2012-12-17T09:38:15-06:00 2012-04-30 410746749 CLIFTONLARSONALLEN LLP 114 E EVERETT DIXON IL 61021 990 2011-05-01 363164329 DEKALB COUNTY HOSPICE INC DEKA 8157563000 2727 SYCAMORE ROAD NO 1B DEKALB IL 601159204 LOREN FOELSKE 8157561521 2012-12-12 1 KELLY JACKSON HARDY P00747242 8152842285 2011 2016-02-24 21:20:13Z KEVIN P POORTEN 2727 SYCAMORE ROAD NO 1B DEKALB IL 601159204 1956452 0 X WWW.DEKALBCOUNTYHOSPICE.ORG X 1981 IL TO PROVIDE HOSPICE SERVICES TO TERMINALLY ILL INDIVIDUALS. 10 9 28 300 0 0 223270 201302 1480726 1739366 -66940 5554 6125 6406 1643181 1952628 0 0 0 0 1371906 1416047 0 0 3615 685778 670850 2057684 2086897 -414503 -134269 624699 970141 886642 676097 -261943 294044 X OUR MISSION IS TO ASSIST PEOPLE TO LIVE WITH DIGNITY AND HOPE IN WAYS THAT BEST MEET THEIR NEEDS WHILE COPING WITH END-OF-LIFE ISSUES AND TO SUPPORT GRIEVING FAMILY AND COMMUNITY MEMBERS. 0 0 2010003 1739366 ORGANIZATION PROVIDED HOSPICE SERVICES TO THE COMMUNITY. OVER 300 VOLUNTEERS PROVIDED 4,782 HOURS OF SUPPORTIVE SERVICES TO PATIENTS/FAMILIES, FUNDRAISING EFFORTS, OFFICE SUPPORT, BEREAVEMENT SERVICES, AND EQUIPMENT AND SUPPLY DELIVERY. THE TRANSITIONS PROGRAM PROVIDED EMOTIONAL SUPPORT AND CASE MANAGEMENT TO 33 TERMINALLY ILL INDIVIDUALS WITH A PROGNOSIS OF 1 YEAR OR LESS, AT NO COST TO THE CLIENT. VOLUNTEERS ARE A KEY COMPONENT TO THIS PROGRAM. OFFERED AT NO COST TO ATTENDEES, POWERFUL TOOLS FOR CAREGIVERS CLASSES ARE OFFERED 2 TIMES DURING THE YEAR, WITH 6 SESSIONS IN EACH CLASS TO PROVIDE EDUCATION AND SUPPORT TO CAREGIVERS LIVING IN THE COMMUNITY AT LARGE.MAILED AN AVERAGE OF 4,853 BEREAVEMENT CARE NEWSLETTERS 5 TIMES A YEAR. MAILED AN AVERAGE OF 285 SUPPORT MAILINGS MONTHLY TO THE NEWLY BEREAVED. MAILED 572 BOOKLETS OUT AT THE HOLIDAYS TO FAMILIES FACING FIRST HOLIDAY SEASON AFTER DEATH. 305 HOURS OF COMMUNITY CONTACT WAS PROVIDED IN THE FORM OF BEREAVEMENT GROUPS, BEREAVED PARENT CANDLE LIGHT SERVICE, MEMORIAL TEDDY BEAR WORKSHOPS, 1:1 GRIEF SUPPORT WITH COMMUNITY MEMBERS, AND CHURCH, CIVIC GROUP, NURSING HOME EDUCATION AND SUPPORT. 3.5 HOURS SPENT PROVIDING COMMUNITY EDUCATION ABOUT THE PROGRAM, SERVICES, AND GENERAL GRIEF. 2010003 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 5 0 1 28 1 0 0 0 0 0 0 0 0 0 0 X 10 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IL X LOREN FOELSKE - VP FINANCE KHS 8157561521 ONE KISH HOSPITAL DRIVE DEKALB IL 60115 X JANICE FRITSCH 1.00 X X 0 0 0 KURT SCHWEITZER 1.00 X X 0 0 0 KEVIN POORTEN 1.00 X 0 698961 102663 DR MICHAEL THORNTON 1.00 X 0 0 0 MARVIN BARNES 1.00 X X 0 0 0 MARY GAWRYS 1.00 X X 0 0 0 STACI HOSTE 1.00 X 0 0 0 KAREN MASON 1.00 X 0 0 0 JUDY BERGESON 1.00 X 0 0 0 MARK HILDE 1.00 X 0 0 0 ELISA RUBECK 1.00 X 0 0 0 RUTH WALKER 1.00 X 0 0 0 KAREN HAGEN 40.00 X 90827 0 21781 LOREN FOELSKE 1.00 X 0 316761 41819 90827 1015722 166263 0 0 1 0 HOSPICE PHARMACIA BOX 510818 PHILADELPHIA PA 19175 MEDICAL SERVICES 124560 KISHWAUKEE COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MEDICAL