2024-04-29T14:49:58-05:00 2023-06-30 440160260 FORVIS LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2022-07-01 581341530 HOSPICE OF GASTON COUNTY INC HOSP 7048342000 2525 COURT DRIVE GASTONIA NC 280531747 DAVID O'CONNOR EVP, CFO 7048342000 2024-04-29 1 DAVID OCONNOR 999009999 1 AMY BIBBY P00445891 8282542254 2024-04-29 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DAVID O'CONNOR 2525 COURT DRIVE GASTONIA NC 280531747 11337894 0 X WWW.GASTONHOSPICE.ORG X 1978 NC TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 12 12 102 44 0 0 242761 210347 10130781 10504669 1478512 531632 19162 66720 11871216 11313368 0 0 0 0 7401665 7295459 0 0 0 4706996 5454911 12108661 12750370 -237445 -1437002 27403909 27115508 973777 853745 26430132 26261763 X TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 0 0 11540279 10504669 SEE SCHEDULE O.GASTON HOSPICE PROVIDES SERVICES TO PEOPLE WHO HAVE A LIFE-LIMITING ILLNESS THAT IS NO LONGER RESPONDING TO CURATIVE TREATMENT. GASTON HOSPICE SERVES ANY RESIDENT OF GASTON COUNTY AND THE SURROUNDING AREA WHO HAS BEEN DIAGNOSED WITH A LIFE EXPECTANCY OF SIX MONTHS OR LESS. HOSPICE PROVIDES A VARIETY OF SERVICES INCLUDING: PAIN AND SYMPTOM MANAGEMENT, ASSISTANCE WITH FINANCIAL AND LEGAL ISSUES FROM A MEDICAL SOCIAL WORKER, EMOTIONAL AND SPIRITUAL SUPPORT FROM LICENSED COUNSELORS AND CHAPLAINS, CERTIFIED NURSING ASSISTANTS TO HELP WITH PERSONAL CARE, VOLUNTEERS TO HELP PROVIDE COMPANIONSHIP AND RUN ERRANDS, RESPITE CARE WHEN FAMILY CAREGIVERS NEED A BREAK, AND MEDICATIONS/EQUIPMENT/ SUPPLIES. THESE SERVICES ARE PROVIDED TO PATIENTS IN THEIR HOMES, IN THE 19-BED INPATIENT FACILITY ROBIN JOHNSON HOUSE, IN LONG-TERM CARE FACILITIES OR IN THE HOSPITAL. GASTON PALLIATIVE CARE OFFERS PALLIATIVE CARE TO RESIDENTS OF GASTON COUNTY LONG-TERM CARE FACILITIES, AS WELL AS PATIENTS AT CAROMONT REGIONAL MEDICAL CENTER. 11540279 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 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 30 0 1 102 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X THE ORGANIZATION 7048342000 2525 COURT DRIVE GASTONIA NC 28054 MS RUTH NEELY PAST CHAIR AS OF 2/1/2023 1.00 X X 0 0 0 MS ANN DAVIS CHAIR AS OF 2/1/2023 1.00 X X 0 0 0 MR DAVID RATCHFORD VICE CHAIR AS OF 2/1/2023 1.00 X X 0 0 0 MS SHARON SMITH SECRETARY 1.00 X X 0 0 0 MRJIM WARREN TREASURER 1.00 X X 0 0 0 MS JAMIE HESTER GRIFFITH DIRECTOR 1.00 X 0 0 0 DR MICHAEL CASE DIRECTOR 1.00 X 0 0 0 MR WILLIAM ANTHONY DIRECTOR 1.00 X 0 0 0 MS PATTI LINEBERGER DIRECTOR 1.00 X 0 0 0 MR MEL PARENT DIRECTOR 1.00 X 0 0 0 MS AMI PARKER DIRECTOR 1.00 X 0 0 0 REV BENJAMIN HINTON DIRECTOR 1.00 X 0 0 0 DR JOAN MARTIN DIRECTOR 1.00 X 0 0 0 MS JENNIFER JONES DIRECTOR 1.00 X 0 0 0 DR JOHN WATTS DIRECTOR 1.00 X 0 0 0 MR SCOTT GRIFFIN DIRECTOR 1.00 X 0 0 0 MS MARTHA WILLIARD DIRECTOR 1.00 X 0 0 0 MR K CHRISTOPHER PEEK CEO 1.00 54.00 X 0 1558081 286732 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 54.00 X 0 884243 174464 MS LEIGH HICKMAN CLO/ASST. SEC. 1.00 54.00 X 0 465494 103464 DR REBECCA BROWN PHYSICIAN 40.00 X 173269 0 22926 MS ANNA MARIE SHINDLER ON CALL RN HOSPICE 40.00 X 203565 0 55412 MS KATHERINE BLACKMON DIRECTOR HOSPICE PALLIATIVE CA 40.00 X 148696 0 10192 MS HEATHER MERRITT ADMISSION RN HOSPICE 40.00 X 159993 0 25188 MS JEANNIE JONES ON CALL RN HOSPICE 40.00 X 135714 0 30268 821237 2907818 708646 19 0 1 0 CROSS COUNTRY STAFFING PO BOX 404682 ATLANTA GA 30384 TEMPORARY PERSONNEL 366142 1 28679 3575 178093 210347 PROGRAM OPERATIONS 900099 10504669 10504669 10504669 482718 482718 48914 0 48914 48914 48914 90866 3575 24526 66340 66340 MISCELLANEOUS REVENUE 900099 380 380 380 11313368 10504669 0 598352 X 5908543 5400040 508503 197656 101931 95725 820805 711737 109068 368455 333349 35106 43178 43178 1518688 1237659 281029 190483 152494 37989 6806 6806 188817 165204 23613 104425 102859 1566 3491 3441 50 43346 43346 617385 617385 68477 789 67688 MEDICAL SERVICES 1557076 1557076 MEDICAL SUPPLIES 655793 655793 EQUIPMENT RENTAL & MAIN 312775 309714 3061 BAD DEBT 70042 70042 74129 70614 3515 12750370 11540279 1210091 0 1753 10349 2190 1815 1008540 946973 24464 6205 12704350 5830143 6095748 6874207 20264049 19267283 7165 8676 27403909 27115508 973777 853745 973777 853745 X 26430132 26261763 26430132 26261763 27403909 27115508 -1437002 1268633 0 X X 0 1 X 1 0 X 485895 298469 307347 242761 210347 1544819 485895 298469 307347 242761 210347 1544819 92629 1452190 431350 380093 353657 524645 482718 2172463 2091 284 194 566 380 3515 3720797 51641366 0.39030 0.46490 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 250438 250438 9218416 4382128 4836288 1350819 1350819 1847059 1410397 436662 37618 37618 0 6874207 X 12493470 1268633 24689 1293322 11200148 43178 70042 113220 11313368 12661839 24689 24689 12637150 43178 70042 113220 12750370 PART X, LINE 2: THE SYSTEM IS A NOT-FOR-PROFIT CORPORATION AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM HAS DETERMINED THAT IT DOES NOT HAVE ANY UNRECOGNIZED TAX BENEFITS OR OBLIGATIONS AS OF JUNE 30, 2023 AND 2022. PART XI, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 24,689. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 70,042. PART XII, LINE 2D - OTHER ADJUSTMENTS: FUNDRAISING EXPENSES 24,689. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 70,042. GOLF TOURNAMENT 74571 3575 70996 3775 1774 16518 ANNUAL FUND 19870 19870 2459 94441 3575 90866 3775 1774 18977 24526 66340 0 1 0 0 0 1 1 0 0 MR K CHRISTOPHER PEEK CEO 0 948458 0 411971 0 197652 0 263009 0 23723 0 1844813 0 158940 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 580745 0 194511 0 108987 0 150741 0 23723 0 1058707 0 86689 MS LEIGH HICKMAN CLO/ASST. SEC. 0 362901 0 101731 0 862 0 87394 0 16070 0 568958 0 0 MS ANNA MARIE SHINDLER ON CALL RN HOSPICE 192426 0 11000 0 139 0 34304 0 21108 0 258977 0 0 0 DR REBECCA BROWN PHYSICIAN 152969 0 20300 0 0 0 6842 0 16084 0 196195 0 0 0 MS HEATHER MERRITT ADMISSION RN HOSPICE 150493 0 9500 0 0 0 9299 0 15889 0 185181 0 0 0 MS JEANNIE JONES ON CALL RN HOSPICE 121245 0 14342 0 127 0 14363 0 15905 0 165982 0 0 0 MS KATHERINE BLACKMON DIRECTOR HOSPICE PALLIATIVE CA 133365 0 14788 0 543 0 9921 0 271 0 158888 0 0 0 PART I, LINE 3 COMPENSATION PAID TO CEO OF CAROMONT HEALTH, INC. WAS PAID BY CAROMONT REGIONAL MEDICAL CENTER, A RELATED ORGANIZATION. CAROMONT REGIONAL MEDICAL CENTER UTILIZED THE FOLLOWING METHODS TO DETERMINE APPROPRIATE COMPENSATION FOR CEO THAT HAD INFLUENCE OVER THE ORGANIZATION'S ACTIVITIES: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACTS - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 111,541 K. CHRISTOPHER PEEK - $ 223,809 LEIGH HICKMAN - $ 55,268 PART I, LINE 6 EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES WHICH INCLUDE A FINANCIAL GOAL ATTRIBUTABLE TO OPERATING MARGIN. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CORPORATION IS CAROMONT HEALTH, INC., A NORTH CAROLINA NOT-FOR-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS ARE ELECTED BY THE CORPORATION'S SOLE MEMBER, CAROMONT HEALTH, INC., AT ITS ANNUAL MEETING UP TO FIFTHTEEN (15) OF WHOM WILL BE FROM NOMINATIONS RECOMMENDED BY THE CORPORATION, AS SET FORTH IN THE BYLAWS, AND TWO (2) OF WHOM WILL BE SELECTED BY CAROMONT HEALTH, INC. FORM 990, PART VI, SECTION A, LINE 7B THE FOLLOWING POWERS OF THE CORPORATION SHALL BE RESERVED TO CAROMONT HEALTH, INC., THE PARENT CORPORATION AND HOLDING COMPANY OF THE CORPORATION: (A) FINANCIAL POWERS, INCLUDING THE POWER TO APPROVE AN OPERATING BUDGET FOR THE CORPORATION, POWER TO APPROVE COMPENSATION PLANS, AND POWER TO ASSUME DEBT ON BEHALF OF THE CORPORATION; (B) GOVERNING POWERS, INCLUDING THE POWER TO APPROVE ALL CHANGES TO THE GOVERNING DOCUMENTS OF THE CORPORATION AND POWER TO APPROVE THE MISSION, VISION AND VALUES OF THE CORPORATION; AND (C) STRATEGIC POWERS, INCLUDING THE POWER TO APPROVE ALL CERTIFICATE OF NEED APPLICATIONS WHICH THE CORPORATION MAY FILE IN ANY STATE, AND THE POWER TO APPROVE ALL SALE OR LEASE TRANSACTIONS OF THE CORPORATION. IN ADDITION, THE CORPORATION SHALL NOT BE DISSOLVED, EXCEPT UPON A MAJORITY VOTE OF THE BOARD OF DIRECTORS, AND THE APPROVAL OF THE CORPORATION'S SOLE MEMBER. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH PRIOR TO PRESENTATION TO THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS OF THE BOARD OF DIRECTORS, MEMBERS OF SENIOR LEADERSHIP, ANY PHYSICIAN HOLDING A LEADERSHIP OR ADMINISTRATIVE POSITION WITHIN THE ORGANIZATION, DIRECTORS, RESEARCH STUDY PERSONNEL, MANAGERS AND ALL STAFF MEMBERS OF THE PURCHASING AND MARKETING DEPARTMENTS AND ANY OTHER DEPARTMENT DEEMED TO HAVE MATERIAL DECISION MAKING RESPONSIBILITIES ON BEHALF OF CAROMONT HEALTH SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE INDIVIDUAL'S OBLIGATION TO IMMEDIATELY MAKE THE CORPORATE COMPLIANCE OFFICER AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID INDIVIDUAL'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES ARE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE COMPLIANCE OFFICER. QUESTIONNAIRES SUBMITTED BY DIRECTORS ARE REVIEWED ANNUALLY BY THE NOMINATING COMMITTEE OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO, COO, CPE AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY CAROMONT REGIONAL MEDICAL CENTER, A SUBSIDIARY OF CAROMONT HEALTH, INC. THE COMPENSATION OF ALL CAROMONT EXECUTIVES FOR EACH YEAR IS ESTABLISHED BY THE COMPENSATION COMMITTEE OF THE CAROMONT HEALTH BOARD OF DIRECTORS, BASED ON GUIDANCE AND OPINIONS PROVIDED BY AN INDEPENDENT, THIRD-PARTY COMPENSATION CONSULTANT. A MAJORITY OF THE BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND ALL ARE FREE FROM ANY CONFLICT OF INTEREST. ANY COMPENSATION COMMITTEE MEMBER WHO DEVELOPS A CONFLICT OF INTEREST DURING HIS/HER TERM WITH RESPECT TO THE DISCUSSION OF ANY EXECUTIVE'S COMPENSATION DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING MEMBERS OF THE COMPENSATION COMMITTEE. THE COMPENSATION COMMITTEE