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
COMMUNITY NURSES HOME HEALTH & HOSPICE INC
Employer identification number
25-0996070
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.") .
59,825
26,192
63,582
191,461
120,982
462,042
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......
5,580,905
5,659,568
5,310,293
4,756,407
4,788,734
26,095,907
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.
5,640,730
5,685,760
5,373,875
4,947,868
4,909,716
26,557,949
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
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
c
Add lines 7a and 7b..
0
8
Public support (Subtract line 7c from line 6.)
26,557,949
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...
5,640,730
5,685,760
5,373,875
4,947,868
4,909,716
26,557,949
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
240
428
1,154
2,747
1,911
6,480
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
0
c
Add lines 10a and 10b.
240
428
1,154
2,747
1,911
6,480
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.)
..
0
13
Total support. (Add lines 9, 10c, 11, and 12.)..
5,640,970
5,686,188
5,375,029
4,950,615
4,911,627
26,564,429
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
99.976 %
16
Public support percentage from 2012 Schedule A, Part III, line 15
...............
16
99.980 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f))
......
17
0.024 %
18
Investment income percentage from 2012 Schedule A, Part III, line 17
.............
18
0.020 %
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:
Software Version:
-
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
COMMUNITY NURSES HOME HEALTH & HOSPICE INC
Employer identification number
25-0996070
Return Reference
Explanation
FORM 990, PART III, LINE 1
MISSION COMMUNITY NURSES HOME HEALTH AND HOSPICE, INC. IS A HOME HEALTH LICENSED, MEDICARE CERTIFIED ORGANIZATION PROVIDING SKILLED NURSING, THERAPY, NUTRITIONIST, SOCIAL WORK, HOME HEALTH AIDE, AND HOSPICE SERVICES TO THOSE IN NEED OF HEALTH SERVICES IN ORDER TO REMAIN IN THE COMFORT OF THEIR HOMES. NURSES SPECIALLY TRAINED IN IV, WOUND, AND HOSPICE, ALONG WITH PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPISTS UTILIZE THE LATEST TECHNOLOGY IN TELEHEALTH, INR, WOUND CARE, AND SONOGRAM TO PROVIDE FOR PATIENTS OF ALL AGES. AFTER DISCHARGE, CONTACT IS MAINTAINED WITH THE PATIENT THROUGH POST-DISCHARGE PHONE CALLS AND OUR SENIOR OUTREACH PROGRAM. OUR HOSPICE STAFF PROVIDES FOR END-OF-LIFE CARE WHETHER THE PATIENT DECIDES TO REMAIN IN THE HOME, HOSPITAL, OR NURSING HOME SETTING. SUPPORT AND BEREAVEMENT SERVICES ARE ALSO PROVIDED FOR THE FAMILY, ALONG WITH GROUP BEREAVEMENT EVENTS, SUCH AS THE BUTTERFLY RELEASE MEMORIAL SERVICE AND CAMP FLUTTERBY, A TWO-DAY GRIEF CAMP FOR CHILDREN. THESE SERVICES ARE PROVIDED BY DEDICATED STAFF TWENTY-FOUR HOURS PER DAY, AND NO ONE IS TURNED AWAY BECAUSE OF INABILITY TO PAY.
FORM 990, PART VI, SECTION A, LINE 2
FAMILY OR BUSINESS RELATIONSHIPS PAULA FRITZ EDDY AND JUNE SORG HAVE A BUSINESS RELATIONSHIP. PAULA FRITZ EDDY AND GENNARO AIELLO HAVE A BUSINESS RELATIONSHIP. FORM 990, PART VI, SECTION A, LINE 3 MANAGEMENT CONTROL THE ORGANIZATION'S NON-PROFIT, EXEMPT, PARENT ORGANIZATION, COMMUNITY NURSES, INC. PROVIDES MANAGEMENT SERVICES TO COMMUNITY NURSES HOME HEALTH & HOSPICE, INC.