SERVICES 117323 BETHANY HEALTHCARE 3298 RESOURCE PARKWAY DEKALB IL 60115 MEDICAL SERVICES 106583 KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 MANAGEMENT SERVICES 103835 4 16847 7128 177327 4067 201302 NET PATIENT SERVICE RE 621610 1739366 1739366 1739366 5554 5554 895 85 810 810 9335 3739 5596 5596 1952628 1739366 0 11960 118915 118915 940660 940660 50321 50321 231736 231736 74415 74415 95322 95322 125 125 2400 2400 107242 36488 70754 8159 7468 691 333439 330515 2924 58588 58588 55253 55253 6087 6087 FLOWERS AND CONDOLENCES 2423 2423 MISCELLANEOUS EXPENSE 907 907 DUES AND LICENSES 675 675 EMPLOYEE RECOGNITION AN 230 230 2086897 2010003 73279 3615 75 75 203804 488456 284593 257618 8316 7439 35581 35581 0 0 127911 216553 624699 970141 256312 264372 630330 411725 886642 676097 X -376214 169720 114271 124324 -261943 294044 624699 970141 X -134269 690256 X X 0 1 1 X 0 X 314619 203848 343029 225030 201302 1287828 314619 203848 343029 225030 201302 1287828 171856 1115972 6078 3372 3270 2138 5554 20412 4177 3120 6691 3348 6406 23742 1331982 7851656 0.83780 0.82790 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 35581 35581 0 0 OTHER RECEIVABLES 103967 DUE FROM RELATED ENTITIES 219 INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION 112367 216553 DUE TO RELATED ENTITIES 411725 411725 1952628 2086897 -134269 690256 690256 555987 1956452 3824 3824 1952628 0 1952628 2090721 3824 3824 2086897 0 2086897 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION 12,212. OTHER -11,956. CAPITAL CONTRIBUTION RECEIVED FROM KISHHEALTH SYSTEM 690,000. TOTAL TO SCHEDULE D, PART XI, LINE 8: 690,256. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSES 3,824. PART XIII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSES 3,824. PART XI, LINE 10, EXCESS OR (DEFICIT) FOR THE YEAR PER FINANCIAL STATEMENTS: LINE 10 IDENTIFIES FINANCIAL STATEMENT INCOME AS EQUALING $555,987. FINANCIAL STATEMENT INCOME IS ACTUALLY $(134,269). THE DIFFERENCE IN THESE AMOUNTS IS REPORTED AS A CAPITAL CONTRIBUTION FROM KISHHEALTH SYSTEM IN THE AMOUNT OF $690,000. FOR FINANCIAL STATEMENT PURPOSES, THIS TRANSACTION WAS RECORDED VIA AN ENTRY TO EQUITY. THERE IS ALSO A NET ADJUSTMENT OF $256 INCLUDED IN EQUITY TO ACCOUNT FOR THE REMAINING CHANGE IN NET EQUITY. THIS ADJUSTMENT CONSISTS OF AN INCREASE IN DCH'S INTEREST IN THE INVESTMENT ASSETS OF KISHHEALTH FOUNDATION IN THE AMOUNT OF A $12,212 AND AN OTHER DECREASE IN THE AMOUNT OF $11,956. THESE ITEMS ARE INCLUDED IN THE RECONCILIATION AT PART XI AS ITS INCLUSION IS NECESSARY TO RECONCILE THE CHANGE IN THE EQUITY BALANCE, BUT ARE NOT A COMPONENT OF FINANCIAL STATEMENT INCOME. 