2014-03-25T19:58:31-05:00 2013-06-30 861065772 Deloitte Tax LLP 111 South Wacker Drive Chicago IL 60606 990 2012-07-01 621136742 Alexian Village of Tennessee ALEX 4238860100 437 Alexian Way Signal Mountain TN 373771860 Robin Baschnagel 4238860100 2014-03-25 1 Laura Gillespie P00855604 3124861000 2012 2015-11-30 17:44:51Z Robin Baschnagel 437 Alexian Way Signal Mountain TN 373771860 23083316 0 0928 X www.alexianbrothershealth.org X 1983 TN Continuing Care Retirement Center. 7 4 488 100 0 0 64503 542841 11453410 22454998 153636 85477 0 0 11671549 23083316 0 0 0 0 5677284 8104509 0 0 0 5061071 13710097 10738355 21814606 933194 1268710 54020259 58981417 33042145 33042069 20978114 25939348 X Alexian Village of Tennessee ("AVT") carries out the healing mission of the Catholic Church as an Alexian Brothers ministry by identifying and developing effective responses to the health and housing needs of those we are called to serve. 0 0 15385595 19587401 Alexian Village of Tennessee ("AVT") provides a continuum of services to residents of AVT (133,590 resident days served), assisted living services to residents of Alexian Inn (9,578 days served) and residents of the health care center (35,200 days served) that maximizes dignity and independence. Although reimbursement for services rendered is critical to the operation and stability for the continuum of services, as a charitable organization, it is recognized that not all persons served possess the ability to purchase essential services needed for care and our mission is to serve the community with respect to providing health care services. In 2013, over $43,000 was provided in charitable care at costs. AVT also serves the communities of Signal Mountain and Chattanooga by providing programs throughout the year. Meeting rooms are provided at no costs to local charitable organizations and community groups. As a religious organization, AVT also employs staff to provide chaplaincy services. There are multiple chapels at AVT, which have daily interdenominational services & programs. 1302596 1902175 Alexian Brothers Valley Residence ("ABVR") is a separate and distinct division of AVT. It exists to provide a secure environment to those suffering from dementia or Alzheimer's disease. On average, 40.4 residents were served each day of 2013. Such services include nursing assistance with activities of daily living, recreational activities, meal preparation and dining, and spiritual wellness. In addition, ABVR provides short term respite care and an adult day care program, also to serve those suffering from dementia or Alzheimer's disease. 815088 965422 Alexian Grove is a separate and distinct division of the AVT organization. It exists to provide independent, residential retirement living while promoting the well-being of all those served through a delivery of quality services. Alexian Grove is home to over 30 senior citizens in independent apartments (on average 30 persons served each day). In keeping with our commitment to serve all members of Chattanooga and the surrounding community, free or subsidized care and other activities and programs to support the community at large are considered and provided when appropriate. 17503279 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 33 0 1 488 1 0 0 0 0 0 0 0 0 0 0 X 7 4 1 0 0 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 TN X Tim Booth 4237553437 250 East 10th St Chattanooga TN 37402 X Matthew Fox end 712 40.00 0.00 X X 0 244310 68491 Robin Baschnagel start 1012 40.00 0.00 X X 0 50945 1056 Kathleen Puri RN MSN 1.00 0.00 X X 0 0 0 Robert Main 1.00 0.00 X X 0 0 0 Linda Bennett 1.00 0.00 X X 0 0 0 Brother Andrew Thome CFA 1.00 0.00 X 0 0 0 John Turongian 0.00 40.00 X 0 339442 50851 Mark Frey 0.00 40.00 X 0 1434790 179527 Donna Gauthier 0.00 40.00 X 0 71007 15381 Jim Lewandowski 0.00 40.00 X 0 468370 805832 Tim Booth 40.00 0.00 X 0 120543 19824 0 2729407 1140962 0 0 1 0 Anthem Blue Cross PO Box 105183 Atlanta GA 303485183 Health Insurance 1304137 Alexian Brothers Health System 3040 W Salt Creek Lane Arlington Heights IL 60005 Management Services 852648 New Blue Construction PO Box 15903 Chattanooga TN 37415 Construction Contractor 443058 Tennessee Lawn Care PO Box 264 Signal Mountain TN 37377 Lawn Care Service 200550 2 Days Home Improvement 511 Landcaster Avenue Chattanooga TN 37415 Construction Contractor 131456 5 542841 542841 Lifecare & Independent 623000 12082853 12082853 Skilled Nursing 623000 3570135 3570135 Assisted Living 623000 3497775 3497775 Medicare & Medicaid 623000 2527882 2527882 Adult Day Care 624100 46354 46354 729999 729999 22454998 85477 85477 23083316 22454998 0 85477 6093006 5319367 773639 119347 106555 12792 1436147 1244391 191756 456009 413366 42643 47497 47497 26167 26167 428689 358366 70323 96250 2910 93340 378948 312042 66906 13372 290 13082 1657747 1657747 23907 9008 14899 6683 5733 950 335926 324470 11456 1883037 1841777 41260 122298 122298 Food and Env. Services 4782394 4782394 Management Fees - ABHS 1656109 1656109 Property & Bed Taxes 827348 827348 Medical Supplies 418388 418388 1005337 706475 298862 21814606 