2016-11-11T08:29:53-06:00 2015-12-31 221478099 COHNREZNICK LLP 7501 WISCONSIN AVE SUITE 400E BETHESDA MD 20814 990 2015-01-01 461851763 PEDIATRIC SPECIALISTS OF VIRGINIA LLC PEDI 7032892433 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 LEON MOORES MD CEO 7032892433 2016-11-10 1 FRED HUTCHISON P00640420 7037446700 2015 2017-02-10 21:41:12Z LEON MOORES MD 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 19669498 0 X PSVCARE.ORG X 2013 VA To provide a market-leading pediatric specialist physician capacity in Northern Virginia through the joint efforts of the Members, Inova Health Care Services (Inova) and Children's National Medical Center (CNMC). 8 0 285 0 0 0 401982 30209 9693583 19597942 25989 37278 0 -22953 10121554 19642476 0 0 0 0 15916214 26632454 0 0 5002 8260879 15375014 24177093 42007468 -14055539 -22364992 14358617 15760860 3597696 7935368 10760921 7825492 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 38226795 19597942 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. 38226795 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 12 0 1 285 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 1886593 495017 PATRICK CHRISTIANSEN TRUSTEE 1.00 49.00 X 0 931698 160822 LORING FLINT TRUSTEE 1.00 49.00 X 0 941132 171016 DAVID WESSEL TRUSTEE 1.00 49.00 X 0 1070322 169126 DOUG MYERS TRUSTEE 1.00 49.00 X 0 1017798 161315 ELIZABETH FLURY TRUSTEE 1.00 49.00 X 0 923287 174898 ROBERT FILDES TRUSTEE 37.00 X 276424 0 40375 CARLY VARELA TRUSTEE 38.00 X 193013 0 49654 WILLIAM JUDD COO 40.00 X 195277 0 12774 LEON MOORES MD CEO 40.00 X 465728 147026 25150 MARGARET HARRIS SENIOR DIRECTOR, FINANCE 40.00 X 108005 0 9431 JEFFREY HANWAY CHIEF SURGICAL OFFICER 40.00 X 618266 0 18276 IAN LEIBOWITZ CHIEF MEDICAL OFFICER 40.00 X 341065 0 54300 SADHNA SHANKAR MEDICAL DIRECTOR 40.00 X 294339 0 25687 CATHERINE CHAO PHYSICIAN 40.00 X 317258 0 27270 MARSHALL SCHORIN PHYSICIAN 40.00 X 314525 0 40628 OTTO LOUIS-JACQUES PHYSICIAN 40.00 X 311902 0 16700 GEORGE GANTSOUDES PHYSICIAN 40.00 X 307038 0 55977 RAMESH PATEL MEDICAL DIRECTOR 40.00 X 369721 0 59427 GREG FLORENTIN FORMER COO 40.00 X 121571 0 17218 4234132 6917856 1785061 56 1 1 0 LIBERTY LANGUAGE SERVICE LLC 1604 SPRING HILL ROAD SUITE 262 VIENNA VA 22182 TRANSLATION SERVICES 286100 OASIS OUTSOURCING 2054 VISTA PARKWAY SUITE 300 WEST PALM BEACH FL 33411 HUMAN RESOURCES OUTSOURCING 184299 ECG MANAGEMENT CONSULTANTS 11512 EL CAMINO REAL 200 SAN DIEGO CA 92130 HEALTHCARE ADVISORY SERVICES 128277 PERFECTIONIST CLEANING SERVICES INC PO BOX 230353 CENTREVILLE VA 20120 JANITORIAL SERVICES 120838 MILLENNIUM HEALTH CONSULTING LLC PO BOX 1658 ISSAQUAH WA 98027 HEALTHCARE ADVISORY SERVICES 119169 5 28379 1830 30209 NET PATIENT SERVICE REVENUE 621400 19597942 19597942 19597942 37278 37278 4069 28379 27022 -22953 -22953 19642476 19597942 0 14325 2144250 2144250 19331709 17398873 1932836 799490 727536 71954 3046906 2772684 274222 1310099 1192190 117909 571618 520172 51446 7241 6589 652 57099 51960 5139 2655489 2416495 238994 16367 14894 1473 233945 212890 16475 4580 232504 211579 20925 2511643 2285595 226048 97100 88361 8722 17 58191 52954 4832 405 1596734 1453028 143706 1056600 961506 95094 MEDICAL SUPPLIES 5311517 4833480 478037 REPAIRS AND MAINTENANCE 314513 286207 28306 BAD DEBT 304000 276640 27360 TAXES AND LICENSES 172775 157225 15550 177678 161687 15991 42007468 38226795 3775671 5002 921430 1832550 1057078 1863329 175534 