2023-11-09T08:51:16-06:00 2022-12-31 410746749 CLIFTONLARSONALLEN LLP 220 S 6TH STREET SUITE 300 MINNEAPOLIS MN 55402 990 2022-01-01 464564958 AUGUSTANA MOUNT OLIVET HOSPICE CARE LLC AUGU 9528555000 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 STACY LYSEN PRESIDENT/CEO 9528555000 2023-11-07 1 STACY LYSEN 999009999 1 MATTHEW WOCKEN P01598291 6123764500 2023-11-03 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z GRACE HOSPICE STACY LYSEN 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 17062858 0 X WWW.GRACEHOSPICECARING.ORG X LLC 2014 MN PROVIDE HOSPICE SERVICES TO THE ELDERLY. 6 6 144 43 0 0 1150574 290210 12455312 15841374 12873 -29074 0 0 13618759 16102510 600000 500000 0 0 6858818 8283247 0 0 69174 5669528 7287750 13128346 16070997 490413 31513 4903582 4719491 1565675 1310861 3337907 3408630 X OUR MISSION IS TO SERVE GOD BY RECOGNIZING THAT EVERY PERSON DESERVES TO LIVE OUT HIS OR HER LIFE WITH RESPECT AND DIGNITY, FREE OF PAIN, AND IN AN ENVIRONMENT THAT PROMOTES QUALITY OF LIFE. 0 0 14184955 500000 15841374 AUGUSTANA MOUNT OLIVET HOSPICE, LLC ("THE LLC") IS A JOINT VENTURE BETWEEN AUGUSTANA CARE (EIN: 41-1728753) AND MOUNT OLIVET CAREVIEW HOME (EIN: 41-0802697). AUGUSTANA CARE AND MOUNT OLIVET CAREVIEW HOME ARE THE ONLY MEMBERS OF THE LLC. BOTH MEMBERS ARE MINNESOTA NONPROFIT CORPORATIONS AND TAX EXEMPT PUBLIC CHARITIES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AUGUSTANA CARE IS A PUBLIC CHARITY UNDER SECTIONS 509(A)(1) AND 170(B)(1)(A)(VI). MOUNT OLIVET CAREVIEW HOME IS A PUBLIC CHARITY UNDER SECTION 509 (A)(2).HOSPICE CARE:THE LLC PROVIDES END-OF-LIFE CARE TO PATIENTS, WHEREVER THEY LIVE, THAT HAVE BEEN CERTIFIED AS BEING TERMINALLY ILL WITH LESS THAN SIX MONTHS OF LIFE. THE PURPOSES OF THE LLC INCLUDE:(A) TO PROVIDE END-OF-LIFE SERVICES THAT SUPPORTS EACH INDIVIDUAL'S PHYSICAL, SPIRITUAL, CULTURAL AND EMOTIONAL NEEDS TO ENHANCE THEIR QUALITY OF LIFE;(B) TO SUPPORT AND HELP PATIENTS AND FAMILIES THROUGH THEIR END OF LIFE JOURNEY UTILIZING A TEAM APPROACH OF: MEDICAL DIRECTOR, NURSES, SOCIAL WORKERS, CHAPLAINS, HOME HEALTH AIDES, MUSIC THERAPISTS, MASSAGE THERAPISTS, GRIEF COUNSELORS, MEDICATIONS RELATED TO TERMINAL DIAGNOSIS, DURABLE MEDICAL EQUIPMENT, 24/7 ON-CALL SUPPORT AND VOLUNTEERS;(C) TO PROVIDE 13 MONTHS OF BEREAVEMENT SERVICES;(D) TO ACCEPT ALL WHO ARE ELIGIBLE TO HOSPICE SERVICES REGARDLESS OF ABILITY TO PAY;(E) A FAITH-BASED ORGANIZATION BRINGING HOSPICE CARE TO PATIENTS AND FAMILIES THAT BEST FITS THEIR NEEDS; AND(F) OTHER PROGRAMS AS MAY FROM TIME TO TIME THAT IS APPROPRIATE TO THE ACCOMPLISHMENT OF THIS COMPANY'S CHARITABLE PURPOSE. 14184955 1 1 0 0 0 0 0 0 0 0 1 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 13 0 144 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 MN X KATHY YOUNGQUIST - CASSIA SERVICES 9528555000 7171 OHMS LN EDINA MN 55439 BERNIE CABLE-PROKOP CHAIR 0.25 X X 0 0 0 TIMOTHY HOKANSON VICE CHAIR 0.25 X X 0 0 0 KATHY KOPP SECRETARY 0.25 X X 0 0 0 MATTHEW KERN TREASURER 0.25 X X 0 0 0 EILEEN CARTWRIGHT DIRECTOR 0.25 X 0 0 0 DAVID LOSE DIRECTOR 0.25 X 0 0 0 SARAH VAN WINKLE PRESIDENT/CEO 40.00 X 180236 0 22014 STACY LYSEN DIRECTOR OF NURSING 40.00 X 139136 0 32175 JOLENE BAKER RN CLINICAL SUPERVISOR 40.90 X 108200 0 11735 SARA NELSON RN CLINICAL SUPERVISOR 40.00 X 100758 0 11077 KATHLEEN