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ObjectId: 201913199349301856 - Submission: 2019-11-15
TIN: 21-0662542
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
18
Open to Public Inspection
Name of the organization
CAPE REGIONAL MEDICAL CENTER INC
Employer identification number
21-0662542
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
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) 2018
Page 2
Schedule J (Form 990) 2018
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
JOANNE CARROCINO FACHE
TRUSTEE - PRESIDENT/CEO
(i)
(ii)
621,426
-------------
0
62,856
-------------
0
45,247
-------------
0
53,166
-------------
0
16,379
-------------
0
799,074
-------------
0
0
-------------
0
2
MARK R GILL
VP FINANCE/CFO
(i)
(ii)
432,498
-------------
0
29,197
-------------
0
1,074
-------------
0
47,637
-------------
0
40,262
-------------
0
550,668
-------------
0
0
-------------
0
3
ANDREA MCCOY MD
CHIEF MEDICAL OFFICER
(i)
(ii)
351,452
-------------
0
34,746
-------------
0
1,600
-------------
0
9,725
-------------
0
42,762
-------------
0
440,285
-------------
0
0
-------------
0
4
RICHARD WHEATLEY
CHIEF INFORMATION OFFICER
(i)
(ii)
245,523
-------------
0
20,183
-------------
0
1,042
-------------
0
11,295
-------------
0
28,248
-------------
0
306,291
-------------
0
0
-------------
0
5
ROSEMARY DUNN EFF 6118
CHIEF NURSING OFFICER
(i)
(ii)
161,828
-------------
0
0
-------------
0
0
-------------
0
2,354
-------------
0
13,019
-------------
0
177,201
-------------
0
0
-------------
0
6
BYRON K HUNTER
VP HUMAN RESOURCES
(i)
(ii)
254,482
-------------
0
22,532
-------------
0
1,084
-------------
0
32,404
-------------
0
40,187
-------------
0
350,689
-------------
0
0
-------------
0
7
JOANNE VAUL
VP PHYS INTEGRATION & AMB SVCS
(i)
(ii)
231,885
-------------
0
34,627
-------------
0
934
-------------
0
10,395
-------------
0
1,832
-------------
0
279,673
-------------
0
0
-------------
0
8
THOMAS J PIRATZKY CFRE
EXEC DIR - CAPE REGIONAL FDN
(i)
(ii)
219,031
-------------
0
17,476
-------------
0
7,144
-------------
0
9,563
-------------
0
39,378
-------------
0
292,592
-------------
0
0
-------------
0
9
MICHAEL SLUSARZ
VP MKTG/BUSINESS DEVELOPMENT
(i)
(ii)
165,538
-------------
0
18,090
-------------
0
0
-------------
0
4,399
-------------
0
41,263
-------------
0
229,290
-------------
0
0
-------------
0
10
DEBORAH BAEHSER RN
VP PAT CARE SVCS (TERM 5/18)
(i)
(ii)
91,275
-------------
0
20,887
-------------
0
14,519
-------------
0
1,599
-------------
0
10,927
-------------
0
139,207
-------------
0
0
-------------
0
11
RICHARD ARTYMOWICZ PHARMD
DIRECTOR OF PHARMACY
(i)
(ii)
173,917
-------------
0
23,033
-------------
0
1,694
-------------
0
11,894
-------------
0
41,162
-------------
0
251,700
-------------
0
0
-------------
0
12
SUSAN JOHNSON
PHARMACIST
(i)
(ii)
177,044
-------------
0
0
-------------
0
15,211
-------------
0
10,075
-------------
0
36,232
-------------
0
238,562
-------------
0
0
-------------
0
13
FRANK VAUL
DIRECTOR OF FINANCE
(i)
(ii)
167,888
-------------
0
16,613
-------------
0
976
-------------
0
7,827
-------------
0
39,536
-------------
0
232,840
-------------
0
0
-------------
0
14
JAMES NUSS PHARMD
PHARMACIST
(i)
(ii)
160,572
-------------
0
0
-------------
0
24,309
-------------
0
7,728
-------------
0
37,592
-------------
0
230,201
-------------
0
0
-------------
0
15
GRETCHEN W SORENSEN RPH
PHARMACIST
(i)
(ii)
142,839
-------------
0
0
-------------
0
11,803
-------------
0
9,587
-------------
0
15,891
-------------
0
180,120
-------------
0
0
-------------
0
Schedule J (Form 990) 2018
Page 3
Schedule J (Form 990) 2018
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; QUESTION 4B
THE DEFERRED COMPENSATION AMOUNT REPORTED IN SCHEDULE J, PART II, COLUMN C FOR THE FOLLOWING INDIVIDUALS INCLUDES UNVESTED BENEFITS IN AN INTERNAL REVENUE CODE SECTION 457(F) PLAN (NON-QUALIFIED DEFERRED COMPENSATION PLAN) WHICH ARE SUBJECT TO A SUBSTANTIAL RISK OF COMPLETE FORFEITURE. ACCORDINGLY, THE INDIVIDUALS MAY NEVER ACTUALLY RECEIVE THIS UNVESTED BENEFIT AMOUNT. THE AMOUNTS OUTLINED HEREIN WERE NOT INCLUDED IN EACH INDIVIDUAL'S 2018 FORM W-2, BOX 5 AS TAXABLE MEDICARE WAGES: JOANNE CARROCINO, FACHE, $42,235; MARK R. GILL, $32,018 and BYRON K. HUNTER, $19,006.
SCHEDULE J, PART I; QUESTION 6A
THE DEFERRED COMPENSATION AMOUNT REPORTED IN SCHEDULE J, PART II, COLUMN C MAY INCLUDE ADDITIONAL CONTRIBUTIONS MADE BY CAPE REGIONAL MEDICAL CENTER ("CRMC") TO EMPLOYEES THAT PARTICIPATE IN THE CRMC INTERNAL REVENUE CODE SECTION 403(B) DEFINED CONTRIBUTION RETIREMENT PLAN. ACCORDING TO ARTICLE 35 OF CRMC'S COLLECTIVE BARGAINING AGREEMENT, IF CRMC'S AUDITED INCOME FROM OPERATIONS AS REPORTED IN ITS AUDITED FINANCIAL STATEMENTS EXCEEDS CERTAIN THRESHOLDS OUTLINED IN THE COLLECTIVE BARGAINING AGREEMENT, CRMC WILL CONTRIBUTE ADDITIONAL FUNDS INTO EACH PARTICIPATING MEMBER'S INTERNAL REVENUE CODE SECTION 403(B) DEFINED CONTRIBUTION RETIREMENT PLAN ACCOUNT. THERE WERE NO ADDITIONAL FUNDS CONTRIBUTED BY THE ORGANIZATION DURING THE YEAR ENDED DECEMBER 31, 2018.
SCHEDULE J, PART I; QUESTION 7
CERTAIN INDIVIDUALS INCLUDED IN SCHEDULE J, PART II RECEIVED A BONUS DURING CALENDAR YEAR 2018 WHICH AMOUNTS WERE INCLUDED IN COLUMN B(II) HEREIN AND IN EACH INDIVIDUAL'S 2018 FORM W-2, BOX 5, AS TAXABLE MEDICARE WAGES. PLEASE REFER TO THIS SECTION OF THE FORM 990, SCHEDULE J FOR THIS INFORMATION BY PERSON BY AMOUNT.
Schedule J (Form 990) 2018
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