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ObjectId: 202221319349300727 - Submission: 2022-05-11
TIN: 58-2322328
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
FAYETTE COMMUNITY HOSPITAL INC
Employer identification number
58-2322328
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
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) 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
Dr Patrick Battey MD
Board Member
(i)
(ii)
0
-------------
662,056
0
-------------
459,176
0
-------------
199,405
0
-------------
123,219
0
-------------
14,090
0
-------------
1,457,946
0
-------------
106,119
2
Mr Michael Mandl
Board Member
(i)
(ii)
0
-------------
778,484
0
-------------
564,842
0
-------------
86,725
0
-------------
156,690
0
-------------
12,477
0
-------------
1,599,218
0
-------------
0
3
Mr Stephen D Porter
Board Member & CEO
(i)
(ii)
425,454
-------------
0
238,850
-------------
0
103,440
-------------
0
81,088
-------------
0
17,590
-------------
0
866,422
-------------
0
0
-------------
0
4
Mr Scott Wolfe
CFO
(i)
(ii)
325,600
-------------
0
111,764
-------------
0
42,088
-------------
0
17,100
-------------
0
11,784
-------------
0
508,336
-------------
0
0
-------------
0
5
Mr David Nipper
COO
(i)
(ii)
290,335
-------------
0
101,642
-------------
0
9,249
-------------
0
17,100
-------------
0
19,705
-------------
0
438,031
-------------
0
0
-------------
0
6
Ms Merry Heath
CNO
(i)
(ii)
198,435
-------------
0
68,228
-------------
0
4,870
-------------
0
14,244
-------------
0
7,942
-------------
0
293,719
-------------
0
0
-------------
0
7
Dr Angela Swayne
CMO
(i)
(ii)
325,488
-------------
0
110,199
-------------
0
16,547
-------------
15,236
-------------
16,800
1,215
-------------
468,685
-------------
16,800
0
-------------
0
8
Ms Rhonda Manos
Dir Pharmacy
(i)
(ii)
199,526
-------------
0
26,958
-------------
0
5,003
-------------
0
10,566
-------------
0
6,765
-------------
0
248,818
-------------
0
0
-------------
0
9
Ms Mary Mcfarland
Sr. Dir. Cardiovasc Svcs
(i)
(ii)
165,312
-------------
0
28,317
-------------
0
3,310
-------------
0
11,871
-------------
0
6,656
-------------
0
215,466
-------------
0
0
-------------
0
10
Ms Tonya Pearson
Clinical Coordinator
(i)
(ii)
182,675
-------------
0
1,298
-------------
0
1,262
-------------
11,038
-------------
549
-------------
196,822
-------------
0
0
-------------
0
11
Mr Monsy Jacob
Medical Physicist
(i)
(ii)
207,490
-------------
0
1,298
-------------
0
3,068
-------------
0
5,916
-------------
0
16,670
-------------
0
234,442
-------------
0
0
-------------
0
12
Ms Sandra Biles
Dir Inpatient Services
(i)
(ii)
166,431
-------------
0
22,977
-------------
0
4,671
-------------
0
11,699
-------------
0
10,384
-------------
0
216,162
-------------
0
0
-------------
0
13
Mr Michael McAnder
Treasurer (End 7/20)
(i)
(ii)
0
-------------
357,162
0
-------------
0
0
-------------
927,767
0
-------------
66,931
0
-------------
5,196
0
-------------
1,357,056
0
-------------
498,228
14
Mr Thomas Arnold
Treasurer (Eff 7/20)
(i)
(ii)
0
-------------
424,857
0
-------------
245,916
0
-------------
156,777
0
-------------
79,670
0
-------------
13,247
0
-------------
920,467
0
-------------
62,570
15
Ms Elizabeth Leddy
Secretary
(i)
(ii)
0
-------------
459,494
0
-------------
335,067
0
-------------
49,241
0
-------------
109,035
0
-------------
17,590
0
-------------
970,427
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
SCHEDULE J, PART I, LINE 1A: OTHER COMPENSATION ITEMS
ELIZABETH LEDDY, THOMAS ARNOLD, STEPHEN PORTER, DR. PATRICK BATTEY AND MICHAEL MANDL RECEIVED A DISCRETIONARY SPENDING ACCOUNT TOTALING $12,000, A FIXED AMOUNT DETERMINED BY THEIR JOB LEVEL. MICHAEL MCANDER RECEIVED A DISCRETIONARY SPENDING AMOUNT TOTALING $7,385. THIS SPENDING ACCOUNT WAS INCLUDED IN THEIR TAXABLE WAGES.
SCHEDULE J, PART I, LINE 3: COMPENSATION OF THE CEO/EXECUTIVE DIRECTOR
THE COMPENSATION FOR THE PRESIDENT/CEO OF PIEDMONT FAYETTE HOSPITAL IS SET BY THE ENTITY'S PARENT, PIEDMONT HEALTHCARE, INC. PLEASE SEE THE SCHEDULE O NARRATIVE FOR FORM 990, PART VI, SECTION B, LINE 15A & 15B FOR ADDITIONAL INFORMATION.
SCHEDULE J, PART I, LINE 4B: SUPPLEMENTAL COMPENSATION INFORMATION
MICHAEL MCANDER RECEIVED A PAYMENT OF $498,228 FROM HIS SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THOMAS ARNOLD RECEIVED A PAYMENT OF $62,570 FROM HIS SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. DR. PATRICK BATTEY RECEIVED A PAYMENT OF $106,119 FROM HIS SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. THE FOLLOWING EMPLOYEES PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN, BUT DID NOT RECEIVE CURRENT YEAR PAYMENTS: STEPHEN PORTER MICHAEL MANDL ELIZABETH LEDDY
SCHEDULE J, PART I, LINE 7: NON-FIXED PAYMENTS
CERTAIN EMPLOYEES PARTICIPATED IN AN "ANNUAL INCENTIVE PLAN" UNDER WHICH THEY RECEIVED NON-FIXED BONUS PAYMENTS BASED ON JOB LEVEL AND SEVERAL DIFFERENT PERFORMANCE METRICS.
Schedule J (Form 990) 2020
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