2012-11-12T12:32:25-06:00 2011-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2011-01-01 330261016 Providence TrinityCare Hospice Foundation PROV 3102573535 2601 Airport Drive No 230 Torrance CA 90505 Barbara Roberts 3102573535 2012-11-12 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2011 2016-02-24 21:20:13Z Barbara Roberts 2601 Airport Drive No 230 Torrance CA 90505 6401684 0 X www.trinitycarehospice.org X 1987 CA Support TrinityCare Hospice in Torrance, CA. 11 10 0 280 0 0 4031082 1576678 0 0 133010 195333 48170 28018 4212262 1800029 686957 1115347 0 0 391937 437190 0 0 357558 116682 147146 1195576 1699683 3016686 100346 5922575 5852714 415371 342203 5507204 5510511 X As People of Providence, we reveal God's love for all, especially the poor and vulnerable, through our compassionate service.Support TrinityCare Hospice in Torrance, CA. 0 0 445329 445329 0 Trinity Kids Care Program Started in 2001,TrinityKids Care remains the only dedicated pediatric hospice program in Los Angeles and Orange counties. The program helps children with life-limiting conditions live as normal a life as possible, for as long as possible, in their own homes. The program gives these families access to a continuum of total care with the primary goal of keeping the children in their homes with their families. Funding is used to support the medical doctor, nurses, social workers, home health aides, chaplains and staff. Funding is also used for pharmaceuticals, medical equipment and other supplies that are necessary but whose costs are in excess of the insurance reimbursement. In 2011, TrinityKids Care served 156 children and their families. Through a pilot program of the State of California, we began providing in-home palliative care services to a limited number of children with specific life-limiting conditions who are on Medi-Cal and live in Orange County. Beginning in October 2011, the State's pilot program allowed us to include children in Los Angeles County. 334991 334991 0 The Gathering Place Located in Redondo Beach, The Gathering Place is a center for loss and life transitions, offering counseling to those in the community who have suffered the death of a loved one from any cause. It is staffed by licensed professionals, graduate-level mental health interns, and trained volunteers. The Gathering Place serves all ages - children through adults - whether or not their loved one was on our Providence TrinityCare hospice service. During 2011, 2,804 children, teens and adults were assisted through the grief process by The Gathering Place, funded through Providence TrinityCare Hospice Foundation. 143073 143073 0 Patient Care Assistance (Charity Care) Charity Care funding is used to cover the costs of hospice care for those patients who have a financial need and require our services. Providence TrinityCare Hospice has a long-standing devotion to improve the quality of life to all those needing end-of-life and/or palliative care, regardless of their financial standing or economic condition. No patient is ever turned away regardless of their ability to pay for our services. Often times, families find themselves unable to afford the care that their loved one needs. This can be due to their already substantial medical bills, lack of insurance, or because they have reached their individual lifetime cap for their insurance. In times like these, we offer charity care, which covers the expenses of our patient's hospice care for the duration of their time with our service. 32481 32481 0 Transitional Care Center Hospice Rooms 29808 29808 0 Necessities of Life Some of our patients find their financial resources exhausted by a long illness. Necessities of Life assists in paying for the basic essentials for the patient and the family. These may include rent, phone or utility bills, food, crisis care, respite care medical supplies, medications and medical co-payments. 64489 64489 0 Palliative CareThis medical specialty provides expertise in treating the pain and other symptoms of serious and life-threatening illness, and in supporting the patient's family. The goals of care include assuring comfort and helping the patient enjoy life as much as possible. This service receives limited reimbursement through health insurers, and is mostly funded through donations from community members. 