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
2011
Open to Public Inspection
Name of the organization
THE LONG ISLAND HOME
Employer identification number
11-2837244
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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—2011.
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—2010.
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—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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) 2007
(b) 2008
(c) 2009
(d) 2010
(e) 2011
(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 2011 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2010 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2011 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2010 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2011.
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—2010.
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) 2011
Schedule A (Form 990 or 990-EZ) 2011
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) 2011
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
2011
Open to Public Inspection
Name of the organization
THE LONG ISLAND HOME
Employer identification number
11-2837244
Identifier
Return Reference
Explanation
FORM 990, PART I, LINE 1
THE LONG ISLAND HOME IS A 501(c)(3) CHARITABLE ORGANIZATION THAT OPERATES SOUTH OAKS HOSPITAL FOR MENTAL HEALTH SERVICES AND BROADLAWN MANOR NURSING AND REHABILITATION CENTER FOR COMPREHENSIVE LONG-TERM AND SUB-ACUTE CARE. THE LONG ISLAND HOME OFFERS A BROAD CONTINUUM OF HEALTHCARE AND REHABILITATION SERVICES FOR ALL AGES, AS WELL AS GERIATRIC CARE AND GERI-PSYCHIATRIC SERVICES FOR LONG-TERM AND SHORT-TERM PATIENTS. THE LONG ISLAND HOME PROVIDES INNOVATIVE, EFFECTIVE AND COST-EFFICIENT SERVICES WITHIN AN INTEGRATED COMMUNITY HEALTH DELIVERY SYSTEM, AND PROMOTES THE HIGHEST PRACTICAL LEVELS OF WELLNESS AND INDEPENDENCE FOR PATIENTS AND FAMILIES.
FORM 990, PART III, LINE 1
MISSION STATEMENT: TO PROVIDE QUALITY CARE WITH DIGNITY AND COMPASSION. VISION: THE LONG ISLAND HOME WILL WORK COLLABORATIVELY TO PROVIDE INNOVATIVE, EFFECTIVE AND COST-EFFICIENT SERVICES WITHIN AN INTEGRATED COMMUNITY HEALTH DELIVERY SYSTEM. AN EXPANDING CONTINUUM OF CARE WILL PROVIDE ALTERNATIVES AND CHOICES FOR TREATMENT AND SUPPORT, PROMOTING HIGHEST PRACTICABLE LEVELS OF WELLNESS AND INDEPENDENCE FOR PATIENTS AND FAMILIES. WE WILL CONTINUE OUR SHIFT IN EMPHASIS FROM ILLNESS TO WELLNESS, FROM SERVICE TO OUTCOMES AND FROM INDIVIDUAL PERFORMANCE TO COLLABORATION WITH CONSUMERS AND PARTICIPATIVE LEADERSHIP MODEL.
