2016-11-14T15:54:14-06:00 2015-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2015-01-01 911041617 PROVIDENCE GENERAL FOUNDATION PROV 4252587500 PO Box 1067 Everett WA 98206 Lori Kloes Executive Director 4252587500 2016-11-14 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2015 2017-02-10 21:41:12Z Lori Kloes PO Box 1067 Everett WA 98206 11261187 0 X washington.providence.org/donate X 1978 WA Support of Snohomish County Regional Health Care System. 23 22 0 200 0 0 2887378 2444487 0 0 837576 1104686 -140656 -154468 3584298 3394705 5256607 3582580 0 0 686594 630090 0 12000 583520 453875 411395 6397076 4636065 -2812778 -1241360 22633538 20497497 1856605 1955877 20776933 18541620 As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support of Snohomish County Regional Health Care System. 0 0 2621993 2621993 0 Funding supported the build-out of an additional operating room in the Providence Regional Medical Center Everett (PRMCE) Patient Care Tower. With the addition of ten new surgeons in several different specialties, there was a need for operating room availability to accommodate population growth and an increase in market share - people choosing to seek care in their own community. Currently, there are more than 15,300 surgeries performed at PRMCE. There was also the purchase of a new Siemens Bi-Plane Angiography system for the operating room. The equipment was essential for facilitating interventions for acute stroke and aneurysms. 825021 825021 0 Program support for Providence Regional Medical Center Everett included funding for the Providence Autism Center operations. The Center continued to grow and reimbursements did not cover the cost of care for this vulnerable population. A grant was also given to Hospice and Home Care to support their campaign to build a designated Hospice Care Center at PRMCE's Colby Campus. Funding was provided for Camp Prov, a day camp for children with disabilities and their siblings. 135566 135566 0 Cancer patient emergency fund, dental and medical assistance to low income individuals, education scholarships for medical and nursing staff and staff emergency funds. Additional support provided for programs improving access to dental and medical care in Snohomish County. Support was also provided for a program in partnership with Everett Gospel Mission, where homeless patients discharged from the hospital can recuperate safely in beds set aside in a special area at the Mission. 3582580 1 1 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 1 1 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 X 28 0 1 0 0 0 0 0 0 1 1 0 0 0 0 X 23 22 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 0 0 0 WA X Karl E Fritschel CPA 4255253339 2001 Lind Ave SW Renton WA 98057 X Ayers Shirley Director 1.00 0.00 X 0 0 0 Bell Doug Director 1.00 0.00 X 0 0 0 Brandt Tony Director 1.00 0.00 X 0 0 0 Cymbaluk Jeff Director 1.00 0.00 X 0 0 0 Downey Bob Director 1.00 0.00 X 0 0 0 Duffy Mark Treasurer 1.00 0.00 X X 0 0 0 Finley Jim MD Director 1.00 0.00 X 0 0 0 Gaffney Jan Director 1.00 0.00 X 0 0 0 Halladay Janice First Vice Chair 1.00 0.00 X X 0 0 0 Hall Andy Director 1.00 0.00 X 0 0 0 Harkins Dan Eff 515 Director 1.00 0.00 X 0 0 0 Hunter Kathy Director 1.00 0.00 X 0 0 0 Jubie Harvey Director 1.00 0.00 X 0 0 0 Jubie Larry Second Vice Chair 1.00 0.00 X X 0 0 0 Lane Tom Director 1.00 0.00 X 0 0 0 Larson Gail Secretary 1.00 0.00 X X 0 0 0 Messner Jean Chair 1.00 0.00 X X 0 0 0 Pieper Kevin MD Director 1.00 0.00 X 0 0 0 Rodland Carol Director 1.00 0.00 X 0 0 0 Ryan Patrick MD Thru 115 Director 1.00 0.00 X 0 0 0 Sheldon Mel Director 1.00 0.00 X 0 0 0 Simmons Preston Director 1.00 0.00 X 0 0 0 Wharton Marcia MD Director 1.00 0.00 X 0 0 0 Kloes Lori Eff 615 Executive Director 50.00 0.00 X X 134971 0 25921 Black Carolyn Thru 515 Executive Director 50.00 0.00 X X 169551 0 12535 304522 0 38456 2 0 1 1 Merrill Lynch 2707 Colby Avenue Suite 1401 Everett WA 98201 Investment Management Services 172349 Tulalip Resort & Casino 10200 Quil Ceda Blvd Tulalip WA 98271 Catering Services 152933 2 35000 943612 1465875 37486 2444487 348977 348977 8221873 7466164 755709 755709 755709 210652 943612 400318 -189666 -189666 35198 0 35198 35198 3394705 0 0 950218 3477014 3477014 105566 105566 326683 126426 200257 210450 81241 129209 92957 15932 77025 31150 31150 12000 12000 172349 172349 47708 10259 37449 1260 1260 84465 24886 59579 44444 44444 2240 2240 3477 85 3392 14280 5248 9032 904 904 Donor/Board Recog. 