2014-05-11T17:52:24-05:00 2013-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2012-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR 7048342000 2014-05-11 1 AMY BIBBY P00445891 8282542254 2012 2015-11-30 17:44:51Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 6752537 0 X WWW.CAROMONT.ORG X 1985 NC TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 7 5 0 0 0 0 2606923 2096539 0 0 -65559 877217 0 0 2541364 2973756 3045308 940179 0 0 0 89044 0 0 0 8346 52279 3053654 1081502 -512290 1892254 15940285 18862054 0 18542 15940285 18843512 X TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 1081502 940179 0 SEE SCHEDULE OTHE PRIMARY PURPOSE OF THE CAROMONT HEALTH FOUNDATION IS TO PARTNER WITH COMMUNITY DONORS TO FUND INITIATIVES AND EQUIPMENT THAT WILL IMPROVE THE HEALTH OF THE COMMUNITIES WE SERVE. THE FOUNDATION PROVIDES GRANTS TO PROGRAMS WITHIN CAROMONT HEALTH. IN FISCAL YEAR 2013, THE FOUNDATION AWARDED $317,197 THAT FUNDED PROGRAMS SUCH AS: MEDICATIONS AND SERVICES TO INDIGENT PATIENTS, EDUCATION TO STAFF AND THE COMMUNITY ON HEART FAILURE AND STROKE AWARENESS, SPONSORSHIP OF A SUMMER CAMP FOR CHILDREN WITH ASTHMA, AND THE DEVELOPMENT OF A COMMUNITY OBESITY PROGRAM.THE FOUNDATION PROVIDES EXTERNAL FUNDING TO PARTNER GROUPS. IN FISCAL YEAR 2013, THE FOUNDATION PROVIDED $240,000 TO GASTON FAMILY HEALTH SERVICES; A LOCAL FEDERALLY QUALIFIED HEALTHCARE CLINIC THAT PROVIDES HEALTH CARE, HEALTH EDUCATION, AND PREVENTIVE CARE SERVICES TO PATIENTS WITHOUT REGARD TO THEIR ABILITY TO PAY. THE FOUNDATION ALSO PROVIDES SCHOLARSHIPS TO SEVERAL AREA COLLEGE STUDENTS WHO PLAN TO ENTER THE HEALTH CARE FIELD. IN FISCAL YEAR 2013, THE FOUNDATION AWARDED $85,592 TO 18 STUDENTS THROUGH FOUR SEPARATE SCHOLARSHIP PROGRAMS. 1081502 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 0 0 0 0 0 0 0 0 0 0 0 0 0 X 7 5 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 JAMES R BEAM 1.00 1.00 X X 0 0 0 MR W BARRY SMITH 1.00 1.00 X X 0 0 0 MRS MARY FRANCES FORRESTER 1.00 1.00 X 0 0 0 SUSIE BROWN 1.00 1.00 X 0 0 0 MR DAVID ALLEN SMITH 1.00 1.00 X 0 0 0 MR WILLIAM K GARY SR 1.00 X 0 0 0 KELVIN C HARRIS MD 1.00 41.00 X 0 310185 20271 DR CHARLES NIEMEYER 1.00 X 0 0 0 RANDALL L KELLEY 1.00 49.00 X 0 832695 166291 DOUG LUCKETT 1.00 49.00 X 0 508051 85174 DAVID O'CONNOR 1.00 49.00 X 0 483333 93652 MARIA LONG 1.00 49.00 X 0 383962 47836 0 2518226 413224 0 0 1 0 0 2089906 6633 2096539 327658 327658 4328340 3778781 549559 549559 549559 2973756 0 0 877217 854587 854587 85592 85592 89044 89044 20010 20010 696 696 23472 23472 8101 8101 1081502 1081502 0 0 469425 99938 1163 12849220 15926015 2621640 2834938 15940285 18862054 18542 0 18542 X 13318645 16008574 2621640 2834938 15940285 18843512 15940285 18862054 1892254 1010973 0 X X 0 1 X 1 0 X 1553180 774819 3788620 2606923 2096539 10820081 1553180 774819 3788620 2606923 2096539 10820081 1997831 8822250 463406 262328 372927 287217 327658 1713536 74835 74835 12608452 0.69970 0.63320 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 2621640 3620 295268 85592 2834936 2342709 364160 9986 95215 2621640 750985 1505133 100784 7680 6513 2342709 40686 750000 -39463 238 750985 30235 15043 -1785 2807 40686 1.00000 0 0 0 MACKIE SCHOLARSHIP FUND 45622 SHOVELIN SCHOLARSHIP FUND 2385938 HUDSON NURSING SCHOLARSHIP FUND 397854 BUCCI SCHOLARSHIP FUND 5524 2834938 X 3044550 1010973 1010973 2033577 940179 940179 2973756 141323 0 141323 940179 940179 1081502 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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, 2013 AND 2012, RESPECTIVELY. FISCAL YEARS ENDING ON OR AFTER JUNE 30, 2010 REMAIN SUBJECT TO EXAMINATION BY FEDERAL AND STATE TAX AUTHORITIES. PART XI, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 940,179. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 940,179. 1 GASTON FAMILY HEALTH SERVICES 991 WEST HUDSON BOULEVARD GASTONIA NC 28054 581958398 501(C)(3) 240389 FEDERALLY QUALIFIED HEALTH DEPARTMENT OFFERING MEDICAL CARE TO LOW INCOME RESIDENTS OF GASTON COUNTY GASTON MEMORIAL HOSPITAL INC 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 588905 VARIOUS COMMUNITY HEALTH INITIATIVES CAROMONT MEDICAL GROUP 2525 COURT DRIVE GASTONIA NC 28053 561479712 501(C)(3) 25293 PATIENT CARE MEDICAL DEVICE 3 0 NURSING EDUCATION SCHOLARSHIPS 18 85592 FMV SHOVELIN, BUCCI, AND HUDSON NURSING SCHOLARSHIPS PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, 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 0 1 0 0 0 1 1 0 0 KELVIN C HARRIS MD 0 165127 0 144758 0 300 0 6976 0 13295 0 330456 0 0 RANDALL L KELLEY 0 577693 0 232988 0 22014 0 156204 0 10087 0 998986 0 0 DOUG LUCKETT 0 372857 0 127707 0 7487 0 74601 0 10573 0 593225 0 0 DAVID O'CONNOR 0 351082 0 124821 0 7430 0 79460 0 14192 0 576985 0 0 MARIA LONG 0 280995 0 102230 0 737 0 45890 0 1946 0 431798 0 0 PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION GASTON MEMORIAL HOSPITAL FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 69,460 MARIA LONG - 34,427 DOUG LUCKETT - 72,101 RANDALL L. KELLEY - 152,984 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 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 APPLICABLE EMPLOYEE AND DIRECTOR SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE EMPLOYEE'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 EMPLOYEE'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES SHALL BE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE RESPONSIBILITY OFFICER. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO 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 DIRECTORS AND 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. RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT. PART XII, LINE 2C THE PROCESS FOR THIS HAS NOT CHANGED FROM THE PRIOR YEAR. 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