FORM 990, PART III, LINE 4A
SOUTH OAKS HOSPITAL (SOH) IS A FREESTANDING PYSCHIATRIC HOSPITAL LISCENSED PURSUANT TO ARTICLE 31 OF NEW YORK STATE MENTAL HEALTH HYGIENE LAW. THE FACILITY IS ACCREDITED BY THE JOINT COMMISSION. OUR COMPREHENSIVE BEHAVIORAL HEALTH CONTINUUM OFFERS A BROAD RANGE OF INTERVENTION AND TREATMENT SETTINGS. THE HOSPITAL IS LICENSED BY THE NEW YORK STATE OFFICE OF MENTAL HEALTH (OMH) AND OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES (OASAS). MENTAL HEALTH SERVICES ARE PROVIDED TO CHILDREN, ADOLESCENTS, ADULTS, AND GERIATRICS, AND ACUTE DETOXIFICATION AND SUBSTANCE REHABILITATION SERVICES ARE PROVIDED TO ADULTS AND GERIATRICS. SOUTH OAKS ALSO PROVIDES PARTIAL HOSPITALIZATION TREATMENT FOR ADULTS AND ADOLESCENTS AS CERTIFIED BY THE NEW YORK STATE OFFICE OF MENTAL HEALTH. THIS SETTING PROVIDES INTENSIVE PSYCHIATRIC TREATMENT IN A STRUCTURED ENVIRONMENT. RETURN TO THE COMMUNITY IS FACILITATED THROUGH CASE MANANGEMENT, DISCHARGE PLANNING, CLINICAL SUPPORT (FAMILY) SERVICES, ACTIVITIES THERAPY, AND REHABILITATION READINESS DETERMINATION. THE PARTIAL HOSPITALIZATION ADDICTION TREATMENT PROGRAM SERVES PATIENTS IN NEED OF INTENSIVE CHEMICAL DEPENDENCY REHABILITATION WHO ARE ABLE TO RESIDE AT HOME AND ATTEND A TREATMENT PROGRAM DAILY. THIS PROGRAM IS CERTIFIED BY THE NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES FOR ADULTS AND GERIATRICS. COMPREHENSIVE OUTPATIENT BEHAVIORAL SERVICES (COBS) PROGRAM SERVICES YOUTHS AND FAMILIES WITHIN THE COMMUNITY. COBS INTEGRATES MENTAL HEALTH SERVICES AND SUBSTANCE ABUSE SERVICES WITH PRIMARY CARE PROVIDERS FOR A MORE HOLISTIC APPROACH TO TREATMENT. OUR GOAL IS TO DELIVER FLEXIBLE SERVICES THAT EMPHASIZE COLLABORATION AND INTEGRATION WITH SCHOOLS, PRIMARY CARE PROVIDERS, THE JUVENILE JUSTICE SYSTEM AND THE WORKPLACE. OUTPATIENT ALCOHOL AND SUBSTANCE ABUSE SERVICES IS CERTIFIED BY THE NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES AND IS FOR OTHER DRUGS (SEDATIVE/HYPNOTIC/ANXIOLYTIC), INTOXICATION, WITHDRAWAL, OR THREATENED WITHDRAWAL.
FORM 990, PART III, LINE 4B
BROADLAWN MANOR NURSING AND REHABILITATION CENTER IS A COMPREHENSIVE RESIDENTIAL HEALTH CARE FACILITY LICENSED PURSUANT TO ARTICLE 28 OF THE NEW YORK STATE PUBLIC HEALTH LAW OFFERING PROGRESSIVE AND INNOVATIVE CARE. INCLUDED IN THEIR FACILITY BEDS ARE A 40 BED SUBACUTE UNIT AND TWO 40 BED UNITS DEDICATED TO ALZHEIMER'S DISEASE AND RELATED DEMENTIAS. IN ADDITION TO TRADITIONAL GERIATRIC SERVICES, THE NURSING CENTER PROVIDES A NUMBER OF SPECIALTY SERVICES INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, INTRAVENOUS THERAPY, WOUND CARE, ANTIBIOTIC THERAPY, CASE MANAGEMENT, RECREATION THERAPY, PAIN MANAGEMENT AND SUPPORT GROUPS. ADULT DAY HEALTH SERVICES PROVIDES THERAPEAUTIC, MEDICAL, SOCIAL, REHABILITATIVE AND RECREATIONAL SERVICES TO THE MEDICALLY IMPAIRED OLDER ADULT AND THE DISABLED.
FORM 990, PART VI, SECTION B, LINE 11b
MANAGEMENT WORKS DILIGENTLY TO COMPLETE THE FORM 990 AND ATTACHED SCHEDULES IN A THOROUGH MANNER. MANAGEMENT PRESENTS THE FORM 990 TO THE BOARD OF TRUSTEES, OR DESIGNATED COMMITTEE TO REVIEW. PRIOR TO FILING THE RETURN, ALL TRUSTEES ARE PROVIDED THE FORM 990 AND MANAGEMENT TEAM MEMBERS ARE AVAILABLE TO ANSWER ANY QUESTIONS.
FORM 990, PART VI, SECTION B, LINE 12c
THE CONFLICT OF INTEREST POLICY IS MONITORED BY THE ORGANIZATION'S COMPLIANCE OFFICER. THE ORGANIZATION USES REASONABLE EFFORTS TO OBTAIN CONFLICTS INFORMATION FROM EACH PERSON COVERED BY THE POLICY. THE POLICY COVERS ALL TRUSTEES, BOARD COMMITTEE MEMBERS WHO ARE NOT TRUSTEES, OFFICERS AND KEY MANAGEMENT PERSONNEL. EACH INTERESTED PERSON IS RESPONSIBLE TO REPORT WHETHER A POTENTIAL CONFLICT EXISTS WHEN CONSIDERING A PROPOSED TRANSACTION OR ARRANGEMENT. THE BOARD OR BOARD COMMITTEE DELIBERATING THE PROPOSED TRANSACTION OR ARRANGEMENT WILL DETERMINE WHETHER AN ACTUAL CONFLICT EXISTS. AN INTERESTED PERSON THAT HAS AN ACTUAL CONFLICT MAY NOT PARTICIPATE IN THE DELIBERATIONS OR USE PERSONAL INFLUENCE IN THE MATTER AND HIS/HER VOTE WILL NOT BE COUNTED IN DETERMINING WHETHER TO APPROVE THE PROPOSED TRANSACTION OR ARRANGEMENT.
FORM 990, PART VI, SECTION B, LINE 15b
THE ORGANIZATION'S BOARD ADOPTED A COMPENSATION POLICY (THE "POLICY") FOR COVERED INDIVIDUALS. PURSUANT TO THE POLICY, A COMPENSATION COMMITTEE OF INDEPENDENT DIRECTORS WAS ESTABLISHED TO REVIEW THE COMPENSATION OF ALL EMPLOYEES SPECIFIED AS HAVING RECEIVED RENUMERATION FROM THE ORGANIZATION; SPECIFICALLY, THE ORGANIZATION'S PRESIDENT AND CHIEF EXECUTIVE OFFICER AND THE ORGANIZATION'S CHIEF FINANCIAL OFFICER. THE COMPENSATION COMMITTEE IS ADVISED BY OUTSIDE COUNSEL AND AN INDEPENDENT COMPENSATION CONSULTANT, EACH OF WHOM OPINE TO THE COMPENSATION COMMITTEE THAT THE LEVEL OF COMPENSATION PAID AND THE PROCESS BY WHICH COMPENSATION IS ESTABLISHED MEET APPLICABLE IRS REASONABLENESS AND "SAFE HARBOR" STANDARDS.
FORM 990, PART VI, SECTION C, LINE 19
THESE DOCUMENTS ARE NOT MADE AVAILABLE TO THE PUBLIC THROUGH THE ORGANIZATION.
FORM 990, SCHEDULE R, PART II
COLUMN B, LINE 1
THE LONG ISLAND HOME FOUNDATION ACCEPTS CONTRIBUTIONS AND HAS FUNDRAISING EVENTS TO SUPPORT, FUND AND ASSIST THE LONG ISLAND HOME.
FORM 990, PART XI, LINE 5
OTHER CHANGES IN NET ASSETS OR FUND BALANCES: CHANGE IN EQUITY INTEREST IN THE LIH FOUNDATION 26,274 CHANGE IN ADDITIONAL MINIMUM PENSION LIABILITY (7,219,327) CHANGE IN INTEREST RATE SWAP (2,392,120) CHANGE IN POSTRETIREMENT LIABILITY (21,101) NET TRANSFER OF NET ASSETS 50,243 ----------- TOTAL OTHER CHANGES IN NET ASSETS OR FUND BALANCES (9,556,031) ===========
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.