2022-08-15T11:47:10-05:00 2021-09-30 390859910 BAKER TILLY US LLP 1570 FRUITVILLE PIKE SUITE 400 LANCASTER PA 17601 990 2020-10-01 264183569 KING'S DAUGHTERS MEDICAL SPECIALTIES INC KING 6064084000 2201 LEXINGTON AVENUE ASHLAND KY 41101 AUTUMN MCFANN TREASURER 6064084000 2022-08-12 1 AUTUMN MCFANN 999009999 KERRI N BOGDA CPA P00760402 7177404863 X 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z KRISTIE WHITLATCH 2201 LEXINGTON AVENUE ASHLAND KY 41101 68148299 0 X WWW.KINGSDAUGHTERSHEALTH.COM X 2009 KY TO DELIVER QUALITY HEALTHCARE SERVICES WHICH PROVIDE VALUE TO THE PATIENT, PAYER, AND KDHS. 8 8 219 8 0 0 1379977 0 51182102 68093591 1380 -12336 184263 21140 52747722 68102395 0 0 0 0 63163720 81590833 0 0 0 9733613 9128591 72897333 90719424 -20149611 -22617029 20238680 18582367 148805167 16484386 -128566487 2097981 X KING'S DAUGHTERS MEDICAL SPECIALTIES (KDMS) IS AN INTERGRATED SYSTEM OF MEDICAL SPECIALISTS AND PRIMARY CARE PHYSICIANS DESIGNED TO PROVIDE AN AVENUE FOR PHYSICIAN RECRUITMENT, RETENTION, AND EMPLOYMENT. CONTINUED ON SCHEDULE "O".KDMS PROVIDES ACCESS TO INFORMATION TECHNOLOGY, AS WELL AS LEADERSHIP AND DIRECTION IN A RAPIDLY TRANSFORMING HEALTHCARE ENVIRONMENT WITH CHANGING PAYOR DEMANDS. THE GOALS OF KDMS INCLUDE THE DELIVERY OF QUALITY SERVICE WHICH PROVIDES VALUE TO THE PATIENT, THE PAYOR, AND THE HEALTH SYSTEM. 0 0 90719424 0 68093591 KDMS HAS 29 MEDICAL SPECIALTIES PLUS PRIMARY CARE PHYSICIANS PROVIDING SERVICES IN 39 DIFFERENT LOCATIONS. THERE ARE 124 PHYSICIANS AND 87 ADVANCED PRACTITIONERS THAT MAKE UP THE PROVIDERS. KDMS SAW APPROXIMATELY 85,833 PATIENTS DURING FY2021 AND PROVIDED $638,459 OF CHARITY CARE. 90719424 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 X 0 0 219 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 1 1 0 1 1 0 0 0 1 1 1 1 1 1 1 0 KY X LAURIE STEWART CONTROLLER 6064089640 2201 LEXINGTON AVENUE ASHLAND KY 41101 KRISTIE WHITLATCH NON-VOTING PRESIDENT 1.25 60.75 X X 0 935505 40469 AUTUMN MCFANN NON-VOTING TREASURER 1.25 60.75 X X 0 488592 37309 SHERYL MAHANEY NON-VOTING SECRETARY 1.25 60.75 X X 0 482139 43259 DAVID JONES BOARD CHAIRMAN 0.25 6.25 X X 0 0 0 MARK NEWMAN BOARD VICE CHAIR 0.25 6.25 X 0 0 0 STEPHEN ADDINGTON DIRECTOR 0.25 2.50 X 0 0 0 MARK BIRDWHISTELL DIRECTOR 0.25 2.50 X 0 0 0 TOM BURNETTE DIRECTOR 0.25 2.50 X 0 0 0 CRAIG COLLINS DIRECTOR 0.25 2.50 X 0 0 0 ERIC MONDAY DIRECTOR 0.25 2.50 X 0 0 0 JOHN STEWART DIRECTOR 0.25 2.50 X 0 0 0 SARA MARKS VP/COO 1.25 59.00 X 0 421725 47343 SRIHARSHA VELURY MD PHYSICIAN 40.00 X 1350032 0 25967 OMRAN ABUL-KHOUDOUD MD PHYSICIAN 40.00 X 1334560 0 53235 ZANE DARNELL MD PHYSICIAN 40.00 X 1641697 0 50593 JENNIFER LISTERMAN MD PHYSICIAN 40.00 X 1386279 0 47343 RODERICK TOMPKINS MD