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 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 signing officer EVP, CFO 7048342000 2018-05-07 1 Amy Bibby P00445891 8282542254 2016 2022-09-23 18:48:47Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 2284746 0 X WWW.CAROMONT.ORG X 1985 NC To raise money to fund programs, initiatives, and capital projects that are centered on meeting the medical needs of the communities we serve. 14 9 5 0 0 0 725359 1047104 0 0 350829 1237642 0 0 1076188 2284746 605180 728097 0 0 307844 230866 0 0 0 92168 82877 1005192 1041840 70996 1242906 20784243 22993406 42282 24039 20741961 22969367 X To raise money to fund programs, initiatives, and capital projects that are centered on meeting the medical needs of the communities we serve. 0 0 1021800 728097 0 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 covered by CaroMont Health. 1021800 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 8 0 1 5 1 0 0 0 0 0 1 1 0 0 0 0 X 14 9 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 Mr W Michael Dickson Chair 1.00 2.00 X X 0 0 0 Mrs Mary Frances Forrester director 1.00 X 0 0 0 DR RAMADA SMITH Director 1.00 X 0 526459 25795 Mr William K Gary Sr Director 1.00 X 0 0 0 Kelvin C Harris MD Director 1.00 40.00 X 0 264045 31513 Dr Charles Niemeyer Director 1.00 X 0 0 0 Ms Lenora Crabtree Director 1.00 X 0 0 0 Ms Martha Burris Director/Vice Chair 1.00 X X 0 0 0 Mr Timothy Paschall Director 1.00 X 0 0 0 Mr Joseph B Davis Jr Director/Treasurer 1.00 2.00 X X 0 0 0 Mr Henry Massey Jr Director 1.00 X 0 0 0 Ms Janie Parks Peak Director/Secretary 1.00 X X 0 0 0 Mrs Jennifer Thomas Stultz Director 1.00 X 0 0 0 MS JASMIN STONE DIrector 1.00 X 0 84899 13429 DOUG LUCKETT CEO/PRESIDENT (THRU. MAR '17) 1.00 54.00 X 0 942496 185029 DAVID O'CONNOR EVP/CFO/Asst. Treasurer 1.00 54.00 X 0 565374 108958 MARIA LONG EVP CLO/AS (THRU. APRIL '17) 1.00 54.00 X 0 470930 81698 K CHRISTOPHER PEEK CEO/PRES. (BEG. MAY '17) 1.00 54.00 X 0 0 0 LEIGH HICKMAN CLO/AS (BEG. MAY '17) 1.00 54.00 X 0 195813 20451 TODD DAVIS INTERIM CEO/PRES.(MAR'17-MAY'17) 1.00 54.00 X 0 465740 100433 Debra R Windley Director of Development 49.00 X 0 103826 111 0 3619582 567417 0 1 1 0 0 293703 753401 100000 1047104 338222 338222 899420 0 899420 899420 899420 2284746 0 0 1237642 627468 627468 100629 100629 171869 171869 11533 11533 34788 34788 12676 12676 20040 20040 39782 39782 21085 21085 1970 1970 1041840 1021800 20040 0 406341 367648 4393 50017 30222 389974 2067 17426 17052675 18520152 3288545 3648189 20784243 22993406 42282 24039 42282 24039 X 17446629 19299439 3295332 3669928 20741961 22969367 20784243 22993406 1242906 984500 0 X X 0 1 X 1 0 X 2096539 317425 739624 725359 1047104 4926051 2096539 317425 739624 725359 1047104 4926051 4926051 327658 177645 347712 469723 338222 1660960 6587011 0.74780 0.83480 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3295330 117530 357695 100629 3669926 3261864 179889 -87779 58644 3295330 3116780 126795 118310 100021 3261864 2834936 3020 389680 110856 3116780 2621640 3620 295268 85592 2834936 1.00000 0 0 0 MACKIE SCHOLARSHIP FUND 41826 SHOVELIN SCHOLARSHIP FUND 2884882 HUDSON NURSING SCHOLARSHIP FUND 353795 BUCCI SCHOLARSHIP FUND 6544 WOMEN OPTIMIZE WELLNESS FUND 204963 EMPLOYEE SCHOLARSHIP FUND 91033 DAMORE SCHOLARSHIP FUND 30933 ONCOLOGY SCHOLARSHIP FUND 34213 3648189 X 2625518 984500 984500 1641018 20040 623688 643728 2284746 398112 0 398112 20040 623688 643728 1041840 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, 2017 and 2016. Part XI, Line 4b - Other Adjustments: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 623,688. Part XII, Line 4b - Other Adjustments: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 623,688. 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 476695 VARIOUS COMMUNITY HEALTH INITIATIVES GIRLS ON THE RUN OF GASTON COUNTY 214 EAST FRANKLIN BLVD GASTONIA NC 28052 474179257 501(C)(3) 7365 Community Assistance HEART SOCIETY OF GASTON COUNTY MEDICATION ASSISTANCE 1201 EAST GARRISON BLVD GASTONIA NC 28054 561330921 501(C)(3) 5000 Community Assistance HOSPICE OF GASTON COUNTY INC 2525 COURT DRIVE GASTONIA NC 280531747 581341530 501(C)(3) 104409 VARIOUS COMMUNITY HEALTH INITIATIVES BACKPACK WEEKEND FOOD PROGRAM INC PO BOX 551030 GASTONIA NC 28055 471591744 501(C)(3) 20000 Community Assistance BOYS AND GIRLS CLUB PO BOX 23 GASTONIA NC 28053 561419498 501(C)(3) 10000 Community Assistance 6 SCHOLARSHIPS 30 100629 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 DR RAMADA SMITH Director 0 440253 0 82849 0 3357 0 0 25795 0 25795 526459 0 0 Kelvin C Harris MD Director 0 190779 0 71457 0 1809 0 14069 0 17444 0 295558 0 0 DOUG LUCKETT CEO/PRESIDENT (THRU. MAR '17) 0 618606 0 202993 0 120897 0 167333 0 17696 0 1127525 0 119305 DAVID O'CONNOR EVP/CFO/Asst. Treasurer 0 387072 0 96743 0 81559 0 91314 0 17644 0 674332 0 77497 MARIA LONG EVP CLO/AS (THRU. APRIL '17) 0 327957 0 79402 0 63571 0 80385 0 1313 0 552628 0 63064 LEIGH HICKMAN CLO/AS (BEG. MAY '17) 0 173521 0 21634 0 658 0 8690 0 11761 0 216264 0 0 TODD DAVIS INTERIM CEO/PRES.(MAR'17-MAY'17) 0 337568 0 79573 0 48599 0 82815 0 17618 0 566173 0 47780 Debra R Windley Director of Development 0 86136 0 17009 0 681 0 0 0 111 0 103937 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 - $ 75,414 Maria Long - 63,307 Doug Luckett - 151,347 Todd Davis, MD - 66,915 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 100000 FMV 0 0 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 members of the Board of Director shall be 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, 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. 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 Gaston Emergency Physicians Inc 2531 Court Drive Gastonia NC 28054 562209423 Supporting Organization NC 501(c)(3) Line 11A, I CaroMont Health Inc 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 0 1 1 1 1