2013-05-14T08:12:06-05:00 2012-06-30 470757164 ALEGENT CREIGHTON HEALTH 12809 W DODGE ROAD OMAHA NE 68154 990 2011-07-01 364003095 HARBOR HOUSE HARB 4023434323 12809 W DODGE ROAD OMAHA NE 68154 SCOTT M WOOTEN 4023434323 2013-05-13 1 ANGELA LEA P01051055 4023434413 2011 2016-02-25 16:41:14Z SCOTT M WOOTEN 12809 WEST DODGE ROAD OMAHA NE 68142 2749594 0 X WWW.HOSPICEHOUSEOMAHA.ORG X 1994 NE TO PROVIDE CARE IN A HOMELIKE ENVIRONMENT TO THE TERMINALLY ILL. 23 23 0 91 0 0 399337 688961 1688198 1971043 2186 2369 110545 87221 2200266 2749594 16960 9993 0 0 0 0 0 0 0 2178554 2366894 2195514 2376887 4752 372707 3491053 3926632 32378 105035 3458675 3821597 TO EMBRACE RESIDENTS LIVING WITH TERMINAL ILLNESSES AND THEIR FAMILIES AND FRIENDS WITH COMPASSIONATE CARE AND COMFORT, AND TO PROVIDE END-OF-LIFE EDUCATION IN THE COMMUNITY. 0 0 2241843 9993 1971043 HARBOR HOUSE, DOING BUSINESS AS HOSPICE HOUSE-THE JOSIE HARPER RESIDENCE, OPERATES A LICENSED 26-BED RESIDENTIAL FACILITY WHICH PROVIDES 24-HOUR PROFESSIONAL CARE AND SUPERVISION TO SERVE THE SPIRITUAL, EMOTIONAL, AND PHYSICAL NEEDS OF TERMINALLY ILL RESIDENTS AND THEIR FAMILIES IN A HOME-LIKE SETTING. HARBOR HOUSE PROVIDED SERVICES TO 612 RESIDENTS IN FISCAL 2012. IN ADDITION TO RESIDENTIAL LIVING SPACE, THE BUILDING ALSO INCLUDES CLASSROOMS, STORAGE, SHOWER FACILITIES FOR FAMILIES AND GUESTS, AND A RESOURCE LIBRARY. 2241843 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 5 0 1 0 0 0 0 0 0 0 0 0 0 0 X 23 23 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X SCOTT M WOOTEN SENIOR VPCFO 4023434323 12809 W DODGE ROAD OMAHA NE 68154 DEBRA ROMBERGER MD 1.00 X 0 0 0 BARBARA FITZGERALD 1.00 X 0 0 0 RICHARD HACHTEN II 1.00 X 0 0 0 CAROLYN HARPER 1.00 X 0 0 0 JOANIE KUSH 1.00 X 0 0 0 ROBERT LANGDON MD 1.00 X 0 0 0 PIERRE LAVEDAN MD 1.00 X 0 0 0 SUNNY LUNDGREN 1.00 X 0 0 0 SUZY SHRIER 1.00 X 0 0 0 JACKIE THIELEN APRN-NP 1.00 X 0 0 0 JAMES SUMMERFELT 1.00 X X 0 0 0 WILLIAM SUTTON 1.00 X 0 0 0 THERESA FRANCO RN MSN 1.00 X X 0 0 0 JAYNE MCCORMICK MD 1.00 X 0 0 0 ROSEANNE GOLLAN 1.00 X 0 0 0 CARL GREINER MD 1.00 X 0 0 0 SUSAN KAMBHU MD 1.00 X 0 0 0 ROSEMARY LEBEDA 1.00 X 0 0 0 NEIL FORTKAMP 1.00 X X 0 0 0 STEVE GOESER 1.00 X 0 0 0 BERNARD SU MD 1.00 X 0 0 0 DIANE RANDOLPH 1.00 X 0 0 0 CINDY ALLOWAY 1.00 X 0 0 0 DENISE MCNITT 1.00 X 0 0 0 GARY GEORGE 40.00 X 81846 0 12381 81846 0 12381 0 0 0 1 ALEGENT CREIGHTON HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 MANAGEMENT SERVICES 1929191 1 688961 688961 NET DAILY RESIDENT SVC 621500 1971043 1971043 1971043 2369 2369 OTHER OPERATING REVENU 900099 87221 87221 87221 2749594 1971043 0 89590 9993 9993 1929191 1794147 135044 243214 243214 39657 39657 1120 1120 145988 145988 OTHER 6826 6826 MEMBERSHIP & DUES 600 600 TAXES/LICENSES 298 298 2376887 2241843 135044 0 82827 100705 183288 181910 80750 324437 470062 28707 26685 3373517 1834166 1685339 1539351 1120082 1527169 66373 0 3491053 