5777 2140 3637 Dues and Subscriptions 3164 249 2915 Donor Cultivation 177 177 4636065 3582580 469965 583520 1749112 551647 2721485 1426568 150 12610 34257 17205264 17280820 945067 1204055 22633538 20497497 33000 229000 1823605 1440316 0 286561 1856605 1955877 X 4937760 4500000 15052860 13255307 786313 786313 20776933 18541620 22633538 20497497 X -1241360 -985784 -8169 X X 0 1 X 1 0 X 9795531 2725279 2838779 2887378 2444487 20691454 9795531 2725279 2838779 2887378 2444487 20691454 5185526 15505928 271947 363414 321484 361922 348977 1667744 22359198 0.69350 0.77570 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 1 X 1305423 9856 66843 1248436 1296785 73570 64932 1305423 2003210 25 161863 868313 1296785 1860587 142623 2003210 1883718 -23131 1860587 0.24110 0.63960 0.11930 0 0 0 Life Interest in Real Property 116167 Cash Surrender Value of Life Insurance 475381 Beneficial Interest in Assets Held in Trusts 612507 1204055 CGA Obligation 286561 286561 X 2789348 -985784 37080 -948704 3738052 -343347 -343347 3394705 5024662 37080 408488 445568 4579094 56971 56971 4636065 Part IV, Line 2b: During 2010, Providence Regional Medical Center transferred assets, as an agency transaction, to the Foundation to be held on its behalf. Part V, Line 4: Primary uses are for Women's and Children's Services and the Cancer Center. Part X, Line 2: The audited financial statements do not contain a footnote regarding the organization's liability for uncertain tax positions under FIN 48. Part XI, Line 4b - Other Adjustments: Special Event Expenses -400,318. Non-Cash Event Revenue 56,971. Part XII, Line 2d - Other Adjustments: Special Event Expenses 400,318. 2014 Special Event Expenses (Paid in 2015) 4,670. 2014 Gaming Expenses (Paid in 2015) 3,500. Part XII, Line 4b - Other Adjustments: Non-Cash Event Revenue 56,971. Festival of Trees 827715 661679 166036 31624 121634 1460 197979 The Epicurean Affair 157174 139245 17929 2706 35563 4 169375 142688 26687 9352 1154264 943612 210652 31624 124340 1460 242894 400318 -189666 35198 1 1.00000 35198 35198 WA 1 0 0 0 1.00000 Ashley Bontje 916 Pacific Avenue Everett WA 98201 0 Ashley Bontje 0 Foundation Staff oversees volunteers that facilitate the raffles at the Foundation fundraising events. X 0 1 PH & S - WA dba Providence Regional Medical Center Everett 916 Pacific Avenue Everett WA 98201 510216586 501(c)(3) 3291311 55703 Cash Newspapers available for staff, patients, visitors Help multiple programs in the medical center and Healthcare Clinic including staffing, equipment, educational conferences, patient education and support, screening and prevention. Providence Hospice & Home Care Foundation 2731 Wetmore Avenue Everett WA 98201 272552749 501(c)(3) 100000 Fund capital expenditures and equipment for Providence Hospice and Home Care of Snohomish County. Project Access Northwest 1111 Harvard Avenue Seattle WA 98122 204377921 501(c)(3) 10000 Funding for community-based initiatives to improve health and reduce costs. Everett Gospel Mission 222 52nd Street Everett WA 98203 910780146 501(c)(3) 20000 Funding for designated beds at the shelter to allow homeless patients a safe place to rest and recover after treatment. 4 0 Cancer Patient Assistance 135 7719 42131 Cost Assists cancer patients experiencing financial hardships as a result of their cancer diagnosis. Funds help pay for food, rent, utilities, prescriptions and other critical expenses when they are out of work or strapped by unplanned medical expenses. Scholarship and Education Assistance 56 36099 9000 Cost Nursing and Medical Staff Education Scholarships Helping Hands 19 6497 Cost Offers a place for Providence Regional Medical Center Everett employees to turn when a financial or medical emergency occurs. Diabetes Programs 4 2600 Cost Helps patients who are in need of financial assistance pay for their medications. Mobile Dental Services 4 1520 Cost Dental services for low income patients. Part I, Line 2: In the application for support, we request a detailed explanation of the kind of services provided to the community along with specific financial data. If the application for support is approved, we send a letter indicating the amount of the support along with a request for documentation of how the funds were used. A majority of the grants are made to the Medical Center, so the Foundation has access to the financial records and can review them for appropriate use. The scholarships and education assistance provided to nurses are merit and criteria-based. The nursing council reviews and approves the applications for support based on the type of