Form990
Click to see attachment
Department of the Treasury
Internal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation)

MediumBullet The organization may have to use a copy of this return to satisfy state reporting requirements.
OMB No. 1545-0047
2011
Open to Public Inspection
A For the calendar year, or tax year beginning 07-01-2011 and ending 06-30-2012
BCheck if applicable:
CName of organization
MERCY HOME HEALTH BERRYVILLE
 
Doing Business As
 
 
Number and street (or P.O. box if mail is not delivered to street address)
804 W Freeman Suite 4
 
Room/suite
City or town, state or country, and ZIP + 4
Berryville, AR72616
D Employer identification number

87-0781247
E Telephone number

G Gross receipts $ 942,905
F Name and address of principal officer:
Scott Reynolds
1235 E Cherokee
Springfield,MO65804
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
www.mercy.net
H(a)
Is this a group return for
affiliates?
H(b)
Are all affiliates included?
If "No," attach a list. (see instructions)
H(c)
Group exemption number MediumBullet0928
K Form of organization:
 
L Year of formation: 2007
M State of legal domicile: AR
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: AS THE SISTERS OF MERCY BEFORE US, WE BRING TO LIFE THE HEALING MINISTRY OF JESUS THROUGH OUR COMPASSIONATE CARE AND EXCEPTIONAL SERVICE.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a)..... 3 5
4 Number of independent voting members of the governing body (Part VI, line 1b) .... 4 2
5 Total number of individuals employed in calendar year 2011 (Part V, line 2a) ... 5 0
6 Total number of volunteers (estimate if necessary) .... 6 16
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a 0
b Net unrelated business taxable income from Form 990-T, line 34 .. 7b  
Revenues; Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 0 0
9 Program service revenue (Part VIII, line 2g) ......... 1,199,194 942,905
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 0 0
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 0 0
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)................... 1,199,194 942,905
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 0 0
14 Benefits paid to or for members (Part IX, column (A), line 4)..... 0 0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 886,815 706,636
16a Professional fundraising fees (Part IX, column (A), line 11e)..... 0 0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet0    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f).... 366,587 426,790
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 1,253,402 1,133,426
19 Revenue less expenses. Subtract line 18 from line 12....... -54,208 -190,521
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 0 0
21 Total liabilities (Part X, line 26)............. 0 0
22 Net assets or fund balances. Subtract line 21 from line 20..... 0 0
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
JumboBullet
Type or print name and title.
Paid preparer use only
Print/type preparer's name
 
Preparer's signature
Date
PTIN
Firm's name Right pointing arrowhead image

Firm's EIN Right pointing arrowhead image
Firm's address Right pointing arrowhead image



Phone no.
May the IRS discuss this return with the preparer shown above? See instructions .........bullet
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y
Form 990 (2011)
Form 990 (2011)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response to any question in this Part III .........
1
Briefly describe the organization’s mission: AS THE SISTERS OF MERCY BEFORE US, WE BRING TO LIFE THE HEALING MINISTRY OF JESUS THROUGH OUR COMPASSIONATE CARE AND EXCEPTIONAL SERVICE.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? ....................
If “Yes,” describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program services? ..........................
If “Yes,” describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations and section 4947(a)(1) trusts are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 1,133,426 including grants of $   ) (Revenue $ 942,905 )
MERCY HEALTH SPRINGFIELD COMMUNITIES AND ITS SUBSIDIARIES PROVIDE HIGH-QUALITY, COMPASSIONATE, FAITH-BASED HEALTH CARE IN A VARIETY OF TRADITIONAL MEDICAL SETTINGS. THIS ORGANIZATION, AS PART OF MERCY HEALTH SPRINGFIELD COMMUNITIES, PROVIDES SERVICES TO THE COMMUNITIES WE SERVE, WITH PARTICULAR CONCERN FOR THE ECONOMICALLY POOR, IN THE WAY OF INPATIENT HOSPITAL SERVICES, OUTPATIENT SERVICES, EMERGENCY ROOM CARE, HOME HEALTH SERVICES, AND PHYSICIAN CLINIC OFFICE VISITS.
4b (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4c (Code:   ) (Expenses $   including grants of $   ) (Revenue $   )
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet$ 1,133,426
Form 990 (2011)
Form 990 (2011)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If “Yes,” complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? ........
2
 
No
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If “Yes,” complete Schedule C, Part I..........
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities? If “Yes,” complete Schedule C,
Part II.........................
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If “Yes,” complete Schedule C, Part III........................
5
 
No
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If “Yes,” complete Schedule D, Part I....................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas or historic structures? If “Yes,” complete Schedule D, Part II...
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If “Yes,” complete Schedule D, Part III ....................
8
 
No
9
Did the organization report an amount in Part X, line 21; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If “Yes,”
complete Schedule D, Part IV...................
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If “Yes,” complete Schedule D, Part V
10
 
No
11
If the organization’s answer to any of the following questions is ‘Yes,’ then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable:
a
Did the organization report an amount for land, buildings, and equipment in Part X, line10? If “Yes,” complete Schedule D, Part VI.
11a
 
No
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VII.
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part VIII.
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If “Yes,” complete Schedule D, Part IX.
11d
 
No
e
Did the organization report an amount for other liabilities in Part X, line 25? If “Yes,” complete Schedule D, Part X.
11e
 
No
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If “Yes,” complete Schedule D, Part X.
11f
 
No
12a
Did the organization obtain separate, independent audited financial statements for the tax year?
If “Yes,” complete Schedule D, Parts XI, XII, and XIII
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If “Yes,” and if the organization answered ‘No’ to line 12a, then completing Schedule D, Parts XI, XII, and XIII is optional
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If “Yes,” complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States?....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States or aggregate foreign investments valued at $100,000 or more? If “Yes,” complete Schedule F, Part I.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or assistance to any organization or entity located outside the U.S.? If “Yes,” complete Schedule F, Part II..
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or assistance to individuals located outside the U.S.? If “Yes,” complete Schedule F, Part III..
16
 
No
17
Did the organization report a total of more than $15,000, of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If “Yes,” complete Schedule G, Part I
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If “Yes,” complete Schedule G, Part II..........
18
 
No
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If “Yes,” complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospitals? If “Yes,” complete Schedule H.....
20a
 
No
b
If “Yes” to line 20a, did the organization attach a copy of its audited financial statement to this return? Note. All Form 990 filers that operated one or more hospitals must attach audited financial statements.
20b
 