3926632 32378 32324 0 72711 32378 105035 X 3425330 3660162 18345 120135 15000 41300 3458675 3821597 3491053 3926632 X 372707 -9785 X 0 1 1 X 0 X 291786 358244 316819 399337 688961 2055147 1717485 1773674 1607804 1798743 2058264 8955970 2009271 2131918 1924623 2198080 2747225 11011117 31250 10000 5000 185000 231250 0 31250 10000 5000 185000 231250 10779867 66010 27115 4958 2186 2369 102638 66010 27115 4958 2186 2369 102638 2075281 2159033 1929581 2200266 2749594 11113755 0.97000 0.94190 0.00920 0.01480 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 33345 137875 9785 161435 21000 12345 33345 26507 5507 21000 58080 14420 45993 26507 0.25000 0.75000 0 0 320000 320000 2301108 1220281 1080827 737961 600115 137846 14448 13770 678 1539351 DUE TO MEMBER 72711 72711 2749594 2376887 372707 -9785 -9785 362922 2601726 -9993 -9993 2611719 137875 137875 2749594 2366894 0 2366894 9993 9993 2376887 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE INTENDED TO HELP WITH THE ORGANIZATIONAL OPERATIONS OF HARBOR HOUSE. PART XI, LINE 8 - OTHER ADJUSTMENTS: RELEASED FROM RESTRICTIONS -9,785. PART X, LINE 2 - HOSPICE HOUSE HAS BEEN RECOGNIZED AS A NOT-FOR PROFIT ORGANIZATION BY THE INTERNAL REVENUE SERVICE AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. IN ACCORDANCE WITH FASB INTERPRETATION NO. 48, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, INCLUDED IN FASB ASC SUBTOPIC 740-10, INCOME TAXES-OVERALL, HOSPICE HOUSE RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. SUCH TAX POSITIONS, WHICH ARE MORE THAN 50% LIKELY OF BEING REALIZED, ARE MEASURED AT THEIR HIGHEST VALUE. CHANGES IN RECOGNITION OR MEASUREMENT ARE REFLECTED IN THE PERIOD IN WHICH THE CHANGE IN JUDGMENT OCCURS. DURING 2012 AND 2011, MANAGEMENT DETERMINED THAT THERE ARE NO INCOME TAX POSITIONS REQUIRING RECOGNITION IN THE FINANCIAL STATEMENTS. PART XII, LINE 2D - CHARITY CARE - ($9,993). PART XII, LINE 4B - RESTRICTED CONTRIBUTIONS - $137,875. PART XIII, LINE 4B - CHARITY CARE - $9,993. 1 CHARITY CARE 14 9993 BOOK REDUCTION OR WRITE OFF OF PATIENT SERVICES. PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: THESE FUNDS ARE DIRECTLY USED TO OFFSET THE PATIENTS ACCOUNTS RECEIVABLE. SCHEDULE I, PART I, LINE 1: HARBOR HOUSE RECOGNIZES THE RIGHT TO QUALITY HEALTHCARE REGARDLESS OF AGE, SEX, RACE, RELIGION, NATIONAL ORIGIN, OR ABILITY TO PAY. HARBOR HOUSE PROVIDES CHARITY CARE TO PATIENTS WITH DEMONSTRATED INABILITY TO PAY FOR MEDICALLY NECESSARY SERVICES. 0 0 0 0 0 0 0 0 0 SUPPLEMENTAL INFORMATION PART III GARY GEORGE IS AN OFFICER BECAUSE HE IS THE EXECUTIVE DIRECTOR OF HARBOR HOUSE. HE IS PAID BY ALEGENT CREIGHTON HEALTH, WHO ACTS AS A MANAGEMENT COMPANY THROUGH A COORDINATION OF SERVICES AGREEMENT. THE AMOUNT PAID TO GARY GEORGE WAS $81,846, WHICH WAS REPORTED ON FORM 990, PART VII. FORM 990, PART VI, SECTION A, LINE 2 RICHARD HACHTEN, CINDY ALLOWAY AND DENISE MCNITT - BUSINESS