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. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
BLUEGRASS REGIONAL PSYCHIATRIC SERVICES INC
Employer identification number
61-1286230
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 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 monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(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. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
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 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
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—2012.
If the organization did not check a 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—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
1,500
1,500
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......
36,339,373
37,639,373
37,639,373
38,663,000
25,936,994
176,218,113
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.
36,340,873
37,639,373
37,639,373
38,663,000
25,936,994
176,219,613
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
0
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
176,219,613
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
36,340,873
37,639,373
37,639,373
38,663,000
25,936,994
176,219,613
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
47,949
40,329
41,147
29,607
16,118
175,150
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
47,949
40,329
41,147
29,607
16,118
175,150
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.)
..
16,426
76,850
23,274
18,588
34,631
169,769
13
Total support. (Add lines 9, 10c, 11, and 12.)..
36,405,248
37,756,552
37,703,794
38,711,195
25,987,743
176,564,532
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 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
99.800 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.800 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.100 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.120 %
19a
33 1/3% support tests—2013.
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—2012.
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) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and 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) 2013
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.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
BLUEGRASS REGIONAL PSYCHIATRIC SERVICES INC
Employer identification number
61-1286230
Return Reference
Explanation
FORM 990, PART III, LINE 3
THE ORGANIZATION MANAGED THE STATE HOSPITAL UNTIL SEPTEMBER 2013. AFTER SEPTEMBER, THE ORGANIZATION ENTERED INTO A STAFFING AGREEMENT WITH THE NEW MANAGEMENT COMPANY TO PROVIDE STAFFING UNTIL JUNE 2014. THE ORGANIZATION NO LONGER MANAGES OR PROVIDES STAFFING AT THE STATE HOSPITAL AS OF 06/30/2014.
FORM 990, PART VI, SECTION B, LINE 11
A DRAFT OF THE RETURN IS REVIEWED FIRST BY INTERNAL MANAGEMENT. AFTER INTERNAL MANAGEMENT HAS REVIEWED THE RETURN AND ANY CHANGES ARE MADE, A DRAFT IS MADE AVAILABLE FOR REVIEW AND PRESENTATION TO THE ORGANIZATIONS AUDIT/FINANCE COMMITTEE AND CHIEF FINANCIAL OFFICER (CFO). FINALLY, THE AUDIT/FINANCE COMMITTEE AND CFO MEET WITH THE INDEPENDENT TAX PREPARER TO REVIEW FORM 990 AND MAKE ANY FINAL CHANGES PRIOR OT ITS FILING. A DRAFT IS ALSO MADE AVAILABLE FOR THE BOARD OF DIRECTORS TO REVIEW.
FORM 990, PART VI, SECTION B, LINE 12C
EACH BOARD MEMBER SIGNS THE CONFLICT OF INTEREST STATEMENT ANNUALLY AND HAS A BRIEF OVERVIEW OF THE REQUIREMENT TO DISCLOSE. NEW BOARD MEMBERS HAVE AN ORIENTATION WHICH INCLUDES THE DETAILS OF THE POLICY. KEY EMPLOYEES ARE GIVEN A REVIEW OF THE POLICY ANNUALLY AND NEW KEY EMPLOYEES ARE EDUCATED ON THE POLICY IN DAY TWO OF ORIENTATION.
FORM 990, PART VI, SECTION B, LINE 15
THE COMPENSATION OF THE PRESIDENT/CEO IS REVIEWED AT INITIAL APPOINTMENT AND ANNUALLY THEREAFTER. NATIONWIDE SURVEYS ARE USED WHICH INCLUDE THE STATE OF KENTUCKY AND OTHER NOT FOR PROFIT ORGANIZATIONS. THE BOARD OF DIRECTORS IS GIVEN THIS INFORMATION WHICH IS REVIEWED AND DISCUSSED. THE BOARD THEN DETERMINES THE SALARY OF THE PRESIDENT/CEO. FOR OTHER OFFICERS OR KEY EMPLOYEES NATIONAL AND LOCAL SURVEY INFORMATION IS REVIEWED BY THE HUMAN RESOURCES DIRECTOR TO ASSIST IN DETERMINING SALARIES. WHEN BROAD SALARY ADJUSTMENTS ARE DEEMED NECESSARY IN ORDER TO BE IN LINE WITH LOCAL MARKETS, THE INFORMATION IS REVIEWED AND APPROVED BY THE BOARD OF DIRECTORS.
FORM 990, PART VI, SECTION C, LINE 19
AUDITED FINANCIAL STATEMENTS ARE SUBMITTED TO BOTH THE COMMONWEALTH OF KENTUCKY AS REQUIRED BY CONTRACT AND TO THE FEDERAL CLEARINGHOUSE AS REQUIRED. GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE CORPORATE LOCATION.
FORM 990, PART VII
THE INDIVIDUALS LISTED BELOW WORK MORE THAN 40 HOURS EACH WEEK ON AVERAGE WHEN THIS ORGANIZATION AND ALL RELATED ORGANIZATIONS ARE AGGREGATED. PAUL R. BEATRICE SHANNON P. WARE DAVID E. HANNA, PHD TAMBARA A. NALLE DANA R. ROYSE THE ORGANIZATION PAYING THE COMPENSATION PROVIDED THE INFORMATION FOR THE INDIVIDUALS ESTIMATED HOURS, COMPENSATION AND BENEFITS.
FORM 990, PART XI, LINE 9:
DISTRIBUTIONS TO OTHER BOARDS -22,837. DISTRIBUTION TO MANAGING BOARD -27,912.
FORM 990, PART XII, LINE 2C
THE PROCESS HAS NOT CHANGED FROM PRIOR YEAR. BLUEGRASS REGIONAL PSYCHIATRIC SERVICES, INC. IS AUDITED AS PART OF THE BLUEGRASS.ORG, INC. CONSOLIDATED GROUP. BLUEGRASS REGIONAL PSYCHIATRIC SERVICES, INC. IS INCLUDED IN THE BLUEGRASS.ORG, INC. AND AFFILIATES CONSOLIDATED FINANCIAL STATEMENTS. THE ORGANIZATION HAS AN AUDIT/FINANCE COMMITTEE THAT OVERSEES THE AUDIT OF THE FINANCIAL STATEMENTS AND THE SELECTION OF THE INDEPENDENT AUDITOR.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.