2025-10-27T14:04:49-05:00 2024-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2024-01-01 464564958 AUGUSTANA MOUNT OLIVET HOSPICE CARE LLC AUGU 9528555000 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 STACY LYSEN PRESIDENT/CEO 9528555000 2025-10-24 1 0 KURT BENNION CPA P01469618 4252506100 2025-10-24 2024 2025-03-06 01:10:19Z GRACE HOSPICE STACY LYSEN 1015 4TH AVENUE NORTH MINNEAPOLIS MN 55405 23999603 0 X WWW.GRACEHOSPICECARING.ORG X LLC 2014 MN PROVIDE HOSPICE SERVICES TO THE ELDERLY. 6 6 163 84 0 0 212553 291624 18997715 23561117 67688 146242 3250 620 19281206 23999603 0 0 0 0 9500540 10450823 0 0 49308 8695225 11697807 18195765 22148630 1085441 1850973 5840419 7441219 1338633 1588359 4501786 5852860 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 19684654 0 23561117 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 SUPPORT 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. 19684654 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 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 17 0 163 1 0 0 0 0 0 0 0 0 0 0 0 0 X 6 6 1 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 TIMOTHY HOKANSON CHAIR 0.25 X X 0 0 0 KATHY KOPP VICE CHAIR 0.25 X X 0 0 0 MATTHEW KERN CEO 0.25 X X 0 0 0 NANCY NASH SECRETARY 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 STACY LYSEN PRESIDENT/CEO 46.00 X 160094 0 27450 ALYSSA LANGE NURSE PRACTITIONER 40.00 X 106361 0 29060 JENNIFER SEYFER DIRECTOR OF QUALITY & COMPLIANCE 40.00 X 130567 0 13197 KELSEY TIETJE DIRECTOR OF MARKETING 40.00 X 116171 0 17523 RACHEL JACKSON DIRECTOR OF HOSPICE 40.00 X 113213 0 32715 SARA WARD HOSPICE STAFF MANAGER 40.00 X 114277 0 21330 740683 0 141275 7 0 1 0 BETTERRX LLC PO BOX 29650 PHOENIX AZ 850389650 PHARMACY BENEFIT MANAGEMENT 1955040 CASSIA SERVICES 7171 OHMS LANE EDINA MN 55439 MANAGEMENT SERVICES 471222 INTERNAL MEDICINE & GERIATRIC ASSOCIATIO 21490 FAIRVIEW ST EXCELSIOR MN 55331 MEDICAL DIRECTOR SERVICES 210000 INTELLA TRIAGE LLC 8011 BROOKS CHAPEL ROAD BRENTWOOD TN 37027 AFTERHOURS COVERAGE 181184 4 291624 10185 291624 HOSPICE CARE 624100 23561117 23561117 23561117 85960 85960 60282 0 60282 60282 60282 MISCELLANEOUS INCOME 900099 620 620 620 23999603 23561117 0 146862 X 187544 187544 8643425 7797835 845590 184632 169804 14828 796662 724971 71691 638560 566415 72145 471222 471222 27258 27258 8848635 8848635 14366 14366 393126 27326 316492 49308 102037 102037 54948 54948 312689 283038 29651 33716 20528 13188 41415 41415 29752 29752 NURSING EQUIPMENT 996770 996770 NURSING SUPPLIES 248013 248013 MISCELLANEOUS EXPENSES 67926 1070 66856 DUES AND SUBSCRIPTIONS 30037 249 29788 25897 25897 22148630 19684654 2414668 49308 2847742 3510342 4499 7649 1704756 2456974 49322 41736 623524 323519 73015 300005 1002385 1055233 158700 69280 5840419 7441219 1189729 1517377 148904 70982 1338633 1588359 X 4501786 5852860 4501786 5852860 5840419 7441219 X 1850973 101 -500000 X X 0 1 X 1 0 X 649399 1150574 290210 212553 291624 2594360 12411028 12455312 15841374 18997715 23561117 83266546 13060427 13605886 16131584 19210268 23852741 85860906 0 0 0 85860906 60926 96592 43030 56689 85960 343197 60926 96592 43030 56689 85960 343197 3250 620 3870 13121353 13702478 16174614 19270207 23939321 86207973 0.99600 0.99600 0.00400 0.00390 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS INCOME - 2023 AMOUNT: $ 3,250. 2024 AMOUNT: $ 620. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 139550 132020 7530 483974 191499 292475 300005 RIGHT-OF-USE LEASE LIABILITIES 70982 70982 X 23999704 101 101 23999603 0 23999603 22148630 0 22148630 0 22148630 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. X X X X X 0 0 0 0 0 0 0 0 0 STACY LYSEN PRESIDENT/CEO 159914 0 0 0 180 0 6800 0 20650 0 187544 0 0 0 FORM 990, PART VI, SECTION A, LINE 2 EILEEN CARTWRIGHT AND TIMOTHY HOKANSON HAVE A BUSINESS RELATIONSHIP. 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, CORPORATE COMPLIANCE, COORDINATED ADVERTISING & MARKETING, PHILANTHROPY, AND NEW BUSINESS DEVELOPMENT. 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 501(C)(3) 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 STACY LYSEN, IS SET BY TWO REPRESENTATIVES OF THE PARTNERING AGENCIES: BOB DAHL, CEO OF AUGUSTANA, AND TIM HOKANSON, ADMINISTRATOR OF MOUNT OLIVET CAREVIEW HOME AND APPROVED BY THE ORGANIZATION'S BOARD OF DIRECTORS. THE COMPENSATION IS SET 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 2024. 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 8,848,635. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,848,635. FORM 990, PART XI, LINE 9: OWNERS DISTRIBUTION - AUGUSTANA -250,000. OWNERS DISTRIBUTION - MOUNT OLIVET -250,000. FORM 990, PART XII, LINE 2C: OVERSIGHT OF THE AUDIT PROCESS IS HANDLED BY THE BOARD OF DIRECTORS.