1 X X X X 0 1 0 0 0 0 0 0 0 KEVIN POORTEN 0 515921 0 183040 0 0 0 79288 0 23375 0 801624 0 0 LOREN FOELSKE 0 249213 0 67548 0 0 0 19288 0 22531 0 358580 0 0 PART I, LINE 4B THE ORGANIZATION'S CEO PARTICIPATES IN A NONQUALIFIED DEFERRED COMPENSATION PLAN. CONTRIBUTIONS FOR CALENDAR YEAR 2011 WERE $60,000. SUPPLEMENTAL INFORMATION PART III PART I, LINE 3: THE ORGANIZATION RELIED ON A RELATED ORGANIZATION THAT USED ONE OR MORE METHODS DESCRIBED TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION. KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT COMPANY OF DCH 95322 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF DEKALB COUNTY HOSPICE. THE PURPOSE OF KHS IS TO PROVIDE MANAGEMENT AND SUPPORT SERVICES TO ITS RELATED ORGANIZATIONS, ALL OF WHICH PROVIDE HEALTHCARE SERVICES. FEES PAID TO KHS ARE IN EXCHANGE FOR THESE SERVICES, INCLUDING THE ORGANIZATIONS SHARE OF COMPENSATION OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES. 0 KISHWAUKEE COMMUNITY HOSPITAL COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER-SISTER AFFILIATE 117323 KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS AN AFFILIATE OF DEKALB COUNTY HOSPICE (SAME PARENT CORPORATION). KCH IS UTILIZED BY DEKALB COUNTY HOSPICE FOR MEDICAL TREATMENTS AND SUPPLIES AS WELL AS COLLECTION SERVICES. 0 KISHWAUKEE COMMUNITY HOSPITAL COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, BROTHER-SISTER AFFILIATE 53976 KISHWAUKEE COMMUNITY HOSPITAL (KCH) IS AN AFFILIATE OF DEKALB COUNTY HOSPICE (SAME PARENT CORPORATION). DEKALB COUNTY HOSPICE RENTS SPACE IN THE BUILDING OWNED BY KCH. 0 KISHHEALTH SYSTEM COMMON DIRECTORS/OFFICERS/KEY EMPLOYEES, KHS IS PARENT COMPANY OF DCH 690000 KISHHEALTH SYSTEM (KHS) IS THE PARENT ORGANIZATION OF DEKALB COUNTY HOSPICE. KHS TRANSFERRED FUNDS VIA AN CAPITAL CONTRIBUTION TO DCH DURING THE YEAR. 0 FORM 990, PART VI, SECTION A, LINE 2 KEVIN POORTEN AND LOREN FOELSKE ARE BOTH EMPLOYEES OF KISHEALTH SYSTEM, THE PARENT ORGANIZATION OF DEKALB COUNTY HOSPICE. MR. POORTEN IS PRESIDENT AND CEO OF KISHHEALTH SYSTEM AND SERVES AS AN EX-OFFICIO DIRECTOR FOR ALL ORGANIZATIONS RELATED TO KISHHEALTH SYSTEM. MR. FOELSKE SERVES AS THE VICE-PRESIDENT - FINANCE OF KISHHEALTH SYSTEM. FORM 990, PART VI, SECTION A, LINE 6 KISHHEALTH SYSTEM IS THE SOLE MEMBER OF DEKALB COUNTY HOSPICE. FORM 990, PART VI, SECTION A, LINE 7A AS THE SOLE MEMBER AND PARENT ORGANIZATION OF DEKALB COUNTY HOSPICE, KISHHEALTH SYSTEM HAS THE RIGHT TO ELECT CERTAIN MEMBERS OF THE HOSPICE GOVERNING BOARD. PER THE HOSPICE'S BYLAWS, THE VOTING TRUSTEES ARE ELECTED BY THE KHS BOARD AT EACH ANNUAL MEETING. FORM 990, PART VI, SECTION A, LINE 7B KISHHEALTH SYSTEM (KHS) SERVES AS THE SOLE MEMBER AND PARENT ORGANIZATION OF DEKALB COUNTY HOSPICE. THE BYLAWS OF THE HOSPICE STATE THAT THE HOSPICE BOARD MAY TAKE NO ACTION PERTAINING TO THE FOLLOWING WITHOUT APPROVAL OF THE KHS BOARD: A. APPROVING THE ANNUAL OPERATING AND CAPITAL BUDGETS FOR THE HOSPICE; B. ELECTING THE MEMBERS OF THE HOSPICE'S BOARD; C. APPROVING THE STRATEGIC PLAN FOR THE HOSPICE; D. APPROVING THE DISPOSITION OF ANY ASSETS OF THE HOSPICE OTHER THAN IN THE ORDINARY COURSE OF BUSINESS OF THE HOSPICE; E. APPROVING ANY CHANGE IN MEMBERSHIP OF THE HOSPICE; F. APPROVING, EVALUATING