Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions. Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HOSPICE OF THE BLUEGRASS INC
Employer identification number
61-0978097
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.................................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2012 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2013.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2012.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2013.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2,898,750
1,960,098
2,896,487
1,836,386
2,818,653
12,410,374
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
60,967,495
63,863,892
61,662,371
60,860,113
56,657,052
304,010,923
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
0
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
0
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
0
6
Total. Add lines 1 through 5.
63,866,245
65,823,990
64,558,858
62,696,499
59,475,705
316,421,297
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
10,049
543,145
19,164
20,408
592,766
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
0
0
0
0
0
0
c
Add lines 7a and 7b..
0
10,049
543,145
19,164
20,408
592,766
8
Public support (Subtract line 7c from line 6.)
315,828,531
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2009
(b) 2010
(c) 2011
(d) 2012
(e) 2013
(f) Total
9
Amounts from line 6...
63,866,245
65,823,990
64,558,858
62,696,499
59,475,705
316,421,297
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
1,239,239
1,410,694
1,191,994
1,659,204
2,091,116
7,592,247
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
1,239,239
1,410,694
1,191,994
1,659,204
2,091,116
7,592,247
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
0
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
282,052
162,894
138,664
467,607
160,124
1,211,341
13
Total support. (Add lines 9, 10c, 11, and 12.)..
65,387,536
67,397,578
65,889,516
64,823,310
61,726,945
325,224,885
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f))
.........
15
97.110 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
97.300 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
2.330 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
2.110 %
19a
33 1/3% support tests—2013.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2012.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2013
Schedule A (Form 990 or 990-EZ) 2013
Page 4
Part IV
Supplemental Information.
Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2013
Additional Data
Software ID:
13000248
Software Version:
2013v3.1
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.
OMB No. 1545-0047
2013
Open to Public Inspection
Name of the organization
HOSPICE OF THE BLUEGRASS INC
Employer identification number
61-0978097
Return Reference
Explanation
Form 990, Part III, Line 2, New program services
KATS, A DIVISION OF HOSPICE OF THE BLUEGRASS, IS A TRANSITIONAL CARE PROGRAM THAT HELPS QUALIFYING PATIENTS ADJUST TO COMING HOME AFTER A STAY IN THE HOSPITAL AND MAKES SURE THEY CARE FOR THEMSELVES CORRECTLY AFTER LEAVING THE HOSPITAL IN AN EFFORT TO KEEP THEM FROM HAVING TO BE READMITTED SOON AFTER DISCHARGE.
FORM 990, PART V, LINE 2A, EMPLOYEES REPORTED ON FORM W-3
HOSPICE OF THE BLUEGRASS, INC. (HOB) EIN 61-0978097 IS THE COMMON PAYING AGENT FOR PALLIATIVE CARE CENTER OF THE BLUEGRASS, INC. (PCC), A RELATED ORGANIZATION. THEREFORE, ALL APPLICABLE IRS TAX FILINGS ARE REPORTED BY HOB. THE TOTAL NUMBER OF EMPLOYEES REPORTED ON FORM W-3 AND FILED BY THE COMMON PAYING AGENT, HOB, FOR 2013 WAS 916. FOR PURPOSES OF REPORTING THE NUMBER OF EMPLOYEES ON THE FORM 990, LINE 2A FOR HOB AND PCC, THERE WERE 899 AND 17 REPORTED FOR EACH RESPECTIVE ORGANIZATION.
Form 990, Part VI, Sec A, Line 1a, Delegate broad authority to a committee
THE EXECUTIVE COMMITTEE CONSISTS OF THE CHAIRMAN OF THE BOARD, THE VICE CHAIRMAN OF THE BOARD, THE IMMEDIATE PAST CHAIRMAN OF THE BOARD, THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, THE SECRETARY, AND THE TREASURER. THE ONLY COMMITTEE MEMBER NOT ON THE GOVERNING BODY (THE BOARD) IS THE IMMEDIATE PAST CHAIRMAN OF THE BOARD WHO SERVES ON THE EXECUTIVE COMMITTEE AS AN EX-OFFICIO, NON-VOTING AND NON-FIDUCIARY MEMBER. THE EXECUTIVE COMMITTEE MAY HAVE AND EXERCISE ALL AUTHORITY OF THE BOARD OF DIRECTORS IN DEALING WITH THE DAY-TO-DAY MANAGEMENT OF THE ORGANIZATION TO THE EXTENT PERMITTED BY LAW. THE ACTIONS TAKEN SHALL BE REPORTED TO THE BOARD EITHER BY WRITTEN MINUTES OR REPORT BY THE CHAIRMAN.
