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ObjectId: 201723189349306802 - Submission: 2017-11-14
TIN: 52-1532556
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
ADVENTIST HEALTHCARE INC
Employer identification number
52-1532556
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
No
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
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 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
No
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
ROSEMARIE MELENDEZ
BOARD MEMBER
(i)
(ii)
126,781
-------------
0
19,682
-------------
0
164
-------------
0
7,054
-------------
0
22,798
-------------
0
176,479
-------------
0
0
-------------
0
2
TERRY FORDE
PRESIDENT & CEO, AHC
(i)
(ii)
858,253
-------------
0
345,275
-------------
0
19,872
-------------
0
192,324
-------------
0
36,308
-------------
0
1,452,032
-------------
0
0
-------------
0
3
JAMES G LEE
EVP & CFO, AHC
(i)
(ii)
486,641
-------------
0
164,696
-------------
0
5,532
-------------
0
78,265
-------------
0
33,738
-------------
0
768,872
-------------
0
0
-------------
0
4
JOHN SACKETT
EVP & COO OF AHC & PRESIDENT OF SGMC
(i)
(ii)
528,948
-------------
0
180,270
-------------
0
6,396
-------------
0
105,519
-------------
0
48,486
-------------
0
869,619
-------------
0
0
-------------
0
5
ERIK WANGSNESS
PRESIDENT, WAH
(i)
(ii)
398,917
-------------
0
101,245
-------------
0
5,177
-------------
0
87,247
-------------
0
33,280
-------------
0
625,866
-------------
0
0
-------------
0
6
JASON C COE
PRESIDENT, HRMC
(i)
(ii)
65,297
-------------
0
247,095
-------------
0
40,269
-------------
0
3,322
-------------
0
16,253
-------------
0
372,236
-------------
0
38,327
-------------
0
7
KEITH BALLENGER
VP, HOME HEALTH
(i)
(ii)
183,081
-------------
0
46,758
-------------
0
8,297
-------------
0
32,225
-------------
0
22,402
-------------
0
292,763
-------------
0
0
-------------
0
8
JAMES DAMRON
VP & CHIEF DEVELOPMENT OFFICER, AHC
(i)
(ii)
248,986
-------------
0
47,437
-------------
0
52,165
-------------
0
9,120
-------------
0
15,360
-------------
0
373,068
-------------
0
0
-------------
0
9
KENNETH B DESTEFANO
VP & GENERAL COUNSEL, AHC
(i)
(ii)
346,392
-------------
0
93,928
-------------
0
8,402
-------------
0
48,565
-------------
0
29,422
-------------
0
526,709
-------------
0
0
-------------
0
10
MAUREEN DYMOND
VP, FINANCIAL OPERATIONS, AHC
(i)
(ii)
201,411
-------------
0
55,138
-------------
0
3,269
-------------
0
29,506
-------------
0
30,404
-------------
0
319,728
-------------
0
0
-------------
0
11
PATRICK GARRETT
SVP & PHYSICIAN INTEGRATION, AHC
(i)
(ii)
376,205
-------------
0
137,471
-------------
0
5,903
-------------
0
103,155
-------------
0
15,061
-------------
0
637,795
-------------
0
0
-------------
0
12
CHRISTOPHER GHION
VP, CHIEF INFORMATION OFFICER, AHC
(i)
(ii)
280,101
-------------
0
71,347
-------------
0
2,494
-------------
0
68,684
-------------
0
5,642
-------------
0
428,268
-------------
0
0
-------------
0
13
SUSAN L GLOVER
SVP & SYSTEM QUALITY, AHC
(i)
(ii)
294,169
-------------
0
97,549
-------------
0
4,819
-------------
0
57,189
-------------
0
30,592
-------------
0
484,318
-------------
0
0
-------------
0
14
THOMAS GRANT
VP, PUBLIC RELATIONS&MARKETING, AHC
(i)
(ii)
207,422
-------------
0
55,410
-------------
0
3,520
-------------
0
51,275
-------------
0
4,386
-------------
0
322,013
-------------
0
0
-------------
0
15
DEBRA ILLIG
VP, CLINICAL EFFECT.&PATIENT SAFETY,
(i)
(ii)
185,236
-------------
0
48,710
-------------
0
2,624
-------------
0
35,152
-------------
0
19,936
-------------
0
291,658
-------------
0
0
-------------
0
16
MARTA BRITO PEREZ
SVP & CHIEF HR OFFICER, AHC
(i)
(ii)
332,015
-------------
0
111,787
-------------
0
4,880
-------------
0
73,321
-------------
0
31,678
-------------
0
553,681
-------------
0
0
-------------
0
17
KRISTEN PULIO
VP, REVENUE MANAGEMENT, AHC
(i)
(ii)
219,145
-------------
0
58,483
-------------
0
3,120
-------------
0
52,875
-------------
0
8,340
-------------
0
341,963
-------------
0
0
-------------
0
18
BRENT REITZ
VP & ADMINISTRATOR, ARHM
(i)
(ii)
277,052
-------------
0
68,451
-------------
0
3,457
-------------
0
56,731
-------------
0
26,447
-------------
0
432,138
-------------
0
0
-------------
0
19
EUNMEE SHIM
VP,BUS. DEV.&STRATEGIC PLANNING, AHC
(i)
(ii)
297,883
-------------
0
79,834
-------------
0
10,511
-------------
0
62,248
-------------
0
29,660
-------------
0
480,136
-------------
0
0
-------------
0
20
CARLOS VARGAS
VP, HUMAN RESOURCES, AHC
(i)
(ii)
208,747
-------------
0
38,206
-------------
0
2,365
-------------
0
42,230
-------------
0
24,994
-------------
0
316,542
-------------
0
0
-------------
0
21
KEVIN YOUNG
PRESIDENT, BHWS
(i)
(ii)
299,676
-------------
0
0
-------------
0
4,311
-------------
0
62,989
-------------
0
27,746
-------------
0
394,722
-------------
0
0
-------------
0
22
DANIEL L COCHRAN
VP & CFO, SGMC
(i)
(ii)
321,133
-------------
0
87,238
-------------
0
4,323
-------------
0
74,759
-------------
0
21,312
-------------
0
508,765
-------------
0
0
-------------
0
23
MARISSA CUMMINGS LESLIE
MEDICAL DIRECTOR
(i)
(ii)
277,926
-------------
0
10,000
-------------
0
269
-------------
0
10,781
-------------
0
9,148
-------------
0
308,124
-------------
0
0
-------------
0
24
DAVID SMITH
VP OF OPERATIONS
(i)
(ii)
236,372
-------------
0
63,295
-------------
0
4,338
-------------
0
50,798
-------------
0
19,296
-------------
0
374,099
-------------
0
0
-------------
0
25
KEVIN SMOTHERS
VP & CHIEF MEDICAL OFFICER
(i)
(ii)
408,145
-------------
0
110,888
-------------
0
7,295
-------------
0
88,477
-------------
0
33,666
-------------
0
648,471
-------------
0
0
-------------
0
26
JOAN VINCENT
CHIEF NURSING OFFICER, SGMC
(i)
(ii)
241,340
-------------
0
65,555
-------------
0
60,205
-------------
0
12,223
-------------
0
3,573
-------------
0
382,896
-------------
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
PART I, LINE 1A
ADVENTIST HEALTHCARE DOES NOT HAVE A WRITTEN POLICY REGARDING REIMBURSEMENT OR PROVISION OF CLUB EXPENSES. HOWEVER, ADVENTIST HEALTHCARE OWNS A CORPORATE MEMBERSHIP AT A LOCAL GOLF CLUB, IN WHICH THREE ADVENTIST HEALTHCARE EMPLOYEES CAN BE DESIGNATED TO USE THE FACILITIES. CLUB EXPENSES ARE PAID BY ADVENTIST HEALTHCARE, BUT ARE TREATED AS TAXABLE INCOME TO THE RESPECTIVE ADVENTIST HEALTHCARE EMPLOYEES, SUBJECT TO FEDERAL AND STATE TAX WITHHOLDINGS. THE CLUB EXPENDITURES ARE REVIEWED ANNUALLY BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES, IN ACCORDANCE WITH IRS INTERMEDIATE SANCTION GUIDELINES.
PART I, LINE 3
COMPENSATION DEFINED. THE COMPENSATION REPORTED FOR THE EMPLOYEES SET FORTH ON SCHEDULE J IS COMPRISED OF THE FOLLOWING: BASE COMPENSATION INCLUDES NONDISCRETIONARY PAYMENTS, AGREED UPON IN ADVANCE, CONTINGENT ONLY UPON THE PAYEES' PERFORMANCE OF AGREED UPON SERVICES (SUCH AS SALARY OR FEES). INCENTIVE COMPENSATION INCLUDES PAYMENTS BASED ON SATISFACTION OF PRE-DETERMINED PERFORMANCE TARGETS SUCH AS QUALITY/PATIENT SAFETY GOALS, EMPLOYEE AND CUSTOMER ENGAGEMENT GOALS, ORGANIZATIONAL GROWTH, AND FINANCIAL PERFORMANCE, AMONG OTHER THINGS. OTHER REPORTABLE COMPENSATION INCLUDES AN EXECUTIVE RETENTION 457F PLAN, WHICH BECAME EFFECTIVE ON JANUARY 1, 2015. PRE-TAX