2020-08-11T11:45:17-05:00 2019-09-30 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2018-10-01 464564958 AUGUSTANA MOUNT OLIVET HOSPICE CARE LLC AUGU 9528555000 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 SARAH VAN WINKLE PRESIDENT/CEO 9528555000 2020-08-10 1 MATT WOCKEN P01598291 6123764500 2020-08-07 67.137.57.251 2020-08-10 08:08:29 CD P 80E1F4C36FD5403AFF9C3193509FEE9CEC8C2CF0 8DF0D5A1DBF8E44DE93554FEEDBEEE801640FE4C 2018 2020-09-23 17:36:50Z GRACE HOSPICE SARAH VAN WINKLE 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 10771995 0 X WWW.GRACEHOSPICECARING.ORG X LLC 2014 MN PROVIDE HOSPICE SERVICES TO THE ELDERLY. 6 6 93 69 0 0 75979 95381 8530622 10661798 9 0 -7341 -17302 8599269 10739877 0 400000 0 0 4292208 5023204 0 0 0 4049260 4622817 8341468 10046021 257801 693856 1699845 2406503 709057 721859 990788 1684644 X OUR MISSION IS TO SERVE GOD BY RECOGNIZING THAT EVERY PERSON DESERVES TO LIVE OUT HIS OR HER LIFE WITH RESPECT AND DIGNITY, FREE OF PAIN, AND IN AN ENVIRONMENT THAT PROMOTES QUALITY OF LIFE. 0 0 8358973 400000 10661798 AUGUSTANA MOUNT OLIVET HOSPICE, LLC ("THE LLC") IS A JOINT VENTURE BETWEEN AUGUSTANA CARE (EIN: 41-1728753) AND MOUNT OLIVET CAREVIEW HOME (EIN: 41-0802697). AUGUSTANA CARE AND MOUNT OLIVET CAREVIEW HOME ARE THE ONLY MEMBERS OF THE LLC. BOTH MEMBERS ARE MINNESOTA NONPROFIT CORPORATIONS AND TAX EXEMPT PUBLIC CHARITIES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AUGUSTANA CARE IS A PUBLIC CHARITY UNDER SECTIONS 509(A)(1) AND 170(B)(1)(A)(VI). MOUNT OLIVET CAREVIEW HOME IS A PUBLIC CHARITY UNDER SECTION 509 (A)(2).HOSPICE CARE:THE LLC PROVIDES END-OF-LIFE CARE TO PATIENTS, IN THEIR HOME, THAT ARE CERTIFIED AS BEING TERMINALLY ILL WITH LESS THAN SIX MONTHS OF LIFE. THE PURPOSES OF THE LLC INCLUDE:(A) TO PROVIDE END-OF-LIFE SERVICES THAT SUPPORTS EACH INDIVIDUAL'S PHYSICAL, SPIRITUAL, CULTURAL AND EMOTIONAL NEEDS TO ENHANCE THEIR QUALITY OF LIFE;(B) TO SUPPORT AND HELP PATIENTS AND FAMILIES THROUGH THEIR END OF LIFE JOURNEY UTILIZING A TEAM APPROACH OF: MEDICAL DIRECTOR, NURSES, SOCIAL WORKERS, CHAPLAINS, HOME HEALTH AIDES, MUSIC THERAPISTS, MASSAGE THERAPISTS, GRIEF COUNSELORS, MEDICATIONS RELATED TO TERMINAL DIAGNOSIS, DURABLE MEDICAL EQUIPMENT, 24/7 ON-CALL SUPPORT AND VOLUNTEERS;(C) TO PROVIDE 13 MONTHS OF BEREAVEMENT SERVICES;(D) TO ACCEPT ALL WHO ARE ELIGIBLE TO HOSPICE SERVICES REGARDLESS OF ABILITY TO PAY;(E) A FAITH-BASED ORGANIZATION BRINGING HOSPICE CARE TO PATIENTS AND FAMILIES THAT BEST FITS THEIR NEEDS; AND(F) OTHER PROGRAMS AS MAY FROM TIME TO TIME THAT IS APPROPRIATE TO THE ACCOMPLISHMENT OF THIS COMPANY'S CHARITABLE PURPOSE.IN FISCAL YEAR 2019, WE PROVIDED HOSPICE SERVICES TO 573 HOSPICE PATIENTS AND FAMILIES. 8358973 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 15 0 93 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 MN X KATHY YOUNGQUIST - A&E CARE SERVICES 9528555000 7171 OHMS LN EDINA MN 55439 SARAH VAN WINKLE PRESIDENT/CEO 45.00 0.00 X 174243 0 6098 STACY LYSEN DIRECTOR OF NURSING 45.00 0.00 X 131042 0 21753 BERNIE CABLE-PROKOP CHAIR 2.00 0.00 X X 0 0 0 TIMOTHY HOKANSON VICE CHAIR 2.00 0.00 X X 0 0 0 SHARON WILSON SECRETARY 2.00 0.00 X X 0 0 0 EILEEN CARTWRIGHT DIRECTOR 2.00 0.00 X 0 0 0 MATTHEW KERN DIRECTOR 2.00 0.00 X 0 0 0 