2018-05-07T15:37:00-05:00 2017-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2016-07-01 560619359 GASTON MEMORIAL HOSPITAL INC GAST 7048342000 2525 Court Drive GASTONIA NC 28054 signing officer EVP, CFO 7048342000 2018-05-07 1 Amy Bibby P00445891 8282542254 2016 2022-09-23 18:48:47Z CAROMONT REGIONAL MEDICAL CTR DAVID O'CONNOR 2525 Court Drive GASTONIA NC 28054 484379001 0 X WWW.CAROMONT.ORG X 1945 NC To provide exceptional health care to the communities we serve. 13 9 3580 207 396371 49707 425622 484202 460065910 479845593 331205 30286 4437368 3487850 465260105 483847931 1196625 913014 0 0 183770425 199154895 0 0 0 250673308 250531058 435640358 450598967 29619747 33248964 434982179 425694209 330366723 315375438 104615456 110318771 To provide exceptional health care to the communities we serve. 0 0 420140294 913014 479993132 CaroMont's philosophy of care plays three distinct roles. It's a health system that strategically invests in the future of healthcare, from research to education. It's an active community partner, driving programs that encourage healthy choices even before patients walk through our doors. It's a dynamic organization on a path of continuous improvement, delivering both world-class medicine and compassionate, personal care. The fiscal year ending June 30, 2017 saw CaroMont Health living its vision to be a nationally recognized leader and valued community partner. The complete 2017 Community Report can be found at www.caromonthealth.org 420140294 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 782 0 1 3580 1 1 1 0 0 0 0 0 0 0 0 0 X 13 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 K Christopher Peek CHAIR (CEO/PRES. BEG. MAY '17) 45.00 10.00 X X 0 0 0 MR Barry M Pomeroy SEC. THRU. MAY'17/CHAIR BEG.MAY'17 1.00 1.00 X X 0 0 0 MR DONNIE LOFTIS VICE CHAIR 1.00 2.00 X X 851 0 0 MR JAMES R Beam TREASURER 1.00 1.00 X X 0 0 0 MR MICHAEL PRICE Director (RESIGNED 5/17) 1.00 1.00 X 0 0 0 Ms Annette Carter Director 1.00 1.00 X 0 0 0 MR JOSEPH B DAVIS JR Director 1.00 2.00 X 0 0 0 MR TIMOTHY E GAUSE Director 1.00 2.00 X 600 0 0 MR WILLIAM ANTHONY Director 1.00 1.00 X 0 0 0 MR W MICHAEL DICKSON Director 1.00 2.00 X 0 0 0 Dr Charles Meakin III Director 1.00 3.00 X 0 0 0 Ms Pearl Burris Floyd Director 1.00 2.00 X 0 0 0 Mr J Christopher Howell Director (RESIGNED 10/16) 1.00 1.00 X 0 0 0 Dr GE Ward Adcock III PAST Chief-of-Staff 1.00 1.00 X 0 312229 31458 MR TOM KEIGHER DIRector 1.00 2.00 X 0 21639 0 DR PATRICK RUSSO CHIEF-OF-STAFF 1.00 2.00 X 0 618820 37077 MR DAVID PAYSEUR DIRECTOR 1.00 1.00 X 0 0 0 David O'Connor EVP/CFO/Asst. Treasurer 45.00 10.00 X 565374 0 108958 Maria Long EVP CLO/AS (THRU. APRIL '17) 45.00 10.00 X 470930 0 81698 Doug Luckett CEO/PRESIDENT (THRU. MAR '17) 45.00 10.00 X 942496 0 185029 Todd Davis md EVP/CMO (INTERIM CEO/PRES.MAR'17-MAY'17) 45.00 10.00 X 465740 0 100433 LEIGH HICKMAN CLO/AS (BEG. MAY '17) 45.00 10.00 X 195813 0 20451 Kathleen K Besson EVP/COO 40.00 X 484475 0 104409 ANDREA K SERRA VP COMMUNITY CARE 40.00 X 331780 0 62022 Elizabeth McCraw VP Human Resources 40.00 X 326971 0 70836 MICHAEL R JOHNSON VP CIO 40.00 X 377716 0 40534 RICHARD C BLACKBURN VP Support Services 40.00 X 295509 0 41876 MOHAMADSALIM M SAIYED CHIEF MEDICAL INFO OFFICER 40.00 X 420544 0 23039 WAYNE F SHOVELIN FORMER CEO 0.00 X 171650 0 0 5050449 952688 907820 144 1 1 0 ARAMARK CT 12483 COLLECTION CENTER DRIVE CHICAGO IL 60693 BIOMED EQUIPMENT SERVICES 4509076 BRASFIELD AND GORRIE LLC PO BOX 11407 BIRMINGHAM AL 352460351 CONSTRUCTION MANAGEMENT 4385048 EPIC SYSTEMS CORPORATION PO BOX 88314 MILWAUKEE WI 532880314 SOFTWARE SYSTEMS 3836401 MORRISONS MANAGEMENT SPECIALISTS PO BOX 102289 ATLANTA GA 30368 CAFETERIA MANAGEMENT 3598546 EDIFICE INC PO BOX 36349 CHARLOTTE NC 28236 CONTRACTOR 2073400 75 476694 7508 484202 PATIENT SERVICES REVENUE 621500 476357283 476357283 ANCILLARY REVENUE 621500 3488310 3488310 479845593 224306 68033 156273 414 0 194434 414 -194434 -194020 -194020 376996 336636 40360 40360 CAFETERIA & VENDING INCOME 722210 2159782 2159782 MISCELLANEOUS 900099 636585 636585 OUTSIDE LAB SERVICES 621500 296717 296717 354406 147539 31621 175246 3447490 483847931 479993132 396371 2974226 890175 890175 22839 22839 