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ObjectId: 202021569349300517 - Submission: 2020-06-04
TIN: 26-0806477
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
ASPIRUS ONTONAGON HOSPITAL INC
Employer identification number
26-0806477
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
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
No
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
JOHN HEISLER
CHAIRMAN / SVP AND CHIEF
(i)
(ii)
0
-------------
304,853
0
-------------
56,609
0
-------------
54,606
0
-------------
16,506
0
-------------
23,636
0
-------------
456,210
0
-------------
40,214
2
SARA LUSIGNAN TERMED 119
VICE CHAIRMAN/ VP OF FINAN
(i)
(ii)
0
-------------
221,639
0
-------------
27,914
0
-------------
23,675
0
-------------
10,593
0
-------------
46,593
0
-------------
330,414
0
-------------
22,547
3
CHARLES NELSON TERMED 918
REGIONAL CEO- UP
(i)
(ii)
0
-------------
228,200
0
-------------
52,435
0
-------------
40,905
0
-------------
15,209
0
-------------
61,928
0
-------------
398,677
0
-------------
34,297
4
MATT HEYWOOD
PRESIDENT & CEO ASPIRUS
(i)
(ii)
0
-------------
869,672
0
-------------
267,317
0
-------------
19,754
0
-------------
16,506
0
-------------
179,058
0
-------------
1,352,307
0
-------------
0
5
SIDNEY SCZYGELSKI
SR. VP OF FINANCE/CFO
(i)
(ii)
0
-------------
514,118
0
-------------
87,791
0
-------------
52,974
0
-------------
16,506
0
-------------
101,162
0
-------------
772,551
0
-------------
49,137
6
CARI LOGEMANN
SVP & GENERAL COUNSEL
(i)
(ii)
0
-------------
372,200
0
-------------
58,440
0
-------------
21,758
0
-------------
16,506
0
-------------
65,130
0
-------------
534,034
0
-------------
19,856
7
RICK NEVERS
SVP REG OPS SYSTEM INT OFF
(i)
(ii)
0
-------------
356,162
0
-------------
55,425
0
-------------
44,966
0
-------------
16,506
0
-------------
62,775
0
-------------
535,834
0
-------------
38,383
8
MICHAEL MCGRAIL
SVP SYSTEM CMO
(i)
(ii)
0
-------------
400,085
0
-------------
73,833
0
-------------
11,606
0
-------------
14,262
0
-------------
66,485
0
-------------
566,271
0
-------------
0
9
RUTH RISLEY-GRAY
SVP NURSING, CNO
(i)
(ii)
0
-------------
286,934
0
-------------
52,327
0
-------------
52,861
0
-------------
16,506
0
-------------
60,755
0
-------------
469,383
0
-------------
45,015
10
ERIC ANDERSON
SVP SERVICE LINE & PATIENT
(i)
(ii)
0
-------------
274,871
0
-------------
45,840
0
-------------
13,291
0
-------------
15,344
0
-------------
64,786
0
-------------
414,132
0
-------------
11,262
11
TODD RICHARDSON
SVP CIO
(i)
(ii)
0
-------------
297,875
0
-------------
56,000
0
-------------
41,412
0
-------------
16,506
0
-------------
71,874
0
-------------
483,667
0
-------------
38,563
12
GRACE TOUSIGNANT
REGIONAL CNO
(i)
(ii)
0
-------------
178,847
0
-------------
21,055
0
-------------
2,595
0
-------------
4,639
0
-------------
23,320
0
-------------
230,456
0
-------------
0
13
RENEE SMITH
EXECUTIVE DIRECTOR ANI
(i)
(ii)
0
-------------
348,984
0
-------------
64,382
0
-------------
42,194
0
-------------
16,506
0
-------------
29,102
0
-------------
501,168
0
-------------
33,431
14
F DEAN DANNER JR TERMED 618
SVP AMBULATORY SERVICES & PRES ACI
(i)
(ii)
0
-------------
161,114
0
-------------
111,152
0
-------------
113,959
0
-------------
14,416
0
-------------
13,290
0
-------------
413,931
0
-------------
66,173
15
DEANNA WILSON TERMED 1218
VP PATIENT CARE SERVICES
(i)
(ii)
140,109
-------------
0
17,588
-------------
0
3,887
-------------
0
8,124
-------------
0
14,394
-------------
0
184,102
-------------
0
0
-------------
0
16
TERRENCE ASPLUND
PHYSICIAN
(i)
(ii)
134,280
-------------
0
0
-------------
0
3,793
-------------
0
6,906
-------------
0
12,352
-------------
0
157,331
-------------
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 1A
HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE AND TRAVEL FOR COMPANIONS, WHEN APPLICABLE, WAS ADDED TO THE INDIVIDUAL'S COMPENSATION AT FAIR MARKET VALUE. HOUSING ALLOWANCE OR RESIDENCE FOR PERSONAL USE - J. TISCHER $3,889 - INCLUDED IN INCOME. TRAVEL FOR COMPANIONS - INCLUDED IN INCOME M. HEYWOOD - $177 S. SCZYGELSKI - $273 R. NEVERS - $273 J. HEISLER - $177 J. TISCHER - $267 S. LUSIGNAN - $177 E. ANDERSON - $237 R. RISLEY-GRAY - $199 R. SMITH - $135
PART I, LINE 3
FOR THE PURPOSES OF DETERMINING COMPENSATION, THE FILING ORGANIZATION, ASPIRUS ONTONAGON HOSPITAL, INC. RELIED ON THE RELATED ORGANIZATIONS TO ESTABLISH COMPENSATION OF THE CEO, OTHER OFFICES, AND KEY EMPLOYEES. THE RELATED ORGANIZATIONS USED THE FOLLOWING PRACTICES FOR ESTABLISHING COMPENSATION FOR SUCH INDIVIDUALS: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, WRITTEN EMPLOYMENT CONTRACT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE.
PART I, LINES 4A-B
SCHEDULE J, PART I, LINE 4B - SUPPLEMENTAL NONQUALIFIED RETIREMENT 457(B) DISTRIBUTION: S. SCZYGELSKI $49,137 R. NEVERS $38,383 J. HEISLER $40,214 R. RISLEY-GRAY $45,015 T. RICHARDSON $38,563 E. ANDERSON $11,262 C. NELSON $34,297 S. LUSIGNAN $22,547 C. LOGEMANN $19,856 R. SMITH $33,431 D. DANNER $66,173 KEY EMPLOYEES OF THE ORGANIZATION OR A PARTICIPATING AFFILIATE ARE ELIGIBLE TO PARTICIPATE IN THE PLAN. THE PLAN YEAR IS JANUARY 1 TO DECEMBER 31ST. EMPLOYER CONTRIBUTIONS: THE CONTRIBUTION MADE BY THE EMPLOYER IS A THREE-TIERED STRUCTURE DEPENDING UPON THE EXECUTIVE'S POSITION, WHICH ARE AS FOLLOWS: 9% FOR VICE PRESIDENT, 13% FOR SENIOR LEADERSHIP COUNCIL, AND 15% FOR THE CEO. IF A PARTICIPANT TERMINATES DURING THE YEAR, THE PARTICIPANT'S EXECUTIVE ALLOWANCE IS PRORATED BASED ON THE NUMBER OF FULL CALENDAR MONTHS FROM THE BEGINNING OF THE PLAN YEAR TO THE BEGINNING OF THE CALENDAR YEAR MONTH CLOSEST TO THE CHANGE OR TERMINATION OF EMPLOYMENT. DISTRIBUTIONS: CONTINUATION OF EMPLOYMENT THROUGH THE DEFERRED VESTING DATE; THE DATE ON WHICH THE PARTICIPANT'S EMPLOYMENT IS TERMINATED AS A RESULT OF DEATH OR DISABILITY; THE DATE ON WHICH THE PARTICIPANT INCURS AN INVOLUNTARY SEPARATION FROM SERVICE WITHOUT REASONABLE CAUSE; OR THE DATE THAT IS 24 MONTHS FOLLOWING THE PARTICIPANT'S SEPARATION FROM SERVICE, BUT ONLY IF THE PARTICIPANT'S INTEREST HAS NOT BEEN FORFEITED FOR COMPETITION DURING SUCH 24 MONTH PERIOD AND THE PARTICIPANT HAS NOT ENGAGED IN COMPETITION AFTER HIS OR HER SEPARATION FROM SERVICE AND PRIOR TO HIS OR HER DEATH, THE PARTICIPANT SHALL BE VESTED AT HIS OR HER DATE OF DEATH.
Schedule J (Form 990) 2018
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