2023-05-08T09:36:37-05:00 2022-06-30 440160260 FORVIS LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2021-07-01 561455630 CAROMONT HEALTH SERVICES CARO 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 DAVID O'CONNOR EVP, CFO 7048342000 2023-05-08 1 DAVID OCONNOR 999009999 AMY BIBBY P00445891 8282542254 2023-05-08 3 AAL1 IAL1 2021 2023-04-26 12:10:37Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 19175361 0 X WWW.CAROMONT.ORG X 1984 NC TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 3 1 185 0 0 0 0 0 16423888 19135810 0 44 137237 39507 16561125 19175361 0 0 0 0 8308598 9588507 0 0 0 7180146 7933617 15488744 17522124 1072381 1653237 12627199 9483012 981831 734245 11645368 8748767 X TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 0 0 16369835 19135810 SEE SCHEDULE O.CAROMONT HEALTH IS A NOT-FOR-PROFIT HEALTH SYSTEM HEADQUARTERED IN GASTONIA, NC THAT PROVIDES INPATIENT AND OUTPATIENT MEDICAL SERVICES WITHIN FIVE COUNTIES AND TWO STATES. ANCHORED BY THE 435-BED, ACUTE CARE HOSPITAL, CAROMONT REGIONAL MEDICAL CENTER, THE HEALTH SYSTEM EMPLOYS NEARLY 4,5000 HEALTHCARE PROFESSIONALS WITH A MEDICAL STAFF MEMBERSHIP OF MORE THAN 450.CAROMONT HEALTH SERVICES OWNS AND OPERATES CAROMONT SPECIALTY SURGERY, COURTLAND TERRACE AND CAROMONT ENDOSCOPY CENTER.CAROMONT SPECIALTY SURGERY IS A FREE-STANDING AMBULATORY SURGERY CENTER ON THE CAMPUS OF CAROMONT REGIONAL MEDICAL CENTER, WHICH PERFORMS OPHTHALMOLOGY, ENT, COSMETIC AND ORTHOPEDIC SURGICAL PROCEDURES. IN FISCAL YEAR 2022, THE CENTER PERFORMED APPROXIMATELY 3,554 SURGICAL PROCEDURES. COURTLAND TERRACE IS A SKILLED NURSING FACILITY LICENSED FOR 77 SKILLED NURSING BEDS AND 19 ASSISTED LIVING BEDS. SKILLED NURSING SERVICES PROVIDED AT COURTLAND TERRACE INCLUDE SHORT-TERM REHABILITATION, ALZHEIMER'S' SPECIAL CARE AND LONG-TERM CARE. IN FISCAL YEAR 2022, THE NURSING HOME PROVIDED CARE TO AN AVERAGE OF 82 PATIENTS EACH DAY. CAROMONT ENDOSCOPY CENTER IS A FREE-STANDING OUTPATIENT ENDOSCOPY CENTER, LOCATED IN BELMONT AND OPENED IN 2012. CAROMONT ENDOSCOPY CENTER PROVIDES OUTPATIENT ENDOSCOPIC PROCEDURES FOR UPPER ENDOSCOPY AND SCREENING COLONOSCOPY. IN FISCAL YEAR 2022, THE CENTER PERFORMED 5,660 PROCEDURES. 16369835 1 0 0 0 0 0 0 0 0 0 1 0 0 0 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 31 0 1 185 1 0 0 0 0 0 0 0 0 0 0 0 0 X 3 1 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X THE ORGANIZATION 7048342000 2525 COURT DRIVE GASTONIA NC 28054 REV PEARL BURRIS-FLOYD CHAIR 1.00 1.00 X X 0 106553 0 MS JANIE PEAK DIRECTOR 1.00 1.00 X 0 0 0 MR BOB HOVIS DIRECTOR (BEGIN 1/1/22) 1.00 2.00 X 0 19872 0 MR TOM EFIRD DIRECTOR (THROUGH 12/31/21) 1.00 1.00 X 0 0 0 MR K CHRISTOPHER PEEK CEO 1.00 54.00 X 0 1491823 253847 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 54.00 X 0 816772 147842 MS LEIGH HICKMAN VP/CLO/ASST. SEC. 1.00 54.00 X 0 440881 82961 MS LINDA WITCHER ADMINISTRATOR 40.00 X 131264 0 13874 MS SHERRY WEAVER ASSISTANT CLINICAL MANAGER 40.00 X 114734 0 1954 MS ELIZABETH MBIAH LPN 40.00 X 107448 0 15799 MS MELVA RAMIREZ CNA II COURTLAND 40.00 X 105309 0 17553 MS BRIANA PACKER LEAD THERAPIST COURTLAND 40.00 X 102442 0 14057 561197 2875901 547887 7 0 1 0 CROSS COUNTRY STAFFING PO BOX 404682 ATLANTA GA 30384 TEMPORARY STAFFING 824868 1 OUTPATIENT SERVICES 621400 18904280 18904280 PROGRAM SERVICE INVESTMENTS 900099 231530 231530 19135810 44 44 MISCELLANEOUS 900099 38737 38737 CAFETERIA 900099 770 770 39507 19175361 19135810 0 39551 X 7611113 6826730 784383 262505 235452 27053 1175417 1054281 121136 539472 483875 55597 2085147 2063357 21790 160326 119241 41085 524556 495630 28926 42310 37842 4468 1254 1254 1965 1965 1090977 1090977 56078 11677 44401 MEDICAL SUPPLIES 2927408 2927408 BAD DEBT 892587 892587 EQUIPMENT RENTAL & MAIN 119378 119378 MISCELLANEOUS 18794 11400 7394 12837 12837 17522124 16369835 1152289 0 8647 3599 843854 872358 185814 206900 65000 29015075 20673021 9354052 8342054 2169832 58101 12627199 9483012 653514 734621 328317 -376 981831 734245 X 11645368 8748767 11645368 8748767 12627199 9483012 X 1653237 -4549838 X X 0 1 X 1 0 X 18520171 12580296 5939875 2095965 922308 1173657 8121145 6938256 1182889 277794 232161 45633 8342054 ESTIMATED 3RD PARTY SETTLEMENTS -376 -376 X 15921243 0 15921243 3254118 3254118 19175361 16629537 0 16629537 892587 892587 17522124 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, 2022 AND 2021. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 892,587. EQUITY TRANSFER FROM AFFILIATES 2,361,531. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 892,587. 0 1 0 0 0 1 1 0 0 MR K CHRISTOPHER PEEK CEO 0 904884 0 369925 0 217014 0 231203 0 22644 0 1745670 0 147084 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 544529 0 158779 0 113464 0 125198 0 22644 0 964614 0 81550 MS LEIGH HICKMAN VP/CLO/ASST. SEC. 0 340398 0 99649 0 834 0 67628 0 15333 0 523842 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 - $ 104,898 K. CHRISTOPHER PEEK - 215,253 LEIGH HICKMAN - 51,975 PART I, LINE 6 THE EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES IS BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES WHICH INCLUDE A FINANCIAL GOAL ATTRIBUTABLE TO OPERATING MARGIN. THE MANAGER INCENTIVE PLAN IS BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. STEPHEN O'CONNOR FAMILY RELATIONSHIP WITH OFFICER 4660 COMPENSATION FOR EMPLOYEE SERVICES 0 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 CONSISTS OF THREE (3) MEMBERS ALL OF WHOM ARE APPOINTED BY CAROMONT HEALTH, INC. AND AT LEAST TWO (2) OF WHOM MUST ALSO BE MEMBERS OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH. 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, DECISIONS OF THE GOVERNING BODY INCLUDING THE ELECTION AND REMOVAL OF MEMBERS OF THE BOARD OF DIRECTORS MUST BE APPROVED BY THE CORPORATION'S SOLE MEMBER, CAROMONT HEALTH, INC. 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 RESPONSIBILITY 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 RESPONSIBILITY 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, CMO AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY CAROMONT REGIONAL MEDICAL CENTER, A SUBSIDIARY OF CAROMONT HEALTH, INC AND RELATED ORGANIZATION OF CAROMONT HEALTH SERVICES. 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. PURSUANT TO THE COMMITTEE CHARTER FOR THE COMPENSATION COMMITTEE OF THE BOARD, THE BOARD OF DIRECTORS OF THE SUPPORTING ORGANIZATION APPROVES THE EXECUTIVE COMPENSATION PHILOSOPHY, WHICH ESTABLISHES THE PARAMETERS FOR ALL EXECUTIVE COMPENSATION DECISIONS. THE BOARD OF DIRECTORS OF THE SUPPORTING ORGANIZATION DELEGATES ALL COMPENSATION DECISIONS FOR ALL EXECUTIVES TO THE COMPENSATION COMMITTEE, PROVIDED SUCH DECISIONS ARE CONSISTENT WITH THE COMPENSATION PHILOSOPHY. BOARD APPROVAL MUST BE OBTAINED WHEN COMPENSATION DECISIONS DEVIATE FROM THE COMPENSATION PHILOSOPHY. 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. 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 1,156,928. MANAGEMENT AND GENERAL EXPENSES 21,109. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,178,037. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 361,234. MANAGEMENT AND GENERAL EXPENSES 681. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 361,915. OTHER PROFESSIONAL FEES: PROGRAM SERVICE EXPENSES 93,884. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 93,884. SURGERY FEES: PROGRAM SERVICE EXPENSES 440,638. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 440,638. CONSULTING FEES: PROGRAM SERVICE EXPENSES 10,673. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,673. FORM 990, PART XI, LINE 9: EQUITY TRANSFER FROM AFFILIATE -2,361,531. ADJUSTMENT RELATED TO GASB 87 -2,188,307. 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 11B, II N/A 0 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 9 CAROMONT HEALTH INC 0 CAROMONT MEDICAL GROUP INC 2528 COURT DRIVE GASTONIA NC 28054 561479712 MEDICAL GROUP NC 501(C)(3) LINE 9 CAROMONT HEALTH INC 0 HOSPICE OF GASTON COUNTY INC 2529 COURT DRIVE GASTONIA NC 28054 581341530 HOSPICE CARE NC 501(C)(3) LINE 7 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 GASTON COUNTY PO BOX 1578 GASTONIA NC 280531578 566000300 GOVERNMENT ADMINISTRATION NC N/A 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1