2354485 470897 1883588 73541 73541 152357575 136104047 16253528 9046971 7986886 1060085 24375078 21518910 2856168 10947245 9664494 1282751 56256 56256 316231 316231 152000 152000 34122 34122 9 9 39715655 36512993 3202662 715101 136628 578473 4497330 2637878 1859452 1286367 1286367 10469553 10469553 180656 87395 93261 693988 267075 426913 7809416 7809416 36551033 36551033 1746530 1746530 UBI TAX 36249 36249 Supplies 78247815 78247815 Bad Debt 56708778 56708778 NC Medicaid Assessment 4536703 4536703 6777266 6354085 423181 450598967 420140294 30458673 0 34281 85308 58169462 59370305 7784308 8636439 7985020 7359203 620606879 350139766 274951499 270467113 9539 10012 4919920 6309913 2311646 2311646 78816504 71144270 434982179 425694209 41809328 44093209 183724702 177366739 104832693 93915490 330366723 315375438 X 104605917 107430448 9539 2888323 104615456 110318771 434982179 425694209 X 33248964 451 -27546100 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 0 0 0 1 55888 0 1 53388 109276 0 Part II-B, Line 1: Annual dues were paid to the North Carolina Hospital Association and the American Hospital Association, of which $21,388 was determined to be expenditures used in lobbying activities by these organizations. An additional $32,000 in fees were paid for lobbying expenditures. Lobbying registration is in the name of CaroMont Health, Inc. Lobbying expenditures are reporting on the Gaston Memorial Hospital, Inc Form 990. 9521 1013 693 9841 10002 -278 203 9521 10186 630 405 1219 10002 9488 1251 553 10186 8149 1500 962 1123 9488 1.00000 0 0 4513806 4513806 309348348 152673140 156675208 9951749 7372756 2578993 273237180 188464611 84772569 23555796 1629259 21926537 270467113 NET PENSION ASSET & PENSION DEFERRAL 15845733 DEFERRED FINANCING COSTS 1475892 OTHER RECEIVABLES 3240641 457B PLAN ASSETS 10216591 DEFERRED CHARGE - INTEREST RATE SWAP 23293578 457F PLAN ASSETS 1121835 PREPAID COUNTY LEASE 15950000 71144270 457B PLAN LIABILITY 10216591 ESTIMATED 3RD PARTY SETTLEMENTS 54387023 INTEREST RATE SWAP LIABILITY 23293578 457F PLAN LIABILITY 1121835 PENSION DEFERRED INFLOW 4896463 93915490 X 399514334 451 451 399513883 9 84334039 84334048 483847931 393866204 336636 336636 393529568 9 57069390 57069399 450598967 Part V, Line 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR ONCOLOGY MEDICATIONS FOR INDIGENT PATIENTS. 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, 2017 and 2016. Part XI, Line 4b - Other Adjustments: BAD DEBT INTERCOMPANY Transfer FROM Affiliate 26,552,880. CHANGE IN VALUE OF INTEREST RATE SWAP 993,220. BAD DEBT 56,708,778. EXPENSES IN REVENUES 933. AUXILIARY REVENUES 414,864. COSTS OF GOODS SOLD -336,636. Part XII, Line 2d - Other Adjustments: COSTS OF GOODS SOLD 336,636. Part XII, Line 4b - Other Adjustments: BAD DEBT 56,708,778. EXPENSES IN REVENUES 933. AUXILIARY EXPENSES 359,679. 1 1 1 X 1 1 1 0 1 1 9443177 9443177 0.02400 66836427 52614230 14222197 0.03610 76279604 52614230 23665374 0.06010 2356119 11360 2344759 0.00600 2302565 247627 2054938 0.00520 758360 191321 567039 0.00140 1322543 1322543 0.00340 6739587 450308 6289279 0.01600 83019191 53064538 29954653 0.07610 2266417 2266417 0.00580 2266417 2266417 0.00580 56708778 5751299 99336520 114283576 -14947056 X 1 1 1 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 X X X 4 Diagnostic Imaging Centers and 6 OP Serivce Center CAROMONT REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X 15 1 0 1 1 X www.caromonthealth.org X www.gastongov.com/departments/health-and-human-services X X 1 15 1 http://www.caromonthealth.org/documents/For-Healthcare-Professionals/Gaston 0 1 X 200.000000000000 300.000000000000 X X X X 1 1 X X X X 1 X SEE DISCLOSURE X SEE DISCLOSURE X SEE DISCLOSURE X X X X X X X 1 0 X X X X X 1 X 0 0 CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 5: Gaston County Community Health Assessment was conducted by the following partners: The Gaston County Department of Health and Human Services, Gaston Together, United Way of Gaston County and CaroMont Health. Data in this assessment is derived from three sources: 1) Gaston County Health Data, 2) County Health Rankings and 3) Gaston County Quality of Life Survey, 2015. The Quality of Life Survey was conducted to assess the opinions of Gaston County residents regarding their personal health. To get a comprehensive picture of these opinions, four diverse groups were interviewed: 1) community leaders, 2) community residents, 3) high school juniors and 4) persons living in low-income areas throughout the county. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 6b: The Hospital conducted their CHNA with the following organizations: Gaston County Health Department, Gaston Together, and United Way of Gaston County. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 7d: Partnering agencies presented the CHNA at workshops, meeting and on agency websites to encourage community stakeholders to use them to enhance the wellbeing of Gaston County and its residents. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 11: The CHNA was presented to the CaroMont Health Board on 5/23/16 which led into a discussion resulting in the following priorities being approved: 1) Increase mental health services provided by LCSWs in CaroMont Medical Group practices and 2) Standardization of chronic opioid management in CaroMont Medical Group. These priorities are a part of CaroMont Health's Corporate Goals. Identified needs that are not being addressed are: 1) illegal drug abuse, 2) teen pregnancy and 3) alcohol abuse. These can be better addressed by other local organizations. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 13b: Regardless of income, assets are also used to determine if a patient qualifies for charity. Below is the verbiage from this policy: Exempt AssetsThe primary residence on up to one acre of land, one automobile for each working aged adult, and other assets, including but not limited to, retirement funds, investments and other financial assets, cash value of life insurance policies, and equity in property or real assets, totaling up to $25,000 are also exempt from consideration as assets in determining charity care eligibility. Annual income from property of real assets will be deducted from the amount of equity in the asset when calculating the exemption. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 15e: CaroMont Health has a team dedicated to educating and/or assisting patients with other state or government agencies that may be a source of assistance. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 16j: Plain language brochures at registration sites. Proactively communicating verbally or in writing to scheduled patients prior to service. Communicating in-house, during service, or after service to those most likely to require financial assistance. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 18e: Collection actions are taken after reasonable efforts have been made to determine patient's eligibility for assistance. CAROMONT REGIONAL MEDICAL CENTER Part V, Section B, Line 20e: Plain language brochures at registration sites. Proactively communicating verbally or in writing to scheduled patient prior to service. Communicating in-house, during service, or after service to those most likely to require financial assistance. Part I, Line 3c: Free care is provided to patients with a FPG of 200% or less. All other patients receive an insurance discount based on their individual insurance plan agreement or an uninsured discount for the self pay. Uninsured discounts are comparable to our insurance discounts.Regardless of income, assets are also used to determine if a patient qualifies for Charity. Below is the verbiage from this policy:Exempt AssetsTHE PRIMARY RESIDENCE ON UP TO ONE ACRE OF LAND, ONE AUTOMOBILE FOR EACH WORKING AGED ADULT, AND OTHER ASSETS up to $25,000 INCLUDING BUT NOT LIMITED TO, RETIREMENT FUNDS, INVESTMENTS AND OTHER FINANCIAL ASSETS, CASH VALUE OF LIFE INSURANCE POLICIES, AND EQUITY IN PROPERTY OR REAL ASSETS ARE ALSO EXEMPT FROM CONSIDERATION AS ASSETS IN DETERMINING CHARITY CARE ELIGIBILITY. ANNUAL INCOME FROM PROPERTY OF REAL ASSETS WILL be deducted from the amount of equity in the asset when calculating the exemption.Part 1, Line 6A:COMMUNITY BENEFIT REPORT: The organization's community benefit report made available to the public contains community benefits for all related organizations to the hospital. Part