PHYSICIAN 40.00 X 1134705 0 53293 6847273 2327961 398811 172 0 1 0 KEVIN WILLIS MD 91 PRIVATE DR 1277 IRONTON OH 45638 PHYSICIAN 574127 MILLENNIAL PSYCHIATRIC SERVICE 201 PROVIDENCE HILL DR ASHLAND KY 41101 BEHAVIORAL MEDICINE PHYSICIAN 431150 LOCUMTENENSCOM PO BOX 405547 ATLANTA GA 303845547 LOCUM TENENS PHYSICIANS 206805 UNIVERSITY PHYSICIANS & SURGEONS INC 1600 MEDICAL CTR DR HUNTINGTON WV 25701 ORTHOPEDIC PHYSICIANS 119832 4 NET PATIENT SERVICE REVENUE 621110 67953765 67953765 MEANINGFUL USE REVENUE 900099 139826 139826 68093591 27 27 1656 0 1656 1656 1656 33541 45904 -12363 -12363 -12363 QUALITY INCENTIVE 900099 19484 19484 19484 68102395 68093591 0 8804 115790 115790 73579140 73579140 2365371 2365371 2860506 2860506 2670026 2670026 2523572 2523572 532 532 46426 46426 143724 143724 8228 8228 349815 349815 2534544 2534544 BAD DEBT EXPENSE 3369226 3369226 DUES & SUBSCRIPTIONS 129175 129175 SUPPLIES 10996 10996 REPAIRS AND MAINTENANCE 504 504 11849 11849 90719424 90719424 0 0 1786348 2361922 6707473 7155602 517800 663842 6893613 4967228 2627137 1926385 8599922 6474616 20238680 18582367 11953055 15456072 136852112 1028314 148805167 16484386 X -128566487 2097981 -128566487 2097981 20238680 18582367 X -22617029 153281497 X 0 1 X 1 0 X 1379977 1379977 55401502 53254249 54133927 51182102 68093591 282065371 55401502 53254249 54133927 52562079 68093591 283445348 0 0 0 283445348 4575 7280 10191 3036 1683 26765 4575 7280 10191 3036 1683 26765 105075 67614 26980 182607 19484 401760 55511152 53329143 54171098 52747722 68114758 283873873 0.99850 0.99660 0.00010 0.00040 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS - 2016 AMOUNT: $ 5. MEDICAL RECORDS - 2016 AMOUNT: $ 26,493. 2017 AMOUNT: $ 30,958. 2018 AMOUNT: $ 20,979. 2019 AMOUNT: $ 75. QUALITY INCENTIVE - 2016 AMOUNT: $ 78,577. 2017 AMOUNT: $ 36,656. 2018 AMOUNT: $ 6,001. 2019 AMOUNT: $ 18,534. 2020 AMOUNT: $ 19,484. EMPLOYEE RETENTION CREDIT - 2019 AMOUNT: $ 163,998. 140000 140000 1528350 713991 814359 5225263 4253237 972026 1926385 GOODWILL 5451812 OPERATING LEASES 1022804 6474616 KENTUCKY SALES TAX PAYABLE 4867 OPERATING LEASE LIABILITY 1023447 1028314 X PART X, LINE 2: THE MEDICAL CENTER, KHF, KBNH, CDC, KHI, KDMT, KDMS, KDHF AND KDOH HAVE BEEN RECOGNIZED BY THE IRS AS SECTION 501(C)(3) CHARITABLE ORGANIZATIONS. SECTION 501(C)(3) ORGANIZATIONS ARE EXEMPT FROM FEDERAL AND STATE INCOME TAXES ON RELATED INCOME. THESE ORGANIZATIONS DO NOT ENGAGE IN SIGNIFICANT UNRELATED ACTIVITIES AND THEREFORE NO TAX IS RECORDED. 