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 Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2018
Open to Public Inspection
Name of the organization
THE GOOD SHEPHERD REHABILITATION
HOSPITAL
Employer identification number

23-1371947
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
Yes
 
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) 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
1JOHN KRISTEL
PRESIDENT/CEO (UNTIL 11/24/18)
(i)

(ii)
0
-------------
656,000
0
-------------
0
0
-------------
0
0
-------------
9,250
0
-------------
16,022
0
-------------
681,272
0
-------------
0
2JAMES J DALEY MD
TRUSTEE
(i)

(ii)
177,931
-------------
0
17,500
-------------
0
0
-------------
0
0
-------------
0
10,927
-------------
0
206,358
-------------
0
0
-------------
0
3RONALD J PETULA
SVP & CFO
(i)

(ii)
0
-------------
306,190
0
-------------
19,800
0
-------------
0
0
-------------
8,192
0
-------------
9,807
0
-------------
343,989
0
-------------
0
4MIKE CIRBA
CIO (UNTIL 06/15/19)
(i)

(ii)
0
-------------
175,747
0
-------------
3,500
0
-------------
0
0
-------------
9,100
0
-------------
810
0
-------------
189,157
0
-------------
0
5SAMUEL A MIRANDA JR
SVP & CNO (UNTIL 09/22/18)
(i)

(ii)
0
-------------
241,484
0
-------------
15,728
0
-------------
232,648
0
-------------
4,034
0
-------------
4,918
0
-------------
498,812
0
-------------
118,935
6SANDEEP SINGH
SVP & CMO
(i)

(ii)
305,661
-------------
0
169,364
-------------
0
0
-------------
0
14,479
-------------
0
16,101
-------------
0
505,605
-------------
0
0
-------------
0
7ASARE B CHRISTIAN
ASSOCIATE MEDICAL DIRECTOR
(i)

(ii)
237,949
-------------
0
63,188
-------------
0
0
-------------
0
10,893
-------------
0
10,986
-------------
0
323,016
-------------
0
0
-------------
0
8DEMETRICE L WARD PURVIS
STAFF PHYSIATRIST
(i)

(ii)
184,003
-------------
0
89,136
-------------
0
0
-------------
0
13,612
-------------
0
13,189
-------------
0
299,940
-------------
0
0
-------------
0
9JAMES B KIM
STAFF PHYSIATRIST
(i)

(ii)
226,939
-------------
0
41,772
-------------
0
0
-------------
0
18,356
-------------
0
12,871
-------------
0
299,938
-------------
0
0
-------------
0
10KIMBERLY S KUCHINSKI
PROG. DIR. PEDS PHYSIATRY
(i)

(ii)
225,960
-------------
0
38,695
-------------
0
0
-------------
0
12,894
-------------
0
15,470
-------------
0
293,019
-------------
0
0
-------------
0
11ANDREW G REISH
STAFF PHYSIATRIST
(i)

(ii)
146,875
-------------
0
107,434
-------------
0
0
-------------
0
7,621
-------------
0
10,810
-------------
0
272,740
-------------
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
PART I, LINE 3 THE CEO IS COMPENSATED BY GOOD SHEPHERD REHABILITATION NETWORK ("GSRN"), AN AFFILIATED TAX-EXEMPT ORGANIZATION. THE HOSPITAL RELIED ON GSRN'S USE OF COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH COMPENSATION.
PART I, LINES 4A-B FOLLOWING INDIVIDUALS ARE SCHEDULED TO RECEIVE SEVERANCE PAYMENTS DURING CALENDAR YEAR 2019 AND 2020: - MIKE CIRBA (CIO) - SAMUEL A. MIRANDA (SVP & CNO) SAMUEL A. MIRANDA (SVP & CNO) RECEIVED DISTRIBUTIONS FROM 457(F) PLAN IN THE AMOUNT OF $232,648 DURING CALENDAR YEAR 2018.
PART I, LINE 7 GSRN HAS A PERFORMANCE COMPENSATION PROGRAM IN PLACE WHICH IS APPROVED BY THE BOARD. CERTAIN MEMBERS OF MANAGEMENT CAN RECEIVE AN ANNUAL PERFORMANCE PAYMENT WHEN PRE-DEFINED AND PRE-APPROVED FINANCIAL AND NON-FINANCIAL GOALS ARE ACHIEVED. FOR FISCAL YEAR 2019, A PERFORMANCE PAYMENT WAS NOT ACHIEVED. IN LIEU OF A PERFORMANCE PAYMENT, SPOT BONUSES WERE PAID. THIS IS NOT GUARANTEED EACH YEAR.
Schedule J (Form 990) 2018
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