335846 66808 31755 10752103 1932607 8903026 8819496 1412571 1929507 1224220 941708 597950 6669 14358617 15760860 3042277 4425843 555419 3509525 3597696 7935368 X 10760921 7825492 10760921 7825492 14358617 15760860 X -22364992 -43537 19473100 X 0 1 X 1 0 X 401982 34278 436260 1557548 9693583 19597942 30849073 25989 37278 63267 1557548 10121554 19669498 31348600 0 0 0 31348600 1557548 10121554 19669498 31348600 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 8184652 1521927 6662725 2227614 410680 1816934 339837 339837 8819496 PROFESSIONAL LIABILITY 1239934 DEFERRED RENT 2064105 DUE TO RELATED PARTIES 205486 3509525 X 19316716 -43537 -309245 -352782 19669498 -27022 -27022 19642476 41725245 27022 27022 41698223 309245 309245 42007468 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 asthere 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 -304,000. Investment Expense -5,245. Part XI, Line 4b - Other Adjustments: Special Events Expense -27,022. Part XII, Line 2d - Other Adjustments: Special Events Expense 27,022. Part XII, Line 4b - Other Adjustments: Bad Debt Expense 304,000. Investment Expense 5,245. STRIDE FORWARD 5K 32448 28379 4069 4427 78 700 21817 32448 28379 4069 4427 78 700 21817 27022 -22953 X X X X X X 0 1 0 0 0 0 0 0 0 RICHARD MAGENHEIMER TRUSTEE 0 686647 0 455969 0 743977 0 478579 0 16438 0 2381610 0 603000 PATRICK CHRISTIANSEN TRUSTEE 0 628958 0 265216 0 37524 0 145096 0 15726 0 1092520 0 0 LORING FLINT TRUSTEE 0 607509 0 296099 0 37524 0 151048 0 19968 0 1112148 0 0 DAVID WESSEL TRUSTEE 0 528999 0 475919 0 65404 0 95752 0 73374 0 1239448 0 0 DOUG MYERS TRUSTEE 0 504053 0 467784 0 45961 0 92751 0 68564 0 1179113 0 0 ELIZABETH FLURY TRUSTEE 0 490436 0 430061 0 2790 0 88252 0 86646 0 1098185 0 0 ROBERT FILDES TRUSTEE 232511 0 38250 0 5663 0 14733 0 25642 0 316799 0 0 0 CARLY VARELA TRUSTEE 160653 0 31000 0 1360 0 7372 0 42282 0 242667 0 0 0 WILLIAM JUDD COO 193832 0 0 0 1445 0 11124 0 1650 0 208051 0 0 0 LEON MOORES MD CEO 463751 147026 0 0 1977 0 15900 0 9250 0 490878 147026 0 0 JEFFREY HANWAY CHIEF SURGICAL OFFICER 479184 0 136800 0 2282 0 15900 0 2376 0 636542 0 0 0 IAN LEIBOWITZ CHIEF MEDICAL OFFICER 292703 0 45000 0 3362 0 15900 0 38400 0 395365 0 0 0 SADHNA SHANKAR MEDICAL DIRECTOR 233791 0 58750 0 1798 0 14452 0 11235 0 320026 0 0 0 CATHERINE CHAO PHYSICIAN 273726 0 41250 0 2282 0 15900 0 11370 0 344528 0 0 0 MARSHALL SCHORIN PHYSICIAN 277630 0 30000 0 6895 0 15900 0 24728 0 355153 0 0 0 OTTO LOUIS-JACQUES PHYSICIAN 269200 0 40500 0 2202 0 15900 0 800 0 328602 0 0 0 GEORGE GANTSOUDES PHYSICIAN 305912 0 0 0 1126 0 31900 0 24077 0 363015 0 0 0 RAMESH PATEL MEDICAL DIRECTOR 319830 0 45144 0 4747 0 33900 0 25527 0 429148 0 0 0 GREG FLORENTIN FORMER COO 96583 0 24749 0 239 0 2484 0 14734 0 138789 0 0 0 Part I, Line 4b INOVA SERP Plan Payments Richard Magenheimer $101,665 CNMC SERP Plan Payments Douglas Myers $79,501 David Wessel, MD $82,502 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 two Management Committee representatives are physicians employed by the organization and mutually agreed upon by the Members. Form 990, Part VI, Section B, line 11 The Form 990 is prepared by a third party and initially provided to the Sr. Director of Finance, 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 Speciallist 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 Board. Form 990, Part VI, Section C, line 18 The Form 1023 and Form 990 are available at the address listed on page 1 of the Form 990 upon request during regular business hours. Form 990, Part VI, Section C, line 19 Form 990s are disclosed on the Guidestar website. 