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ObjectId: 201843169349302639 - Submission: 2018-11-12
TIN: 39-0869788
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.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
17
Open to Public Inspection
Name of the organization
THEDACARE MEDICAL CENTER - NEW LONDON
INC
Employer identification number
39-0869788
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
Yes
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
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) 2017
Page 2
Schedule J (Form 990) 2017
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
HAROLDSON SARAH MD
BOARD MEMBER/PHYSICIAN
(i)
(ii)
0
-------------
173,260
0
-------------
13,962
0
-------------
335
0
-------------
7,449
0
-------------
20,113
0
-------------
215,119
0
-------------
0
2
ANDRABI IMRAN MD
PRESIDENT AND CEO - SYSTEM
(i)
(ii)
43,831
-------------
394,482
17,144
-------------
154,293
90
-------------
807
0
-------------
0
1,434
-------------
12,906
62,499
-------------
562,488
0
-------------
0
3
SCHMIDT WILLIAM
CEO - SHAWANO & NEW LONDON
(i)
(ii)
116,424
-------------
116,424
5,075
-------------
5,075
31,361
-------------
31,361
3,683
-------------
3,683
10,496
-------------
10,496
167,039
-------------
167,039
0
-------------
0
4
THOMPSON MARK
CFO & COO - SYSTEM
(i)
(ii)
8,903
-------------
80,123
17,331
-------------
155,978
52
-------------
464
111
-------------
996
382
-------------
3,439
26,779
-------------
241,000
0
-------------
0
5
GRUNER DEAN
FORMER PRESIDENT AND CEO
(i)
(ii)
46,701
-------------
420,307
15
-------------
135
35,296
-------------
317,661
609
-------------
5,480
1,538
-------------
13,845
84,159
-------------
757,428
0
-------------
0
6
OLSON TIM
FORMER CFO - SYSTEM
(i)
(ii)
50,525
-------------
454,722
15
-------------
135
21,709
-------------
195,383
810
-------------
7,290
2,380
-------------
21,423
75,439
-------------
678,953
0
-------------
0
7
BURMEISTER BRIAN
FORMER VP SR AMC & TC
(i)
(ii)
39,725
-------------
357,522
15
-------------
135
3,872
-------------
34,850
810
-------------
7,290
2,267
-------------
20,406
46,689
-------------
420,203
0
-------------
0
8
AUSLOOS JODI
INTERIM CIO
(i)
(ii)
23,829
-------------
214,457
15
-------------
135
3,781
-------------
34,027
387
-------------
3,483
1,263
-------------
11,369
29,275
-------------
263,471
0
-------------
0
9
PISTONE MAUREEN
VP SR HR SERVICES
(i)
(ii)
33,415
-------------
300,731
15
-------------
135
9,290
-------------
83,610
810
-------------
7,290
2,277
-------------
20,492
45,807
-------------
412,258
0
-------------
0
10
REED LAURA
FORMER COO/CHIEF NURSING EXEC
(i)
(ii)
24,736
-------------
222,620
15
-------------
135
2,976
-------------
26,786
724
-------------
6,517
1,490
-------------
13,408
29,941
-------------
269,466
0
-------------
0
11
REDMAN-SCHELL JENNIFER
VP SR PHYS, BEHAV, TRANS
(i)
(ii)
15,802
-------------
300,235
7
-------------
142
2,337
-------------
44,400
405
-------------
7,695
1,531
-------------
29,088
20,082
-------------
381,560
0
-------------
0
12
LONG GREGORY MD
CMO
(i)
(ii)
49,036
-------------
441,324
15
-------------
135
9,928
-------------
89,350
810
-------------
7,290
2,506
-------------
22,555
62,295
-------------
560,654
0
-------------
0
13
KORITTNIG SHAY
CRNA
(i)
(ii)
210,559
-------------
0
42,750
-------------
0
463
-------------
0
9,736
-------------
0
25,418
-------------
0
288,926
-------------
0
0
-------------
0
14
MANN WILLIAM
VP SR STRATEGY
(i)
(ii)
39,210
-------------
352,894
15
-------------
135
8,533
-------------
76,796
810
-------------
7,290
1,078
-------------
9,705
49,646
-------------
446,820
0
-------------
0
15
MATHESON JAMES
FORMER VP SR STRATEGY
(i)
(ii)
27,938
-------------
251,445
15
-------------
135
1,465
-------------
13,186
546
-------------
4,917
3,243
-------------
29,184
33,207
-------------
298,867
0
-------------
0
Schedule J (Form 990) 2017
Page 3
Schedule J (Form 990) 2017
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
ALL EXECUTIVES AT THE LEVEL OF VICE PRESIDENT OR ABOVE RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT A MAXIMUM AMOUNT OF $6,800, THAT IS TAXED UPON REIMBURSEMENT. ALL EXECUTIVES AT A LEVEL OF VICE PRESIDENT AND ABOVE ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES REIMBURSED TO THEM, AND TAXED UPON REIMBURSEMENT. ONE EXECUTIVE, NOT PART OF THE SENIOR LEADERSHIP TEAM, RECEIVED REIMBURSEMENT FOR A LOCAL COUNTRY CLUB MEMBERSHIP THAT ENDED 9/1/2017. 12 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 3 EMPLOYEES RECEIVED FITNESS CLUB DUES REIMBURSEMENTS.
PART I, LINE 4B
NONQUALIFIED PLAN DESCRIPTION: SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVEST IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS.
PART I, LINE 7
EXECUTIVE AT RISK COMPENSATION PLAN: THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG KEY EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE BONUS AMOUNTS THAT THE EXECUTIVE WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2016 TO DECEMBER 31, 2016) TO RECEIVE THEIR 2017 BONUSES. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE BONUS PLAN OR DIES, THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN BONUS WILL BE FORFEITED. CARING FOR SUCCESS THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FUFILLMENT OF THEDACARE'S MISSION. EMPLOYEE ELIGIBILITY IS BASED ON THE NUMBER OF HOURS WORKED. AND ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS DETERMINED BASED ON BOTH FINANCIAL AND EMPLOYEE HEALTH AND SAFETY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN.
Schedule J (Form 990) 2017
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