AND/OR REMOVING THE PRESIDENT AND CEO AND REVIEWING AND APPROVING THE EMPLOYMENT CONTRACT OF THE PRESIDENT AND CEO AND ESTABLISHING COMPENSATION FOR SUCH OFFICE; G. APPROVING THE ADOPTION OF AND AMENDMENTS TO THE ORGANIZATIONAL DOCUMENTS, INCLUDING THE ARTICLES OF INCORPORATION OR THE BYLAWS OF THE HOSPICE; H. APPROVING THE ADOPTION OF A PLAN OF MERGER OR ADOPTING A PLAN OF CONSOLIDATION WITH ANOTHER CORPORATION; I. EXERCISING ALL RIGHTS THAT THE HOSPICE HAS AS A SHAREHOLDER OR MEMBER OF A SUBSIDIARY ENTITY; J. AUTHORIZING THE SALE, LEASE, EXCHANGE, OR MORTGAGE OF ALL OR SUBSTANTIALLY ALL OF THE PROPERTY AND ASSETS OF THE HOSPICE; K. AUTHORIZING THE VOLUNTARY DISSOLUTION OF THE HOSPICE OR REVOKING PROCEEDINGS THEREOF; L. ADOPTING A PLAN FOR THE DISTRIBUTION OF THE ASSETS OF THE HOSPICE; M. APPROVING ANY AFFILIATIONS OF THE HOSPICE; N. SELECTING OF THE MEDICAL DIRECTOR OF THE HOSPICE; O. REQUIRING MINUTES OF MEETINGS, FINANCIAL RECORDS AND SUCH OTHER INFORMATION AS MAY BE NECESSARY TO PROPERTY EVALUATE THE PERFORMANCE OF THE HOSPICE; P. TRANSFERRING MONEY OR PROPERTY AMONG THE HOSPICE, KHS AND ONE OR MORE SUBSIDIARY CORPORATION; AND Q. INITIATING ACTION TO REMOVE OR REINSTATE A DIRECTOR IN ACCORDANCE WITH SECTION 4.14. SUBJECT TO THE AUTHORITY OF THE BOARD AS SET FORTH IN THIS ARTICLE IV, THE KHS BOARD MAY INITIATE AND APPROVE ANY OF THE FOREGOING ON BEHALF OF THE HOSPICE. FORM 990, PART VI, SECTION B, LINE 11 A DRAFT COPY OF FORM 990 IS PROVIDED TO THE GOVERNING BODY (BOARD OF DIRECTORS) AND THE GOVERANCE COMMITTEE FOR REVIEW BY THE RETURN PREPARER PRIOR TO FILING. THE ORGANIZATION'S CEO, CFO, AND OTHER MEMBERS OF THE ACCOUNTING DEPARTMENT ARE ALSO PROVIDED A COPY OF THE RETURN FOR THEIR REVIEW. THE CHAIR OF THE AUDIT COMMITTEE AND THE AUDIT COMMITTEE MEMBERS ARE ALSO PROVIDED DRAFT COPIES AND REVIEW. IF CHANGES ARE NECESSARY, THEY ARE REPORTED TO THE RETURN PREPARER AND INCORPORATED INTO THE FINAL RETURN. FORM 990, PART VI, SECTION B, LINE 12C CONFLICTS OF INTEREST ARE INVESTIGATED BY APPOINTED MEMBERS OF THE GOVERANCE COMMITTEE ON AN ONGOING BASIS. IF IT IS DETERMINED THAT AN INDIVIDUAL FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL INFORM THE INDIVIDUAL OF SUCH A BELIEF AND AFFORD HIM AN OPPORTUNITY TO EXPLAIN. AFTER SAID EXPLANATION, THE BOARD SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION AS DEEMED NECESSARY. THE CONFLICT OF INTEREST POLICY IS REVIEWED BY THE BOARD ANNUALLY AND UPDATED AS NEEDED. FORM 990, PART VI, SECTION B, LINE 15 THROUGH THE OVERSIGHT OF THE BOARD OF DIRECTORS EXECUTIVE COMPENSATION COMMITTEE, THE KISHHEALTH SYSTEM EXECUTIVE TOTAL COMPENSATION PROGRAM WILL BE COMPETITIVELY POSITIONED IN THE MARKET PLACE OF RELEVANT ORGANIZATIONS AND FALL WITHIN THE SAFE HARBOR GUIDELINES ESTABLISHED BY THE INTERMEDIATE SANCTIONS RULES. THE EXECUTIVE COMPENSATION COMMITTEE IS MADE UP OF THREE MEMBERS OF THE BOARD OF DIRECTORS WHO MEET THE BOARD APPROVED DEFINITION OF "INDEPENDENT DIRECTORS". ANNUALLY THE EXECUTIVE COMPENSATION COMMITTEE CONTRACTS WITH SULLIVAN, COTTER AND ASSOCIATES, AN INDEPENDENT HUMAN RESOURCES CONSULTING FIRM TO PROVIDE THE COMMITTEE ANALYSIS AND COMPARABILITY DATA. USING THE SUPPLIED DATA THE COMPENSATION COMMITTEE APPROVES EACH EXECUTIVE'S TOTAL CASH COMPENSATION AND PROVIDES CONTEMPORANEOUS SUBSTANTIATION OF THE DELIBERATION AND DECISION. TOTAL CASH COMPENSATION IS DEFINED AS THE SUM OF BASE SALARIES PLUS INCENTIVE AWARDS. BASED ON THE COMPARABILITY DATA AND THE PERFORMANCE OF EACH EXECUTIVE IN MEETING GOALS AND STRATEGIC OBJECTIVES, THE EXECUTIVE COMPENSATION COMMITTEE APPROVES INCREASES AND INCENTIVE AWARDS FOR EACH EXECUTIVE WITHIN THE GUIDELINES ESTABLISHED. THE EXECUTIVE COMPENSATION COMMITTEE REPORTS ON ALL COMPENSATION MATTERS TO THE FULL BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST IN WRITING TO ADMINISTRATION. DESCRIPTION OF HOURS FOR RELATED ORGANIZATIONS FORM 990, PART VII, COLUMN (B) AVERAGE HOURS PER WEEK FOR THE INDIVIDUALS IDENTIFIED AS OFFICER'S ARE ESTIMATES OF THE INDIVIDUALS TOTAL TIME PER WEEK UTILIZED FOR WORK RELATED TO DEKALB COUNTY HOSPICE. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: CHANGE IN INTEREST IN NET ASSETS OF KISHHEALTH FOUNDATION 12,212. OTHER -11,956. CAPITAL CONTRIBUTION RECEIVED FROM KISHHEALTH SYSTEM 690,000. TOTAL TO FORM 990, PART XI, LINE 5: 690,256. RESPONSIBILITY FOR OVERSIGHT OF FINANCIAL STATEMENTS FORM 990, PART XI, LINE 2C NO CHANGES IN THIS PROCESS WERE MADE DURING THE TAX YEAR. THE ORGANIZATION MAINTAINS AN INDEPENDENT AUDIT COMMITTEE WHICH IS RESPONSIBLE FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS. THIS COMMITTEE IS ALSO RESPONSIBLE FOR THE SELECTION OF THE INDEPENDENT AUDITOR. MEMBERS OF THE AUDIT COMMITTEE ARE ALSO MEMBERS OF THE KISHHEALTH SYSTEM BOARD OF DIRECTORS. KISHEALTH SYSTEM IS THE PARENT CORPORATION OF DEKALB COUNTY HOSPICE, INC. KISHHEALTH SYSTEM ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649080 PARENT CORPORATION OF 501(C)(3) HEALTH SYSTEM IL 501(C)(3) 11B N/A 0 KISHHEALTH FOUNDATION ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363649077 SUPPORT OF CHARITABLE HEALTH ORGANIZATIONS IL 501(C)(3) 7 N/A 0 KISHWAUKEE COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 237087041 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 VALLEY WEST COMMUNITY HOSPITAL ONE KISH HOSPITAL DRIVE DEKALB IL 60115 364244337 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 COMMUNITY CARES CLINIC INC 3100 SYCAMORE ROAD DEKALB IL 60115 800424001 HEALTHCARE SERVICES, PRIMARILY ACUTE CARE IL 501(C)(3) 3 N/A 0 KISHWAUKEE PHYSICIANS GROUP INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 651293967 HEALTHCARE SERVICES, PRIMARILY FAMILY PRACTICE IL 501(C)(3) 3 N/A 0 HEALTH PROGRESS INC ONE KISH HOSPITAL DRIVE DEKALB IL 60115 363824138 INVESTMENT IN HEALTHCARE RELATED SMALL BUSINESSES IL N/A C 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0