FORM 990, PART VI, SECTON A, LINES 6, 7A, 7B
MEMBERS ELK REGIONAL HEALTH CENTER, INC. (ELK), AND PENN HIGHLANDS HEALTHCARE (PHH) HOLDS CERTAIN POWERS OVER CNI AND ITS SUBSIDIARIES, INCLUDING THE ELECTION AND REMOVAL OF OFFICERS AND DIRECTORS AND ANY AND ALL AMENDMENTS TO THE BYLAWS OR OTHER ORGANIZATIONAL/GOVERNANCE DOCUMENTS. PHH AND ELK SHALL HAVE THE FOLLOWING POWERS WITH RESPECT TO THE ELECTION AND REMOVAL OF DIRECTORS: PRIOR TO THE END OF PHH'S FISCAL YEAR, THE PHH BOARD WILL MEET TO ELECT THE DIRECTORS, WITH THE EXCEPTION OF EX-OFFICIO DIRECTORS. AT LEAST SIXTY (60) DAYS IN ADVANCE OF THIS MEETING, ELK SHALL PROVIDE TO PHH'S GOVERNANCE/NOMINATING COMMITTEE (THE "PHH GOVERNANCE/NOMINATING COMMITTEE") A LIST OF ONE OR MORE CANDIDATES (THE NUMBER OF CANDIDATES TO BE DETERMINED IN THE PHH GOVERNANCE/NOMINATING COMMITTEE'S DISCRETION) FOR EACH EXPIRING DIRECTOR POSITION, WITH THE EXCEPTION OF ANY EX-OFFICIO DIRECTORS. THE LIST OF CANDIDATES SHALL HAVE BEEN DEVELOPED BY ELK IN CONSULTATION WITH THE BOARD OF CNI AND ITS SUBSIDIARIES. THE PHH GOVERNANCE/NOMINATING COMMITTEE SHALL REVIEW EACH CANDIDATE IN ACCORDANCE WITH THE CRITERIA SET FORTH IN THE PHH BYLAWS, THE CRITERIA, IF ANY, SET FORTH IN CNHH&H'S BYLAWS OR POLICIES FOR WHICH SAID CANDIDATE IS BEING CONSIDERED FOR BOARD SERVICE, AND THE POLICIES AND RULES OF PHH, INCLUDING, WITHOUT LIMITATION, THE CONFLICT INTEREST POLICY (ALL OF WHICH SHALL BE REFERRED TO COLLECTIVELY HEREIN AS THE "ELIGIBILITY CRITERIA") AND DEVELOP A LIST OF ONE OR MORE CANDIDATES FOR EACH OPEN POSITION (THE NUMBER OF CANDIDATES TO BE DETERMINED IN THE PHH GOVERNANCE/NOMINATING COMMITTEE'S DISCRETION). ONCE THE SLATE OF CANDIDATES IS NOMINATED BY THE PHH GOVERNANCE/NOMINATING COMMITTEE, THE BOARD OF ELK SHALL SUBMIT TO THE PHH BOARD FOR ELECTION SUCH SLATE OF CANDIDATES FOR THE OPEN BOARD POSITIONS. THE PHH BOARD MAY ELECT BY A VOTE OF THE MAJORITY OR REFUSE TO ELECT EACH CANDIDATE SUBMITTED BY THE BOARD OF ELK AND MAY NOT ELECT ANY CANDIDATE NOT SUBMITTED BY THE BOARD OF ELK AND NOMINATED BY THE PHH GOVERNANCE/NOMINATING COMMITTEE. THE BOARD OF PHH HAS THE POWER TO REMOVE SUCH DIRECTOR AT ANY TIME WITH OR WITHOUT CAUSE. IN THE EVENT THAT CNHH&H DESIRES TO FILL A VACANCY OCCURRING ON ITS BOARD, THE PHH GOVERNANCE/NOMINATING COMMITTEE AND THE BOARD OF PHH, AT THE REQUEST OF ELK, SHALL ACT TO FILL SUCH VACANCY. SUBJECT TO THE APPROVAL OF ELK AND PHH AS SET FORTH IN THE BYLAWS, THE ARTICLES AND THE BYLAWS MAY BE ALTERED, AMENDED, OR REPEALED AND NEW BYLAWS OR ARTICLES MAY BE ADOPTED BY THE AFFIRMATIVE VOTE OF TWO-THIRDS (2/3) OF THE BOARD. WRITTEN NOTICE OF THE INTENT TO AMEND THE BYLAWS OR THE ARTICLES AND A DRAFT OF THE PROPOSED CHANGE SHALL BE SENT TO ALL DIRECTORS, BY THE SECRETARY, AT LEAST FIVE (5) DAYS PRIOR TO ANY MEETING AT WHICH AMENDMENT OF THE BYLAWS OR THE ARTICLES IS INTENDED.