conference, education or certification sought, whether employees are in good standing, and the availability of funds. Other grants are monitored through review of receipts provided and approved. X 1 1 0 0 0 0 0 0 0 0 0 Kloes Lori Eff 615 Executive Director 134971 0 0 0 0 0 14527 0 11394 0 160892 0 0 0 Black Carolyn Thru 515 Executive Director 116958 0 36668 0 15925 0 7634 0 4901 0 182086 0 0 0 Part I, Line 1a The Foundation maintains an annual membership at the Everett Golf & County Club for the Executive Director. This membership is used to cultivate donors, board members and volunteers and is not considered a taxable benefit to the Executive Director. FORM 990, SCHEDULE J, PART II - COMPENSATION The entire balance of compensation for Carolyn Black & Lori Kloes is paid through Providence Regional Medical Center Everett. X Printed Goods 2 28486 FMV X Equip.,Decor 1 9000 FMV 0 0 1 0 Part I, Column (b): The amounts shown on Part I, Col. B reflect the number of donations received of the specific type of item. Form 990, Part VI, Section A, line 2 Larry Jubie and Harv Jubie have a family relationship. Form 990, Part VI, Section A, line 7b A member of the Board of Directors may be removed at the request of the Board of Directors of Providence Regional Medical Center Everett if the latter, in its absolute discretion, deems such member to be unqualified in any respect, provided no more than one member of the Board shall be removed pursuant to this provision in any one calendar year. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff of Providence Health & Services - Washington and reviewed by the internal Director of Taxes and external tax advisors. The Foundation Director and signing Officer will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c All members of the Governing Board respond to and sign a Conflict of Interest Policy Statement at the January Board meeting annually. Members disclose any actual or apparent conflict of interest in the disclosure document and also orally to the other Board members at the annually meeting. Conflicts are noted and members are excused from decision that are in conflict with private interests. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Providence retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, Providence benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles & advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. Providence's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. Based on the above principles and guidelines, an annual salary review is handled by the HR Department of Providence Regional Medical Center Everett. Form 990, Part VI, Section C, line 19 These documents are made available on request through the Business Office. Form 990, Part XI, line 9: 2014 Special Event Expenses (Paid in 2015) -4,670. 2014 Gaming Expenses (Paid in 2015) -3,500. Rounding 1. FORM 990, PART XII, LINE 2C - AUDIT & COMPLIANCE The Board Treasurer and Finance Committee assists the Board of Directors with the oversight of the integrity of the financial statements and reporting, the audit process and the internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the internal and external auditors; the investment committee; and informs the Board of Directors of critical risk areas and recommended mitigation. FORM 990, PART I, LINE 5 & PART V, LINE 2A - EMPLOYEE COMPENSATION The employees working at the Foundation are paid by Providence Health & Services - WA. dba Providence Regional Medical Center Everett. Therefore, no W-2s are issued by the reporting organization. FORM 990, PART I, LINE 6 - VOLUNTEERS Services provided were in support of various Foundation-related programs and a variety of tasks including: * Special events organizers/support workers * Third-party event volunteers Their service was tied to the following Foundation programs: * The Epicurean Affair (special event) * Festival of Trees (special event) * Friends of Providence Donor Society * Wheels on the Waterfront (special event) * Pink the Rink (special event) FORM 990, SCHEDULE R - PROVIDENCE AFFILIATION Providence General Foundation is affiliated with PH & S - WA. dba Providence Regional Medical Center Everett and provides a majority of its grants to this organization. However, based on the Articles of Incorporation and Bylaws of the Foundation, PH & S - WA. dba Providence Regional Medical Center Everett does not exercise enough control of the Foundation to be considered a related organization. Therefore, no Schedule R is required for the Foundation.