Form990


Department of the TreasuryInternal Revenue Service
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)
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OMB No. 1545-0047
2021
Open to Public Inspection
A For the 2021 calendar year, or tax year beginning 01-01-2021 , and ending 12-31-2021
BCheck if applicable:
CName of organization
Capital Hospice
 
 
Doing business as
Capital Caring
 
Number and street (or P.O. box if mail is not delivered to street address)
3180 Fairview Park Drive 500
 
Room/suite
City or town, state or province, country, and ZIP or foreign postal code
Falls Church, VA22042
D Employer identification number

54-1920770
E Telephone number

G Gross receipts $ 116,669,205
F Name and address of principal officer:
Tom Koutsoumpas
3180 Fairview Park Drive 500
Falls Church,VA22042
I
Tax-exempt status: (   ) LeftBullet (insert no.) or
J
Website:MediumBullet
WWW.CAPITALCARING.ORG
H(a)
Is this a group return for
subordinates?
H(b)
Are all subordinates
included?
If "No," attach a list. See instructions.
H(c)
Group exemption number MediumBullet  
K Form of organization:  
L Year of formation: 1998
M State of legal domicile: VA
Part I
Summary
Activities & Governance 1 Briefly describe the organization’s mission or most significant activities: THE MISSION OF CAPITAL HOSPICE IS TO IMPROVE CARE FOR THOSE FACING LIFE-LIMITING ILLNESSES THROUGH DIRECT SUPPORT OF PATIENTS AND THEIR FAMILIES, PUBLIC EDUCATION AND ADVOCACY.
2 Check this box MediumBullet
3 Number of voting members of the governing body (Part VI, line 1a) ........ 3 8
4 Number of independent voting members of the governing body (Part VI, line 1b) ..... 4 7
5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) ...... 5 1,016
6 Total number of volunteers (estimate if necessary) ............. 6 542
7a Total unrelated business revenue from Part VIII, column (C), line 12 ........ 7a 0
b Net unrelated business taxable income from Form 990-T, Part I, line 11 ......... 7b 0
Revenues Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) ......... 8,258,648 7,828,621
9 Program service revenue (Part VIII, line 2g) ......... 97,018,241 97,888,206
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d ) .... 2,879,386 3,688,721
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 196,375 151,956
12 Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12) 108,352,650 109,557,504
Expenses; 13 Grants and similar amounts paid (Part IX, column (A), lines 1–3 )... 42,782 8,295
14 Benefits paid to or for members (Part IX, column (A), line 4).....   0
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10) 82,301,103 68,628,557
16a Professional fundraising fees (Part IX, column (A), line 11e) .....   0
b Total fundraising expenses (Part IX, column (D), line 25) MediumBullet4,267,958    
17 Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e).... 45,998,360 44,353,204
18 Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25) 128,342,245 112,990,056
19 Revenue less expenses. Subtract line 18 from line 12....... -19,989,595 -3,432,552
Net Assets or Fund Balances; Beginning of Current Year End of Year
20 Total assets (Part X, line 16)............. 64,552,568 46,704,036
21 Total liabilities (Part X, line 26)............. 39,647,615 27,228,746
22 Net assets or fund balances. Subtract line 21 from line 20..... 24,904,953 19,475,290
Part II
Signature Block
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.
Sign Here
JumboBullet
Signature of officer Date
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Type or print name and title
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Print/Type preparer's name
Preparer's signature
Date
PTIN
Firm's name MediumBullet

Firm's EIN MediumBullet
Firm's address MediumBullet



Phone no.
May the IRS discuss this return with the preparer shown above? (see instructions) ..........
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No. 11282Y Form 990 (2021)
Form 990 (2021)
Page 2
Part III
Statement of Program Service Accomplishments
Check if Schedule O contains a response or note to any line in this Part III..............
1
Briefly describe the organization’s mission: THE MISSION OF CAPITAL HOSPICE IS TO IMPROVE CARE FOR THOSE FACING LIFE-LIMITING ILLNESSES THROUGH DIRECT SUPPORT OF PATIENTS AND THEIR FAMILIES, PUBLIC EDUCATION AND PUBLIC ADVOCACY.
2
Did the organization undertake any significant program services during the year which were not listed on
the prior Form 990 or 990-EZ? .....................
If "Yes," describe these new services on Schedule O.
3
Did the organization cease conducting, or make significant changes in how it conducts, any program
services? ...........................
If "Yes," describe these changes on Schedule O.
4
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code:   ) (Expenses $ 72,639,181 including grants of $ 8,295 ) (Revenue $ 89,739,475 )
CAPITAL HOSPICE PROVIDES EXPERT MEDICAL, EMOTIONAL, SPIRITUAL AND PRACTICAL CARE AND SUPPORT TO PATIENTS WITH SERIOUS, PROGRESSIVE ILLNESS AND THEIR FAMILIES 24 HOURS A DAY, SEVEN DAYS A WEEK TO PATIENTS WHEREVER THEY LIVE BY QUALIFIED PHYSICIANS, NURSES, NURSES' AIDES, SOCIAL WORKERS, NON-DENOMINATIONAL CHAPLAINS AND OTHER PROFESSIONALS. IT IS THE OBJECTIVE OF CAPITAL HOSPICE TO PROVIDE CARE TO ANYONE MEDICALLY ELIGIBLE, REGARDLESS OF THE PATIENT'S ABILITY TO PAY. CAPITAL HOSPICE PROVIDED SERVICES TO 8,366 PATIENTS DURING 2021 AND HAD 449,113 PATIENT DAYS OF CARE. CAPITAL HOSPICE HAD COSTS RELATED TO SERVICES AND SUPPLIES UNDER ITS CHARITY CARE POLICY OF APPROXIMATELY $1,819,000 IN 2021.
4b (Code:   ) (Expenses $ 10,067,101 including grants of $ 0 ) (Revenue $ 5,850,877 )
HALQUIST MEMORIAL INPATIENT CENTER, ADLER CENTER FOR CARING, CAPITAL CARING CENTER - GREENBELT AND CAPITAL CARING CENTER - WASHINGTON, DC: INPATIENT UNITS TO PROVIDE CARE FOR OUR HOSPICE PATIENTS THAT NEED CONSTANT MONITORING AND WHOSE PAIN AND SYMPTOMS CAN'T BE ADEQUATELY MANAGED AT HOME. IT IS THE OBJECTIVE OF THE INPATIENT UNITS TO MAKE OUR PATIENTS AS SYMPTOM FREE AND AS COMFORTABLE AS POSSIBLE. THE HALQUIST MEMORIAL INPATIENT CENTER PROVIDED CARE TO 150 PATIENTS AND HAD 1,129 PATIENT DAYS OF CARE IN 2021. THE ADLER CENTER FOR CARING PROVIDED CARE TO 451 PATIENTS AND HAD 3,630 PATIENT DAYS OF CARE IN 2021. THE CAPITAL CARING CENTER - GREENBELT PROVIDED CARE TO 110 PATIENTS AND HAD 716 PATIENT DAYS OF CARE IN 2021. THE CAPITAL CARING CENTER - WASHINGTON, DC PROVIDED CARE TO 289 PATIENTS AND HAD 2,698 PATIENT DAYS OF CARE IN 2021.
4c (Code:   ) (Expenses $ 8,624,236 including grants of $ 0 ) (Revenue $ 2,525,906 )
CAPITAL PALLIATIVE CARE CONSULTANTS PROVIDES PHYSICIAN SERVICES TO OUR HOSPICE PATIENTS, AND TO NON-HOSPICE ELIGIBLE PATIENTS WHO ARE IN NEED OF SYMPTOM MANAGEMENT. IT IS THE OBJECTIVE OF CAPITAL PALLIATIVE CARE CONSULTANTS TO PROVIDE PHYSICIAN SERVICES TO ALL PATIENTS IN NEED OF SYMPTOM MANAGEMENT, REGARDLESS OF THE PATIENT'S ABILITY TO PAY. CAPITAL PALLIATIVE CARE CONSULTANTS PROVIDED 28,161 PATIENT VISITS DURING 2021.
4d Other program services (Describe in Schedule O.)
(Expenses $   including grants of $   ) (Revenue $   )
4e Total program service expensesMediumBullet91,330,518
Form 990 (2021)
Form 990 (2021)
Page 3
Part IV
Checklist of Required Schedules
Yes
No
1
Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule AClick to see attachment.....................
1
Yes
 
2
Is the organization required to complete Schedule B, Schedule of Contributors? See instructions. Click to see attachment...
2
Yes
 
3
Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I.............
3
 
No
4
Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II.........
4
 
No
5
Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Rev. Proc. 98-19? If "Yes," complete Schedule C, Part III..
5
 
 
6
Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I.........................
6
 
No
7
Did the organization receive or hold a conservation easement, including easements to preserve open space,
the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II....
7
 
No
8
Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes,"
complete Schedule D, Part III..............
8
 
No
9
Did the organization report an amount in Part X, line 21 for escrow or custodial account liability; serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV..............
9
 
No
10
Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi endowments? If "Yes," complete Schedule D, Part VClick to see attachment......
10
Yes
 
11
If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X, as applicable.
a
Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete
Schedule D, Part VI. Click to see attachment...................
11a
Yes
 
b
Did the organization report an amount for investments—other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII.......
11b
 
No
c
Did the organization report an amount for investments—program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII.......
11c
 
No
d
Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IXClick to see attachment............
11d
Yes
 
e
Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part XClick to see attachment
11e
Yes
 
f
Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization’s liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part XClick to see attachment
11f
Yes
 
12a
Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete
Schedule D, Parts XI and XII......................
12a
 
No
b
Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional Click to see attachment
12b
Yes
 
13
Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E
13
 
No
14a
Did the organization maintain an office, employees, or agents outside of the United States? .....
14a
 
No
b
Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV.........
14b
 
No
15
Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If “Yes,” complete Schedule F, Parts II and IV.....
15
 
No
16
Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If “Yes,” complete Schedule F, Parts III and IV...
16
 
No
17
Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I. See instructions. ....
17
 
No
18
Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II............ Click to see attachment
18
Yes
 
19
Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III...................
19
 
No
20a
Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H....
20a
 
No
b
If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return?
20b
 
 
21
Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If “Yes,” complete Schedule I, Parts I and II.....
21
 
No
Form 990 (2021)
Form 990 (2021)
Page 4
Part IV
Checklist of Required Schedules (continued)
Yes
No
22
Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If “Yes,” complete Schedule I, Parts I and III........
22
 
No
23
Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5, about compensation of the organization’s current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J....................... Click to see attachment
23
Yes
 
24a
Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If “Yes,” answer lines 24b through 24d and complete Schedule K. If “No,” go to line 25a...............
24a
 
No
b
Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception?...
24b
 
 
c
Did the organization maintain an escrow account other than a refunding escrow at any time during the year
to defease any tax-exempt bonds? ...............
24c
 
 
d
Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year?...
24d
 
 
25a
Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I ....
25a
 
No
b
Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization’s prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I.......................
25b
 
No
26
Did the organization report any amount on Part X, line 5 or 22 for receivables from or payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part II...........
26
 
No
27
Did the organization provide a grant or other assistance to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or employee thereof, a grant selection committee member, or to a 35% controlled entity (including an employee thereof) or family member of any of these persons?
If "Yes," complete
Schedule L, Part III.........................
27
 