0 1 0 0 0 0 0 1 0 ZANE DARNELL MD PHYSICIAN 1639765 0 0 0 1932 0 24625 0 25968 0 1692290 0 0 0 JENNIFER LISTERMAN MD PHYSICIAN 1385439 0 0 0 840 0 21375 0 25968 0 1433622 0 0 0 OMRAN ABUL-KHOUDOUD MD PHYSICIAN 1313128 0 0 0 21432 0 24625 0 28610 0 1387795 0 0 0 SRIHARSHA VELURY MD PHYSICIAN 1344488 0 0 0 5544 0 24625 0 1342 0 1375999 0 0 0 RODERICK TOMPKINS MD PHYSICIAN 1132773 0 0 0 1932 0 24625 0 28668 0 1187998 0 0 0 KRISTIE WHITLATCH NON-VOTING PRESIDENT 0 677159 0 188424 0 69922 0 24625 0 15844 0 975974 0 33599 AUTUMN MCFANN NON-VOTING TREASURER 0 368175 0 105244 0 15173 0 21375 0 15934 0 525901 0 0 SHERYL MAHANEY NON-VOTING SECRETARY 0 337930 0 106630 0 37579 0 24625 0 18634 0 525398 0 27204 SARA MARKS VP/COO 0 318464 0 99059 0 4202 0 21375 0 25968 0 469068 0 0 PART I, LINE 3 COMPENSATION FOR THE CEO IS DETERMINED BY ASHLAND HOSPITAL CORPORATION (RELATED ORGANIZATION) USING THE FOLLOWING METHODS: INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY/STUDY, AND APPROVAL BY THE BOARD/COMPENSATION COMMITTEE. PART I, LINE 4B FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN: - KRISTIE WHITLATCH $26,376 - AUTUMN MCFANN $14,333 - SHERYL MAHANEY $6,828 - SARA MARKS $3,362 FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM 457(F) EXECUTIVE RETENTION PLAN PAYOUTS: - KRISTIE WHITLATCH $33,599 - SHERYL MAHANEY $27,204 THE CEO AND CERTAIN VICE PRESIDENTS, WHOSE BENEFIT IN THE QUALIFIED TAX SHELTERED ANNUITY PLAN IS LIMITED DUE TO THE IRS COMPENSATION AND BENEFIT LIMITS, RECEIVE A BENEFIT RESTORATION CONTRIBUTION UNDER THE DEFERRED ANNUITY PLAN THAT IS PAID AS A TAXABLE DISTRIBUTION TO THE PARTICIPANT ANNUALLY. PART I, LINE 7 NONFIXED PAYMENTS ARE MADE AS A PART OF THE MEDICAL CENTER'S TEAM INCENTIVE AWARD (TIA) PLAN. ALL TEAM MEMBERS ARE ELIGIBLE FOR THE TIA. THE TIA IS PAID OUT BASED UPON SUCCESSFUL COMPLETION OF BOTH QUANTITATIVE AND QUALITATIVE STRATEGIC GOALS, SET ANNUALLY BY THE MEDICAL CENTER LEADERSHIP TEAM AND APPROVED BY THE BOARD OF DIRECTORS. BROOKE VASS SEE PART V 115790 SEE PART V 0 SCH L, PART IV: (A) NAME OF PERSON: BROOKE VASS(B) RELATIONSHIP BETWEEN INTERESTED PERSON AND ORGANIZATION: SISTER OF AUTUMN MCFANN (TREASURER)(D) DESCRIPTION OF TRANSACTION: EMPLOYEE COMPENSATION FORM 990, PART V, LINE 1A: THERE IS NO SEPARATE FORM 1096 FILED BY KING'S DAUGHTERS MEDICAL SPECIALITIES, INC. ("KDMS"). ALL THE PAYMENTS ARE MADE BY ASHLAND HOSPITAL CORPORATION ("AHC"), AN AFFILIATE ENTITIY, UNDER ITS EIN 61-0444716. FORM 990, PART VI, SECTION A, LINE 6 ASHLAND HOSPITAL CORPORATION (AHC) IS THE SOLE CORPORATE MEMBER OF KING'S DAUGHTERS MEDICAL SPECIALTIES, INC. (KDMS). AHC, A 501(C)(3) ENTITY, IS THE PARENT ORGANIZATION OF AN INTEGRATED HEALTHCARE DELIVERY SYSTEM. FORM 990, PART VI, SECTION A, LINE 7A THE KDMS BOARD IS FOLDED INTO THE MAIN BOARD OF TRUSTEES OF THE HEALTH SYSTEM. THE BUSINESS OF KDMS IS AN AGENDA ITEM OF THE FULL BOARD INDEPENDENTLY OR THROUGH ITS COMMITTEE. FORM 990, PART