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
St John Home Care
Employer identification number
38-3408684
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.") ....
237,597
196,639
124,105
100,816
166,531
825,688
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..
237,597
196,639
124,105
100,816
166,531
825,688
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.
825,688
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..
237,597
196,639
124,105
100,816
166,531
825,688
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
806,198
10,633
141,014
761,254
1,719,099
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).
2,544,787
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
148,298,568
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
32.450 %
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
37.330 %
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.") .
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......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
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...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
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
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
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
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
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
St John Home Care
Employer identification number
38-3408684
Identifier
Return Reference
Explanation
Form 990, Part VI, Section A, line 6
St. John Home care has a single corporate member, St. John Health.
Form 990, Part VI, Section A, line 7a
St. John Home care has a single corporate member, St. John Health, who has the ability to elect members to the governing body.
Form 990, Part VI, Section A, line 7b
All decisions that have a material impact to St. John Home Care financial information or corporation as a whole are subject to approval by its sole corporate member, St. John Health, the parent.
Form 990, Part VI, Section B, line 11
Management works diligently to complete the Form 990 and attached schedules in a thorough manner. Prior to filing the return all board members are provided the Form 990 and management team members are available to answer any board member questions.
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, key employee, 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 will decide if conflict of interest exist. Each director, principal officer, key employee and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflict 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.
Form 990, Part VI, Section B, line 15
This process was done at the related entity level.
Form 990, Part VI, Section C, line 19
The organization will provide any documents open to public inspection upon request.
Form 990, Part VII, Section A:
The compensation listed is for services provided to this organization or a related organization in an employee capacity, and not for participation in this organization's board.
Changes in Net Assets or Fund Balances:
Form 990, Part XI, line 5:
Net unrealized gains on investments: 635,672.
Form 990, Part III:
St. John Home Care Community Benefit Report For the Year Ended June 30, 2011 This report illustrates the significant degree to which St. John Home Care contributes to the positive health status of the communities it serves. As a member of Ascension Health, the nation's largest Catholic healthcare system, St. John Home Care continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. The goal of St. John Home Care is to perpetuate the healing mission of the church. St. John Home Care furthers this goal through delivery of patient services, care to the elderly and indigent, patient education and health awareness programs for the community, and medical research. Our concern for all human life and dignity of each person leads the organization to provide medical services to all people in the community without regard to the patient's race, creed, national origin, economic status, or ability to pay. In order to portray the full breadth of our contribution, our community benefit information is described below: ORGANIZATIONAL COMMITMENT TO PROVIDING COMMUNITY BENEFIT: St. John Home Care provides a substantial portion of its services to the elderly and poor. St. John Home Care seeks to improve the physical, mental, social and spiritual health status of its surrounding community. In addition to providing health care services to all individuals who require medical attention, St. John Home Care has developed the following programs to help achieve its mission: - EXPANDING AWARENESS, EDUCATION, AND HEALTH PROMOTION: St. John Home Care believes that it is essential to educate people regarding the types of behavior that improve their chances of living a healthy life. St. John Home Care has invested significantly in unique, top quality health education and materials to accomplish its goals. - 16th Annual Senior Expo - Breast Cancer Walk - ONS Lecture-Home Palliative Care Program Discussion - St. John Hospice Oktoberfest - Caring Coalition Conference with The Jewish Hospice & Chaplaincy Network - MEDICAL EDUCATION: St. John Home Care believes that, in order to provide the best health care to the community, the clinical associates need to receive ongoing education. Some examples of the education for July 2010 through June 2011 include: 1. "Soup and Support" Grief Program at St. Mary's Queen of Creation(5/11, 6/11) 2. Caregiver Support Group at St. Joan of Arc (4/11) 3. Grief and Loss Support Group at St. Joan of Arc (1/11) 4. Caring Coalition Conference with