65176 65176 0 Other - The Camden GroupProvidence TrinityCare Hospice and Foundation engaged in a strategic planning process with its Boards, staff and volunteers. The purpose of this was to envision the future for our organizations. This process included in depth research to understand the needs of the communities we serve, the current market and potential unmet future needs. The outcome of this process is a multi-year plan that will guide the organizations' focus to provide the highest quality hospice and palliative care to adults and children in their own homes; and to educate clinicians both inside and outside of Providence TrinityCare Hospice to provide this much needed care. 191954 191954 1115347 1 1 0 0 0 0 0 0 0 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 X 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 X 11 10 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 CA X Karl E Fritschel CPA 4255253339 1801 Lind Ave SW 9016 Renton WA 980579016 X Scott Sharpe 5.00 X X 0 0 0 Bruce Brusavich Thru 911 1.00 X 0 0 0 Kitty Edler Thru 911 1.00 X 0 0 0 Althea Halchuck Thru 911 1.00 X 0 0 0 Gary S Kuwahara CPA 1.00 X 0 0 0 Noreen Miller Thru 911 1.00 X 0 0 0 Patty Ochi Thru 911 1.00 X 0 0 0 Jim Sala 1.00 X 0 0 0 Neil Siegel Thru 911 1.00 X 0 0 0 Tom Sullivan 1.00 X 0 0 0 Mari Tokashiki Thru 911 1.00 X 0 0 0 Terri Warren 55.00 X 0 186701 24599 Ned Mansour 2.00 X X 0 0 0 James A Zapp 1.00 X X 0 0 0 John Kirk 2.00 X X 0 0 0 Michael Clark 1.00 X 0 0 0 Bunni Dybnis 1.00 X 0 0 0 Marcia Potter 1.00 X 0 0 0 Barbara Roberts 50.00 X 0 138794 13559 0 325495 38158 0 0 1 0 0 2190 189302 561076 33418 790692 45705 1576678 119305 119305 4622662 4546634 76028 76028 76028 83039 189302 55021 28018 28018 1800029 0 0 223351 1100442 1100442 14905 14905 145922 58369 87553 209901 83960 125941 55716 22287 33429 25651 10260 15391 110 110 23259 23259 88087 11450 76637 25282 6675 18607 9564 9564 Dues & Subscriptions 844 844 1699683 1115347 226778 357558 1410872 1210706 69358 62707 17209 17865 496 784 10510 10510 0 0 4182096 4366684 242544 193968 5922575 5852714 9502 17999 405869 324204 415371 342203 X 2551734 2612951 2955470 2897560 5507204 5510511 5922575 5852714 X 100346 -97039 X X 0 1 1 X 1 1 X 1269342 1202308 1290151 4031082 1576678 9369561 1269342 1202308 1290151 4031082 1576678 9369561 2810245 6559316 138758 63134 32130 32440 119305 385767 19371 1963 23079 48170 28018 120601 9875929 0.66420 0.63980 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1243229 85543 1328772 1098431 144798 1243229 849767 248664 1098431 1288493 -438726 849767 1.00000 0.00000 0.00000 0 0 10510 10510 0 0 Due to Affiliates 264255 Obligations under Split Interest Agreements 59949 324204 1800029 1699683 100346 -97039 -97039 3307 1679730 -97039 -97039 1776769 23259 1 23260 1800029 1676423 0 1676423 23259 1 23260 1699683 Description of Intended Use of Endowment Funds: Part V, Line 4: The Endowment funds are Board Designated and are quasi endowments in nature. They can be used for any purpose the Board designates within the charitable purposes of the organization. Description of Uncertain Tax Positions Under FIN 48: Part X: The Health System recognizes the effect of income tax positions only if those positions are more likely than not of being sustained. Recognized income tax positions are measured at the largest amount that is greater than 50% likely of being realized. Changes in recognition or measurement are reflected in the period in which the change in judgment occurs. Part XII, Line 4b - Other Adjustments: Rounding 1. Part XIII, Line 4b - Other Adjustments: Rounding 1. Sunday By The Sea 188845 117264 71581 44990 For Our Children 72038 72038 7946 1 11458 11458 2085 272341 189302 83039 55021 55021 28018 1 Providence TrinityCare Hospice 2601 Airport Dr Ste 230 Torrance CA 90505 953264139 501(C)(3) 1100442 Cost Support various Charitable programs 1 0 Necessities of Life, 29 14905 Cost Payment of expenses on behalf of needy families served by the Hospice. Expenses covered include rent, utilities, groceries, funeral expenses, among others. Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The grant funds are recorded as a separate restricted fund and each month amount is transferred for the grant purpose expenses. This way the use of grant fund is monitored at the end of each month. The grant money is distributed based on the total expenses incurred on each specific program. The accountant runs the expense report each month for each program from the database and distributes grant money to those programs. These program expenses are limited by budget prepared at the beginning of the year. 0 0 0 0 0 0 0 0 0 Terri Warren 0 167816 0 17529 0 1356 0 10529 0 14070 0 211300 0 0 Barbara Roberts 0 120159 0 18635 0 0 0 7128 0 6431 0 152353 0 0 Supplemental Information Part III FORM 990, SCHEDULE J, PART II - EXECUTIVE PERFORMANCE AWARDS PROGRAM The Providence Executive Performance Awards Program provides