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ObjectId: 201711359349305466 - Submission: 2017-05-15
TIN: 93-0386868
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" on Form 990, Part IV, line 23.
Attach to Form 990.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
15
Open to Public Inspection
Name of the organization
Mercy Medical Center Inc
Employer identification number
93-0386868
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.
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
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 in 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.
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 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 non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
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) 2015
Page 2
Schedule J (Form 990) 2015
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 and/or 1099-MISC compensation
(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
1
KELLY MORGAN
President/CEO
(i)
(ii)
10,231
-------------
518,023
0
-------------
101,969
358
-------------
155,628
0
-------------
15,775
3,261
-------------
13,256
13,850
-------------
804,651
0
-------------
42,577
2
Ketul Patel
Ex Officio/President CEO CHI Franciscan Health
(i)
(ii)
0
-------------
827,296
0
-------------
300,000
0
-------------
97,300
0
-------------
135,180
0
-------------
31,800
0
-------------
1,391,576
0
-------------
0
3
RAHUL AGARWAL
VP Business Development
(i)
(ii)
231,394
-------------
0
37,324
-------------
0
36,694
-------------
0
10,120
-------------
0
35,324
-------------
0
350,856
-------------
0
0
-------------
0
4
DEBRA BOSWELL
Chief Operating Officer
(i)
(ii)
286,097
-------------
0
56,281
-------------
0
35,995
-------------
0
15,013
-------------
0
13,734
-------------
0
407,120
-------------
0
0
-------------
0
5
JASON GRAY
Chief Medical Officer/President CMG
(i)
(ii)
354,925
-------------
0
65,648
-------------
0
58,781
-------------
0
11,166
-------------
0
16,436
-------------
0
506,956
-------------
0
0
-------------
0
6
JOHN KASBERGER
Chief Financial Officer
(i)
(ii)
162,614
-------------
0
36,831
-------------
0
141,490
-------------
0
18,218
-------------
0
23,478
-------------
0
382,631
-------------
0
0
-------------
0
7
CHRISTOPHER KINYON
Former Pharmacy Director
(i)
(ii)
0
-------------
152,689
0
-------------
3,634
0
-------------
6,423
0
-------------
9,698
0
-------------
11,713
0
-------------
184,157
0
-------------
0
8
LAWRENCE COX
Director Imaging
(i)
(ii)
141,705
-------------
0
10,567
-------------
0
7,783
-------------
0
8,770
-------------
0
38,955
-------------
0
207,780
-------------
0
0
-------------
0
9
ANN FULLER
Unit Director
(i)
(ii)
132,131
-------------
0
18,514
-------------
0
1,484
-------------
0
9,126
-------------
0
38,860
-------------
0
200,115
-------------
0
0
-------------
0
10
CONSTANCE KINMAN
Director Critical Care
(i)
(ii)
137,534
-------------
0
9,814
-------------
0
1,685
-------------
0
8,962
-------------
0
38,860
-------------
0
196,855
-------------
0
0
-------------
0
11
DEBRA RINAKER
Unit Director - Speciality
(i)
(ii)
133,806
-------------
0
9,335
-------------
0
1,863
-------------
0
8,333
-------------
0
14,482
-------------
0
167,819
-------------
0
0
-------------
0
12
JERRY SMEAD
Pharmacy Director
(i)
(ii)
175,478
-------------
0
12,885
-------------
0
619
-------------
0
10,193
-------------
0
7,310
-------------
0
206,485
-------------
0
0
-------------
0
Schedule J (Form 990) 2015
Page 3
Schedule J (Form 990) 2015
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 PAYMENTS
POST-TERMINATION PAYMENTS ARE ADDRESSED IN EXECUTIVE EMPLOYMENT AGREEMENTS FOR CATHOLIC HEALTH INITIATIVES ("CHI") AND RELATED ORGANIZATIONS' EMPLOYEES AT THE LEVEL OF VICE PRESIDENT AND ABOVE, INCLUDING THE MBO CEOS. THESE EMPLOYMENT AGREEMENTS REQUIRE THAT IN ORDER FOR THE EXECUTIVE TO RECEIVE POST-TERMINATION PAYMENTS, THESE INDIVIDUALS MUST EXECUTE A GENERAL RELEASE AND SETTLEMENT AGREEMENT. POST-TERMINATION PAYMENT ARRANGEMENTS ARE PERIODICALLY REVIEWED FOR OVERALL REASONABLENESS IN LIGHT OF THE EXECUTIVE'S OVERALL COMPENSATION PACKAGE.
Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation
Compensation for the top management official was established and paid by Catholic Health Initiatives (CHI), a related organization. CHI used the following to establish the top management official's compensation: (1) Compensation Committee; (2) Independent Compensation Consultant; (3) Written Employment Contracts; (4) Compensation Survey or Study; (5) Approval by the Board or Compensation Committee.
Schedule J, Part I, Line 4a Severance or change-of-control payment
Post-termination payments are addressed in executive employment agreements for Catholic Health Initiatives (CHI) and related organizations' employees at the level of Vice President and above, including the MBO CEOs. These employment agreements require that in order for the executive to receive post-termination payments, these individuals must execute a general release and settlement agreement. Post-termination payment arrangements are periodically reviewed for overall reasonableness in light of the executive's overall compensation package. The following reportable individuals received severance payments from Catholic Health Initiatives (a related organization during the 2015 calendar year, and these severance payments were included in the individual's W-2 income and reportable compensation on Schedule J: John Kasberger - $106,243
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
During the 2015 calendar year Catholic Health Initiatives (CHI), a related organization, maintained a supplemental non-qualified deferred compensation plan for MBO CEOs/Presidents and other CHI employees at the level of Senior Vice President and above. The following reportable individuals were eligible to participate in that plan: Kelly Morgan, Ketul Patel During 2015 the following contributions were made by CHI to the deferred compensation plan: Ketul Patel- $133,333 During 2015 the following distributions were made by CHI from the deferred compensation plan: Kelly Morgan - $42,577 Due to the "super" vesting rules under the CHI deferred compensation plan, participants who have met certain requirements such as age, years of service or more than 5 years of plan participation are eligible to receive their 2015 contributions in cash. These cash payouts are included in the participant's reportable compensation in column (iii) Other Reportable Compensation on Schedule J Part II. During 2015, the following contributions that would have been made by CHI to the deferred compensation plan were paid in cash: Kelly Morgan - $46,846
Schedule J (Form 990) 2015
Additional Data
Software ID:
15000238
Software Version:
2015v3.0