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Object ID: 202202809349300725 - Rendered 2024-05-02
TIN: 61-1740292
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
Spectrum Health System Group Return
Employer identification number
61-1740292
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
Yes
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
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
DARRYL ELMOUCHI MD
See Schedule O
(i)
(ii)
903,047
-------------
0
538,865
-------------
0
5,941
-------------
0
476,695
-------------
0
128,974
-------------
0
2,053,522
-------------
0
102,381
-------------
0
2
LOREN HAMEL MD
See Schedule O
(i)
(ii)
0
-------------
710,570
0
-------------
1,027,012
0
-------------
25,561
0
-------------
185,800
0
-------------
28,181
0
-------------
1,977,124
0
-------------
674,590
3
BRIAN BRASSER
See Schedule O
(i)
(ii)
489,902
-------------
0
196,828
-------------
0
3,903
-------------
0
148,044
-------------
0
79,642
-------------
0
918,319
-------------
0
48,543
-------------
0
4
Chad Tuttle
See Schedule O
(i)
(ii)
509,311
-------------
0
185,600
-------------
0
3,141
-------------
0
72,042
-------------
0
83,687
-------------
0
853,781
-------------
0
29,502
-------------
0
5
LOWELL HAMEL MD
See Schedule O
(i)
(ii)
445,011
-------------
0
276,442
-------------
0
7,316
-------------
0
16,634
-------------
0
18,045
-------------
0
763,448
-------------
0
95,002
-------------
0
6
PAUL KONOPACKI
See Schedule O
(i)
(ii)
0
-------------
311,374
0
-------------
141,594
0
-------------
702
0
-------------
93,649
0
-------------
58,739
0
-------------
606,058
0
-------------
44,099
7
Robert Fitzgerald MD
See Schedule O
(i)
(ii)
430,882
-------------
0
77,078
-------------
0
8,252
-------------
0
23,200
-------------
0
27,231
-------------
0
566,643
-------------
0
0
-------------
0
8
John Schuen MD
See Schedule O
(i)
(ii)
324,184
-------------
0
67,824
-------------
0
15,840
-------------
0
24,644
-------------
0
32,021
-------------
0
464,513
-------------
0
0
-------------
0
9
MARY ANN PATER
See Schedule O
(i)
(ii)
0
-------------
96,835
0
-------------
267,892
0
-------------
1,815
0
-------------
4,297
0
-------------
6,279
0
-------------
377,118
0
-------------
175,143
10
RAY CRUSE
See Schedule O
(i)
(ii)
254,154
-------------
0
63,184
-------------
0
2,202
-------------
0
15,046
-------------
0
40,126
-------------
0
374,712
-------------
0
0
-------------
0
11
Simin Beg
See Schedule O
(i)
(ii)
257,250
-------------
0
59,971
-------------
0
7,839
-------------
0
22,997
-------------
0
23,288
-------------
0
371,345
-------------
0
0
-------------
0
12
MELINDA GRUBER
See Schedule O
(i)
(ii)
216,638
-------------
0
42,062
-------------
0
1,127
-------------
0
14,549
-------------
0
48,598
-------------
0
322,974
-------------
0
0
-------------
0
13
Vicki Weaver
President, SHF - Part Year
(i)
(ii)
119,971
-------------
0
102,388
-------------
0
79,171
-------------
0
5,154
-------------
0
4,821
-------------
0
311,505
-------------
0
0
-------------
0
14
Kelly Dyer
President, SHF
(i)
(ii)
188,692
-------------
0
50
-------------
0
15,920
-------------
0
4,936
-------------
0
40,823
-------------
0
250,421
-------------
0
0
-------------
0
15
CHRISTINA FREESE DECKER
See Schedule O
(i)
(ii)
0
-------------
1,488,804
