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ObjectId: 202132259349302723 - Submission: 2021-07-13
TIN: 04-3109579
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
CHARLTON LONG TERM CARE SERVICES INC
Employer identification number
04-3109579
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
KEITH HOVAN
EX-OFFICIO/ PRESIDENT & CEO SHG
(i)
(ii)
0
-------------
1,170,000
0
-------------
585,000
0
-------------
456,564
0
-------------
320,798
0
-------------
21,456
0
-------------
2,553,818
0
-------------
241,828
2
WADE BROUGHMAN
TREASURER/EVP FIN & CFO SHG
(i)
(ii)
0
-------------
613,000
0
-------------
229,900
0
-------------
26,913
0
-------------
121,069
0
-------------
17,950
0
-------------
1,008,832
0
-------------
0
3
RENEE CLARK
ASST CLERK/ EVP & COO SHG
(i)
(ii)
0
-------------
575,000
0
-------------
172,500
0
-------------
82,294
0
-------------
131,100
0
-------------
21,456
0
-------------
982,350
0
-------------
75,570
4
MICHAEL BARRETTI DO
EX-OFFICIO (UNTIL 12/2019)
(i)
(ii)
0
-------------
425,001
0
-------------
169,847
0
-------------
144,180
0
-------------
15,600
0
-------------
13,939
0
-------------
768,567
0
-------------
0
5
CHRISTOPHER CHENEY MD
TRUSTEE (UNTIL 12/2019)
(i)
(ii)
0
-------------
228,373
0
-------------
105,830
0
-------------
33,838
0
-------------
15,600
0
-------------
410
0
-------------
384,051
0
-------------
0
6
JAY S SCHACHNE MD
TRUSTEE (AS OF 1/2020)
(i)
(ii)
0
-------------
186,879
0
-------------
136,412
0
-------------
26,600
0
-------------
15,600
0
-------------
8,310
0
-------------
373,801
0
-------------
0
7
GEORGINA NOUAIME MD
EX-OFFICIO (AS OF 1/2020)
(i)
(ii)
0
-------------
253,846
0
-------------
22,000
0
-------------
55,851
0
-------------
15,600
0
-------------
14,256
0
-------------
361,553
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
OFFICERS, DIRECTORS, AND TRUSTEES OF CHARLTON LONG TERM CARE SERVICES (CLTCS) RECEIVE NO COMPENSATION FOR THEIR ROLES IN THESE CAPACITIES. OFFICERS, DIRECTORS, AND TRUSTEES (BOTH CURRENT AND FORMER) WITH REPORTABLE COMPENSATION ARE COMPENSATED BY THE RELATED ORGANIZATIONS, SOUTHCOAST HOSPITALS GROUP, INC. (SHG) AND SOUTHCOAST PHYSICIANS GROUP, INC. (SPG) FOR SERVICES RENDERED OR AS PART OF A DEFERRED COMPENSATION ARRANGEMENT.
Schedule J, Part I, Line 3
CLTCS RELIED ON AFFILIATE SHG, A RELATED ORGANIZATION, TO ESTABLISH THE COMPENSATION FOR THE PRESIDENT. SHG CHECKED THE FOLLOWING BOXES WHICH WERE USED TO ESTABLISH COMPENSATION OF THE PRESIDENT: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE.
Schedule J, Part I, Line 4
OFFICERS, DIRECTORS AND TRUSTEES 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 TERMINATION OF EMPLOYMENT DO FULLY VESTED PARTICIPANTS RECEIVE DISTRIBUTIONS FROM THE PLAN. CONTRIBUTIONS VEST THE EARLIER OF JULY 1 OF THE THIRD 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. (1) RENEE CLARK $77,740, (2) KEITH HOVAN $309,434. IN ADDITION TO THE ABOVE OUTLINED PLAN, THE FOLLOWING INDIVIDUALS ALSO HAVE SEPARATE SUPPLEMENTAL NON-QUALIFIED RETIREMENT PLANS. KEITH HOVAN - SOUTHCOAST HOSPITALS GROUP, INC. ESTABLISHED AN EXECUTIVE BENEFIT PLAN FOR THE BENEFIT OF KEITH HOVAN. UNDER THE TERMS OF THE PLAN, MR. HOVAN BECAME FULLY VESTED AS OF JUNE 30, 2018. ANNUAL CREDITS TO THE PLAN ARE IMMEDIATELY VESTED AND INCLUDED IN SCH J, PART II, COLUMN (B)(III). PURSUANT TO THE PLAN $132,400 WAS INCLUDED IN MR. HOVAN'S 2019 FORM W-2 AND SCHEDULE J, PART II, COLUMN (B)(III).
Schedule J, Part I, Line 7
RELATED ORG SHG - SOME EXECUTIVES CASH COMPENSATION IS AT RISK AND PAID VIA AN INCENTIVE PLAN IN WHICH EXECUTIVE AND ORGANIZATION PERFORMANCE IS ASSESSED BY THE BOARD OF TRUSTEES AGAINST PRE-DETERMINED MEASURES. HOWEVER, NOT PAID THROUGH THIS ORGANIZATION, CLTCS.
Schedule J (Form 990) 2019
Additional Data
Software ID:
19009572
Software Version:
v1.00