RETAINS JURISDICTION OVER THE TOTAL COMPENSATION PACKAGE FOR EXECUTIVES AND REVIEWS EXECUTIVE BENEFITS AND PERQUISITES AS WELL AS TOTAL CASH COMPENSATION. COMPENSATION FOR THE CEO IS ESTABLISHED THROUGH A PROCESS OF PERFORMANCE EVALUATION, COMPARISON WITH COMPARABLE MARKET DATA AND DETERMINATION BY THE COMPENSATION COMMITTEE OF ACCEPTABLE SALARY RANGE AND PERCENTILE RANKING. ALL COMPENSATION DECISIONS FOR THE CEO ARE APPROVED BY THE COMPENSATION COMMITTEE, AS LONG AS THE COMPENSATION DECISIONS ARE CONSISTENT WITH THE EXECUTIVE COMPENSATION PHILOSOPHY. THE PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVE MANAGEMENT, UTILIZES COMPENSATION SURVEYS AND STUDIES. FULL COLLECTED COMPENSATION INFORMATION AND ANY COMPENSATION OPINIONS PROVIDED DURING THESE PROCESSES WILL BE KEPT WITH THE COMPENSATION COMMITTEE OR BOARD MINUTES, AS APPLICABLE. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS MADE AVAILABLE TO THE PUBLIC UPON REQUEST AND ON WWW.GUIDESTAR.ORG. FORM 990, PART VI, SECTION C, LINE 19 AT THIS TIME, THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE NOT MADE AVAILABLE TO THE PUBLIC. THE ENTIRE ORGANIZATION'S COMBINED FINANCIAL STATEMENTS ARE MADE AVAILABLE UPON REQUEST. FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 250,749. MANAGEMENT AND GENERAL EXPENSES 7,729. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 258,478. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 106,025. MANAGEMENT AND GENERAL EXPENSES 41,521. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 147,546. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 50. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 50. CONSULTING FEES: PROGRAM SERVICE EXPENSES 26,812. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 26,812. OTHER FEES: PROGRAM SERVICE EXPENSES 845,632. MANAGEMENT AND GENERAL EXPENSES 42,000. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 887,632. MEDICAL PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 8,391. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,391. MANAGEMENT SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 78,404. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 78,404. PHYSICIAN LEADERSHIP FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 111,375. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 111,375. PART XII, LINE 2C THIS PROCESS HAS NOT CHANGED FROM PRIOR YEARS. FORM 990, PART V AND PART VII THE FILING ORGANIZATION USES A RELATED ORGANIZATION FOR ITS PAYROLL FUNCTION. ALL W-2S ARE FILED BY THE COMMON PAYMASTER. HOWEVER, AMOUNTS PAID BY THE COMMON PAYMASTER ARE TREATED AS IF PAID DIRECTLY BY THE ORGANIZATION FOR WHICH SERVICES ARE PERFORMED. CAROMONT HEALTH INC 2525 COURT DRIVE GASTONIA NC 28054 581636959 MEDICAL SERVICES NC 501(C)(3) LINE 12B, II N/A 0 CAROMONT HEALTH SERVICES INC 2526 COURT DRIVE GASTONIA NC 28054 561455630 OUTPATIENT SERVICES NC 501(C)(3) LINE 3 CAROMONT HEALTH INC 0 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 7 CAROMONT HEALTH INC 0 CAROMONT MEDICAL GROUP INC 2528 COURT DRIVE GASTONIA NC 28054 561479712 MEDICAL GROUP NC 501(C)(3) LINE 10 CAROMONT HEALTH INC 0 GASTON MEMORIAL HOSPITAL INC 2530 COURT DRIVE GASTONIA NC 28054 560619359 HOSPITAL NC 501(C)(3) LINE 3 CAROMONT HEALTH INC 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1