0
-------------
1,310,151
0
-------------
6,628
0
-------------
1,114,333
0
-------------
239,313
0
-------------
4,159,229
0
-------------
252,668
16
PRAVEEN THADANI
See Schedule O
(i)
(ii)
0
-------------
858,367
0
-------------
184,907
0
-------------
30,309
0
-------------
414,368
0
-------------
130,365
0
-------------
1,618,316
0
-------------
0
17
BEN GIELDA MD
See Schedule O
(i)
(ii)
627,390
-------------
0
97,374
-------------
0
1,165
-------------
0
14,500
-------------
0
7,523
-------------
0
747,952
-------------
0
0
-------------
0
18
JEFFREY POSTMA
DIRECTOR, LCHW
(i)
(ii)
489,905
-------------
0
126,180
-------------
0
4,977
-------------
0
14,500
-------------
0
26,172
-------------
0
661,734
-------------
0
0
-------------
0
19
Annica Waalkes
See Schedule O
(i)
(ii)
285,920
-------------
0
87,172
-------------
0
1,844
-------------
0
16,843
-------------
0
1,294
-------------
0
393,073
-------------
0
0
-------------
0
20
Talawnda Bragg
See Schedule O
(i)
(ii)
281,748
-------------
0
7,580
-------------
0
6,498
-------------
0
22,906
-------------
0
19,637
-------------
0
338,369
-------------
0
0
-------------
0
21
MICHELINO MANCINI
See Schedule O
(i)
(ii)
223,256
-------------
0
62,225
-------------
0
338
-------------
0
7,839
-------------
0
264
-------------
0
293,922
-------------
0
0
-------------
0
22
DEBRA JOHNSON
See Schedule O
(i)
(ii)
189,361
-------------
0
20,881
-------------
0
1,158
-------------
0
10,182
-------------
0
15,486
-------------
0
237,068
-------------
0
0
-------------
0
23
LESLIE FLAKE
SVP, Finance - Hospital & Medical Group
(i)
(ii)
527,316
-------------
0
211,522
-------------
0
1,305
-------------
0
63,855
-------------
0
69,720
-------------
0
873,718
-------------
0
49,528
-------------
0
24
Martha Boonstra
See Schedule O
(i)
(ii)
439,197
-------------
0
166,828
-------------
0
5,457
-------------
0
67,043
-------------
0
54,452
-------------
0
732,977
-------------
0
35,076
-------------
0
25
Andrea Leslie
See Schedule O
(i)
(ii)
332,406
-------------
0
133,427
-------------
0
3,121
-------------
0
90,832
-------------
0
63,268
-------------
0
623,054
-------------
0
30,909
-------------
0
26
NORMA TIRADO-KELLENBERGER
SVP, Human Resources, LHNSJ
(i)
(ii)
0
-------------
302,984
0
-------------
145,960
0
-------------
3,278
0
-------------
47,217
0
-------------
58,800
0
-------------
558,239
0
-------------
47,097
27
Angela Ditmar
President, SHP
(i)
(ii)
302,834
-------------
0
95,011
-------------
0
3,489
-------------
0
67,588
-------------
0
51,841
-------------
0
520,763
-------------
0
0
-------------
0
28
ROBIN SARKAR
VP - INFORMATION SERVICES, LHNSJ
(i)
(ii)
0
-------------
271,344
0
-------------
124,874
0
-------------
6,522
0
-------------
14,406
0
-------------
64,555
0
-------------
481,701
0
-------------
37,774
29
NATALIE BAGGIO
VP - PATIENT CARE CNE, LHNSJ
(i)
(ii)
299,087
-------------
0
73,746
-------------
0
353
-------------
0
34,099
-------------
0
40,799
-------------
0
448,084
-------------
0
0
-------------
0
30
Drew Dostal
See Schedule O
(i)
(ii)
318,614
-------------
0
35,000
-------------
0
5,195
-------------
0
9,868
-------------
0
62,024
-------------
0
430,701
-------------
0
0
-------------
0
31
Karen Pakkala
See Schedule O
(i)
(ii)
312,500
-------------
0
53,493
-------------
