2017-11-13T13:22:46-06:00 2016-12-31 346565596 ERNST & YOUNG US LLP 312 WALNUT ST SUITE 1900 CINCINNATI OH 45202 990 2016-01-01 461851763 PEDIATRIC SPECIALISTS OF VIRGINIA LLC PEDI 7032892433 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 LEON MOORES MD CEO 7032892433 2017-11-08 1 JULIE L SPARKS P01268401 5136121400 167.201.241.175 2017-11-08 09:14:37 ES P 7B679794C43C21C3204AD1DE02D62BF36AA11E4C 7B679794C43C21C3204AD1DE02D62BF36AA11E4C 2016 2018-03-14 21:41:22Z LEON MOORES MD 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 24552814 0 X PSVCARE.ORG X 2013 VA To provide a market-leading pediatric specialist physician capacity in Northern Virginia. 8 0 330 0 0 0 30209 272153 19597942 24225750 37278 49027 -22953 -13697 19642476 24533233 0 14698 0 0 26632454 29996981 0 0 8225 15375014 17200400 42007468 47212079 -22364992 -22678846 15760860 19720721 7935368 9162215 7825492 10558506 X Pediatric Specialists of Virginia's (PSV) charitable mission is to meet the pediatric specialist staffing needs of Inova and 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 42965898 14698 24225750 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, and adolescent gynecology 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 Hospital, 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. 42965898 1 1 0 0 0 0 0 0 0 0 1 0 0 0 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 1 0 0 0 1 11 0 1 330 1 0 0 0 0 0 0 0 0 0 0 X 8 0 0 0 0 0 1 1 0 1 1 0 0 1 1 0 1 1 1 1 1 0 VA X PEDIACTRIC SPECIALISTS OF VIRGINIA LLC 7038486630 3023 HAMAKER COURT FAIRFAX VA 22031 RICHARD MAGENHEIMER TRUSTEE 1.00 49.00 X 0 1986784 474786 PATRICK CHRISTIANSEN TRUSTEE 1.00 49.00 X 0 1279560 372080 LORING FLINT TRUSTEE 1.00 49.00 X 0 1763138 285285 DAVID WESSEL TRUSTEE 1.00 49.00 X 0 1057323 146373 DOUG MYERS TRUSTEE 1.00 49.00 X 0 879033 127896 ELIZABETH FLURY TRUSTEE 1.00 49.00 X 0 875256 141574 ROBERT FILDES TRUSTEE 30.00 0.00 X 231901 0 35457 CARLY VARELA TRUSTEE 38.00 0.00 X 212656 0 47771 DAVID ASHMAN TRUSTEE 40.00 0.00 X 0 341625 40894 WILLIAM JUDD COO 40.00 0.00 X 240735 0 35192 LEON MOORES MD CEO 40.00 0.00 X 605342 0 42556 MARGARET HARRIS SENIOR DIRECTOR, FINANCE 40.00 0.00 X 160271 0 13659 JEFFREY HANWAY CHIEF SURGICAL OFFICER 40.00 0.00 X 609751 0 19735 IAN LEIBOWITZ CHIEF MEDICAL OFFICER 40.00 0.00 X 346352 0 48656 SADHNA SHANKAR MEDICAL DIRECTOR 40.00 0.00 X 178463 0 16133 CHRISTOPHER LAWLOR MEDICAL DIRECTOR 40.00 0.00 X 252598 0 48778 CATHERINE CHAO PHYSICIAN 40.00 0.00 X 317703 0 25516 RUPA DAINER PHYSICIAN 40.00 0.00 X 320553 0 42527 OTTO LOUIS-JACQUES PHYSICIAN 40.00 0.00 X 311585 0 18949 GEORGE GANTSOUDES PHYSICIAN 40.00 0.00 X 553251 0 58694 RAMESH PATEL PHYSICIAN 40.00 0.00 X 365157 0 56411 4706318 8182719 2098922 68 0 1 0 LIBERTY LANGUAGE SERVICE LLC 1604 SPRING HILL ROAD SUITE 262 VIENNA VA 22182 TRANSLATION SERVICES 327082 QUADRANT INC 1881 Campus Commons Dr 300 RESTON VA 20191 STAFFING SERVICES 326218 OASIS OUTSOURCING 2054 VISTA PARKWAY SUITE 300 WEST PALM BEACH FL 33411 HUMAN RESOURCES OUTSOURCING 193003 ECG MANAGEMENT CONSULTANTS 11512 EL CAMINO REAL 200 SAN