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
A COPY OF THE ORGANIZATION'S FINAL FORM 990 (INCLUDING REQUIRED SCHEDULES), AS ULTIMATELY FILED WITH THE IRS, WAS PROVIDED TO EACH VOTING MEMBER OF THE ORGANIZATION'S GOVERNING BODY AND OFFICERS IN ATTENDANCE AT THE AUDIT AND FINANCE COMMITTEE MEETING ON AUGUST 22, 2014 PRIOR TO ITS FILING WITH THE IRS. IN ADDITION, THE ORGANIZATION'S RETURN PREPARER AND MANAGEMENT PRESENTED A FORM 990 SUMMARY REPORT AT THIS MEETING.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
ALL ORGANIZATION PERSONNEL, MEMBERS OF THE GOVERNING BODY AND ADVISORY BOARDS ARE COVERED UNDER THE ORGANIZATION'S CONFLICT OF INTEREST POLICY. IN THE EVENT A SITUATION ARISES WHEREBY AN EMPLOYEE HAS A CONFLICT OF INTEREST, HE/SHE IS OBLIGATED TO REPORT THAT POTENTIAL TO THE PRESIDENT/CEO. DISCLOSURE OF A POTENTIAL CONFLICT AND THE PRESIDENT/CEO'S DECISION REGARDING THE ACTIONS WILL BE NOTED IN A FILE KEPT BY THE PRESIDENT/CEO. IN THE EVENT A SITUATION EXISTS WHEREBY A MEMBER OF THE GOVERNING BODY OR ADVISORY COMMITTEE HAS A CONFLICT OF INTEREST, HE/SHE IS OBLIGATED TO REPORT THAT POTENTIAL TO THE GOVERNING BODY. THE GOVERNING BODY WILL THEN RENDER A DECISION OF THAT MEMBER'S ELIGIBILITY TO VOTE ON ANY PARTICULAR ISSUE. DISCLOSURE OF A POTENTIAL CONFLICT AND THE GOVERNING BODY'S DECISION REGARDING THE CONFLICT WILL BE NOTED IN THE MINUTES.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
THE CEO/PRESIDENT'S COMPENSATION IS ESTABLISHED AND APPROVED ANNUALLY BY THE EXECUTIVE COMMITTEE OF THE BOARD OF DIRECTORS. THE COMMITTEE UTILIZES DATA PROVIDED BY INDEPENDENT COMPENSATION CONSULTANT STUDIES TO PROVIDE A BASIS FOR COMPARISON ALONG WITH AN ASSESSMENT OF THE CEO TO ARRIVE AT THE COMPENSATION AMOUNT. THIS PROCESS WAS LAST UNDERTAKEN IN THE 1ST QUARTER OF 2013. THE APPROVAL OF THE CEO/PRESIDENT'S COMPENSATION IS DOCUMENTED IN THE EXECUTIVE COMMITTEE MEETING MINUTES.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICIES ARE NOT REQUIRED TO BE DISCLOSED PUBLICLY PURSUANT TO INTERNAL REVENUE CODE (IRC) SECTION 6104. THESE DOCUMENTS MAY BE DISCLOSED BASED UPON THE DISCRETION OF THE BOARD.
FORM 990, PART VII, SECTION A, LINE 1A, COLUMN (B), HOURS FOR RELATED ORGANIZATIONS
EMPLOYEES HAVING ONE HOUR OR LESS PER WEEK AS HOURS FOR RELATED ORGANIZATIONS DO NOT HAVE REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS LISTED AS THE VALUE OF THEIR COMPENSATION FOR RELATED ORGANIZATIONS IS IDENTIFIED AS A COMPONENT OF PURCHASED SERVICES AND NOT AS REPORTABLE COMPENSATION.
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
CHANGE IN VALUE OF INTEREST RATE SWAP - 98102; WRITE OFF OF PLEDGES - -30650;
Schedule M, part I, column (b), Line 17, Number of contributions or items contributed.
NUMBER OF CONTRIBUTIONS
Schedule M, part I, column (b), Line other, Number of contributions or items contributed.
OTHER=DURABLE MEDICAL EQUIPMENT :
Schedule M, part I, column (b), Line other, Number of contributions or items contributed.
OTHER=OFFICE SUPPLIES AND EQUIPMENT :
Schedule M, part I, column (b), Line other, Number of contributions or items contributed.
OTHER=PATIENT AND FAMILY COMFORT ITEMS :
Schedule M, part I, column (b), Line 17, Number of contributions or items contributed.
NUMBER OF CONTRIBUTIONS
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.