Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
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Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 57,702 | 32,452 | 27,374 | 24,188 | 4,715 | 146,431 |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.... | 0 | |||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 4 | Total. Add lines 1 through 3 | 57,702 | 32,452 | 27,374 | 24,188 | 4,715 | 146,431 |
| 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).. | 0 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 146,431 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 57,702 | 32,452 | 27,374 | 24,188 | 4,715 | 146,431 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 71,112 | 141,173 | 98,047 | 75,647 | 62,587 | 448,566 |
| 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 VI.).. | 17,270 | 71,151 | 24,665 | 10,163 | 21,610 | 144,859 |
| 11 | Total support. Add lines 7 through 10 | 739,856 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 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 | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | ||||||
| 6 | Total. Add lines 1 through 5 | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | ||||||
| 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. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support. (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2018 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
|---|
| AFFILIA HOME HEALTH IS A COMMUNITY SERVICE ORGANIZATION THAT PROVIDES COMPREHENSIVE HOME HEALTH CARE TO PEOPLE OF ALL AGES IN LANCASTER, BERKS, CHESTER, SCHUYLKILL AND DAUPHIN COUNTIES AND THEIR SURROUNDING AREA REGARDLESS OF THEIR ABILITY TO PAY. AFFILIA HOME HEALTH PROVIDES SKILLED NURSING, THERAPHY, MEDICAL SOCIAL SERVICES, AND HOME HEALTH AID SERVICES. FOR FISCAL YEAR ENDED JUNE 30, 2019, 55% OF OUR SERVICES PROVIDED WERE SPECIFICALLY TO MEDICARE AND MEDICAID PATIENTS. |
| Return Reference | Explanation |
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| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990,PART VI, SECTION A, LINE 3 | DELEGATION OF MANAGEMENT DUTIES LANCASTER GENERAL HEALTH (EIN 23-2250941) AND LANCASTER GENERAL HOSPITAL (EIN 23-1365353) PROVIDE MANAGEMENT SERVICES TO AFFILIA HOME HEALTH. SUCH SERVICES INCLUDE, BUT ARE NOT LIMITED TO, ACCOUNTING, AUDIT, HUMAN RESOURCES, INFORMATION TECHNOLOGY, AND MANAGEMENT OVERSIGHT. ------------------------------- |
| FORM 990, PART VI, SECTION A, LINE 4 | CHANGES TO GOVERNING DOCUMENTS SEPARATION OF BRANCHES AND OWNERSHIP OCCURED ON DECEMBER 31, 2018. BYLAWS WERE AMENDED UPON SEPARATION. PLEASE SEE SCHEDULE N, PART II FOR FURTHER DETAILS. ------------------------------- |
| FORM 990, PART VI, SECTION A, LINE 6 | CLASSES OF MEMBER OR STOCKHOLDERS AS OF JANUARY 1, 2012 TO DECEMBER 31,2018, THE MEMBERS OF THE CORPORATION SHALL BE LANCASTER GENERAL HEALTH (EIN 22-2250941), A PENNSYLVANIA NONPROFIT CORPORATION. READING HOSPITAL (EIN 23-1352204), A PENNSYLVANIA NONPROFIT CORPORATION. UPMC PINNACLE HOSPITALS, (EIN 25-1778658), A PENNSYLVANIA NONPROFIT CORPORATION. SUBSEQUENT TO DECEMBER 31, 2018 THE SOLE MEMBER OF THE CORPORATION IS LANCASTER GENERAL HEALTH. ------------------------------ |
| FORM 990, PART VI, SECTION A, LINE 7A | MEMBERS OR STOCKHOLDERS THE BOARD OF DIRECTORS OF THE CORPORATION SHALL BE COMPOSED OF EIGHT DIRECTORS. THIS NUMBER MAY BE INCREASED OR DECREASED, HOWEVER, THE PERCENTAGE OF PHYSICIAN DIRECTORS SHALL NEVER BE MORE THAN 20 PERCENT OF THE TOTAL NUMBER OF DIRECTORS IN OFFICE. AT THE BEGINNING OF THE FISCAL YEAR THE BOARD OF DIRECTORS CONSISTED OF THREE DIRECTORS EACH OF LG HEALTH (EIN 22-2250941) AND READING HOSPITAL (EIN 23-1352204), AND THE REMAINING ELECTED BY UPMC PINNACLE HOSPITALS (EIN 23-2024121). EACH DIRECTOR SHALL BE APPOINTED FOR A THREE YEAR TERM. UPON SEPARATION EFFECTIVE JANUARY 1ST, 2019, NUMBER OF MEMBERS DECREASE ONLY INCLUDING LG HEALTH MEMBERS. ------------------------------ |