I, Line 7: The costing methodology used is a cost accounting system. All patient segments are included. This system assigns direct costs to supplies, procedures, routine and specialty room rates based on the department of origination. Fixed costs are allocated based on statistical basis. These costs are then aggregated at the patient level and tabulated by payor type. No cost to charge ratios were used in the calculations. Part I, Ln 7 Col(f): 56,708,778 Bad Debt Expense removed from total expenses prior to calculating Percent of Total Expense. PART I, LINE 7H: RESEARCH ACTIVITIES: CaroMont Health is involved in approximately 75 research studies, approximately forty percent of which are Clinical Trials Cooperative Group Program studies sponsored by the National Cancer Institute (NCI). CaroMont Health also participates in drug and device studies sponsored by various pharmaceutical, biotechnology, and device companies, as well as unfunded nursing and pharmacy research studies. Part II, Community Building Activities: Workforce Development - CaroMont Health's recruitment of employees, physicians and advanced care practitioners into the five counties the system serves is driven by the changing landscape of health care reform. The system recruits based on a Medical Staff Development Plan that identifies community health care needs for the next five years. The system's goal is to be pro-active and anticipatory so that the health care needs of the community are met in a quality-driven and convenient manner. Part III, Line 2: Charges for services provided in the emergency department are evaluated for charity based on means testing. Charges for services provided elsewhere in the hospital are evaluated for charity based on means testing and/or applications filed by the patients. If no means testing is done and no application is filed, the unpaid amount is written-off to bad debt. The % of patients qualifying for charity in the Emergency Department was applied to the remainder of the hospital to determine the % of bad debt patients who could have been charity. PART III, LINE 2: Charges written off to bad debt were tabulated at the patient level and are reported at the amount charged to patients. Accounts are reserved as bad debt based on an accounts receivable aging methodology. When accounts are sent to a collection agency, they are written off the accounts receivable system. Any subsequent collections on the accounts are posted as recoveries and reduce the expense. All uninsured patients receive a discount on their bill, which is recorded as a contractual adjustment. The amount of the uninsured discounts are excluded from bad debt expense. Part III, LINE 3: Charges for services provided in the emergency department are evaluated for charity based on means testing. Charges for services provided elsewhere in the hospital are evaluated for charity based on means testing and/or applications filed by the patients. If no means testing is done and no application is filed, the unpaid amount is written-off to bad debt. The % of patients qualifying for charity in the Emergency Department was applied to the remainder of the hospital to determine the % of bad debt patients who could have been charity. Part III, LINE 4: The organization's financial statements do not contain a footnote on bad debt expense. Bad debt expense is reported as a deduction from patient revenue. Part III, Line 8: The Medicare cost report standard costing methodology was followed when filing the cost report. This is a step down methodology that applies the average patient cost to Medicare patients. The cost report does not allow hospitals to report all operating costs. Because of these two issues, the Medicare cost report methodology understates the true cost of treating Medicare patients. Using total costs from Medicare patients, the hospital had an acutal Medicare shortfall of $21.0 million. Part III, Line 9b: The policy contains provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. Below is verbiage from the charity policy:CAROMONT REGIONAL MEDICAL CENTER offers medical services free or at a reduced rate through the Charity Care Program. Determination of full or partial Charity