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ObjectId: 202121379349303127 - Submission: 2021-05-17
TIN: 85-0138775
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
OTERO COUNTY HOSPITAL ASSOCIATION
Employer identification number
85-0138775
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
Yes
b
Any related organization?
......................
6b
Yes
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
GREG RICHARDSON MD
BOARD MEMBER/PHYSICIAN (THRU 8/19)
(i)
(ii)
250,226
-------------
0
2,000
-------------
0
88,531
-------------
0
28,625
-------------
0
25,323
-------------
0
394,705
-------------
0
0
-------------
0
2
ANDREW LANCASTER
BOARD MEMBER
(i)
(ii)
231,395
-------------
0
2,000
-------------
0
10,372
-------------
0
9,130
-------------
0
27,088
-------------
0
279,985
-------------
0
0
-------------
0
3
POLLY HICKMAN
BOARD MEMBER
(i)
(ii)
114,543
-------------
0
2,750
-------------
0
11,968
-------------
0
4,928
-------------
0
27,088
-------------
0
161,277
-------------
0
0
-------------
0
4
WILLIAM POLLARD
CMO
(i)
(ii)
631,206
-------------
0
150,213
-------------
0
23,401
-------------
0
48,250
-------------
0
24,349
-------------
0
877,419
-------------
0
0
-------------
0
5
ROBERT JAMES HECKERT
CEO
(i)
(ii)
407,977
-------------
0
227,030
-------------
0
22,477
-------------
0
29,615
-------------
0
84
-------------
0
687,183
-------------
0
0
-------------
0
6
BASHER NASER
CFO
(i)
(ii)
305,558
-------------
0
260,474
-------------
0
2,238
-------------
0
9,828
-------------
0
27,088
-------------
0
605,186
-------------
0
0
-------------
0
7
ROBERT MIDDLETON
VP OF PHYSICIAN CARE/CNO
(i)
(ii)
221,274
-------------
0
47,600
-------------
0
40,313
-------------
0
8,877
-------------
0
27,088
-------------
0
345,152
-------------
0
0
-------------
0
8
KERRY BOLIN
CNO/VP OF QUALITY/PATIENT SAFETY
(i)
(ii)
115,234
-------------
0
18,640
-------------
0
6,330
-------------
0
4,976
-------------
0
10,560
-------------
0
155,740
-------------
0
0
-------------
0
9
PETER SEAMAN
VP OF FINANCE
(i)
(ii)
177,350
-------------
0
45,600
-------------
0
4,466
-------------
0
27,527
-------------
0
17,494
-------------
0
272,437
-------------
0
0
-------------
0
10
ALBERT ESPARSEN
VP OF PHYSICIAN PRACTICE
(i)
(ii)
154,673
-------------
0
38,247
-------------
0
4,250
-------------
0
7,210
-------------
0
18,113
-------------
0
222,493
-------------
0
0
-------------
0
11
CHARLES RACE
PHYSICIAN
(i)
(ii)
777,166
-------------
0
44,000
-------------
0
76,108
-------------
0
29,250
-------------
0
26,205
-------------
0
952,729
-------------
0
0
-------------
0
12
FERIAL ABOOD
PHYSICIAN
(i)
(ii)
325,302
-------------
0
327,146
-------------
0
34,455
-------------
0
27,297
-------------
0
9,665
-------------
0
723,865
-------------
0
0
-------------
0
13
KATRINA ROLEN
PHYSICIAN
(i)
(ii)
480,624
-------------
0
50,944
-------------
0
14,215
-------------
0
9,128
-------------
0
18,113
-------------
0
573,024
-------------
0
0
-------------
0
14
GURDIAL DHILLON
PHYSICIAN
(i)
(ii)
292,831
-------------
0
231,973
-------------
0
14,471
-------------
0
4,372
-------------
0
6,960
-------------
0
550,607
-------------
0
0
-------------
0
15
JAMES DUMONT
PHYSICIAN
(i)
(ii)
387,038
-------------
0
125,650
-------------
0
1,056
-------------
0
9,899
-------------
0
18,113
-------------
0
541,756
-------------
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
PART I, LINE 4B
ROBERT JAMES HECKERT PARTICIPATES IN A 457(F) DEFERRED COMPENSATION PLAN; HOWEVER, THE HOSPITAL DID NOT MAKE ANY CONTRIBUTIONS TO THE PLAN IN FY 2020.
PART I, LINE 6
THE ORGANIZATION'S OFFICERS LISTED IN PART VII, SECTION A, ARE EVALUATED ANNUALLY BASED ON A SET OF EVIDENCE-BASED GOALS THAT DETERMINE THEIR ELIGIBILITY FOR ADDITIONAL COMPENSATION. THE SELECT GOALS ARE WEIGHTED IN A HIERARCHY OF CORE AND JOB-SPECIFIC COMPETENCIES, WHICH INCLUDE QUALITY OF CARE, FINANCIAL PERFORMANCE, AND PATIENT PERCEPTION OF CARE MEASURE. ONE OF THE CRITERIA DESIGNED TO ENHANCE ALIGNMENT OF THE ORGANIZATION'S GOAL FOR CONTINUED FINANCIAL STABILITY IS IMPROVEMENT OF NET EARNINGS OF BOTH THE HOSPITAL AND ITS RELATED ORGANIZATIONS.
PART I, LINE 7
BONUSES WERE AWARDED FOR ALL EMPLOYEES FOR MEETING ORGANIZATIONAL GOALS AND WERE APPROVED BY THE BOARD.
Schedule J (Form 990) 2019
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