No
28
Was the organization a party to a business transaction with one of the following parties (see the Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions):
a
A current or former officer, director, trustee, key employee, creator or founder, or substantial contributor? If "Yes," complete Schedule L, Part IV......................
28a
 
No
b
A family member of any individual described in line 28a? If "Yes," complete Schedule L, Part IV.....Click to see attachment
28b
Yes
 
c
A 35% controlled entity of one or more individuals and/or organizations described in line 28a or 28b? If "Yes," complete Schedule L, Part IV..................... Click to see attachment
28c
Yes
 
29
Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M..Click to see attachment
29
Yes
 
30
Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M .................Click to see attachment
30
Yes
 
31
Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I
31
 
No
32
Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II........................
32
 
No
33
Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I............Click to see attachment
33
Yes
 
34
Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1.........................Click to see attachment
34
Yes
 
35a
Did the organization have a controlled entity within the meaning of section 512(b)(13)?
35a
 
No
b
If ‘Yes’ to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 ...
35b
 
 
36
Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2.............
36
 
No
37
Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI
37
 
No
38
Did the organization complete Schedule O and provide explanations on Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. ............
38
Yes
 
Part V
Statements Regarding Other IRS Filings and Tax Compliance
Check if Schedule O contains a response or note to any line in this Part V...........
Yes
No
1a
Enter the number reported in box 3 of Form 1096. Enter -0- if not applicable ..
1a
163
b
Enter the number of Forms W-2G included on line 1a. Enter -0- if not applicable .
1b
0
c
Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? ..................
1c
Yes
 
Form 990 (2021)
Form 990 (2021)
Page 5
Part V
Statements Regarding Other IRS Filings and Tax Compliance (continued)
2a
Enter the number of employees reported on Form W-3, Transmittal of Wage and
Tax Statements, filed for the calendar year ending with or within the year covered by this return ..................
2a
1,016
b
If at least one is reported on line 2a, did the organization file all required federal employment tax returns?
Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file. See instructions.
2b
Yes
 
3a
Did the organization have unrelated business gross income of $1,000 or more during the year?...
3a
 
No
b
If “Yes,” has it filed a Form 990-T for this year? If “No” to line 3b, provide an explanation in Schedule O...
3b
 
 
4a
At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? ..
4a
 
No
b
If "Yes," enter the name of the foreign country: MediumBullet
See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).
5a
Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? ..
5a
 
No
b
Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction?
5b
 
No
c
If "Yes," to line 5a or 5b, did the organization file Form 8886-T? ............
5c
 
 
6a
Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? ...
6a
 
No
b
If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? ......................
6b
 
 
7
Organizations that may receive deductible contributions under section 170(c).
a
Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? ....................
7a
 
No
b
If "Yes," did the organization notify the donor of the value of the goods or services provided? .....
7b
 
 
c
Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? .........................
7c
 
No
d
If "Yes," indicate the number of Forms 8282 filed during the year ....
7d
 
e
Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract?
7e
 
No
f
Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? ..
7f
 
No
g
If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? ......................
7g
 
 
h
If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? ..........................
7h
 
 
8
Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? ........
8
 
 
9
Sponsoring organizations maintaining donor advised funds.
a
Did the sponsoring organization make any taxable distributions under section 4966?........
9a
 
 
b
Did the sponsoring organization make a distribution to a donor, donor advisor, or related person?...
9b
 
 
10
Section 501(c)(7) organizations. Enter:
a
Initiation fees and capital contributions included on Part VIII, line 12 ...
10a
 
b
Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities
10b
 
11
Section 501(c)(12) organizations. Enter:
a
Gross income from members or shareholders .........
11a
 
b
Gross income from other sources. (Do not net amounts due or paid to other sources against amounts due or received from them.) ..........
11b
 
12a
Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041?
12a
 
 
b
If "Yes," enter the amount of tax-exempt interest received or accrued during the year.
12b
 
13
Section 501(c)(29) qualified nonprofit health insurance issuers.
a
Is the organization licensed to issue qualified health plans in more than one state? .........
Note. See the instructions for additional information the organization must report on Schedule O.
13a
 
 
b
Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans ....
13b
 
c
Enter the amount of reserves on hand ............
13c
 
14a
Did the organization receive any payments for indoor tanning services during the tax year?.....
14a
 
No
b
If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O..
14b
 
 
15
Is the organization subject to the section 4960 tax on payment(s) of more than $1,000,000 in remuneration or excess parachute payment(s) during the year? ....................
If "Yes," see the instructions and file Form 4720, Schedule N.
15
 
No
16
Is the organization an educational institution subject to the section 4968 excise tax on net investment income? ..
If "Yes," complete Form 4720, Schedule O.
16
 
No
17
Section 501(c)(21) organizations. Did the trust, any disqualified person, or mine operator engage in any activities that would result in the imposition of an excise tax under section 4951, 4952, or 4953? ..
If "Yes," complete Form 6069.
17
 
 
Form 990 (2021)
Form 990 (2021)
Page 6
Part VI
Governance, Management, and Disclosure. For each "Yes" response to lines 2 through 7b below, and for a "No" response to lines 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions.
Check if Schedule O contains a response or note to any line in this Part VI..............
Section A. Governing Body and Management
Yes
No
1a
Enter the number of voting members of the governing body at the end of the tax year
1a
8
If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O.
b
Enter the number of voting members included in line 1a, above, who are independent
1b
7
2
Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? .................
2
 
No
3
Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors or trustees, or key employees to a management company or other person? .
3
 
No
4
Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? .
4
 
No
5
Did the organization become aware during the year of a significant diversion of the organization’s assets? .
5
 
No
6
Did the organization have members or stockholders? ................
6
Yes
 
7a
Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? ....................
7a
Yes
 
b
Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? ...................
7b
Yes
 
8
Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following:
a
The governing body? .......................
8a
Yes
 
b
Each committee with authority to act on behalf of the governing body? ............
8b
Yes
 
9
Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization’s mailing address? If "Yes," provide the names and addresses in Schedule O.......
9
 
No
Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.)
Yes
No
10a
Did the organization have local chapters, branches, or affiliates? ............
10a
 
No
b
If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes?
10b
 
 
11a
Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? ............................
11a
Yes
 
b
Describe on Schedule O the process, if any, used by the organization to review this Form 990. .....
12a
Did the organization have a written conflict of interest policy? If "No," go to line 13.......
12a
Yes
 
b
Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? ..........................
12b
Yes
 
c
Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe on Schedule O how this was done...................
12c
Yes
 
13
Did the organization have a written whistleblower policy? ...............
13
Yes
 
14
Did the organization have a written document retention and destruction policy? .........
14
Yes
 
15
Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision?
a
The organization’s CEO, Executive Director, or top management official ...........
15a
 
No
b
Other officers or key employees of the organization ................
15b
 
No
If "Yes" to line 15a or 15b, describe the process on Schedule O. See instructions.
16a
Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? ......................
16a
 
No
b
If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization’s exempt status with respect to such arrangements? ............
16b
 
 
Section C. Disclosure
17
List the states with which a copy of this Form 990 is required to be filedMediumBullet
CA , CO , CT , DC , FL , GA , IL , MD , MA , MN , MO , NJ , NY , NC , OH , PA , SC , TN , VA , WA , WV
18
Section 6104 requires an organization to make its Form 1023 (1024 or 1024-A, if applicable), 990, and 990-T (section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply.
19
Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year.
20
State the name, address, and telephone number of the person who possesses the organization's books and records:
MediumBulletTHE ORGANIZATION3180 Fairview Park Drive   Suite,VA220421206 (703) 531-6231
Form 990 (2021)
Form 990 (2021)
Page 7
Part VII
Compensation of Officers, Directors,Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors
Check if Schedule O contains a response or note to any line in this Part VII..............
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees
1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization’s tax year.
RoundBullet List all of the organization’s current officers, directors, trustees (whether individuals or organizations), regardless of amount
of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid.

RoundBullet List all of the organization’s current key employees, if any. See the instructions for definition of "key employee."
RoundBullet List the organization’s five current highest compensated employees (other than an officer, director, trustee or key employee)
who received reportable compensation (box 5 of Form W-2, Form 1099-MISC, and/or box 1 of Form 1099-NEC) of more than $100,000 from the
organization and any related organizations.

RoundBullet List all of the organization’s former officers, key employees, or highest compensated employees who received more than $100,000
of reportable compensation from the organization and any related organizations.

RoundBullet List all of the organization’s former directors or trustees that received, in the capacity as a former director or trustee of the
organization, more than $10,000 of reportable compensation from the organization and any related organizations.

See the instructions for the order in which to list the persons above.
Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee.
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(1) LYNN MENTO
 
BOARD CHAIR
 1.0
.................
3.0 		X   X       0 0 0
(2) Rev Dr TYRONE PITTS
 
BOARD VICE CHAIR
 1.0
.................
3.0 		X   X       0 0 0
(3) TERENCE BURNS
 
TREASURER (through Aug 2021)
 1.0
.................
3.0 		X   X       0 0 0
(4) TOM KOUTSOUMPAS
 
PRESIDENT/CEO
 40.0
.................
3.0 		X   X       536,983 0 20,567
(5) BILL NOVELLI
 
Board Member
 1.0
.................
3.0 		X           0 0 0
(6) CLIFFORD E BARNES
 
BOARD MEMBER
 1.0
.................
3.0 		X           0 0 0
(7) DIANE TY
 
BOARD MEMBER
 1.0
.................
3.0 		X           0 0 0
(8) JOHN ADAMS
 
BOARD MEMBER
 1.0
.................
3.0 		X           0 0 0
(9) SUE HARGREAVES
 
BOARD MEMBER
 1.0
.................
3.0 		X           0 0 0
(10) DAVID A SCHWIND
 
CHIEF FINANCIAL OFFICER (Through July 2021)
 40.0
.................
0 		    X       294,271 0 22,334
(11) GARY BACHER
 
CHIEF OF STATEGY, POLICY & LEGAL AFFAIRS
 40.0
.................
0 		      X     332,365 0 25,303
(12) KEITH EVERETT
 
CHIEF PERFORMANCE & COMPLIANCE OFFICER
 40.0
.................
0 		      X     161,654 0 24,245
(13) KIERAN SHAH
 
CHIEF GROWTH OFFICER
 40.0
.................
0 		      X     205,275 0 11,358
(14) KIMBERLY GROVE
 
CHIEF OF STAFF
 40.0
.................
0 		      X     158,369 0 22,306
(15) MATTHEW KESTENBAUM MD
 
CHIEF MEDICAL OFFICER (CMO)
 40.0
.................
0 		      X     281,285 0 7,404
(16) STEVE CONE
 
CHIEF OF COMMUNICATIONS, MARKETING & PHILANTHROPY
 40.0
.................
0 		      X     208,898 0 8,785
(17) SUSAN BORIS
 
CHIEF OF CLINICAL OPERATIONS (Through July 2021)
 40.0
.................
0 		      X     181,451 0 19,305
Form 990 (2021)
Form 990 (2021)
Page 8
Part VII
Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued)
(A)
Name and title 		(B)
Average hours per week (list any hours for related organizations below dotted line) 		(C)
Position (do not check more than one box, unless person is both an officer and a director/trustee) 		(D)
Reportable compensation from the organization (W-2/1099-MISC/1099-NEC) 		(E)
Reportable compensation from related organizations (W-2/1099-MISC/1099-NEC) 		(F)
Estimated amount of other compensation from the organization and related organizations
Individual Trustee or Director; Institutional Trustee; OfficerInd; Key Employee; Highest compensated employee; FormerOfcrDirectorTrusteeInd;
(18) HEIDI YOUNG MD
 
