2021-08-16T15:25:38-05:00 2020-09-30 390859910 BAKER TILLY US LLP 1570 FRUITVILLE PIKE SUITE 400 LANCASTER PA 17601 990 2019-10-01 264183569 KING'S DAUGHTERS MEDICAL SPECIALTIES INC KING 6064084000 2201 LEXINGTON AVENUE ASHLAND KY 41101 AUTUMN MCFANN TREASURER 6064084000 2021-08-15 1 KERRI N BOGDA CPA P00760402 7177404863 X 2019 2022-09-23 18:48:47Z KRISTIE WHITLATCH 2201 LEXINGTON AVENUE ASHLAND KY 41101 52747722 0 X WWW.KINGSDAUGHTERSHEALTH.COM X 2009 KY TO DELIVER QUALITY HEALTHCARE SERVICES WHICH PROVIDE VALUE TO THE PATIENT, PAYER, AND KDHS. 2 1 180 1 0 0 0 1379977 54133927 51182102 8449 1380 28636 184263 54171012 52747722 0 0 0 0 59864030 63163720 0 0 0 8309773 9733613 68173803 72897333 -14002791 -20149611 17359074 20238680 125775950 148805167 -108416876 -128566487 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 PAYER DEMANDS. THE GOALS OF KDMS INCLUDE THE DELIVERY OF QUALITY SERVICE WHICH PROVIDES VALUE TO THE PATIENT, THE PAYER, AND KING'S DAUGHTERS HEALTH SYSTEM (KDHS). 0 0 72897333 0 51182102 KDMS HAS 29 MEDICAL SPECIALTIES PLUS PRIMARY CARE PHYSICIANS PROVIDING SERVICES IN 39 DIFFERENT LOCATIONS. THERE ARE 105 PHYSICIANS AND 58 ADVANCED PRACTITIONERS THAT MAKE UP THE PROVIDERS. KDMS SAW APPROXIMATELY 75,476 PATIENTS DURING FY2020 AND PROVIDED $663,055 OF CHARITY CARE. 72897333 1 1 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 0 180 1 0 0 0 0 0 0 0 0 0 0 0 0 X 2 1 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 KY X LAURIE STEWART CONTROLLER 6064089640 2201 LEXINGTON AVENUE ASHLAND KY 41101 SRIHARSHA VELURY MD PHYSICIAN 40.00 X 1601026 0 16908 OMRAN ABUL-KHOUDOUD MD PHYSICIAN 40.00 X 1526452 0 38444 ZANE DARNELL MD PHYSICIAN 40.00 X 1486771 0 34670 JENNIFER LISTERMAN MD PHYSICIAN 40.00 X 1221365 0 34670 RODERICK TOMPKINS MD PHYSICIAN 40.00 X 1191695 0 41394 KRISTIE WHITLATCH PRESIDENT 1.25 61.25 X X 0 781097 80370 AUTUMN MCFANN NON-VOTING TREASURER 1.25 61.25 X X 0 522077 76217 SHERYL MAHANEY NON-VOTING SECRETARY 1.25 61.25 X X 0 409633 80728 DAVID JONES CHAIRMAN 0.25 5.75 X X 0 0 0 7027309 1712807 403401 137 0 1 0 RIVERSIDE ANESTHESIA PSC 425 LEWIS HARGETT CIRCLE LEXINGTON KY 405033590 ANESTHESIA SERVICES 6205137 KEVIN WILLIS MD 91 PRIVATE DR 1277 IRONTON OH 45638 PHYSICIAN 616336 MILLENNIAL PSYCHIATRIC SERVICE 201 PROVIDENCE HILL DR ASHLAND KY 41101 BEHAVIORAL MEDICINE PHYSICIAN 239400 UNIVERSITY PHYSICIANS & SURGEONS INC 1600 MEDICAL CTR DR HUNTINGTON WV 25701 ORTHOPEDIC PHYSICIANS 119832 MOHAMMAD AL-MADANI MD 1532 MONTGOMERY AVE VILLANOVA PA 190851917 LOCUM TENENS PHYSICIAN 110501 5 1379977 1379977 NET PATIENT SERVICE REVENUE 621110 51006382 51006382 MEANINGFUL USE REVENUE 900099 175720 175720 51182102 1380 1380 1656 0 1656 1656 1656 EMPLOYEE RETENTION CREDIT 900099 163998 163998 QUALITY INCENTIVE 900099 18534 18534 MEDICAL RECORDS 900099 75 75 182607 52747722 51182102 0 185643 80466 80466 58339457 58339457 499906 499906 2195706 2195706 2048185 2048185 3106833 3106833 15989 15989 39282 39282 41540 41540 103587 103587 11378 11378 369888 369888 2425023 2425023 BAD DEBT EXPENSE 3514805 3514805 DUES & SUBSCRIPTIONS 103185 103185 REPAIRS AND MAINTENANCE 1727 1727 SUPPLIES 376 376 72897333 72897333 0 0 2990881 1786348 6023438 6707473 447696 517800 7342457 4715320 2443995 2627137 5453064 8599922 17359074 20238680 6572172 11953055 119203778 136852112 125775950 148805167 X -108416876 -128566487 -108416876 -128566487 17359074 20238680 -20149611 0 X X 0 1 X 1 1 1 X 1379977 1379977 46017760 55401502 53254249 54133927 51182102 259989540 46017760 55401502 53254249 54133927 52562079 261369517 0 0 0 261369517 73690 4575 7280 10191 3036 98772 73690 4575 7280 10191 3036 98772 409224 105075 67614 26980 182607 791500 46500674 55511152 53329143 54171098 52747722 262259789 0.99660 0.99540 0.00040 0.00080 X SCHEDULE A, PART III, LINE 12, EXPLANATION OF OTHER INCOME: MISCELLANEOUS - 2016 AMOUNT: $ 5. MEDICAL RECORDS - 2015 AMOUNT: $ 24,240. 