 
Form 990 (2011)
Form 990 (2011)
Page 4
Part IV
Checklist of Required Schedules (continued)
21
Did the organization report more than $5,000 of grants and other assistance to any government or organization in the United States on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II..
21
 
No
22
Did the organization report more than $5,000 of grants and other assistance to individuals in the United States on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III.....
22
 
No
23
Did the organization answer “Yes” to Part VII, Section A, questions 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If “Yes,” complete Schedule J................ Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer questions 24b–24d and complete Schedule K. If “No,” go to line 25................
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds?......................
24c
 
 
d
Did the organization act as an “on behalf of” issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3) and 501(c)(4) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If “Yes,” complete Schedule L, Part I......
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If “Yes,” complete Schedule L, Part I................
25b
 
No
26
Was a loan to or by a current or former officer, director, trustee, key employee, highly compensated employee, or disqualified person outstanding as of the end of the organization’s tax year? If “Yes,” complete Schedule L,
Part II.........................
26
 
No
27
Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If “Yes,” complete Schedule L, Part III.........
27
 
No
28
Was the organization a party to a business transaction with one of the following parties? (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, or key employee? If “Yes,” complete Schedule L, Part IV .........................
28a
 
No
b
A family member of a current or former officer, director, trustee, or key employee? If “Yes,”
complete Schedule L, Part IV...................
28b
 
No
c
An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or owner? If “Yes,” complete Schedule L, Part IV..
28c
 
No
29
Did the organization receive more than $25,000 in non-cash contributions? If “Yes,” complete Schedule M
29
 
No
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If “Yes,” complete Schedule M............
30
 
No
31
Did the organization liquidate, terminate, or dissolve and cease operations? If “Yes,” complete Schedule N,
Part I...........................
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If “Yes,” complete Schedule N, Part II.......................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If “Yes,” complete Schedule R, Part I........ Click to see attachment
33
 
No
34
Was the organization related to any tax-exempt or taxable entity? If “Yes,” complete Schedule R, Parts II, III, IV, and V, line 1..................... Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
Yes
 
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If “Yes,” complete Schedule R, Part V, line 2... Click to see attachment
35b
 
No
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If “Yes,” complete Schedule R, Part V, line 2........... Click to see attachment
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If “Yes,” complete Schedule R, Part VIClick to see attachment
37
 
No
38
Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11 and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Form 990 (2011)
Form 990 (2011)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response to any question in this Part V .........
Yes
No
1a
Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable. .......
1a
0
b
Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable.
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
 
 
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements filed for the calendar year ending with or within the year covered by this return .....................
2a
0
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?

Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. (see instructions)
2b
 
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?.............................
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No,” provide an explanation in Schedule O.....
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account or securities account)?.......................
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for Form TD F 90-22.1, Report of Foreign Bank and Financial Accounts.
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year?..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If “Yes” to line 5a or 5b, did the organization file Form 8886-T? ........
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible?..........
6a
 
No
b
If “Yes,” did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible?........................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor?....................
7a
 
No
b
If “Yes,” did the organization notify the donor of the value of the goods or services provided?.....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282?...........................
7c
 
No
d
If “Yes,” indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?..........................
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract?..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required?...................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C?...............
7h
 
 
8
Sponsoring organizations maintaining donor advised funds and section 509(a)(3) supporting organizations. Did the supporting organization, or a donor advised fund maintained by a sponsoring organization, have excess business holdings at any time during the year?................
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the organization make any taxable distributions under section 4966?.........
9a
 
 
b
Did the organization make a distribution to a donor, donor advisor, or related person?......
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them) ........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If “Yes,” enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state?
Note. All 501(c)(29) organizations must list in Schedule O each state in which they are licensed to issue qualified health plans, the amount of reserves required by each state, and the amount of reserves the organization allocated to each state.
13a
 
 
b
Enter the aggregate amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans.
13b
 
c
Enter the aggregate amount of reserves on hand.
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
 
b
If "Yes," has it filed a Form 720 to report these payments? If “No,” provide an explanation in Schedule O..
14b
 
 
Form 990 (2011)
Form 990 (2011)
Page 6
Part VI
Governance, Management, and Disclosure For each “Yes” response to lines 2 through 7b below, and for a “No” response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response to any question in this Part VI .........
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
If the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
1a
5
b
Enter the number of voting members included in line 1a, above, who are independent .................
1b
2
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed?
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? .................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ............
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .........................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ..........
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If “Yes,” provide the names and addresses in Schedule O .....
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal
Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If “Yes,” did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? ....
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form?
11a
Yes
 
b
Describe in Schedule O the process, if any, used by the organization to review the Form 990. .....
12a
Did the organization have a written conflict of interest policy? If “No,” go to line 13.......
12a
Yes
 
b
Were officers, directors or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If “Yes,” describe in Schedule O how this was done ....................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes," to line 15a or 15b, describe the process in Schedule O (see instructions).
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If “Yes,” did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the States with which a copy of this Form 990 is required to be filedMediumBullet
18
Section 6104 requires an organization to make its Form 1023 (or 1024 if applicable), 990, and 990-T (501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how), the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, physical address, and telephone number of the person who possesses the books and records of the organization: MediumBullet
Scott Reynolds
1235 E Cherokee
Springfield,MO65804
(314) 579-6100
Form 990 (2011)
Form 990 (2011)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response to any question in this Part VII .........
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation, and current key employees. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest
compensated employees; and former such persons.
Check this box if neither the organization nor any related organizations compensated any current or former officer, director, or trustee.
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;
(1) Michelle Gann
Board member
 40.0 X           0 90,425 8,268
(2) PEGGY KJELGAARD PHD
BOARD MEMBER
 1.0 X           0 0 0
(3) DAN MUMAUGH
BOARD MEMBER
 1.0 X           0 0 0
(4) SCOTT REYNOLDS
VP-FINANCE
 60.0 X   X       0 282,351 35,968
(5) MICHELE SCHAEFER
VP-REGIONAL OPERATIONS
 60.0 X           0 416,586 64,462
(6) Jon Swope
Chief executive officer
 60.0     X       0 682,221 243,717
(7) CHRIS KNACKSTEDT
CHIEF FINANCIAL OFFICER
 60.0     X       0 625,750 96,425
(8) BRADLEY KIM DAY
PRESIDENT CENTRAL COMM
 60.0       X     0 833,159 436,266
(9) TANYA MARION
REGIONAL VP-HUMAN RESOURCES
 60.0       X     0 160,391 16,041
(10) MICHAEL MERRIGAN
Regional VP-General Counsel
 60.0       X     0 320,923 65,228














