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ObjectId: 202223149349303032 - Submission: 2022-11-10
TIN: 84-0816047
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
21
Open to Public Inspection
Name of the organization
PIKES PEAK HOSPICE AND PALLIATIVE
CARE INC
Employer identification number
84-0816047
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
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) 2021
Page 2
Schedule J (Form 990) 2021
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, 1099-MISC compensation, and/or 1099-NEC
(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
TIM J BOWEN
DIRECTOR/CHIEF EXECUTIVE OFFICER
(i)
(ii)
0
-------------
583,405
0
-------------
251,574
0
-------------
457,416
0
-------------
195,574
0
-------------
30,292
0
-------------
1,518,261
0
-------------
366,856
2
PAUL TOSETTI
CHIEF FINANCIAL OFFICER
(i)
(ii)
0
-------------
227,903
0
-------------
56,317
0
-------------
1,497
0
-------------
52,842
0
-------------
1,962
0
-------------
340,521
0
-------------
0
3
DAWN DARVALICS
PRESIDENT
(i)
(ii)
199,798
-------------
0
32,939
-------------
0
188
-------------
0
34,895
-------------
0
22,262
-------------
0
290,082
-------------
0
0
-------------
0
Schedule J (Form 990) 2021
Page 3
Schedule J (Form 990) 2021
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
FOR COMPENSATION PAID TO OFFICERS FROM A RELATED TAX-EXEMPT ENTITY, THE ORGANIZATION RELIED ON THE RELATED ORGANIZATION THAT USED ONE OR MORE OF THESE METHODS TO ESTABLISH THE COMPENSATION OF THOSE OFFICERS.
PART I, LINE 4B
CARE SYNERGY, A RELATED TAX-EXEMPT ORGANIZATION, ESTABLISHED A SECTION 457(F) NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR THE EXCLUSIVE BENEFIT OF CERTAIN EXECUTIVES. FUNDS ARE SUBJECT TO RISK OF FORFEITURE BY PLAN PARTICIPANTS AND ARE AVAILABLE TO THE CREDITORS OF CARE SYNERGY. IN ACCORDANCE WITH THE BOARD OF DIRECTORS' INTENT, CARE SYNERGY WILL FUND INDIVIDUAL PARTICIPANT ACCOUNTS THROUGH INVESTMENT OPTIONS DIRECTED BY THE PARTICIPANTS. THE DEFERRED COMPENSATION PLAN IS PARTIALLY FUNDED, AND CARE SYNERGY REPORTS THE DEFERRALS AND RELATED FUNDING IN ACCRUED EXPENSES AND INVESTMENTS, RESPECTIVELY, IN THE BALANCE SHEET. THE FOLLOWING INDIVIDUALS PARTICIPATED IN THE 457(F) NON-QUALIFIED DEFERRED COMPENSATION PLAN IN 2021, FOR WHICH THE EXPENSE WAS INCURRED BY THE SPONSORING ORGANIZATIONS, BUT THE FUNDS HAVE NOT VESTED OR BEEN PAID OUT TO THESE INDIVIDUALS AND AS SUCH, ARE NOT INCLUDED IN THE AMOUNTS ON SCHEDULE J, PART II: TIM BOWEN (CARE SYNERGY CEO): $183,974 PAUL TOSETTI (CARE SYNERGY CFO): $44,606 DAWN DARVALICS (PIKES PEAK HOSPICE PRESIDENT): $32,847 DURING CALENDAR YEAR 2021 THE CEO RECEIVED A PAYMENT OF $447,894 FROM THE 457(F) PLAN. THE PAYMENT IS INCLUDED IN THE AMOUNTS REPORTED ON SCHEDULE J, PART II, COLUMN (B)(III).
PART I, LINE 7
THE ORGANIZATION AND THE COMPENSATION COMMITTEE OF CARE SYNERGY, A RELATED TAX-EXEMPT ORGANIZATION, ANNUALLY REVIEWS THE PERFORMANCES OF THE EXECUTIVE STAFF AND OTHER STAFF TO DETERMINE IF ADDITIONAL COMPENSATION IN THE FORM OF BONUSES WILL BE PAID. THE DETERMINATION OF BONUSES IS BASED ON ACHIEVEMENT OF CERTAIN METRICS INCLUDED IN OVERALL STRATEGIC OBJECTIVES INCLUDING FINANCIAL PERFORMANCE, PATIENT CENSUS GROWTH, AND QUALITY RATINGS. DURING CALENDAR YEAR ENDED DECEMBER 31, 2021, THE ORGANIZATION AND/OR CARE SYNERGY AWARDED THE DIRECT/CEO, CHIEF FINANCIAL OFFICER, PRESIDENT, DIRECTOR OF CLINICAL SERVICES, PHYSICIANS, AND THE NURSE PRACTITIONER A BONUS BASED ON REVIEW OF THEIR PERFORMANCES AND SERVICES TO THE ORGANIZATION.
SCHEDULE J, PART II:
THE COMPENSATION PAID TO THE DIRECTOR/CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER IS PAID FOR BY CARE SYNERGY, A RELATED TAX-EXEMPT ORGANIZATION. CARE SYNERGY'S COMPENSATION COMMITTEE ENGAGES AN INDEPENDENT THIRD-PARTY COMPENSATION AND BENEFITS CONSULTANT TO CONDUCT A MARKET ANALYSIS, WHICH INCLUDES COMPARISONS OF SIMILARLY SIZED HOSPICES AND OTHER HEALTHCARE ORGANIZATIONS, TO DETERMINE COMPENSATION AMOUNTS FOR THESE INDIVIDUALS.
SCHEDULE J, PART II:
THE COMPENSATION PAID TO THE CHIEF EXECUTIVE OFFICER AND THE CHIEF FINANCIAL OFFICER IS PAID FOR BY CARE SYNERGY, A RELATED TAX-EXEMPT ORGANIZATION. IN ADDITION TO PROVIDING SERVICES TO PIKES PEAK HOSPICE AND PALLIATIVE CARE, INC., TOP MANAGEMENT OFFICIALS LISTED ABOVE ALSO PROVIDE SERVICES IN THEIR RESPECTIVE POSITIONS TO OTHER RELATED TAX-EXEMPT ORGANIZATIONS. THE AMOUNTS REPORTED ON FORM 990, PART VII, SECTION A REPRESENT COMPENSATION AND BENEFITS PAID TO THESE INDIVIDUALS FOR THEIR SERVICES TO THE FILING ORGANIZATION AS WELL AS OTHER TAX-EXEMPT ORGANIZATIONS.
Schedule J (Form 990) 2021
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