2012-05-11T11:28:10-05:00 2011-06-30 KPMG LLP TWO CENTRAL PARK PLAZA SUITE 1501 OMAHA NE 68102 990 2010-07-01 470733773 HOSPICE OF SOUTHWEST IOWA HOSP 4023434323 12809 WEST DODGE ROAD OMAHA NE 68154 SCOTT M WOOTEN 4023434323 2012-05-11 1 LORRAINE A EGGER 4023481450 2010 2016-02-24 21:20:13Z SCOTT M WOOTEN 12809 WEST DODGE ROAD OMAHA NE 68154 1601896 0 X HOSPICEOFSOUTHWESTIOWA.ORG X 1990 NE A COMMUNITY WHERE ALL INDIVIDUALS AND FAMILIES HAVE ACCESS TO IMPECCABLE END OF LIFE CARE. 9 8 0 31 0 0 135077 77831 1176118 1521137 322 653 216 2275 1311733 1601896 385 486 0 0 0 0 0 0 0 1273971 1483561 1274356 1484047 37377 117849 1673987 1221066 209016 81663 1464971 1139403 CHERISHING LIFE'S JOURNEY THROUGH AN EXTRAORDINARY COMMITMENT TO COMPASSION, COMFORT AND HOLISTIC CARE. 0 0 1262981 486 1523412 HOSPICE OF SOUTHWEST IOWA IS A MEDICARE CERTIFIED HOSPICE PROGRAM THAT SERVES PATIENTS WHO HAVE BEEN DIAGNOSED WITH A LIFE LIMITING CONDITION. THE PROGRAM SERVES PATIENTS THAT RESIDE IN SEVEN SOUTHWEST IOWA COUNTIES. THE MAIN OFFICE IS LOCATED IN COUNCIL BLUFFS WITH A MULTI-SITE LOCATION IN CORNING, IOWA. HOSPICE OF SOUTHWEST IOWA PLANS TO BUILD AN INPATIENT HOSPICE FACILITY UPON THE COMPLETION OF A COMMUNITY CAPITAL CAMPAIGN. 1262981 1 1 0 1 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 X 8 0 1 0 0 0 0 0 0 0 0 0 0 0 X 9 8 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 X SCOTT M WOOTEN ALEGENT HEALTH 4023434323 12809 WEST DODGE ROAD OMAHA NE 68154 X MARIE KNEDLER 1.00 X X 0 0 0 HELEN BLEICHER 1.00 X 0 0 0 EMMET TINLEY 1.00 X X 0 0 0 SUSAN TINLEY 1.00 X 0 0 0 MARVIN ARNPRIESTER 1.00 X X 0 0 0 KATHRYNE CUTLER 1.00 X 0 0 0 JAMES SUMMERFELT 1.00 X 0 0 0 MIKE ADAMS 1.00 X 0 0 0 MARIE FERNANDEZ 1.00 X 0 0 0 0 0 0 0 0 0 0 ALEGENT HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 MANAGEMENT SERVICES 853063 1 77831 77831 NET PATIENT SERVICE RE 621500 1521137 1521137 1521137 653 653 OTHER OPERATING REVENU 900099 2275 2275 2275 1601896 1523412 0 653 486 486 853063 639797 213266 7800 7800 251 251 15120 15120 6701 6701 166753 166753 27228 27228 27407 27407 3538 3538 1690 1690 3608 3608 PURCHASED SERVICES 359278 359278 BAD DEBTS 5905 5905 MEMBERSHIPS & DUES 3931 3931 OTHER MISC EXPENSES 1288 1288 TAXES & LICENSES 0 1484047 1262981 221066 0 116150 42724 590917 104925 130593 235847 692008 4438 686327 687570 150000 150000 1673987 1221066 17150 22628 191866 59035 209016 81663 X 797408 881285 667563 258118 1464971 1139403 1673987 1221066 X 117849 -443417 X 0 1 1 X 0 X 500125 1182338 100318 135077 77831 1995689 466819 1205838 1176118 1521137 4369912 500125 1649157 1306156 1311195 1598968 6365601 31000 31000 0 31000 31000 6334601 5 17988 5749 322 653 24717 5 17988 5749 322 653 24717 280 216 2275 2771 500130 1667425 1311905 1311733 1601896 6393089 0.99090 0.98840 0.00390 0.00500 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 1 251 0 0 0 251 0 667563 33972 443417 258118 590336 110765 33538 667563 673447 75193 158304 590336 1.00000 0 0 206000 206000 11096 4438 6658 474912 