Form 990 (2011)
Form 990 (2011)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and Title 		(B)
Average hours per week (describe hours for related organizations in Schedule O) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W- 2/1099-MISC) 		(E)
Reportable compensation from related organizations (W- 2/1099-MISC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; Officer; Key Employee; Highest compensated employee; Former;


























1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)............MediumBullet 0 3,411,806 966,375
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organizationMediumBullet0
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If “Yes,” complete Schedule J for such individual .............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person .....
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet0
Form 990 (2011)
Form 990 (2011)
Page 9
Part VIII
Statement of Revenue
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512, 513, or 514
Contributions, Gifts, Grants and Other Similar Amounts 1a Federated campaigns..1a  
b Membership dues....1b  
c Fundraising events....1c  
d Related organizations...1d  
e Government grants (contributions)1e  
f All other contributions, gifts, grants, and
similar amounts not included above1f 		 
g Noncash contributions included in lines 1a-1f:$  
h Total. Add lines 1a-1f.......MediumBullet 0
Program Service Revenue Business Code
2a NET PATIENT SERVICE REVENUE 621,610 942,905 942,905    
b
c
d
e
f All other program service revenue .        
g Total. Add lines 2a–2f........MediumBullet 942,905
Other Revenue 3 Investment income (including dividends, interest
and other similar amounts).....MediumBullet 0      
4 Income from investment of tax-exempt bond proceeds..MediumBullet 0      
5 Royalties............MediumBullet 0      
(i) Real (ii) Personal
6a Gross rents    
b Less: rental expenses    
c Rental income or (loss)    
d Net rental income or (loss).......MediumBullet        
(i) Securities (ii) Other
7a Gross amount from sales of assets other than inventory    
b Less: cost or other basis and sales expenses    
c Gain or (loss)    
d Net gain or (loss)..........MediumBullet 0      
8a Gross income from fundraising events (not including
$  
of contributions reported on line 1c). See Part IV, line 18 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from fundraising events..MediumBullet 0    
9a Gross income from gaming activities.
See Part IV, line 19 ...
a  
b Less: direct expenses ...b  
c Net income or (loss) from gaming activities...MediumBullet 0      
10a Gross sales of inventory, less
returns and allowances .
a  
b Less: cost of goods sold ..b  
c Net income or (loss) from sales of inventory..MediumBullet 0      
Miscellaneous Revenue Business Code
11a            
b            
c            
d All other revenue ....        
e Total. Add lines 11a–11d ......MediumBullet 0
12 Total revenue. See Instructions....MediumBullet 942,905 942,905    
Form 990 (2011)
Form 990 (2011)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A) but are not required to complete columns (B), (C), and (D).
Check if Schedule O contains a response to any question in this Part IX. .........
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising expenses
1 Grants and other assistance to governments and organizations in the United States. See Part IV, line 21 0  
2 Grants and other assistance to individuals in the United States. See Part IV, line 22 0  
3 Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16 0  
4 Benefits paid to or for members 0  
5 Compensation of current officers, directors, trustees, and key employees .... 0      
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) .... 0      
7 Other salaries and wages 699,291 699,291    
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 0      
9 Other employee benefits ....... 7,345 7,345    
10 Payroll taxes ........... 0      
11 Fees for services (non-employees):        
a Management ...... 0      
b Legal ......... 0      
c Accounting ........... 0      
d Lobbying ........... 0      
e Professional fundraising. See Part IV, line 17.. 0  
f Investment management fees ...... 0      
g Other .......... 120,423 120,423    
12 Advertising and promotion .... 1,491 1,491    
13 Office expenses ....... 112,476 112,476    
14 Information technology ...... 0      
15 Royalties .. 0      
16 Occupancy ........... 33,203 33,203    
17 Travel ............ 94,021 94,021    
18 Payments of travel or entertainment expenses for any federal, state, or local public officials ...... 0      
19 Conferences, conventions, and meetings .... 0      
20 Interest ........... 0      
21 Payments to affiliates ....... 0      
22 Depreciation, depletion, and amortization ..... 0      
23 Insurance .............. 0      
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24f. If line 24f amount exceeds 10% of line 25, column (A) amount, list line 24f expenses on Schedule O.)
a MEDICAL SUPPLIES 48,787 48,787    
b REPAIRS & MAINTENANCE 6,812 6,812    
c MISCELLANEOUS 9,577 9,577    
d
e
f All other expenses        
25 Total functional expenses. Add lines 1 through 24f 1,133,426 1,133,426 0 0
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2011)
Form 990 (2011)
Page 11
Part X Balance Sheet
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash—non-interest-bearing .......... 0 1 0
2 Savings and temporary cash investments ....... 0 2 0
3 Pledges and grants receivable, net ......... 0 3 0
4 Accounts receivable, net ......... 0 4 0
5 Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
Schedule L .......... 0 5 0
6 Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
Schedule L .......... 0 6 0
7 Notes and loans receivable, net ............. 0 7 0
8 Inventories for sale or use .............. 0 8 0
9 Prepaid expenses and deferred charges ............ 0 9 0
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a  
b Less: accumulated depreciation. ..... 10b   0 10c  
11 Investments—publicly traded securities .......... 0 11 0
12 Investments—other securities. See Part IV, line 11 ...... 0 12 0
13 Investments—program-related. See Part IV, line 11 .. 0 13 0
14 Intangible assets ......... 0 14 0
15 Other assets. See Part IV, line 11 ........... 0 15 0
16 Total assets. Add lines 1 through 15 (must equal line 34)... 0 16 0
Liabilities 17 Accounts payable and accrued expenses . 0 17 0
18 Grants payable .......... 0 18 0
19 Deferred revenue .......... 0 19 0
20 Tax-exempt bond liabilities .......... 0 20 0
21 Escrow or custodial account liability. Complete Part IV of Schedule D.. 0 21 0
22 Payables to current and former officers, directors, trustees, key
employees, highest compensated employees, and disqualified
persons. Complete Part II of Schedule L.......... 0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 0 23 0
24 Unsecured notes and loans payable to unrelated third parties .... 0 24 0
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D..... 0 25 0
26 Total liabilities. Add lines 17 through 25..... 0 26 0
Net Assets or Fund Balance Organizations that follow SFAS 117, check here MediumBullet and complete lines 27 through 29, and lines 33 and 34.
27 Unrestricted net assets ..... 0 27 0
28 Temporarily restricted net assets ..... 0 28 0
29 Permanently restricted net assets ..... 0 29 0
Organizations that do not follow SFAS 117, check here MediumBullet and complete lines 30 through 34.
30 Capital stock or trust principal, or current funds .....   30  
31 Paid-in or capital surplus, or land, building or equipment fund .....   31  
32 Retained earnings, endowment, accumulated income, or other funds   32  
33 Total net assets or fund balances ..... 0 33 0
34 Total liabilities and net assets/fund balances ..... 0 34 0
Form 990 (2011)
Form 990 (2011)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response to any question in this Part XI .........
1
Total revenue (must equal Part VIII, column (A), line 12) ...
1
942,905
2
Total expenses (must equal Part IX, column (A), line 25) ....
2
1,133,426
3
Revenue less expenses. Subtract line 2 from line 1 ...
3
-190,521
4
Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) ..
4
0
5
Other changes in net assets or fund balances (explain in Schedule O) ...
5
190,521
6
Net assets or fund balances at end of year. Combine lines 3, 4, and 5 (must equal Part X, line 33, column (B)) ....
6
0
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response to any question in this Part XII .........
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain in
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?....
2a
 