a lump sum award annually as a percent of the executive's base pay. Percent opportunities are aligned with our total compensation philosophy as outlined in Part VI, Section B, Line 15 (Process for determining compensation of top management, officers & key employees). The performance award is based on the level of accomplishment of annual system objectives and personal objectives. In 2011, 50 percent of the participant awards were based on pre-determined organizational goals consistent with Providence's five strategic priorities of: mission driven, financially responsible, people centered, service oriented and quality focused. In 2011 the percent allocation for each of these strategic priorities was: Mission driven 10% Financially responsible 10% People centered 10% Service oriented 10% Quality focused 10%. X 1 35435 Market Value X 1 10270 Market Value 0 0 1 0 Method for Determining Number of Contributors: Part I, Column (b): The amounts shown on Part I, Col. B reflect the number of donations received of the specific type of item. Form 990, Part VI, Section A, line 4 Bylaws were revised creating one Board for Providence TrinityCare Hospice and Providence TrinityCare Hospice Foundation. Form 990, Part VI, Section A, line 6 Providence TrinityCare Hospice is the sole Corporate Member. Form 990, Part VI, Section A, line 7a The powers of the Corporate Member include the provision to approve the number of Trustees if less than 7 or greater than 20, appoint Board of Trustees of the Foundation, and to remove such Trustees at any time with or without cause. Form 990, Part VI, Section A, line 7b The following powers are reserved exclusively to the Corporate Member: A) To adopt and amend the Articles of Incorporation and the By laws of the Foundation after consultation with the Foundation Board of Trustees. B) To approve the merger, consolidation, or affiliation of the Foundation with another corporation, organization or program, or the dissolution of the Foundation. C) To approve any strategic plan of the Foundation. D) To approve the annual fundraising plan including special events, annual, capital and planned giving activities. E) To approve the acceptance of any gift that carries conditions or limitations or any gift restricted to services, programs or facilities not currently offered or approved to be offered by the Corporate Member's Board of Directors. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by external tax advisors. The Foundation Director and signing Board Officer will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c All employees and Trustees are required to review and sign the Providence Health & Services Conflict of Interest Disclosure statement. This statement indicates that they have received a copy of Providence's policies on confidentiality and conflict of interest. This form is re-reviewed and re-signed each year and the forms are kept on file in the Foundation's offices. Questions about conflict of interest are first brought to the Corporate Member of the Board of Trustees. Further questions would be brought to the Hospice Operating Board of Directors for resolution. Form 990, Part VI, Section B, line 15 It is Providence's intention to make financial information accessible and transparent. Although the filing of Form 990 provides insight into how Providence achieves its Mission, delivers its programs and stewards its finances, deciphering the information directly from Form 990 can be challenging. The following paragraphs provide further information about the process we use to determine compensation for top management, officers and key employees. Providence has a single fiduciary Board, with responsibility for financial oversight associated with fulfillment of the Providence Mission, developing system policies, protecting the assets entrusted to the organization and overseeing the strategic and operational affairs of Providence's legal entities. Providence also maintains a network of community ministry boards with responsibility for quality of care oversight, community relations, advocacy and community needs assessments. Providence has a consistent compensation philosophy for all of its employees, including our senior executives. Salaries for senior executives are determined by the Providence Board's Human Resources Committee and approved by the full Board of Directors, none of whom is a Providence employee. The Board retains an independent consultant each year to review salaries of those in the most significant leadership roles in the organization. Part of the consultant's role is to review an extensive array of compensation surveys of