2022-11-03T11:18:49-05:00 2021-12-31 346565596 ERNST & YOUNG US LLP 221 E 4TH ST SUITE 2900 CINCINNATI OH 45202 990 2021-01-01 461851763 PEDIATRIC SPECIALISTS OF VIRGINIA LLC PEDI 7032892433 8095 INNOVATION PARK DRIVE FINANCE FAIRFAX VA 22031 LAUREL BLAKEMORE MD CEO 7032892433 2022-11-03 1 LAUREL BLAKEMORE MD 999009999 JULIE L SPARKS P01268401 5136121400 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z X LAUREL BLAKEMORE MD 8095 INNOVATION PARK DRIVE FINANCE FAIRFAX VA 22031 38526456 0 X PSVCARE.ORG X 2013 VA TO PROVIDE A MARKET-LEADING PEDIATRIC SPECIALIST PHYSICIAN CAPACITY IN NORTHERN VIRGINIA. 8 6 443 0 0 0 830474 1541087 31464718 36593583 761263 390118 -3384 -4146 33053071 38520642 10349 2730 0 0 37723517 40950485 0 0 2034 17192688 18607966 54926554 59561181 -21873483 -21040539 25094629 27579335 13790712 16729957 11303917 10849378 X PEDIATRIC SPECIALISTS OF VIRGINIA'S (PSV) CHARITABLE MISSION IS TO MEET THE PEDIATRIC SPECIALIST STAFFING NEEDS OF INOVA AND CHILDREN'S NATIONAL MEDICAL CENTER (CNMC) AND TO PROVIDE PEDIATRIC SPECIALIST CONSULTS TO PEDIATRIC PATIENTS AS REQUESTED BY INOVA OR CNMC. ALSO TO EXPAND OUTPATIENT PEDIATRIC SPECIALIST SERVICES IN NORTHERN VIRGINIA THROUGH THE OPERATION OF AMBULATORY CARE SITES, AMONG OTHER VEHICLES. 0 0 53295598 2730 36593583 PSV PROVIDES MEDICAL CARE AND RELATED SERVICES TO CHILDREN WHO SEEK DIAGNOSIS, TREATMENT, AND CARE WITHOUT REGARD TO RACE, COLOR, CREED, SEX, DISABILITY, NATIONAL ORIGIN, SEXUAL ORIENTATION, OR POVERTY STATUS. PSV'S PHYSICIANS AND ALLIED STAFF PROVIDE SERVICES IN THE FOLLOWING PEDIATRIC SPECIALTY AREAS: GASTROENTEROLOGY, ORTHOPEDICS, NEPHROLOGY, GENETICS, HEMATOLOGY/ONCOLOGY, ENDOCRINOLOGY, RHEUMATOLOGY, INFECTIOUS DISEASES, PSYCHOLOGY, NEUROLOGY, PSYCHIATRY, ALLERGY AND IMMUNOLOGY, DEVELOPMENTAL PEDIATRICS, NEUROSURGERY, PHYSICAL MEDICINE AND REHABILITATION, ADOLESCENT GYNECOLOGY, UROLOGY, PULMONARY MEDICINE, OTOLARYNGOLOGY, OPHTHALMOLOGY, AND PLASTIC SURGERY TO ALL PEDIATRIC PATIENTS ON A NON-DISCRIMINATORY BASIS. IN ADDITION, PSV OPERATES AN OUTPATIENT SURGERY CENTER AND PROVIDES PEDIATRIC ANESTHESIOLOGY SERVICES. PSV ENGAGES IN ACTIVITIES THAT EDUCATE THE COMMUNITY WITH RESPECT TO AREAS OF CRITICAL HEALTH CARE IMPORTANCE. THROUGH ITS AFFILIATION WITH INOVA AND CHILDREN'S NATIONAL MEDICAL CENTER, PSV PARTICIPATES IN HEALTH SCREENINGS, HEALTH FAIRS, AND HEALTH EDUCATION CLASSES MADE AVAILABLE TO ALL RESIDENTS IN THE COMMUNITY, WHETHER OR NOT THEY ARE PATIENTS OF PSV. PSV'S EMPLOYED PHYSICIANS ALSO PARTICIPATE IN ACADEMIC AND RESEARCH PROGRAMS. PSV PHYSICIANS SERVE AS FACULTY FOR AREA