No
b
Were the organization’s financial statements audited by an independent accountant?........
2b
Yes
 
c
If “Yes,” to 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. ...........................
2c
Yes
 
d
If “Yes” to line 2a or 2b, check a box below to indicate whether the financial statements for the year were issued on a separate basis, consolidated basis, or both:
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? ................
3a
 
No
b
If “Yes,” did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. ..
3b
 
 
Form 990 (2011)
Additional Data


Software ID:  
Software Version:  
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990 or 990EZ)

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.
right arrow Attach to Form 990 or Form 990-EZ. right arrow See separate instructions.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY HOME HEALTH BERRYVILLE
 
Employer identification number

87-0781247
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
f
g
(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)
 
No
(ii) a family member of a person described in (i) above? ......................
11g(ii)
 
No
(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................
11g(iii)
 
No
h
(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
(1) MERCY HOSPITAL SPRINGFIELD
  		440552485 03 Yes   Yes   Yes   0
Total                 0

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
12
 
13
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
18
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
Section C. Computation of Public Support Percentage
15
15
 
16
16
 
Section D. Computation of Investment Income Percentage
17
17
 
18
18
 
19a
b
20
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:  
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet Attach to Form 990. SchJMediumBullet See separate instructions.
OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HOME HEALTH BERRYVILLE
 
Employer identification number

87-0781247
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all the expenses described above? If "No," complete Part III to explain....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....
2
 
 
3
Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? ...............
4a
 
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? ........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ...........................
5a
 
No
b
Any related organization? .........................
5b
 
No
If "Yes," to line 5a or 5b, describe in Part III.
6
For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ...........................
6a
 
No
b
Any related organization? .........................
6b
 
No
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
 
No
8
Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................
8
 
No
9
If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990
Cat. No. 50053T
Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and column (E) for that individual.
(A) Name (B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation
reported as deferred
in prior Form 990
(i) Base compensation (ii) Bonus & incentive compensation (iii) Other reportable compensation
(1) SCOTT REYNOLDS (i)
(ii)		 0
190,368 		0
48,425 		0
43,558 		0
23,993 		0
11,975 		0
318,319 		0
0
(2) MICHELE SCHAEFER (i)
(ii)		 0
310,176 		0
63,076 		0
43,334 		0
56,610 		0
7,852 		0
481,048 		0
0
(3) Jon Swope (i)
(ii)		 0
463,948 		0
191,212 		0
27,061 		0
230,083 		0
13,634 		0
925,938 		0
0
(4) CHRIS KNACKSTEDT (i)
(ii)		 0
408,170 		0
127,077 		0
90,503 		0
83,509 		0
12,916 		0
722,175 		0
0
(5) BRADLEY KIM DAY (i)
(ii)		 0
598,570 		0
203,887 		0
30,702 		0
422,839 		0
13,427 		0
1,269,425 		0
0
(6) TANYA MARION (i)
(ii)		 0
111,560 		0
30,030 		0
18,801 		0
3,958 		0
12,083 		0
176,432 		0
0
(7) MICHAEL MERRIGAN (i)
(ii)		 0
214,349 		0
66,366 		0
40,208 		0
49,457 		0
15,771 		0
386,151 		0
0









Schedule J (Form 990) 2011

Schedule J (Form 990) 2011
Page 3
Part III
Supplemental Information
Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.
Identifier Return Reference Explanation
Supplemental Compensation Information   FORM 990, SCHEDULE J, PART I, QUESTION 3 OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR PROCESS WAS BEGUN FOR THOSE CLASSIFIED AS OFFICERS (AND THUS DISQUALIFIED PERSONS), THE ORGANIZATION RELIES UPON MERCY HEALTH, WHICH USES THE FOLLOWING TO ESTABLISH THE COMPENSATION: EXTERNAL MARKET SALARY SURVEYS, EXTERNAL MARKET SALARY STUDIES, ENGAGEMENT OF AN INDEPENDENT COMPENSATION CONSULTANT, AND REVIEW/APPROVAL OF COMPENSATION BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF MERCY HEALTH. FOR THOSE CLASSIFIED AS KEY EMPLOYEES, THE ORGANIZATION USES THE FOLLOWING TO ESTABLISH THE COMPENSATION: EXTERNAL MARKET SALARY SURVEYS, EXTERNAL MARKET SALARY STUDIES, AND REVIEW/APPROVAL OF EXECUTIVE MANAGEMENT. COMPENSATION REVIEWS ARE COMPLETED ON AN ANNUAL BASIS, AND A REVIEW WAS COMPLETED DURING THE REPORTING YEAR. FORM 990, SCHEDULE J, PART I, QUESTION 4B MERCY HEALTH OFFERS SUPPLEMENTAL RETIREMENT PLANS TO CERTAIN EXECUTIVES WHICH PROVIDE BENEFITS UPON RETIREMENT BASED ON COMPENSATION, AGE AT THE TIME OF BENEFIT COMMENCEMENT, LENGTH OF SERVICE WITH THE COMPANY AND/OR ITS AFFILIATES, AND LENGTH OF TENURE IN THE PLAN. THE INDIVIDUALS REPORTABLE ON THIS RETURN WHO PARTICIPATE IN THE SUPPLEMENTAL RETIREMENT PLANS ARE CHRIS KNACKSTEDT AND JON SWOPE. THE AMOUNT OF ALL ACCRUED BENEFITS IS INCLUDED IN COMPENSATION AMOUNTS PROVIDED IN SCHEDULE J, PART II, COLUMN (C).
Schedule J (Form 990) 2011

