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ObjectId: 201733179349305908 - Submission: 2017-11-13
TIN: 57-1067254
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
Bon Secours-St Francis Xavier
Hospital Inc
Employer identification number
57-1067254
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
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
Yes
b
Any related organization?
......................
6b
Yes
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) 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
Brian Cuddy MD
Chair (See Sch O)
(i)
(ii)
16,000
-------------
902,196
0
-------------
156,015
0
-------------
12,491
0
-------------
31,530
0
-------------
29,291
16,000
-------------
1,131,523
0
-------------
0
2
John B Holloway Jr
Board Member (See Sch O)
(i)
(ii)
0
-------------
296,962
0
-------------
40,000
0
-------------
0
0
-------------
13,530
0
-------------
15,221
0
-------------
365,713
0
-------------
0
3
John A Spratt MD
Board Member (See Sch O)
(i)
(ii)
0
-------------
760,048
0
-------------
46,200
0
-------------
14,530
0
-------------
34,180
0
-------------
28,454
0
-------------
883,412
0
-------------
0
4
Susan Datta MD
Board Member (See Sch O)
(i)
(ii)
0
-------------
200,311
0
-------------
0
0
-------------
5,516
0
-------------
22,961
0
-------------
25,282
0
-------------
254,070
0
-------------
0
5
David Dunlap
President & CEO of CAHS (through Oct
(i)
(ii)
0
-------------
639,036
0
-------------
379,800
0
-------------
211,770
0
-------------
370,211
0
-------------
19,414
0
-------------
1,620,231
0
-------------
281,269
6
Lorraine Lutton
President & CEO of CAHS (from Nov)
(i)
(ii)
0
-------------
27,500
0
-------------
100,000
0
-------------
9,942
0
-------------
53,174
0
-------------
0
0
-------------
190,616
0
-------------
0
7
Bret Johnson
CFO & SVP / Treasurer
(i)
(ii)
0
-------------
382,635
0
-------------
190,926
0
-------------
68,296
0
-------------
250,189
0
-------------
30,794
0
-------------
922,840
0
-------------
147,258
8
Matthew Severance
SVP Operations & CEO, Roper Hospital
(i)
(ii)
0
-------------
488,321
0
-------------
241,017
0
-------------
40,481
0
-------------
211,102
0
-------------
25,904
0
-------------
1,006,825
0
-------------
147,362
9
Todd Shuman MD
MD SVP & Chief Physician Officer
(i)
(ii)
0
-------------
472,124
0
-------------
164,846
0
-------------
594
0
-------------
153,154
0
-------------
16,701
0
-------------
807,419
0
-------------
44,599
10
Allen Carroll
Regional CEO & CEO BSSF
(i)
(ii)
409,338
-------------
0
199,802
-------------
0
27,865
-------------
0
161,965
-------------
0
16,701
-------------
0
815,671
-------------
0
117,204
-------------
0
11
Anthony Jackson
VP and CEO MPH
(i)
(ii)
0
-------------
279,791
0
-------------
50,000
0
-------------
27,635
0
-------------
77,430
0
-------------
22,185
0
-------------
457,041
0
-------------
0
12
Steven Sapiro MD
Chief Medical Officer (through Apr)
(i)
(ii)
0
-------------
446,614
0
-------------
176,870
0
-------------
35,576
0
-------------
34,180
0
-------------
6,747
0
-------------
699,987
0
-------------
73,815
13
Stanley Wilson MD
Interim VP Medical Affairs & CMO
(i)
(ii)
0
-------------
327,034
0
-------------
89,392
0
-------------
8,877
0
-------------
31,530
0
-------------
18,199
0
-------------
475,032
0
-------------
0
14
Douglas Bowling
CSO & VP
(i)
(ii)
0
-------------
332,898
0
-------------
177,568
0
-------------
28,664
0
-------------
139,730
0
-------------
19,578
0
-------------
698,438
0
-------------
109,200
15
Gregory Edwards
VP & General Council/ Secretary
(i)
(ii)
0
-------------
353,160
0
-------------
143,580
0
-------------
25,445
0
-------------
129,312
0
-------------
27,045
0
-------------
678,542
0
-------------
82,884
16
Melanie Stith
VP Human Resources
(i)
(ii)
0
-------------
228,237
0
-------------
87,085
0
-------------
225
0
-------------
79,277
0
-------------
28,577
0
-------------
423,401
0
-------------
