2013-11-08T18:09:27-06:00 2012-12-31 410746749 CLIFTONLARSONALLEN LLP 4250 N FAIRFAX DRIVE SUITE 1020 ARLINGTON VA 22203 990 2012-01-01 521114719 MONTGOMERY HOSPICE INC MONT 3019214400 1355 PICCARD DRIVE NO 100 ROCKVILLE MD 20850 ANN MITCHELL 3019214400 2013-10-30 1 KAREN GRIES P00078514 5712279500 2012 2016-02-24 21:20:13Z ANN MITCHELL 1355 PICCARD DRIVE NO 100 ROCKVILLE MD 20850 22952576 0 X WWW.MONTGOMERYHOSPICE.ORG X 1979 MD TO GENTLE THE JOURNEY THROUGH SERIOUS ILLNESS AND LOSS WITH SKILL AND COMPASSION. 23 22 297 275 0 0 1143592 791825 20961488 22144610 5025 6975 2437 9166 22112542 22952576 0 700000 0 0 13762497 16230484 0 0 66723 6811584 5495284 20574081 22425768 1538461 526808 9241669 9796799 2361569 2389891 6880100 7406908 TO GENTLE THE JOURNEY THROUGH SERIOUS ILLNESS AND LOSS WITH SKILL AND COMPASSION. SIGNIFICANT ACTIVITIES INCLUDE HOSPICE SERVICES AS WELL AS BEREAVEMENT SUPPORT, PASTORAL CARE, ADMINISTRATIVE ASSISTANCE, COMMMUNITY EDUCATION AND OUTREACH. 0 0 19323803 700000 22144610 HOSPICE AND BEREAVEMENT SERVICES: THE ORGANIZATION PROVIDES SPECIALIZED MEDICAL AND PSYCHOSOCIAL END-OF-LIFE CARE TO MONTGOMERY COUNTY, MD RESIDENTS LIVING WITH A LIFE-LIMITING ILLNESS, AS WELL AS THEIR FAMILIES, WITH AN INTERDISCIPLINARY TEAM OF TRAINED PROFESSIONALS (AND VOLUNTEERS). IN 2012, MONTGOMERY HOSPICE SERVED MORE THAN 2,100 PATIENTS AND THEIR FAMILIES. OUR INPATIENT UNIT, CASEY HOUSE, IS THE ONLY ALL-HOSPICE ACUTE CARE FACILITY IN MONTGOMERY COUNTY. IN 2012, MORE THAN 575 PATIENTS WITH SERIOUS PAIN OR OTHER SYMPTOMS RECEIVED INTENSIVE NURSING AND MEDICAL CARE AND ATTENTION AT CASEY HOUSE. MONTGOMERY HOSPICE ALSO PROVIDED BEREAVEMENT SERVICES TO ALMOST 9,600 INDIVIDUALS, AND END-OF-LIFE CARE EDUCATION TO MORE THAN 9,300 CLINICIANS AND PEOPLE IN THE LAY COMMUNITY. 19323803 1 1 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 10 0 297 1 0 0 0 0 0 0 0 0 0 0 X 23 22 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 0 0 MD X X MONICA ESCALANTE CFO 3019214400 1355 PICCARD DRIVE ROCKVILLE MD 20850 PAUL E ALPUCHE JR 1.00 X 0 0 0 ADRIENNE C KOHN 1.00 X 0 0 0 JASON A KIRSCH 1.00 X 0 0 0 ANN MITCHELL 35.00 11.00 X X 208216 0 14219 PAUL S NICHOLSON 1.00 X X 0 0 0 MICHAEL G BANKS ESQ 1.00 X 0 0 0 RICHARD A BINDER MD 1.00 X 0 0 0 BRIAN A CARPENTER MD 1.00 X 0 0 0 LYA MALL KARM MD 1.00 X 0 0 0 DEBORA S MCGREGOR 1.00 X 0 0 0 BERYL L FEINBERG 1.00 X X 0 0 0 MARK K LI MD 1.00 X 0 0 0 BARRY R MEIL 1.00 X 0 0 0 SHEILA E BOLAND 1.00 X 0 0 0 STERLING KING JR DRP 1.00 X X 0 0 0 JOSE A QUIROS MD 1.00 X 0 0 0 STEVEN V ROBERTS 1.00 X 0 0 0 CATHERINE S LEGGETT 1.00 X 0 0 0 HON PAUL A MCGUCKIAN 1.00 X 0 0 0 WILLIAM M SCHLOSSENBERG 1.00 X 0 0 0 HONG QI 1.00 X 0 0 0 RONALD M WOLFSHEIMER 1.00 X X 0 0 0 DARREN M POPKIN 1.00 X 0 0 0 MONICA ESCALANTE 45.00 X 137493 0 5579 GEOFFREY COLEMAN 48.00 X 166163 0 8702 ROBERT