2016 AMOUNT: $ 26,493. 2017 AMOUNT: $ 30,958. 2018 AMOUNT: $ 20,979. 2019 AMOUNT: $ 75. QUALITY INCENTIVE - 2015 AMOUNT: $ 384,984. 2016 AMOUNT: $ 78,577. 2017 AMOUNT: $ 36,656. 2018 AMOUNT: $ 6,001. 2019 AMOUNT: $ 18,534. EMPLOYEE RETENTION CREDIT - 2019 AMOUNT: $ 163,998. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 140000 140000 1657373 660786 996587 5545084 4054534 1490550 2627137 GOODWILL 5451812 OPERATING LEASES 1071339 DUE TO KING'S DAUGHTERS MEDICAL CENTER - OHIO 2076771 8599922 DUE TO KING'S DAUGHTERS MEDICAL CENTER 135762450 KENTUCKY SALES TAX PAYABLE 4069 DUE TO KHI 14254 OPERATING LEASE LIABILITY 1071339 136852112 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 SRIHARSHA VELURY MD PHYSICIAN 1597692 0 0 0 3334 0 15600 0 1308 0 1617934 0 0 0 OMRAN ABUL-KHOUDOUD MD PHYSICIAN 1506289 0 0 0 20163 0 12600 0 25844 0 1564896 0 0 0 ZANE DARNELL MD PHYSICIAN 1484988 0 0 0 1783 0 12600 0 22070 0 1521441 0 0 0 JENNIFER LISTERMAN MD PHYSICIAN 1220590 0 0 0 775 0 12600 0 22070 0 1256035 0 0 0 RODERICK TOMPKINS MD PHYSICIAN 1189912 0 0 0 1783 0 15600 0 25794 0 1233089 0 0 0 KRISTIE WHITLATCH PRESIDENT 0 602821 0 126776 0 51500 0 65600 0 14770 0 861467 0 27321 AUTUMN MCFANN NON-VOTING TREASURER 0 334600 0 74839 0 112638 0 62600 0 13617 0 598294 0 105450 SHERYL MAHANEY NON-VOTING SECRETARY 0 305674 0 68833 0 35126 0 65600 0 15128 0 490361 0 24859 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 $17,224 - AUTUMN MCFANN $2,607 - SHERYL MAHANEY $4,493 FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM 457(F) EXECUTIVE RETENTION PLAN PAYOUTS: - KRISTIE WHITLATCH $27,321 - AUTUMN MCFANN $105,450 - SHERYL MAHANEY $24,859 FOLLOWING INDIVIDUALS RECEIVED PAYMENTS FROM 457(F) EXECUTIVE RETENTION PLAN DEFERRALS: - KRISTIE WHITLATCH $50,000 - SHERYL MAHANEY $50,000 - AUTUMN MCFANN $50,000 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 80466 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 EFFECTIVE JUNE 2017, AHC EXECUTIVE MEMBERS MADE THE DECISION TO FOLD THE KDMS BOARD INTO THE MAIN BOARD OF TRUSTEES AND THAT THE BUSINESS OF KDMS BE MANAGED AS AN AGENDA ITEM BY THE FULL BOARD INDEPENDENTLY OR THROUGH ITS COMMITTEE STRUCTURE. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE CONTROLLER AND THE CFO OF KING'S DAUGHTERS MEDICAL CENTER. AFTER THIS REVIEW, BUT BEFORE IT IS FILED WITH THE IRS, THE FINAL 990 WILL BE PROVIDED TO THE FULL BOARD OF DIRECTORS THROUGH AN E-MAIL SENT TO EACH BOARD MEMBER. 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 EXECUTIVE COMMITTEE OF KING'S DAUGHTERS BOARD OF TRUSTEES, KDMC SET COMPENSATION FOR THE TEAM MEMBERS, LEADERS AND EXECUTIVES USING A 2016 SULLIVAN COTTER AND ASSOCIATES COMPENSATION REVIEW AS WELL AS REVIEW OF LOCAL AND REGIONAL SALARY INFORMATION. A NEW COMPENSATION STUDY FOR TEAM MEMBERS, LEADERS AND EXECUTIVES WAS NOT PERFORMED IN THE PAST YEAR. THE PRIMARY OBJECTIVE OF KING'S DAUGHTERS COMPENSATION PHILOSOPHY IS TO HAVE COMPENSATION AND BENEFITS SET THAT REFLECTS OTHER SIMILAR INDEPENDENT NOT FOR PROFIT HEALTHCARE SERVICES AS WELL AS REFLECTS THE WORK PERFORMANCE OF THE ORGANIZATION. HOWEVER, SULLIVAN COTTER, AN INDEPENDENT COMPENSATION EXPERT, DID REVIEW 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 XII, LINE 3B: THE ORGANIZATION AND AFFILIATES RECEIVED FEDERAL FUNDING DURING THE YEAR WHICH REQUIRES A SINGLE AUDIT. THE AUDIT HAS NOT BEEN COMPLETED YET BUT IS SCHEDULED TO BE PREPARED IN ACCORDANCE WITH THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133. ASHLAND HOSPITAL CORPORATION 2201 LEXINGTON AVENUE ASHLAND KY 41101 610444716 HEALTHCARE KY 501(C)(3) LINE 3 KING'S DAUGHTERS HEALTH SYSTEM 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 KING'S DAUGHTERS HEALTH SYSTEM 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 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