2021-10-26T12:09:18-05:00 2020-12-31 346565596 ERNST & YOUNG US LLP 221 E 4TH ST SUITE 2900 CINCINNATI OH 45202 990 2020-01-01 461851763 PEDIATRIC SPECIALISTS OF VIRGINIA LLC PEDI 7032892433 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 LAUREL BLAKEMORE MD CEO 7032892433 2021-10-26 1 LAUREL BLAKEMORE MD 999009999 JULIE L SPARKS P01268401 5136121400 2 AAL1 IAL1 2020 2022-09-23 18:48:47Z LAUREL BLAKEMORE MD 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 33060526 0 X PSVCARE.ORG X 2013 VA TO PROVIDE A MARKET-LEADING PEDIATRIC SPECIALIST PHYSICIAN CAPACITY IN NORTHERN VIRGINIA. 8 6 425 0 0 0 139277 830474 35051576 31464718 802924 761263 -13700 -3384 35980077 33053071 15907 10349 0 0 37102459 37723517 0 0 6411 19219867 17192688 56338233 54926554 -20358156 -21873483 24285075 25094629 10884557 13790712 13400518 11303917 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 49519623 10349 31454718 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, OCULOPLASTIC SURGERY, 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 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 EIGHT DISTINCT LOCATIONS IN NORTHERN VIRGINIA AND MARYLAND. 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. 49519623 1 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 28 0 1 425 1 0 0 0 0 0 0 0 0 0 0 0 0 X 8 6 0 0 0 0 1 1 0 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 ALEC KING TRUSTEE, ENDING 10-2-20 1.00 0.00 X 0 0 0 MICHELLE MCGUIRE TRUSTEE, BEGINNING 10-3-20 1.00 0.00 X 0 0 0 DAVID WESSEL 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 TRUSTEE 1.00 0.00 X 0 0 0 EMILY HATTWICK TRUSTEE, MEDICAL DTR 40.00 0.00 X 339805 0 41810 CARLY VARELA TRUSTEE, PHYSICIAN 38.00 0.00 X 238565 0 14791 LAUREL BLAKEMORE MD CEO, BEGINNING 10-19-20 40.00 0.00 X 207823 0 3374 LEON MOORES MD CEO, ENDING 10-18-20 12.00 0.00 X 135000 0 0 WILLIAM JUDD COO 40.00 0.00 X 286694 0 18783 MARGARET HARRIS CHIEF FINANCIAL OFFICER 40.00 0.00 X 185747 0 14892 RUPA DAINER CHIEF SURGICAL OFFICER 40.00 0.00 X 407453 0 42894 GEORGE GANTSOUDES PHYSICIAN 40.00 0.00 X 691087 0 44906 CANDICE HOLDEN PHYSICIAN 40.00 0.00 X 655395 0 42661 MERYL LUDWIG PHYSICIAN 40.00 0.00 X 501577 0 14381 RAMESH PATEL PHYSICIAN 40.00 0.00 X 458933 0 33683 LAURA ELEANOR GILL-SEALY PHYSICIAN 40.00 0.00 X 650847 0 42274 CHRISTOPHER LAWLOR MEDICAL DIRECTOR 40.00 0.00 X 278834 0 47581 5037760 0 362030 84 1 1 0 LIBERTY LANGUAGE SERVICE LLC 8300 GREENSBORO DR L1-801 TYSONS VA 22102 TRANSLATION SERVICES 201734 ECG MANAGEMENT CONSULTANTS 11512 EL CAMINO REAL 200 SAN DIEGO CA 92130 HEALTHCARE ADVISORY SERVICES 129362 PAYCOM INC 7501 W MEMORIAL ROAD OKLAHOMA CITY OK 73142 PAYROLL SERVICES 126690 3 31713 785638 13123 830474 NET PATIENT SERVICE REVENUE 621400 31464718 31464718 31464718 324707 324707 436556 0 436556 436556 436556 4071 31713 7455 -3384 -3384 33053071 31464718 0 757879 10349 10349 1937628 1937628 30110713 26655902 3454811 961697 858026 103671 2919192 2604503 314689 1794287 1600863 193424 654472 583920 70552 48116 42929 5187 62694 55936 6758 14009 12499 1510 2307132 2055633 248395 3104 54 48 6 237580 211969 25329 282 398167 355245 39897 3025 4248422 3790442 457980 24457 21821 2636 62219 55512 6707 1513535 1350376 163159 1724729 1538803 185926 MEDICAL SUPPLIES 4785030 4785030 BAD DEBT 322901 288092 34809 REPAIRS AND MAINTENANCE 321306 286669 34637 TAXES AND LICENSES 95156 84898 10258 372709 332530 40179 54926554 49519623 5400520 6411 9517844 9668372 2358782 2337895 372963 425237 237985 144323 13556962 9019869 5680979 4537093 5487489 6524303 629033 1457406 24285075 25094629 5804984 6459247 5079573 7331465 10884557 13790712 X 13400518 11303917 13400518 11303917 24285075 25094629 X -21873483 19776882 X 0 1 X 1 0 X 272153 167588 161413 139277 830474 1570905 24225750 30318907 35531910 35051576 31464718 156592861 24497903 30486495 35693323 35190853 32295192 158163766 0 0 0 158163766 49027 145517 32893 802924 324707 1355068 49027 145517 32893 802924 324707 1355068 24546930 30632012 35726216 35993777 32619899 159518834 0.99150 0.99270 0.00850 0.00730 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 9918088 6512359 3405729 3582389 2451240 1131149 56485 56270 215 4537093 LONG TERM INVESTMENTS 1457406 1457406 PROFESSIONAL LIABILITY 1943625 LONG TERM LEASE 2980956 RETIREMENT PLAN LIABILITY 1457406 DUE TO RELATED PARTIES 949478 7331465 X 32718877 -341649 -341649 33060526 -7455 -7455 33053071 54592360 7455 7455 54584905 341649 341649 54926554 PART X, LINE 2: THE COMPANY WAS RECOGNIZED AS A PUBLIC CHARITY GENERALLY EXEMPT FROM FEDERAL INCOME TAXATION UNDER 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 -322,901. OTHER NON OPERATING EXPENSE -15,141. USE OF FUNDS -3,607. PART XI, LINE 4B - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSE -7,455. PART XII, LINE 2D - OTHER ADJUSTMENTS: SPECIAL EVENTS EXPENSE 7,455. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 322,901. USE OF FUNDS 15,141. OTHER NON OPERATING EXPENSE 3,607. STRIDE FORWARD 5K 35784 31713 4071 419 7036 35784 31713 4071 419 7036 7455 -3384 1 TRANSPORTATION ASSISTANCE TO INDIGENT PATIENTS 65 4725 GIFT CARDS TO INDIGENT PATIENTS 7 600 PHARMACEUTICAL ASSISTANCE TO INDIGENT PATIENTS 11 2833 RENT ASSISTANCE TO INDIGENT PATIENTS 1 2191 PART I, LINE 2 PEDIATRIC SPECIALISTS OF VIRGINIA (PSV) OFFERS GIFTS OR GRANTS TO ASSIST INDIGENT FAMILIES WHO ARE STRUGGLING WITH THE DEMANDS OF CARING FOR CHILDREN WITH SERIOUS, COMPLEX AND/OR DEBILITATING HEALTH CONDITIONS. PSV HAS A POLICY THAT OUTLINES ELIGIBILITY AND THE PROCESS, AS WELL AS A FORM, FOR REQUESTING, APPROVING AND DOCUMENTING THESE GIFTS. THE POLICY REQUIRES THE RECIPIENT TO BE A CURRENT PATIENT OF PSV. A PSV SOCIAL WORKER OR OTHER STAFF MEMBER ASSESSES THE FAMILIES' NEEDS, AND REQUESTS ARE APPROVED BY PSV SENIOR LEADERS. PAYMENTS ARE MADE DIRECTLY TO CREDITORS (SUCH AS A LANDLORD, UTILITY COMPANY, ETC.) UPON DOCUMENTATION OF AMOUNTS OWED. SMALLER GIFTS, IN THE FORM OF TRANSPORTATION VOUCHERS, OR GIFT CARDS TO ASSIST WITH GROCERIES OR PHARMACY CO-PAYS, ARE TRACKED USING A LOG. X X X X 0 0 0 0 0 0 0 0 0 GEORGE GANTSOUDES PHYSICIAN 555526 0 135000 0 561 0 14250 0 30656 0 735993 0 0 0 CANDICE HOLDEN PHYSICIAN 528105 0 126000 0 1290 0 14250 0 28411 0 698056 0 0 0 LAURA ELEANOR GILL-SEALY PHYSICIAN 519516 0 130500 0 831 0 14250 0 28024 0 693121 0 0 0 MERYL LUDWIG PHYSICIAN 376610 0 124500 0 467 0 12178 0 2203 0 515958 0 0 0 RAMESH PATEL PHYSICIAN 361881 0 85500 0 11552 0 14250 0 19433 0 492616 0 0 0 RUPA DAINER CHIEF SURGICAL OFFICER 355268 0 51624 0 561 0 12660 0 30234 0 450347 0 0 0 EMILY HATTWICK TRUSTEE, MEDICAL DTR 283242 0 55273 0 1290 0 14250 0 27560 0 381615 0 0 0 CHRISTOPHER LAWLOR MEDICAL DIRECTOR 234128 0 43600 0 1106 0 14250 0 33331 0 326415 0 0 0 WILLIAM JUDD COO 238979 0 46530 0 1185 0 14250 0 4533 0 305477 0 0 0 CARLY VARELA TRUSTEE, PHYSICIAN 200272 0 37883 0 410 0 9900 0 4891 0 253356 0 0 0 LAUREL BLAKEMORE MD CEO, BEGINNING 10-19-20 157376 0 50000 0 447 0 0 0 3374 0 211197 0 0 0 MARGARET HARRIS CHIEF FINANCIAL OFFICER 168442 0 15872 0 1433 0 9449 0 5443 0 200639 0 0 0 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 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 PSV 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 2020 BY LLC MEMBERS 19,776,882.