474912 687570 GOODWILL 150000 150000 DUE TO MEMBER 59035 59035 1601896 1484047 117849 -443417 -443417 -325568 1563785 -33972 -33972 1597757 4139 4139 1601896 1479908 0 1479908 4139 4139 1484047 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: ENDOWMENT FUNDS ARE INTENDED TO HELP WITH THE ORGANIZATIONAL OPERATIONS OF HOSPICE OF SOUTHWEST IOWA. PART XI, LINE 8 - OTHER ADJUSTMENTS: WRITE-OFF OF PLEDGE RECEIVABLE -443,417. PART X, LINE 2 - HOSPICE OF SOUTHWEST IOWA HAS RECOGNIZED AS A NOT-FOR-PROFIT ORGANIZATION BY THE INTERNAL REVENUE SERVICE (IRS) 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. HOSPICE OF SOUTHWEST IOWA 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 JUDGEMENT OCCURS. DURING 2011 AND 2010, MANAGEMENT DETERMINED THAT THERE ARE NO INCOME TAX POSITIONS REQUIRING RECOGNITION IN THE FINANCIAL STATEMENTS. PART XII, LINE 2D - RESTRICTED CONTRIBUTIONS RECLASS - ($33,972). PART XII, LINE 4B AND PART XIII, LINE 4B - HOME HEALTH REVENUE - ($4,139). MARIE KNEDLER-BOARD MEMBER PEOPLE'S BANK-DIRECTOR 42724 BANKING SERVICES 0 FORM 990, PART VI, SECTION A, LINE 2 EMMET TINLEY AND SUSAN TINLEY - FAMILY RELATIONSHIP. MARVIN ARNPRIESTER, KATHRYNE CUTLER, SUSAN TINLEY, JAMES SUMMERFELT AND EMMET TINLEY - BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 HOSPICE OF SOUTHWEST IOWA ENTERED INTO A COORDINATION OF SERVICES AGREEMENT WITH ALEGENT HEALTH FOR ALEGENT HEALTH TO PERFORM AND MANAGE FINANCIAL SERVICES FOR A MONTHLY FEE. SERVICES INCLUDE BUT ARE NOT LIMITED TO FINANCIAL REPORTING, BUDGETING, BILLING AND COLLECTION, 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. IN ADDITION, HOSPICE OF SOUTHWEST IOWA LEASES ALL EMPLOYEES FROM ALEGENT HEALTH. ALEGENT HEALTH IS THE PARENT OF ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM, ONE OF HOSPICE OF SOUTHWEST IOWA CORPORATE MEMBERS. FORM 990, PART VI, SECTION A, LINE 6 THE CORPORATE MEMBERS OF HOSPICE OF SOUTHWEST IOWA ARE ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION OF POTTAWATTAMIE COUNTY, IOWA. FORM 990, PART VI, SECTION A, LINE 7A ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION POTTAWATTAMIE COUNTY, IOWA SHALL APPOINT ONE HALF OF THE VOTING MEMBERS OF THE CORPORATION'S BOARD OF DIRECTORS, SUBJECT TO THE RATIFICATION OF EACH MEMBER'S APPOINTMENTS BY THE OTHER MEMBER. IF A CORPORATE MEMBER DOES NOT RATIFY THE APPOINTMENT OF ONE OR MORE OF THE DIRECTORS APPOINTED BY THE OTHER CORPORATE MEMBER, THEN THE PROCESS SET FORTH ABOVE WILL BE REPEATED UNTIL SUCH TIME AS ALL OF THE DIRECTOR POSITIONS ARE FILLED. FORM 990, PART VI, SECTION A, LINE 7B THE BUSINESS AFFAIRS OF HOSPICE OF SOUTHWEST IOWA SHALL BE MANAGED BY OR UNDER THE DIRECTION OF THE BOARD OF DIRECTORS EXCEPT THAT THE FOLLOWING ACTIONS SHALL BE EFFECTIVE ONLY IF APPROVED BY THE BOARD OF DIRECTORS OF THE CORPORATION AND BY BOTH ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION OF POTTAWATTAMIE COUNTY, IOWA: 1. ADOPTION OR AMENDMENT OF THE UNIFIED PHILOSOPHY AND MISSION. 