23,275
17
Keith Neuman
VP & Chief Information Officer
(i)
(ii)
0
-------------
273,834
0
-------------
0
0
-------------
18,161
0
-------------
70,025
0
-------------
24,134
0
-------------
386,154
0
-------------
0
18
Carolyn Donohue
VP Nursing/ Senior Nurse Exec RHI
(i)
(ii)
0
-------------
204,412
0
-------------
76,174
0
-------------
13,122
0
-------------
61,269
0
-------------
7,758
0
-------------
362,735
0
-------------
30,309
19
Pennie Peralta
VP Nursing/ Sr. Nurse Exec SFX
(i)
(ii)
181,093
-------------
0
75,386
-------------
0
13,464
-------------
0
57,561
-------------
0
18,201
-------------
0
345,705
-------------
0
46,519
-------------
0
20
Tavia Buck
VP Nursing/Sr. Nurse Exec MPH
(i)
(ii)
0
-------------
140,688
0
-------------
52,578
0
-------------
90
0
-------------
41,208
0
-------------
1,960
0
-------------
236,524
0
-------------
15,129
21
Mark Dickson
VP Mission
(i)
(ii)
0
-------------
178,287
0
-------------
72,280
0
-------------
387
0
-------------
55,071
0
-------------
21,532
0
-------------
327,557
0
-------------
26,201
22
Wanda Brockmeyer
Director of Emergency Serv
(i)
(ii)
0
-------------
156,607
0
-------------
19,620
0
-------------
3,031
0
-------------
10,291
0
-------------
8,006
0
-------------
197,555
0
-------------
0
23
Peter DiNicola
Dir. Plant Engineering
(i)
(ii)
0
-------------
212,113
0
-------------
25,904
0
-------------
594
0
-------------
32,554
0
-------------
4,278
0
-------------
275,443
0
-------------
0
24
Vanessa Shamrock
Director of Lab Services
(i)
(ii)
0
-------------
133,641
0
-------------
18,607
0
-------------
406
0
-------------
7,039
0
-------------
11,075
0
-------------
170,768
0
-------------
0
25
Francis Wyckoff Jr
Director of Pharmacy
(i)
(ii)
0
-------------
203,073
0
-------------
25,000
0
-------------
8,941
0
-------------
31,117
0
-------------
9,370
0
-------------
277,501
0
-------------
0
26
Mike DeGennaro
Director of Imaging
(i)
(ii)
0
-------------
156,734
0
-------------
10,000
0
-------------
481
0
-------------
7,778
0
-------------
7,159
0
-------------
182,152
0
-------------
0
27
Stephanie McKoin
Director of Perioperative Services
(i)
(ii)
0
-------------
173,103
0
-------------
22,369
0
-------------
1,938
0
-------------
9,995
0
-------------
21,162
0
-------------
228,567
0
-------------
0
28
George Khoury MD
Physician
(i)
(ii)
18,500
-------------
1,166,768
0
-------------
278,120
0
-------------
16,914
0
-------------
31,530
0
-------------
32,577
18,500
-------------
1,525,909
0
-------------
0
29
John Steichen MD
Physician
(i)
(ii)
20,600
-------------
1,137,744
0
-------------
90,147
0
-------------
12,257
0
-------------
31,530
0
-------------
28,454
20,600
-------------
1,300,132
0
-------------
0
30
John McCrosson MD
Physician
(i)
(ii)
6,000
-------------
1,007,774
0
-------------
133,790
0
-------------
10,828
0
-------------
31,530
0
-------------
28,795
6,000
-------------
1,212,717
0
-------------
0
31
Robert Morgan Stuart MD
Physician
(i)
(ii)
17,500
-------------
858,257
0
-------------
199,755
0
-------------
9,097
0
-------------
31,530
0
-------------
30,045
17,500
-------------
1,128,684
0
-------------
0
32
Robert Lowery MD
Physician
(i)
(ii)
9,500
-------------
600,475
0
-------------
488,617
0
-------------
14,239
0
-------------
31,530
0
-------------
25,672
9,500
-------------
1,160,533
0
-------------
0
33
Melinda Cardell
Chief Information Officer (Former)
(i)
(ii)
0
-------------
185,667
0
-------------
64,882
0
-------------
350
0
-------------
12,836
0
-------------
9,649
0
-------------
273,384
0
-------------
0
34
C Scott Ferguson
Director of Material Serv (Former)
(i)
(ii)
0
-------------
163,585
0
-------------
22,653
0
-------------
1,709
0
-------------
11,052
0
-------------
23,145
0
-------------
222,144
0
-------------
0
35
Susan Oliver
Director of Periop Endo (Former)
(i)
(ii)
0
-------------
115,435
0
-------------
18,502
0
-------------
738
0
-------------
4,700
0
-------------