CONTRIBUTIONS ARE ACCUMULATED ANNUALLY AND ARE DISTRIBUTED ON JANUARY 1ST OF THE 2ND YEAR, IF STILL EMPLOYED OR SOONER BASED ON CERTAIN EXCEPTIONS. THERE IS TYPICALLY A 2 YEAR DEFERRAL PERIOD BEFORE PAYMENTS ARE RELEASED. THE FIRST PAYMENT ON THE EXECUTIVE RETENTION PLAN, RELATED TO CONTRIBUTIONS ACCUMULATED IN 2015, WILL GENERALLY BE DISTRIBUTED ON JANUARY 1, 2017 AND CONTRIBUTIONS ACCUMULATED IN 2016 WILL GENERALLY BE DISTRIBUTED ON JANUARY 1, 2018. IN ADDITION, OTHER REPORTABLE COMPENSATION INCLUDES LONG-TERM DISABILITY COVERAGE, CELL PHONE ALLOWANCES, CASH-OUT OF UNUSED PAID TIME OFF (PTO) HOURS (ONLY FOR EMPLOYEES WHO LEAVE OUR ORGANIZATION), IMPUTED VALUE OF LIFE INSURANCE BENEFITS, TAXABLE PAYABLE PAY, AND SEVERANCE, AS APPLICABLE. CERTAIN EXECUTIVES CAN ALSO RECEIVE REPORTABLE COMPENSATION THROUGH A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP), ONCE THEY HAVE VESTED IN THE PLAN; HOWEVER EXECUTIVES LISTED ON THIS TAX RETURN HAVE NOT YET RECEIVED THIS BENEFIT SINCE THEY HAVE MET THE VESTING REQUIREMENTS. NON-TAXABLE BENEFITS INCLUDES PRE-TAX PAYROLL DEDUCTIONS (SUCH AS FLEXIBLE MEDICAL SPENDING, DEPENDENT CARE, AND EMPLOYEE HEALTH BENEFIT PREMIUM), AND THE EMPLOYER PORTION OF CERTAIN EMPLOYEE BENEFITS SUCH AS HEALTH INSURANCE, DENTAL INSURANCE, VISION INSURANCE, LIFE INSURANCE, BASE CONTRIBUTIONS TO RETIREMENT PLANS, MATCHING OF EMPLOYEES' RETIREMENT CONTRIBUTIONS, ETC. PAY PRACTICE: ADVENTIST HEALTHCARE UTILIZES A SINGLE EMPLOYER ID FOR ALL OF ITS AFFILIATED ENTITIES FOR EMPLOYMENT PURPOSES. AS SUCH, ACTUAL COMPENSATION AND BENEFITS ARE CHARGED TO THE RESPECTIVE ENTITIES AND THE RESULTING COMPENSATION AND BENEFITS ARE REPORTED ON EACH AFFILIATE IRS FORM 990 AS IF PAID DIRECTLY BY SUCH AFFILIATE. AS APPLICABLE, THE SAME AND NON-ADDITIVE COMPENSATION AND EMPLOYMENT BENEFIT PLAN CONTRIBUTION AMOUNTS WERE ALSO DISCLOSED IN THE ADVENTIST HEALTHCARE INC. RELATED ENTITIES RETURNS. INDEPENDENT GUIDELINES: WHEN SETTING COMPENSATION FOR THE OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, AND THE HIGHEST COMPENSATED EMPLOYEES, ADVENTIST HEALTHCARE FULLY COMPLIES WITH THE PROCEDURAL SAFE GUARDS EMBODIED IN IRS REGULATIONS. COMPENSATION FOR ADVENTIST HEALTHCARE OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, AND THE HIGHEST COMPENSATED EMPLOYEES IS ENTIRELY SET BY A COMMITTEE OF ADVENTIST HEALTHCARE BOARD OF TRUSTEES. IN SETTING COMPENSATION, THE GOVERNING BOARD COMMITTEE RELIES UPON MARKET COMPARABILITY DATA PROVIDED BY AN INDEPENDENT OUTSIDE COMPENSATION CONSULTANT WHO PROVIDES A SUMMARY OF HEALTH CARE SALARIES AND BENEFITS FOR COMPARABLE SIZED ORGANIZATIONS BOTH NATIONALLY AND IN THE BALTIMORE-WASHINGTON REGION. TO FURTHER ENSURE REASONABLENESS, BOTH COMPENSATION AND BENEFITS ARE TARGETED AT THE 50TH PERCENTILE (OR MEDIAN) OF THE MARKET.
PART I, LINE 4B
CERTAIN EMPLOYEES RECEIVED COMPENSATION FROM AN EXECUTIVE RETENTION 457F PLAN, WHICH BECAME EFFECTIVE ON JANUARY 1, 2015. PRE-TAX CONTRIBUTIONS ARE ACCUMULATED ANNUALLY AND ARE DISTRIBUTED ON JANUARY 1ST OF THE 2ND YEAR, IF STILL EMPLOYED OR SOONER BASED ON CERTAIN EXCEPTIONS. THERE IS TYPICALLY A 2 YEAR DEFERRAL PERIOD BEFORE PAYMENTS ARE RELEASED. THE FIRST PAYMENT ON THE EXECUTIVE RETENTION PLAN, RELATED TO CONTRIBUTIONS ACCUMULATED IN 2015, WILL GENERALLY BE DISTRIBUTED ON JANUARY 1, 2017 AND CONTRIBUTIONS ACCUMULATED IN 2016 WILL GENERALLY BE DISTRIBUTED ON JANUARY 1, 2018. THE FOLLOWING EMPLOYEES LISTED BELOW RECEIVED EARLY LUMP-SUM CASH PAYMENTS ON THEIR 457F PLANS: JASON COE: $39,388 JAMES DAMRON: $50,412 JOAN VINCENT: $53,082
Schedule J (Form 990) 2016
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