2011-05-13T09:43:06-05:00 2010-06-30 KPMG LLP TWO CENTRAL PARK PLAZA SUITE 1501 OMAHA NE 681021626 990 2009-07-01 364003095 HARBOR HOUSE HARB 4023434323 12809 W 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 68142 1929581 0 X N/A X 1994 NE To provide care in a homelike environment to the terminally ill. 23 23 0 454 0 0 388244 316819 1772013 1580464 27115 4958 1661 27340 2189033 1929581 82764 52372 0 0 0 0 2332933 2337914 2415697 2390286 -226664 -460705 3799191 3328616 39056 34693 3760135 3293923 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 2251663 52372 1580464 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 481 RESIDENTS IN FISCAL 2010. IN ADDITION TO RESIDENTIAL LIVING SPACE, THE BUILDING ALSO INCLUDES CLASSROOMS, STORAGE, SHOWER FACILITIES FOR FAMILIES AND GUESTS, AND A RESOURCE LIBRARY. 2251663 1 1 0 0 0 0 0 0 1 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 1 2 0 1 0 0 0 0 0 0 0 0 0 0 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 A 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 J 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 SALLY KAMPFE 1.00 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 1.00 X 0 0 0 DIANE RANDOLPH 1.00 X 0 0 0 CINDY ALLOWAY 1.00 X 0 0 0 MARY LEE FITZSIMMONS 1.00 X 0 0 0 GARY GEORGE 40.00 X 78916 0 10574 78916 0 10574 0 0 0 1 ALEGENT HEALTH 12809 WEST DODGE ROAD OMAHA NE 68154 MANAGEMENT SERVICES 1829600 ALL MIDLANDS HEALTH SERVICES 8610 West Dodge Road OMAHA NE 68114 STAFFING AGENCY 135963 2 316819 316819 NET DAILY RESIDENT SVC 621500 1580464 1580464 1580464 4958 4958 OTHER OPERATING REVENU 900099 27340 27340 27340 1929581 1580464 0 32298 52372 52372 1829600 1717737 111863 15000 15000 11760 11760 2292 2292 217071 217071 37588 37588 516 516 490 490 147343 147343 29169 29169 PURCHASED SERVICES 43623 43623 MISCELLANEOUS 2704 2704 MEMBERSHIP & DUES 650 650 TAXES/LICENSES 108 108 2390286 2251663 138623 0 251 250 237815 241842 1400 500228 513645 32037 27639 3373517 1541597 1960155 1831920 1067305 660960 0 52360 3799191 3328616 39056 34693 39056 34693 X 3733628 3272923 11507 6000 15000 15000 3760135 3293923 3799191 3328616 X 0 1 1 X 0 X 263149 715180 291786 388244 316819 1975178 1324452 1464598 1717485 1773674 1607804 7888013 1587601 2179778 2009271 2161918 1924623 9863191 30000 413237 31250 10000 484487 0 30000 413237 31250 10000 484487 9378704 24796 56095 66010 27115 4958 178974 24796 56095 66010 27115 4958 178974 1612397 2235873 2075281 2189033 1929581 10042165 0.93390 0.92970 0.01780 0.01830 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 26507 5507 21000 58080 14420 45993 26507 0.71430 0.28570 0 0 320000 320000 2301108 1014715 1286393 14449 13206 1243 737960 513676 224284 1831920 1929581 2390286 -460705 -3874 -3874 -464579 1847564 0 1847564 82017 82017 1929581 2312143 -78143 -78143 2390286 0 2390286 Part V, Line 4: Description of Intended Use of Endowment Funds: ENDOWMENT FUNDS ARE INTENDED TO HELP WITH THE ORGANIZATIONAL OPERATIONS OF HARBOR HOUSE. PART X, LINE 2 - HARBOR HOUSE ADOPTED FASB INTERPRETATION NO. 48, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES, INCLUDED IN FASB ASC SUBTOPIC 740-10, INCOME TAXES - OVERALL, HARBOR HOUSE 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 XI, LINE 8 - RESTRICTED CONTRIBUTIONS RECLASS - ($3,874). PART XII, LINE 4B AND PART XIII, LINE 2D - CHARITY CARE RELCASS ($52,372) & MALPRACTICE INSURANCE ($25,771). PART XII, LINE 4B - RESTRICTED CONTRIBUTIONS RECLASS - $3,874. 1 CHARITY CARE 48 52372 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 THROUGH THE COORDINATION OF SERVICES AGREEMENT. HOWEVER, COMPENSATION IS NOT REPORTED ON SCHEDULE J BECAUSE IT IS BELOW THE REPORTING THRESHOLD. Form 990, Part VI, Section A, line 2 NEIL FORTKAMP and SUSAN KAMBHU - FAMILY RELATIONSHIP. STEPHEN 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 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 HARBOR HOUSE 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 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. 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. HOWEVER, PER THE INSTRUCTIONS THOSE 1099S ISSUED BY ALEGENT HEALTH ON BEHALF OF HARBOR HOUSE ARE REPORTED.