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
NATHAN ADELSON HOSPICE INC
Employer identification number
88-0161009
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.") .
907,815
1,696,788
2,817,989
2,563,452
3,351,243
11,337,287
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......
25,802,951
25,593,777
27,614,948
30,667,566
27,662,707
137,341,949
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.
26,710,766
27,290,565
30,432,937
33,231,018
31,013,950
148,679,236
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
0
0
0
0
0
0
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
0
0
0
0
0
8
Public support (Subtract line 7c from line 6.)
148,679,236
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...
26,710,766
27,290,565
30,432,937
33,231,018
31,013,950
148,679,236
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
161
233
262
500
1,150
2,306
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
161
233
262
500
1,150
2,306
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.)
..
35,483
36,453
35,176
47,354
40,923
195,389
13
Total support. (Add lines 9, 10c, 11, and 12.)..
26,746,410
27,327,251
30,468,375
33,278,872
31,056,023
148,876,931
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
99.860 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.860 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0 %
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
NATHAN ADELSON HOSPICE INC
Employer identification number
88-0161009
Return Reference
Explanation
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body
THE CEO, CFO AND A REPRESENTATIVE FROM THE ORGANIZATION'S TAX PREPARATION FIRM REVIEW THE COMPLETED FORM 990 WITH THE ORGANIZATION'S FINANCE COMMITTEE. THE FINANCE COMMITTEE REPORTS ON ITS REVIEW OF THE FORM 990 TO THE FULL BOARD OF TRUSTEES AND RECOMMENDS APPROVAL FOR FILING. ALL MEMBERS OF THE BOARD OF TRUSTEES RECEIVE COPIES OF THE FORM 990 FOR REVIEW PRIOR TO FILING WITH THE IRS. ALL ACTIONS TAKEN BY THE FINANCE COMMITTEE AND BOARD OF TRUSTEES RELATED TO THE REVIEW AND APPROVAL OF THE FORM 990 ARE DOCUMENTED IN THE MEETING MINUTES.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy
ALL BOARD OF TRUSTEE MEMBERS, OFFICERS, AND KEY EMPLOYEES (INTERESTED PERSONS) ARE REQUIRED TO FILE AN ANNUAL DISCLOSURE OF POTENTIAL OR ACTUAL CONFLICTS OF INTEREST WITH THE ORGANIZATION. DISCLOSURES ARE REVIEWED BY THE BOARD PRESIDENT AND COPIES ARE PROVIDED TO OUR INDEPENDENT AUDITORS. INTERESTED PERSONS WITH A CONFLICT OF INTEREST ARE PROHIBITED FROM PARTICIPATING IN DELIBERATIONS/VOTING RELATED TO A TRANSACTION WHERE A CONFLICT EXISTS.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official
