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
HOSPICE OF MICHIGAN INC
Employer identification number
38-2255529
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.") .
3,267,837
3,083,008
3,493,488
3,765,644
2,892,021
16,501,998
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......
61,721,217
60,338,222
54,509,312
62,695,097
62,680,933
301,944,781
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
32,156
90,320
23,250
95,790
23,078
264,594
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
65,021,210
63,511,550
58,026,050
66,556,531
65,596,032
318,711,373
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
0
0
0
0
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
0
0
0
0
0
c
Add lines 7a and 7b..
0
0
0
0
0
0
8
Public support (Subtract line 7c from line 6.)
318,711,373
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...
65,021,210
63,511,550
58,026,050
66,556,531
65,596,032
318,711,373
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
130,602
145,243
176,810
169,494
146,917
769,066
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
130,602
145,243
176,810
169,494
146,917
769,066
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
185,986
14,287
139,104
165,753
35,497
540,627
13
Total support. (Add lines 9, 10c, 11, and 12.)..
65,337,798
63,671,080
58,341,964
66,891,778
65,778,446
320,021,066
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
99.590 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.520 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.240 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.260 %
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:
13000248
Software Version:
2013v3.1
-
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
HOSPICE OF MICHIGAN INC
Employer identification number
38-2255529
Return Reference
Explanation
FORM 990, PART III, LINE 1, ORGANIZATION MISSION
OUR VISION IS THAT HOSPICE OF MICHIGAN WILL BE MICHIGAN'S LEADING PROVIDER OF COMFORT CARE SERVICES TO INDIVIDUALS AND FAMILIES COPING WITH A LIFE-LIMITING ILLNESS. OUR VALUES INCLUDE: (1) QUALITY SERVICE - TO PROVIDE THE HIGHEST QUALITY SERVICE; RESPOND TO OUR PATIENTS' AND FAMILIES' NEEDS; AND AFFIRM PATIENT SELF-DETERMINATION, EMPOWERMENT, AND CHOICE; (2) TEAMWORK - TO TREAT EVERYONE WITH RESPECT AND ENCOURAGE STAFF'S PERSONAL AND PROFESSIONAL DEVELOPMENT; (3) RESOURCE STEWARDSHIP - TO DEMONSTRATE GOOD STEWARDSHIP OF OUR RESOURCES; (4) MISSION OUTREACH - TO ACKNOWLEDGE AND EMBRACE RELIGIOUS, ETHNIC, AND CULTURAL DIVERSITY; AND (5) SACRED SPACE - TO HONOR LIFE TO THE END, VALUING EVERY FORM OF HEALING; BE WITNESS TO THE SPIRIT OF LIFE; BE PRIVILEGED TO PROTECT THE SACREDNESS OF LEAVING, HONORING THE FEELING OF LOSS; AND ASSURE THAT PATIENTS AND FAMILIES ACHIEVE THEIR QUALITY OF LIFE GOAL WHILE UNDER OUR CARE.
Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee
THE EXECUTIVE COMMITTEE SHALL CONSIST OF THE CHAIRPERSON OF THE BOARD, THE VICE CHAIRPERSON, THE SECRETARY-TREASURER, THE IMMEDIATE PAST CHAIRPERSON OF THE BOARD, THE PRESIDENT AND THE CHAIRS OF THE CLINICAL SERVICES AND ORGANIZATIONAL QUALITY, FINANCE AND AUDIT, BOARD DEVELOPMENT AND EVALUATION, AND NOMINATING COMMITTEES AS WELL AS THE CHAIRPERSON OF THE HOSPICE OF MICHIGAN FOUNDATION BOARD OF TRUSTEES. THE EXECUTIVE COMMITTEE SHALL POSSESS AND EXERCISE THE AUTHORITY AND POWERS OF THE BOARD OF TRUSTEES IN THE MANAGEMENT AND DIRECTION OF THE CORPORATION IN THE INTERIM PERIODS BETWEEN MEETINGS OF THE BOARD AND SHALL DISCHARGE THE DUTIES OF SAID BOARD DURING SUCH INTERIM PERIODS, EXCEPT THAT THE EXECUTIVE COMMITTEE SHALL NOT HAVE POWER OR AUTHORITY TO: (A) AMEND THE ARTICLES OF INCORPORATION; (B) DISSOLVE THE CORPORATION OR REVOKE A DISSOLUTION; (C) AMEND THE BYLAWS OF THE CORPORATION; OR (D) FILL VACANCIES IN THE BOARD.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
A FINAL DRAFT OF THE FULL FORM 990 IS REVIEWED WITH OUR TAX ADVISORS AND APPROVED BY AN EXECUTIVE COMMITTEE OF THE BOARD, AND THEN A COPY OF THE FULL FORM 990 DRAFT IS SENT OUT TO EACH VOTING MEMBER OF THE GOVERNING BODY. THESE REVIEWS TAKE PLACE PRIOR TO FILING THE FORM 990 WITH THE IRS.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
PROCEDURE: EMPLOYEES, BOTH PAID AND UNPAID (FROM HERE FORWARD REFERRED TO AS "EMPLOYEE"), AND BOARD MEMBERS, HAVE A FUNDAMENTAL OBLIGATION TO ACT IN THE BEST INTEREST OF PATIENT CARE AND HOSPICE OF MICHIGAN (HOM). EVERY BOARD MEMBER AND EMPLOYEE IS RESPONSIBLE FOR ACTING CONSISTENT WITH THIS OBLIGATION WHEN ENGAGING IN ACTIVITIES, AND SHOULD NOT LET OTHER PERSONAL AND FINANCIAL INTERESTS INTERFERE WITH THIS OBLIGATION. GENERAL PRACTICE GUIDELINES: (1) HOSPICE OF MICHIGAN REQUIRES THAT ALL MEMBERS OF ITS BOARDS OF TRUSTEES AND EMPLOYEES DISCLOSE INTERESTS THAT COULD RESULT IN A CONFLICT. ANNUALLY, ALL BOARD MEMBERS SIGN OFF ON A CONFLICT OF INTEREST POLICY AND DISCLOSE ANY SITUATION WHICH MAY REPRESENT A CONFLICT. THE CORPORATE COMPLIANCE OFFICER (CCO) ALSO HAS ACCESS TO THE BOARD AT LEAST ANNUALLY. THE ORGANIZATION ALSO UTILIZES C-TRAC (CROWE TAX RISK ASSESSMENT AND CONTROL), A TOOL PROVIDED BY OUR TAX ADVISORS, TO SEND CONFLICT OF INTEREST SURVEYS TO ALL VOTING BOARD MEMBERS, EXECUTIVES, AND THE HIGHEST PAID STAFF. (2) ALL BOARD MEMBERS AND EMPLOYEES ARE REQUIRED TO SUBMIT A DISCLOSURE STATEMENT, IF THERE IS A CONFLICT OF INTEREST THAT MEETS THE STATED DEFINITION, AT THE BEGINNING OF EMPLOYMENT OR TERM. (3) IF A MATTER ARISES IN WHICH A MEMBER OF THE BOARD OR EMPLOYEE HAS A CONFLICT OF INTEREST, THE INDIVIDUAL SHALL PROMPTLY DISCLOSE IT TO THE CEO, OR THE CASE OF THE CEO, THE BOARD CHAIRPERSON. (4) AN INDIVIDUAL WITH A POTENTIAL CONFLICT OF INTEREST SHALL NOT PROCEED TO MAKE ANY DECISION OR TAKE ANY ACTION ON BEHALF OF THE ORGANIZATION WITHOUT APPROVAL OF THE BOARD OF TRUSTEES. (5) HOM EMPLOYEES ARE PRECLUDED FROM ENGAGING IN ACTIVITIES WITH ANY "VENDOR OR SUPPLIER BUSINESS" (AS THAT TERM IS DEFINED IN THE POLICY) THAT DOES OR SEEKS BUSINESS WITH HOM WHICH MAY RESULT IN A PERSONAL BENEFIT TO THE EMPLOYEE AT THE EXPENSE OF HOM OR MAY INFLUENCE THE EMPLOYEE'S DECISIONS ON MATTERS INVOLVING HOM AND A VENDOR OR SUPPLIER BUSINESS.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES MEETS ANNUALLY IN MARCH TO REVIEW AND APPROVE AS APPROPRIATE, FUNDS TO BE ALLOCATED FOR TOTAL COMPENSATION FOR THE ORGANIZATION'S PRESIDENT/CEO, INCLUDING BASE SALARY, BONUS, CAR ALLOWANCE, AND OTHER BENEFITS. THE EXECUTIVE COMMITTEE ALSO DETERMINES IF THE PRESIDENT/CEO'S CONTRACT NEEDS TO BE UPDATED OR RENEWED AT THIS TIME. MINUTES ARE TAKEN UP UNTIL THE POINT WHERE DISCUSSION OF COMPENSATION TAKES PLACE AND VOTE/DECISION IS MADE IN REGARDS TO COMPENSATION. THE CEO AND EXECUTIVE ASSISTANT ARE EXCUSED FROM THE MEETING AT THIS POINT WHILE DISCUSSION AND DECISION IS MADE. IN ADDITION, IN 2013 AN EXTERNAL COMPENSATION STUDY WAS PERFORMED TO ASSESS EXECUTIVE COMPENSATION; THIS EXTERNAL COMPENSATION STUDY IS PLANNED TO BE PERFORMED ANNUALLY. THE COMPENSATION STUDY AIMS TO PRICE POSITIONS AT MARKET BY USING LOCAL, NATIONAL, AND INDUSTRY SPECIFIC SURVEY DATA. AN OUTSIDE CONSULTANT IS ENGAGED THROUGH AN AFFILIATION WITH AMERICAN SOCIETY OF EMPLOYERS (ASE). MARKET DATA WAS GATHERED THROUGH CRAINS TOP NON-PROFIT SURVEY, ASE NATIONAL EXECUTIVE COMPENSATION SURVEY, NATIONALLY COMPARED 990'S OF THE 37 LARGEST HOSPICE'S, AS WELL AS THE TOP 32 HOSPITALS WITH REVENUE $150 MILLION OR LESS. TWO OPTIONS ARE PRESENTED TO THE EXECUTIVE COMMITTEE BASED ON THE MARKET DATA THAT WAS GATHERED.
FORM 990, PART VI, LINE 15B, PROCESS USED TO ESTABLISH COMPENSATION OF OTHER OFFICERS/KEY EMPLOYEES
THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES MEETS ANNUALLY IN MARCH TO REVIEW AND APPROVE AS APPROPRIATE, FUNDS TO BE ALLOCATED FOR TOTAL COMPENSATION FOR THE ORGANIZATION'S CHIEF ADMINISTRATIVE OFFICER, CHIEF FINANCIAL OFFICER, CHIEF OPERATING OFFICER, CHIEF MEDICAL OFFICER, CHIEF MARKETING OFFICER AND CHIEF FUNDRAISING OFFICER, INCLUDING BASE SALARY, BONUS, CAR ALLOWANCE, AND OTHER BENEFITS. MINUTES ARE TAKEN UP UNTIL THE POINT WHERE DISCUSSION OF COMPENSATION TAKES PLACE AND VOTE/DECISION IS MADE IN REGARDS TO COMPENSATION. THE CEO AND EXECUTIVE ASSISTANT ARE EXCUSED FROM THE MEETING AT THIS POINT WHILE DISCUSSION AND DECISION IS MADE. IN ADDITION, IN 2013 AN EXTERNAL COMPENSATION STUDY WAS PERFORMED TO ASSESS EXECUTIVE COMPENSATION; THIS EXTERNAL COMPENSATION STUDY IS PLANNED TO BE PERFORMED ANNUALLY. THE COMPENSATION STUDY AIMS TO PRICE POSITIONS AT MARKET BY USING LOCAL, NATIONAL, AND INDUSTRY SPECIFIC SURVEY DATA. AN OUTSIDE CONSULTANT IS ENGAGED THROUGH AN AFFILIATION WITH AMERICAN SOCIETY OF EMPLOYERS (ASE). MARKET DATA WAS GATHERED THROUGH CRAINS TOP NON-PROFIT SURVEY, ASE NATIONAL EXECUTIVE COMPENSATION SURVEY, NATIONALLY COMPARED 990'S OF THE 37 LARGEST HOSPICE'S, AS WELL AS THE TOP 32 HOSPITALS WITH REVENUE $150 MILLION OR LESS. TWO OPTIONS ARE PRESENTED BY THE PRESIDENT/CEO TO THE EXECUTIVE COMMITTEE BASED ON THE MARKET DATA THAT WAS GATHERED.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
FINANCIAL STATEMENTS ARE PROVIDED ANNUALLY IN THE ANNUAL REPORT THAT IS LOCATED ON OUR EXTERNAL WEBSITE (WWW.HOM.ORG). OTHER SPECIFIC DOCUMENTS CAN BE AVAILABLE UPON REQUEST.
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
CHANGE IN PLEDGE DISCOUNT - 4028;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.