WASHINGTON 42.00 X 139182 0 11587 JANET CAUFFIEL 42.00 X 128554 0 5436 779608 0 45523 5 0 1 0 PRO CARE PBM 3090 PREMIERE PKWY -SUITE 100 DULUTH GA 30097 PHARMACY 1172878 GLOBAL MEDICAL CARE 8332 BRISTOL COURT -SUITE 108 JESSUP MD 20794 DURABLE MED EQUIP 496121 MEDLINE INDUSTRIES PO BOX 382075 PITTSBURGH PA 15251 MEDICAL SUPPLIES 262168 FIRST CHOICE MEDICAL SUPPLY 127 INTERSTATE DR RICHLAND MS 39218 MEDICAL SUPPLIES 173717 4 791825 791825 PATIENT SERVICE REVENUE 624100 22144610 22144610 22144610 6975 6975 MISCELLANEOUS REVENUE 624100 9166 9166 9166 22952576 22144610 0 16141 700000 700000 540371 170146 303502 66723 13417995 12590323 827672 1258823 1153187 105636 1013295 925176 88119 27520 27520 49387 49387 495129 481026 14103 14700 2341 12359 587945 70391 517554 174808 174808 611688 203521 408167 418886 415670 3216 12609 12609 6779 6779 348485 81951 266534 308709 95342 213367 MEDICAL EQUIPMENT, SUPL 2259207 2259207 MISCELLANEOUS EXPENSE 129092 125182 3910 LAUNDRY AND LINEN SUPPL 50340 50340 22425768 19323803 3035242 66723 767 600 3321698 2468795 2807608 3237645 280311 246607 5724455 2813147 2830411 2911308 6000 874 925844 9241669 9796799 2217689 2056537 69664 143880 263690 2361569 2389891 X 6880100 7406908 6880100 7406908 9241669 9796799 526808 0 X 0 1 X 1 0 X 166309 368239 317078 1143592 791825 2787043 10628977 13140770 17038437 20961488 22144610 83914282 10795286 13509009 17355515 22105080 22936435 86701325 0 0 0 86701325 5627 1772 1945 5025 6975 21344 5627 1772 1945 5025 6975 21344 2841 9163 1856 2437 9166 25463 10803754 13519944 17359316 22112542 22952576 86748132 0.99950 0.99940 0.00020 0.00030 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3695745 3695745 3147870 326203 326792 105120 3695745 1216353 1931517 121488 121488 3147870 0 0 640826 640826 2373111 771036 1602075 860457 640705 219752 687570 448654 238916 1162491 952752 209739 2911308 INVESTMENT IN PALLIATIVE MEDICINE CONSULTANTS OF GREATER WASHINGTON, LLC -17 INTERCOMPANY INVESTMENT TRANSFER 500000 DUE FROM FOUNDATION 419047 DUE FROM PMC 6814 925844 DEFERRED RENT PAYABLE - LEASE 263690 263690 X DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE HOSPICE AND THE FOUNDATION ARE TAX-EXEMPT ENTITIES AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC). PALLIATIVE MEDICINE IS A LIMITED LIABILITY COMPANY WHOSE OPERATING RESULTS FLOW THROUGH TO THE HOSPICE, WHICH IS ITS SOLE CORPORATE MEMBER. NONE OF THESE ENTITIES ARE CLASSIFIED AS A PRIVATE FOUNDATION AS DEFINED BY THE INTERNAL REVENUE SERVICE. THE IRC PROVIDES FOR TAXATION OF UNRELATED BUSINESS INCOME UNDER CERTAIN CIRCUMSTANCES. THE HOSPICE AND ITS AFFILIATED ENTITIES HAVE NO SIGNIFICANT UNRELATED BUSINESS INCOME; HOWEVER, SUCH STATUS IS SUBJECT TO FINAL DETERMINATION UPON EXAMINATION OF THE RELATED INCOME TAX RETURNS BY THE APPROPRIATE TAXING AUTHORITIES. THE TAX RETURNS