2012-11-12T20:07:16-06:00 2011-12-31 410746749 CLIFTONLARSONALLEN LLP 4250 N FAIRFAX DRIVE SUITE 1020 ARLINGTON VA 22203 990 2011-01-01 521114719 MONTGOMERY HOSPICE INC MONT 3019214400 1355 PICCARD DRIVE NO 100 ROCKVILLE MD 20850 ANN MITCHELL 3019214400 2012-11-05 1 KAREN GRIES P00078514 5712279500 2011 2016-02-24 21:20:13Z ANN MITCHELL 1355 PICCARD DRIVE NO 100 ROCKVILLE MD 20850 22112542 0 X WWW.MONTGOMERYHOSPICE.ORG X 1979 MD TO GENTLE THE JOURNEY THROUGH SERIOUS ILLNESS AND LOSS WITH SKILL AND COMPASSION. 23 22 291 287 0 0 317088 1143592 17038437 20961488 1945 5025 2356 2437 17359826 22112542 0 0 0 0 11349391 13762497 0 0 69568 5100106 6811584 16449497 20574081 910329 1538461 7079103 9241669 1827464 2361569 5251639 6880100 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 17015032 20963925 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 2011, MONTGOMERY HOSPICE SERVED MORE THAN 2,000 PATIENTS AND THEIR FAMILIES. OUR INPATIENT UNIT, CASEY HOUSE, IS THE ONLY ALL-HOSPICE ACUTE CARE FACILITY IN MONTGOMERY COUNTY. IN 2011, MORE THAN 550 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 9,000 INDIVIDUALS, AND END-OF-LIFE CARE EDUCATION TO MORE THAN 7,000 CLINICIANS AND PEOPLE IN THE LAY COMMUNITY. 17015032 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 1 16 0 291 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 MARTHA FLORY 3019214400 1355 PICCARD DRIVE NO 100 ROCKVILLE MD 20850 PAUL E ALPUCHE JR 1.00 X 0 0 0 ARNOLD J KOHN 1.00 X 0 0 0 JASON A KIRSCH 1.00 X 0 0 0 ANN MITCHELL 53.00 X X 201183 0 13460 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 ALEXANDER A ZUKIWSKI M 1.00 X 0 0 0 JOSEPH KAPLAN MD 1.00 X 0 0 0 BERYL L FEINBERG 1.00 X X 0 0 0 DAVID J KRESSLER PHD 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 ALICIA B JIMENEZ 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 SEN LENOARD H TEITELBAUM 1.00 X 0 0 0 RONALD M WOLFSHEIMER 1.00 X X 0 0 0 SEN ROGER MANNO 1.00 X 0 0 0 GEOFFREY COLEMAN 47.00 X 169621 0 9019 ROBERT WASHINGTON 45.00 X 117836 0 10839 JANET CAUFFIEL 45.00 X 129948 0 5104 MONICA ESCALANTE 45.00 X 135849 0 5028 754437 0 43450 5 0 1 0 CENTER FOR NON-PROFIT ADVANCEMENT 1666 K ST NW 440 WASHINGTON DC 20006 EMPLOYEE HEALTH INS 948835 ROBERT HOME MEDICAL 20465 SENECA MEADOW PKWY GERMANTOWN MD 20876 DURABLE MED EQUIP 885231 PRO CARE PBM 3090 PREMIERE PKWY STE 100 DULUTH GA 30097 PHARMACY 771813 FIRST CHOICE MEDICAL SUPPLY 127 INTERSTATE DR RICHLAND MS 39218 MEDICAL SUPPLIES 340425 SUNCOAST SOLUTIONS 5771 ROOSEVELT BLVD CLEARWATER FL 33760 COMPUTER APP SUPPORT 134847 7 1143592 1143592 PATIENT SERVICE REVENU 624100 20961488 20961488 20961488 5025 5025 MEALS - NON-PATIENT 624100 2333 2333 OTHER MISCELLANEOUS 624100 104 104 2437 22112542 20963925 0 5025 393283 232301 96589 64393 11467247 10215232 1252015 185100 142742 37183 5175 860664 808761 51903 856203 762844 93359 284835 284835 46086 46086 560577 553345 7232 142604 120007 22597 510400 510400 142991 142991 573843 217286 356557 326099 322519 3580 71476 49215 22261 1481 1481 218848 218848 313891 313891 MEDICAL EQUIPMENT, SUPL 2048190 2048190 TRANSFER INTERCOMPANY D 1449234 1449234 LAUNDRY AND LINEN SUPPL 58761 58761 MISCELLANEOUS EXPENSE 29723 29096 627 32545 5499 