2. THE SALE, LEASE, TRANSFER, ENCUMBRANCE OR DISPOSITION OF THE TANGIBLE PROPERTY OR INVESTMENTS OF THE CORPORATION HAVING A FAIR MARKET VALUE IN ANY INDIVIDUAL TRANSACTION IN EXCESS OF ONE MILLION DOLLARS ($1,000,000) OR SUCH GREATER AMOUNT AS MAY BE DETERMINED FROM TIME TO TIME BY ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION OF POTTAWATTAMIE COUNTY, IOWA. 3. INCURRENCE, ASSUMPTION OR GUARANTY BY THE CORPORATION IN ANY INDIVIDUAL TRANSACTION OF LONG-TERM INDEBTEDNESS, INCLUDING CAPITAL LEASES OUTSTANDING FOR MORE THAN 365 DAYS, IN EXCESS OF THE GREATER OF FIVE HUNDRED THOUSAND DOLLARS ($500,000), OR SUCH GREATER AMOUNT AS MAY BE DETERMINED FROM TIME TO TIME BY ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION OF POTTAWATTAMIE COUNTY, IOWA. 4. MERGER, DISSOLUTION, CONSOLIDATION OR SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION, EXCEPT FOR A MERGER IN WHICH HOSPICE OF SOUTHWEST IOWA IS THE SURVIVING ENTITY, AND THE TOTAL BOOK VALUE OF THE ASSETS OF THE MERGING ENTITY DOES NOT EXCEED TWENTY-FIVE PERCENT OF THE TOTAL BOOK VALUE OF THE ASSETS OF THE CORPORATION, OR SUCH GREATER VALUE AS MAY BE DETERMINED FROM TIME TO TIME BY ALEGENT HEALTH-BERGAN MERCY HEALTH SYSTEM AND VISITING NURSE ASSOCIATION OF POTTAWATTAMIE COUNTY, IOWA. FORM 990, PART VI, SECTION B, LINE 11 HOSPICE OF SOUTHWEST IOWA AND ALEGENT HEALTH HAVE A COORDINATION OF SERVICE AGREEMENT IN WHICH ALEGENT PROVIDES THE ACCOUNTING AND FINANCE FUNCTIONS FOR HOSPICE OF SOUTHWEST IOWA FOR A MONTHLY FEE. THE TAX DEPARTMENT OF ALEGENT HEALTH PREPARES THE FORM 990 FOR HOSPICE OF SOUTHWEST IOWA. FOLLOWING THE PREPARATION OF FORM 990 BY ALEGENT HEALTH INTERNAL TAX STAFF, THE RETURN IS REVIEWED BY THE ALEGENT HEALTH TAX DIRECTOR, CHIEF FINANCIAL OFFICER, EXTERNAL TAX ADVISOR, AND HOSPICE OF SOUTHWEST IOWA'S EXECUTIVE DIRECTOR. 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 - HOSPICE OF SOUTHWEST IOWA HAS ADOPTED THE CONFLICT INVESTIGATION PROCESS OF ALEGENT 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 HOSPICE OF SOUTHWEST IOWA HAS ADOPTED THE CONFLICT OF INTEREST POLICY OF ALEGENT HEALTH, WHICH IS AVAILABLE TO THE PUBLIC AT WWW.ALEGENT.COM. HOSPICE OF SOUTHWEST IOWA 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: WRITE-OFF OF PLEDGE RECEIVABLE -443,417. TOTAL TO FORM 990, PART XI, LINE 5: -443,417. FORM 990, PART I, LINE 5 AND PART V, LINE 2A: HOSPICE OF SOUTHWEST IOWA DOES NOT HAVE ANY EMPLOYEES. INDIVIDUALS PROVIDING SERVICES TO PATIENTS OF HOSPICE OF SOUTHWEST IOWA ARE LEASED FROM ALEGENT HEALTH. FORM 990, PART V, LINE 1A: AS PART OF THE COORDINATION OF SERVICES AGREEMENT WITH ALEGENT HEALTH, ALEGENT HEALTH PERFORMS THE ACCOUNTS PAYABLE FUNCTION FOR HOSPICE OF SOUTHWEST IOWA. HOSPICE OF SOUTHWEST IOWA REIMBURSES ALEGENT HEALTH FOR VENDOR PAYMENTS, THEREFORE NO FORM 1099S ARE ISSUED BY HOSPICE OF SOUTHWEST IOWA. ALEGENT HEALTH ISSUES THE FORM 1099S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. ANY 1099S ISSUED BY ALEGENT HEALTH ON BEHALF OF HOSPICE OF SOUTHWEST IOWA ARE REPORTED.