2016-08-11T08:19:35-05:00 2015-09-30 410746749 CLIFTONLARSONALLEN LLP 220 SOUTH SIXTH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2014-10-01 464564958 AUGUSTANA MOUNT OLIVET HOSPICE CARE LLC AUGU 6122385225 1425 10TH AVENUE SOUTH NO 100 MINNEAPOLIS MN 55404 CRAIG A KITTELSON VP - FINANCE/CFO 6122385225 2016-07-26 1 EMILY SCHEEVEL P01814921 6123764500 2014 2016-12-15 16:53:06Z GRACE HOSPICE SARAH VAN WINKLE 1425 10TH AVENUE SOUTH NO 100 MINNEAPOLIS MN 55404 2866937 0 X WWW.GRACEHOSPICECARING.ORG X LIMITED LIABILITY COMPANY 2014 MN PROVIDE HOSPICE SERVICES TO THE ELDERLY. 7 6 11 29 0 0 500000 309203 110191 2557734 0 0 0 0 610191 2866937 0 0 0 0 298515 1262616 0 0 0 172379 1127224 470894 2389840 139297 477097 251603 983647 112306 367252 139297 616395 X OUR MISSION IS TO RECOGNIZE 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 1838007 0 2557734 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). THE LLC PROVIDES END-OF-LIFE CARE TO PATIENTS, WHEREVER THEY LIVE, THAT HAVE BEEN CERTIFIED AS BEING TERMINALLY ILL WITH LESS THAN SIX MONTHS OF LIFE. THE PURPOSES OF THE LLC INCLUDE:(A) TO PROVIDE HOME CARE AND END-OF-LIFE SERVICES THAT SUPPORTS EACH INDIVIDUAL'S PHYSICAL, SPIRITUAL, CULTURAL, SOCIAL AND RECREATIONAL NEEDS TO ENHANCE THEIR QUALITY OF LIFE;(B) TO SUPPORT, AID AND DEVELOP METHODS AND MEANS TO MAKE THE LIVES OF PERSONS IN THEIR HOMES AND AT THE END OF THEIR LIVES AS INDEPENDENT, HEALTHFUL, MEANINGFUL AND SECURE AS POSSIBLE IN AN ENVIRONMENT WHICH EMPHASIZES CHRISTIAN CARE AND CONCERN, INCLUDING BUT NOT LIMITED TO HOME CARE, HOSPICE AND PALLIATIVE CARE SERVICES, FACILITIES AND PROGRAMS FOR SUPPORTIVE SERVICES AND EDUCATION FOR PERSONS IN THEIR HOMES AND AT THE END OF THEIR LIVES, THEIR FAMILIES, PROFESSIONALS WHO SERVE SUCH PERSONS, AND OTHER MEMBERS OF THE COMMUNITIES SERVED BY THIS COMPANY; AND(C) SUCH OTHER FACILITIES OR PROGRAMS AS MAY FROM TIME TO TIME BE APPROPRIATE TO THE ACCOMPLISHMENT OF THIS COMPANY'S CHARITABLE PURPOSES.IN FY 2015, WE PROVIDED HOSPICE SERVICES TO 191 PEOPLE. SERVICES INCLUDED MEDICAL DIRECTOR, NURSING, SOCIAL SERVICES, CHAPLAINS, HOME HEALTH AIDES, MEDICATIONS RELATED TO TERMINAL ILLNESS, MEDICAL EQUIPMENT, 24/7 ON-CALL SUPPORT, AND BEREAVEMENT SUPPORT FOR FAMILY MEMBERS FOR 13 MONTHS AFTER THE DEATH. 1838007 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 0 11 1 0 0 0 0 0 0 0 0 0 0 X 7 6 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 MN X AUGUSTANA CARE SERVICES 6122385205 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 BERNIE CABLE-PROKOP CHAIR 1.00 X X 0 0 0 TIMOTHY HOKANSON VICE CHAIR 1.00 X X 0 0 0 DAN SEIDELMANN TREASURER 1.00 X X 0 0 0 SHARON WILSON SECRETARY 1.00 X X 0 0 0 EILEEN CARTWRIGHT BOARD MEMBER 1.00 X 0 0 0 THOMAS MACNALLY BOARD MEMBER 1.00 X 0 0 0 SARAH VAN WINKLE PRESIDENT/CEO 45.00 X X 143165 0 0 143165 0 0 1 0 0 0 AUGUSTANA CARE SERVICES 1007 EAST 14TH STREET MINNEAPOLIS MN 55404 MANAGEMENT SERVICES 108248 1 309203 309203 HOSPICE CARE 624100 2557734 2557734 2557734 2866937 2557734 0 0 X 143485 143485 928700 824502 104198 2229 1714 515 105427 81073 24354 82775 63653 19122 108248 108248 330 330 4857 4857 616870 616870 23988 23988 40321 3269 37052 44472 44472 37902 37902 49123 42070 7053 9827 8228 1599 5516 5516 7162 7162 NURSING EQUIPMENT 123425 123425 NURSING SUPPLIES 29635 29635 BAD DEBT EXPENSE 17055 17055 LICENSES, PERMITS AND F 5600 5600 2893 150 2743 2389840 1838007 551833 0 120332 263377 110191 671170 4029 15813 40697 7410 17051 33287 251603 983647 112306 367252 112306 367252 X 139297 616395 139297 616395 251603 983647 477097 0 X 0 0 0 X 500000 309203 809203 110191 2557734 2667925 610191 2866937 3477128 500000 300000 800000 0 500000 300000 800000 2677128 610191 2866937 3477128 X SCHEDULE A, PART III, COLUMN E THE AMOUNTS INCLUDED IN COLUMN E FOR TAX YEAR 2013 ARE FOR A SHORT PERIOD STARTING ON JANUARY 13, 2014 AND ENDING ON SEPTEMBER 30, 2014. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 40697 7410 33287 33287 FORM 990, PART VI, SECTION A, LINE 2 1. BERNADINE CABLE-PROKOP AND DAN SIEDELMANN - BUSINESS RELATIONSHIP 2. BERNADINE CABLE-PROKOP AND SHARON WILSON - BUSINESS RELATIONSHIP 3. DAN SIEDELMANN AND SHARON WILSON - BUSINESS RELATIONSHIP 4. THOMAS MACNALLY AND EILEEN CARTWRIGHT - BUSINESS RELATIONSHIP 5. THOMAS MACNALLY AND TIMOTHY HOKANSON - BUSINESS RELATIONSHIP 6. EILEEN CARTWRIGHT AND TIMOTHY HOKANSON - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 3 AUGUSTANA CARE SERVICES PROVIDES MANAGEMENT SERVICES FOR AUGUSTANA MOUNT OLIVET HOSPICE CARE, LLC. AUGUSTANA CARE SERVICES PROVIDES FINANCIAL ACCOUNTING, HUMAN RESOURCES, INFORMATION TECHNOLOGY, MARKETING, COMPLIANCE AND RISK MANAGEMENT, OPERATIONAL OVERSIGHT, AND TELEPHONE AND INTERNET SERVICES. 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 GOVERNORS 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 11 THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED IN DETAIL BY THE PRESIDENT/CEO OF THE ORGANIZATION ALONG WITH AUGUSTANA CARE'S VP OF FINANCE/CFO. THE FORM 990 WAS THEN PRESENTED TO THE FULL BOARD OF DIRECTORS BY THE VP OF FINANCE/CFO OF AUGUSTANA CARE 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 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 616,870. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 616,870.