VI, SECTION B, LINE 11B THE 990 WILL BE REVIEWED BY THE CFO AND CONTROLLER BEFORE IT IS FILED WITH THE IRS. THE 990 WILL BE KEPT ON FILE AND AVAILABLE FOR REVIEW BY BOARD MEMBERS UPON REQUEST. FORM 990, PART VI, SECTION B, LINE 12C KING'S DAUGHTERS MEDICAL CENTER REQUIRES ALL DIRECTORS, OFFICERS, AND KEY EMPLOYEES TO COMPLY WITH ITS CONFLICTS OF INTEREST POLICY, WHICH TRACKS THE IRS' RECOMMENDED POLICY WITH RESPECT TO SUCH OFFICERS AND DIRECTORS. MEMBERS OF THE MEDICAL CENTER'S BOARD OF DIRECTORS MUST ANNUALLY IDENTIFY, IN WRITING, ANY INTEREST THAT COULD GIVE RISE TO A CONFLICT, SUCH AS A LEADERSHIP POSITION IN A CONFLICTING ORGANIZATION; DISCLOSURE IS NOT LIMITED TO FINANCIAL CONFLICTS. LEADERSHIP EMPLOYEES MUST ANNUALLY CERTIFY, IN WRITING, THAT THEY KNOW OUR CONFLICTS OF INTEREST POLICY AND PROCEDURE AND HAVE NO CONFLICTS OF INTEREST. IN ADDITION, EMPLOYEES OF THE MEDICAL CENTER CERTIFY THAT NO CONFLICTS OF INTEREST EXIST OR OBTAIN AN ADVANCE WAIVER OF ANY CONFLICTS. THE MEDICAL CENTER'S HUMAN RESOURCES AND CORPORATE COMPLIANCE DEPARTMENTS MAINTAIN ALL RELEVANT DISCLOSURES AND SIGNATURES. ALL EMPLOYEES PROVIDE ANNUAL CONFLICT CHECKS. IF A CONFLICT OF INTEREST IS REPORTED, THE VICE PRESIDENT TO WHOM THE REPORTING EMPLOYEE DIRECTLY OR INDIRECTLY REPORTS, TOGETHER WITH THE CEO, CHIEF CORPORATE COMPLIANCE OFFICER AND GENERAL COUNSEL, DETERMINES IF A CONFLICT EXISTS. IF THE REPORTING EMPLOYEE IS A VICE PRESIDENT, THE CEO, IN CONSULTATION WITH THE GENERAL COUNSEL, DETERMINES IF A CONFLICT EXISTS. ANNUALLY, BOARD MEMBERS DISCLOSE PERSONAL AND PROFESSIONAL RELATIONSHIPS TO THE SECRETARY OF THE BOARD. IF A POTENTIAL CONFLICT EXISTS, THE BOARD SECRETARY OR A BOARD MEMBER WILL IDENTIFY THE CONFLICT, OR POTENTIAL CONFLICT, AND THE BOARD MEMBER WILL BE REMOVED FROM ANY PART OF THE DECISION-MAKING PROCESS, AND HAS NO ROLE IN THE INSTANCE IN WHICH THE CONFLICT EXISTS. A BOARD MEMBER WHO HAS A CONFLICT OF INTEREST MUST ABSTAIN FROM ANY RELEVANT DISCUSSION OR VOTE. IF A CONFLICT OF INTEREST IS DISCOVERED AFTER THE FACT, THE CEO AND VICE PRESIDENT, TOGETHER WITH THE GENERAL COUNSEL, IF APPROPRIATE, REVIEW THE INSTANCE IN WHICH THE CONFLICT OCCURRED. THOSE LEADERS DETERMINE WHETHER THE CONFLICTED INDIVIDUAL INFLUENCED THE DECISION-MAKING OR PROFITED FROM THE CONFLICT. THE CONFLICTED INDIVIDUAL IS REMOVED FROM ANY FURTHER INVOLVEMENT. IN ADDITION, ANY FAILURE TO REPORT CONFLICTS OF INTEREST VIOLATES THE MEDICAL CENTER'S POLICY AND COULD RESULT IN DISCIPLINARY ACTION, UP TO AND INCLUDING TERMINATION OF EMPLOYMENT OR REMOVAL FROM THE MEDICAL CENTER'S BOARD OF DIRECTORS. MEDICAL STAFF MEMBERS ARE REQUIRED BY THE MEDICAL STAFF BYLAWS TO DISCLOSE CONFLICTS OF INTEREST. ONCE DISCLOSED, THE MEDICAL STAFF MEMBER