0
6,737
-------------
0
17,400
-------------
0
36,105
-------------
0
426,235
-------------
0
0
-------------
0
32
KENDALL TROYER
See Schedule O
(i)
(ii)
242,084
-------------
0
61,422
-------------
0
1,973
-------------
0
14,675
-------------
0
54,735
-------------
0
374,889
-------------
0
0
-------------
0
33
LYNN TODMAN
VP - HEALTH EQUITY, LHNSJ
(i)
(ii)
0
-------------
250,884
0
-------------
51,191
0
-------------
1,631
0
-------------
9,021
0
-------------
24,061
0
-------------
336,788
0
-------------
0
34
BILL HOEFER
PRESIDENT, SHZ
(i)
(ii)
193,570
-------------
0
40,000
-------------
0
38,846
-------------
0
7,015
-------------
0
34,818
-------------
0
314,249
-------------
0
0
-------------
0
35
Kevin Smith
See Schedule O
(i)
(ii)
194,009
-------------
0
56,528
-------------
0
1,217
-------------
0
10,518
-------------
0
21,961
-------------
0
284,233
-------------
0
0
-------------
0
36
THOMAS HUYCK
VP - LEGAL & GENERAL COUNSEL, LHNSJ
(i)
(ii)
0
-------------
221,315
0
-------------
50
0
-------------
10,649
0
-------------
6,031
0
-------------
39,978
0
-------------
278,023
0
-------------
0
37
KENNETH O'NEILL
VP - CLINICAL INTEGRATION, LHNSJ - PART YEAR
(i)
(ii)
83,999
-------------
0
85,155
-------------
0
1,061
-------------
0
5,938
-------------
0
11,375
-------------
0
187,528
-------------
0
18,487
-------------
0
38
DANIEL WASSENHOVE
DIRECTOR OF BUSINESS & COMMUNITY OPs, HAH
(i)
(ii)
108,903
-------------
0
12,315
-------------
0
2,716
-------------
0
5,930
-------------
0
20,434
-------------
0
150,298
-------------
0
0
-------------
0
39
Hossain Marandi
President, HDVCH, SHH
(i)
(ii)
594,904
-------------
0
0
-------------
0
2,056
-------------
0
10,777
-------------
0
93,805
-------------
0
701,542
-------------
0
0
-------------
0
40
THOMAS POW
PHYSICIAN, LHNSJ
(i)
(ii)
1,269,330
-------------
0
7,901
-------------
0
14,503
-------------
0
17,400
-------------
0
26,819
-------------
0
1,335,953
-------------
0
0
-------------
0
41
Marcus Haw
Div Chief, Peds-Cardiothoracic Surgery, SHH
(i)
(ii)
1,026,566
-------------
0
130,133
-------------
0
21,269
-------------
0
20,300
-------------
0
33,061
-------------
0
1,231,329
-------------
0
0
-------------
0
42
DILIP ARORA
PHYSICIAN, LHNSJ
(i)
(ii)
1,080,425
-------------
0
28,011
-------------
0
14,503
-------------
0
17,400
-------------
0
22,806
-------------
0
1,163,145
-------------
0
0
-------------
0
43
SANJAY PATRA
Division Chief, Neurosurgery, SHMG
(i)
(ii)
977,139
-------------
0
113,752
-------------
0
9,335
-------------
0
20,300
-------------
0
32,484
-------------
0
1,153,010
-------------
0
0
-------------
0
44
PAUL MAZARIS
Physician, Neurosurgery, SHMG
(i)
(ii)
1,052,540
-------------
0
1,145
-------------
0
9,335
-------------
0
20,300
-------------
0
11,796
-------------
0
1,095,116
-------------
0
0
-------------
0
45
GWEN SANDEFUR
See Schedule O
(i)
(ii)
0
-------------
0
125,895
-------------
0
755,414
-------------
0
0
-------------
0
0
-------------
0
881,309
-------------
0
0
-------------
0
46
DOMINIC SANFILIPPO
FORMER INTERIM KEY EMPLOYEE, HDVCH, SHH
(i)
(ii)
541,105
-------------
0
175,234
-------------
0
20,303
-------------
0
44,984
-------------
0
27,024
-------------
0
808,650
-------------
0
0
-------------
0
47
Mary Kay Vandriel
See Schedule O
(i)
(ii)
333,800