Care will be based on the patient's income, family size, and assets. Potential eligibility exists only after reimbursement efforts from all other third party resources, federal, state, and local assistance programs have been exhausted. Part VI, Line 2: CaroMont Health establishes community priorities through a number of mechanisms:1. Leadership opinions are sought to help identify needed services in the community via partnerships with the Gaston County Department of Health & Human Services, local non-profit organizations focused on health improvement in our communities and other health-focused entities. CaroMont Health also works with community agencies to conduct community needs assessments and quality of life surveys every two to three years. 2. Patient satisfaction data is analyzed to determine where and/or how services need to be improved.3. Service area data (vital statistics, demographics and utilization) are analyzed for trends. This information is coordinated with public health data to determine voids and service area health problems.4. Findings from community surveys/reports published by other organizations (United Way, Chamber of Commerce, Partnership for Children, Gaston County Government, etc.) are gathered and reviewed for pertinence to community health problems.5. Board members, senior leadership, and department directors are involved in numerous organizations in the community. Through this network of relationships, further information about the community and the needs of area residents and organizations are used in the development of programs and services available though CaroMont Health. Part VI, Line 3: The organization informs and educates the patients about their eligibility for assistance in several ways. A Charity and financial summary is on our website, and brochures are distributed in the Emergency Room and all other registration sites. Specifically trained staff (Financial Counselors and Benefit Eligibility Specialists) proactively make contact with patients prior to, at time of service, and/or after discharge to discuss eligibility for Medicaid and other insurance benefits and offer assistance with the applications. The communication is attempted as soon as possible. Written communication is made prior to collection agency placement. Part VI, Line 4: Gaston County, located in the Piedmont Region of North Carolina, is the organization's primary market. Lincoln, Cleveland and York County, as well as the northwest portion of Mecklenburg County, make up the health system's secondary market. According to the U.S. Census Bureau, Gaston County had an estimated population of 216,965, a median household income of $42,429 (2011-2015) and 17.3% of persons in poverty. The ethic/racial demographics state that 79.2% of the population identify themselves as White, 16.7% as Black or African American, 6.8% as Hispanic and 1.5% as Asian. Part VI, Line 5: Community HealthOur community health initiatives are focused primarily on disease prevention and better management of chronic illnesses. That includes working with local employers on innovative programs and collaborating with our health care neighbors, managing illness within our own workforce and heavily focusing on successful care coordination for patients with chronic disease. Additionally, CaroMont provides more thousands of dollars annually in sponsorship and grant support for local non-profits, community programs and services, and other community initiatives aimed at improving the health of our community. Through innovation and a focus on community wellness, CaroMont Health is determined to make positive impact on health and wellness of the populations we serve. Patient Centered Medical HomeThe Patient-Centered Medical Home is a health care setting that facilitates partnerships between patients and their personal physicians. The program provides medical practices with information about organizing patient-centered care, working in teams, and coordinating and tracking during the continuum of care. Currently, all Primary Care Practices in our system are recognized as Level 3 Patient-Centered Medical Homes by the National Committee of Quality Assurance (NCQA) - the highest recognition