2021-05-05T10:37:02-05:00 2020-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2019-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR EVP, CFO 7048342000 2021-05-05 1 AMY BIBBY P00445891 8282542254 2019 2022-09-23 18:48:47Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 2167745 0 X WWW.CAROMONT.ORG X 1985 NC TO ENGAGE AND INSPIRE OUR COMMUNITY TO SUPPORT CAROMONT HEALTH IN PROVIDING COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE 12 8 4 0 0 0 3105603 1293604 0 0 1176103 874141 791 0 4282497 2167745 767013 755358 0 0 198105 248835 0 0 0 139786 697629 1104904 1701822 3177593 465923 27053439 27264388 33678 25801 27019761 27238587 X TO ENGAGE AND INSPIRE OUR COMMUNITY TO SUPPORT CAROMONT HEALTH IN PROVIDING COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE 0 0 1652361 755358 SEE SCHEDULE OTHE CAROMONT HEALTH FOUNDATION RAISES MONEY FOR PROGRAMS, INITIATIVES AND CAPITAL PROJECTS CENTERED ON MEETING THE HEALTH-RELATED NEEDS AND IMPROVING THE QUALITY OF LIFE IN OUR COMMUNITY. IN ADDITION, THE CAROMONT HEALTH FOUNDATION OPERATES A GRANTS PROGRAM BENEFITING BOTH INTERNAL DEPARTMENTS AND LOCAL NON-PROFIT ORGANIZATIONS, AS WELL AS MANAGING SEVEN ACADEMIC SCHOLARSHIP FUNDS. ONE-HUNDRED PERCENT OF CONTRIBUTIONS GO DIRECTLY TO SUPPORT FOUNDATION PROGRAMS, OPERATING COSTS ARE GENEROUSLY COVERED BY CAROMONT HEALTH. 1652361 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 4 0 1 4 1 0 0 0 0 0 0 0 0 0 0 0 0 X 12 8 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 JANIE PARKS PEAK CHAIR 1.00 X X 0 0 0 MR BILL GROSS VICE CHAIR 1.00 X X 0 0 0 MRS SHELLEY FRYE COLLINS SECRETARY 1.00 X X 0 0 0 MR TIMOTHY PASCHALL FORMER VICE CHAIR 1.00 X X 0 0 0 MR JOSEPH B DAVIS JR FORMER TREASURER 1.00 2.00 X X 0 0 0 MR JAKE GRAY III DIRECTOR 1.00 1.00 X 0 0 0 MRS JENNIFER THOMAS STULTZ DIRECTOR 1.00 1.00 X 0 0 0 RAMADA S SMITH DIRECTOR 1.00 40.00 X 0 452823 40201 ASHLEY LONG DIRECTOR 1.00 45.00 X 0 193091 18053 MR REEVES MCGLOHON DIRECTOR 1.00 X 0 0 0 MR BOB HOVIS DIRECTOR 1.00 2.00 X 0 18699 0 JASMINE S STONE DIRECTOR 1.00 40.00 X 0 95527 17774 MS LENORA CRABTREE DIRECTOR 1.00 X 0 0 0 MS MARTHA BURRIS DIRECTOR 1.00 X 0 0 0 MS MARY BARGER DIRECTOR 1.00 X 0 0 0 AMI PARKER DIRECTOR 1.00 1.00 X 0 0 0 K CHRISTOPHER PEEK CEO 1.00 54.00 X 0 858440 194798 DAVID M O'CONNOR EVP/ASST. TREASURER 1.00 54.00 X 0 643022 127057 LEIGH HICKMAN CLO/ASST. SEC. 1.00 54.00 X 0 268134 26264 KATHRYN C WAYNE DIRECTOR OF DEVELOPMENT 40.00 X 111217 0 27547 111217 2529736 451694 1 0 1 0 0 534478 759126 1293604 510942 510942 363199 0 363199 363199 363199 2167745 0 0 874141 X 614607 614607 140751 140751 193750 193750 8541 8541 32918 32918 13626 13626 49461 49461 237473 237473 410695 410695 1701822 1652361 49461 0 183832 734154 1838521 981295 41802 37232 20194845 19695136 4794439 5816571 27053439 27264388 33678 25801 33678 25801 X 20533529 20485181 6486232 6753406 27019761 27238587 27053439 27264388 465923 -247097 0 X X 0 1 X 1 0 X 725359 1047104 578246 3105598 1293604 6749911 725359 1047104 578246 3105598 1293604 6749911 18988 6730923 469723 338222 436381 593590 510942 2348858 791 791 9099560 0.73970 0.73920 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3930785 2810378 147349 135107 6753405 3835087 74346 172984 151632 3835087 3669926 45458 238927 119224 3835087 3295330 117530 357695 100629 3669926 3261864 179889 -87779 58644 3295330 1.00000 0 0 0 MACKIE SCHOLARSHIP FUND 5108 SHOVELIN SCHOLARSHIP FUND 3082660 HUDSON NURSING SCHOLARSHIP FUND 333347 BUCCI SCHOLARSHIP FUND 5872 WOMEN OPTIMIZE WELLNESS FUND 263822 EMPLOYEE SCHOLARSHIP FUND 60749 DAMORE SCHOLARSHIP FUND 35518 ONCOLOGY SCHOLARSHIP FUND 93612 SELF SCHOLARSHIP 27630 TAVR HYBRID OR FUND 1653567 COVID19 254686 5816571 X 838589 -247097 -247097 1085686 49461 1032598 1082059 2167745 619763 0 619763 49461 1032598 1082059 1701822 PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS. 