Additional Data


Software ID:  
Software Version:  
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.
MediumBullet Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2011
Open to Public
Inspection
Name of the organization
MERCY HOME HEALTH BERRYVILLE
 
Employer identification number

87-0781247
Identifier Return Reference Explanation
FORM 990, Part V, QUESTION 1A   VENDORS FOR THE FILING ORGANIZATION ARE PAID BY MERCY HEALTH (EIN 43-1423050). AS SUCH, ALL REQUIRED FORM 1099 AND FORM 1096 REPORTING IS MADE (WITH LIMITED EXCEPTIONS) UNDER THE MERCY HEALTH EIN. FORM 990, PART V, QUESTION 2A EMPLOYEES ARE PAID BY A RELATED ORGANIZATION UNDER A COMMON PAYMASTER ARRANGEMENT. AS SUCH, ALL REQUIRED PAYROLL FILING (INCLUDING W-2 AND W-3'S) WAS REPORTED UNDER THE RELATED ORGANIZATION'S EIN. FORM 990, PART VI, QUESTIONS 6, 7A, & 7B THE FILING ORGANIZATION HAS A SOLE CORPORATE MEMBER, MERCY HEALTH SPRINGFIELD COMMUNITIES. THE FOLLOWING CORPORATE POWERS AND RESPONSIBILITIES SHALL BE RESERVED TO THE CORPORATE MEMBER AND SHALL REQUIRE THE ACTION OR APPROVAL, AS APPLICABLE, OF THE CORPORATE MEMBER: -ADOPTION OF OR REVISION TO THE PHILOSOPHY, MISSION AND VALUES ACCORDING TO WHICH THE CORPORATION IS OPERATED; -APPROVAL OR ADOPTION OF ANY AMENDMENT OF THE ARTICLES OF INCORPORATION OF THE CORPORATION, OR ADOPTION OF ANY AMENDMENT OF THESE BYLAWS; -ADOPTION OF A PLAN OF MERGER, DISSOLUTION OR CONSOLIDATION OF THE CORPORATION; -AUTHORIZATION OR APPROVAL, AS APPLICABLE, OF THE SALE OF, OR SERIES OF RELATED SALES WHICH AT THE OUTSET ARE INTENDED BY THE CORPORATION TO ULTIMATELY RESULT IN THE SALE OF, ALL OR SUBSTANTIALLY ALL OF THE CORPORATION'S PROPERTY; -APPOINTMENT OF THE EXECUTIVE DIRECTOR OF THE CORPORATION (OR HIS OR HER SUBSTITUTE OR SUCCESSOR), IN CONSULTATION WITH THE BOARD; -REMOVAL OF THE EXECUTIVE DIRECTOR OF THE CORPORATION, WITH OR WITHOUT CAUSE; -AUTHORIZATION OR APPROVAL, AS APPLICABLE, OF THE SALE, CONVEYANCE, LEASE, TRANSFER, OR DISPOSITION OF THE CORPORATION'S PROPERTY, INCURRENCE OF DEBT OR OF ENCUMBRANCE OF THE CORPORATION'S PROPERTY; -AFTER CONSULTATION WITH THE BOARD, AUTHORIZATION OR APPROVAL OR AMENDMENT, AS APPLICABLE, OF THE STRATEGIC AND FINANCIAL PLANS, GOALS, AND OBJECTIVES OF THE CORPORATION, INCLUDING, WITHOUT LIMITATION, THE OPERATING AND CAPITAL BUDGETS, INCURRENCE OF DEBT, INVESTMENTS, FINANCIAL TARGETS AND CAPITAL LEASES; -APPOINTMENT OF THE BOARD AS SET FORTH IN ARTICLE V; -REMOVAL OF BOARD MEMBERS AS SET FORTH IN ARTICLE V; AND, -AUTHORIZATION OR APPROVAL, AS APPLICABLE, OF ANY UNBUDGETED EXPENDITURES OR UNBUDGETED INCURRENCE OF DEBT BY THE CORPORATION IN EXCESS OF THOSE AMOUNTS PERMITTED BY THE POLICY ESTABLISHED BY THE CORPORATE MEMBER FROM TIME TO TIME. FORM 990, PART VI, QUESTION 11B DSCR THE PROCESS USED BY MANAGEMENT &/OR GOVERNING BODY TO REVIEW 990 THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM USING INFORMATION PROVIDED BY THE FILING ORGANIZATION. A DRAFT FORM 990 IS REVIEWED BY THE FILING ORGANIZATION'S FINANCE TEAM, INCLUDING THE CONTROLLER AND THE VICE-PRESIDENT OF FINANCE. THE DRAFT FORM 990 IS ALSO REVIEWED BY MERCY HEALTH'S TAX DEPARTMENT, TO ENSURE ACCURACY AND CONSISTENCY WITH OTHER RELATED ORGANIZATIONS' FORM 990S. AFTER QUESTIONS ARISING FROM THE VARIOUS REVIEWS ARE ADDRESSED AND INCORPORATED INTO THE FORM 990, A REVISED DRAFT IS MADE AVAILABLE TO BOTH THE FILING ORGANIZATION'S LEADERSHIP TEAM, INCLUDING THE CFO AND CEO, AND THE BOARD OF DIRECTORS FOR THEIR REVIEW. THE FORM 990 IS THEN SIGNED AND FILED WITH THE IRS. FORM 990, PART VI, QUESTION 12C DESCRIPTION OF PROCESS TO MONITOR TRANSACTIONS FOR CONFLICTS OF INTEREST OFFICERS, DIRECTORS, KEY EMPLOYEES AND OTHER DISQUALIFIED PERSONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE ANNUALLY AND DID SO IN THE NORMAL COURSE FOR THE YEAR ENDED JUNE 30, 2012. THIS PROCESS IS ADMINISTERED AT THE MERCY HEALTH LEVEL BY MERCY'S BUSINESS RISK (INTERNAL AUDIT) DEPARTMENT. THE QUESTIONNAIRES ARE REVIEWED WITH LEADERSHIP AT THE LOCAL LEVEL AND POTENTIAL CONFLICTS DISCUSSED AND RESOLVED. THE CONFLICTS AND THEIR RESPECTIVE RESOLUTIONS ARE SHARED AT THE MERCY LEVEL WITH A TEAM INCLUDING MERCY'S CHIEF FINANCIAL OFFICER, CHIEF COMPLIANCE OFFICER AND OTHER MEMBERS OF FINANCE, LEGAL AND HR. SUMMARY RESULTS ARE REVIEWED WITH MERCY'S FINANCE, AUDIT AND COMPLIANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, LINE 19 PUBLIC AVAILABILITY OF GOVERNING POLICIES GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST BUT ARE NOT PUBLISHED PUBLICLY. FORM 990, PART VII, SECTION A, COLUMN B AVERAGE HOURS PER WEEK SEVERAL INDIVIDUALS LISTED IN PART VII ARE DISCLOSED AS TRUSTEES, DIRECTORS, OFFICERS, AND KEY EMPLOYEES ON MULTIPLE FORM 990S OF ENTITIES INCLUDED WITHIN MERCY HEALTH. THE AVERAGE HOURS PER WEEK DISCLOSED IN PART VII IS AN ESTIMATE OF THE HOURS PER WEEK THAT THE LISTED INDIVIDUAL SPENDS ON BOTH THE FILING ORGANIZATION AND ALL RELATED ORGANIZATIONS. FORM 990, PART XI, QUESTION 5 OTHER CHANGES IN NET ASSETS MERCY HOME HEALTH BERRYVILLE IS A FUNCTIONALLY INTEGRATED ENTITY WITH MERCY HOSPITAL SPRINGFIELD. AT THE END OF THE YEAR, THE BALANCE SHEET AND INCOME STATEMENT ARE INTEGRATED WITH MERCY HOSPITAL SPRINGFIELD. FORM 990, PART XII, QUESTION 2C OVERSIGHT OR SELECTION PROCESS THE FILING ORGANIZATION'S FINANCIAL STATEMENTS WERE INCLUDED IN MERCY HEALTH AND SUBSIDIARIES' ANNUAL FINANCIAL STATEMENT AUDIT. MERCY HEALTH AND SUBSIDIARIES RECEIVED AN UNQUALIFIED OPINION FROM THE EXTERNAL AUDITORS FOR FISCAL 2012 (THE TAX YEAR CURRENTLY BEING REPORTED). HOWEVER, NO SEPARATE AUDIT OPINION IS ISSUED ON THE FINANCIAL STATEMENTS OF THE FILING ORGANIZATION. THE ULTIMATE RESPONSIBILITY FOR OVERSIGHT OF THE FINANCIAL STATEMENT AUDIT AND SELECTION OF THE EXTERNAL AUDITOR LIES WITH THE FINANCE, AUDIT, AND COMPLIANCE COMMITTEE OF MERCY HEALTH BOARD OF DIRECTORS. AUDIT RESULTS ARE COMMUNICATED TO THIS COMMITTEE.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990 or 990-EZ) 2011