a clinic can obtain.Accountable Care OrganizationThe Institute for Healthcare Improvement has established a trio of objectives called the Triple Aim, which CaroMont Health has adopted:1 Improve the health of the population2 Enhance the patient experience (quality, access, reliability)3 Control costsThese three objectives are all critical components in being what is known in the industry as an Accountable Care Organization (ACO). In our steps toward becoming an ACO, CaroMont Health has executed changes that have lead, and will continue to lead, to better coordinated care with better outcomes at lower costs for patients. We also embrace the "medical home" concept, which is a national initiative designed to improve health care quality. Medical homes are patient centered, team-based approaches to care that have been shown to reduce hospital admissions and decrease costs. During fiscal year 2016 CaroMont's Medicare Shared Savings Program successfully reported shared savings while providing excellent care for the more than 10,000 beneficiaries in our area. Part VI, Line 6: CaroMont Regional Medical Center is a 435-bed acute care hospital associated with CaroMont Health, a regional, independent, not-for-profit health care system located in Gastonia, NC. The system is also comprised of Courtland Terrace, a 96-bed skilled nursing facility; Gaston Hospice, which includes the 19-bed Robin Johnson House inpatient facility; and CaroMont Medical Group, a network of 42 primary and specialty physician offices. CaroMont Health's vision is to be a nationally recognized leader and valued partner in promoting individual health and vibrant communities.CaroMont Regional Medical Center has 4 off-site imaging locations, a same-day surgery center, and 1 off-site emergency department. CaroMont Health also has a free-standing endoscopy center, 1 ambulatory surgery center, and 1 occupational medicine clinic. Part VI, Line 7, Reports Filed With States NC 1 Gaston Family Health Services 991 West Hudson Boulevard Gastonia NC 28052 581958398 501(c)(3) 307992 Federally qualified Health Department offering medical care to low income residents. GASTON COUNTY 128 WEST MAIN AVE GASTONIA NC 28052 566000300 GOVERNMENTAL 439045 Community Assistance Gaston Regional Chamber 601 W Franklin Blvd Gastonia NC 28053 560232990 501(c)(6) 14000 Community Assistance Gaston Together PO Box 817 Gastonia NC 28053 562048064 501(c)(3) 26500 Community Assistance GASTON COUNTY FAMILY YMCA 201 SOUTH CLAY STREET GAStonia NC 28052 560655420 501(c)(3) 140500 Community Assistance Community Foundation 1201 E Garrison Blvd Gastonia NC 28052 581340834 501(c)(3) 20000 Community Assistance Montcross Area Chamber of Commerce PO Box 368 Belmont NC 28012 560710166 501(c)(6) 12500 Community Assistance Gastonia Grizzlies PO Box 177 Gastonia NC 28053 421554288 n/a 36500 Community Assistance Holy Angels Foundation 660 Wilkinson Blvd Belmont NC 28012 561762654 501(c)(3) 16450 Community Assistance McAdenville Foundation PO Box 1939 McAdenville NC 28101 560623961 501(c)(3) 10000 Community Assistance GASTON COUNTY SCHOOLS PO BOX 1397 Gastonia NC 280531397 566001032 GOVERNMENTAL 61411 Community Assistance UNITED WAY OF GASTON COUNTY 200 EAST FRANKLIN BLVD GAStonia NC 28052 560653356 501(c)(3) 12000 Community Assistance GIRLS ON THE RUN 190 S OAKLAND STREET GAStonia NC 28052 474179257 501(c)(3) 10000 Community Assistance GREATER GASTON DEVELOPMENT CORPORATION 620 NORTH MAIN STREET BELMONT NC 28012 471726248 501(c)(3) 10000 fmv Nutritional supplements Community Assistance MOUNT HOLLY FARMERS MARKET PO BOX 352 MT HOLLY NC 28120 260464156 501(c)(3) 6000 Community Assistance GASTONIA EAST ROTARY CLUB 145 SOUTH MARIETTA STREET GASTonia NC 28052 237096884 501(c)(3) 8000 Community Assistance Daniel Stowe Botanical Garden 6500 S New Hope Rd Belmont NC 28012 208362933 501(c)(3) 30500 Community Assistance THE GASTON GAZETTE 1893 REMOUNT RD GASTOnia NC 28054 472464986 501(c)(6) 8000 Community Assistance FAMILY CHRISTIAN CENTER PO BOX 12528 Gastonia NC 28052 561749935 501(c)(3) 7000 Community Assistance HEART SOCIETY OF GASTON CTY 1201 EAST GARRISON BLVD Gastonia NC 28054 561330921 501(c)(3) 6000 Community Assistance BACKPACK WEEKEND