FOR THE FISCAL YEARS ENDED 2009 THROUGH 2011 ARE OPEN TO EXAMINATION BY FEDERAL AND STATE AUTHORITIES PART XII, LINE 4B - OTHER ADJUSTMENTS: INTERCOMPANY CHARGE 0 MONTGOMERY HOSPICE FOUNDATION INC 1355 PICCARD DRIVE ROCKVILLE MD 20850 521664426 501(C)(3) 700000 TO SUPPORT THE ORGANIZATION'S CHARITABLE ACTIVITIES 1 X X 0 0 0 0 0 0 0 0 0 ANN MITCHELL 191026 0 17190 0 0 0 6105 0 8114 0 222435 0 0 0 GEOFFREY COLEMAN 166163 0 0 0 0 0 0 0 8702 0 174865 0 0 0 ROBERT WASHINGTON 139182 0 0 0 0 0 3678 0 7909 0 150769 0 0 0 FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE PRESIDENT AND MEMBERS OF THE FINANCE COMMITTEE BEFORE FILING. THE CHAIRMAN GIVES A SUMMARY REPORT TO THE BOARD. A COPY OF THE FORM 990 IS PROVIDED TO THE GOVERNING BODY PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C ALL INDIVIDUALS, UPON APPOINTMENT TO THE BOARD OF DIRECTORS, ANY BOARD DESIGNATED COMMITTEE, OR MONTGOMERY HOSPICE STAFF OR VOLUNTEER POSITION, SHALL BE REQUIRED TO EXAMINE AND SIGN AN INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST. IN THE EVENT A CONFLICT OF INTEREST OR POTENTIAL CONFLICT ARISES, THE CONFLICT OF INTEREST STATEMENT MUST PROMPTLY BE UPDATED AND BROUGHT TO THE ATTENTION OF THE PRESIDENT/CEO AND/OR CHAIRMAN OF THE BOARD. IF THE MATTER CONCERNS A STAFF MEMBER OR VOLUNTEER, THE CHANGE SHOULD BE PRESENTED TO THE INDIVIDUAL'S SUPERVISOR. THE INDIVIDUAL BOARD MEMBERS, WHO HAVE A CONFLICT OF INTEREST WITH THEIR CURRENT BUSINESS RELATIONSHIP AND THE HOSPICE, WILL WITHDRAW THEMSELVES FROM BOARD DISCUSSIONS AND VOTING. FORM 990, PART VI, SECTION B, LINE 15A REVIEW FOR PRESIDENT (CEO) IS CONDUCTED ANNUALLY BY THE EXECUTIVE COMMITTEE MEMBERS. MEMBERS MAY INTERVIEW PRESIDENT'S COLLEAGUES CONCERNING THEIR INTERACTION AND RELATIONSHIP WITH PRESIDENT. OTHER ANALYSIS INCLUDE WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY AND APPROVAL BY THE EXECUTIVE COMMITTEE. 2012 WAS THE MOST RECENT YEAR IN WHICH THE COMPENSATION PROCESS WAS REVIEWED. KEY EMPLOYEES ARE GIVEN ANNUAL PERFORMANCE REVIEWS BY THEIR IMMEDIATE SUPERVISOR INCLUDING CEO. THE PERFORMANCE SUMMARY IS REVIEWED AND DISCUSSED WITH THE CEO. AN ANALYSIS OF COMPARABLE STAFF POSITIONS AND SIMILAR HOSPICE ORGANIZATIONS IS DONE BY HR DEPARTMENT. DATA FROM BENCHMARK REPORTS PROVIDED BY NHPCO AND MVI ARE ALSO USED IN THIS ANALYSIS. FORM 990, PART VI, SECTION C, LINE 19 FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AND ALSO SUMMARIZED ON THE ORGANIZATION'S WEBSITE. MONTGOMERY HOSPICE FOUNDATION INC 1355 PICCARD DRIVE 100 ROCKVILLE MD 20850 521664426 CHARITABLE FOUNDATION FOR THE BENEFIT OF THE HOSPICE MD 501(C)(3) LINE 11B, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MONTGOMERY HOSPICE FOUNDATION INC C 791825 CASH VALUE MONTGOMERY HOSPICE FOUNDATION INC N 90000 CASH VALUE MONTGOMERY HOSPICE FOUNDATION INC B 700000 CASH VALUE