17503279 4311327 0 223636 371410 1944883 1335163 108273 90563 125814 97602 56685106 2790306 46333647 53894800 2982927 816742 2301079 2375137 54020259 58981417 2467072 2434901 919651 29655422 30607168 33042145 33042069 X 18714820 23445913 1798102 2034619 465192 458816 20978114 25939348 54020259 58981417 X 1268710 82346 3610178 X X 0 1 X 1 0 X 244922 169787 78402 64503 542841 1100455 21471012 22074021 22598336 11453410 22454998 100051777 21715934 22243808 22676738 11517913 22997839 101152232 0 0 0 101152232 128476 277269 181137 153636 85477 825995 128476 277269 181137 153636 85477 825995 21844410 22521077 22857875 11671549 23083316 101978227 0.99190 0.99620 0.00810 0.00380 X Schedule A, Part IV, Supplemental Information: Schedule A, Part IV: For the year ended 6/30/12, the organization filed a short period return due to a change of accounting period. Thus, the amounts in column 2011 of Schedule A reflect the tax year 1/1/2012 6/03/2012 activity. Prior balances have been rolled backward. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 465192 -6376 458816 464231 961 465192 511922 2309 50000 464231 517303 14232 19613 511922 504858 12445 517303 1.00000 0 1 1 1930000 1930000 50896095 2127984 48768111 3859011 662322 3196689 53894800 Unamortized Life Entry Fees 30480814 Resident Security Deposits 88020 Reserve for Outstanding Ins Losses 36072 Resident Personal Funds 2262 30607168 Part X Line 2: Alexian Village Of Tennessee does not file a separate audit report, but is part of the Alexian Brothers Health System consolidated audit report. There is no ASC 740 (fka FIN 48) footnote for the current year. 1 1 0 0 0 0 0 0 0 Matthew Fox end 712 0 123136 0 37574 0 83600 0 29978 0 38513 0 312801 0 15963 John Turongian 0 273039 0 55523 0 10880 0 22993 0 27858 0 390293 0 10880 Mark Frey 0 1110138 0 263024 0 61628 0 137956 0 41571 0 1614317 0 44628 Jim Lewandowski 0 328372 0 88552 0 51446 0 779279 0 26553 0 1274202 0 33988 Supplemental Information Part III Part I, Line 3: Alexian Brothers Health System, a related organization of Alexian Village Of Tennessee, uses all of the items in Schedule J, Part I, Line 3 to establish the compensation of the organization's CEO. Part I, Line 4a: The following individual listed in Schedule J was paid the referenced amount of severance in calendar 2012: Matthew Fox - $67,637 Part I, Line 4b: Alexian Brothers Health System offers a Supplemental Employee Retirement Plan to all employees who participate in the executive benefits program and whose compensation exceeds the IRS allowable limit for a qualified pension plan. The purpose of the plan is to restore retirement benefits that are restricted because of compensation limits for the executives. The amount paid in calendar 2012 was included in income in Schedule J for the following individual: Jim Lewandowski - $19,123 Form 990, Part VI, Section A, line 2 John Turongian, Matthew Fox, Donna Gauthier, Mark Frey, Robin Baschnagel, and Jim Lewandowski have a business relationship due to joint employment by a common health system entity. Form 990, Part VI, Section A, line 6 Alexian Village of Tennesse has two members, Alexian Brothers Health System (the "National Member") and Alexian Brothers Senior Ministries (the "Area Member"). Form 990, Part VI, Section A, line 7a Alexian Brothers Health System has the authority to appoint and remove Directors and Executive Officers of Alexian Village of Tennessee. Form 990, Part VI, Section A, line 7b All decisions that have a material impact to Alexian Village of Tennessee's financial information or corporation as a whole are subject to approval by the National Member, Alexian Brothers Health System. Form 990, Part VI, Section B, line 11 Alexian Village of Tennessee is an affiliate of Alexian Brothers Health System ("ABHS" or "the System"), which is a Catholic not for profit health system. ABHS is the National Member for each entity within the System. Alexian Village of Tennessee's Form 990 goes through an intensive review process at the System's Corporate level prior to being filed with the IRS. The entire Form 990 is reviewed by Alexian Village of Tennessee's financial officer and the CEO. The Form 990 is also reviewed at the System Corporate level by the Chief Accounting Officer for the System. The Vice President, General Counsel for the System reviews all sections of the Form 990 with the exception of the compensation disclosures. The Vice President of Human Resources for ABHS reviews all compensation disclosures for each entity within ABHS. These reviews were conducted before the Form 990 was signed and filed with the IRS. In addition, there is also a Compensation Committee that reports to the ABHS Board of Governors. This Committee reviews the Compensation disclosures for all entities within the System. Alexian Village of Tennessee's board reports to the ABHS Board of Governors, which has ultimate oversight of the activities of all entities within the System. The Audit Committee of the ABHS Board of Governors has responsibility for and oversight of the Tax Compliance process. The Audit Committee provides oversight for the Form 990 process for the entire System and reviews detailed Forms 990 for the System as requested. It then reports back to the ABHS Board of Governors on the results of these activities. The Forms 990 not reviewed by the Audit Committee are available to the Audit Committee members upon request. The Audit Committee did not review the 2012 Form 990 for Alexian Village Tennessee. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest, must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committees with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflict of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax-exempt purpose. Form 990, Part VI, Section B, line 15 In determining compensation of the organization's CEO, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee of the Board of Governors of Alexian Brothers Health System, a related organization, reviewed and approved the compensation. In the review of the compensation, the CEO, was compared to individuals at other similarly situated organizations that hold the same or a similar title. During the review and approval of the compensation, the documentation of the decision was recorded in the Compensation Committee minutes. The individual was not present when his compensation was decided. In determining compensation of other officers or key employees of the organization, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The Compensation Committee reviewed and approved the compensation. In the review of the compensation, the other officers or key employees of the organization were compared to other similarly situated organizations' employees who hold the same or similar title. During the review and approval of the compensation by the Compensation Committee, documentation of the decision was recorded in the minutes. Form 990, Part VI, Section C, line 19 The financial statements of Alexian Village of Tennessee are available through the National Reporting Municipal Services Information Repository (NRMSIR). Conflicts of Interest statements and the governing documents of Alexian Village of Tennessee are not made available to the public. Form 990, Part VII, Section A: Officers and certain key employees for Alexian Village of Tennessee provide services to Alexian Brothers Health System (the National Member) and its subsidiaries. Hours worked are not tracked on an entity by entity basis, and a 40 hour work week is used as a proxy for all individuals listed on Part VII if employed by the filing organization or a related organization (even though more hours may be worked on average). Therefore, all officers, directors, trustees, and key employee hours reported on Form 990, Part VII, Compensation of Officers, Directors, Trustees, Key Employee, Highest Compensated Employee represent aggregate hours for worked per week for all entities. Form 990, Part VII, Section A: Compensation amount for John Turongian represents payment for services rendered to Alexian Brothers Senior Ministries, a related entity and compensation amounts for Mark Frey, Donna Gauthier and Jim Lewandowski represent payment for services rendered to Alexian Brothers Health System, a related entity. The amounts are not for services as a board member of Alexian Village of Tennessee. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: Equity Transfer from Affiliate 3,810,203. Transfers for Operating Purposes -200,025. Form 990, Part XII, Line 2b - Audit Disclosure: The financial statements of Alexian Village of Tennessee were audited on a consolidated basis. The Audit Committee of the Board of Governors of Alexian Brothers Health System has been delegated the responsibility to oversee the audited financial statements and the selection of the independent accountants that audits the financial statements. Form 990 Part VIII, Line 3; Part X, Line 12: The amount reflected as dividends and interest reflects Alexian Village of Tennessee's share of interest, dividends and realized gains/losses from Alexian Village Of Tennessee's beneficial share in the Alexian Brothers Health System, Inc. Investment Trust (ABHSIT). ABHSIT is a related entity whose purpose is to pool the investments of the not-for-profit entities in ABHS and acts as an internal mutual fund. Details of gains and losses are shown on the Form 990 of ABHSIT. Ascension Health PO Box 45998 St Louis MO 63145 311662309 National Health System MO Section 501(c)(3) Schedule A, Line 11a Ascension Health Alliance 0 Alexian Brothers Health System 3040 W Salt Creek Lane Arlington Heights IL 60005 363260495 Supports provision of healthcare services for related corporations IL Section 501(c)(3) Schedule A, Line 11c Ascension Health 0 Alexian Brothers Bonaventure House 825 Wellington Avenue Chicago IL 60657 363527899 Housing and supportive care services for persons with HIV/AIDS IL Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers Health System Inc Investment Trust 3040 W Salt Creek Lane Arlington Heights IL 60005 363801585 Manages pooled investments of related not-for-profit entities IL Section 501(c)(3) Schedule A, Line 11c Alexian Brothers Health System 1 Alexian Brothers Specialty Group 3040 W Salt Creek Lane Arlington Heights IL 60005 800710751 Specialty physician practice group IL Section 501(c)(3) Schedule A, Line 3 Alexian Brothers Health System 1 Alexian Brothers of San Jose Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 941530037 Acute care hospital (sold in 1998) TX Section 501(c)(3) Schedule A, Line 11c Alexian Brothers Health System 1 Alexian Brothers Services Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 431295333 HUD housing MO Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Village of Milwaukee Inc 9301 N 76th Street Milwaukee WI 53223 391351584 Continuing care retirement community WI Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers Community Services 425 Cumberland Street Suite 110 Chattanooga TN 37404 364344423 Provides comprehensive & coordinated community based services IL Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers Senior Neighbors 250 East 10th Street Chattanooga TN 37402 620646376 Supports the provision of community services for senior citizens TN Section 501(c)(3) Schedule A, Line 7 Alexian Brothers Health System 1 Alexian Brothers Senior Ministries 3040 W Salt Creek Lane Arlington Heights IL 60005 364484290 Supports the provision of healthcare services for related corporations IL Section 501(c)(3) Schedule A, Line 11c Alexian Brothers Health System 1 Alexian Elderly Services Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 392039667 Community outreach WI Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers Lansdowne Village 4624 Lansdowne St Louis MO 63116 431470362 Skilled nursing facility MO Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers Sherbrooke Village 4005 Ripa Avenue St Louis MO 63125 431592502 Skilled nursing facility MO Section 501(c)(3) Schedule A, Line 9 Alexian Brothers Health System 1 Alexian Brothers of St Louis Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 430653236 Acute care hospital (sponsorship transferred in 1997) MO Section 501(c)(3) Schedule A, Line 11c Alexian Brothers Health System 1 Alexian Brothers Hospital Network 3040 W Salt Creek Lane Arlington Heights IL 60005 363276552 Supports the provision of healthcare services for related corporations IL Section 501(c)(3) Schedule A, Line 11c Alexian Brothers Health System 1 Savelli Properties Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 363308965 Owns or leases properties where healthcare services are delivered IL Section 501(c)(2) N/A Alexian Brothers Health System 1 Alexian Brothers Center for Mental Health 3436 N Kennicott Avenue Arlington Heights IL 60004 363045007 Outpatient community mental health services IL Section 501(c)(3) Schedule A, Line 7 Alexian Brothers Health System 1 Alexian Brothers Behavioral Health Hospital 1650 Moon Lake Blvd Hoffman Estates IL 60194 364251848 Behavioral health hospital IL Section 501(c)(3) Schedule A, Line 3 Alexian Brothers Health System 1 St Alexius Medical Center 1555 Barrington Road Hoffman Estates IL 60194 364251846 Acute care hospital IL Section 501(c)(3) Schedule A, Line 3 Alexian Brothers Health System 1 Alexian Brothers Ambulatory Group 3040 W Salt Creek Lane Arlington Heights IL 60005 364336931 Physician services IL Section 501(c)(3) Schedule A, Line 3 Alexian Brothers Health System 1 Alexian Brothers Medical Center 800 Biesterfield Road Elk Grove Village IL 60007 362596381 Acute care hospital TX Section 501(c)(3) Schedule A, Line 3 Alexian Brothers Health System 1 Alexian Rehabilitation Services LLC 935 Beisner Road Elk Grove Village IL 60007 300221481 Rehabilitation hospital IL N/A Illinois NeuroMeg Center LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 870783164 Provision of NeuroMeg services IL N/A Elk Grove MOB Limited Partnership 3040 W Salt Creek Lane Arlington Heights IL 60005 363853289 Medical office building IL N/A Workplace Solutions LLC 1100 E Woodfield Road Schaumburg IL 60173 364095007 Provision of EAP services IL N/A Bonaventure Medical Foundation LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 363978153 Manages managed care contracts DE N/A Neurosciences Equipment LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 861115516 Ownership of Gamma Knife IL N/A St Alexius Center for Sleep Health LLC 1300 S Main Street Lombard IL 60148 205876371 Operation of sleep lab IL N/A Thelen Corporation 3040 W Salt Creek Lane Arlington Heights IL 60005 363266316 Owns/leases property; joint venture partner IL N/A C 0 Alexian Brothers Health Providers Association Inc 3040 W Salt Creek Lane Arlington Heights IL 60005 363853286 Messenger model IPA IL N/A C 0 Alexian Brothers Corpus Christi Housing Project LLC 3040 W Salt Creek Lane Arlington Heights IL 60005 943465394 Tax credit financed housing IL N/A C 0 Alexian Village of Elk Grove 3040 W Salt Creek Lane Arlington Heights IL 60005 352211303 Tax credit financed housing IL N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 Alexian Brothers Health System P 1408711 FMV Alexian Brothers Health System R 2142327 FMV Alexian Brothers Health System S 3810203 FMV Alexian Brothers Senior Ministries P 113482 FMV