RELATIONSHIP. STEVE GOESER, DIANE RANDOLPH, AND JACKIE THIELEN - BUSINESS RELATIONSHIP. JOANIE KUSH AND JAMES SUMMERFELT - BUSINESS RELATIONSHIP. NEIL FORTKAMP, THERESA FRANCO, AND JAMES SUMMERFELT - BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 HARBOR HOUSE ENTERED INTO A COORDINATION OF SERVICES AGREEMENT WITH ALEGENT CREIGHTON HEALTH TO PERFORM AND MANAGE FINANCIAL SERVICES FOR A MONTHLY FEE. SERVICES INCLUDE BUT ARE NOT LIMITED TO FINANCIAL REPORTING, BUDGETING, BILLING AND COLLECTIONS, FIXED ASSET MANAGEMENT AND TAX RETURN PREPARATION. IN ADDITION TO FINANCIAL SERVICES, ALEGENT HEALTH PROVIDES INFORMATION SYSTEMS SUPPORT, SECURITY, RISK MANAGEMENT AND CORPORATE COMPLIANCE, PURCHASING, MAINTENANCE AND VARIOUS OTHER SUPPORT SERVICES. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATE MEMBERS OF HARBOR HOUSE ARE ALEGENT CREIGHTON HEALTH, THE VISITING NURSE ASSOCIATION OF THE MIDLANDS, NEBRASKA METHODIST HOSPITAL AND THE NEBRASKA MEDICAL CENTER. FORM 990, PART VI, SECTION A, LINE 7A EACH CORPORATE MEMBER WILL BE EQUALLY REPRESENTED ON THE BOARD OF DIRECTORS. THE NUMBER OF VOTING DIRECTORS SHALL BE NO LESS THAN FOUR (4), THE EXACT NUMBER TO BE DETERMINED FROM TIME TO TIME BY DECISION OF THE CORPORATE MEMBERS. CURRENTLY, EACH MEMBER APPOINTS SIX (6) DIRECTORS, FOR A TOTAL OF TWENTY-FOUR (24) DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B SUBJECT TO THE NEBRASKA NONPROFIT CORPORATION ACT AND OTHER APPLICABLE LAW, THE CORPORATE MEMBERS, BY UNANIMOUS AGREEMENT, SHALL HAVE THE POWER TO: A. FIX THE NUMBER OF DIRECTORS OF THE CORPORATION B. APPROVE, AMEND, OR REPEAL THE BYLAWS OR ARTICLES OF INCORPORATION OF THE CORPORATION C. APPROVE THE MERGER, DISSOLUTION OR CONSOLIDATION OR REORGANIZATION OF THE CORPORATION. D. APPROVE THE FORMATION OF OTHER ENTITIES BY THE CORPORATION. E. APPROVE THE ACQUISITION, SALE, LEASE, TRANSFER OR OTHER ALIENATION OF SUBSTANTIALLY ALL OF THE PROPERTY OF THE CORPORATION, OTHER THAN IN THE USUAL AND REGULAR COURSE OF THE CORPORATIONS BUSINESS. F. APPROVE DEBT INCURRED BY THE CORPORATION IN EXCESS OF $25,000. G. APPROVE THE LONG-RANGE FINANCIAL AND STRATEGIC PLAN FOR THE CORPORATION. H. APPROVE ASSESSMENT UPON, OR REQUIRE CAPITAL CONTRIBUTIONS BY, THE CORPORATE MEMBERS. I. APPROVE ANY DISTRIBUTIONS OF CAPITAL OR NET EARNINGS OF THE CORPORATION. UPON EXERCISE OF ANY POWER DESCRIBED ABOVE, EACH CORPORATE MEMBER SHALL PROMPTLY DELIVER TO THE CORPORATION A DULY EXECUTED CERTIFICATE OR OTHER DOCUMENT EVIDENCING THE APPROVAL OF THAT EXERCISE OF POWER BY SUCH CORPORATE MEMBER. FORM 990, PART VI, SECTION B, LINE 11 HARBOR HOUSE AND ALEGENT CREIGHTON HEALTH HAVE A COORDINATION OF SERVICE AGREEMENT IN WHICH ALEGENT PROVIDES THE ACCOUNTING AND FINANCE FUNCTIONS FOR HARBOR HOUSE FOR A MONTHLY FEE. THE TAX DEPARTMENT OF ALEGENT CREIGHTON HEALTH PREPARES THE FORM 990 FOR HARBOR HOUSE. FOLLOWING THE PREPARATION OF FORM 990 BY ALEGENT CREIGHTON