Additional Data


Software ID:  
Software Version:  
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBulletAttach to Form 990. MediumBullet See separate instructions.

OMB No. 1545-0047
2011
Open to Public Inspection
Name of the organization
MERCY HOME HEALTH BERRYVILLE
 
Employer identification number

87-0781247
Part I
Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)
(a)
Name, address, and EIN of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income
(e)
End-of-year assets


 		(f)
Direct controlling
entity

















Part II
Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section
(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled organization
Yes No
(1) Advance Care Hospital

300 Werner Street

Hot Springs,AR71913
71-0816634 		Hospital AR 501(C)(3) 3 Mercy Health
 
Yes
 
(2) Casa de Misericordia

1602 Mcclelland Street

Laredo,TX78044
74-2912461 		Shelter TX 501(C)(3) 7 MM Laredo
 
Yes
 
(3) Laredo Medical Group

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-2764726 		Inactive TX 501(C)(3) 9 MHS-TX
 
Yes
 
(4) McAuley Portfolio Management Company

14528 S Outer Forty Ste 100

Chesterfield,MO63017
26-1708048 		Port Mgmt MO 501(C)(3) 11b Mercy Health
 
Yes
 
(5) Mercy Clinic East Communites

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1771217 		Phys Group MO 501(C)(3) 9 MHEC
 
Yes
 
(6) Mercy Clinic Fort Smith Communitites

7301 Rogers Avenue

Fort Smith,AR72917
26-1318597 		Phys Clinic AR 501(C)(3) 9 MHFSC
 
Yes
 
(7) Mercy Clinic Hot Springs Communitites

1 Mercy Lane

Hot Springs,AR71913
26-1125131 		Phys Clinic AR 501(C)(3) 9 MHHSC
 
Yes
 
(8) Mercy Clinic Oklahoma Communities

4300 W Memorial Road

Oklahoma City,OK73120
27-0473057 		Phys Group OK 501(C)(3) 9 MHOC
 
Yes
 
(9) Mercy Clinic Springfield Communities

1965 Fremont Street Ste 2950

Springfield,MO65804
43-1560263 		Phys Group MO 501(C)(3) 9 MHSC
 
Yes
 
(10) Mercy Family Center

14528 S Outer Forty Ste 100

Chesterfield,MO63017
72-1069468 		counseling MO 501(C)(3) 7 Mercy Health
 
Yes
 
(11) Mercy Foundation for Health Innovation

14528 S Outer Forty Ste 100

Chesterfield,MO63017
20-0901499 		Foundation MO 501(C)(3) 11b Mercy Health
 
Yes
 
(12) Mercy Health

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1423050 		Sup Hlth Sys MO 501(C)(3) 1 NA
 
 
No
(13) Mercy Health East Communities

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-1718408 		Hlth System MO 501(C)(3) 11b Mercy Health
 
Yes
 
(14) Mercy Health Fort Smith Communities

7301 Rogers Avenue

Fort Smith,AR72917
26-1318515 		Holding Co AR 501(C)(3) 11b Mercy Health
 
Yes
 
(15) Mercy Health Foundation Ardmore

1011 14th Avenue NW

Ardmore,OK73401
71-0962525 		Foundation OK 501(C)(3) 11a MH Ardmore
 
Yes
 
(16) Mercy Health Foundation Berryville

214 Carter Street

Berryville,AR72616
71-0759301 		Foundation AR 501(C)(3) 11a MH Berryvill
 
Yes
 
(17) Mercy Health Foundation Fort Scott

401 Woodland Hills Blvd

Fort Scott,KS66701
48-1077073 		Foundation KS 501(C)(3) 11c Mercy KS Com
 
Yes
 
(18) Mercy Health Foundation Hot Springs

300 Werner Street

Hot Springs,AR71913
71-0804718 		Foundation AR 501(C)(3) 11b MHHS
 
Yes
 
(19) Mercy Health Foundation Independence

800 W Myrtle

Independence,KS67301
48-1079981 		Foundation KS 501(C)(3) 11a Mercy KS Com
 
Yes
 
(20) Mercy Health Foundation Joplin

2817 St Johns Blvd

Joplin,MO64804
27-0906136 		Foundation MO 501(C)(3) 11a MHSMKC
 
Yes
 
(21) Mercy Health Foundation NW Arkansas

2710 Rife Medical Lane

Rogers,AR72758
71-0601687 		Foundation AR 501(C)(3) 11c MH Rogers
 
Yes
 
(22) Mercy Health Foundation OF Oklahoma

4300 W Memorial Road

Oklahoma City,OK73120
45-4732301 		Foundation OK 501(C)(3) 11a MHOC
 
Yes
 
(23) Mercy Health Foundation OK City

4300 W Memorial Road

Oklahoma City,OK73120
73-1593024 		Foundation OK 501(C)(3) 11a MHOC
 
Yes
 
(24) Mercy Health Foundation Springfield

1235 E Cherokee Street

Springfield,MO65804
32-0195818 		Foundation MO 501(C)(3) 11b MHSC
 
Yes
 
(25) Mercy Health Foundation St Louis

14528 S Outer Forty Ste 100

Chesterfield,MO63017
56-2410020 		Foundation MO 501(C)(3) 11b MHEC
 
Yes
 
(26) Mercy Health Foundation Washington

901 E Fifth Street

Washington,MO63090
56-2410022 		Foundation MO 501(C)(3) 11b MHEC
 
Yes
 
(27) Mercy Health Hot Springs Communities

300 Werner Street

Hot Springs,AR71913
26-1125064 		Holding Co AR 501(C)(3) 11b Mercy Health
 
Yes
 
(28) Mercy Health NW Arkansas Communities

2710 Rife Medical Drive

Rogers,AR72758
62-1684203 		Phys Group AR 501(C)(3) 11b Mercy Health
 
Yes
 
(29) Mercy Health Oklahoma Communities

4300 W Memorial Road

Oklahoma City,OK73120
73-1453048 		Holding co OK 501(C)(3) 11b Mercy Health
 
Yes
 
(30) Mercy Health Springfield Communitites

1235 E Cherokee Street

Springfield,MO65804
43-1856028 		Holding Co MO 501(C)(3) 11b Mercy Health
 
Yes
 
(31) Mercy Health SW MOKS Communitites

2817 St Johns Blvd

Joplin,MO64804
30-0584463 		Hlth System MO 501(C)(3) 11b Mercy Health
 
Yes
 
(32) Mercy Health System of Texas Inc

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-2764727 		Inactive TX 501(C)(3) 11b Mercy Health
 