DIEGO CA 92130 HEALTHCARE ADVISORY SERVICES 154418 PERFECTIONIST CLEANING SERVICES INC PO BOX 230353 CENTREVILLE VA 20120 JANITORIAL SERVICES 136812 5 50650 221503 272153 NET PATIENT SERVICE REVENUE 621400 24225750 24225750 24225750 49027 49027 5884 50650 19581 -13697 -13697 24533233 24225750 0 35330 14698 14698 3146009 3146009 21343165 19139139 2204026 919018 836306 82712 3086607 2808812 277795 1502182 1366986 135196 523493 476379 47114 49367 44924 4443 40505 36860 3645 13918 12665 1253 2789804 2538721 247908 3175 24088 21920 2168 226357 205985 15759 4613 198071 180245 17826 3051374 2776751 274623 105203 95752 9451 49545 45086 4372 87 1805428 1642939 162489 718949 654244 64705 MEDICAL SUPPLIES 6483087 5899609 583478 BAD DEBT 468581 426409 42172 REPAIRS AND MAINTENANCE 276283 251418 24865 TELEPHONE 62451 56830 5621 313896 287211 26335 350 47212079 42965898 4237956 8225 1832550 5573808 1863329 1647745 335846 536150 31755 17927 11359947 3425811 8819496 7934136 1929507 2558641 941708 659196 6669 793118 15760860 19720721 4425843 5493564 3509525 3668651 7935368 9162215 X 7825492 10558506 7825492 10558506 15760860 19720721 X -22678846 47902 25363958 X 0 1 X 1 0 X 401982 34278 272153 708413 1557548 9693583 19597942 24225750 55074823 1557548 10095565 19632220 24497903 55783236 0 0 0 55783236 25989 37278 49027 112294 25989 37278 49027 112294 -13697 -13697 1557548 10121554 19669498 24533233 55881833 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8767602 2561436 6206166 2592345 864375 1727970 7934136 PROFESSIONAL LIABILITY 1727824 LONG TERM LEASE 1940827 3668651 X 24036881 47902 -563836 -515934 24552815 -19582 -19582 24533233 46667825 19582 19582 46648243 563836 563836 47212079 Part X, Line 2: The Company was recognized as a public charity, not a foundation, 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 -468,581. Other Non Operating Expense -45,693. Use of Funds -49,562. Part XI, Line 4b - Other Adjustments: Special Events Expense -19,582. Part XII, Line 2d - Other Adjustments: Special Events Expense 19,582. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 468,581. Use of Funds 49,562. Other Non Operating Expense 45,693. STRIDE FORWARD 5K 56534 50650 5884 4517 21 700 14343 56534 50650 5884 4517 21 700 14343 19581 -13697 1 Mortgage Assistance to Indigent Patients 3 3233 Rent Assistance to Indigent Patients 2 3800 Utility Assistance to Indigent Patients 1 1110 Transportation Assistance to Indigent Patients 26 1055 Gift Cards to Indigent Patients 46 5500 PART III, COLUMN B 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 X X 0 1 0 0 0 0 0 0 0 RICHARD MAGENHEIMER TRUSTEE 0 690063 0 762692 0 534029 0 453279 0 21507 0 2461570 0 195000 PATRICK CHRISTIANSEN TRUSTEE 0 646810 0 503820 0 128930 0 355329 0 16751 0 1651640 0 45703 LORING FLINT TRUSTEE 0 634652 0 641962 0 486524 0 264364 0 20921 0 2048423 0 320171 DAVID WESSEL TRUSTEE 0 560842 0 428723 0 67758 0 97727 0 48646 0 1203696 0 0 DOUG MYERS TRUSTEE 0 503808 0 318004 0 57221 0 92751 0 35145 0 1006929 0 0 ELIZABETH FLURY TRUSTEE 0 497063 0 375010 0 3183 0 88252 0 53322 0 1016830 0 0 ROBERT FILDES