MEDICAL SCHOOLS, PARTICIPATING IN THE MEDICAL EDUCATION PROGRAMS OF THE AFFILIATED HOSPITALS AND INSTRUCTING STUDENTS. BY ENGAGING IN PATIENT CARE AND TEACHING ACTIVITIES AT THE MEMBERS' HOSPITALS, PSV PROMOTES THE HEALTH AND WELL BEING OF THE COMMUNITIES SERVED AND FOSTERS A DYNAMIC AND INTERACTIVE LEARNING ENVIRONMENT FOR FUTURE PHYSICIANS. PSV'S EMPLOYED PHYSICIANS AND ALLIED STAFF ALSO CONDUCT MEDICAL RESEARCH TO ADVANCE THE STUDY AND PRACTICE OF MEDICINE AND TO FIND CURES FOR DISEASES. RESULTS OF THE RESEARCH WILL BE MADE AVAILABLE TO THE GENERAL PUBLIC. PSV'S PHYSICIANS PROVIDE SERVICES TO PATIENTS AT SIX DISTINCT LOCATIONS IN NORTHERN VIRGINIA. BY PROVIDING HIGHLY-SPECIALIZED PEDIATRIC PHYSICIAN CARE TO ALL CHILDREN IN THE LARGE, DIVERSE, AND GROWING NORTHERN VIRGINIA COMMUNITY, PSV FULFILLS A VALUABLE COMMUNITY NEED. PSV WILL MAKE AVAILABLE TO ALL CHILDREN, INCLUDING INDIGENT CHILDREN WHO REQUIRE MEDICAL CARE, THE SERVICES OF ITS PHYSICIANS AND OF ITS QUALIFIED HEALTH CARE PROFESSIONALS CONSISTENT WITH PSV'S POLICIES FOR PROVIDING NEEDED MEDICAL SERVICES TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. 53295598 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 1 443 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 0 0 1 0 1 1 1 1 1 0 0 1 1 0 1 1 1 1 1 0 VA X PEDIATRIC SPECIALISTS OF VIRGINIA LLC 7038486630 3023 HAMAKER COURT FAIRFAX VA 22031 JOANNA FAZIO BEG 121721 TRUSTEE 1.00 0.00 X 0 0 0 MICHELLE MCGUIRE TRUSTEE 1.00 0.00 X 0 0 0 DAVID WESSEL MD CHAIRMAN 1.00 0.00 X 0 0 0 DAVID ASHMAN TRUSTEE 1.00 0.00 X 0 0 0 STEVE NARANG MD TRUSTEE 1.00 0.00 X 0 0 0 ALICE POPE TRUSTEE 1.00 0.00 X 0 0 0 TONI ARDABELL ENDING 121621 TRUSTEE 1.00 0.00 X 0 0 0 RUPA DAINER BEGINNING 121721 TRUSTEE, CHIEF SURGICAL OFFICER 40.00 0.00 X 381978 0 46265 EMILY HATTWICK MD TRUSTEE, MEDICAL DTR 40.00 0.00 X 329600 0 44822 CARLY VARELA MD ENDING 121621 TRUSTEE, PHYSICIAN 38.00 0.00 X 227892 0 10063 LAUREL BLAKEMORE MD CEO 40.00 0.00 X 738273 0 20649 WILLIAM JUDD COO 40.00 0.00 X 276550 0 18244 MARGARET HARRIS CHIEF FINANCIAL OFFICER 40.00 0.00 X 174052 0 14100 GEORGE GANTSOUDES PHYSICIAN 40.00 0.00 X 607870 0 46560 CANDICE HOLDEN PHYSICIAN 40.00 0.00 X 594248 0 43694 MERYL LUDWIG PHYSICIAN 40.00 0.00 X 482416 0 13717 JOSEPH LETZELTER III PHYSICIAN 40.00 0.00 X 558829 0 25272 LAURA ELEANOR GILL-SEALY PHYSICIAN 40.00 0.00 X 596502 0 44279 LEON MOORES MD PHYSICIAN, FORMER CEO 40.00 0.00 X 414253 0 21162 CHRISTOPHER LAWLOR PHYSICIAN, FORMER KEY EMPLOYEE 40.00 0.00 X 251232 0 45140 5633695 0 393967 87 1 1 0 LIBERTY LANGUAGE SERVICE LLC 8300 GREENSBORO DR L1-801 TYSONS