efile Public Visual Render
ObjectId: 202101339349304805 - Submission: 2021-05-13
TIN: 52-0591639
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
James Lawrence Kernan Hospital Inc
Employer identification number
52-0591639
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
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) 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
John W Ashworth III
INTERIM PRESIDENT AND CEO, UMMS (ENDED 11/19)
(i)
(ii)
0
-------------
899,601
0
-------------
664,660
0
-------------
153,229
0
-------------
11,200
0
-------------
25,955
0
-------------
1,754,645
0
-------------
0
2
Mohan Suntha MD
PRESIDENT AND CEO, UMMS
(i)
(ii)
0
-------------
1,414,919
0
-------------
421,551
0
-------------
266,415
0
-------------
11,200
0
-------------
29,702
0
-------------
2,143,787
0
-------------
0
3
Karen E Doyle MBA
ASSISTANT SECRETARY
(i)
(ii)
0
-------------
258,898
0
-------------
68,515
0
-------------
39,552
0
-------------
10,762
0
-------------
30,999
0
-------------
408,726
0
-------------
0
4
Michelle Gourdine MD
DIRECTOR
(i)
(ii)
0
-------------
547,551
0
-------------
134,255
0
-------------
25,290
0
-------------
78,778
0
-------------
746
0
-------------
786,620
0
-------------
0
5
Robert A Chrencik
FORMER PRESIDENT AND CEO UMMS
(i)
(ii)
0
-------------
876,297
0
-------------
0
0
-------------
619,695
0
-------------
11,200
0
-------------
22,423
0
-------------
1,529,615
0
-------------
0
6
CYNTHIA A KELLEHER
PRESIDENT AND CEO
(i)
(ii)
289,510
-------------
0
163,203
-------------
0
72,347
-------------
0
11,200
-------------
0
21,444
-------------
0
557,704
-------------
0
0
-------------
0
7
W Walter Augustin III CPA
VP FINANCIAL SERVICES AND CFO
(i)
(ii)
221,651
-------------
0
75,452
-------------
0
27,033
-------------
0
9,230
-------------
0
23,404
-------------
0
356,770
-------------
0
0
-------------
0
8
Krishnab Gourab MD
VP MEDICAL AFFAIRS AND CMO
(i)
(ii)
319,465
-------------
0
116,277
-------------
0
19,749
-------------
0
37,741
-------------
0
1,960
-------------
0
495,192
-------------
0
0
-------------
0
9
Cheryl D Lee RN MSN
VP PATIENT SERVICES AND CNO
(i)
(ii)
194,869
-------------
0
67,418
-------------
0
24,515
-------------
0
8,005
-------------
0
18,448
-------------
0
313,255
-------------
0
0
-------------
0
10
Nadeem Aslam
DIRECTOR OF PHARMACY
(i)
(ii)
158,051
-------------
0
20,344
-------------
0
137
-------------
0
5,766
-------------
0
23,702
-------------
0
208,000
-------------
0
0
-------------
0
11
James Collins
PHARMACIST
(i)
(ii)
158,181
-------------
0
0
-------------
0
1,454
-------------
0
7,255
-------------
0
31,907
-------------
0
198,797
-------------
0
0
-------------
0
12
Thomas J Merkle
PHYSICIAN
(i)
(ii)
207,358
-------------
0
50,000
-------------
0
198
-------------
0
7,938
-------------
0
28,284
-------------
0
293,778
-------------
0
0
-------------
0
13
Rosana D Themistocles
NURSE
(i)
(ii)
182,022
-------------
0
0
-------------
0
751
-------------
0
7,500
-------------
0
20,541
-------------
0
210,814
-------------
0
0
-------------
0
14
Lobna Zada
DENTAL CLINICAL CHIEF
(i)
(ii)
286,976
-------------
0
0
-------------
0
1,885
-------------
0
14,000
-------------
0
18,361
-------------
0
321,222
-------------
0
0
-------------
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 4a Severance or change-of-control payment
DURING THE FISCAL YEAR-ENDED JUNE 30, 2020, CERTAIN OFFICERS AND KEY EMPLOYEES HAVE RECEIVED SEVERANCE PAYMENTS. THESE AMOUNTS ARE REPORTED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II, LINE B (III), OTHER REPORTABLE COMPENSATION. THE INDIVIDUAL AND AMOUNT IS LISTED BELOW: ROBERT A. CHRENCIK, $422,881
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
DURING THE FISCAL YEAR- ENDED JUNE 30, 2020, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UMMS SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE NOT VESTED IN THE PLAN THEREFORE THE ACCRUED CONTRIBUTION TO THE PLAN FOR THE FISCAL YEAR IS REPORTED ON SCHEDULE J, PART II, COLUMN C, RETIREMENT AND OTHER DEFERRED COMPENSATION: KRISHNAB GOURAB, MD MICHELLE GOURDINE, MD DURING THE FISCAL YEAR-ENDED JUNE 30, 2020, CERTAIN OFFICERS AND KEY EMPLOYEES PARTICIPATED IN THE UNIVERSITY OF MARYLAND MEDICAL SYSTEM (UMMS) SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN. THE INDIVIDUALS LISTED BELOW HAVE VESTED IN THE PLAN IN A PRIOR YEAR, THEREFORE THE CONTRIBUTIONS TO THE PLAN FOR THE FISCAL YEAR ARE REPORTED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II, LINE B (III), OTHER REPORTABLE COMPENSATION: KAREN DOYLE JOHN W. ASHWORTH III W. WALTER AUGUSTIN, III CHERYL D. LEE CYNTHIA KELLEHER MOHAN SUNTHA, MD ROBERT A. CHRENCIK
Schedule J, Part I, Line 7 Non-fixed payments
BONUSES PAID ARE BASED ON A NUMBER OF VARIABLES INCLUDING BUT NOT LIMITED TO INDIVIDUAL GOAL ACHIEVEMENTS AS WELL AS ORGANIZATION OPERATION ACHIEVEMENTS. THE FINAL DETERMINATION OF THE BONUS AMOUNT IS DETERMINED AND APPROVED BY THE BOARD AS PART OF THE OVERALL COMPENSATION REVIEW OF THE OFFICERS AND KEY EMPLOYEES.
Schedule J (Form 990) 2019
Additional Data
Software ID:
19010655
Software Version:
2019v5.0