PO BOX 551030 GAStonia NC 28055 471591744 501(c)(3) 5000 Community Assistance GASTON RESIDENTIAL 905 A NORTH NEW HOPE ROAD GAStonia NC 28054 510138261 501(c)(3) 5000 Community Assistance NC HOSPITAL FOUNDATION PO BOX 4449 CARY NC 275194449 560641290 501(c)(3) 5000 fmv Misc Med Equipment Community Assistance SHELTER OF GASTON COUNTY 330 NORTH MARIETTA STREET GAStonia NC 28052 566000300 GOVERNMENTAL 5000 Community Assistance 20 4 AUXILIARY SCHOLARSHIPS 7 9698 ONCOLOGY PHARMACY ASSISTANCE 6 693 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. Schedule I, Part III The purpose of the Gertrude Clinton Health Careers Scholarship is to encourage medical and health-related professionals in the field of human services to practice their specialties at CaroMont Regional Medical Center or in Gaston County. X X 0 0 X X X X X 1 1 0 0 0 1 1 0 0 Dr GE Ward Adcock III PAST Chief-of-Staff 0 191508 0 119424 0 1297 0 14143 0 17315 0 343687 0 0 DR PATRICK RUSSO CHIEF-OF-STAFF 0 569318 0 47387 0 2115 19402 0 17675 0 37077 618820 0 0 David O'Connor EVP/CFO/Asst. Treasurer 387072 0 96743 0 81559 0 91314 0 17644 0 674332 0 77497 0 Maria Long EVP CLO/AS (THRU. APRIL '17) 327957 0 79402 0 63571 0 80385 0 1313 0 552628 0 63064 0 Doug Luckett CEO/PRESIDENT (THRU. MAR '17) 618606 0 202993 0 120897 0 167333 0 17696 0 1127525 0 119305 0 Todd Davis md EVP/CMO (INTERIM CEO/PRES.MAR'17-MAY 337568 0 79573 0 48599 0 82815 0 17618 0 566173 0 47780 0 LEIGH HICKMAN CLO/AS (BEG. MAY '17) 173521 0 21634 0 658 0 8690 0 11761 0 216264 0 0 0 Kathleen K Besson EVP/COO 345017 0 85867 0 53591 0 86788 0 17621 0 588884 0 49906 0 ANDREA K SERRA VP COMMUNITY CARE 238381 0 57856 0 35543 0 53316 0 8706 0 393802 0 34450 0 Elizabeth McCraw VP Human Resources 232234 0 59225 0 35512 0 53391 0 17445 0 397807 0 35168 0 MICHAEL R JOHNSON VP CIO 263882 0 107971 0 5863 0 23009 0 17525 0 418250 0 0 0 RICHARD C BLACKBURN VP Support Services 209823 0 52685 0 33001 0 41876 0 0 0 337385 0 31683 0 MOHAMADSALIM M SAIYED CHIEF MEDICAL INFO OFFICER 331788 0 87369 0 1387 0 14430 0 8609 0 443583 0 0 0 WAYNE F SHOVELIN FORMER CEO 0 0 0 0 171650 0 0 0 0 0 171650 0 0 0 Part I, Line 1a THE ORGANIZATION HAS A POLICY TO ADDRESS WHEN SPOUSAL TRAVEL IS PERMITTED AND PAYS CLUB DUES FOR THE EXECUTIVE FOR BUSINESS PURPOSES AS PART OF THE EMPLOYMENT CONTRACT. Part I, Lines 4a-b During the year the organization paid severance payments to the Former Officer, Key Employee, and Highly Compensated Employee identified below: Wayne F. Shovelin, Former Officer $171,650 The following individuals received deferred compensation allocations from the filing organization from a Supplemental Executive Retirement Plan (SERP): David O'Connor - $ 75,414 Maria Long - 63,307 Doug Luckett - 151,347 Andrea K. Serra - 36,265 Kathleen K. Besson - 67,556 Elizabeth McCraw - 36,428 Todd Davis, MD - 66,915 Richard C. Blackburn - 32,783 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. CERTAIN CAROMONT MEDICAL GROUP, INC. PHYSICIAN'S COMPENSATION PACKAGES ARE BASED ON THE INDIVIDUAL PHYSICIANS NET RESULTS FROM OPERATIONS AS CALCULATED BASED SOLELY ON HIS/HER NET CHARGES LESS HIS/HER ALLOCABLE SHARE OF CLINIC OVERHEAD COSTS. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HVF7 2003-01-23 120000000 SEE PART VI 0 0 0 B NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HG64 2008-01-31 118400000 SEE PART VI 0 0 0 A 1300000 123594002 5150936 1256069 3386000 91583288 22217709 2005 0 1 1 1 B 57080000 118650022 610174 917471 1553718 28952424 86616044 2009 1 0 1 1 A 0 0 1 1 1 1 0.00140 0.00000 0.00140 0 1 0.00110 0 1 B 0 0 1 1 1 1 0.00010 0.00000 0.00010 0 1 0.00040 0 1 A 0 0 0 1 1 1 MERRILL LYNCH CAPITAL SERVICES 31.600000000000 1 0 0 0 1 B 0 0 1 1 0 1 MERRILL LYNCH DERIVATIVE PRODUCTS 21.000000000000 1 0 0 0 1 A 1 B 1 Date Rebate Computation Performed Issuer Name: NORTH CAROLINA MEDICAL CARE COMMISSION Date the Rebate Computation was Performed: 03/18/2013 Issuer Name: NORTH CAROLINA MEDICAL CARE COMMISSION Date the Rebate Computation was Performed: 02/25/2013 Schedule K Supplental Information THREE 501(C)(3) ORGANIZATIONS WITHIN THE PARENT-SUBSIDIARY CONTROLLED GROUP BENEFIT FROM THE BONDS AS FOLLOWS: GASTON MEMORIAL HOSPITAL, INC. (56-0619359) CAROMONT