VA 22102 TRANSLATION SERVICES 401438 PAYCOM INC 7501 W MEMORIAL ROAD OKLAHOMA CITY OK 73142 PAYROLL SERVICES 140669 ECG MANAGEMENT CONSULTANTS 11512 EL CAMINO REAL 200 SAN DIEGO CA 92130 HEALTHCARE ADVISORY SERVICES 117473 SCOLIOSIS SOLUTIONS LLC 3023 HAMAKER COURT SUITE LL50 FAIRFAX VA 22023 X-RAY SERVICES 107650 4 30406 1492918 17763 1541087 NET PATIENT SERVICE REVENUE 621400 36593583 36593583 36593583 386611 386611 3507 0 3507 3507 3507 1668 30406 5814 -4146 -4146 38520642 36593583 0 385972 2730 2730 2128345 2128345 32376018 28452872 3923146 1064641 943591 121050 3409807 3022112 387695 1971674 1747495 224179 678374 601243 77131 12708 11263 1445 54835 48600 6235 21432 18995 2437 2735527 2424498 309020 2009 1009 894 115 291901 258712 33189 449188 398115 51073 4181672 3706216 475456 39239 34778 4461 106101 94037 12064 1539889 1364804 175085 2517306 2231088 286218 MEDICAL SUPPLIES 4452184 4452184 BAD DEBT 642053 569052 73001 REPAIRS AND MAINTENANCE 338592 300094 38498 TAXES AND LICENSES 86846 76972 9874 459110 406908 52177 25 59561181 53295598 6263549 2034 9668372 10688913 2337895 2534738 425237 688073 144323 156266 13841746 10559758 4537093 3281988 6524303 8361737 1457406 1867620 25094629 27579335 6459247 8056457 7331465 8673500 13790712 16729957 X 11303917 10849378 11303917 10849378 25094629 27579335 X -21040539 466461 20119539 X 0 1 X 1 0 X 167588 161413 139277 830474 1541087 2839839 30318907 35531910 35051576 31464718 36593583 168960694 30486495 35693323 35190853 32295192 38134670 171800533 0 0 0 171800533 145517 32893 802924 324707 386611 1692652 145517 32893 802924 324707 386611 1692652 30632012 35726216 35993777 32619899 38521281 173493185 0.99020 0.99150 0.00980 0.00850 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9918088 7661462 2256626 3103193 2283201 819992 820465 615095 205370 3281988 LONG TERM INVESTMENTS 1867620 F 1867620 PROFESSIONAL LIABILITY 2038787 LONG TERM LEASE 3374422 RETIREMENT PLAN LIABILITY 1867620 DUE TO RELATED PARTIES 1392671 8673500 X 38329191 466461 -663726 -197265 38526456 -5814 -5814 38520642 58903269 5814 5814 58897455 663726 663726 59561181 PART X, LINE 2: THE COMPANY WAS RECOGNIZED AS A PUBLIC CHARITY, NOT A FOUNDATION, GENERALLY EXEMPT FROM FEDERAL INCOME TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE PURSUANT TO A DETERMINATION LETTER ISSUED BY THE IRS IN JANUARY 2015 EFFECTIVE SEPTEMBER 30, 2013. THE COMPANY IS ENTITLED TO RELY ON THIS DETERMINATION AS LONG AS THERE ARE NO SUBSTANTIAL CHANGES IN ITS CHARACTER, PURPOSES, OR METHODS OF OPERATION. MANAGEMENT HAS CONCLUDED THAT THERE HAVE BEEN NO SUCH CHANGES