SNELL RN CLINICAL SUPERVISOR 40.20 X 104414 0 24216 KELSEY TIETJE DIRECTOR OF MARKETING 40.00 X 105911 0 14527 738655 0 115744 6 0 1 0 HOSPICE PHARMACY SOLUTIONS PO BOX 161583 ATLANTA GA 30321 PHARMACY BENEFIT MANAGER 447023 ENCLARA PHARMACIA PO BOX 745791 ATLANTA GA 30374 PHARMACY BENEFIT MANAGER 443458 CASSIA SERVICES 7171 OHMS LANE EDINA MN 55439 MANAGEMENT SERVICES 317799 INTERNAL MEDICINE & GERIATRIC ASSOCIATIO 21490 FAIRVIEW ST EXCELSIOR MN 55331 MEDICAL DIRECTOR 192500 4 48564 241646 290210 HOSPICE CARE 624100 15841374 15841374 15841374 43030 43030 888244 960348 -72104 -72104 -72104 16102510 15841374 0 -29074 X 500000 500000 202250 202250 6684614 6108777 575837 143138 126966 16172 751877 666929 84948 501368 444723 56645 317799 317799 22940 22940 5279456 5279456 2438 2438 296110 23826 203110 69174 129812 129812 53113 53113 164369 146503 17866 11446 6422 5024 22664 22664 36066 36066 NURSING EQUIPMENT 694530 694530 NURSING SUPPLIES 157319 157319 BAD DEBT EXPENSE 34512 34512 MISCELLANEOUS EXPENSES 27871 6721 21150 37305 119 37186 16070997 14184955 1816868 69174 87268 1904081 61320 2966 1204443 1594254 67140 15518 501377 256087 58451 245290 3424960 957382 4903582 4719491 1385011 1111885 124046 180664 74930 1565675 1310861 X 3337907 3408630 3337907 3408630 4903582 4719491 31513 39210 0 X X 0 1 X 1 0 X 95381 16345 649399 1150574 290210 2201909 10661798 3109115 12411028 12455312 15841374 54478627 10757179 3125460 13060427 13605886 16131584 56680536 0 0 0 56680536 63 60926 96592 43030 200611 63 60926 96592 43030 200611 14816 14816 10771995 3125523 13121353 13702478 16174614 56895963 0.99620 0.99590 0.00350 0.00320 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - FUNDRAISING EVENT REVENUES - 2018 AMOUNT: $ 14,816. FORM 990, SCHEDULE A, COLUMN D: COLUMN D, 2019, IS FOR A SHORT PERIOD THAT BEGAN ON OCTOBER 1, 2019 AND ENDED ON DECEMBER 31, 2019. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 129510 129510 0 197864 126577 71287 174003 174003 245290 DUE TO AFFILIATES 74930 74930 X 16141720 39210 39210 16102510 0 16102510 15570997 0 15570997 500000 500000 16070997 PART X, LINE 2: AS A LIMITED LIABILITY COMPANY, THE COMPANY IS NOT SUBJECT TO FEDERAL OR STATE INCOME TAXES AND ITS INCOME IS ALLOCATED TO AND REPORTED IN THE TAX RETURNS OF ITS MEMBERS, WHICH ARE BOTH NON-PROFIT CORPORATIONS. THE COMPANY FOLLOWS THE ACCOUNTING STANDARD FOR CONTINGENCIES IN EVALUATING THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES RECOGNIZED IN AN ENTITY'S FINANCIAL STATEMENTS. THE STANDARD PRESCRIBES RECOGNITION AND MEASUREMENT OF TAX PROVISIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN THAT ARE NOT CERTAIN TO BE REALIZED. THE MEMBERS' INCOME TAX RETURNS ARE SUBJECT TO REVIEW AND EXAMINATION BY FEDERAL, STATE, AND LOCAL AUTHORITIES. PART XII, LINE 4B - OTHER ADJUSTMENTS: EQUITY TRANSFER 500,000. 1 AUGUSTANA CARE 7171 OHMS LANE EDINA MN 55439 411728753 501(C)(3) 0 250000 N/A N/A GENERAL SUPPORT MOUNT OLIVET CAREVIEW HOME 7171 OHMS LANE EDINA MN 55439 410802697 501(C)(3) 0 250000 N/A N/A GENERAL SUPPORT 2 0 PART I, LINE 2: THE TRANSFERS WERE MADE TO THE MEMBERS, WHO ARE BOTH 501 (C)(3) ORGANIZATIONS, AND WERE USED FOR GENERAL OPERATING SUPPORT. NO FOLLOW-UP OR OVERSIGHT WAS CONDUCTED REGARDING THE SPECIFIC USE OF TRANSFERRED FUNDS. X X X X X 0 0 0 0 0 0 0 0 0 SARAH VAN WINKLE PRESIDENT/CEO 179017 0 0 0 1219 0 5964 0 16050 0 202250 0 0 0 STACY LYSEN DIRECTOR OF NURSING 129136 0 10000 0 0 0 5962 0 26213 0 171311 0 0 0 FORM 990, PART VI, SECTION A, LINE 3 CASSIA SERVICES PROVIDES THE FOLLOWING SERVICES TO AUGUSTANA MOUNT OLIVET HOSPICE CARE, LLC: FINANCIAL ACCOUNTING, OPERATIONAL OVERSIGHT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, CLINICAL NURSING CONSULTATION, AND CORPORATE COMPLIANCE. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE ORGANIZATION ARE AUGUSTANA CARE AND MOUNT OLIVET CAREVIEW HOME, BOTH MINNESOTA NON-PROFIT CORPORATIONS EXEMPT FROM FEDERAL INCOME TAXES UNDER SECTION 501C3 OF THE CODE AND AFFILIATED WITH THE EVANGELICAL LUTHERAN CHURCH OF AMERICA. THE INCUMBENT CHIEF EXECUTIVE OFFICER OF EACH MEMBER SHALL BE THE MEMBER DELEGATE OF EACH MEMBER ENTITLED TO VOTE ON BEHALF OF THE VOTING INTERESTS OF EACH MEMBER. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF GOVERNORS SHALL CONSIST OF AT LEAST SIX GOVERNORS, THREE OF WHOM SHALL BE APPOINTED BY THE MEMBER DELEGATE OF AUGUSTANA CARE AND THREE OF WHOM SHALL BE APPOINTED BY THE MEMBER DELEGATE OF MOUNT OLIVET CAREVIEW HOME. FORM 990, PART VI, SECTION A, LINE 7B THE ARTICLES OF ORGANIZATION AND THE BYLAWS OF THIS ORGANIZATION MAY BE AMENDED OR RESTATED ONLY BY THE UNANIMOUS APPROVAL OF THE MEMBERS. ANY PROPOSED AMENDMENTS RELATING TO THE AFFILIATION REQUIREMENTS OF THE ELCA SHALL BE SUBMITTED TO THE ELCA FOR COMMENT PRIOR TO THEIR EFFECTIVE DATE. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WAS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM AND REVIEWED BY THE ORGANIZATION'S CFO. THE FORM 990 WAS MADE AVAILABLE TO THE FULL BOARD OF DIRECTORS PRIOR TO BEING FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C INFORMATION REGARDING THE HOSPICE'S POLICY ON CONFLICTS OF INTEREST IS PROVIDED DURING ORIENTATION OF NEW STAFF, VOLUNTEERS, AND BOARD MEMBERS. MEMBERS OF THE BOARD OF DIRECTORS AND HOSPICE STAFF SUBMIT A FORM TO DISCLOSE PERSONAL OR FINANCIAL INTERESTS THAT COULD POTENTIALLY INTERFERE WITH THEIR DUTIES AND RESPONSIBILITIES TO GRACE HOSPICE. DISCLOSURE FORMS ARE SUBMITTED AT THE TIME OF HIRE OR BOARD APPOINTMENT, ANNUALLY, AND WHENEVER A POTENTIAL CONFLICT ARISES. FAILURE TO DISCLOSE EXISTING OR POTENTIAL CONFLICTS OF INTEREST IS GROUNDS FOR TERMINATION OF EMPLOYMENT OR BOARD APPOINTMENT. POTENTIAL CONFLICTS OF INTEREST ARE REVIEWED BY THE BOARD OF DIRECTORS AND/OR BY THE HOSPICE ADMINISTRATOR TO DETERMINE APPROPRIATE ACTION. FORM 990, PART VI, SECTION B, LINE 15A THE COMPENSATION FOR SARAH VAN WINKLE, PRESIDENT/CEO, IS SET BY TWO REPRESENTATIVES OF THE PARTNERING AGENCIES: BOB DAHL, CEO OF AUGUSTANA CARE, AND TIM HOKANSON, ADMINISTRATOR OF MOUNT OLIVET CAREVIEW HOME AND APPROVED BY THE ORGANIZATION'S BOARD OF DIRECTORS. THEY SET SARAH'S COMPENSATION BY REVIEWING SALARY SURVEYS SPECIFIC TO HOSPICE AGENCIES. ADDITIONALLY, THEY REVIEW FINANCIAL OUTCOMES, GROWTH OUTCOMES, QUALITY INDICATORS, AND STAFF RETENTION. THIS PROCESS WAS LAST PERFORMED IN 2021. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART IX, LINE 11G OTHER FEES FOR SERVICES: PROGRAM SERVICE EXPENSES 5,279,456. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,279,456. FORM 990, PART XII, LINE 2C: OVERSIGHT OF THE AUDIT PROCESS IS HANDLED BY THE BOARD OF DIRECTORS.