A RELATED TAX EXEMPT ORGANIZATION. SANFORD J. LINDEN - DEVOTES APPROXIMATELY 1 HOUR PER WEEK TO HOSPICE OF MICHIGAN, INC., A RELATED TAX EXEMPT ORGANIZATION. LLOYD HANSEN - DEVOTES APPROXIMATELY 1 HOUR PER WEEK TO HOSPICE OF MICHIGAN, INC., A RELATED TAX EXEMPT ORGANIZATION.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.