FORM 990, PART VI, SECTION B, LINE 11B
FORM 990 REVIEW PROCESS THE FORM 990 IS PREPARED BY AN INDEPENDENT ACCOUNTING FIRM BASED ON THE AUDITED FINANCIAL STATEMENTS AND INFORMATION PROVIDED BY THE ACCOUNTING DEPARTMENT OF THE ORGANIZATION. A DRAFT OF THE 990 IS THOROUGHLY REVIEWED BY THE CFO AND CEO. AFTER ALL CHANGES ARE MADE, IT IS PRESENTED TO THE BOARD OF DIRECTORS BEFORE BEING FILED.
FORM 990, PART VI, SECTION B, LINE 12C
CONFLICT OF INTEREST POLICY COMPLIANCE EVERY YEAR, A QUESTIONNAIRE REGARDING BUSINESS AND FAMILY RELATIONSHIPS IS GIVEN TO THE BOARD OF DIRECTORS & OFFICERS. THESE QUESTIONNAIRES ARE THEN REVIEWED AND ANY CONFLICTS ARE BROUGHT TO THE ATTENTION OF THE BOARD. ANY BOARD MEMBER WITH A CONFLICT OF INTEREST MUST ABSTAIN FROM VOTING ON ANY ISSUES RELATED TO THAT CONFLICT.
FORM 990, PART VI, SECTION B, LINES 15A & 15B
COMPENSATION DETERMINATION SALARIES ARE REVIEWED ANNUALLY DURING THE BUDGET PROCESS, COMPARED TO THE HOME CARE SALARY & BENEFITS REPORT PRODUCED BY THE NATIONAL ASSOCIATION OF HOMECARE FOR REASONABLENESS, AND APPROVED BY THE BOARD OF DIRECTORS. THE CEO'S AND CFO'S COMPENSATION ARE SPECIFICALLY APPROVED BY THE BOARD.
FORM 990, PART VI, SECTION C, LINE 19
GOVERNING DOCUMENT AVAILABILITY THE ARTICLES OF INCORPORATION ARE AVAILABLE ON THE PENNSYLVANIA DEPARTMENT OF STATE'S WEBSITE. ALL DOCUMENTS ARE AVAILABLE TO THE PUBLIC UPON WRITTEN REQUEST.
FORM 990, PART XI, LINE 9
CHANGE IN NET ASSETS TRANSFER TO AFFILIATE $236,310* FAIR VALUE ADJUSTMENT 136,074 ---------- TOTAL $372,384 *IN OCTOBER 2012, ELK REGIONAL HEALTH CENTER (HEALTH CENTER) SIGNED AN AFFILIATION AGREEMENT EFFECTIVE JULY 1, 2013, WITH PENN HIGHLANDS HEALTHCARE, A PENNSYLVANIA NONPROFIT CORPORATION (PENN HIGHLANDS). PENN HIGHLANDS BECAME THE SOLE MEMBER OF THE HEALTH CENTER. THE AFFILIATION AGREEMENT REQUIRED ASSETS AND LIABILITIES BE RECORDED AT FAIR VALUE AS OF JULY 1, 2013, ON THE PENN HIGHLANDS HEALTHCARE FINANCIAL STATEMENTS. THE HEALTH CENTER ELECTED TO PUSH DOWN ANY FAIR VALUE ADJUSTMENTS TO THE STANDALONE HEALTH CENTER FINANCIAL STATEMENTS. AS A RESULT, A CONSOLIDATED $5,084,233 ADJUSTMENT WAS MADE PRIMARILY TO ADJUST THE CARRYING VALUE OF PROPERTY AND EQUIPMENT TO FAIR VALUE. EACH ENTITY WAS ALLOCATED THEIR SHARE OF THE ADJUSTMENT, AND THE FAIR VALUE ADJUSTMENT IS REPORTED IN THE RECONCILIATION AMOUNT ABOVE. THE AMOUNTS REPORTED ON SCHEDULE D, PART VI, INCLUDE THIS ADJUSTMENT TO FAIR VALUE.
FORM 990, PART XII, LINE 2C
AS A RESULT OF THE AMENDMENT OF THE BYLAWS RELATED TO THE MERGER WITH PENN HIGHLANDS HEALTHCARE (PHH), PHH NOW HOLDS THE SOLE POWER OVER THE SELECTION OF THE INDEPENDENT ACCOUNTANT.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.