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. Part VI, 7b The business affairs for the organization are managed solely by the Management Committee which has full and complete authority, power and discretion to manage and control the business, affairs and properties of the organization, to make all decisions regarding those matters and to perform any and all other acts or activities customary or incident to the management of the company. No Member, by virtue of having the status of a Member, shall solely have any management power over the business and affairs of the organization or actual or apparent authority to enter into contracts on behalf of, or to otherwise bind, the organization. Form 990, Part XI, line 9: CONTRIBUTED CAPITAL IHCS AND CNMC 19,473,100. INOVA HEALTH CARE SERVICES 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 540620889 HOSPITAL SYSTEM VA 501(C)(3) 3 N/A 0 CHILDREN'S NATIONAL MEDICAL CENTER 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640403 SUPPORT DELIVERY OF HEALTHCARE DC 501(C)(3) 11, II N/A 0 INOVA HEALTH SYSTEM FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541071867 FUNDRAISING VA 501(C)(3) 11, III N/A 0 IMANCO INC 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541340725 PAYROLL CORPORATION VA 501(C)(3) 11,I N/A 0 INOVA VNA HOME CARE 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541277164 HOME CARE SERVICES VA 501(C)(3) 9 N/A 0 INTOTAL HEALTH LLC 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 201581237 HMO VA 501(C)(3) 9 N/A 0 ALEXANDRIA HOSPITAL FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 410241913 FUNDRAISING VA 501(C)(3) 11, I N/A 0 LOUDOUN HOSPITAL CENTER 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 540525802 HOSPITAL VA 501(C)(3) 3 N/A 0 LOUDOUN NURSING AND REHABILITATION CENTER 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541361310 REHABILITATION SERVICES VA 501(C)(3) 9 N/A 0 LOUDOUN HEALTH SERVICES 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 541555489 SURGERY CENTER VA 501(C)(3) 9 N/A 0 LOUDOUN HEALTHCARE FOUNDATION 8110 GATEHOUSE ROAD SUITE 400W FALLS CHURCH VA 22042 542011240 FUNDRAISING VA 501(C)(3) 11, I N/A 0 CHILDREN'S RESEACH INSTITUTE 111 MICHIGAN AVE NW WASHINGTON DC 20010 521654453 RESEARCH DC 501(C)(3) 9 N/A 0 CHILDREN'S HOSPITAL 111 MICHIGAN AVE NW WASHINGTON DC 20010 530196580 HEALTH CARE DC 501(C)(3) 9 N/A 0 SAFE KIDS WORLDWIDE 1301 PENNSYLVANIA AVE NW WASHINGTON DC 20004 521627574 INJURY PREVENTI0N DC 501(C)(3) 11, I N/A 0 CHILDREN'S HOSPTIAL SELF INSURANCE TRUST 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640399 INSURANCE DC 501(C)(3) 11, III N/A 0 CHILDREN'S HOSPITAL FOUNDATION 111 MICHIGAN AVE NW WASHINGTON DC 20010 521640402 FUNDRAISING DC 501(C)(3) 7 N/A 0 BRAINY CAMPS ASSOCIATION 111 MICHIGAN AVE NW WASHINGTON DC 20010 271547370 CHILD CAMPS DC 501(C)(3) 11, I N/A 0 CHILDREN'S NATIONAL ADVOC AND PUBLIC POLIC 111 MICHIGAN AVE NW WASHINGTON DC 20010 271564354 ADVOCACY DC 501(C)(3) 11, II N/A 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 INOVA HEALTH CARE SERVICES C 9736550 FMV CHILDREN'S NATIONAL MEDICAL CENTER C 9736550 FMV INOVA HEALTH CARE SERVICES S 606793 GENERAL LEDGER CHILDREN'S NATIONAL MEDICAL CENTER S 189974 GENERAL LEDGER