Yes
 
(33) Mercy Hospital Ardmore

1011 14th Avenue NW

Ardmore,OK73401
73-1500629 		Hospital OK 501(C)(3) 3 MHOC
 
Yes
 
(34) Mercy Hospital Aurora

500 Porter Avenue

Aurora,MO65605
43-1936696 		Hospital MO 501(C)(3) 3 MHSC
 
Yes
 
(35) Mercy Hospital Berryville

214 Carter Street

Berryville,AR72616
71-0759299 		Hospital AR 501(C)(3) 3 MHSC
 
Yes
 
(36) Mercy Hospital Carthage

3125 Dr Russell Smith Way

Carthage,MO64836
45-3808607 		Hospital MO 501(C)(3) 3 MHSMKC
 
Yes
 
(37) Mercy Hospital Cassville

94 Main Street

Cassville,MO65625
43-1936699 		Hospital MO 501(C)(3) 3 MHSC
 
Yes
 
(38) Mercy Hospital Columbus

220 Pennsylvania Avenue

Columbus,KS66725
27-0842031 		Hospital MO 501(C)(3) 3 MHSMKC
 
Yes
 
(39) Mercy Hospital El Reno

2115 Parkview Drive

El Reno,OK73036
27-2716065 		Hospital OK 501(C)(3) 3 MHOC
 
Yes
 
(40) Mercy Hospital Fort Smith

7301 Rogers Avenue

Fort Smith,AR72917
71-0240352 		Hospital AR 501(C)(3) 3 MHFSC
 
Yes
 
(41) Mercy Hospital Healdton

918 South 8th Street

Healdton,OK73438
26-3173902 		Hospital OK 501(C)(3) 3 MH Ardmore
 
Yes
 
(42) Mercy Hospital Hot Springs

300 Werner Street

Hot Springs,AR71913
71-0236913 		Hospital AR 501(C)(3) 3 MHHSC
 
Yes
 
(43) Mercy Hospital Joplin

2817 St Johns Blvd

Joplin,MO64804
27-0814858 		Hospital MO 501(C)(3) 3 MHSMKC
 
Yes
 
(44) Mercy Hospital Lebanon

100 Hospital Drive

Lebanon,MO65536
43-1767432 		Hospital MO 501(C)(3) 3 MHSC
 
Yes
 
(45) Mercy Hospital Logan County Inc

200 South Academy

Guthrie,OK73044
45-2998842 		Hospital OK 501(C)(3) 3 MHOC
 
Yes
 
(46) Mercy Hospital of Laredo

14528 S Outer Forty Ste 100

Chesterfield,MO63017
74-1189682 		Inactive TX 501(C)(3) 3 MHS-TX
 
Yes
 
(47) Mercy Hospital Oklahoma City

4300 W Memorial Road

Oklahoma City,OK73120
73-0579285 		Hospital OK 501(C)(3) 3 MHOC
 
Yes
 
(48) Mercy Hospital Ozark

801 W River Street

Ozark,AR72949
71-0689680 		Hospital AR 501(C)(3) 3 MHFS
 
Yes
 
(49) Mercy Hospital Paris

500 E Academy

Paris,AR72855
71-0655753 		Hospital AR 501(C)(3) 3 MHFS
 
Yes
 
(50) Mercy Hospital Rogers

2710 Rife Medical Lane

Rogers,AR72758
71-0294390 		Hospital AR 501(C)(3) 3 MHNWAC
 
Yes
 
(51) Mercy Hospital Springfield

1235 E Cherokee Street

Springfield,MO65804
44-0552485 		Hospital MO 501(C)(3) 3 MHSC
 
 
No
(52) Mercy Hospital Tishomingo

1000 South Byrd

Tishomingo,OK73460
27-4433830 		Hospital OK 501(C)(3) 3 MH Ardmore
 
Yes
 
(53) Mercy Hospital Waldron

1341 W 6th Street

Waldron,AR72958
71-0557895 		Hospital AR 501(C)(3) 3 MHFS
 
Yes
 
(54) Mercy Hospital Watonga Inc

500 Clarence Nash Blvd

Watonga,OK73772
45-5199762 		Hospital OK 501(C)(3) 3 MHOC
 
Yes
 
(55) Mercy Hospitals East Communities

14528 S Outer Forty Ste 100

Chesterfield,MO63017
43-0653493 		Hospital MO 501(C)(3) 3 MHEC
 
Yes
 
(56) Mercy Kansas Communities Inc

401 Woodland Hills Blvd

Ft Scott,KS66701
48-0956045 		Hospital KS 501(C)(3) 3 MHSMKC
 
Yes
 
(57) Mercy Medical Research Institute

1235 E Cherokee Street

Springfield,MO65804
87-0796305 		Research MO 501(C)(3) 4 MHSC
 
Yes
 
(58) Mercy Ministries of Laredo

2500 Zacatecas

Laredo,TX78046
20-0198462 		outreach TX 501(C)(3) 7 Mercy Health
 
Yes
 
(59) Mercy St Francis Hospital

100 W Highway 60

Mountain View,MO65548
44-0607149 		Hospital MO 501(C)(3) 3 MHSC
 
Yes
 
(60) Mercy Support Services

14528 S OUTER FORTY STE 100

CHESTERFIELD,MO63017
43-1677952 		Inactive MO 501(C)(3) 11c MHEC
 
Yes
 
(61) MHM SUPPORT SERVICES

14528 S OUTER FORTY STE 100

CHESTERFIELD,MO63017
20-2553101 		Hlth System MO 501(C)(3) 11B MERCY HEALTH
 
Yes
 
(62) Mission Clinical Services

300 Werner Street

Hot Springs,AR71913
13-4239691 		nursing home AR 501(C)(3) 9 MHHSC
 
Yes
 
(63) St Edward Mercy Foundation

PO Box 17000

Fort Smith,AR72917
23-7330425 		Foundation AR 501(C)(3) 7 MHFS
 
Yes
 
(64) St John's Children's Hospital Inc

1235 E Cherokee Street

Springfield,MO65804
 Inactive MO 501(C)(3) 3 MHSC
 
Yes
 
(65) St Mary's Hospital of Enid Oklahoma

14528 S Outer Forty Ste 100

Chesterfield,MO63017
73-0614655 		Inactive OK 501(C)(3) 3 MHOC
 
Yes
 
(66) The Sister M Cornelia Blasko Foundation

100 W Highway 60

Mountain View,MO65548
43-1873914 		Foundation MO 501(C)(3) 11a MSFH
 
Yes
 
(67) Unity Ambulatory Care

14528 S OUTER FORTY STE 100

CHESTERFIELD,MO63017
43-1861745 		Inactive MO 501(C)(3) 11c MHEC
 
Yes
 
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V—UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No
(1) Merc Ambu Surg CTR

7301 Rogers Av
Fort Smith,AR72903
71-0827721 		AMBUL SURG CENTER AR NA
  		                 
(2) RES OPT & INNOV

645 Maryville Centre Dr 200
St Louis,MO63141
46-0468368 		CENTRAL DIST. MO NA
  		                 
(3) SO OK DIAG CTR

1011 14TH Ave NW
Ardmore,OK73401
43-1971232 		MRI Services OK NA
  		                 
(4) Fort Smith EMS

1701 S Greenwood
Fort Smith,AR72901
71-0416615 		Emergency Med AR NA
  		                 
(5) St Ed Mer Med MOB

7301 Rogers Ave
Fort Smith,AR72903
71-0554050 		Office Building AR NA
  		                 




Part IV
Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)
(a)
Name, address, and EIN of related organization



 		(b)
Primary activity



 		(c)
Legal domicile
(state or
foreign
country)
 		(d)
Direct controlling
entity


 		(e)
Type of entity
(C corp, S corp,
or trust)

 		(f)
Share of total income



 		(g)
Share of
end-of-year
assets

 		(h)
Percentage
ownership
(1) Frontenac Properties Inc
14528 S Outer Forty Suite 100
Chesterfield,MO63017
52-1914421 		HOLDING COMP DE NA
  		C-Corp      
(2) Inveno Health Inc
1235 E Cherokee Street
Springfield,MO65804
26-4509571 		IT SERVICES MO NA
  		C-Corp      
(3) Mercy Community Services Inc
401 Woodland Hills Blvd
Fort Scott,KS66701
48-1078101 		RETAIL PHARMACY KS NA
  		C-Corp      
(4) Mercy Health Center Condominium Inc
4300 W Memorial Rd
Oklahoma City,OK73120
68-0640970 		REAL ESTATE OK NA
  		C-Corp      
(5) Mercy Health Network of the Southern Reg
1011 14th Avenue NW
Ardmore,OK73401
73-1580607 		HEALTH CARE OK NA
  		C-Corp      
(6) Mercy Health Network Inc
4300 W Memorial Road
Oklahoma City,OK73120
73-1381689 		HEALTH CARE OK NA
  		C-Corp      
(7) Mercy Managed Care Corporation
4300 W Memorial Road
Oklahoma City,OK73120
73-1441665 		HOLDING COMP OK NA
  		C-Corp      
(8) UH L Corp Inc
645 Maryville Centre Drive Suite 1
St Louis,MO63141
74-2499535 		HOLDING COMP MO NA
  		C-Corp      
(9) Unity Support Services Inc
645 Maryville Centre Drive Suite 1
St Louis,MO63141
43-1797042 		PRACTICE MGT MO NA
  		C-Corp      
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 3
Part V
Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)
Note. Complete line 1 if any entity is listed in Parts II, III or IV.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .
1a
 
No
b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1b
 
No
c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1c
 
No
d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1d
 
No
e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1e
 
No
f Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1f
 
No
g Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1g
 
No
h Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1h
 
No
i Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1i
 
No
j Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .
1j
 
No
k Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .
1k
 
No
l Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .
1l
 
No
m Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .
1m
 
No
n Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1n
 
No
o Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1o
 
No
p Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1p
 
No
q Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1q
 
No
r Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1r
 
No
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of other organization 		(b)
Transaction
type(a-r) 		(c)
Amount involved 		(d)
Method of determining amount involved
(1)
(2)
(3)
(4)
(5)
(6)
Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(e)
Are all
partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V—UBI
amount in box
20 of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2011
Schedule R (Form 990) 2011
Page 5
Part VII
Supplemental Information
Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
Identifier Return Reference Explanation
Additional Data


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