Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
SchJMediumBullet Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2017
Open to Public Inspection
Name of the organization
BLYTHEDALE CHILDREN'S HOSPITAL
 
Employer identification number

13-1739922
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.
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.
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
1LAWRENCE LEVINE
CHIEF EXECUTIVE OFFICER 		(i)

(ii)		 632,975
-------------
0 		127,300
-------------
0 		268,394
-------------
0 		35,834
-------------
0 		45,597
-------------
0 		1,110,100
-------------
0 		0
-------------
0
2JOHN CANNING
CHIEF FINANCIAL OFFICER 		(i)

(ii)		 369,235
-------------
0 		60,000
-------------
0 		65,310
-------------
0 		10,405
-------------
0 		52,550
-------------
0 		557,500
-------------
0 		0
-------------
0
3SCOTT KLEIN
CHIEF MEDICAL OFFICER 		(i)

(ii)		 430,893
-------------
0 		65,000
-------------
0 		810
-------------
0 		13,656
-------------
0 		53,843
-------------
0 		564,202
-------------
0 		0
-------------
0
4JILL WEGENER
CHIEF NURSING OFFICER 		(i)

(ii)		 205,717
-------------
0 		24,825
-------------
0 		966
-------------
0 		9,869
-------------
0 		14,290
-------------
0 		255,667
-------------
0 		0
-------------
0
5JANE MACDONALD
CHIEF DEVELOPMENT OFFICER 		(i)

(ii)		 219,129
-------------
0 		30,850
-------------
0 		3,697
-------------
0 		37,089
-------------
0 		26,664
-------------
0 		317,429
-------------
0 		0
-------------
0
6RONALD GALLO
CHIEF HUMAN RESOURCES OFFI 		(i)

(ii)		 219,603
-------------
0 		30,920
-------------
0 		2,772
-------------
0 		41,748
-------------
0 		38,845
-------------
0 		333,888
-------------
0 		0
-------------
0
7MAUREEN DESIMONE
CHIEF ADMINISTRATIVE OFFICER 		(i)

(ii)		 281,482
-------------
0 		20,000
-------------
0 		11,195
-------------
0 		30,853
-------------
0 		39,763
-------------
0 		383,293
-------------
0 		0
-------------
0
8SUSAN GOODBODY MURRAY
CHIEF ENGAGEMENT OFFICER 		(i)

(ii)		 184,618
-------------
0 		18,565
-------------
0 		573
-------------
0 		25,408
-------------
0 		14,495
-------------
0 		243,659
-------------
0 		0
-------------
0
9ADAM HERBST
CHIEF LEGAL & COMPLIANCE 		(i)

(ii)		 125,231
-------------
0 		11,100
-------------
0 		173
-------------
0 		5,141
-------------
0 		12,872
-------------
0 		154,517
-------------
0 		0
-------------
0
10BYRON FERNANDEZ
UNIT CHIEF PEDIATRICS 		(i)

(ii)		 301,787
-------------
0 		0
-------------
0 		276
-------------
0 		17,436
-------------
0 		44,822
-------------
0 		364,321
-------------
0 		0
-------------
0
11JAY SELMAN
CHIEF NEUROLOGY 		(i)

(ii)		 199,171
-------------
0 		0
-------------
0 		1,046
-------------
0 		0
-------------
0 		10,793
-------------
0 		211,010
-------------
0 		0
-------------
0
12KATHY SILVERMAN
UNIT CHIEF PEDIATRICS 		(i)

(ii)		 244,516
-------------
0 		0
-------------
0 		1,370
-------------
0 		43,144
-------------
0 		24,281
-------------
0 		313,311
-------------
0 		0
-------------
0
13RUTH ALEJANDRO
PHYSICIAN 		(i)

(ii)		 198,111
-------------
0 		0
-------------
0 		180
-------------
0 		10,934
-------------
0 		45,299
-------------
0 		254,524
-------------
0 		0
-------------
0
14MARY DIDIE
CLINICAL CHIEF 		(i)

(ii)		 196,758
-------------
0 		0
-------------
0 		1,525
-------------
0 		69,890
-------------
0 		45,948
-------------
0 		314,121
-------------
0 		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 4B SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN - EFFECTIVE AS OF JANUARY 1, 2008, THE HOSPITAL IMPLEMENTED THE BLYTHEDALE CHILDREN'S HOSPITAL SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP) TO PROVIDE PENSION BENEFITS FOR A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES. THIS PLAN IS UNFUNDED AND A TARGET DEFINED BENEFIT PLAN. LAWRENCE LEVINE RECEIVED PAYMENTS FROM A SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN DURING THE YEAR IN THE AMOUNT OF $251,927 UNDER THE TERMS OF THE BLYTHEDALE CHILDREN'S HOSPITAL SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN FOR LAWRENCE LEVINE. EFFECTIVE AS OF JANUARY 1, 2012 THE HOSPITAL IMPLEMENTED AN ADDITIONAL SERP. THIS PLAN IS UNFUNDED AND A DEFINED CONTRIBUTION PLAN. FOR EACH PLAN YEAR THE HOSPITAL WILL MAKE A CONTRIBUTION ON BEHALF OF THE PARTICIPANT IN AN AMOUNT EQUAL TO TEN PERCENT (10%) OF THE PARTICIPANT'S BASE COMPENSATION. IN 2016, THE ANNUAL CONTRIBUTION RATE OF THE ADDITIONAL DEFINED CONTRIBUTION SERP PLAN WAS AMENDED TO FIFTEEN PERCENT (15%) OF THE PARTICIPANT'S BASE COMPENSATION. BOTH PLANS ARE MAINTAINED TO PROVIDE DEFERRED COMPENSATION TO A MEMBER OF A SELECT GROUP OF MANAGEMENT OR HIGHLY COMPENSATED EMPLOYEES. IN 2017, THE HOSPITAL CONTRIBUTED $55,697 TO A SERP ON BEHALF OF JOHN CANNING.
PART I, LINE 7 BLYTHEDALE ENGAGED SULLIVAN, COTTER AND ASSOCIATES IN 2017 TO DEVELOP AND PROVIDE RECOMMENDATIONS TO THE COMENSATION COMMITTEE OF THE BOARD REGARDING PAYMENT OF AN ANNUAL PERFORMANCE INCENTIVE PLAN FOR EMPLOYEES WITH MANAGEMENT RESPONSIBILITIES. THIS INCENTIVE PLAN CONDITIONS PAYMENTS BASED UPON THE ACHIEVEMENT OF MULTIPLE INDIVIDUAL AND ORGANIZATIONAL MEASURES. FUNDING FOR THE PLAN IS DEPENDENT UPON ANNUAL BOARD OF DIRECTORS APPROVAL. BASED UPON THE FINANCIAL CONDITIONS TOWARD THE END OF EACH FISCAL YEAR, THE BOARD WILL EVALUATE THE APPROPRIATENESS OF ESTABLISHING A LUMP SUM POOLED AMOUNT. EVEN IF ALL RELEVANT PERFORMANCE MEASURES ARE ACHIEVED, THE BOARD OF DIRECTORS RETAINS FULL DISCRETION TO MAKE, NOT MAKE OR REDUCE THE AMOUNT OF ANY INCENTIVE AWARDS.
Schedule J (Form 990) 2017
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