HEALTH INTERNAL TAX STAFF, THE RETURN IS REVIEWED BY THE ALEGENT CREIGHTON HEALTH TAX DIRECTOR, CHIEF FINANCIAL OFFICER, AND HARBOR HOUSE'S FINANCE COMMITTEE. ADDITIONALLY, THE BOARD OF DIRECTORS ARE PROVIDED A WEB LINK THAT DIRECTS THEM TO THE FINAL TAX RETURN AND ALL REQUIRED SCHEDULES. QUESTIONS ARE REFERRED TO THE ALEGENT HEALTH TAX DIRECTOR AND THE BOARD IS NOTIFIED OF THE DATE THE TAX RETURN WILL BE FILED. FORM 990, PART VI, SECTION B, LINE 12C WRITTEN CONFLICT OF INTEREST POLICY - HARBOR HOUSE HAS ADOPTED THE CONFLICT INVESTIGATION PROCESS OF ALEGENT CREIGHTON HEALTH. ANNUAL COMPLETION OF THE DISCLOSURE STATEMENT IS REQUIRED BY THE BOARD OF DIRECTORS. STATED DISCLOSURES ARE INVESTIGATED BY AN APPOINTED DISINTERESTED PERSON OR COMMITTEE THAT IS SELECTED BY THE CHAIRMAN OF THE BOARD. AFTER EXERCISING DUE DILIGENCE, THE BOARD SHALL DETERMINE WHETHER THE CORPORATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT WITH REASONABLE EFFORTS FROM A PERSON OR ENTITY THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST. IF A MORE ADVANTAGEOUS TRANSACTION OR ARRANGEMENT IS NOT REASONABLY ATTAINABLE UNDER CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT OF INTEREST, THE BOARD SHALL DETERMINE BY A MAJORITY VOTE OF THE DISINTERESTED DIRECTORS WHETHER THE TRANSACTION OR ARRANGEMENT IS IN THE CORPORATION'S BEST INTEREST FOR ITS OWN BENEFIT AND WHETHER THE TRANSACTION IS FAIR AND REASONABLE TO THE CORPORATION. FINALLY, THE BOARD MAKES ITS DECISION AS TO WHETHER TO ENTER INTO THE TRANSACTION OR ARRANGMENT IN CONFORMITY WITH SUCH DETERMINATION. AT ANY TIME A BOARD MEMBER MAY DECLARE A CONFLICT OF INTEREST AND RECUSE HIM/HERSELF FROM THE DISCUSSION. THE INDIVIDUAL IS ALSO REQUIRED TO DISCLOSE ANY KNOWN OR POSSIBLE CONFLICTS OF INTEREST THAT ARISE DURING THE CALENDAR YEAR. FORM 990, PART VI, SECTION C, LINE 19 HARBOR HOUSE HAS ADOPTED THE CONFLICT OF INTEREST POLICY OF ALEGENT CREIGHTON HEALTH, WHICH IS AVAILABLE TO THE PUBLIC AT WWW.ALEGENT.COM. HARBOR HOUSE DOES NOT MAKE THE GOVERNING DOCUMENTS OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. HOWEVER, THE ARTICLES OF INCORPORATION ARE AVAILABLE AT WWW.SOS.STATE.NE.US. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: RELEASED FROM RESTRICTIONS -9,785. TOTAL TO FORM 990, PART XI, LINE 5: -9,785. FORM 990, PART I, LINE 5 AND PART V, LINE 2A HARBOR HOUSE DOES NOT HAVE ANY EMPLOYEES. INDIVIDUALS PROVIDING SERVICES TO PATIENTS OF HARBOR HOUSE ARE LEASED FROM ALEGENT CREIGHTON HEALTH. FORM 990, PART V, LINE 1A AS PART OF THE COORDINATION OF SERVICES AGREEMENT WITH ALEGENT CREIGHTON HEALTH, ALEGENT CREIGHTON HEALTH PERFORMS THE ACCOUNTS PAYABLE FUNCTION FOR HARBOR HOUSE. HARBOR HOUSE REIMBURSES ALEGENT CREIGHTON HEALTH FOR VENDOR PAYMENTS, THEREFORE NO FORM 1099'S ARE ISSUED BY HARBOR HOUSE. ALEGENT CREIGHTON HEALTH ISSUES THE FORM 1099 AND COMPLIES WITH BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS.