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ObjectId: 202212279349300516 - Submission: 2022-08-15
TIN: 35-0593390
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
DEACONESS HOSPITAL INC
Employer identification number
35-0593390
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
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
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) 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
SHAWN MCCOY
CEO OF DEACONESS HEALTH SYSTEM
(i)
(ii)
451,449
-------------
439,940
316,050
-------------
0
520,216
-------------
8,000
116,510
-------------
104,297
19,760
-------------
19,760
1,423,985
-------------
571,997
256,719
-------------
256,719
2
MAQBOOL AHMED MD
DIRECTOR
(i)
(ii)
0
-------------
789,016
0
-------------
46,412
360
-------------
160,449
0
-------------
17,292
0
-------------
754
360
-------------
1,013,923
0
-------------
0
3
SCOTT CORDTS MD
DIRECTOR
(i)
(ii)
255,661
-------------
0
51,498
-------------
0
31,402
-------------
5,200
17,292
-------------
0
26,016
-------------
0
381,869
-------------
5,200
0
-------------
0
4
MIA HINDI MD
DIRECTOR
(i)
(ii)
0
-------------
1,059,796
0
-------------
139,778
15,500
-------------
299,868
0
-------------
12,969
0
-------------
28,076
15,500
-------------
1,540,487
0
-------------
0
5
CHERYL WATHEN
CHIEF FINANCIAL OFFICER
(i)
(ii)
270,709
-------------
266,991
139,230
-------------
0
104,889
-------------
8,200
84,752
-------------
55,349
19,923
-------------
19,923
619,503
-------------
350,463
50,282
-------------
50,282
6
JAMES PORTER MD
PRESIDENT OF DEACONESS HEALTH SYSTEM
(i)
(ii)
613,687
-------------
891
189,484
-------------
0
319,761
-------------
3,200
153,695
-------------
0
35,212
-------------
255
1,311,839
-------------
4,346
316,206
-------------
0
7
CHERONA HAJEWSKI
CHIEF NURSING OFFICER
(i)
(ii)
335,091
-------------
0
86,671
-------------
0
147,861
-------------
0
91,118
-------------
0
20,596
-------------
0
681,337
-------------
0
140,613
-------------
0
8
LYNN LINGAFELTER
CHIEF OPERATION OFFICER
(i)
(ii)
468,988
-------------
51,352
132,157
-------------
0
70,906
-------------
4,800
98,560
-------------
18,605
27,233
-------------
3,026
797,844
-------------
77,783
66,902
-------------
0
9
JOANN WOOD MD
CHIEF MEDICAL OFFICER
(i)
(ii)
106,391
-------------
22,500
24,802
-------------
0
2,407
-------------
0
10,186
-------------
5,435
5,262
-------------
1,315
149,048
-------------
29,250
0
-------------
0
10
MARC FLORENCE
VICE PRESIDENT
(i)
(ii)
294,480
-------------
73,545
94,867
-------------
0
47,454
-------------
0
65,303
-------------
13,590
28,588
-------------
7,147
530,692
-------------
94,282
43,602
-------------
0
11
BRADLEY SCHEU MD
VICE PRESIDENT
(i)
(ii)
0
-------------
354,827
6,248
-------------
178,517
0
-------------
32,710
0
-------------
20,434
0
-------------
34,064
6,248
-------------
620,552
0
-------------
0
12
RAGHAV GUPTA MD
ANESTHESIOLOGIST
(i)
(ii)
383,232
-------------
0
657,253
-------------
0
47,377
-------------
0
8,646
-------------
0
26,472
-------------
0
1,122,980
-------------
0
0
-------------
0
13
VENKATESH MADADI MD
ANESTHESIOLOGIST
(i)
(ii)
889,477
-------------
0
14,591
-------------
0
79,025
-------------
0
17,292
-------------
0
27,667
-------------
0
1,028,052
-------------
0
0
-------------
0
14
PAUL MICK MD
ANESTHESIOLOGIST
(i)
(ii)
773,467
-------------
0
74,474
-------------
0
119,793
-------------
0
8,646
-------------
0
18,013
-------------
0
994,393
-------------
0
0
-------------
0
15
RAJESH PATEL MD
ANESTHESIOLOGIST
(i)
(ii)
695,001
-------------
0
14,591
-------------
0
51,886
-------------
0
0
-------------
0
30,511
-------------
0
791,989
-------------
0
0
-------------
0
16
MARK MURRAY MD
ANESTHESIOLOGIST
(i)
(ii)
650,917
-------------
0
15,098
-------------
0
92,482
-------------
0
8,646
-------------
0
12,918
-------------
0
780,061
-------------
0
0
-------------
0
17
LINDA WHITE
FORMER CEO EMERITA, FOUNDATION EXEC.
