2017-04-18T00:00:00-05:00 2016-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2015-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR EVP, CFO 7048342000 2017-04-19 1 AMY BIBBY P00445891 8282542254 2015 2021-01-29 14:40:06Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 1195082 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. 13 11 3 0 0 0 739624 725359 0 0 1432169 350829 0 0 2171793 1076188 498993 605180 0 0 233927 307844 0 0 0 134795 92168 867715 1005192 1304078 70996 21591133 20784243 38933 42282 21552200 20741961 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 984779 605180 0 SEE SCHEDULE OA DOLLAR IN 1946 WAS VERY DIFFERENT FROM A DOLLAR TODAY, BUT WHEN GIVEN TO A GREAT CAUSE, THE DIFFERENCE IT CAN MAKE IN A PERSON'S LIFE REMAINS THE SAME: PRICELESS.DONATIONS MADE TO THE CAROMONT HEALTH FOUNDATION DON'T JUST FUND PROGRAMS, INITIATIVES AND EQUIPMENT ESSENTIAL TO MEETING OUR COMMUNITY'S NEEDS-THEY MAKE A VAST AND POSITIVE IMPACT ON LIFE HERE. FOR EVERY GENEROUS DONOR, EVERY DOLLAR IS AN INVESTMENT IN A HEALTHY FUTURE FOR GASTON COUNTY AND A VITAL INGREDIENT IN SUPPORTING FAMILIES, OUTREACH, EDUCATION OPPORTUNITIES, SCHOLARSHIPS, FREE HEALTH SCREENINGS AND SO, SO MUCH MORE. MOST OF THESE CONTRIBUTIONS ARE GRATEFULLY RECEIVED FROM A VARIETY OF SOURCES: OUTSIDE DONORS, AN INTERNAL EMPLOYEE GIVING PROGRAM, VOLUNTEERS, FUNDRAISING AND LOCAL GROUPS.TACKLING THE TOUGH HEALTHCARE ISSUES OUR REGION FACES IS, AND HAS ALWAYS BEEN, A KEY ELEMENT OF OUR MISSION. THERE ARE SPECIAL FUNDS TO SUPPORT SUCH IMPORTANT WORK, AND WE'RE PROUD TO INVEST IN PROJECTS FUNDAMENTAL TO BETTERING THE HEALTH OF OUR REGION, BOTH TODAY AND INTO THE FUTURE. 984779 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 0 0 0 0 0 1 0 0 0 1 19 0 1 3 1 0 0 0 0 0 1 1 0 0 0 0 X 13 11 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 - 2016 1.00 2.00 X X 0 0 0 MRS MARY FRANCES FORRESTER CHAIR - 2014 1.00 X X 0 0 0 MRS JASMINE SICILIA DIRECTOR 1.00 X 0 90614 8126 MR WILLIAM K GARY SR DIRECTOR 1.00 X 0 0 0 KELVIN C HARRIS MD DIRECTOR 1.00 X 0 317716 31159 DR CHARLES NIEMEYER DIRECTOR 1.00 X 0 0 0 MS LENORA CRABTREE DIRECTOR 1.00 X 0 0 0 MS MARTHA BURRIS DIRECTOR 1.00 X 0 0 0 MR TIMOTHY PASCHALL DIRECTOR 1.00 X 0 0 0 MR JOSEPH B DAVIS JR DIRECTOR 1.00 1.00 X 0 0 0 MR HENRY MASSEY JR DIRECTOR 1.00 X 0 0 0 MS JANIE PARKS PEAK DIRECTOR 1.00 X 0 0 0 MRS JENNIFER THOMAS STULTZ DIRECTOR 1.00 X 0 0 0 MR JAMES W BAILEY DIRECTOR (THROUGH 8/15) 1.00 1.00 X 0 0 0 DOUG LUCKETT CEO/PRESIDENT 1.00 54.00 X 0 939128 180413 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 54.00 X 0 581461 107692 MARIA LONG EVP CHIEF LEGAL OFFICER/AS 1.00 54.00 X 0 458895 80718 DEBRA R WINDLEY DIRECTOR OF DEVELOPMENT 49.00 X 157788 0 14118 RANDALL L KELLEY FORMER OFFICER 0.00 X 0 502177 0 157788 2889991 422226 1 1 1 0 0 379600 345759 725359 469723 469723 118894 -118894 -118894 -118894 1076188 0 0 350829 546536 546536 58644 58644 247232 247232 12230 12230 33413 33413 14969 14969 20413 20413 29609 29609 41272 41272 874 874 1005192 984779 20413 0 410838 406341 253424 4393 44213 30222 5556 2067 17622509 17052675 3254593 3288545 21591133 20784243 38933 42282 38933 42282 X 18290334 17446629 3261866 3295332 21552200 20741961 21591133 20784243 70996 -881235 0 X X 0 1 X 1 0 X 2606923 