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, 2020 AND 2019. PART XI, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 355,029. GRANTS IN REVENUES 677,569. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 355,029. GRANTS IN REVENUES 677,569. 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 508807 COMMUNITY ASSISTANCE GASTON COLLEGE FOUNDATION 201 HIGHWAY 321 SOUTH DALLAS NC 28034 237079454 501(C)(3) 30800 COMMUNITY ASSISTANCE CANCER SERVICES OF GASTON COUNTY 306 S COLUMBIA STREET GASTONIA NC 28054 561164253 501(C)(3) 20000 COMMUNITY ASSISTANCE OLIVE BRANCH MINISTRY 1223 1ST AVE NW HICKORY NC 28601 474497173 501(C)(3) 20000 OPERATIONAL SUPPORT BACKPACK WEEKEND FOOD PROGRAM PO BOX 551030 GASTONIA NC 28055 471591744 501(C)(3) 20000 OPERATIONAL SUPPORT HEART SOCIETY OF GC 1201 EAST GARRISON BLVD GASTONIA NC 28054 561330921 501(C)(3) 10000 OPERATIONAL SUPPORT NORTH CHARLOTTE ROWING 3138 CHANNELVIEW LANDING BELMONT NC 28012 464057146 501(C)(3) 5000 OPERATIONAL SUPPORT 7 SCHOLARSHIPS 46 140751 SHOVELIN, BUCCI, HUDSON AND MACKIE NURSING SCHOLARSHIPS PART I, LINE 2: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED. 0 1 0 0 0 0 1 0 0 RAMADA S SMITH DIRECTOR 0 439938 0 10000 0 2885 0 19617 0 20584 0 493024 0 0 ASHLEY LONG DIRECTOR 0 171067 0 21876 0 148 0 7794 0 10259 0 211144 0 0 K CHRISTOPHER PEEK CEO 0 657863 0 192930 0 7647 0 174008 0 20790 0 1053238 0 0 DAVID M O'CONNOR EVP/ASST. TREASURER 0 449942 0 101741 0 91339 0 106289 0 20768 0 770079 0 75414 LEIGH HICKMAN CLO/ASST. SEC. 0 238796 0 28618 0 720 0 12366 0 13898 0 294398 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 HE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 86,689 K. CHRISTOPHER PEEK - 158,940 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. X 2 103172 FMV 0 0 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 MEMBERS OF THE BOARD OF DIRECTOR ARE ELECTED AT WILL BY ITS SOLE MEMBER OF THE CORPORATION ACTING THROUGH ITS BOARD OF DIRECTORS AT ITS ANNUAL MEETING FROM A SLATE OF NOMINEES PROVIDED TO THE CAROMONT HEALTH, INC. BOARD BY THE FOUNDATION. ALL DIRECTORS ARE SUBJECT TO REMOVAL BY THE CAROMONT HEALTH BOARD OF DIRECTORS. 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 OR 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. 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. 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 205,666. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 205,666. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 24,410. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 24,410. ALLOCATION FEES: PROGRAM SERVICE EXPENSES 7,397. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 7,397. PART XII, LINE 2C THE PROCESS FOR THIS HAS NOT CHANGED FROM THE PRIOR YEAR. 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 CAROMONT HEALTH SERVICES INC 2526 COURT DRIVE GASTONIA NC 28054 561455630 OUTPATIENT SERVICES NC 501(C)(3) LINE 3 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 0 1 1 0 0 0 0 0 1 0 0 1 0 1 0 1 1 1 1