AND, THEREFORE, THE COMPANY'S STATUS AS A PUBLIC CHARITY EXEMPT FROM FEDERAL INCOME TAXATION REMAINS IN EFFECT. THE STATE IN WHICH THE COMPANY OPERATES ALSO PROVIDES GENERAL EXEMPTION FROM STATE INCOME TAXATION FOR ORGANIZATIONS THAT ARE EXEMPT FROM FEDERAL INCOME TAXATION. HOWEVER, THE COMPANY IS SUBJECT TO BOTH FEDERAL AND STATE INCOME TAXATION AT CORPORATE TAX RATES ON ITS UNRELATED BUSINESS INCOME. EXEMPTION FROM OTHER STATE TAXES, SUCH AS REAL AND PERSONAL PROPERTY TAXES, IS SEPARATELY DETERMINED. THE COMPANY HAD NO UNRECOGNIZED TAX BENEFITS, OR SUCH AMOUNTS WERE IMMATERIAL DURING THE PERIODS PRESENTED. FOR TAX PERIODS WITH RESPECT TO WHICH NO UNRELATED BUSINESS INCOME WAS RECOGNIZED, THE COMPANY WAS NOT REQUIRED TO FILE ANY INCOME TAX RETURNS. PART XI, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT EXPENSE -642,053. OTHER NON OPERATING EXPENSE -21,673. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSE -5,814. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSE 5,814. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 642,053. OTHER NON OPERATING EXPENSE 21,673. STRIDE FORWARD 5K 32074 30406 1668 75 5739 32074 30406 1668 75 5739 5814 -4146 X X X X 0 0 0 0 0 0 0 0 0 LAUREL BLAKEMORE MD CEO 735951 0 0 0 2322 0 0 0 20649 0 758922 0 0 0 GEORGE GANTSOUDES PHYSICIAN 499060 0 108000 0 810 0 14500 0 32060 0 654430 0 0 0 LAURA ELEANOR GILL-SEALY PHYSICIAN 491292 0 104400 0 810 0 14500 0 29779 0 640781 0 0 0 CANDICE HOLDEN PHYSICIAN 479927 0 113079 0 1242 0 14500 0 29194 0 637942 0 0 0 JOSEPH LETZELTER III PHYSICIAN 461858 0 96485 0 486 0 14500 0 10772 0 584101 0 0 0 MERYL LUDWIG PHYSICIAN 382000 0 99930 0 486 0 11527 0 2190 0 496133 0 0 0 LEON MOORES MD PHYSICIAN, FORMER CEO 413538 0 0 0 715 0 14500 0 6662 0 435415 0 0 0 RUPA DAINER BEGINNING 121721 TRUSTEE, CHIEF SURGICAL OFFICER 335789 0 45379 0 810 0 14500 0 31765 0 428243 0 0 0 EMILY HATTWICK MD TRUSTEE, MEDICAL DTR 273085 0 55273 0 1242 0 14500 0 30322 0 374422 0 0 0 CHRISTOPHER LAWLOR PHYSICIAN, FORMER KEY EMPLOYEE 210583 0 39584 0 1065 0 12932 0 32208 0 296372 0 0 0 WILLIAM JUDD COO 230107 0 45302 0 1141 0 13910 0 4334 0 294794 0 0 0 CARLY VARELA MD ENDING 121621 TRUSTEE, PHYSICIAN 189417 0 37883 0 592 0 8404 0 1659 0 237955 0 0 0 MARGARET HARRIS CHIEF FINANCIAL OFFICER 159332 0 12602 0 2118 0 8863 0 5237 0 188152 0 0 0 FORM 990, PART VI, SECTION A, LINE 4 THE LIMITED LIABILITY COMPANY OPERATING AGREEMENT FOR PEDIATRIC SPECIALISTS OF VIRGINIA WAS AMENDED AND RESTATED ON 6/24/2022, EFFECTIVE DATE TO BE DETERMINED. MEMBERS DESIRED TO AMEND AND RESTATE THE PRIOR AGREEMENT TO ADDRESS CERTAIN