Jewish Hospice & Chaplaincy Network (3/11) 5. Hospice Pediatric Memorial Service at St. Joan of Arc (2/11) 6. Home Care Red Cross Blood Drive (9/10) 7. "ROPE-Reaching Our Potential Everyday Support Program" at Capuchan Soup Kitchen (9/10-4/11) 8. Palliative Care Phone Support for patients in the community (all year) 9. "Losing a Parent" Grief Support Group at St. Alans (10/10-11/10) 10. "Learning to Live with Loss and Change" Grief Education Program at St. Mary's Catholic Church 10/10-11/10) 11. "Hope for the Holidays" holiday support group at St. Joan of Arc (11/10-12/10) 12. Grief and Holidays at Immanual Lutheran Church (11/10) 13. Hospice Memorial Service at Fisher Auditorium (10/10) 14. Hospice Memorial Service at St. Joan of Arc (4/11) 15. Hospice Memorial Service at River District (4/11) 16. Sterling Height Senior Expo, Educating Seniors about Hospice and Home Care (9/10) 17. St. John Hospice Oktoberfest (11/10) 18. Hospice lecture to Oakland Hospital Residents and Medical students (10/10) 19. Hospice lecture to Baker college nursing students (10/10, 5/10) 20. Home Care lecture to Oakland Hospital Residents (8/10) 21. Pain lecture to nursing staff at Cherrywood ECF (11/10) 22. Crackerbarrel SJHMC nurse residency program Hospice lecture (12/10) 23. Pain lecture to medical staff at Prestige Commons AAL (12/10, 1/11) 24. Pain lecture to nurses at Fox Run (2/11) 25. Hospice lecture to nurses at Fox Run (3/11) 26. Compassion Fatigue Lecture to Geriatric Social Workers of Southeastern Michigan (2/11) 27. Clinical Practicum for Nursing for Life Course from MSU College of Nursing (7/10) 28. HHA Signs and Symptoms of Heart Failure Lecture (8/10) 29. Barton Transfer Chair In-Service (10/10) 30. Wound Care and Pressure Ulcer Prevention (12/10) 31. HHA Preventing Falls, Transfer Techniques (2/11) 32. HHA Hoyer Lift, Ambulation Hip Precautions (6/11) 33. Safety/Security In-Service presented by a Detroit Police Officer (6/11) 34. Med-Cure Whole Body Donation In-Service 2 sessions (3/11 and 4/11) 35. Annual Competencies-10 sessions-(4/11 and 5/11) In the spirit of principles adopted by Ascension Health, St. John Home Care has taken proactive steps to address those issues that will affect accessibility, the financing, and the delivery of healthcare to all persons, especially the uninsured, underinsured, and the underserved. During the fiscal year ending June 2011, the estimated unreimbursed cost of services provided to the elderly, uninsured, and underinsured totaled $1,208,475. St. John Home Care provides a substantial portion of its services to the elderly and poor. During the fiscal year ending June 2011, approximately 63% of the values of services rendered were to elderly patients under the Medicare program, and approximately 14% of the services were provided to patients who were deemed indigent under state, county, or Medical Center Guidelines. St. John Home Care offers a financial assistance program that responds to the needs of the elderly, poor persons with disabilities, the chronically mentally ill, or those who find it hard to meet basic needs due to on-going poverty. The care of the poor program is communicated to the public through case managers stationed at hospitals throughout St John Health System and through St. John Home Care liaisons located in various patient care facilities in the area. The patient accounting department also assists patients in filling out required paperwork and submitting appropriate documentation. OPERATIONS AND GOVERNANCE: - St. John Home Care has a continuum governing body in which independent persons representative of the community comprise a majority; - St. John Home Care engages in the training and education of health care professionals; and participates in Medicaid, Medicare, CHAMPUS, Tricare, and/or other government-sponsored health care programs. PATIENT SERVICES: St. John Home Care provides the following outpatient medical services to the community: Certified Nursing care, Hospice and Infusion care. During the fiscal year ending June 2011, St. John Home Care provided 125,006 certified visits; 72,658 Hospice days and 51,771 Infusion days to our patients. FINANCIAL INFORMATION: The financial information presented below was prepared in accordance with the Catholic Health Association's (CHA) community benefit reporting guidelines. These guidelines recommend the following: - Report care of the poor at cost, not charges: Do not include bad debt, contractual allowances, and quick pay discounts as part of care of the poor expense. Do not count Medicare shortfall as a community benefit. Report the net expense for community benefit services, i.e., the total community benefit expense minus any associated revenue from patients, payers, and other external sources. - The CHA reporting guidelines reflect a conservative approach to reporting quantifiable community benefit. The goal of the reporting guidelines is to produce community benefit financial reports that reflect true costs and that describe community benefit activities that increase access to health care and improve community health. For fiscal year ended June 2011: 1) Care of the poor - at cost = $287,743 2) Government sponsored health care - net expense = $920,732 Unpaid cost of public indigent care programs (includes Medicaid, SCHIP, other safety net programs; does not include Medicare shortfall) Total quantifiable community benefit as determined in accordance with CHA reporting guidelines = $1,208,475 SUPPLEMENTAL INFORMATION: Bad debt = $319,782 Total quantifiable community benefit, including bad debt = $1,528,257
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.