HPM PHYSICIAN
 40.0
.......................0 		        X   267,858 0 26,848
(19) JOHN MCCUE MD
 
HPM PHYSICIAN
 40.0
.......................0 		        X   270,791 0 12,977
(20) LEE ANNE WEST MD
 
EXECUTIVE DIRECTOR, INPATIENT SERVICES
 40.0
.......................0 		        X   281,075 0 25,550
(21) MICHAEL BYAS-SMITH MD
 
MEDICAL DIRECTOR
 40.0
.......................0 		        X   388,475 0 27,461
(22) RAY JAY GARCIA MD
 
HPM PHYSICIAN
 40.0
.......................0 		        X   243,499 0 5,350
















1b Sub-Total................MediumBullet
c Total from continuation sheets to Part VII, Section A....MediumBullet
d Total (add lines 1b and 1c)...........MediumBullet 3,812,249 0 259,793
2
Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization MediumBullet95
Yes
No
3
Did the organization list any former officer, director or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual ..............
3
 
No
4
For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If "Yes," complete Schedule J for such
individual...........................
4
Yes
 
5
Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If "Yes," complete Schedule J for such person ........
5
 
No
Section B. Independent Contractors
1
Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization’s tax year.
(A)
Name and business address 		(B)
Description of services 		(C)
Compensation
INOVA FAIRFAX HOSPITAL

3300 GALLOWS ROAD
FALLS CHURCH,VA22042 		GENERAL INPATIENT SERVICES 1,493,674
Crescent Cities Nursing & Rehab Center

4409 East West Highway
Riverdale,MD20737 		Nursing Home Services 631,356
LAYHILL SNF

3227 BEL PRE ROAD
SILVER SPRING,MD20906 		NURSING HOME SERVICE 547,346
MANORCARE LARGO

600 LARGO ROAD
LARGO,MD20774 		NURSING HOME SERVICES 531,000
CAROLL MANOR NURSING HOME

1150 VARNUM STREET NE
WASHINGTON,DC200172180 		NURSING HOME SERVICES 515,338
2
Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization MediumBullet21
Form 990 (2021)
Form 990 (2021)
Page 9
Part VIII
Statement of Revenue
Check if Schedule O contains a response or note to any line in this Part VIII.............
(A)
Total revenue 		(B)
Related or
exempt
function
revenue 		(C)
Unrelated
business
revenue 		(D)
Revenue
excluded from
tax under sections
512 - 514
Contributions, Gifts, Grants, and OtherAmt Similar Amounts 1a Federated campaigns..1a  
b Membership dues..1b  
c Fundraising events..1c 65,000
d Related organizations1d  
e Government grants (contributions)1e 599,160
f All other contributions, gifts, grants, and similar amounts not included above1f 7,164,461
g Noncash contributions included in lines 1a - 1f:$ 1g 269,998
h Total. Add lines 1a-1f.......MediumBullet 7,828,621
Program Service RevenueAmt Business Code
2a PATIENT SERVICES 621620 97,888,206 97,888,206    
b
c
d
e
f All other program service revenue. 0 0 0 0
g Total. Add lines 2a–2f .....MediumBullet 97,888,206
OtherAmtRevenueAmt 3 Investment income (including dividends, interest, and othersimilar amounts) ......MediumBullet 377,074     377,074
4 Income from investment of tax-exempt bond proceedsMediumBullet        
5 Royalties...........MediumBullet        
(ii) Personal (i) Real
6a Gross rents   168,725 6a
b Less: rental expenses   242,821 6b
c Rental income or (loss) 0 -74,096 6c
d Net rental income or (loss).......MediumBullet -74,096     -74,096
(ii) Other (i) Securities
7a Gross amount from sales of assets other than inventory   10,178,527 7a
b Less: cost or other basis and sales expenses   6,866,880 7b
c Gain or (loss) 0 3,311,647 7c
d Net gain or (loss).........MediumBullet 3,311,647     3,311,647
8a Gross income from fundraising events (not including $ 65,000of contributions reported on line 1c). See Part IV, line 18 ....
8a 0
b Less: direct expenses ... 8b 2,000
c Net income or (loss) from fundraising events..MediumBullet -2,000   -2,000
9a Gross income from gaming activities.
See Part IV, line 19 ...
9a  
b Less: direct expenses ... 9b  
c Net income or (loss) from gaming activities..MediumBullet        
10a Gross sales of inventory, less
returns and allowances ..
10a  
b Less: cost of goods sold .. 10b  
c Net income or (loss) from sales of inventory..MediumBullet        
Business Code Miscellaneous Revenue
11a THRIFT STORE REVENUE 900099 220,804 220,804    
b educational materials fees 900099 3,699 3,699    
c FOOD SERVICE REVENUE 900099 3,236 3,236    
d All other revenue .... 313 313 0 0
e Total. Add lines 11a–11d ...... MediumBullet 228,052
12 Total revenue. See instructions.....MediumBullet 109,557,504 98,116,258 0 3,612,625
Form 990 (2021)
Form 990 (2021)
Page 10
Part IX
Statement of Functional Expenses
Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A).Check if Schedule O contains a response or note to any line in this Part IX..............
Do not include amounts reported on lines 6b,
7b, 8b, 9b, and 10b of Part VIII. 		(A)
Total expenses 		(B)
Program service expenses 		(C)
Management and general expenses 		(D)
Fundraising
expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 .... 8,295 8,295
2 Grants and other assistance to domestic individuals. See Part IV, line 22 ...........    
3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16. .............    
4 Benefits paid to or for members .......    
5 Compensation of current officers, directors, trustees, and key employees ........... 2,360,549 2,188,259 141,886 30,404
6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ......... 358,442 58,832 247,306 52,304
7 Other salaries and wages........ 54,204,796 47,075,639 6,367,888 761,269
8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) .... 794,907 691,235 91,904 11,768
9 Other employee benefits ....... 6,771,366 5,895,712 779,591 96,063
10 Payroll taxes ........... 4,138,497 3,598,753 478,479 61,265
11 Fees for services (non-employees):        
a Management ......        
b Legal ......... 336,453   336,453  
c Accounting ........... 35,583   35,583  
d Lobbying ...........        
e Professional fundraising services. See Part IV, line 17    
f Investment management fees ...... 82,498   82,498  
g Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) 16,701,189 11,890,885 4,463,345 346,959
12 Advertising and promotion .... 580,431 2,802 576,526 1,103
13 Office expenses ....... 1,760,887 807,888 703,884 249,115
14 Information technology ...... 3,011,056 705,413 1,993,071 312,572
15 Royalties ..        
16 Occupancy ........... 4,848,834 2,545,529 63,771 2,239,534
17 Travel ............ 1,380,973 1,087,194 290,527 3,252
18 Payments of travel or entertainment expenses for any federal, state, or local public officials .        
19 Conferences, conventions, and meetings .... 60,247 29,298 30,949 0
20 Interest ........... 46,633 0 10,220 36,413
21 Payments to affiliates .......        
22 Depreciation, depletion, and amortization .. 1,170,114 988,798 161,841 19,475
23 Insurance ... 451,100 418,175 27,115 5,810
24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a MEDICAL SUPPLIES 10,053,792 10,014,996 38,796 0
b BAD DEBT 3,314,952 3,314,952 0 0
c
d
e All other expenses 518,462 7,863 469,947 40,652
25 Total functional expenses. Add lines 1 through 24e 112,990,056 91,330,518 17,391,580 4,267,958
26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here MediumBullet if following SOP 98-2 (ASC 958-720).        
Form 990 (2021)
Form 990 (2021)
Page 11
Part X
Balance Sheet
Check if Schedule O contains a response or note to any line in this Part IX..............
(A)
Beginning of year 		(B)
End of year
Assets 1 Cash–non-interest-bearing ........ 15,010 1 2,880
2 Savings and temporary cash investments ......... 2,771,516 2 1,374,684
3 Pledges and grants receivable, net ...... 135,875 3 420,881
4 Accounts receivable, net ............. 21,183,935 4 12,500,099
5 Loans and other receivables from any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .......
100,000 5 0
6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), and persons described in section 4958(c)(3)(B) ...
0 6 0
7 Notes and loans receivable, net ........... 0 7  
8 Inventories for sale or use ............ 0 8  
9 Prepaid expenses and deferred charges ...... 1,237,714 9 509,002
10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 39,087,041
b Less: accumulated depreciation 10b 18,602,743 20,144,865 10c 20,484,298
11 Investments—publicly traded securities . 14,717,436 11 7,134,207
12 Investments—other securities. See Part IV, line 11 ..... 16,373 12 16,373
13 Investments—program-related. See Part IV, line 11 .. 0 13  
14 Intangible assets ...............   14  
15 Other assets. See Part IV, line 11 ........... 4,229,844 15 4,261,612
16 Total assets. Add lines 1 through 15 (must equal line 33)... 64,552,568 16 46,704,036
Liabilities 17 Accounts payable and accrued expenses ..... 17,082,140 17 18,280,071
18 Grants payable ...   18  
19 Deferred revenue .........   19  
20 Tax-exempt bond liabilities .........   20  
21 Escrow or custodial account liability. Complete Part IV of Schedule D   21  
22 Loans and other payables to any current or former officer, director, trustee, key employee, creator or founder, substantial contributor, or 35% controlled entity or family member of any of these persons .........
0 22 0
23 Secured mortgages and notes payable to unrelated third parties .. 22,274,670 23 8,731,745
24 Unsecured notes and loans payable to unrelated third parties ..   24  
25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17 - 24). Complete Part X of Schedule D 290,805 25 216,930
26 Total liabilities. Add lines 17 through 25.. 39,647,615 26 27,228,746
Net Assets or Fund Balance Organizations that follow FASB ASC 958, check here MediumBullet and complete lines 27, 28, 32, and 33.
27 Net assets without donor restrictions .......... 15,858,795 27 10,584,662
28 Net assets with donor restrictions ........... 9,046,158 28 8,890,628
Organizations that do not follow FASB ASC 958, check here MediumBullet and complete lines 29 through 33.
29 Capital stock or trust principal, or current funds .....   29  
30 Paid-in or capital surplus, or land, building or equipment fund ...   30  
31 Retained earnings, endowment, accumulated income, or other funds   31  
32 Total net assets or fund balances ........... 24,904,953 32 19,475,290
33 Total liabilities and net assets/fund balances ........ 64,552,568 33 46,704,036
Form 990 (2021)
Form 990 (2021)
Page 12
Part XI
Reconcilliation of Net Assets
Check if Schedule O contains a response or note to any line in this Part XI..............
1
Total revenue (must equal Part VIII, column (A), line 12) ............
1
109,557,504
2
Total expenses (must equal Part IX, column (A), line 25) ............
2
112,990,056
3
Revenue less expenses. Subtract line 2 from line 1 ..............
3
-3,432,552
4
Net assets or fund balances at beginning of year (must equal Part X, line 32, column (A)) ..
4
24,904,953
5
Net unrealized gains (losses) on investments ...............
5
-1,997,111
6
Donated services and use of facilities .................
6
0
7
Investment expenses .....................
7
0
8
Prior period adjustments .....................
8
0
9
Other changes in net assets or fund balances (explain in Schedule O) ........
9
0
10
Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 32, column (B))
10
19,475,290
Part XII
Financial Statements and Reporting
Check if Schedule O contains a response or note to any line in this Part XII.............
Yes
No
1
Accounting method used to prepare the Form 990:  
If the organization changed its method of accounting from a prior year or checked "Other," explain on
Schedule O.
2a
Were the organization’s financial statements compiled or reviewed by an independent accountant?
2a
 