3,855
0
-------------
143,230
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 4b
The Vice Presidents, CFO, and CEO participate in the 457(f) Plan. The following participants received compensation through a 457(f) Plan: David Dunlap - $137,676 (from a related organization) Bret Johnson - $65,744 (from a related organization) Steven Shapiro - $35,195 (from a related organization) Douglas Bowling - $28,070 (from a related organization) Greg Edwards - $25,295 (from a related organization) Matt Severance - $35,642 (from a related organization) Allen Carroll - $26,764 (from a related organization) Pennie Peralta - $12,870 (from a related organization) Carolyn Donohue - $12,051 (from a related organization)
Part I, Line 6
Goals are developed each year to support the organization's strategic initiatives for people, quality, financial, growth and service. The Ad Hoc Compensation Committee approves the system goals annually and reports to the full Board of Directors. Progress on each metric is reported to the board each month on the corporate scorecard. At year end, the Ad Hoc Compensation Committee approves the final scorecard number and reports results to the full board. Annual incentives for the executives are based on 60% on the corporate scorecard and 40% on individual performance. Executives maintain an individual scorecard on the leader evaluation manager and discuss results monthly with the President/CEO. The President/CEO approves the individual executive scorecard. System Vice Presidents and the system CEO are eligible to participate in a long term incentive plan (LTIP). An LTIP typically takes place over a three year period and does not vest until the end of the third year. To receive payment, executives must still be employed by the system at the end of the plan period. Each LTIP has a financial and clinical objective that is aligned with the organization's strategic goals. Threshold, target, and maximum performance ranges are established for these objectives and are measured based on performance against similar organizations or compared to an internal metric such as an improvement over prior performance. These targets and objectives are approved by the Ad Hoc Compensation Committee. The incentive is earned based on the satisfaction of the threshold, target, or maximum performance ranges. The Ad Hoc Compensation Committee also approves the final LTIP performance score and the amount paid to executives under the plan. Results are reported to the full board annually.
Part I, Line 7
See the response to Line 6 above.
Part II, Line 1: Compensation from unrelated organizations
Carolinas Healthcare System (CHS), an unrelated organization, provides the compensation of Mr. David L. Dunlap, CEO through October, CareAlliance Health Services; Ms. Lorraine Lutton, CEO from November, CareAlliance Health Services; and Mr. Bret D. Johnson, CFO, CareAlliance Health Services. Mr. Dunlap, Ms. Lutton, and Mr. Johnson are employees of CHS and their compensation is paid by CareAlliance Health Services, a related organization, through a management fee to CHS. Additional information: CareAlliance Health Services has board representations from the 3 founding organizations: the Medical Society of SC (6 board members), Bon-Secours Health System, Inc. (6 board members), and Carolinas Healthcare System (1 board member). None of the 13 appointed board members receive compensation for their membership. Additionally, 4 of the 6 board members appointed by the Medical Society of South Carolina also serve on the board of the Medical Society. None receive compensation for their services as a board member. It is the founding members' intent that the members of the Board of Directors are appointed to such positions because they have a willingness to serve the needs of the system as a whole and not the needs of any individual founding member.
Schedule J (Form 990) 2016
Additional Data
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