2012-05-11T11:28:10-05:00 2011-06-30 KPMG LLP TWO CENTRAL PARK PLAZA SUITE 1501 OMAHA NE 681021626 990 2010-07-01 364003095 HARBOR HOUSE HARB 4023434323 12809 W 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 68142 2200266 0 X WWW.HOSPICEHOUSEOMAHA.ORG X 1994 NE TO PROVIDE CARE IN A HOMELIKE ENVIRONMENT TO THE TERMINALLY ILL. 23 23 0 328 0 0 316819 399337 1580464 1688198 4958 2186 27340 110545 1929581 2200266 52372 16960 0 0 0 0 0 0 0 2337914 2178554 2390286 2195514 -460705 4752 3328616 3491053 34693 32378 3293923 3458675 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 2066177 16960 1688198 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 461 RESIDENTS IN FISCAL 2011. IN ADDITION TO RESIDENTIAL LIVING SPACE, THE BUILDING ALSO INCLUDES CLASSROOMS, STORAGE, SHOWER FACILITIES FOR FAMILIES AND GUESTS, AND A RESOURCE LIBRARY. 2066177 1 1 0 0 0 0 0 0 1 1 0 0 0 0 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 X 4 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 STEPHEN LEMON MD 1.00 X 0 0 0 SUNNY LUNDGREN 1.00 X 0 0 0 SUZY SHRIER 1.00 X 0 0 0 DAVID SILVERBERG MD 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 80093 0 10607 80093 0 10607 0 0 0 1 ALEGENT HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 MANAGEMENT SERVICES 1729777 1 399337 399337 NET DAILY RESIDENT SVC 621500 1688198 1688198 1688198 2186 2186 OTHER OPERATING REVENU 900099 110545 110545 110545 2200266 1688198 0 112731 16960 16960 1729777 1614801 114976 4871 4871 9490 9490 197988 197988 33535 33535 2302 2302 146581 146581 22011 22011 PURCHASED SERVICES 31221 31221 MEMBERSHIP & DUES 600 600 TAXES/LICENSES 178 178 2195514 2066177 129337 0 250 82827 241842 183288 513645 324437 27639 28707 3373517 1688178 1831920 1685339 660960 1120082 52360 66373 3328616 3491053 34693 32378 34693 32378 X 3272923 3425330 6000 18345 15000 15000 3293923 3458675 3328616 3491053 X 4752 160000 X 0 1 1 X 0 X 715180 291786 358244 316819 399337 2081366 1464598 1717485 1773674 1607804 1798743 8362304 2179778 2009271 2131918 1924623 2198080 10443670 413237 31250 10000 5000 459487 0 413237 31250 10000 5000 459487 9984183 56095 66010 27115 4958 2186 156364 56095 66010 27115 4958 2186 156364 2235873 2075281 2159033 1929581 2200266 10600034 0.94190 0.93390 0.01480 0.01780 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 21000 12345 33345 26507 5507 21000 58080 14420 45993 26507 0.45000 0.55000 0 0 320000 320000 2301107 1117498 1183609 737961 557086 180875 14449 13594 855 1685339 2200266 2195514 4752 160000 160000 164752 2155117 -16960 -16960 2172077 28189 28189 2200266 2162710 -15844 -15844 2178554 16960 16960 2195514 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: CONTRIBUTED CAPITAL 160,000. PART X, LINE 2 - HARBOR 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 2011 AND 2010, MANAGEMENT DETERMINED THAT THERE ARE NO INCOME TAX POSITIONS REQUIRING RECOGNITION IN THE FINANCIAL STATEMENTS. PART XII, LINE 2D - CHARITY CARE - ($16,960). PART XII, LINE 4B - MALPRACTICE INSURANCE - $15,000, MISCELLANEOUS EXPENSE - $844 AND RESTRICTED CONTRIBUTIONS - $12,345. PART XIII, LINE 2D - MALPRACTICE INSURANCE - ($15,000) & MISCELLANEOUS EXPENSE - ($844). PART XIII, LINE 4B - CHARITY CARE - $16,960. 1 CHARITY CARE 30 16960 BOOK REDUCE 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 HEALTH, WHO ACTS AS A MANAGEMENT COMPANY THROUGH A COORDINATION OF SERVICES AGREEMENT. THE AMOUNT PAID TO GARY GEORGE WAS $80,093, 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 AND DIANE RANDOLPH - BUSINESS RELATIONSHIP. THERESA FRANCO AND ROSEMARY LEBEDA - BUSINESS RELATIONSHIP. STEPHAN LEMON AND STEVE GOESER - BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 HARBOR HOUSE 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 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 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 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 HEALTH PREPARES THE FORM 990 FOR HARBOR HOUSE. 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 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 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 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: CONTRIBUTED CAPITAL 160,000. TOTAL TO FORM 990, PART XI, LINE 5: 160,000. 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 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 HARBOR HOUSE. HARBOR HOUSE REIMBURSES ALEGENT HEALTH FOR VENDOR PAYMENTS, THEREFORE NO FORM 1099S ARE ISSUED BY HARBOR HOUSE. ALEGENT HEALTH ISSUES THE FORM 1099 AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS.