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ObjectId: 201713129349303071 - Submission: 2017-11-08
TIN: 20-5276923
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
16
Open to Public Inspection
Name of the organization
Good Shepherd Hospice Inc
Employer identification number
20-5276923
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 nonfixed
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) 2016
Page 2
Schedule J (Form 990) 2016
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
Kathy L Fernandez
president/ceo
(i)
(ii)
0
-------------
497,200
0
-------------
112,329
0
-------------
328,533
0
-------------
80,884
0
-------------
27,751
0
-------------
1,046,697
0
-------------
112,329
2
Hubert Darrell White Jr
Chief Legal Officer
(i)
(ii)
0
-------------
288,834
0
-------------
71,985
0
-------------
2,792
0
-------------
208,380
0
-------------
24,057
0
-------------
596,048
0
-------------
71,985
3
Audra Farish
Chief Human Resources officer
(i)
(ii)
0
-------------
215,249
0
-------------
53,000
0
-------------
7,657
0
-------------
58,430
0
-------------
1,930
0
-------------
336,266
0
-------------
53,000
4
Donald D Evans
Chief Integration and Business Development Officer
(i)
(ii)
0
-------------
205,867
0
-------------
26,497
0
-------------
10,067
0
-------------
55,459
0
-------------
4,356
0
-------------
302,246
0
-------------
26,497
5
Sharon P Saucier
Chief Compliance & Clinical Officer
(i)
(ii)
0
-------------
234,621
0
-------------
0
0
-------------
8,390
0
-------------
19,938
0
-------------
14,109
0
-------------
277,058
0
-------------
0
6
Ronald S Schonwetter MD
Chief Medical Officer
(i)
(ii)
0
-------------
403,973
0
-------------
104,275
0
-------------
204,731
0
-------------
256,452
0
-------------
34,643
0
-------------
1,004,074
0
-------------
297,797
7
David J O'Neil
Chief Financial Officer
(i)
(ii)
0
-------------
340,107
0
-------------
84,343
0
-------------
12,387
0
-------------
99,872
0
-------------
34,475
0
-------------
571,184
0
-------------
84,343
8
Sheryl J Sypek
Chief Information Officer (partial year)
(i)
(ii)
0
-------------
174,263
0
-------------
15,000
0
-------------
6,865
0
-------------
39,928
0
-------------
19,552
0
-------------
255,608
0
-------------
0
9
Peggy I Bertels
Chief Operating Officer (partial year)
(i)
(ii)
0
-------------
171,166
0
-------------
71,550
0
-------------
211,053
0
-------------
0
0
-------------
21,923
0
-------------
475,692
0
-------------
71,550
10
Michele L Marziano
staff physician
(i)
(ii)
75,239
-------------
132,474
3,947
-------------
8,311
0
-------------
1,111
5,864
-------------
5,864
7,821
-------------
13,127
92,871
-------------
160,887
0
-------------
12,257
11
Sara A Bohn
Staff Physician
(i)
(ii)
168,718
-------------
0
13,750
-------------
0
10,872
-------------
0
0
-------------
0
17,705
-------------
0
211,045
-------------
0
0
-------------
0
12
Robert Weissinger MD
Medical Director (Partial Year)
(i)
(ii)
207,616
-------------
0
0
-------------
0
43,051
-------------
0
0
-------------
0
32,726
-------------
0
283,393
-------------
0
0
-------------
0
Schedule J (Form 990) 2016
Page 3
Schedule J (Form 990) 2016
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 3 PROCESS OF DETERMINING COMPENSATION
THE PRESIDENT & CEO IS PAID BY CHAPTERS HEALTH SYSTEM, INC. (A RELATED ORGANIZATION). CHAPTERS HEALTH SYSTEM USES A COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, FORMS 990 OF OTHER ORGANIZATIONS, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO DETERMINE HER COMPENSATION. GOOD SHEPHERD HOSPICE, INC. RELIES ON CHAPTERS HEALTH SYSTEM TO ENSURE COMPENSATION IS REASONABLE.
Schedule J, Part I, Line 4a Severance or change-of-control payment
During 2016, the following severance payments were made: Robert Weissinger - $40,616 Peggy Bertels - $193,152
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
CHS (a related organization) has a supplemental executive retirement plan (SERP) in which some of the interested persons participate. During 2016, the following payments were made by CHS into the SERP plans of the participants: Kathy Fernandez - $311,631 Ronald Schonwetter - $175,929 H. Darrell White - $150,484 David O'Neil - $30,577 Audra Farish - $18,777 Sharon Jones - $13,085 Donald Evans - $16,274 Sharon Saucier - $16,800 THE FOLLOWING DISTRIBUTIONS WERE PAID DURING 2016: Ronald Schonwetter - $193,522
Schedule J (Form 990) 2016
Additional Data
Software ID:
16000421
Software Version:
2016v3.0