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ObjectId: 202023189349301142 - Submission: 2020-11-13
TIN: 34-6006904
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
19
Open to Public Inspection
Name of the organization
BLANCHARD VALLEY CONTINUING CARE SERVICES
Employer identification number
34-6006904
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 on 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 on 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) 2019
Page 2
Schedule J (Form 990) 2019
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
RICHARD POLDER MD
TRUSTEE
(i)
(ii)
0
-------------
466,626
0
-------------
0
0
-------------
2,827
0
-------------
0
0
-------------
11,552
0
-------------
481,005
-------------
2
SCOTT MALANEY
CHIEF EXECUTIVE OFFICER
(i)
(ii)
0
-------------
609,455
0
-------------
174,853
0
-------------
202,030
0
-------------
16,800
0
-------------
8,001
0
-------------
1,011,139
-------------
3
DAVID CYTLAK
CHIEF FINANCIAL OFFICER
(i)
(ii)
0
-------------
363,976
0
-------------
76,818
0
-------------
34,230
0
-------------
16,800
0
-------------
4,206
0
-------------
496,030
-------------
4
BARBARA PASZTOR
VP, CHIEF NURSING OFFICER
(i)
(ii)
0
-------------
231,552
0
-------------
53,945
0
-------------
25,637
0
-------------
15,753
0
-------------
8,001
0
-------------
334,888
-------------
5
DR DANIEL DAWLEY
PHYSICIAN
(i)
(ii)
184,007
-------------
0
5,154
-------------
0
1,769
-------------
0
11,460
-------------
0
6,839
-------------
0
209,229
-------------
0
-------------
6
DR CHRISTIAN JACOBUS
PHYSICIAN
(i)
(ii)
153,265
-------------
0
7,846
-------------
0
19,160
-------------
0
7,496
-------------
0
12,700
-------------
0
200,467
-------------
0
-------------
7
BRIDGET MUNDY
RESIDENTIAL CARE ADMINISTRATOR
(i)
(ii)
140,753
-------------
0
14,905
-------------
0
171
-------------
0
5,836
-------------
0
5,691
-------------
0
167,356
-------------
0
-------------
8
DEBRA KRINER
DIRECTOR OF NURSING
(i)
(ii)
134,628
-------------
0
14,163
-------------
0
4,510
-------------
0
5,640
-------------
0
3,705
-------------
0
162,646
-------------
0
-------------
Schedule J (Form 990) 2019
Page 3
Schedule J (Form 990) 2019
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, LINE 4C
IN 2019, BLANCHARD VALLEY HEALTH SYSTEM CONTRIBUTED ON BEHALF OF SCOTT MALANEY $19,000 TO A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). THE SERP IS AN UNFUNDED, NONQUALIFIED DEFERRED COMPENSATION ARRANGEMENT CONSISTING OF TWO PLANS: AN ELIGIBLE PLAN SUBJECT TO INTERNAL REVENUE CODE SECTION 457(B) AND AN INELIGIBLE PLAN SUBJECT TO SECTION 457(F). THE 457(B) PLAN WAS ORIGINALLY IMPLEMENTED EFFECTIVE JANUARY 1, 2002. THE 457(F) PLAN WAS ORIGINALLY EFFECTIVE SEPTEMBER 1, 2000 AND WAS RESTATED ON JANUARY 1, 2002 FOR COORDINATION WITH THE 457(B) PLAN. IN 2010 AND 2011, THE 457(F) PLAN WAS FURTHER AMENDED AND RESTATED TO COMPLY WITH THE LATEST REGULATORY GUIDANCE AND PROVIDE FOR A NEW CONTRIBUTION MODEL AND VESTING SCHEDULE. ADDITIONAL EXECUTIVES WERE ALSO ADDED AND DEEMED ELIGIBLE FOR PLAN BENEFITS IN 2010, INCLUDING DAVID CYTLAK. IN 2019, BLANCHARD VALLEY HEALTH SYSTEM CONTRIBUTED ON BEHALF OF DAVID CYTLAK $25,673 TO THE SERP. KEY FEATURES OF THE SERP, AS AMENDED AND RESTATED IN 2010/2011, INCLUDE THE FOLLOWING: * ELIGIBILITY IS LIMITED TO CERTAIN MANAGEMENT OR HIGHLY-COMPENSATED EMPLOYEES OF BVHS (I.E., TOP HAT REFERENCE). FUTURE PARTICIPATION IS UPON NOMINATION BY THE CEO AND APPROVAL BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD. * EMPLOYER CONTRIBUTIONS ARE COMPRISED OF: ** DEFINED CONTRIBUTION TARGET INCOME REPLACEMENT PERCENTAGE CONTRIBUTION: - PROVIDE 60% TARGET INCOME REPLACEMENT FOR CEO (SCOTT MALANEY) - PROVIDE 50% TARGET INCOME REPLACEMENT FOR CFO (DAVID CYTLAK) **EMPLOYEE CONTRIBUTIONS TO THE SERP ACCOUNT ARE NOT ALLOWED. *EACH PARTICIPANT'S 457(B) ACCOUNT WILL BE CREDITED UP TO THE STATUTORY LIMIT ($19,000 IN 2019), WITH THE REMAINING AMOUNT BEING DEPOSITED INTO THE 457(F) ACCOUNT. *EMPLOYER CONTRIBUTIONS TO THE 457(F) PLAN ARE SUBJECT TO A CLASS YEAR VESTING SCHEDULE, WITH A WAITING PERIOD SET AT 2-5 YEARS, DEPENDING ON THE AGE OF THE PARTICIPANT AT THE TIME OF CONTRIBUTION. UPON VESTING, THE FULL VESTED BALANCE WILL BE DISTRIBUTED TO THE PARTICIPANT AND CONSIDERED TAXABLE INCOME. IN ADDITION TO THE VESTING SCHEDULE ABOVE, 100% AND IMMEDIATE VESTING OF THE BENEFIT ACCRUED UPON ATTAINMENT OF NORMAL RETIREMENT AGE, DEATH, DISABILITY, INVOLUNTARY TERMINATION WITHOUT CAUSE, PLAN TERMINATION, OR CHANGE OF CONTROL. *DISTRIBUTION OF THE VESTED PORTION OF THE 457(F) BENEFIT IS PAID AS A LUMP SUM AS SOON AS ADMINISTRATIVELY FEASIBLE.
Schedule J (Form 990) 2019
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