THE COMPENSATION ARRANGEMENTS FOR THE ORGANIZATION'S PRESIDENT & CHIEF EXECUTIVE OFFICER (CEO) AND OTHER SENIOR LEADERS ARE SUBJECT TO THE REVIEW AND APPROVAL OF THE ORGANIZATION'S BOARD OF TRUSTEES. A BOARD OF TRUSTEE APPOINTED COMPENSATION COMMITTEE COMPRISED OF THE SENIOR DIRECTOR OF HUMAN RESOURCES AND THREE INDEPENDENT BOARD OF TRUSTEE MEMBERS, ENSURES THE ORGANIZATION'S PAY STRUCTURE AND BENEFITS PROGRAMS ARE FAIR, COMPETITIVE (BASED ON MARKET DATA), AND ALIGNED WITH THE ORGANIZATION'S BUSINESS STRATEGY AND MISSION. ADDITIONALLY, THE COMMITTEE RESPONSIBILITIES INCLUDE THE FOLLOWING: 1) OVERSEEING ALL ASPECTS OF COMPENSATION PROVIDED TO SENIOR LEADERSHIP OF THE ORGANIZATION, INCLUDING THE PRESIDENT/CEO, IN ORDER TO REWARD PERFORMANCE WHILE ENSURING FISCAL RESPONSIBILITY; 2) ESTABLISHING OVERALL TOTAL COMPENSATION PHILOSOPHY FOR THE ORGANIZATION; 3) ASSURING THAT THE HOSPICE'S COMPENSATION PRACTICES ARE IN COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS; 4) ANALYZING STATE AND NATIONAL SURVEY DATA; AND 5) RETAINING ADVISERS TO INCLUDE COMPENSATION EXPERTS, AS IT MAY DEEM NECESSARY. THE COMPENSATION COMMITTEE PROVIDES AN ANNUAL SALARY ANALYSIS, INCLUDING THE COMPENSATION PACKAGE FOR THE CEO AND OTHER SENIOR LEADERS, TO THE FINANCE COMMITTEE. THE FINANCE COMMITTEE REVIEWS THE COMPENSATION PACKAGE FOR THE CHIEF EXECUTIVE OFFICER AND SENIOR LEADERSHIP, IN AN ANNUAL EXECUTIVE SESSION. ONCE APPROVED BY THE COMMITTEE, THE COMPENSATION PACKAGE AND FORMAL PERFORMANCE EVALUATION FOR THE CHIEF EXECUTIVE OFFICER IS SUBMITTED TO THE FULL BOARD OF TRUSTEES FOR REVIEW AND APPROVAL. FORMAL APPROVAL OF THE ANNUAL COMPENSATION PACKAGE IS DOCUMENTED IN THE MINUTES OF THE BOARD OF TRUSTEES' MEETING. IN Q4 2012, NAH ENGAGED AN INDEPENDENT GROUP, CBIZ HUMAN CAPITAL SERVICES GROUP, TO PERFORM AN ORGANIZATION WIDE COMPENSATION ANALYSIS, INCLUDING A REVIEW OF CURRENT COMPENSATION PRACTICES AND DEVELOPMENT OF A MARKET BASED COMPENSATION PLAN. THE COMPENSATION PLAN FOR 2013 WAS DEVELOPED AND APPROVED BY THE COMPENSATION COMMITTEE BASED ON THIS ANALYSIS AND PRESENTED TO THE FINANCE COMMITTEE/BOARD OF TRUSTEES IN ACCORDANCE WITH COMPANY COMPENSATION POLICIES. IN Q4 2013, CBIZ PROVIDED A REPORT OF ACTUAL 2013 AND PROJECTED 2014 SALARY ADJUSTMENTS FOR ALL ORGANIZATIONS IN THE WESTERN US INCLUDING SPECIFIC HEALTHCARE INDUSTRY COMPENSATION INFORMATION. THEIR REPORT INCLUDED A RECOMMENDED SALARY STRUCTURE UPDATE FOR THE NEXT FISCAL YEAR. THE COMPENSATION COMMITTEE REVIEWED AND APPROVED THE ORGANIZATION'S SALARY STRUCTURE INCLUDING THAT OF THE CEO AND OTHER SENIOR LEADERS FOR THE NEXT FISCAL YEAR. THEIR FINAL RECOMMENDATIONS WERE PRESENTED AND APPROVED BY THE FINANCE COMMITTEE AND BOARD OF TRUSTEES. CBIZ WILL CONTINUE TO PROVIDE UPDATE INFORMATION ANNUALLY THROUGH 2015.
Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees
PLEASE SEE THE NARRATIVE FOR FORM 990, SECTION B, PART VI, LINE 15A.
Form 990, Part VI, Sec C, Line 19, Required documents available to the public
FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICTS OF INTEREST POLICIES ARE NOT REQUIRED DISCLOSURES PURSUANT TO INTERNAL REVENUE CODE (IRS) SECTION 6104. AS SUCH, THE ORGANIZATION'S FINANCIAL STATEMENTS, GOVERNING DOCUMENTS, AND CONFLICT OF INTEREST POLICY ARE NOT AVAILABLE TO THE PUBLIC AT THIS TIME.
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances
CHANGE IN INTEREST IN NAH FOUNDATION - 1228467; NET LOSS FROM SUBSIDIARY - -134971;
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.