(i)
(ii)
8,295
-------------
151,625
0
-------------
16,535
0
-------------
4,280
0
-------------
2,457
0
-------------
5,004
8,295
-------------
179,901
0
-------------
0
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 1A
SOCIAL CLUB DUES ARE PAID FOR LINDA WHITE AND SHAWN MCCOY FOR ORGANIZATION BUSINESS ONLY. ANY PERSONAL USE OF THE CLUB MUST BE PAID BY THE EMPLOYEES.
PART I, LINE 4B
SEVERANCE, NONQUALIFIED, AND EQUITY-BASED PAYMENTS: SEVERANCE NONQUALIFIED EQUITY-BASED SHAWN MCCOY $-0- $19,500 $-0- JAMES PORTER, MD 0 19,500 0 CHERONA HAJEWSKI 0 19,500 0 VENKATESH MADADI, MD 0 19,500 0 RAGHAV GUPTA, MD 0 19,500 0 CHERYL WATHEN 0 19,500 0 LYNN LINGAFELTER 0 19,500 0 MAQBOOL AHMED, MD 0 19,500 0 MARC FLORENCE 0 19,500 0 MIA HINDI 0 19,500 0 BRADLEY SCHEU 0 19,500 0 PAUL MICK 0 18,058 0 SEVERANCE NONQUALIFIED EQUITY-BASED RAJESH PATEL $-0- $19,500 $-0- MARK MURRAY 0 19,500 0 PART I, 4B: SHAWN MCCOY: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $194,912 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $513,438 CHERYL WATHEN: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $100,294 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $100,563 JAMES PORTER: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $122,390 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $316,206 CHERONA HAJEWSKI: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $51,816 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $88,798 LYNN LINGAFELTER: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $93,097 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $66,902 JOANN WOOD SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $15,621 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $0 MARC FLORENCE: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $59,084 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $43,602 BRADLEY SCHEU: SUPPLEMENTAL ACCUMLATION ACCOUNT CONTRIBUTIONS OF $11,788 SUPPLEMENTAL ACCUMLATION ACCOUNT PAYOUT OF $0
PART I, LINE 6
COMPENSATION CONTINGENT UPON NET EARNINGS: INCENTIVE COMPENSATION PAYMENTS MADE BY THE ORGANIZATION ARE BASED UPON SUCCESSFUL ACHIEVEMENT OF ESTABLISHED INPATIENT SATISFACTION MEASURES, OUTPATIENT SATISFACTION MEASURES, COMPLIANCE WITH PUBLICLY REPORTED QUALITY INDICATORS, OPERATING MARGIN AS WELL AS OTHER TECHNICAL AND PERSONAL FUNCTIONAL GOALS OF BOTH THE ORGANIZATION AND RELATED ORGANIZATIONS. DEACONESS HOSPITAL'S INCENTIVE COMPENSATION PROGRAMS ARE FORMULATED TO REWARD BEHAVIOR THAT BALANCES PATIENT NEEDS AND EFFICIENT DELIVERY OF PATIENT CARE TO ENSURE THE BEST OUTCOMES ARE ACHIEVED.
Schedule J (Form 990) 2020
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