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ObjectId: 202022309349302962 - Submission: 2020-08-17
TIN: 04-2794625
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
Southcoast Health System Inc
Employer identification number
04-2794625
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
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
Christopher Cheney MD
Trustee
(i)
(ii)
0
-------------
508,460
0
-------------
0
0
-------------
0
0
-------------
15,600
0
-------------
10,964
0
-------------
535,024
0
-------------
0
2
Keith Hovan
President & CEO/ Ex-Officio
(i)
(ii)
0
-------------
1,112,250
0
-------------
442,800
0
-------------
827,000
0
-------------
281,493
0
-------------
21,008
0
-------------
2,684,551
0
-------------
616,826
3
Linda Bodenmann
Former EVP/COO/ASST CLERK
(i)
(ii)
0
-------------
11,865
0
-------------
115,000
0
-------------
705,063
0
-------------
7,670
0
-------------
1,463
0
-------------
841,061
0
-------------
640,765
4
Kristofer Lindeman
FORMER Treasurer
(i)
(ii)
0
-------------
227,584
0
-------------
7,014
0
-------------
0
0
-------------
12,057
0
-------------
21,008
0
-------------
267,663
0
-------------
0
5
WADE BROUGHMAN
TREASURER/ EVP FIN/ CFO
(i)
(ii)
0
-------------
555,250
0
-------------
175,313
0
-------------
27,452
0
-------------
82,500
0
-------------
17,760
0
-------------
858,275
0
-------------
0
6
RENEE CLARK
ASSISTANT CLERK/ EVP/ COO
(i)
(ii)
0
-------------
552,083
0
-------------
175,313
0
-------------
55,273
0
-------------
126,144
0
-------------
21,408
0
-------------
930,221
0
-------------
47,100
7
DANIEL SOUSA MD
EX-OFFICIO (UNTIL 12/2018)
(i)
(ii)
0
-------------
345,671
0
-------------
15,000
0
-------------
99,299
0
-------------
15,600
0
-------------
14,157
0
-------------
489,727
0
-------------
0
8
MICHAEL BARRETTI DO
EX-OFFICIO (AS OF 1/2019)
(i)
(ii)
0
-------------
425,001
0
-------------
113,889
0
-------------
167,834
0
-------------
15,600
0
-------------
14,157
0
-------------
736,481
0
-------------
0
9
RONNIE BROWNSWORTH
PRESIDENT SHN
(i)
(ii)
0
-------------
566,667
0
-------------
160,000
0
-------------
176,293
0
-------------
0
0
-------------
21,608
0
-------------
924,568
0
-------------
37,383
10
DEBORA ALLWES-LARGOZA
VP OPERATIONS SHN
(i)
(ii)
0
-------------
188,248
0
-------------
0
0
-------------
64,726
0
-------------
0
0
-------------
17,457
0
-------------
270,431
0
-------------
0
11
PATRICK GANNON
OPS DIRECTOR SHN
(i)
(ii)
0
-------------
183,482
0
-------------
5,709
0
-------------
0
0
-------------
11,760
0
-------------
17,160
0
-------------
218,111
0
-------------
0
12
LORI DAKIN
ED OF BEHAVIORAL HEALTH SVCS
(i)
(ii)
0
-------------
177,092
0
-------------
5,492
0
-------------
0
0
-------------
21,854
0
-------------
12,384
0
-------------
216,822
0
-------------
0
13
GAIL POLLI
NURSE PRACTITIONER
(i)
(ii)
0
-------------
140,105
0
-------------
0
0
-------------
8,009
0
-------------
23,971
0
-------------
1,509
0
-------------
173,594
0
-------------
0
14
BARBARA RODERICK
NURSE PRACTITIONER
(i)
(ii)
0
-------------
141,911
0
-------------
2,924
0
-------------
5,036
0
-------------
23,246
0
-------------
10,678
0
-------------
183,795
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
SHS DOES NOT EMPLOY ANY INDIVIDUALS. OFFICERS AND TRUSTEES OF SHS RECEIVE NO COMPENSATION FOR THEIR ROLES IN THESE CAPACITIES. OFFICERS AND TRUSTEES (CURRENT OR FORMER) WITH REPORTABLE COMPENSATION ARE COMPENSATED BY A NON-PROFIT SUBSIDIARY ORGANIZATION'S PAYROLL FOR SERVICES RENDERED AS EMPLOYEES OF THE SUBSIDIARY.
PART I, LINE 3
SOUTHCOAST HOSPITAL GROUP (SHG), A RELATED ORGANIZATION CHECKED THE FOLLOWING BOXES WHICH WERE USED BY SHG TO ESTABLISH COMPENSATION OF THE PRESIDENT: COMPENSATION COMMITTEE INDEPENDENT COMPENSATION CONSULTANT COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE
PART I, LINE 4B
OFFICERS, DIRECTORS, AND KEY EMPLOYEES WHO ARE EMPLOYEES OF SOUTHCOAST PARTICIPATE IN SOUTHCOAST'S 457(F) SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLAN. CONTRIBUTION CREDITS UNDER THE PLAN ARE INCLUDED IN SCHEDULE J, PART, II, COLUMN (C). ONLY UPON TERMINATIONS OF EMPLOYMENT DO FULLY VESTED PARTICIPANTS RECEIVE DISTRIBUTIONS FROM THE PLAN. CONTRIBUTIONS VEST THE EARLIER OF: JULY 1 OF THE 3RD CALENDAR YEAR FOLLOWING THE CALENDAR YEAR IN WHICH THE CONTRIBUTION CREDIT IS MADE; UPON REACHING AGE 62; DEATH; DISABILITY; OR INVOLUNTARY SEPARATION. THE AMOUNT REFLECTED IN SCHEDULE, J, PART II, COLUMN B(III) FOR THE FOLLOWING INDIVIDUALS INCLUDES THE VESTED PORTION OF CONTRIBUTIONS MADE TO THE PLAN WHICH ARE NO LONGER SUBJECT TO THE RISK OF FORFEITURE. KEITH HOVAN - $255,587 RENEE CLARK - $48,128 RONNIE BROWNSWORTH - $122,464 IN ADDITION TO THE ABOVE OUTLINED PLAN, THE FOLLOWING INDIVIDUALS ALSO HAVE SEPARATE SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS: KEITH HOVAN - SOUTHCOAST HOSPITAL GROUP, INC. ESTABLISHED AN EXECUTIVE BENEFIT PLAN FOR THE BENEFIT OF KEITH HOVAN. UNDER THE TERMS OF THE PLAN, A CONTRIBUTION CREDIT, INCLUDED IN SCHEDULE J, PART I, COLUMN (C) IS CREDITED TO HIS ACCOUNT ON A YEARLY BASIS. THE ACCOUNT BALANCE VESTS AS FOLLOWS: JUNE 30, 2013 -50%; JUNE 30, 2016 - 75% AND JUNE 30, 2018 - 100%. PURSUANT TO THE PLAN $557,198 WAS INCLUDED IN MR. HOVAN'S 2018 FORM W-2 AND SCH J, PART II, COLUMN B(III).
Schedule J (Form 990) 2018
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