HEALTH, INC. (58-1636959) CAROMONT HEALTH SERVICES, INC. (56-1455630) CAROMONT REGIONAL MEDICAL CENTER HOLDS THE LIABILITY FOR THE BONDS, PER AUDITED FINANCIAL STATEMENTS. SCHEDULE K, PART I, LINE A, COLUMN (C): THIS BOND ISSUE INCLUDES TWO CUSIPS MATURING ON THE SAME DATE: 65820HVG5 AND 65820HVF7. SCHEDULE K, PART I, COLUMN (F); DESCRIPTION OF PURPOSE: ISSUE A - THE SYSTEM USED THE PROCEEDS FROM THESE BONDS FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO A NEW WOMEN'S CENTER AND PARKING DECK, RENOVATIONS TO EXISTING FACILITIES, AND EQUIPMENT. IN ADDITION, PROCEEDS WERE USED TO REFUND IN ADVANCE OF THEIR MATURITIES $17,000,000 IN PRINCIPAL AMOUNT OF THE SERIES 1998 HOSPITAL REVENUE BONDS, ISSUED ON AUGUST 27, 1998. ISSUE B - THE SYSTEM USED THE PROCEEDS FROM THE BONDS FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO, THE RENOVATION OF CERTAIN FLOORS OF THE PATIENT TOWER, RENOVATION OF THE DAY OF SURGERY UNIT, INSTALLATION OF FIRE SPRINKLERS IN NON-SPRINKLED AREAS, AND THE UPGRADE OF LIFE SAFETY AND CRITICAL POWER. IN ADDITION, THE HOSPITAL USED THE PROCEEDS TO REFUND THE AGGREGATE PRINCIPAL AMOUNT OF THE SERIES 1995 REVENUE BONDS, ISSUED ON NOVEMBER 15, 1995, IN THE AMOUNT OF $41,210,000 AND TO REFUND THE AGGREGATE PRINCIPAL AMOUNT OF THE SERIES 1998 REVENUE BONDS, ISSUED ON AUGUST 27, 1998, IN THE AMOUNT OF $49,710,000. SCHEDULE K, PART II, LINE 3 COLUMN (A): LINE 3 COLUMN (A) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 3,594,002. SCHEDULE K, PART II, LINE 3 COLUMN (B): LINE 3 COLUMN (B) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 249,831. SCHEDULE K, PART II, LINE 11; OTHER SPENT PROCEEDS: OTHER SPENT PROCEEDS INCLUDE DEPOSITS MADE INTO A REFUNDING ESCROW ACCOUNT ALONG WITH INTEREST EARNED ON THE ACCOUNT, BOTH OF WHICH WERE SUBSEQUENTLY USED TO PAY PRINCIPLE AND INTEREST ON THE REFUNDED BONDS. SEE THE RESPONSE FOR PART I, COLUMN (F) FOR DETAILS. SCHEDULE K, PART IV, LINES 3 AND 4A, COLUMN (B): THE SERIES 2008 BONDS WERE ORIGINALLY ISSUED AS VARIABLE BONDS BEARING INTEREST AT WEEKLY RATES. CAROMONT HEALTH, INC. ENTERED INTO INTEREST SWAP AGREEMENTS TO HEDGE ITS INTEREST RISK WITH RESPECT TO A PORTION OF THE SERIES 2008 BONDS. ON SEPTEMBER 1, 2010, THE SERIES 2008 BONDS WERE CONVERTED TO FIXED INTEREST RATES TO MATURITY. HOWEVER, THE INTEREST RATE SWAPS WERE NOT TERMINATED IN CONNECTION WITH SUCH FIXED RATE CONVERSION AND REMAIN IN EFFECT. SCHEDULE K, PART IV, LINE 4C, COLUMN (B): THIS BOND ISSUE HAS TWO HEDGE TERMS: 11.0 YEARS AND 21.0 YEARS. GENA POMEROY FAMILY RELATIONSHIP WITH BOARD MEMBER 52972 COMPENSATION FOR EMPLOYEE SERVICES 0 STEPHEN O'CONNOR FAMILY RELATIONSHIP WITH OFFICER 10465 COMPENSATION FOR EMPLOYEE SERVICES 0 Form 990, Part VI, Section A, line 6 The sole member of the Corporation shall be CaroMont Health, Inc., a North Carolina not-for-profit corporation. Form 990, Part VI, Section A, line 7a The Board of Directors shall consist of fourteen (14) members, all of whom shall be the members of the Board of Directors of CaroMont Health, Inc., and all of whom shall be appointed by 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. 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, 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. PURSUANT TO THE COMMITTEE CHARTER FOR THE COMPENSATION COMMITTEE OF THE BOARD, THE BOARD OF DIRECTORS APPROVES THE EXECUTIVE COMPENSATION PHILOSOPHY, WHICH ESTABLISHES THE PARAMETERS FOR ALL EXECUTIVE COMPENSATION DECISIONS. THE BOARD OF DIRECTORS 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 XI, line 9: INTERCOMPANY Transfer FROM Affiliate -26,552,880. CHANGE IN VALUE OF INTEREST RATE SWAP -993,220. PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM LAST YEAR. FORM 990, PART V AND PART VII COMMON PAYMASTER: 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 10 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 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 Emergency Physicians Inc 2531 Court Drive Gastonia NC 28054 562209423 Supporting Organization NC 501(c)(3) Line 12a, I CaroMont Health Inc 0 GASTON COUNTY PO BOX 1578 GASTONIA NC 280531578 566000300 GOVERNMENT ADMINISTRATION NC N/A 0 0 0 1 0 0 0 0 0 0 0 1 0 0 1 1 1 1 1 1