No
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both:
b
Were the organization’s financial statements audited by an independent accountant?
2b
Yes
 
If ‘Yes,’ check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both:
c
If "Yes," to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant?
2c
Yes
 
If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O.
3a
As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133?
3a
Yes
 
b
If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits.
3b
Yes
 
Form 990 (2021)
Form 990 (2021)
Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Form 990, Special Condition Description:
Special Condition Description
SCHEDULE A
(Form 990)

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.
right arrow Attach to Form 990 or Form 990-EZ.
right arrow Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
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 12, check only one box.)
1
2
3
4
5
6
7
8
9
10
11
12
a
b
c
d
e
f
Enter the number of supported organizations ...............................  
g
Provide the following information about the supported organization(s).
(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
 
   
For Paperwork Reduction Act Notice, see the Instructions for
Form 990 or 990-EZ.
Cat. No. 11285F
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
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 failed to qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") ..            
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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (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 VI.)..            
11 Total support. Add lines 7 through 10  
12
12
 
13
First 5 years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here ........................................right arrow
Section C. Computation of Public Support Percentage
14
14
 
15
15
 
16a
b
17a
b
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 ..................................................... right arrow
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 10 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) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . 5,280,547 4,614,921 4,493,942 10,258,650 7,828,621 32,476,681
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 89,895,820 91,297,648 89,863,153 97,018,241 97,888,206 465,963,068
3 Gross receipts from activities that are not an unrelated trade or business under section 513 ..... 266,550 68,375 63,125 0 0 398,050
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 95,442,917 95,980,944 94,420,220 107,276,891 105,716,827 498,837,799
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.) 498,837,799
Section B. Total Support
Calendar year (or fiscal year beginning in) right arrow (a) 2017 (b) 2018 (c) 2019 (d) 2020 (e) 2021 (f) Total
9 Amounts from line 6... 95,442,917 95,980,944 94,420,220 107,276,891 105,716,827 498,837,799
10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. 840,102 1,042,647 1,125,379 595,637 545,799 4,149,564
b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.           0
c Add lines 10a and 10b. 840,102 1,042,647 1,125,379 595,637 545,799 4,149,564
11 Net income from unrelated business activities not included on 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 VI.) .. 95,332 382,081 485,262 245,339 228,052 1,436,066
13 Total support. (Add lines 9, 10c, 11, and 12.).. 96,378,351 97,405,672 96,030,861 108,117,867 106,490,678 504,423,429
14
Section C. Computation of Public Support Percentage
15
15
98.89 %
16
16
98.87 %
Section D. Computation of Investment Income Percentage
17
17
1 %
18
18
1 %
19a
b
20
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 4
Part IV
Supporting Organizations
(Complete only if you checked a box on line 12 of Part I. If you checked box 12a, of Part I, complete Sections A and B. If you checked box 12b, of Part I, complete Sections A and C. If you checked box 12c, of Part I, complete Sections A, D, and E. If you checked box12d, of Part I, complete Sections A and D, and complete Part V.)
Section A. All Supporting Organizations
Yes
No
1
Are all of the organization’s supported organizations listed by name in the organization’s governing documents?
If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose,
describe the designation. If historic and continuing relationship, explain.
1
 
 
2
Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2).
2
 
 
3a
Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer lines 3b and 3c below.
3a
 
 
b
Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination.
3b
 
 
c
Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use.
3c
 
 
4a
Was any supported organization not organized in the United States ("foreign supported organization")? If “Yes” and if you checked box 12a or 12b in Part I, answer lines 4b and 4c below.
4a
 
 
b
Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If “Yes,” describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations.
4b
 
 
c
Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If “Yes,” explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes.
4c
 
 
5a
Did the organization add, substitute, or remove any supported organizations during the tax year? If “Yes,” answer lines 5b and 5c below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document).
5a
 
 
b
Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document?
5b
 
 
c
Substitutions only. Was the substitution the result of an event beyond the organization's control?
5c
 
 
6
Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If “Yes,” provide detail in Part VI.
6
 
 
7
Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If “Yes,” complete Part I of Schedule L (Form 990) .
7
 
 
8
Did the organization make a loan to a disqualified person (as defined in section 4958) not described on line 7? If “Yes,” complete Part I of Schedule L (Form 990).
8
 
 
9a
Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons, as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If “Yes,” provide detail in Part VI.
9a
 
 
b
Did one or more disqualified persons (as defined on line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If “Yes,” provide detail in Part VI.
9b
 
 
c
Did a disqualified person (as defined on line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If “Yes,” provide detail in Part VI.
9c
 
 
10a
Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If “Yes,” answer line 10b below.
10a
 
 
b
Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings).
10b
 
 
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 5
Part IV
Supporting Organizations (continued)
Yes
No
11
Has the organization accepted a gift or contribution from any of the following persons?
a
A person who directly or indirectly controls, either alone or together with persons described on lines 11b and 11c below, the governing body of a supported organization?
11a
 
 
b
A family member of a person described on 11a above?
11b
 
 
c
A 35% controlled entity of a person described on line 11a or 11b above? If “Yes” to 11a, 11b, or 11c, provide detail in Part VI.
11c
 
 
Section B. Type I Supporting Organizations
Yes
No
1
Did the officers, directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If “No,” describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year.
1
 
 
2
Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If “Yes,” explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised or controlled the supporting organization.
2
 
 
Section C. Type II Supporting Organizations
Yes
No
1
Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If “No,” describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s).
1
 
 
Section D. All Type III Supporting Organizations
Yes
No
1
Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided?
1
 
 
2
Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s).
2
 
 
3
By reason of the relationship described in line 2 above, did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard.
3
 
 
Section E. Type III Functionally-Integrated Supporting Organizations
1
Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions):
a
b
c
2
Activities Test. Answer lines 2a and 2b below.
Yes
No
a
Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities.
2a
 
 
b
Did the activities described on line 2a, above constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement.
2b
 
 
3
Parent of Supported Organizations. Answer lines 3a and 3b below.
a
Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations?If "Yes" or "No", provide details in Part VI.
3a
 
 
b
Did the organization exercise a substantial degree of direction over the policies, programs and activities of each of its supported organizations? If "Yes," describe in Part VI. the role played by the organization in this regard.
3b
 
 
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 6
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations
1
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 0.015 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 0.035 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  
7
Schedule A (Form 990) 2021

Schedule A (Form 990) 2021
Page 7
Part V
Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations(continued)
Section D - Distributions Current Year
1 Amounts paid to supported organizations to accomplish exempt purposes 1  
2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in
excess of income from activity 		2  
3 Administrative expenses paid to accomplish exempt purposes of supported organizations 3  
4 Amounts paid to acquire exempt-use assets 4  
5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) 5  
6 Other distributions (describe in Part VI). See instructions 6  
7Total annual distributions. Add lines 1 through 6. 7  
8 Distributions to attentive supported organizations to which the organization is responsive (provide
details in Part VI). See instructions 		8  
9 Distributable amount for 2021 from Section C, line 6 9  
10 Line 8 amount divided by Line 9 amount 10  
Section E - Distribution Allocations (see instructions) (i)
Excess Distributions 		(ii)
Underdistributions
Pre-2021 		(iii)
Distributable
Amount for 2021
1 Distributable amount for 2021 from Section C, line 6  
2 Underdistributions, if any, for years prior to 2021 (reasonable cause required-- explain in Part VI).
See instructions.		  
3 Excess distributions carryover, if any, to 2021:
a From 2016.......  
b From 2017.......  
c From 2018.......  
d From 2019.......  
e From 2020.......  
fTotal of lines 3a through e  
g Applied to underdistributions of prior years  
h Applied to 2021 distributable amount  
i Carryover from 2016 not applied (see
instructions) 		 
j Remainder. Subtract lines 3g, 3h, and 3i from line 3f.  
4Distributions for 2021 from Section D, line 7:
$  
a Applied to underdistributions of prior years  
b Applied to 2021 distributable amount  
c Remainder. Subtract lines 4a and 4b from line 4.  
5 Remaining underdistributions for years prior to
2021, if any. Subtract lines 3g and 4a from line 2.
If the amount is greater than zero, explain in Part VI.
See instructions. 		 
6 Remaining underdistributions for 2021. Subtract
lines 3h and 4b from line 1. If the amount is greater
than zero, explain in Part VI. See instructions. 		 
7 Excess distributions carryover to 2022. Add lines
3j and 4c. 		 
8 Breakdown of line 7:
a Excess from 2017.....  
b Excess from 2018.....  
c Excess from 2019.....  
d Excess from 2020.....  
e Excess from 2021.....  
Schedule A (Form 990) (2021)

Schedule A (Form 990) 2021
Page 8
Part VI
Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; Part III, line 12; Part IV, Section A, lines 1, 2, 3b, 3c, 4b, 4c, 5a, 6, 9a, 9b, 9c, 11a, 11b, and 11c; Part IV, Section B, lines 1 and 2; Part IV, Section C, line 1; Part IV, Section D, lines 2 and 3; Part IV, Section E, lines 1c, 2a, 2b, 3a and 3b; Part V, line 1; Part V, Section B, line 1e; Part V Section D, lines 5, 6, and 8; and Part V, Section E, lines 2, 5, and 6. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
 
Return Reference Explanation
Schedule A, Part III, Line 12 Other Income DESCRIPTION - OTHER REVENUE, COLUMN A - 95332.0, COLUMN B - 382081.0, COLUMN C - 485262.0, COLUMN D - 245339.0, COLUMN E - 228052.0, COLUMN F - 1436066.0;
Schedule A (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Schedule B
(Form 990)
Department of the Treasury
Internal Revenue Service
Schedule of Contributors

Arrow Bullet Attach to Form 990, 990-EZ, or 990-PF.
Arrow Bullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Organization type (check one):
Filers of:
Section:
Form 990 or 990-EZ






Form 990-PF




Check if your organization is covered by the General Rule or a Special Rule.  
Note: Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
Special Rules
......... Arrow Bullet $  
Caution: An organization that isn't covered by the General Rule and/or the Special Rules doesn't file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ
or on its Form 990PF, Part I, line 2, to certify that it doesn't meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.
Cat. No. 30613XSchedule B (Form 990) (2021)
Schedule B (Form 990) (2021) Page 2
Name of organization
Capital Hospice
  		Employer identification number
54-1920770
Part I
Contributors
Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
RESTRICTED
 
 
 
 
  ,    

$ RESTRICTED


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
(a)
No.		 (b)
Name, address, and ZIP + 4		 (c)
Total contributions		 (d)
Type of contribution
 
 
 
 

$  


(Complete Part II for noncash contributions.)
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page 3
Name of organization
Capital Hospice
  		Employer identification number

54-1920770
Part II
Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
(a)
No. from Part I		 (b)
Description of noncash property given		 (c)
FMV (or estimate)
(See instructions) 		(d)
Date received
 
$    
Schedule B (Form 990) (2021)
Schedule B (Form 990) (2021)
Page 4
Name of organization
Capital Hospice
  		Employer identification number

54-1920770
Part III
Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet$  
Use duplicate copies of Part III if additional space is needed.
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
(a)
No. from Part I		 (b) Purpose of gift (c) Use of gift (d) Description of how gift is held
 
(e) Transfer of gift
Transferee's name, address, and ZIP 4 Relationship of transferor to transferee
 
 
     
 
Schedule B (Form 990) (2021)
Additional Data


Software ID: 21014044
Software Version: 2021v4.2
SCHEDULE D
(Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Financial Statements
SchDMd Bullet Complete if the organization answered "Yes," on Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b.
SchDMd Bullet Attach to Form 990.
SchDMd Bullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6.
(a) Donor advised funds (b) Funds and other accounts
1 Total number at end of year .........    
2 Aggregate value of contributions to (during year)    
3 Aggregate value of grants from (during year)    
4 Aggregate value at end of year ........    
5
Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization’s property, subject to the organization’s exclusive legal control? ............
6
Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................
Part II
Conservation Easements.
Complete if the organization answered "Yes" on Form 990, Part IV, line 7.
1
Purpose(s) of conservation easements held by the organization (check all that apply).
2
Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.
Held at the End of the Year
a Total number of conservation easements ...................... 2a  
b Total acreage restricted by conservation easements .................... 2b  
c Number of conservation easements on a certified historic structure included in (a) ..... 2c  
d Number of conservation easements included in (c) acquired after 7/25/06, and not on a historic structure listed in the National Register ... 2d  
3
Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the
tax year SchDMd Bullet  
4
Number of states where property subject to conservation easement is located SchDMd Bullet  
5
Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? ............
6
Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet  
7
Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year
SchDMd Bullet $  
8
Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .............................
9
In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" on Form 990, Part IV, line 8.
1a
If the organization elected, as permitted under FASB ASC 958, not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.
b
If the organization elected, as permitted under FASB ASC 958, to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:
(i)
Revenue included on Form 990, Part VIII, line 1 .........................SchDMd Bullet $  
(ii)
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
2
If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under FASB ASC 958 relating to these items:
a
Revenue included on Form 990, Part VIII, line 1 ..........................SchDMd Bullet $  
b
Assets included in Form 990, Part X ...............................SchDMd Bullet $  
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 52283D
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 2
Part III
Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)
3
Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):
a
d
b
e
 
c
4
Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.
5
During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?...
Part IV
Escrow and Custodial Arrangements. Complete if the organization answered "Yes" on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21.
1a
Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................
b If "Yes," explain the arrangement in Part XIII and complete the following table: Amount
c Beginning balance ............................. 1c  
d Additions during the year ............................ 1d  
e Distributions during the year .......................... 1e  
f Ending balance ................................ 1f  
2a
Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? ...
b
If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ....
Part V
Endowment Funds.
Complete if the organization answered "Yes" on Form 990, Part IV, line 10.
(a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back
1a Beginning of year balance .... 21,364,380 26,280,077 28,561,942 29,440,790 21,871,836
b Contributions ... 1,073,315 3,238,455 454,796 1,207,637 5,283,990
c Net investment earnings, gains, and losses 4,018,846 1,514,675 4,577,242 -1,598,601 2,998,247
d Grants or scholarships ...          
e Other expenditures for facilities
and programs ... 		15,305,221 9,525,540 7,101,743 275,006 553,487
f Administrative expenses .... 82,498 143,287 212,160 212,878 159,796
g End of year balance ...... 11,068,822 21,364,380 26,280,077 28,561,942 29,440,790
2
Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:
a
Board designated or quasi-endowment SchDMd Bullet17 %
b
Permanent endowment SchDMd Bullet48 %
c
Term endowment SchDMd Bullet35 %
The percentages on lines 2a, 2b, and 2c should equal 100%.
3a
Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes
No
(i) Unrelated organizations .................
3a(i)
 
No
(ii) Related organizations .................
3a(ii)
 
No
b
If "Yes" on 3a(ii), are the related organizations listed as required on Schedule R? .........
3b
 
 
4
Describe in Part XIII the intended uses of the organization's endowment funds.
Part VI
Land, Buildings, and Equipment.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10.
Description of property (a) Cost or other basis
(investment) 		(b) Cost or other basis (other) (c) Accumulated depreciation (d) Book value
1a Land .....   1,793,980 1,793,980
b Buildings ....   19,924,154 6,908,862 13,015,292
c Leasehold improvements   3,986,962 439,647 3,547,315
d Equipment ....   13,343,642 11,217,771 2,125,871
e Other .....   38,303 36,463 1,840
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).)..SchDMdBullet 20,484,298
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 3
Part VII
Investments - Other Securities.
Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12.
(a) Description of security or category
(including name of security)		 (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1) Financial derivatives.........    
(2) Closely-held equity interests........    
(3)Other
(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)Small Bullet  
Part VIII
Investments - Program Related. Complete if the organization answered 'Yes' on Form 990, Part IV, line 11c. See Form 990, Part X, line 13.
(a) Description of investment (b) Book value (c) Method of valuation:
Cost or end-of-year market value
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)Small Bullet  
Part IX
Other Assets.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11d. See Form 990, Part X, line 15.
(a) Description (b) Book value
(1)CASH TEMPORARILY RESTRICTED 3,447,300
(2)CHARITABLE REMAINDER TRUSTS 134,002
(3)CONTRIBUTIONS RECEIVABLE 622,105
(4)DEFERRED COMPENSATION ASSETS 58,205
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........Small Bullet 4,261,612
Part X
Other Liabilities.
Complete if the organization answered 'Yes' on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.
1.(a) Description of liability (b) Book value
(1) Federal income taxes  
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)Small Bullet 216,930
2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII
Schedule D (Form 990) 2021

Schedule D (Form 990) 2021
Page 4
Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1 Total revenue, gains, and other support per audited financial statements ....... 1 99,999,304
2 Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a Net unrealized gains (losses) on investments .... 2a -1,997,111
b Donated services and use of facilities ......... 2b  
c Recoveries of prior year grants ........... 2c  
d Other (Describe in Part XIII.) ............ 2d 1,870,652
e Add lines 2a through 2d ..................... 2e -126,459
3 Subtract line 2e from line 1.................. 3 100,125,763
4 Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b . 4a 82,498
b Other (Describe in Part XIII.) ........... 4b 9,349,243
c Add lines 4a and 4b.................... 4c 9,431,741
5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ...... 5 109,557,504
Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' on Form 990, Part IV, line 12a.
1 Total expenses and losses per audited financial statements ........... 1 106,273,704
2 Amounts included on line 1 but not on Form 990, Part IX, line 25:
a Donated services and use of facilities ......... 2a  
b Prior year adjustments ............ 2b  
c Other losses ................ 2c  
d Other (Describe in Part XIII.) ............ 2d 2,715,389
e Add lines 2a through 2d.................... 2e 2,715,389
3 Subtract line 2e from line 1................... 3 103,558,315
4 Amounts included on Form 990, Part IX, line 25, but not on line 1:
a Investment expenses not included on Form 990, Part VIII, line 7b .. 4a 82,498
b Other (Describe in Part XIII.) ............ 4b 9,349,243
c Add lines 4a and 4b..................... 4c 9,431,741
5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ...... 5 112,990,056
Part XIII
Supplemental Information
Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.
Return Reference Explanation
Schedule D, Part V, Line 4 Intended uses of endowment funds CAPITAL HOSPICE INTENDS TO INVEST ITS PERMANENTLY RESTRICTED ENDOWMENT FUNDS UNTIL THEY REACH FIVE MILLION DOLLARS AT WHICH TIME, WITH THE BOARD OF TRUSTEES APPROVAL, EIGHTY PERCENT OF ANY EARNINGS WOULD BE USED TO SUPPORT ONGOING OPERATIONS AND TWENTY PERCENT WOULD BE ADDED TO THE FUND. TEMPORARILY RESTRICTED FUNDS ARE USED AS INTENDED. THE BOARD DESIGNATED RESTRICTED FUNDS ARE TO BE USED FOR ANY EMERGENCY OR NEW SERVICE THAT THE BOARD APPROVES.
Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote The Consolidated Group are exempt from income taxes on income from related activities under Section 501(c)(3) of the U.S. Internal Revenue Code and corresponding state tax law. Accordingly, no provision has been made for federal or state income taxes. The Consolidated Group has determined that there are no material uncertain tax positions that require recognition or disclosure in the consolidated financial statements. The Consolidated Group is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. The Consolidated Group believes it is no longer subject to income tax examinations prior to 2018.
Schedule D, Part XI, Line 2(d) Other revenues in audited financial statements not in form 990 CAPITAL CARING ADVANCED ILLNESS SERVICES, INC. EARNINGS - 622903 CAPITAL CARING STAY AT HOME SERVICES, INC. EARNINGS - 1002928 RENTAL EXPENSE - 242821 SPECIAL EVENTS EXPENSE - 2000
Schedule D, Part XI, Line 4(b) Other revenues in form 990 not in audited financial statements RENTAL INCOME - 98773 CONTRACT NURSING HOME - 5935518 BAD DEBT EXPENSE - 3314952
Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 CAPITAL CARING ADVANCED ILLNESS SERVICES, INC EXPENSES - 1269421 CAPITAL CARING STAY AT HOME SERVICES, INC. EXPENSES - 1200644 CAPITAL CARING HEALTH, INC. EXPENSES - 503 RENTAL EXPENSE - 242821 SPECIAL EVENTS EXPENSE - 2000
Schedule D, Part XII, Line 4(b) Other expenses in form 990 not in audited financial statements CONTRACTNURSING HOME - 5935518 BAD DEBT - 3314952 RENTAL REVENUE - 98773
Schedule D (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2




SCHEDULE G (Form 990)
Department of the Treasury
Internal Revenue Service
Supplemental Information Regarding
Fundraising or Gaming Activities
Complete if the organization answered "Yes" on Form 990, Part IV, lines 17, 18, or 19, or if the organization entered more than $15,000 on Form 990-EZ, line 6a. right arrowAttach to Form 990 or Form 990-EZ.
right arrowGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Fundraising Activities.Complete if the organization answered "Yes" on Form 990, Part IV, line 17.
Form 990-EZ filers are not required to complete this part.
1
Indicate whether the organization raised funds through any of the following activities. Check all that apply.
a e
b f
c g
d
2a
Did the organization have a written or oral agreement with any individual (including officers, directors, trustees
or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?
b
If "Yes," list the 10 highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization.


(i) Name and address of individual
or entity (fundraiser) 		(ii) Activity (iii) Did fundraiser have custody or control of contributions? (iv) Gross receipts
from activity 		(v) Amount paid to
(or retained by)
fundraiser listed in
col. (i) 		(vi) Amount paid to
(or retained by)
organization
Yes No
             
             
             
             
             
             
             
             
             
             
Total . . . . . . . . . . . . . . . . . . . . right arrow      
3
List all states in which the organization is registered or licensed to solicit contributions or has been notified it is exempt from registration or licensing.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50083H
Schedule G (Form 990) 2021
Schedule G (Form 990) 2021
Page 2
Part II
Fundraising Events. Complete if the organization answered "Yes" on Form 990, Part IV, line 18, or reported more than $15,000 of fundraising event contributions and gross income on Form 990-EZ, lines 1 and 6b. List events with gross receipts greater than $5,000.









VerticalRevenue
(a) Event #1

EMBASSY NIGHT
(event type) 		(b) Event #2

 
(event type) 		(c) Other events

 
(total number) 		(d) Total events
(add col. (a) through col. (c))

1
Gross receipts . . . . .
65,000
 
 
65,000

2
Less: Contributions . . . .
65,000
 
 
65,000
3 Gross income (line 1 minus
line 2) . . . . . .
0
0
0
0



VerticalDirectExpenses
4 Cash prizes . . . . .        
5 Noncash prizes . . . .        
6 Rent/facility costs . . . .        
7 Food and beverages . . .        
8 Entertainment . . . .        
9 Other direct expenses . . . 2,000     2,000
10 Direct expense summary. Add lines 4 through 9 in column (d) . . . . . . . . . . right arrow 2,000
11 Net income summary. Subtract line 10 from line 3, column (d). . . . . . . . . . right arrow -2,000
Part III
Gaming. Complete if the organization answered "Yes" on Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.
VerticalRevenue
(a) Bingo (b) Pull tabs/Instant
bingo/progressive bingo 		(c) Other gaming (d) Total gaming (add col.(a) through col.(c))

1
Gross revenue . . . . .
 
 
 
 
VerticalDirectExpenses

2
Cash prizes . . . . .
 
 
 
 

3
Noncash prizes . . . .
 
 
 
 

4
Rent/facility costs . . . .
 
 
 
 

5
Other direct expenses . . .
 
 
 
 


6

Volunteer labor . . . .
%
%
%


7
Direct expense summary. Add lines 2 through 5 in column (d) . . . . . . . . . . right arrow
 

8
Net gaming income summary. Subtract line 7 from line 1, column (d). . . . . . . . . right arrow
 

9
Enter the state(s) in which the organization conducts gaming activities:
a
Is the organization licensed to conduct gaming activities in each of these states? . . . . . . . .
b
If "No," explain:
 
10a
Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? . . .
b
If "Yes," explain:
 
Schedule G (Form 990) 2021
Schedule G (Form 990) 2021
Page 3
11
Does the organization conduct gaming activities with nonmembers? . . . . . . . . . . .
12
Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity
formed to administer charitable gaming? . . . . . . . . . . . . . . . . .
13
Indicate the percentage of gaming activity conducted in:
a
The organization's facility . . . . . . . . . . . . . . . . . .
13a
%
b
An outside facility . . . . . . . . . . . . . . . . . . . .
13b
%
14
Enter the name and address of the person who prepares the organization's gaming/special events books and records:
Name right arrow
Address right arrow
15a
Does the organization have a contract with a third party from whom the organization receives gaming
revenue? . . . . . . . . . . . . . . . . . . . . . . . .
b
If "Yes," enter the amount of gaming revenue received by the organization right arrow $   and the
amount of gaming revenue retained by the third party right arrow $   .
c
If "Yes," enter name and address of the third party:
Name right arrow
Address right arrow
16
Gaming manager information:
Name right arrow
Gaming manager compensation right arrow $  
Description of services provided right arrow
 
17
Mandatory distributions:
a
Is the organization required under state law to make charitable distributions from the gaming proceeds to
retain the state gaming license? . . . . . . . . . . . . . . . . . . .
b
Enter the amount of distributions required under state law distributed to other exempt organizations or spent
in the organization's own exempt activities during the tax year right arrow$  
Part IV
Supplemental Information. Provide the explanations required by Part I, line 2b, columns (iii) and (v); and Part III, lines 9, 9b, 10b, 15b, 15c, 16, and 17b, as applicable. Also provide any additional information. See instructions.
Return Reference Explanation
Schedule G (Form 990) 2021
Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
b
If any of the boxes on Line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain .....
1b
 
 
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked on Line 1a? ....
2
 
 
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment? .............
4a
Yes
 
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........
4b
Yes
 
c
Participate in, or receive payment from, an equity-based compensation arrangement? .........
4c
 
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization? ....................
5a
 
No
b
Any related organization? .......................
5b
 
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization? ..................
6a
 
No
b
Any related organization? ......................
6b
 
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............
7
Yes
 
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III ..........................
8
 
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................
9
 
 
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
Page 2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A) Name and Title (B) Breakdown of W-2, 1099-MISC compensation, and/or 1099-NEC (C) Retirement and other deferred compensation (D) Nontaxable
benefits		 (E) Total of columns
(B)(i)-(D) 		(F) Compensation in column (B) reported as deferred on prior Form 990
(i) Base
compensation 		(ii) Bonus & incentive
compensation 		(iii) Other reportable compensation
1TOM KOUTSOUMPAS
 
PRESIDENT/CEO 		(i)

(ii)		 536,983
-------------
0 		0
-------------
0 		0
-------------
0 		19,074
-------------
0 		1,493
-------------
0 		557,550
-------------
0 		0
-------------
0
2DAVID A SCHWIND
 
CHIEF FINANCIAL OFFICER (Through July 2021) 		(i)

(ii)		 142,060
-------------
0 		0
-------------
0 		152,211
-------------
0 		4,925
-------------
0 		17,409
-------------
0 		316,605
-------------
0 		44,470
-------------
0
3GARY BACHER
 
CHIEF OF STATEGY, POLICY & LEGAL AFFAIRS 		(i)

(ii)		 332,365
-------------
0 		0
-------------
0 		0
-------------
0 		6,176
-------------
0 		19,127
-------------
0 		357,668
-------------
0 		0
-------------
0
4MATTHEW KESTENBAUM MD
 
CHIEF MEDICAL OFFICER (CMO) 		(i)

(ii)		 281,285
-------------
0 		0
-------------
0 		0
-------------
0 		6,049
-------------
0 		1,355
-------------
0 		288,689
-------------
0 		0
-------------
0
5STEVE CONE
 
CHIEF OF COMMUNICATIONS, MARKETING & PHILANTHROPY 		(i)

(ii)		 208,898
-------------
0 		0
-------------
0 		0
-------------
0 		0
-------------
0 		8,785
-------------
0 		217,683
-------------
0 		0
-------------
0
6KIERAN SHAH
 
CHIEF GROWTH OFFICER 		(i)

(ii)		 205,247
-------------
0 		0
-------------
0 		28
-------------
0 		3,756
-------------
0 		7,602
-------------
0 		216,633
-------------
0 		0
-------------
0
7SUSAN BORIS
 
CHIEF OF CLINICAL OPERATIONS (Through July 2021) 		(i)

(ii)		 113,928
-------------
0 		0
-------------
0 		67,523
-------------
0 		3,954
-------------
0 		15,351
-------------
0 		200,756
-------------
0 		0
-------------
0
8KEITH EVERETT
 
CHIEF PERFORMANCE & COMPLIANCE OFFICER 		(i)

(ii)		 153,681
-------------
0 		0
-------------
0 		7,973
-------------
0 		2,647
-------------
0 		21,598
-------------
0 		185,899
-------------
0 		0
-------------
0
9KIMBERLY GROVE
 
CHIEF OF STAFF 		(i)

(ii)		 148,369
-------------
0 		10,000
-------------
0 		0
-------------
0 		3,352
-------------
0 		18,954
-------------
0 		180,675
-------------
0 		0
-------------
0
10MICHAEL BYAS-SMITH MD
 
MEDICAL DIRECTOR 		(i)

(ii)		 385,325
-------------
0 		3,150
-------------
0 		0
-------------
0 		8,102
-------------
0 		19,359
-------------
0 		415,936
-------------
0 		0
-------------
0
11LEE ANNE WEST MD
 
EXECUTIVE DIRECTOR, INPATIENT SERVICES 		(i)

(ii)		 249,005
-------------
0 		32,070
-------------
0 		0
-------------
0 		6,596
-------------
0 		18,954
-------------
0 		306,625
-------------
0 		0
-------------
0
12HEIDI YOUNG MD
 
HPM PHYSICIAN 		(i)

(ii)		 260,504
-------------
0 		7,354
-------------
0 		0
-------------
0 		5,222
-------------
0 		21,626
-------------
0 		294,706
-------------
0 		0
-------------
0
13JOHN MCCUE MD
 
HPM PHYSICIAN 		(i)

(ii)		 151,048
-------------
0 		102,376
-------------
0 		17,367
-------------
0 		6,180
-------------
0 		6,797
-------------
0 		283,768
-------------
0 		0
-------------
0
14RAY JAY GARCIA MD
 
HPM PHYSICIAN 		(i)

(ii)		 236,479
-------------
0 		7,020
-------------
0 		0
-------------
0 		4,881
-------------
0 		469
-------------
0 		248,849
-------------
0 		0
-------------
0
Schedule J (Form 990) 2021

Schedule J (Form 990) 2021
Page 3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference Explanation
Schedule J, Part I, Line 4a Severance or change-of-control payment During calendar year 2021, the following individuals received a severance payment in the following amounts: David Schwind, $104,177 Susan Boris, $39,231
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan DURING THE 2021 CALENDAR YEAR, CAPITAL HOSPICE MAINTAINED A SUPPLEMENTAL NON-QUALIFIED 457(f) DEFERRED COMPENSATION PLAN. THE FOLLOWING REPORTABLE INDIVIDUALS WERE ELIGIBLE TO PARTICIPATE IN THAT PLAN: - DAVID SCHWIND DURING 2021, THE THERE WERE NO CONTRIBUTIONS MADE BY CAPITAL HOSPICE TO THE PLAN. DURING 2021, THE FOLLOWING DISTRIBUTIONS WERE MADE BY CAPITAL HOSPICE FROM THE PLAN: - DAVID SCHWIND - $44,470.08 DURING THE 2021 CALENDAR YEAR, THE COMPANY MAINTAINED A NON QUALIFIED 457(b) DEFERRED COMPENSATION PLAN FOR THE FOLLOWING EMPLOYEE: JOHN T. KOUTSOUMPAS DURING 2021, THE COMPANY MADE CONTRIBUTIONS TO THE PLAN TOTALLING $10,400. IN 2021, THERE WERE NO DISBURSEMENTS FROM THE PLAN.
Schedule J, Part I, Line 7 Non-fixed payments IF THE ORGANIZATION REACHES ITS BUDGETED AMOUNT OF NET INCOME FROM OPERATIONS FOR THE YEAR THEN EMPLOYEES ARE ELIGIBLE FOR A BONUS, WHICH IS BASED UPON CERTAIN KEY METRICS THAT ARE UNRELATED TO NET INCOME.
Schedule J, Part II Vacation buy-backs DURING calendar year 2021, the following individuals received a vacation buy-back in the following amounts: Susan Boris, $28,292 Keith Everett, $7,724 John McCue, $17,367 Each of these buy-backs are INCLUDED IN OTHER REPORTABLE COMPENSATION ON SCHEDULE J, PART II, COLUMN B(III), AND are NOT CONSIDERED PART OF each person's NORMAL COMPENSATION.
Schedule J (Form 990) 2021