large, not-for-profit health care systems in the United States. Providence is one of the larger health systems in the country, and as such, the Board benchmarks executive compensation against other large, not-for-profit health systems whose revenue is similar to that of Providence. Base salaries for Providence executives are set at the median level of the market, as identified by the independent consultant and reviewed with the Human Resources Committee. Performance incentives allow executives to earn additional compensation if they achieve specific organizational and individual goals for furthering Providence operating principles - advancing the Providence Mission and core values, meeting benchmarks for charity care, achieving quality targets, delivering top-rated customer satisfaction, meeting employee satisfaction goals and reaching financial performance objectives. The Board of Directors conducts a thorough process to ensure performance incentives are aligned with appropriate practices for not-for-profit health care systems. The Board's process for executive compensation fully complies with IRS standards and mirrors the best practices recommended in the "Report to Congress and the Nonprofit Sector on Governance, Transparency, and Accountability" submitted to the Senate Finance Committee by the Panel on the Nonprofit Sector. Based upon the above principles, the Executive Director is reviewed annually by the PHS - So. California HR Department. Form 990, Part VI, Section C, line 19 Public disclosure of governing documents, conflict of interest policy and 990 filings are made available to the public upon written request. The consolidated financial statements are available on our public Internet site www2.providence.org. All governing policies including the conflict of interest policy, as well as 990 filings are available to employees on the Intranet site. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -97,039. AUDIT & COMPLIANCE FORM 990, PART XII, LINE 2C The Providence Health & Services Audit and Compliance Committee assists the Board of Directors with the oversight of the integrity of the financial statements and reporting, the audit process and the internal financial controls and policies; compliance with ethical, legal and regulatory standards and requirements; the independence, qualifications and performance of the internal and external auditors; and informs the Board of Directors of critical risk areas and recommended mitigation. VOLUNTEERS FORM 990, PART I, LINE 6 The volunteers for Providence TrinityCare Hospice Foundation provide an array of services, involved in all aspects of planning and executing our special events, as well as assisting in day-to-day office projects. These services include: paper product preparation and coordination; mailing coordination; event registration; event set-up; event break-down and cleaning; auction item procurement and preparation; auction coordination and execution at special events; filing and information packet assembling. EMPLOYEE COMPENSATION FORM 990, PART I, LINE 5 & PART V, LINE 2A The employees working at the Foundation are paid by Providence Health System - Southern California - EIN# 51-0216589. Therefore, no W-2s are issued by the reporting organization. Providence Health & Services - Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 510216586 Healthcare System WA 501( c)(3) Line 3 Providence Health & Services 0 Providence Health & Services - Oregon 1801 Lind Avenue SW 9016 Renton WA 980579016 510216587 Healthcare System OR 501( c)(3) Line 3 Providence Health & Services 0 Providence Health System - So California 1801 Lind Avenue SW 9016 Renton WA 980579016 510216589 Healthcare System CA 501( c)(3) Line 3 Providence Health & Services 0 Everett Transitional Care Services PO Box 1067 Everett WA 982061067 943264605 Transitional Care WA 501( c)(3) Line 9 N/A 0 Providence Oregon Management Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 930813977 Shell Corporation OR 501( c)(3) Line 1 PH & S - Oregon 0 Providence Plan Partners 3601 SW Murray Blvd 10 Beaverton OR 97005 911861964 Healthcare Services OR 501( c)(4) N/A PH & S - Oregon 0 Providence Health Plan 3601 SW Murray Blvd 10 Beaverton OR 97005 930863097 Health Service Contractor OR 501( c)(4) N/A Providence Plan Partners 0 Providence Health Assurance 3601 SW Murray Blvd 10 Beaverton OR 97005 550828701 Medicaid Healthcare Provider OR 501( c)(4) N/A Providence Health Plan 0 Providence Medical Institute 4101 Torrance Blvd Torrance CA 90503 330283773 Healthcare CA 501( c)(3) Line 11/Type I PHS - 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