TRUSTEE 192417 0 34242 0 5242 0 12055 0 23402 0 267358 0 0 0 CARLY VARELA TRUSTEE 174180 0 37050 0 1426 0 11196 0 36575 0 260427 0 0 0 DAVID ASHMAN TRUSTEE 0 263676 0 66664 0 11285 0 11390 0 29504 0 382519 0 0 WILLIAM JUDD COO 205944 0 33000 0 1791 0 13776 0 21416 0 275927 0 0 0 LEON MOORES MD CEO 506457 0 96600 0 2285 0 15900 0 26656 0 647898 0 0 0 MARGARET HARRIS SENIOR DIRECTOR, FINANCE 150689 0 8250 0 1332 0 9064 0 4595 0 173930 0 0 0 JEFFREY HANWAY CHIEF SURGICAL OFFICER 479184 0 127199 0 3368 0 15900 0 3835 0 629486 0 0 0 IAN LEIBOWITZ CHIEF MEDICAL OFFICER 296739 0 45000 0 4613 0 15900 0 32756 0 395008 0 0 0 SADHNA SHANKAR MEDICAL DIRECTOR 118799 0 58750 0 914 0 10736 0 5397 0 194596 0 0 0 CHRISTOPHER LAWLOR MEDICAL DIRECTOR 211291 0 39600 0 1707 0 15612 0 33166 0 301376 0 0 0 CATHERINE CHAO PHYSICIAN 274168 0 41250 0 2285 0 15900 0 9616 0 343219 0 0 0 RUPA DAINER PHYSICIAN 309418 0 9554 0 1581 0 15900 0 26627 0 363080 0 0 0 OTTO LOUIS-JACQUES PHYSICIAN 268800 0 40500 0 2285 0 15900 0 3049 0 330534 0 0 0 GEORGE GANTSOUDES PHYSICIAN 449958 0 101712 0 1581 0 15900 0 42794 0 611945 0 0 0 RAMESH PATEL PHYSICIAN 319862 0 41093 0 4202 0 15900 0 40511 0 421568 0 0 0 Part I, Line 4b INOVA SERP Plan Payments Richard Magenheimer $104,717 Loring Flint $448,874 Patrick Christiansen $91,406 CNMC SERP Plan Payments Douglas Myers $79,501 David Wessel, MD $84,477 Elizabeth Flury $75,002 Inova SERP Description The Supplemental Executive Retirement Plan (SERP Plan) is a nonqualified retirement plan. Employees eligible to participate are Executive Directors, Assistant Vice Presidents, Vice Presidents, Senior Vice Presidents, Executive Vice Presidents, CFO, COO, and CEO. Each year, a certain percentage of each participant's base salary is contributed to the SERP Plan. This amount ranges from 5% to 20%, depending on position. After three years of continuous participation, participants vest in 50% of their balance at that time and are paid out the vested balance as a taxable event. After a total of six years participation and after attaining age 45, participants are 100% vested and are paid out their remaining balance as a taxable event. Vesting then reverts to a three-year rolling schedule until year 12. Thereafter, the annual contribution is paid out to the participant each year as a taxable event. CNMC Deferred Compensation Plan The Children's National Medical Center Deferred Compensation Plan is a nonqualified deferred compensation plan. Employees eligible to participate are a select group of management or highly compensated employees. Each year, a certain percentage of each participant's base salary is contributed to the SERP Plan. This amount ranges from 5% to 15%, depending on position. Contributions vest after a minimum of two years of continuous participation, and are paid out as a taxable event. Participants may elect a minimum deferral period between 2 and 5 years. After attaining age 65, participants are 100% vested and are paid out their remaining balance as a taxable event. Thereafter, the annual contribution is paid out to the participant each year as a taxable event. 