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
ST BERNARDS HOSPITAL INC
Employer identification number
71-0290019
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.") .
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) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
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
ST BERNARDS HOSPITAL INC
Employer identification number
71-0290019
Return Reference
Explanation
FORM 990, PART III, SECTION A, LINE 4A
ST. BERNARDS MEDICAL CENTER (SBMC) BEGAN SERVING THE CITIZENS OF NORTHEAST ARKANSAS IN THE YEAR 1900. THROUGH ITS MISSION OF PROVIDING CHRIST-LIKE-HEALING TO THE COMMUNITY THROUGH EDUCATION, TREATMENT, AND HEALTH SERVICES IT IS THE SAFETY NET PROVIDER FOR A 23 COUNTY AREA THAT INCLUDES SOUTHEAST MISSOURI. IN ACCORDANCE WITH ITS STATED MISSION AND VALUES OF PROVIDING CHRIST-LIKE HEALING SBMC IS COMMITTED TO PROVIDING HEALTHCARE SERVICES REGARDLESS OF A PERSON'S ABILITY TO PAY. CHARITY IS A CORE COMPONENT OF THE MISSION OF THE OLIVETAN BENEDICTINE SISTERS AND ITS HEALTHCARE MINISTRY. IN THE FISCAL YEAR WHICH ENDED SEPTEMBER 30, 2014, SBMC PROVIDED $8,906,000 IN CHARITY CARE. THE TOTAL AMOUNT OF QUANTIFIABLE COMMUNITY BENEFITS PROVIDED BY ST. BERNARDS MEDICAL CENTER WAS $32,884,056 IN FISCAL YEAR 2014 THROUGH 259,633 ENCOUNTERS WITH INDIVIDUALS INVOLVING HEALTH SCREENINGS, EDUCATION, DONATIONS, AND VOLUNTEER ACTIVITIES. IN PROVIDING EDUCATION, TREATMENT AND HEALTHCARE SERVICES SBMC BELIEVES FINANCIAL MATTERS ARE SECONDARY TO THE RENDERING OF THESE SERVICES. NO PERSON WHO SEEKS THESE SERVICES WILL BE TURNED AWAY. SBMC PROVIDES DIRECT FINANCIAL ASSISTANCE (CHARITY) USING A SLIDING SCALE BASED UPON INCOME LEVELS OF THE CURRENT FEDERAL INCOME POVERTY GUIDELINES AS ESTABLISHED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES. PATIENTS WHO HAVE NO INSURANCE WILL RECEIVE A DISCOUNT FROM CHARGES AND SBMC DOES NOT TAKE LEGAL ACTION AGAINST ANY DEBTOR FOR SERVICES PROVIDED THROUGH ITS MISSION. IN FISCAL YEAR 2014 SBMC PROVIDED 74,588 PATIENT DAYS OF CARE. 36,795 PATIENT DAYS WERE PROVIDED TO THE ELDERLY WHILE 10,361 WERE PROVIDED TO THE MEDICALLY INDIGENT OR WHO HAD MEDICAID COVERAGE. 59,413 PATIENTS WERE SEEN IN THE SBMC EMERGENCY ROOM DURING THE SAME TIME PERIOD. TODAY, AS WELL INTO THE FUTURE, SBMC WILL CONTINUE TO PUT PATIENTS AND COMMUNITY NEEDS FIRST BY FOCUSING ON QUALITY, SAFETY, COST CONTROL, SERVICE, AND DIVERSITY.
FORM 990, PART VI, SECTION A, LINES 6, 7a, & 7b
ST. BERNARDS HEALTHCARE, INC. IS THE SOLE MEMBER OF ST. BERNARDS MEDICAL CENTER. THE MEMBER RESERVES POWER OVER THE FOLLOWING ACTS: A. ANY AGGREGATE BORROWING BY THE CORPORATION OF FUNDS IN EXCESS OF $1 MILLION FOR ANY SINGLE TRANSACTION OR PROJECT. B. ANY PURCHASE, SALE, LEASE, DISPOSITION, EXCHANGE, GIFT PLEDGE, OR MORTGAGE OF REAL ESTATE PROPERTY VALUED IN EXCESS OF $1 MILLION. C. ANY VARIANCE WITH CONGREGATIONL POLICY, PHILOSOPHY, OR ETHICS OF THE MEMBER. D. ANY AMENDMENT, ALTERATION, OR REPEAL OF THE BYLAWS. E. THE POWER OF THE MEMBER TO REMOVE ANY MEMBER OF THE GOVERNING BOARD IF IN THE SOLE DISCRETION OF MEMBER THE GOVERNING BOARD MEMBER ACTS AT VARIANCE WITH CONGREGATIONAL POLICY, PHILOSOPHY, OR THE ETHICS OF THE MEMBER. ALL OF THE DESCRIBED MATTERS SHALL BE SUBJECT TO APPROVAL BY A MAJORITY VOTE OF THE MEMBERS OF THE COUNCIL OF OLIVETAN BENEDICTINE SISTERS, INC.
FORM 990, PART VI, SECTION B, LINE 11B
THE FORM 990 IS REVIEWED BY THE FOLLOWING PERSONS OR GROUPS: CONTROLLER OF ST. BERNARDS HEALTHCARE, INC., VICE PRESIDENT OF FINANCE OF ST. BERNARDS HEALTHCARE, INC., PRESIDENT/CEO OF ST. BERNARDS HEALTHCARE, INC., LEGAL COUNSEL, AND THE AUDIT COMMITTEE OF ST. BERNARDS HEALTHCARE, INC. PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
DIRECTORS AND ABOVE ANNUALLY SUBMIT A WRITTEN STATEMENT DISCLOSING ANY POTENTIAL CONFLICTS OF INTEREST. MANAGEMENT INVESTIGATES ANY POTENTIAL CONFLICTS AND TAKES APPROPRIATE ACTION DEPENDING ON THE NATURE OF THE CONFLICT. LEGAL COUNSEL ALSO REVIEWS ANY POTENTIAL CONFLICTS OF INTEREST AND ADVISES MANAGEMENT.
FORM 990, PART VI, SECTION B, LINE 15A & 15B
THE BOARD OF DIRECTORS SELECTS DIRECTORS TO SERVE ON THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE APPROVES THE INITIAL SALARY AND ANY SUBSEQUENT SALARY ADJUSTMENTS OF ALL MANAGEMENT. THE COMPENSATION COMMITTEE OBTAINS AN INDEPENDENT SALARY SURVEY FROM INTEGRATED HEALTHCARE STRATEGIES ON AN ANNUAL BASIS FOR USE IN DETERMINING THE APPROPRIATE SALARY RANGES FOR MANAGEMENT. THE COMPENSATION COMMITTEE PRESENTS THE INFORMATION TO THE BOARD FOR APPROVAL. IN 2014, AHA AND RASCO SURVEYS WERE COMPLETED FOR COMPENSATION RELATING TO ALL MANAGEMENT PERSONNEL AND ALL OTHER EMPLOYEES OF THE ORGANIZATION.
FORM 990, PART VI, SECTION B, LINE 16B
ALL OPERATING AGREEMENTS OF JOINT VENTURE ARRANGEMENTS IN WHICH THE ORGANIZATION PARTICIPATES CONTAIN A CLAUSE THAT SAFEGUARDS THE ORGANIZATION'S EXEMPT STATUS.
FORM 990, PART VI, SECTION C, LINE 19
THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC.
FORM 990, PART XI, LINE 9
TRANSFER TO AFFILIATE $(27,000,157) CHANGE IN THE PENSION LIABILITY $ 987,726 CHANGE IN INTEREST IN NET ASSETS OF ST. BERNARDS DEVELOPMENT FOUNDATION, INC. $ 1,257,829 -------------------------------------------------------------- TOTAL $(24,754,602)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.