27046 20574081 17015032 3489481 69568 767 767 515233 3321698 3586475 2807608 150184 280311 5268907 2438496 2825258 2830411 1186 874 7079103 9241669 1638033 2217689 189431 143880 1827464 2361569 X 5251639 6880100 5251639 6880100 7079103 9241669 X 1538461 90000 X X 0 1 1 X 0 X 1123939 166309 368239 317078 1143592 3119157 10036727 10628977 13140770 17038437 20961488 71806399 11160666 10795286 13509009 17355515 22105080 74925556 0 0 0 74925556 9289 5627 1772 1945 5025 23658 9289 5627 1772 1945 5025 23658 1753 2841 9163 1856 2437 18050 11171708 10803754 13519944 17359316 22112542 74967264 0.99940 0.99900 0.00030 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3147870 326203 326792 105120 3695745 1216353 1931517 121488 121488 3147870 0.11890 0.83660 0.04450 0 0 593216 593216 2357518 711934 1645584 756346 504853 251493 551530 373179 178351 1010297 848530 161767 2830411 DEFERRED RENT PAYABLE - LEASE 143880 143880 22112542 20574081 1538461 90000 90000 1628461 22112542 0 22112542 0 22112542 20484081 0 20484081 90000 90000 20574081 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPICE IS A TAX-EXEMPT ENTITY AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE HOSPICE HAS 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 2008 THROUGH 2010 ARE OPEN TO EXAMINATION BY FEDERAL AND STATE AUTHORITIES. PART XI, LINE 8 - OTHER ADJUSTMENTS: INTERCOMPANY CHARGE 90,000. PART XIII, LINE 4B - OTHER ADJUSTMENTS: INTERCOMPANY CHARGE 90,000. X X X 0 0 0 0 0 0 0 0 0 ANN MITCHELL 184783 0 16400 0 0 0 5839 0 7621 0 214643 0 0 0 GEOFFREY COLEMAN 163221 0 6400 0 0 0 0 0 9019 0 178640 0 0 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE CONSISTS FO THE BOARD CHAIRPOERSON, VICE CHAIRPERSON, SECRETARY, TREASURER, IMMEDIATE PAST CHAIRPERSON, MONTGOMERY HOSPICE FOUNDATION BOARD CHAIRPERSON AND THE PRESIDENT/CEO, AND SUCH OTHER BOARD MEMBERS AS THE BOARD MAY DEEM APPROPRIATE. THE COMMITTEE SHALL HAVE THE AUTHORITY TO CONDUCT ESSENTIAL HOSPICE BUSINESS BETWEEN BOARD MEETINGS, WHEN DELAY IN ACTION WOULD BE DETRIMENTAL TO THE HOSPICE. THE EXECUTIVE COMMITTEE MAY NOT ACT IN THE FOLLOWING: 1. AMENDING THE ARTICLES OF INCORPORATION OR THE BYLAWS; 2. APPROVING A PLAN OF MERGER OR CONSOLIDATION; 3. FILLING VACANCIES ON THE HOSPICE BOARD OF THE FOUNDATION BOARD OR REMOVING DIRECTORS OR OFFICERS OF EACH BOARD FROM OFFICE; 4. APPOINTING OR REMOVING MEMBERS OF THE EXECUTIVE COMMITTEE; 5. APPOINTING OR REMOVING ANY OFFICER, THE MEDICAL DIRECTOR OR THE PRESIDENT/CEO, WITHOUT THE APPROVAL OF A MAJORITY OF THE BOARD; 6. APPROVING SALE, LEASE, EXCHANGE, MORTGAGE, PLEDGE, OR OTHER DISPOSITION OF ALL, OR SUBSTANTIALLY ALL, THE PROPERTY OR ASSETS OF THE HOSPICE; OR 7. APPROVING VOLUNTARY DISSOLUTION OF THE HOSPICE OR FOUNDATION, OR REVOCATION OF VOLUNTARY DISSOLUTION PROCEEDINGS. 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. 2011 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: INTERCOMPANY CHARGE 90,000. TOTAL TO FORM 990, PART XI, LINE 5: 90,000. FORM 990, PART XII, LINE 2C: THE PROCESS FOR SELECTION AND OVERSIGHT OF THE INDEPENDENT ACCOUNTANT HAS NOT CHANGED FROM PRIOR YEAR. 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 MONTGOMERY HOSPICE FOUNDATION INC C 1143592 CASH VALUE