| FORM 990, PART VI, SECTION A, LINE 7B | DECISIONS REQUIRING APPROVAL BY MEMBERS A MAJORITY OF THE DIRECTORS OF THE BOARD SHALL CONSTITUTE A QUORUM FOR THE TRANSACTION OF BUSINESS. THE ACTS OF A MAJORITY OF THE DIRECTORS PRESENT AND VOTING AT A MEETING AT WHICH A QUORUM IS PRESENT SHALL BE THE ACTS OF THE BOARD. ------------------------------ |
| FORM 990, PART VI, SECTION A, LINE 9 | INTERESTED PERSON NOT AT ORGANIZATION'S ADDRESS BOARD MEMBERS TAMMY L. OBER, MARGARET F. COSTELLA, DOUGLAS W. RINEHART, KAY BRADY AND SUSAN WYNNE CAN BE REACHED AT: LANCASTER GENERAL HEALTH, 555 NORTH DUKE STREET, PO BOX 3555, LANCASTER, PA 17604-3555. BOARD MEMBER DAN AHERN CAN BE REACHED AT THE READING HOSPITAL AND MEDICAL CENTER, 601 SPRUCE STREET, READING PA 19611. BOARD MEMBERS MARY C. AGNEW AND GARY CONNER CAN BE REACHED AT READING HOSPITAL, PO BOX 16052, READING, PA 19612. BOARD MEMBER WILLIAM K. WILKINSON CAN BE REACHED AT PINNACLE HEALTH COMMUNITY HOSPITAL, 4300 LONDONDERRY ROAD, HARRISBURG, PA 17109. BOARD MEMBER JOAN SILVER CAN BE REACHED AT PINNACLE HEALTH SYSTEM, P.O. BOX 8700, HARRISBURG, PA 17105-8700. ------------------------------- |
| FORM 990, PART VI, SECTION B, LINE 11B | REVIEW OF FORM 990 BY GOVERNING BODY THE VICE PRESIDENT CONTROLLER AND THE DIRECTOR OF BUDGETING, FORECASTING AND ACCOUNTING REVIEWED THE FORM 990. FORM 990 WILL ALSO BE PROVIDED TO BOARD MEMBERS UPON COMPLITION PRIOR TO FILING. ------------------------------- |
| FORM 990, PART VI, SECTION B, LINES 15A & 15B | PROCESS TO ESTABLISH COMP OF TOP MANAGEMENT THE FOLLOWING PRACTICES OCCUR IN REGARD TO THE REVIEW AND APPROVAL OF COMPENSATION FOR THE CEO OF AFFILIA HOME HEALTH. AN INDEPENDENT BOARD REVIEWS COMPARATIVE MARKET DATA FOR SIMILARLY SIZED ORGANIZATIONS AS PROVIDED BY A THIRD PARTY CONSULTANT PRIOR TO TAKING ACTION ON ANY COMPENSATION DECISIONS. MINUTES OF THESE PROCEEDINGS ARE DOCUMENTED FOR FUTURE REFERENCE AND BOARD APPROVAL OCCURS BEFORE DECISIONS ARE IMPLEMENTED. THE POSITION OF CEO IS THE ONLY POSITION CONSIDERED TO BE AN EXECUTIVE LEADER THEREBY FOLLOWING PROCESS NOTED ABOVE. ------------------------------- |
| FORM 990, PART VI, SECTION B, LINE 12A | CONFLICT OF INTEREST POLICY IN ORDER TO ASCERTAIN AND EVALUATE ACTUAL OR POTENTIAL CONFLICTS, CERTAIN INTERESTED PERSONS ARE REQUIRED TO FILL OUT A CONFLICT OF INTEREST DISCLOSURE STATEMENT UPON ENTERING EMPLOYMENT OR BECOMING A TRUSTEE OF LANCASTER GENERAL HEALTH OR AN AFFILIATE, AND OTHERS ARE ALSO REQUIRED TO FILL OUT SUCH A STATEMENT ON AN ANNUAL BASIS. IN ADDITION TO THIS REQUIREMENT, ALL OFFICERS AND TRUSTEES, REGARDLESS OF WHETHER OR NOT THEY HAVE FILLED OUT OR HAVE BEEN ASKED TO FILL OUT A CONFLICT OF INTEREST DISCLOSURE STATEMENT, HAVE AN ONGOING AFFIRMATIVE DUTY TO BRING TO THE ATTENTION OF LANCASTER GENERAL HEALTH, SITUATIONS WHICH MAY GIVE RISE TO AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST AS DESCRIBED IN THE POLICY. ------------------------------ |
| FORM 990, PART VI, SECTION B, LINE 14 | DOCUMENT RETENTION AND DESTRUCTION POLICY THE ORGANIZATION HAS THE POLICIES AND PROCEDURES IN PLACE AS MENTIONED IN FORM 990, PART VI, LINE 14. HOWEVER, THEY ARE NOT CURRENTLY APPROVED BY THE GOVERNING BOARD. ------------------------------ |
| FORM 990, PART VI, SECTION C, LINE 19 | REQUIRED DOCUMENTS AVAILABLE TO THE PUBLIC AFFILIA HOME HEALTH DOES NOT MAKE THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. ------------------------------- |
| FORM 990, PART XI, LINE 9 | OTHER CHANGES IN NET ASSETS PERPETUAL TRUST-AMOUNT $ 8,907 PAYOUT PER SEPERATION (3,320,227) ------------ TOTAL $(3,311,370) ----------------------------- |
| Software ID: | |
| Software Version: |