2011-05-13T09:43:06-05:00 2010-06-30 KPMG LLP TWO CENTRAL PARK PLAZA SUITE 1501 OMAHA NE 68102 990 2009-07-01 470733773 HOSPICE OF SOUTHWEST IOWA HOSP 4023434323 12809 WEST DODGE ROAD OMAHA NE 68154 SCOTT M WOOTEN 4023434323 2011-05-13 1 Angela Lea 4023481450 2009 2016-02-24 21:20:13Z SCOTT M WOOTEN 12809 WEST DODGE ROAD OMAHA NE 68154 1311733 0 X N/A X 1990 NE A community where all individuals and families have access to impeccable end of life care. 10 9 0 62 0 0 100318 135077 1205838 1176118 5749 322 216 1311905 1311733 349 385 0 0 0 0 1378802 1273971 1379151 1274356 -67246 37377 1511285 1673987 83691 209016 1427594 1464971 Cherishing life's journey through an extraordinary commitment to compassion, comfort and holistic care. 0 0 1044410 385 1176334 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. 1044410 1 1 0 1 0 0 0 0 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 1 9 0 1 0 0 0 0 0 0 0 0 0 0 10 9 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 LAWRENCE J BECKMAN 1.00 X 0 0 0 MARIE KNEDLER 1.00 X X 0 0 0 Helen BLEICHER 1.00 X 0 0 0 RONALD D JOHNSON 1.00 X 0 0 0 EMMET TINLEY 1.00 X X 0 0 0 SUSAN T TINLEY 1.00 X 0 0 0 MARVIN D ARNPRIESTER 1.00 X X 0 0 0 KATHRYNE A CUTLER 1.00 X 0 0 0 LISA GRONSTAL 1.00 X 0 0 0 JAMES SUMMERFELT 1.00 X 0 0 0 0 0 0 0 0 0 0 ALEGENT HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 Management Services 718757 1 135077 135077 NET PATIENT SERVICE RE 621500 1176118 1176118 1176118 322 322 OTHER OPERATING REVENU 900099 216 216 216 1311733 1176334 0 322 385 385 718757 539068 179689 13700 13700 270 270 56140 19583 36557 5165 5165 141679 141679 18301 18301 54535 54535 4244 4244 1690 1690 36777 36777 Purchased Services 215208 215208 BAD DEBTS 4671 4671 MEMBERSHIPS & DUES 2382 2382 Other Misc Expenses 277 277 Taxes & Licenses 175 175 1274356 1044410 229946 0 46110 116150 528652 590917 132045 130593 689075 2748 654478 686327 150000 150000 1511285 1673987 32884 17150 50807 191866 83691 209016 X 837258 797408 590336 667563 1427594 1464971 1511285 1673987 X 0 1 1 X 0 X 500125 1182338 100318 135077 1917858 466819 1205838 1176118 2848775 500125 1649157 1306156 1311195 4766633 31000 31000 0 31000 31000 4735633 5 17988 5749 322 24064 5 17988 5749 322 24064 280 216 496 500130 1667425 1311905 1311733 4791193 0.98840 0.98420 0.00500 0.00680 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 0 1 270 0 0 0 270 0 590336 110765 33538 667563 673447 75193 158304 590336 1.00000 0 0 206000 206000 11096 2748 8348 471979 471979 686327 GOODWILL 150000 150000 DUE TO MEMBER 191866 191866 1311733 1274356 37377 -110765 -110765 -73388 1200968 -110765 -110765 1311733 0 1311733 1274356 0 1274356 0 1274356 Part V, Line 4: Description of Intended Use of Endowment Funds: ENDOWMENT FUNDS ARE INTENDED TO HELP WITH THE ORGANIZATIONAL OPERATIONS OF HOSPICE OF SOUTHWEST IOWA. PART X - Hospice of Southwest Iowa HAs ADOPTED FASB INTERPRETATION NO. 48, ACCOUNTING FOR UNCERTAINTY, INCLUDED IN FASB ASC SUBTOPIC 740-10, INCOME TAXES - OVERALL, HOSPICE OF SOUTHWEST IOWA 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 JUDGEMENT OCCURS. DURING 2010 AND 2009, MANAGEMENT DETERMINED THAT THERE ARE NO INCOME TAX POSITIONS REQUIRING RECOGNITION IN THE CONSOLIDATED FINANCIAL STATEMENTS. PART XII, LINE 2D - RESTRICTED CONTRIBUTIONS RECLASS - ($110,765). MARIE KNEDLER-BOARD MEMBER PEOPLE'S BANK-DIRECTOR 116946 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 of interest policy and conflict investigation process of Alegent Health. Annual completion of the disclosure statement is required By the Board of DIRECTORS. Stated disclosures are investigated by the Alegent Health Compliance Officer and reported to the Conflicts of Interest Committee. The Conflicts of Interest Committee reviews the investigation and makes recommendations to the Governance Committee. The Governance Committee makes the final determination of whether or not there is a disqualifying event and communicates it to the HOSPICE OF SOUTHWEST IOWA Board OF DIRECTORS. At any time a Board Member may declare a conflict of interest and recuse his/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. 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. HOWEVER, PER THE INSTRUCTIONS, THOSE 1099S ISSUED BY ALEGENT HEALTH ON BEHALF OF HOSPICE OF SOUTHWEST IOWA ARE REPORTED.