DAVID LOSE DIRECTOR 2.00 0.00 X 0 0 0 305285 0 27851 2 0 1 0 HOSPICE PHARMACY SOLUTIONS PO BOX 161583 ATLANTA GA 30321 PHARMACY BENEFIT MANAGER 528692 A&E CARE SERVICES 7171 OHMS LANE EDINA MN 55439 MANAGEMENT SERVICES 429246 INTERNAL MEDICINE & GERIATRIC ASSOC 21490 FAIRVIEW ST EXCELSIOR MN 55331 MEDICAL DIRECTOR 153361 3 70393 24988 95381 HOSPICE CARE 624100 10661798 10661798 10661798 14816 70393 32118 -17302 -17302 10739877 10661798 0 -17302 X 400000 400000 209971 209971 3963806 3516717 447089 57260 47102 10158 471277 387672 83605 320890 263964 56926 429246 429246 924 924 21535 21535 3006331 3006331 39072 39072 142716 18050 124666 83173 83173 42828 293 42535 144409 120848 23561 21469 12286 9183 1566 1566 41646 41646 20552 20552 NURSING EQUIPMENT 485291 485291 NURSING SUPPLIES 98697 98697 RECRUITMENT AND RETENTI 16171 16171 DUES AND SUBSCRIPTIONS 14609 349 14260 12582 1373 11209 10046021 8358973 1687048 0 591493 1117234 954340 1106025 49912 74543 236445 151014 104100 85431 0 23270 1699845 2406503 642158 681149 66899 40710 709057 721859 X 990788 1684644 990788 1684644 1699845 2406503 693856 0 X X 0 1 X 1 0 X 309203 110578 18409 75979 95381 609550 2557734 3980994 5866280 8530622 10661798 31597428 2866937 4091572 5884689 8606601 10757179 32206978 300000 100000 400000 0 300000 100000 400000 31806978 9 9 9 9 30365 14816 45181 2866937 4091572 5884689 8636975 10771995 32252168 0.98620 0.95790 0.00000 0.00000 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2014 AMOUNT: $ 0. 2015 AMOUNT: $ 0. 2016 AMOUNT: $ 0. 2017 AMOUNT: $ 24,440. 2018 AMOUNT: $ 0. FUNDRAISING EVENT REVENUES - 2014 AMOUNT: $ 0. 2015 AMOUNT: $ 0. 2016 AMOUNT: $ 0. 2017 AMOUNT: $ 5,925. 2018 AMOUNT: $ 14,816. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 129510 90657 38853 106935 60357 46578 85431 X 13897518 3157641 3157641 10739877 0 10739877 12544898 2498877 2498877 10046021 0 10046021 PART X, LINE 2: AS A LIMITED LIABILITY COMPANY, THE COMPANY IS NOT SUBJECT TO FEDERAL OR STATE INCOME TAXES AND ITS INCOME IS ALLOCATED TO AND REPORTED IN THE TAX RETURNS OF ITS MEMBERS, WHICH ARE BOTH NON-PROFIT CORPORATIONS. THE COMPANY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE MEMBERS' INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XI, LINE 2D - OTHER ADJUSTMENTS: SHORT PERIOD REVENUES INCLUDED IN SEPARATE FORM 990 3,157,641. PART XII, LINE 2D - OTHER ADJUSTMENTS: SHORT PERIOD EXPENSES INCLUDED IN SEPARATE FORM 990 2,498,877. GALA EVENT 85209 70393 14816 1065 11009 20044 85209 70393 14816 1065 11009 20044 32118 -17302 1 AUGUSTANA CARE 7171 OHMS LANE EDINA MN 55439 411728753 501(C)(3) 200000 0 N/A N/A GENERAL ASSISTANCE MOUNT OLIVET CAREVIEW HOME 5517 LYNDALE AVENUE SOUTH MINNEAPOLIS MN 55419 410802697 501(C)(3) 200000 0 N/A N/A GENERAL ASSISTANCE 2 0 PART I, LINE 2: THE TRANSFERS WERE MADE TO THE MEMBERS, WHO ARE BOTH 501 (C)(3) ORGANIZATIONS, AND WERE USED FOR GENERAL OPERATING SUPPORT. NO FOLLOW-UP OR OVERSIGHT WAS CONDUCTED REGARDING THE SPECIFIC USE OF TRANSFERRED FUNDS. X X X X X 0 0 0 0 0 0 0 0 0 SARAH VAN WINKLE PRESIDENT/CEO 174218 0 0 0 25 0 6098 0 0 0 180341 0 0 0 STACY LYSEN DIRECTOR OF NURSING 121042 0 10000 0 0 0 4830 0 16923 0 152795 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 1. BERNADINE CABLE-PROKOP AND SHARON WILSON - BUSINESS RELATIONSHIP 2. EILEEN CARTWRIGHT AND TIMOTHY HOKANSON - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 3 A&E CARE SERVICES PROVIDES THE FOLLOWING SERVICES TO AUGUSTANA MOUNT OLIVET HOSPICE CARE, LLC: FINANCIAL ACCOUNTING, OPERATIONAL OVERSIGHT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, CLINICAL NURSING CONSULTATION, CORPORATE COMPLIANCE, COORDINATED ADVERTISING AND MARKETING, PHILANTHROPY AND NEW BUSINESS DEVELOPMENT. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE ORGANIZATION ARE AUGUSTANA CARE AND MOUNT OLIVET CAREVIEW HOME, BOTH MINNESOTA NON PROFIT CORPORATIONS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501(A) OF THE INTERNAL CODE AS ORGANIZATIONS DESCRIBED IN SECTION 501(C)(3) OF THE CODE AND AFFILIATED WITH THE EVANGELICAL LUTHERAN CHURCH IN AMERICA. THE INCUMBENT CHIEF EXECUTIVE OFFICER OF EACH MEMBER SHALL BE THE MEMBER DELEGATE OF EACH MEMBER ENTITLED TO VOTE ON BEHALF OF THE VOTING INTERESTS OF EACH MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF GOVENORS SHALL CONSIST OF AT LEAST SIX GOVERNORS, THREE OF WHOM SHALL BE APPOINTED BY THE MEMBER DELEGATE OF AUGUSTANA CARE AND THREE OF WHOM SHALL BE APPOINTED BY THE MEMBER DELEGATE OF MOUNT OLIVET CAREVIEW HOME. FORM 990, PART VI, SECTION A, LINE 7B THE ARTICLES OF ORGANIZATION AND THE BYLAWS OF THIS ORGANIZATION MAY BE AMENDED OR RESTATED ONLY BY THE UNANIMOUS APPROVAL OF THE MEMBERS. ANY PROPOSED AMENDMENTS RELATING TO THE AFFILIATION REQUIREMENTS OF THE ELCA SHALL BE SUBMITTED TO THE ELCA FOR COMMENT PRIOR TO THEIR EFFECTIVE DATE. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED IN DETAIL BY THE ORGANIZATION'S CEO. THE FORM 990 WAS THEN PRESENTED TO THE FULL BOARD OF DIRECTORS BY THE CEO PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C INFORMATION REGARDING THE HOSPICE'S POLICY ON CONFLICTS OF INTEREST IS PROVIDED DURING ORIENTATION OF NEW STAFF, VOLUNTEERS AND BOARD MEMBERS. MEMBERS OF THE BOARD OF DIRECTORS AND HOSPICE STAFF SUBMIT A FORM TO DISCLOSE PERSONAL OR FINANCIAL INTERESTS THAT COULD POTENTIALLY INTERFERE WITH THEIR DUTIES AND RESPONSIBILITIES TO GRACE HOSPICE. DISCLOSURE FORMS ARE SUBMITTED AT THE TIME OF HIRE OR BOARD APPOINTMENT, ANNUALLY, AND WHENEVER A POTENTIAL CONFLICT ARISES. FAILURE TO DISCLOSE EXISTING OR POTENTIAL CONFLICTS OF INTEREST IS GROUNDS FOR TERMINATION OF EMPLOYMENT OR BOARD APPOINTMENT. POTENTIAL CONFLICTS OF INTEREST ARE REVIEWED BY THE BOARD OF DIRECTORS AND/OR BY THE HOSPICE ADMINISTRATOR TO DETERMINE APPROPRIATE ACTION. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION FOR SARAH VAN WINKLE, PRESIDENT/CEO, IS SET BY TWO REPRESENTATIVES OF THE PARTNERING AGENCIES: BOB DAHL, CEO OF AUGUSTANA CARE, AND TIM HOKANSON, ADMINISTRATOR OF MOUNT OLIVET CARE VIEW HOME. THEY SET SARAH'S COMPENSATION BY REVIEWING SALARY SURVEYS SPECIFIC TO HOSPICE AGENCIES. ADDITIONALLY, THEY REVIEW FINANCIAL OUTCOMES, GROWTH OUTCOMES, QUALITY INDICATORS, AND STAFF RETENTION. THIS PROCESS WAS LAST PERFORMED IN 2018. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 3,006,331. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,006,331. FORM 990, PART XII, LINE 2C THE PROCESS FOR THE OVERSIGHT OF THE AUDIT AND SELECTION OF AN ACCOUNTANT HAS NOT CHANGED FROM THE PRIOR YEAR.