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
PROVIDENCE HEALTH SERVICES OF WACO dba PROVIDENCE HEALTHCARE NETWORK
Employer identification number
74-1109636
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.") .
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:
10000105
Software Version:
2010v3.2
-
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
PROVIDENCE HEALTH SERVICES OF WACO dba PROVIDENCE HEALTHCARE NETWORK
Employer identification number
74-1109636
Identifier
Return Reference
Explanation
PHSW dba continued
Providence Health Services of Waco, Inc dba's:Providence Healthcare NetworkProvidence Health CenterDepaul CenterProvidence ParkProvidence Home CareProvidence Breast Health Center
Form 990 Part VII Section A
Compensation reported in these columns is attributable to employees' time devoted each week to this entity and to related organizations as follows:Kent Keahey:Providence Foundation - 3 hoursProvidence Health Alliance - 5 hoursOdis Nichols:Providence Health Alliance - 5 hoursKaren Richardson:Providence Foundation - 3 hoursProvidence Health Alliance - 5 hoursTimothy Martindale:Providence Foundation - 1 hourSr cecile Matushek:Providence Foundation - 1 hour
Form 990, Part VI, Line 19
Form 990, Part VI, Line 19: Other Organization Documents Publicly Available
Organization provides governing documents, conflict of interest policy, and financial statements to the public upon request.
Form 990, Part VI, Line 15b
Form 990, Part VI, Line 15b: Compensation Review and Approval Process for Officers and Key Employees
POLICY:The executive Compensation Committee of the Board of Trustees of Ascension Health has been delegated the responsibility and authority to oversee the Executive Compensation Program, in accordance with the Committee Charter and the Board approved Executive Compensation Responsibility/Authority Matrix. The Committee is charged with overseeing the Program in a manner designed to assure independence, avoid conflicts of interest, ensure reasonableness and market comparability of total compensation, and to otherwise abide by pertinent laws and regulations. The Providence Healthcare Network Wage Plan is reviewed and appropriately revised at least annually, and is maintained as required between reviews.A salary survey is completed in the market for positions at points over the complete range of the wage scale for all levels of employment including key personnel. The proposed wage plan shall be approved by the President and distributed by the Human Resources Department and to Network Administration. Actual employee pay increases are reviewed and approved by Network Administration.
Form 990, Part VI, Line 12c
Form 990, Part VI, Line 12c: Explanation of Monitoring and Enforcement of Conflicts
PROCEDURES:Duty to Disclose: In connection with any actual or possible conflicts of interest, an interested person must disclose the existence of his or her financial interest and all material facts to the Trustees, or to the members of a committee with board delegated powers, considering the proposed transaction or arrangement. Such disclosure shall be made either through the annual questionnaire required under "Annual Statements" or when a conflict not disclosed on the questionnaire otherwise arises. The annual statements are reviewed by the compliance department to ensure no conflicts of interest exist.
Form 990, Part VI, Line 11
Form 990, Part VI, Line 11: Form 990 Review Process
The review process for the 990 Informational Return:Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form to the Board, or a designated committee, to review. Prior to filing the return, all Board Members are provided the Form 990 and management team members are available to answer any Board Members questions.
Form 990, Part VI, Line 7a
Form 990, Part VI, Line 7a: How Members or Shareholders Elect Governing Body
Providence Health Services of Waco has a single corporate member, Ascension Health, who has the ability to elect members to the governing body of the Providence Health Services of Waco.
Form 990, Part VI, Line 6
Form 990, Part VI, Line 6: Explanation of Classes of Members or Shareholder
Ascension Health is the single entity member of the organization.
Client Note 1 - PROVIDENCE HEALTH SERVICES OF WACO 74-1109636FORM 990 - RETURN OF ORGANIZATION EXEMPT FROM INCOME TAXSUPPORTING STATEMENT FYE 6/30/2011PART III, STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTSProvidence Healthcare Network provides a full range of care, including: outpatient care, inpatient care, emergency services, long-term care, mental health care, chemical dependency treatment, child care and senior adult care services and more. Providence Health Alliance Inc. is the part of Providence Healthcare Network that operates fifteen physician clinics that serve Waco and the six surrounding counties. The Providence Clinics accept all payors to provide complete health care for individuals and families. The clinics' team of dedicated health professionals provides a diverse range of services; from routine physicals and preventive medicine, to more complex matters of illness and injury. The clinic specialties include Family Practice, Internal Medicine, Obstetrics/Gynecology, Pulmonology, Cardiovascular Surgery, Pediatrics, Psychiatry, Psychotherapy and Geriatric (senior adult) Medicine. Providence Healthcare Network also includes Providence Health Services of Waco (74-1109636) which operates Providence Health Center (acute care), Providence Park (residential, skilled nursing, and long-term care), DePaul Center (psychiatric care) and Providence Home Care. Providence Healthcare Network also includes Providence Foundation, Inc. (74-2683112), which is the fund-raising division of Providence Healthcare Network and is responsible for the acquisition of capital equipment and advanced technology. Providence Health Services of Waco, Inc. and Providence Foundation, Inc. file separate IRS Forms 990. The following information pertains to Providence Healthcare Network:This report illustrates the significant degree to which Providence Healthcare Network contributes to the positive health status of the communities it serves. As a member of Ascension Health, the nation's largest Catholic healthcare system, Providence Healthcare Network continues to build and strengthen sustainable collaborative efforts that benefit the health of individuals, families, and society as a whole. Ascension Health directs its governance