2015-05-01T09:36:37-05:00 2014-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2013-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR EVP, CFO 7048342000 2015-03-26 1 AMY BIBBY P00445891 8282542254 2013 2016-04-25 22:37:26Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 5384424 0 X WWW.CAROMONT.ORG X 1985 NC TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 9 7 0 0 0 0 2096539 314815 0 0 877217 1193814 0 0 2973756 1508629 940179 692838 0 0 89044 111009 0 0 0 52279 109253 1081502 913100 1892254 595529 18862054 20921013 18542 30238 18843512 20890775 X TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 913100 692838 1508629 SEE SCHEDULE OTHE PRIMARY PURPOSE OF THE CAROMONT HEALTH FOUNDATION IS TO PARTNER WITH COMMUNITY DONORS TO FUND INITIATIVES, PROGRAMS, AND CAPITAL PROJECTS THAT WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. THE FOUNDATION PROVIDES GRANTS TO PROGRAMS WITHIN CAROMONT HEALTH. IN FISCAL YEAR 2014, THE FOUNDATION AWARDED $581,980 THAT FUNDED INITIATIVES SUCH AS: MEDICATIONS AND SERVICES FOR INDIGENT PATIENTS; LUNG CANCER SCREENING FOR INDIGENT PATIENTS; MAMMOGRAPHYS TO INDIGENT PATIENTS; ASSISTANCE FOR ENROLLMENT IN ACA MARKETPLACE INSURANCE PRODUCTS AND TRAINING OF STAFF; EDUCATION PROGRAMS TO THE COMMUNITY ON HEART FAILURE, HEART ATTACK SIGNS & SYMPTOMS, AND STROKE AWARENESS; AND TRAINING TO COMMUNITY PARISH NURSES ON WELLNESS AND HOLISTIC HEALTH. THE FOUNDATION ALSO PROVIDES SCHOLARSHIPS TO MANY AREA COLLEGE STUDENTS WHO PLAN TO SEEK DEGREES IN HEALTH-RELATED MAJORS. IN FISCAL YEAR 2013, THE FOUNDATION AWARDED $110,106 TO 23 STUDENTS THROUGH FOUR SEPARATE SCHOLARSHIP PROGRAMS. 913100 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 X 3 0 1 0 0 0 0 0 0 0 0 0 0 0 X 9 7 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 MRS MARY FRANCES FORRESTER CHAIRMAN 2014 1.00 1.00 X X 0 0 0 MR W BARRY SMITH CHAIRMAN 2013 1.00 1.00 X X 0 0 0 MS SUSIE BROWN DIRECTOR 1.00 1.00 X 0 0 0 MR DAVID ALLEN SMITH DIRECTOR 1.00 1.00 X 0 0 0 MR WILLIAM K GARY SR DIRECTOR 1.00 X 0 0 0 KELVIN C HARRIS MD DIRECTOR 1.00 41.00 X 0 275857 21862 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 DOUG LUCKETT CEO/PRESIDENT 1.00 49.00 X 0 712139 129918 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 49.00 X 0 475002 98510 MARIA LONG EVP CHIEF LEGAL OFFICER/ASST. SECRETARY 1.00 49.00 X 0 381516 72932 RANDALL L KELLEY FORMER OFFICER 0.00 0.00 X 0 690063 48062 0 2534577 371284 0 1 1 0 0 310000 4815 314815 177645 177645 4891964 3875795 1016169 1016169 1016169 1508629 0 0 1193814 581982 581982 110856 110856 106401 106401 1013 1013 3595 3595 73367 73367 32765 32765 3121 3121 913100 913100 0 0 99938 35683 2900 1163 8518 15926015 17760030 2834938 3113882 18862054 20921013 18542 30238 18542 30238 X 16008574 17773993 2834938 3116782 18843512 20890775 18862054 20921013 595529 1451734 0 X X 0 1 X 1 0 X 774819 3788620 2606923 2096539 317425 9584326 774819 3788620 2606923 2096539 317425 9584326 2029758 7554568 262328 372927 287217 327658 177645 1427775 11012101 0.68600 0.69970 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2834936 3020 389680 110856 3116780 2621640 3620 295268 85592 2834936 2342709 364160 9986 95215 2621640 750985 1505133 100784 7680 6513 2342709 40686 750000 -39463 238 750985 1.00000 0 0 0 MACKIE SCHOLARSHIP FUND 50465 SHOVELIN SCHOLARSHIP FUND 2662545 HUDSON NURSING SCHOLARSHIP FUND 395009 BUCCI SCHOLARSHIP FUND 5863 3113882 X 2266222 1451734 1451734 814488 694141 694141 1508629 218959 0 218959 694141 694141 913100 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, 2014 AND 2013, RESPECTIVELY. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2011 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 694,141. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 694,141. 