-------------
0
104,338
-------------
0
4,852
-------------
0
70,630
-------------
0
57,563
-------------
0
571,183
-------------
0
0
-------------
0
48
Cara Jansma
FORMER OFFICER, SHH
(i)
(ii)
264,020
-------------
0
66,157
-------------
0
1,980
-------------
0
16,356
-------------
0
57,461
-------------
0
405,974
-------------
0
0
-------------
0
49
ROBERT CONNORS
FORMER KEY EMPLOYEE, HDVCH, SHH
(i)
(ii)
0
-------------
0
0
-------------
0
161,628
-------------
0
0
-------------
0
0
-------------
0
161,628
-------------
0
0
-------------
0
50
Scott Davis
Former Treasurer, SHCC
(i)
(ii)
0
-------------
0
0
-------------
6,727
0
-------------
111,078
0
-------------
0
0
-------------
0
0
-------------
117,805
0
-------------
6,727
Schedule J (Form 990) 2021
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
Schedule J, Part I, Line 1a First-class or charter travel
The organization has provided first class travel and/or charter travel for certain executive employees and/or board members in limited situations. First class and/or charter travel is utilized when commercial air travel was not available for a destination, or not efficient due to schedules and/or connections, and also for bi-annual board retreat travel. In limited situations where first class travel was utilized, it was paid for as part of a corporate award airline mileage program at no additional cost to the organization. To the extent the benefit is deemed reportable, it is treated as taxable compensation in a 1099 or W-2 to the recipient.
Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation
See disclosure on Schedule O for Form 990, Part VI, Sec B, Line 15A
Schedule J, Part I, Line 4a Severance or change-of-control payment
$161,628 Robert Connors $111,078 Scott Davis $755,414 Gwen Sandefur
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
$35,076 Martha Boonstra $48,543 Brian Brasser $6,727 Scott Davis $102,381 Darryl Elmouchi $49,528 Leslie Flake $252,668 Christina Freese Decker $674,590 Loren Hamel $95,002 Lowell Hamel $44,099 Paul Konopacki $30,909 Andrea Leslie $18,487 Kenneth O'Niell 175,143 Mary Anne Pater $37,774 Robin Sarkar $47,097 Norma Tirado-Kellenburger $29,502 Chad Tuttle SCHEDULE J, PART I, LINE 4B IS ANSWERED "YES" BECAUSE CERTAIN INDIVIDUALS, DO "PARTICIPATE IN" SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN(S). SOME INDIVIDUALS RECEIVED DISTRIBUTIONS DURING THE YEAR (AS REPORTED ON THIS LINE) WHEREAS OTHERS PARTICIPATED IN THE PLAN(S) BUT DID NOT RECEIVE DISTRIBUTIONS. DISTRIBUTIONS REPORTED ON THIS LINE ARE ALSO INCLUDED IN SCHEDULE J, PART II, COLUMN F AS COMPENSATION REPORTED IN A PRIOR YEAR WHILE ALSO BEING REPORTED IN THE CURRENT 990 AS TOTAL COMPENSATION. The nonqualified retirement plans are an industry standard and are subject to the funding requirements of nonqualified deferred compensation plans under ERISA and federal tax regulations.
Schedule J, Part I, Line 7 Non-fixed payments
SCHEDULE J, PART I, LINE 7, IS ANSWERED "YES" BECAUSE CERTAIN INDIVIDUALS, WHOSE SALARY AND BENEFITS ARE PAID BY THE REPORTING ORGANIZATION OR A RELATED ORGANIZATION, RECEIVED A NON-FIXED PAYMENT DURING THE YEAR. THE NON-FIXED PAYMENTS ARE INCLUDED IN SCHEDULE J, PART II, COLUMN C.
Schedule J (Form 990) 2021
Additional Data
Software ID:
21014044
Software Version:
2021v4.2