2096539 317425 739624 725359 6485870 2606923 2096539 317425 739624 725359 6485870 6485870 287217 327658 177645 347712 469723 1609955 8095825 0.80110 0.74760 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 3261864 179889 -87779 58644 3295330 3116780 126795 118310 100021 3261864 2834936 3020 389680 110856 3116780 2621640 3620 295268 85592 2834936 2342709 364160 9986 95215 2621640 0 0 0 MACKIE SCHOLARSHIP FUND 43417 SHOVELIN SCHOLARSHIP FUND 2627327 HUDSON NURSING SCHOLARSHIP FUND 316665 BUCCI SCHOLARSHIP FUND 6372 WOMEN OPTIMIZE WELLNESS FUND 172302 EMPLOYEE SCHOLARSHIP FUND 122462 3288545 X -430640 -881235 -881235 450595 20413 605180 625593 1076188 379599 0 379599 20413 605180 625593 1005192 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, 2016 AND 2015, RESPECTIVELY. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2012 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 605,180. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 605,180. 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 419786 FMV VARIOUS COMMUNITY HEALTH INITIATIVES BACKPACK WEEKEND FOOD PROGRAM PO BOX 551030 GASTONIA NC 28055 471591744 501(C)(3) 10000 FMV COMMUNITY ASSISTANCE BOYS AND GIRLS CLUB OF GREATER GASTON PO BOX 23 GASTONIA NC 28053 561419498 501(C)(3) 10000 FMV COMMUNITY ASSISTANCE SCHIELE MUSEUM 1500 E GARRISON BLVD GASTONIA NC 28054 560770432 501(C)(3) 15250 FMV COMMUNITY ASSISTANCE 4 HEALTHCARE EDUCATION SCHOLARSHIPS 21 58644 FMV SHOVELIN, 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. 1 1 0 0 0 0 1 0 0 KELVIN C HARRIS MD DIRECTOR 0 191080 0 125526 0 1110 0 14064 0 17095 0 348875 0 0 DOUG LUCKETT CEO/PRESIDENT 0 604074 0 251233 0 83821 0 161259 0 19154 0 1119541 0 82868 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 380983 0 117308 0 83170 0 89652 0 18040 0 689153 0 78545 MARIA LONG EVP CHIEF LEGAL OFFICER/AS 0 318608 0 97039 0 43248 0 78567 0 2151 0 539613 0 42762 DEBRA R WINDLEY DIRECTOR OF DEVELOPMENT 133912 0 18736 0 5140 0 0 0 14118 0 171906 0 0 0 RANDALL L KELLEY FORMER OFFICER 0 0 0 0 0 502177 0 0 0 0 0 502177 0 214052 PART I, LINE 3 COMPENSATION PAID TO OFFICERS OF GASTON MEMORIAL HOSPITAL FOUNDATION, INC. WAS PAID BY CAROMONT REGIONAL MEDICAL CENTER, A RELATED ORGANIZATION. CAROMONT REGIONAL MEDICAL CENTER UTILIZED THE FOLLOWING METHODS TO DETERMINE APPROPRIATE COMPENSATION FOR OFFICERS 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, LINES 4A-B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 73,752 MARIA LONG - 61,467 DOUG LUCKETT - 146,940 RANDALL L. KELLEY RECEIVED A SEVERANCE PAYMENT BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER IN THE AMOUNT OF $502,177. 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 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 11 THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS OF THE SUPPORTING ORGANIZATION PRIOR TO PRESENTATION TO THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C EACH EMPLOYEE AND DIRECTOR 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, 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. BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE DO NOT HAVE SUBSTANTIAL INFLUENCE OVER THE CORPORATION'S BUSINESS AND ARE FREE OF 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 0 0 0 0 0 1 0 1 1 1 1