1 ROTARY FOUNDATION OF GASTON COUNTY PO BOX 339 GASTONIA NC 28053 201260361 501(C)(3) 25000 COMMUNITY ASSISTANCE CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 406982 VARIOUS COMMUNITY HEALTH INITIATIVES HOSPICE OF GASTON COUNTY 2525 COURT DRIVE GASTONIA NC 28053 581341530 501(C)(3) 150000 HOSPICE HOUSE CAPITAL CAMPAIGN 3 0 HEALTHCARE EDUCATION SCHOLARSHIPS 23 110856 FMV 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. X X X X X 1 1 0 0 0 1 1 0 0 KELVIN C HARRIS MD DIRECTOR 0 189839 0 85118 0 900 0 6600 0 15262 0 297719 0 0 DOUG LUCKETT CEO/PRESIDENT 0 590205 0 121154 0 780 0 113546 0 16372 0 842057 0 0 DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 362570 0 111268 0 1164 0 82348 0 16162 0 573512 0 0 MARIA LONG EVP CHIEF LEGAL OFFICER/ASST. SECRET 0 294902 0 85720 0 894 0 70934 0 1998 0 454448 0 0 RANDALL L KELLEY FORMER OFFICER 0 347736 0 0 0 342327 0 43999 0 4063 0 738125 0 0 PART I, LINES 4A-B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION GASTON MEMEORIAL HOSPITAL FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 69,504 MARIA LONG - 55,601 DOUG LUCKETT - 107,551 RANDALL L. KELLEY - 37,456 RANDALL L. KELLEY RECEIVED A SEVERANCE PAYMENT BY RELATED ORGANIZATION GASTON MEMEORIAL HOSPITAL IN THE AMOUNT OF $331,138. PART I, LINE 6 EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES AND FINANCIAL PERFORMANCE OF THE CONSOLIDATED SYSTEM. MANAGER INCENTIVE PLAN BASED ON CONSOLIDATED CORPORATE AND INDIVIDUAL PERFORMANCE GOALS. FORM 990, PART VI, SECTION A, LINE 1B: BOARD MEMBER INDEPENDENCE: IN CALENDAR YEAR 2014, THE BOARD OF DIRECTORS OF CAROMONT HEALTH CONDUCTED A COMPREHENSIVE REVIEW OF BEST PRACTICES REGARDING INDEPENDENCE OF BOARD MEMBERS. THIS REVIEW RESULTED IN THE DEVELOPMENT OF A BOARD POLICY ON INDEPENDENCE OF BOARD MEMBERS. USING IRS REGULATIONS AND GUIDANCE, INDUSTRY BEST PRACTICES, GUIDANCE AND COMMENTARY APPLICABLE TO NON-PROFIT HEALTHCARE INSTITUTIONS, AND ADVICE OF COUNSEL, THE BOARD OF DIRECTORS DEVELOPED AND IMPLEMENTED A ROBUST POLICY THAT DEFINES INDEPENDENT AND NON-INDEPENDENT DIRECTORS AND CLASSIFIES DIRECTORS ON AN ANNUAL BASIS AS INDEPENDENT AND NON-INDEPENDENT. USING THE IRS REPORTING REQUIREMENTS AS A MINIMUM SET OF CRITERIA FOR DETERMINING THE INDEPENDENT STATUS OF BOARD MEMBERS, THE BOARD'S POLICY GOES BEYOND THE MINIMUM CRITERIA AND DEFINES ADDITIONAL CRITERIA THAT RENDER A BOARD MEMBER NON-INDEPENDENT. ONCE DETERMINED TO HAVE A DISQUALIFYING CONDITION THAT RENDERS THE MEMBER NON-INDEPENDENT, A BOARD MEMBER WHOSE DISQUALIFYING CONDITION HAS BEEN REMEDIED MAY ONLY BE RESTORED TO INDEPENDENT STATUS FOLLOWING A SPECIFIED TIME LIMIT DEFINED IN THE POLICY. IN REPORTING THE NUMBER OF INDEPENDENT DIRECTORS IN PART I, LINE 4 AND PART VI, SECTION A, LINE 1B, THE BOARD OF DIRECTORS HAS DETERMINED THAT IT WILL REPORT THE NUMBER DETERMINED BY ITS POLICY, RECOGNIZING THAT THIS MAY BE A STRICTER INTERPRETATION THAN THE IRS REQUIRES. IN SEATING BOARD COMMITTEES, SUCH AS THE EXECUTIVE COMPENSATION COMMITTEE AND THE AUDIT FINANCE AND INVESTMENT COMMITTEE, THE BOARD DETERMINES A DIRECTOR'S ELIGIBILITY TO SERVE ON THOSE COMMITTEES BASED ON APPLICATION OF THE BOARD'S DEFINITION OF INDEPENDENCE. 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 AND MAY BE REMOVED 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. 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 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 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 AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY GASTON MEMORIAL HOSPITAL, 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. BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND 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 LEAVES THE MEETING AND DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING INDEPENDENT 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 1 0 0 1 1