2013-04-04T11:32:40-05:00 2012-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR 7048342000 2013-04-01 1 AMY BIBBY P00445891 8282542254 2011 2016-03-07 17:11:31Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 4238426 0 X WWW.CAROMONT.ORG X 1985 NC TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 5 4 0 0 0 0 3788620 2606923 0 0 476176 -65559 0 0 4264796 2541364 667258 3045308 0 0 0 0 0 0 0 3195 8346 670453 3053654 3594343 -512290 15964319 15940285 0 0 15964319 15940285 X TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 3053593 3045308 SEE SCHEDULE O.THE GASTON MEMORIAL HOSPITAL FOUNDATION (A SUBSIDIARY OF CAROMONT HEALTH) WAS ESTABLISHED IN 1985. IN ADDITION TO THE FOUNDATION UTILIZING ITS INVESTMENT EARNINGS FOR DONATIONS, CAROMONT HEALTH DONATES UP TO 10% OF ITS OPERATING INCOME TO THE GMH FOUNDATION EACH YEAR. THE FOUNDATION PARTNERS WITH DONORS, CORPORATIONS AND COMMUNITY ORGANIZATIONS TO SUPPORT CAROMONT HEALTH'S MISSION TO PROMOTE INDIVIDUAL HEALTH AND VIBRANT COMMUNITIES. THE FOUNDATION PROVIDES GRANTS TO COMMUNITY ORGANIZATIONS THAT SPONSOR PROGRAMS THAT DIRECTLY SUPPORT CAROMONT HEALTH'S MISSION.DURING FISCAL YEAR 2012, THE FOUNDATION DISTRIBUTED $3,045,308 TO CHARITABLE CAUSES THROUGHOUT GASTON COUNTY, INCLUDING GASTON FAMILY HEALTH SERVICES, GASTON TOGETHER, UNITED WAY, GASTON COUNTY SCHOOLS, HEALTHNET GASTON AND INDIGENT MEDICATION AND SERVICES.THE WAYNE F. SHOVELIN SCHOLARSHIP FUND, A $2.21 MILLION ENDOWMENT PLEDGED BY DUKE KIMBRELL, PROMOTES HIGHER EDUCATION AND ENGAGES LEARNING FOR CAROMONT HEALTH EMPLOYEES, VOLUNTEERS AND FAMILIES. RECIPIENTS ARE SELECTED BASED ON INDIVIDUAL FINANCIAL NEEDS, FUTURE CAREER ASPIRATIONS IN HEALTH CARE, AND CURRENT SCHOLASTIC STANDING. 3053593 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 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 5 4 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 JAMES R BEAM 1.00 X X 0 0 0 MARY FRANCES FORRESTER 1.00 X 0 0 0 DAVID ALLEN SMITH 1.00 X 0 0 0 SUSIE BROWN 1.00 X 0 0 0 W BARRY SMITH 1.00 X 0 0 0 DAVID O'CONNOR 1.00 X 0 569491 38816 MARIA LONG 1.00 X 0 432347 38015 RANDALL L KELLEY 1.00 X 0 0 0 VALINDA L RUTLEDGE 0.00 X 0 766972 18607 0 1768810 95438 0 1 1 0 0 2601214 5709 2606923 287217 287217 1344286 1697062 -352776 -352776 -352776 2541364 0 0 -65559 2950093 2950093 95215 95215 61 61 7500 7500 BANK SERVICE CHARGE 785 785 3053654 3053593 61 0 382 469425 13621227 12849220 2342710 2621640 15964319 15940285 0 0 X 13621608 13318645 2342711 2621640 15964319 15940285 15964319 15940285 X -512290 488256 X X 0 1 1 X 0 X 7205 1553180 774819 3788620 2606923 8730747 7205 1553180 774819 3788620 2606923 8730747 2038611 6692136 377967 463406 262328 372927 287217 1763845 74835 74835 10569427 0.63320 0.54910 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 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 38266 SHOVELIN SCHOLARSHIP FUND 2211232 HUDSON NURSING SCHOLARSHIP FUND 366652 BUCCI SCHOLARSHIP FUND 5490 2621640 2541364 3053654 -512290 129586 358670 488256 -24034 -374419 129586 129586 -504005 3045369 3045369 2541364 8285 0 8285 3045369 3045369 3053654 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: 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, 2012 AND 2011, RESPECTIVELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER 358,670. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 3,045,369. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 3,045,369. 1 GASTON FAMILY HEALTH SERVICES 991 WEST HUDSON BOULEVARD GASTONIA NC 28054 581958398 501(C)(3) 480778 FEDERALLY QUALIFIED HEALTH DEPARTMENT OFFERING MEDICAL CARE TO LOW INCOME RESIDENTS OF GASTON COUNTY HEALTHNET GASTON 700 SOUTH MARIETTA STREET GASTONIA NC 28052 561913112 501(C)(3) 75000 CASE MANAGER, CARE NAVIGATOR AND PROGRAM COORDINATOR GASTON COUNTY HEALTH DEPARTMENT PO BOX 1578 GASTONIA NC 28053 566000300 501(C)(3) 800000 ONGOING VITAL COMMUNITY HEALTH INITIATIVES UNITED WAY OF GASTON COUNTY 200 EAST FRANKLIN BLVD GASTONIA NC 28052 560653356 501(C)(3) 10000 GENERAL ASSISTANCE NORTH CAROLINA MISSIONS OF MERCY DENTAL HEALTH FUND 1600 EVANS ROAD CARY NC 27513 581788699 502(C)(3) 25000 PROVIDE DENTAL CARE TO THE UNINSURED, UNEMPLOYED, ELDERLY, AND DISABLED HOSPICE OF GASTON COUNTY 2525 COURT DRIVE GASTONIA NC 28054 581341530 501(C)(3) 150000 HOSPICE HOUSE EXPANSION ASSISTANCE GASTON MEMORIAL HOSPITAL INC 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 1131072 VARIOUS COMMUNITY HEALTH INITIATIVES 6 1 NURSING EDUCATION SCHOLARSHIP 13 95215 FMV SHOVELIN AND MACKIE 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 0 0 0 0 1 1 0 0 DAVID O'CONNOR 0 332181 0 182565 0 54745 0 9800 0 29016 0 608307 0 0 MARIA LONG 0 274556 0 150300 0 7491 0 12740 0 25275 0 470362 0 0 VALINDA L RUTLEDGE 0 338137 0 260451 0 168384 0 6750 0 11857 0 785579 0 0 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 4 THE BYLAWS WERE AMENDED TO ENHANCE THE GOVERNANCE OF CONFLICTS OF INTEREST WITHIN THE HOSPITAL SYSTEM AND PROHIBIT LOANS WITH OFFICERS AND DIRECTORS. 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 THOUGHT 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 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 PRESIDENT 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 EXECUTIVE VICE PRESIDENT/GENERAL COUNSEL AND THE CORPORATE RESPONSIBILITY OFFICER. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO/ASSISTANT TREASURER AND EVP GENERAL COUNSEL/ASSISTANT SECRETARY 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. 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 RECOMMENDED BY THE COMPENSATION COMMITTEE AND APPROVED BY THE BOARD OF DIRECTORS. 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 129,586. EQUITY TRANSFER 358,670. TOTAL TO FORM 990, PART XI, LINE 5: 488,256. 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 1 1 0 0 1 1