OPERATIONAL CHANGES AND THE ECONOMIC ASPECTS OF THE JOINT VENTURE RELATIONSHIP, AND TO TAKE INTO CONSIDERATION THE SEPARATE EXPANSION OF CERTAIN SERVICES WITHIN EACH OF THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION WAS FORMED AS A LIMITED LIABILITY COMPANY AND HAS TWO MEMBERS: INOVA HEALTH CARE SERVICES AND CHILDREN'S NATIONAL MEDICAL CENTER, BOTH CHARITABLE 501(C)(3) TAX-EXEMPT ORGANIZATIONS, WITH EQUAL INTERESTS. THE MEMBERS ENTERED INTO THE AMENDED AND RESTATED OPERATING AGREEMENT DATED SEPTEMBER 30, 2013 TO ESTABLISH AND OPERATE THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A AS DESCRIBED IN THE OPERATING AGREEMENT, THE GOVERNING BODY OF THE ORGANIZATION IS THE MANAGEMENT COMMITTEE. THE MANAGEMENT COMMITTEE IS COMPRISED OF EIGHT REPRESENTATIVES. THREE OF THE MANAGEMENT COMMITTEE REPRESENTATIVES ARE DESIGNATED AND APPOINTED BY EACH OF THE MEMBERS. THE REMAINING MANAGEMENT COMMITTEE REPRESENTATIVES ARE PHYSICIANS EMPLOYED BY THE ORGANIZATION AND MUTUALLY AGREED UPON BY THE MEMBERS. FORM 990, PART VI, SECTION A, LINE 7B THE OPERATING AGREEMENT PROVIDES FOR CERTAIN DECISIONS TO BE APPROVED BY THE MEMBERS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PREPARED BY A THIRD PARTY AND INITIALLY PROVIDED TO THE CHIEF FINANCIAL OFFICER, THE CHIEF OPERATING OFFICER, AND EXTERNAL TAX CONSULTANTS FOR REVIEW. THE FORM 990 IS FINALLY PRESENTED TO THE FULL MANAGEMENT COMMITTEE FOR REVIEW PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A WRITTEN CONFLICT OF INTEREST POLICY WHICH IS PROVIDED TO AND REVIEWED WITH ALL EMPLOYEES DURING THEIR NEW EMPLOYEE ORIENTATION. THE POLICY REQUIRES THE EMPLOYEE TO DISCLOSE REAL OR POTENTIAL CONFLICTS OF INTEREST, AND ALSO TO REPORT SUSPECTED VIOLATIONS OF THE POLICY TO MANAGEMENT OR HUMAN RESOURCES. THE EMPLOYEE CODE OF CONDUCT ALSO INCLUDES A SECTION DISCUSSING CONFLICTS OF INTEREST AND ALL EMPLOYEES ARE REQUIRED TO ACKNOWLEDGE RECEIPT OF, AND AGREEMENT TO COMPLY WITH, THE CODE OF CONDUCT IN WRITING. FORM 990, PART VI, SECTION B, LINE 15 PEDIATRIC SPECIALISTS OF VIRGINIA, LLC COMPENSATION: THE MANAGEMENT COMMITTEE DETERMINES AND APPROVES COMPENSATION FOR PSV'S CHIEF EXECUTIVE OFFICER, CHIEF OPERATING OFFICER, CHIEF MEDICAL OFFICER, AND CHIEF SURGICAL OFFICER USING A REGIONAL MARKET ANALYSIS OF COMPARABLE POSITIONS. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE NOT CURRENTLY PUBLICLY AVAILABLE. WHILE THE CONFLICT OF INTEREST POLICY IS NOT SPECIFICALLY PUBLICLY DISCLOSED, THE POLICY IS AVAILABLE TO STAFF AND PHYSICIANS. FORM 990, PART XI, LINE 9: CAPTIAL CONTRIBUTED IN 2021 BY LLC MEMBERS 20,119,539.