Additional Data


Software ID: 21014044
Software Version: 2021v4.2
Schedule L
(Form 990)
Department of the Treasury
Internal Revenue Service
Transactions with Interested Persons
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, lines 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b.
MediumBullet Attach to Form 990 or Form 990-EZ.
MediumBulletGo to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and section 501(c)(29) organizations only).
Complete if the organization answered "Yes" on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
1(a) Name of disqualified person (b) Relationship between disqualified person and organization (c) Description of transaction (d) Corrected?
Yes No
2
Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958. ........................... Bullet Image$
 
3
Enter the amount of tax, if any, on line 2, above, reimbursed by the organization ........ Bullet Image$
 

Part II
Loans to and/or From Interested Persons.
Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a, or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22
(a) Name of interested person (b) Relationship with organization (c) Purpose of loan (d) Loan to or from the organization? (e) Original principal amount (f) Balance due (g) In default? (h) Approved by board or committee? (i) Written agreement?
To From Yes No Yes No Yes No
Total ...............Small Bullet $  
Part III
Grants or Assistance Benefiting Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 27.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 50056A
Schedule L (Form 990) 2021
Schedule L (Form 990) 2021
Page 2
Part IV
Business Transactions Involving Interested Persons.
Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between interested person and the organization (c) Amount of transaction (d) Description of transaction (e) Sharing of organization's revenues?
Yes No
(1) CORIE BACHER
  		SPOUSE OF KEY EMPLOYEE 58,832 EMPLOYEE OF CAPITAL HOSPICE   No
(2) HEALTHSPERIAN
  		PRESIDENT/CEO IS >35% OWNER 195,000 PAYMENT FOR PERFORMANCE OF SERVICES   No
(3) CORIANDER STASI-SMITH
  		SPOUSE OF KEY EMPLOYEE 104,610 EMPLOYEE OF CAPITAL HOSPICE   No
Part V
Supplemental Information
Provide additional information for responses to questions on Schedule L (see instructions).
Return Reference Explanation
Schedule L (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2




SCHEDULE M
(Form 990)

Department of the Treasury
Internal Revenue Service
Noncash Contributions
Right pointing arrow large imageComplete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30.
Right pointing arrow large image Attach to Form 990.
Right pointing arrow large imageGo to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Types of Property
(a)
Check if applicable 		(b)
Number of contributions or items contributed 		(c)
Noncash contribution amounts reported on
Form 990, Part VIII, line 1g 		(d)
Method of determining
noncash contribution amounts
1 Art—Works of art .... X 5 196,503 Market value
2 Art—Historical treasures .        
3 Art—Fractional interests ..        
4 Books and publications ..      
5 Clothing and household
goods ....... 		X 10,395 Market value
6 Cars and other vehicles ..        
7 Boats and planes ....        
8 Intellectual property ...        
9 Securities—Publicly traded . X 4 4,081 Market value
10 Securities—Closely held stock .        
11 Securities—Partnership, LLC,
or trust interests .... 		       
12 Securities—Miscellaneous ..        
13 Qualified conservation
contribution—Historic
structures ..... 		       
14 Qualified conservation
contribution—Other ... 		       
15 Real estate—Residential .        
16 Real estate—Commercial ..        
17 Real estate—Other ... X 2 8,380 Market value
18 Collectibles .....        
19 Food inventory ... X 8 13,325 Market value
20 Drugs and medical supplies . X 15 18,498 Market value
21 Taxidermy ......        
22 Historical artifacts ....        
23 Scientific specimens ..        
24 Archeological artifacts ...        
25 Other Right pointing arrow large image ( Event tickets ) X 2 7,625 Market value
26 Other Right pointing arrow large image ( Gift certificates ) X 1 1,891 Market value
27 Other Right pointing arrow large image ( Professional Organization Membership ) X 1 9,300 Market value
28 Other Right pointing arrow large image ( )
29
Number of Forms 8283 received by the organization during the tax year for contributions
for which the organization completed Form 8283, Part IV, Donee Acknowledgement
29
0
Yes
No
30a
During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that it must hold for at least three years from the date of the initial contribution, and which isn't required to be used for exempt purposes for the entire holding period? ...................
30a
 
No
b
If "Yes," describe the arrangement in Part II.
31
Does the organization have a gift acceptance policy that requires the review of any nonstandard contributions?
31
 
No
32a
Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash
contributions? ..........................
32a
 
No
b
If "Yes," describe in Part II.
33
If the organization didn't report an amount in column (c) for a type of property for which column (a) is checked,
describe in Part II.
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 51227J
Schedule M (Form 990) (2021)
Schedule M (Form 990) (2021)
Page 2
Part IISupplemental Information. Provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information.
Return Reference Explanation
Schedule M, Part I Explanations of reporting method for number of contributions Art - Works of art - Number of Contributions Clothing and household goods - Number of Contributions Securities - Publicly traded - Number of Contributions Food inventory - Number of Contributions Drugs and medical supplies - Number of Contributions Other - Event tickets Number of Contributions Real estate - Other - Burial plots/funeral service Number of Contributions Other - Gift certificates Number of Contributions Other - Professional Organization Membership Number of Contributions
Schedule M (Form 990) (2021)

Additional Data


Software ID: 21014044
Software Version: 2021v4.2
SCHEDULE O
(Form 990)

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 990-EZ or to provide any additional information.
MediumBullet Attach to Form 990 or 990-EZ.
MediumBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
Open to Public
Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Return Reference Explanation
Form 990, Part VI, Line 15a PROCESS TO ESTABLISH COMPENSATION OF TOP MANAGEMENT OFFICIAL In 2019 THE EXECUTIVE COMMITTEE OF THE BOARD HAS ENGAGED QUATT AND ASSOCIATES, AN INDEPENDENT CONSULTING GROUP, TO PREPARE A REPORT TO ASSIST WITH ESTABLISHING COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL AND OTHER KEY PERSONNEL. THE REPORT WAS REVIEWED AND APPROVED BY THE EXECUTIVE COMMITTEE AFTER THOROUGH DISCUSSION OF THE DATA, ITS SOURCES AND THE FINDINGS. the organization AS SUBJECT TO INTERMEDIATE SANCTIONS UNDER INTERNAL REVENUE CODE (IRC) SECTION 4958, CONSIDERS THAT THE INTERMEDIATE SANCTIONS MARKET BENCHMARKING METHODOLOGY FOR DISQUALIFIED INDIVIDUALS, CONDUCTED BY QUATT AND ASSOCIATES, HAS PROVIDED A VALID AND ROBUST MEANS OF DETERMINING MARKET BASED COMPENSATION COMPETITIVENESS.
Form 990, Part VI, Line 1a Delegate broad authority to a committee THERE SHALL BE AN EXECUTIVE COMMITTEE COMPOSED OF THE OFFICERS OF THE BOARD. THE EXECUTIVE COMMITTEE SHALL BE EMPOWERED TO ACT ON BEHALF OF THE BOARD UNLESS DEALING WITH MATTERS THE BOARD HAS RESERVED TO ITSELF. THE EXECUTIVE COMMITTEE SHALL SERVE IN AN ADVISORY CAPACITY TO THE BOARD OF TRUSTEES ON MATTERS RELATING TO COMPENSATION OF OFFICERS AND KEY EMPLOYEES (INCLUDING BUT NOT LIMITED TO THE PRESIDENT/CEO) AND TO MANAGEMENT SUCCESSION.
Form 990, Part VI, Line 6 Classes of members or stockholders THE ORGANIZATION'S SOLE CORPORATE MEMBER IS CAPITAL CARING HEALTH, A RELATED TAX-EXEMPT ORGANIZATION.
Form 990, Part VI, Line 7a Members or stockholders electing members of governing body THE ORGANIZATION'S SOLE CORPORATE MEMBER SHALL APPOINT DIRECTORS TO THE BOARD.
Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders THE MEMBER, THROUGH ITS CHAIR OR CEO, OR THROUGH ANY OTHER OFFICER OF THE MEMBER WHO IS AUTHORIZED BY THE BOARD OF DIRECTORS OF THE MEMBER (THE "MEMBER BOARD"), SHALL EXERCISE ALL AUTHORITY AT MEETINGS OF THE CORPORATION AS MEMBERS ARE AUTHORIZED TO EXERCISE.
Form 990, Part VI, Line 11b Review of form 990 by governing body THE 990 FOR CAPITAL HOSPICE IS REVIEWED BY THE CONTROLLER . NEXT, THE 990 IS SENT TO ALL OF THE MEMBERS OF THE BOARD OF TRUSTEES INCLUDING THE PRESIDENT OF CAPITAL HOSPICE FOR THEIR REVIEW AND TO SOLICIT ANY COMMENTS OR QUESTIONS. THE FINANCE AUDIT INVESTMENT COMMITTEE (FAIC) OF THE BOARD MEETS TO REVIEW AND DISCUSS THE FORM 990 IN DETAIL. THIS MEETING IS OPEN TO ALL BOARD MEMBERS INCLUDING THE COMPENSATION AND OTHER COMMITTEE CHAIRS. AFTER THE FORM 990 HAS BEEN REVIEWED BY THE BOARD AND ANY COMMENTS OR QUESTIONS FROM BOARD MEMBERS HAVE BEEN RESPONDED TO, THE FORM 990 WILL BE FINALIZED, SIGNED BY THE PRESIDENT/CEO AND SUBSEQUENTLY FILED WITH THE INTERNAL REVENUE SERVICE.
Form 990, Part VI, Line 12c Conflict of interest policy ALL BOARD MEMBERS, OFFICERS AND KEY MANAGERS ARE REQUIRED TO REPORT ANY REAL OR POTENTIAL OR PERCEIVED CONFLICT OF INTEREST INVOLVING THEM OR ANOTHER PERSON BY PROMPTLY FILING A WRITTEN DISCLOSURE STATEMENT WITH THE PRESIDENT OR CHAIR OF THE BOARD OF TRUSTEES. THE PRESIDENT WILL REVIEW ALL SUCH STATEMENTS AND THE ANNUAL DISCLOSURE STATEMENTS AND DISCUSS WITH THE CHAIR OF THE BOARD ANY POTENTIAL CONFLICTS OF INTEREST. IF THE PRESIDENT AND THE CHAIR OF THE BOARD DETERMINE THAT A POTENTIAL CONFLICT EXISTS, THEN THE BOARD SHALL INFORM THE PERSON OF THE BASIS FOR SUCH BELIEF AND ALLOW THE PERSON TO EXPLAIN AND DISCLOSE. FOR ANY TRANSACTION/ARRANGEMENT DISCUSSED DURING A BOARD MEETING FOR WHICH A CONFLICT OF INTEREST IS DEEMED TO EXIST, THE AFFECTED BOARD MEMBER SHALL NOT BE COUNTED IN DETERMINING THE QUOROM FOR THE MEETING BUT SHALL BE PERMITTED TO BRIEFLY STATE HIS POSITION ON THE MATTER AND ANSWER PERTINENT QUESTIONS OF OTHER BOARD MEMBERS BEFORE VACATING THE GOVERNING BOARD. THE BOARD MEMBER SHALL LEAVE THE GOVERNING BOARD AND A MAJORITY OF THE REMAINING BOARD MEMBERS SHALL DETERMINE WHETHER TO UNDERTAKE SUCH TRANSACTION/ARRANGEMENT. IF THE BOARD DECIDES THAT A PERSON HAS FAILED TO DISCLOSE A CONFLICT OF INTEREST, THE BOARD SHALL TAKE CORRECTIVE ACTION.
Form 990, Part VI, Line 19 Required documents available to the public THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
Form 990, Part VIII, Line 11d Other Miscellaneous Revenue MISCELLANEOUS - Total Revenue: 313, Related or Exempt Function Revenue: 313, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ;
Form 990, Part IX, Line 11g Other Fees PHYSICIAN SERVICES - Total Expense: 231921, Program Service Expense: 231921, Management and General Expenses: , Fundraising Expenses: ; CONTRACT SERVICES NURSING HOME - Total Expense: 5935518, Program Service Expense: 5935518, Management and General Expenses: , Fundraising Expenses: ; CONTRACT SERVICES LABOR - Total Expense: 1623189, Program Service Expense: 1451055, Management and General Expenses: 172134, Fundraising Expenses: ; CONTRACT SERVICES CONSULTANTS - Total Expense: 4061913, Program Service Expense: 141760, Management and General Expenses: 3573194, Fundraising Expenses: 346959; CONTRACT SERVICES INPATIENT - Total Expense: 3062305, Program Service Expense: 3062305, Management and General Expenses: , Fundraising Expenses: ; CONTRACT SERVICES OTHER PATIENT RELATED - Total Expense: 1375687, Program Service Expense: 904396, Management and General Expenses: 471291, Fundraising Expenses: ; CONTRACT SERVICES OTHER - Total Expense: 410656, Program Service Expense: 163930, Management and General Expenses: 246726, Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ; - Total Expense: , Program Service Expense: , Management and General Expenses: , Fundraising Expenses: ;
Schedule A, Part I 509(A)(1) PUBLIC CHARITY DESIGNATION AS A HOSPICE THE HALQUIST MEMORIAL INPATIENT CENTER WAS LICENSED IN 1981 AS ONE OF THE FIRST HOSPICE INPATIENT CENTERS IN THE UNITED STATES AND THE FIRST IN THE STATE OF VIRGINIA. AS SUCH, THE STATE OF VIRGINIA HAD NO CATEGORY FOR LICENSURE THAT WOULD FIT THE FACILITY AND THEREFORE LICENSED THE UNIT AS A GENERAL HOSPITAL. AS A HOSPICE INPATIENT CENTER, THE FACILITY HAS NO EMERGENCY ROOM, OUTPATIENT CENTER, LABS, OR OTHER DIAGNOSTIC SERVICES AS WOULD A GENERAL HOSPITAL. IT SERVES ONLY CAPITAL HOSPICE PATIENTS REQUIRING ACUTE SYMPTOM MANAGEMENT OR PATIENTS IN THEIR FINAL DAYS OF A TERMINAL ILLNESS WHO CAN NO LONGER BE SERVED AT HOME. THE UNIT HAS 15 BEDS AND REPRESENTS ON AVERAGE ONLY 13 OF THE MORE THAN 1300 PATIENTS THAT ARE TREATED BY CAPITAL HOSPICE ON A DAILY BASIS. AS A RESULT, THE COMMUNITY HEALTH NEEDS ASSESSMENT IS NOT APPLICABLE TO HOSPICE INPATIENT BEDS. IN STATES OTHER THAN VIRGINIA, UNITS LIKE HALQUIST ARE LICENSED AS HOSPICE CENTERS AND ARE NOT SUBJECT TO EITHER THE COMMUNITY HEALTH NEEDS ASSESSMENT OR FORM 990, SCHEDULE H. IT IS FOR THIS REASON THAT CAPITAL CARING IS FILING FORM 990 AS A PUBLIC CHARITY DESCRIBED UNDER SECTION 170(B)(1)(A)(VI) OF THE INTERNAL REVENUE CODE. SIMILARLY, MEDICARE HAS RECOGNIZED THAT OUR UNIT IS NOT ACTUALLY A HOSPITAL AND HAS NOT REQUIRED US TO COMPLY WITH MANY OF THE REPORTING REQUIREMENTS APPLICABLE TO HOSPITALS. SERVICES AT THE HALQUIST MEMORIAL INPATIENT CENTER HAVE ALWAYS BEEN BILLED TO MEDICARE UNDER THE CAPITAL HOSPICE MEDICARE PROVIDER NUMBER SO EFFECTIVE FEBRUARY 2020 - CAPITAL HOSPICE SURRENDERED ITS HALQUIST MEMORIAL INPATIENT CENTER MEDICARE IDENTIFICATION NUMBER BACK TO THE CENTER FOR MEDICARE SERVICES (CMS) AND SURRENDERED ITS HALQUIST "HOSPITAL" LICENSE BACK TO THE STATE OF VIRGINIA.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.
Cat. No. 51056K
Schedule O (Form 990) 2021


Additional Data


Software ID: 21014044
Software Version: 2021v4.2
SCHEDULE R
(Form 990)
Department of the Treasury
Internal Revenue Service
Related Organizations and Unrelated Partnerships
MediumBulletComplete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBulletAttach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047
2021
Open to Public Inspection
Name of the organization
Capital Hospice
 
Employer identification number

54-1920770
Part I
Identification of Disregarded Entities. Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a)
Name, address, and EIN (if applicable) of disregarded entity


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Total income


 		(e)
End-of-year assets


 		(f)
Direct controlling
entity
(1) CAPITAL PALLIATIVE CARE CONSULTANTS
3180 FAIRVIEW PARK DRIVE
SUITE 500
FALLS CHURCH,VA22042
52-2361003 		PALLIATIVE VA 1,429,738 5,934,320 CAPITAL HOSPICE
 










Part II
Identification of Related Tax-Exempt Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.
(a)
Name, address, and EIN of related organization


(b)
Primary activity


 		(c)
Legal domicile (state
or foreign country)

 		(d)
Exempt Code section


 		(e)
Public charity status
(if section 501(c)(3))

 		(f)
Direct controlling
entity

 		(g)
Section 512(b)(13) controlled entity?
Yes No
(1)CAPITAL CARING HEALTH
3180 FAIRVIEW PARK DRIVE
SUITE 500
FALLS CHURCH,VA220421206
84-3773372 		MEDICAL SUPPORT SERVICES VA 501(c)(3) Type III-FI NA
 
 
No
(2)CAPITAL CARING ADVANCED ILLNESS SERVICES INC
3180 FAIRVIEW PARK DRIVE
SUITE 500
FALLS CHURCH,VA220421206
84-3787656 		ILLNESS, PALLIATIVE, AND PRIMARY CARE SERVICES VA 501(c)(3) 7 CAPITAL CARING HEALTH
 
 
No
(3)CAPITAL CARING STAY AT HOME SERVICES INC
3180 FAIRVIEW PARK DRIVE
SUITE 500
FALLS CHURCH,VA220421206
84-3797085 		AT HOME MEDICAL SERVICES VA 501(c)(3) 7 CAPITAL CARING HEALTH
 
 
No








For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50135Y
Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 2
Part III
Identification of Related Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, because it had one or more related organizations treated as a partnership during the tax year.
(a)
Name, address, and EIN of
related organization



 		(b)
Primary activity




 		(c)
Legal
domicile
(state or foreign
country)


 		(d)
Direct controlling
entity



 		(e)
Predominant income(related, unrelated, excluded from tax under sections 512-514)

(f)
Share of total income




 		(g)
Share of end-of-year
assets



 		(h)
Disproprtionate allocations?




 		(i)
Code V-UBI
amount in box 20 of
Schedule K-1
(Form 1065)
 		(j)
General or
managing
partner?



 		(k)
Percentage
ownership
Yes No Yes No












Part IV
Identification of Related Organizations Taxable as a Corporation or Trust. Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.
(a)
Name, address, and EIN of
related organization
 		(b)
Primary activity
 		(c)
Legal
domicile
(state or foreign
country)
 		(d)
Direct controlling
entity
 		(e)
Type of entity
(C corp, S corp,
or trust) 		(f)
Share of total income
 		(g)
Share of end-of-year
assets
 		(h)
Percentage
ownership
 		(i)
Section 512(b)(13) controlled entity?
Yes No
(1) Charitable Remainder Trust

3180 FAIRVIEW PARK DRIVE
SUITE 500
FALLS CHURCH,VA22042
 Investments KY Capital Hospice
  		Trust          












Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 3
Part V
Transactions With Related Organizations. Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.
Yes
No
1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?
a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity .....................
1a
 
No
b Gift, grant, or capital contribution to related organization(s) ............................
1b
 
No
c Gift, grant, or capital contribution from related organization(s) ............................
1c
 
No
d Loans or loan guarantees to or for related organization(s) ............................
1d
 
No
e Loans or loan guarantees by related organization(s) ............................
1e
 
No
f Dividends from related organization(s) ............................
1f
 
No
g Sale of assets to related organization(s) ............................
1g
 
No
h Purchase of assets from related organization(s) ............................
1h
 
No
i Exchange of assets with related organization(s) ............................
1i
 
No
j Lease of facilities, equipment, or other assets to related organization(s) .......................
1j
 
No
k Lease of facilities, equipment, or other assets from related organization(s) ......................
1k
 
No
l Performance of services or membership or fundraising solicitations for related organization(s) .....................
1l
Yes
 
m Performance of services or membership or fundraising solicitations by related organization(s) .................
1m
 
No
n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) ...................
1n
Yes
 
o Sharing of paid employees with related organization(s) ............................
1o
Yes
 
p Reimbursement paid to related organization(s) for expenses ............................
1p
 
No
q Reimbursement paid by related organization(s) for expenses ............................
1q
 
No
r Other transfer of cash or property to related organization(s) ............................
1r
Yes
 
s Other transfer of cash or property from related organization(s) ............................
1s
Yes
 
2
If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.
(a)
Name of related organization 		(b)
Transaction
type (a-s) 		(c)
Amount involved 		(d)
Method of determining amount involved





Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 4
Part VI
Unrelated Organizations Taxable as a Partnership. Complete if the organization answered "Yes" on Form 990, Part IV, line 37.
Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.
(a)
Name, address, and EIN of entity 		(b)
Primary activity 		(c)
Legal domicile
(state or foreign
country) 		(d)
Predominant income (related, unrelated, excluded from tax under sections 512-514)

(e)
Are all partners
section
501(c)(3)
organizations? 		(f)
Share of total income




 		(g)
Share of
end-of-year
assets 		(h)
Disproprtionate allocations? 		(i)
Code V-UBI
amount in box 20
of Schedule K-1
(Form 1065) 		(j)
General or
managing
partner? 		(k)
Percentage
ownership
Yes No Yes No Yes No






























Schedule R (Form 990) 2021
Schedule R (Form 990) 2021
Page 5
Part VII
Supplemental Information
Provide additional information for responses to questions on Schedule R. See instructions.
Return Reference Explanation
Schedule R (Form 990) 2021

Additional Data


Software ID: 21014044
Software Version: 2021v4.2