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: Chief Executive Officer determined by regional market analysis for comparable positions. Chief Operating Officer determined by regional market analysis for comparable positions. Chief Medical Officer determined by regional market analysis for comparable positions. Chief Surgical Officer determined by regional market analysis for comparable positions. Compensation for the positions listed above are approved by the Management Committee. 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: CONTRIBUTED CAPITAL IHCS AND CNMC 25,363,958. INOVA HEALTH CARE SERVICES 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 540620889 HOSPITAL SYSTEM VA 501(C)(3) 3 INOVA HEALTH SYSTEM FOUNDATION 0 CHILDREN'S NATIONAL MEDICAL CENTER 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640403 SUPPORT DELIVERY OF HEALTHCARE DC 501(C)(3) 12, II N/A 0 INOVA HEALTH SYSTEM FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541071867 FUNDRAISING VA 501(C)(3) 12, III-FI N/A 0 IMANCO INC 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541340725 PAYROLL CORPORATION VA 501(C)(3) 12, I INOVA HEALTH SYSTEM FOUNDATION 0 INOVA VNA HOME CARE 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541277164 HOME CARE SERVICES VA 501(C)(3) 10 INOVA HEALTH CARE SERVICES 0 INTOTAL HEALTH LLC 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 201581237 HMO VA 501(C)(3) 10 INOVA HEALTH CARE SERVICES 0 ALEXANDRIA HOSPITAL FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 510241913 FUNDRAISING VA 501(C)(3) 12, I INOVA HEALTH CARE SERVICES 0 LOUDOUN HOSPITAL CENTER 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 540525802 HOSPITAL VA 501(C)(3) 3 INOVA HEALTH SYSTEM FOUNDATION 0 LOUDOUN NURSING AND REHABILITATION CENTER 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541361310 REHABILITATION SERVICES VA 501(C)(3) 10 LOUDOUN HOSPITAL CENTER 0 LOUDOUN HEALTH SERVICES 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541555489 SURGERY CENTER VA 501(C)(3) 10 LOUDOUN HOSPITAL CENTER 0 LOUDOUN HEALTHCARE FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 542011240 FUNDRAISING VA 501(C)(3) 12, I LOUDOUN HOSPITAL CENTER 0 CHILDREN'S RESEARCH INSTITUTE 111 MICHIGAN AVE NW WASHINGTON DC 20010 521654453 RESEARCH DC 501(C)(3) 10 CNMC 0 CHILDREN'S HOSPITAL 111 MICHIGAN AVE NW WASHINGTON DC 20010 530196580 HEALTH CARE DC 501(C)(3) 3 CNMC 0 SAFE KIDS WORLDWIDE 1301 PENNSYLVANIA AVE NW WASHINGTON DC 20004 521627574 INJURY PREVENTION DC 501(C)(3) 12, I CNMC 0 CHILDREN'S HOSPITAL SELF INSURANCE TRUST 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640399 INSURANCE DC 501(C)(3) 12, III-FI CNMC 0 CHILDREN'S HOSPITAL FOUNDATION 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640402 FUNDRAISING DC 501(C)(3) 7 CNMC 0 BRAINY CAMPS ASSOCIATION 111 MICHIGAN AVE NW WASHINGTON DC 20010 271547370 CHILD CAMPS DC 501(C)(3) 12, I CH 0 CHILDREN'S NATIONAL ADVOC AND PUBLIC POLICY 111 MICHIGAN AVE NW WASHINGTON DC 20010 271564354 ADVOCACY DC 501(C)(3) 12, II CNMC 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1