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ObjectId: 201431309349300608 - Submission: 2014-05-10
TIN: 35-0593390
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
Attach to Form 990.
See separate instructions.
OMB No. 1545-0047
20
12
Open to Public Inspection
Name of the organization
DEACONESS HOSPITAL INC
Employer identification number
35-0593390
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 in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes in 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
Yes
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all officers,
directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a?
.......
2
Yes
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.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed in 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) and 501(c)(4) organizations only must complete lines 5-9.
5
For persons listed in 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," to line 5a or 5b, describe in Part III.
6
For persons listed in 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
Yes
If "Yes," to line 6a or 6b, describe in Part III.
7
For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
8
Were any amounts reported in 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" to 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) 2012
Page 2
Schedule J (Form 990) 2012
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 in 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 and/or 1099-MISC compensation
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation
reported as deferred
in prior Form 990
(i)
Base compensation
(ii)
Bonus & incentive compensation
(iii)
Other reportable compensation
(1)
LINDA E WHITE
PRESIDENT/ CEO
(i)
(ii)
311,414
317,441
320,304
0
9,668
6,800
138,093
83,645
10,215
10,215
789,694
418,101
0
0
(2)
DAVID A KOEHLER JR MD
DIRECTOR
(i)
(ii)
81,606
144,298
9,709
22,921
6,700
720
0
13,977
0
443
98,015
182,359
0
0
(3)
MATHIAS KOLLECK II
DIRECTOR
(i)
(ii)
218,342
0
54,987
0
51,879
0
21,271
0
23,770
0
370,249
0
0
0
(4)
SHAWN W MCCOY
CHIEF ADMINISTRATIVE OFFIC
(i)
(ii)
341,560
0
155,831
0
3,351
9,000
92,132
0
27,373
0
620,247
9,000
0
0
(5)
CHERYL A WATHEN
CHIEF FINANCIAL OFFICER
(i)
(ii)
156,046
162,500
121,875
0
4,856
8,800
38,866
27,563
20,456
20,456
342,099
219,319
0
0
(6)
JAMES R PORTER MD
CHIEF MEDICAL OFFICER
(i)
(ii)
380,503
0
143,856
0
1,851
2,800
104,326
0
26,735
0
657,271
2,800
0
0
(7)
CHERONA J HAJEWSKI
CHIEF NURSING OFFICER
(i)
(ii)
269,058
0
102,740
0
6,731
0
57,616
0
25,969
0
462,114
0
0
0
(8)
BRUCE E EPMEIER
VICE PRESIDENT
(i)
(ii)
198,588
0
75,846
0
60,803
0
50,170
0
19,360
0
404,767
0
57,102
0
(9)
LARRY F PILE
HR DIRECTOR
(i)
(ii)
94,445
0
34,453
0
150,713
2,205
3,929
0
7,803
0
291,343
2,205
0
0
(10)
LYNN C LINGAFELTER
DIRECTOR ER/SURGICAL
(i)
(ii)
172,162
0
32,485
0
250
0
25,650
0
443
0
230,990
0
0
0
(11)
RICHARD B PERRY
CONTROLLER
(i)
(ii)
144,423
0
62,616
0
1,131
0
13,291
0
16,888
0
238,349
0
0
0
(12)
JOHN L ZABROWSKI
CONTROLLER
(i)
(ii)
172,401
0
33,855
0
1,531
3,000
14,471
0
26,257
0
248,515
3,000
0
0
(13)
JOYCE A THOMAS
PHARMACY DIRECTOR
(i)
(ii)
142,560
0
29,232
0
1,611
0
26,756
0
23,010
0
223,169
0
0
0
(14)
REBECCA L MALOTTE
EXEC. DIRECTOR, CNO
(i)
(ii)
142,470
0
33,740
0
1,063
0
40,360
0
14,263
0
231,896
0
0
0
(15)
VENKATESH R MADADI
ANESTHESIOLOGIST
(i)
(ii)
631,337
0
0
0
49,481
0
37,116
0
19,020
0
736,954
0
0
0
(16)
NIRMAL JOSHI MD
ANESTHESIOLOGIST
(i)
(ii)
651,704
0
0
0
70,702
0
39,351
0
21,193
0
782,950
0
0
0
(17)
RAJESH J PATEL MD
ANESTHESIOLOGIST
(i)
(ii)
699,301
0
0
0
43,956
0
14,412
0
20,183
0
777,852
0
0
0
(18)
AYMAN ELFAR MD
ANESTHESIOLOGIST
(i)
(ii)
560,800
0
0
0
32,381
0
32,233
0
19,597
0
645,011
0
0
0
(19)
LAWRENCE C KILINSKI JR MD
ANESTHESIOLOGIST
(i)
(ii)
551,067
0
0
0
43,398
0
33,309
0
20,350
0
648,124
0
0
0
(20)
HARRY L SMITH JR
FORMER PRESIDENT TERM. JAN
(i)
(ii)
0
0
0
0
392,735
0
23,761
0
20,015
0
436,511
0
19,077
0
Schedule J (Form 990) 2012
Page 3
Schedule J (Form 990) 2012
Page
3
Part III
Supplemental Information
Complete this part to 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.
Identifier
Return Reference
Explanation
PART I, LINE 1A
SOCIAL CLUB DUES ARE PAID FOR LINDA WHITE, JAMES PORTER AND SHAWN MCCOY FOR ORGANIZATION BUSINESS ONLY. ANY PERSONAL USE OF THE CLUB MUST BE PAID BY THE EMPLOYEES.
PART I, LINES 4A-B
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS: SEVERANCE NONQUALIFIED EQUITY-BASED LINDA E. WHITE $ -0- $17,000 $ -0- DAVID A. KOEHLER, JR., MD. 0 17,000 0 SHAWN W. MCCOY 0 17,000 0 JAMES R. PORTER, MD. 0 17,000 0 CHERONA J. HAJEWSKI 0 17,000 0 BRUCE E. EPMEIER 0 17,000 0 VENKATESH R. MADADI, MD. 0 17,000 0 RAJESH J. PATEL, MD. 0 17,000 0 LAWRENCE C. KILINSKI, JR., MD. 0 17,000 0 CHERYL A. WATHEN 0 17,000 0 HARRY L. SMITH, JR. 374,762 0 0 PART I, 4B: CONTRIBUTIONS MADE TO A SUPPLEMENTAL ACCUMULATION ACCOUNT LINDA WHITE: $206,738. SHAWN MCCOY: $77,132. CHERYL WATHEN: $51,429. JAMES PORTER: $89,326. BRUCE EPMEIER: $36,184 CHERONA HAJEWSKI: $42,616. HARRY SMITH: $19,077. PAYOUT FROM A SUPPLEMENTAL ACCUMULATION ACCOUNT BRUCE EPMEIER: $57,102.
PART I, LINE 6
RELATED ORG. COMPENSATION CONTINGENT UPON NET EARNINGS INCENTIVE COMPENSATION PAYMENTS ARE BASED UPON SUCCESSFUL ACHIEVEMENT OF ESTABLISHED INPATIENT SATISFACTION MEASURES, OUTPATIENT SATISFACTION MEASURES, COMPLIANCE WITH PUBLICLY REPORTED QUALITY INDICATORS, OPERATING MARGIN AS WELL AS OTHER TECHNICAL AND PERSONAL FUNCTIONAL GOALS. DEACONESS HOSPITAL'S INCENTIVE COMPENSATION PROGRAMS ARE FORMULATED TO REWARD BEHAVIOR THAT BALANCES PATIENT NEEDS AND EFFICIENT DELIVERY OF PATIENT CARE TO ENSURE THE BEST OUTCOMES ARE ACHIEVED.
Schedule J (Form 990) 2012
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