IS REMOVED FROM ANY DISCUSSION, DECISION-MAKING, AND/OR VOTE ON ANY RELATED ISSUE. FORM 990, PART VI, SECTION B, LINE 15 AT THE DIRECTION OF THE BOARD OF DIRECTORS, KDMC SET COMPENSATION FOR THE TEAM MEMBERS AND LEADERS USING SEDONA PARTNERS AS WELL AS REVIEW OF LOCAL AND REGIONAL SALARY INFORMATION PROVIDED THROUGH A MARSHALL UNIVERSITY SURVEY. IN JANUARY 2021, MERCER PERFORMED A REIVEW OF EXECUTIVE COMPENSATION AND BENEFITS. THE PRIMARY OBJECTIVE OF KING'S DAUGHTERS COMPENSATION PHILOSOPHY IS TO HAVE COMPENSATION AND BENEFITS SET THAT REFLECT OTHER SIMILAR INDEPENDENT NOT FOR PROFIT HEALTHCARE SERVICES AS WELL AS THE WORK PERFORMANCE OF THE ORGANIZATION. SULLIVAN COTTER, AN INDEPENDENT COMPENSATION EXPERT, REVIEWS ALL PHYSICIAN COMPENSATION AND BENEFITS FOR DETERMINATION OF FAIR MARKET VALUE. FORM 990, PART VI, SECTION C, LINE 19 ON A QUARTERLY BASIS, THE FINANCIAL STATEMENTS ARE REPORTED TO THE MUNICIPAL SECURITIES RULEMAKING BOARD AND MADE AVAILABLE ON THEIR WEBSITE. GOVERNING DOCUMENTS AND THE CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST. FORM 990, PART XI, LINE 9: FORGIVENESS OF INTERCOMPANY PAYABLES DUE TO RESTRUCTURING 153,281,497. ASHLAND HOSPITAL CORPORATION 2201 LEXINGTON AVENUE ASHLAND KY 41101 610444716 HEALTHCARE KY 501(C)(3) LINE 3 ROYAL BLUE HEALTH LLC 0 ASHLAND NURSING HOME CORPORATION 2500 STATE ROUTE 5 ASHLAND KY 41102 611386016 NURSING HOME KY 501(C)(3) LINE 10 ASHLAND HOSPITAL CORPORATION 0 KENTUCKY MEDICAL LOGISTICS INC 425 22ND STREET ASHLAND KY 41101 264736971 MEDICAL TRANSPORT KY 501(C)(3) LINE 10 ASHLAND HOSPITAL CORPORATION 0 KING'S DAUGHTERS HEALTH SYSTEM 2201 LEXINGTON AVENUE ASHLAND KY 41101 274553836 HEALTHCARE KY 501(C)(3) LINE 12B, II N/A 0 PORTSMOUTH HOSPITAL CORPORATION 1901 ARGONNE AVENUE PORTSMOUTH OH 45662 453215312 HEALTHCARE OH 501(C)(3) LINE 3 ROYAL BLUE HEALTH LLC 0 KENTUCKY HEART FOUNDATION INC 2201 LEXINGTON AVENUE ASHLAND KY 41101 260791997 MEDICAL RESEARCH KY 501(C)(3) LINE 7 ASHLAND HOSPITAL CORPORATION 0 KING'S DAUGHTERS HEALTH FOUNDATION INC 2201 LEXINGTON AVENUE ASHLAND KY 41101 611035701 FUNDRAISING KY 501(C)(3) LINE 12B, II ASHLAND HOSPITAL CORPORATION 0 CHILD DEVELOPMENT CENTER CORPORATION 2201 LEXINGTON AVENUE ASHLAND KY 41101 010560598 DAYCARE KY 501(C)(3) LINE 10 ASHLAND HOSPITAL CORPORATION 0 KENTUCKY HEART INSTITUTE INC 2201 LEXINGTON AVENUE ASHLAND KY 41101 611255904 PHYSICIANS KY 501(C)(3) LINE 10 ASHLAND HOSPITAL CORPORATION 0 ROYAL BLUE HEALTH LLC 2201 LEXINGTON AVENUE ASHLAND KY 41101 862993817 HEALTHCARE KY 501(C)(3) LINE 12B, II KING'S DAUGHTERS HEALTH SYSTEM 0 ASHLAND MEDICAL PROPERTIES INC 2201 LEXINGTON AVE ASHLAND KY 41101 611079090 RENTALS KY N/A C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1