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ObjectId: 202113169349305036 - Submission: 2021-11-11
TIN: 55-0643304
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
20
Open to Public Inspection
Name of the organization
West Virginia University Hospitals Inc
Employer identification number
55-0643304
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
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 on 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
Yes
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) 2020
Page 2
Schedule J (Form 990) 2020
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
Stephen Tancin
Former VP Ancillary Services
(i)
(ii)
-------------
-------------
297,950
-------------
-------------
-------------
297,950
-------------
-------------
2
Sivaramakrishna Cheetirala
Hospitalist
(i)
(ii)
280,394
-------------
254,881
-------------
326
-------------
-------------
19,210
-------------
554,811
-------------
-------------
3
Douglas Mitchell
VP Chief Nursing Officer
(i)
(ii)
280,097
-------------
67,966
-------------
4,925
-------------
31,230
-------------
16,354
-------------
400,572
-------------
-------------
4
Justin Gibson
Executive Director of Finance
(i)
(ii)
278,056
-------------
67,003
-------------
394
-------------
31,482
-------------
27,083
-------------
404,018
-------------
-------------
5
Michael Shullo
Associate VP, Transplant Program
(i)
(ii)
282,952
-------------
49,571
-------------
1,060
-------------
6,797
-------------
26,505
-------------
366,885
-------------
-------------
6
Melissa McCoy
VP Finance/CFO
(i)
(ii)
184,498
-------------
184,498
46,095
-------------
46,095
3,988
-------------
3,988
31,268
-------------
31,268
13,781
-------------
13,781
279,630
-------------
279,630
-------------
7
Amy Bush
Chief Operating Officer - Childrens
(i)
(ii)
355,962
-------------
88,992
-------------
6,727
-------------
57,437
-------------
26,036
-------------
535,154
-------------
-------------
8
Anthony Condia
VP Marketing and Communications
(i)
(ii)
135,848
-------------
135,848
33,436
-------------
33,436
2,724
-------------
2,724
15,713
-------------
15,713
4,811
-------------
4,811
192,532
-------------
192,532
-------------
9
Afaq Ahmad
Physician
(i)
(ii)
362,842
-------------
155,209
-------------
6,858
-------------
5,585
-------------
24,486
-------------
554,980
-------------
-------------
10
Stanley Morris
Physician
(i)
(ii)
436,790
-------------
23,575
-------------
810
-------------
4,795
-------------
26,745
-------------
492,715
-------------
-------------
11
Paul Beck
Physician
(i)
(ii)
303,526
-------------
135,164
-------------
1,225
-------------
8,462
-------------
16,494
-------------
464,871
-------------
-------------
12
Frank Briggs
VP, WVU Heart Vascular institute
(i)
(ii)
319,974
-------------
79,261
-------------
6,347
-------------
52,667
-------------
16,490
-------------
474,739
-------------
-------------
13
Richard Funnell
VP, Cancer Services
(i)
(ii)
296,866
-------------
73,952
-------------
8,985
-------------
33,219
-------------
19,679
-------------
432,701
-------------
-------------
14
Cheryl Jones
VP, Nursing
(i)
(ii)
203,861
-------------
50,739
-------------
5,407
-------------
25,503
-------------
26,788
-------------
312,298
-------------
-------------
15
Joshua Hack
Chief Medical Physicist
(i)
(ii)
233,242
-------------
500
-------------
312
-------------
5,438
-------------
406
-------------
239,898
-------------
-------------
16
Nathan Burt
VP, Operations
(i)
(ii)
221,621
-------------
25,299
-------------
10,465
-------------
27,384
-------------
25,724
-------------
310,493
-------------
-------------
17
Karyn Wallace
VP, Neuroscience
(i)
(ii)
131,865
-------------
131,865
23,304
-------------
23,304
2,485
-------------
2,485
14,608
-------------
14,608
4,990
-------------
4,990
177,252
-------------
177,252
-------------
Schedule J (Form 990) 2020
Page 3
Schedule J (Form 990) 2020
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
Compensation for WVU Hospitals, Inc. CEO is determined by the WV United Health System compensation committee. The System engages an independent group to perform an executive compensation review and compensation survey every two years. This information is provided to the committee, which is made up of independent board members who are then responsible for setting the compensation packages offered to each executive, ensuring that the compensation package offered does not exceed fair market value.
Part I Line 4b
During 2020, certain individuals reported in Part VII participated in a nonqualified retirement plan. The following is a list of those individuals, plan types and amounts.
Part II Line 1a
Frank Briggs - CAA deferred contributions of 46,666 Nathan Burt - CAA deferred contributions of 21,850 Douglas Mitchell - CAA deferred contributions of 27,297 Anthony Condia - deferred contributions of 13,124 Richard Funnell - deferred contributions of 29,025 Cheryl Jones - deferred contributions of 20,377 Amy Bush - deferred contributions of 52,391 Melissa McCoy - deferred contributions of 27,139 Justin Gibson - deferred contributions of 27,683, and Karyn Wallace - deferred contributions of 12,765. All of the above amounts are properly reported on the Form W-2 for 2020.
Part I Line 4a
Stephen Tancin received 297,950 of severance pay in 2020.
Part II
Amounts reported in Column F as reported as deferred compensation in prior years was distributed by a third party administrator. They are responsible for tax reporting of those payments.
Part I Line 6a
Per the WVUHS Incentive Plan incentives are contingent on meeting a net earning target.
Part I Line 7
Incentive and bonuses are based on goals and productivity measures that are not contingent on revenue.
Schedule J (Form 990) 2020
Additional Data
Software ID:
20011406
Software Version:
20.0.2.0