and management activities toward strong, vibrant, Catholic Health Ministries united in service and healing, and dedicates its resources to spiritually-centered care which sustains and improves the health of the communities it serves. In accordance with Ascension Health's mission of service to those who are poor and vulnerable, each Health Ministry accepts patients regardless of their ability to pay. Providence Healthcare Network has engaged in the following activities to ensure that our mission is accomplished:Unreimbursed Services Provided to the Elderly and the Poor:Providence Healthcare Network provides a substantial portion of its services to the elderly and poor. During the fiscal year ending June 30, 2011, approximately 48.8% of the values of services rendered were to elderly patients under the Medicare program, and approximately 12.1% of the services were provided to patients who were deemed indigent under state, county, or Medical Center Guidelines. In the spirit of principles adopted by Ascension Health, Providence Healthcare Network 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 30, 2011, the estimated unreimbursed cost of services provided to the elderly, uninsured, and underinsured totaled $19.1 million before state uncompensated pool reimbursements.Patient Services: Providence Healthcare Network provides the following inpatient and outpatient medical services to the community:Emergency CarePsychiatric CareGeriatric CareIndependent LivingAssisted LivingLong-term CareSub-Acute CareHome CareDurable Medical EquipmentWound CareRehabilitative Services- Inpatient and OutpatientMRI CenterWomen & Newborns CenterPhysician Clinical ServicesSome of the services listed above operate at a loss in order to ensure that all services are available to meet community health care needs. These include psychiatric care, physician clinical services, and certain acute care departments. During the fiscal year ending June 30, 2011, our Healthcare network treated 18,236 adults and children in the community for a total of 182,950 patient days of service. The Healthcare Network also provided outpatient services including 91,282 visits, 3,560 outpatient surgery patients, 82,804 emergency and minor care visits, and 30,320 homebound patients, 7,293 psychiatric care visits, and 118,195 physician office visits. Community Outreach Activities:Providence Healthcare Network 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, our Ministry has developed the following programs to help achieve its mission:Expanding Awareness, Education, and Health Promotion:Providence Healthcare Network believes that it is essential to educate people regarding the types of behavior that improve their chances of living a healthy life. Providence Healthcare Network has invested significantly in unique, top quality health education programs and materials to accomplish its goals. Pulmonary Support GroupCommunity Skin Cancer ScreeningCommunity General Health Screenings (glucose levels, blood pressure, cholesterol)Worksite Wellness ProgramDiabetic Support GroupHealing Grief SeriesInternal Cardioverter Defibrillator training for ICD patients and familiesLiving Livers ClassesCardiac Support GroupOsteoporosis Support GroupBariatric Support GroupSupport Groups for chemical addictions, anxiety/stress, bipolar disorder,depression and compulsive overeating. Website Educational Materials:All of the above listed support groups are posted on our website www.providence.net. Additionally, we have several services lines that have dedicated websites in order to provide a convenient way to better educate their patients. Also, several of our service lines highlight preventative educational materials.Comprehensive Surgical Weight Loss Center- We post support groups on a dedicated website www.werechanginglives.com which provides health resources necessary to aid individuals in determining whether surgery is the best option and educating patients on lifestyle changes that must occur if the individual choses surgery. Providence Breast Health Center- This website www.providencebhc.com provides resources that encourage women to be proactive about breast health. The web site includes information such as Facts and Figures and links to other crdible national organizations with preventative breast cancer information.DePaul Center- Our psychiatric and substance abuse treatment division, posts the schedule for monthly education seminars on mental health topics and posts supports groups offered to assist in mental health.Providence Stroke Center- Our Stroke website page highlights the signs & symptoms of a stroke, the risk factors and also provides links to other important national organizations that provide additional in-depth preventative information. Joint Camp: With a focus of clinical excellence and patient satisfaction, the Joint Camp's team of highly trained clinicians representing the two leading orthopedic clinics in the community, is dedicated to delivering better overall outcomes in patient care. The Joint Camp not only reduces the length of hospital stay and improves pain management, but enables patients to function at a much higher level than before.Charitable Contributions to Community Organizations:Providence Healthcare Network provides charitable support to many various organizations within our community. Our Mission directs us to serve all persons, particularly the poor and vulnerable, toward improving the health of individuals and communities. We feel it is our calling to support those organizations that serve this same purpose. Listed below are just a few of those organizations that receive charitable contributions from our Ministry:Family Abuse CenterJunior League of WacoAmerican Heart AssociationAmerican Cancer SocietyCommunities in SchoolsMission WacoFamily Health CenterCaritas of WacoC.A.S.ACare Net Pregnancy CenterSusan G. Komen FoundationWaco ISD Adopt a School PartnershipMarch of DimesAlzheimer's AssociationCamp Fire USAWaco Senior LeagueParticipation in Charitable or Public Benefit Programs:Providence Healthcare Network actively participates year round with several organizations in our community. Listed below are several ways our Ministry gets involved:American Heart Association- As the cause sponsor of the American Heart Association, Providence provides substantial financial support which aides their fight against our country's No.1 and No. 3 causes
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.