2012-04-05T15:57:59-05:00 2011-06-30 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2010-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR 7048342000 2012-03-28 1 AMY BIBBY 8282542254 2010 2016-02-24 21:20:13Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 5505833 0 X WWW.CAROMONT.ORG X 1985 NC TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 3 2 0 0 0 0 774819 3788620 0 0 242605 476176 0 0 1017424 4264796 480778 667258 0 0 0 0 0 0 0 9195 3195 489973 670453 527451 3594343 11182026 15964319 70000 0 11112026 15964319 X TO DELIVER EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 670453 667258 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 2011, THE FOUNDATION DISTRIBUTED $667,258 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 $2.25 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. WAYNE SHOVELIN RETIRED IN SEPTEMBER 2009, CONCLUDING 23 YEARS AS PRESIDENT AND CHIEF EXECUTIVE OFFICER OF CAROMONT HEALTH. 670453 1 1 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 3 2 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X 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 MICKEY PRICE 1.00 X 0 0 0 VALINDA L RUTLEDGE 1.00 X 0 1076425 38634 DAVID O'CONNOR 1.00 X 0 692572 39820 MARIA LONG 1.00 X 0 487588 33654 WAYNE F SHOVELIN 0.00 X 0 5914978 0 0 8171563 112108 0 1 1 0 0 2288110 1500510 3788620 372926 372926 1344287 1241037 103250 103250 103250 4264796 0 0 476176 667258 667258 OTHER EXPENSE 3067 3067 BANK SERVICE CHARGE 128 128 670453 670453 0 0 382 10163963 13621227 267078 750985 2342710 11182026 15964319 70000 70000 0 X 10361040 13621608 750986 2342711 11112026 15964319 11182026 15964319 X 3594343 1257950 X 0 1 1 X 0 X 1547946 7205 1553180 774819 3788620 7671770 1547946 7205 1553180 774819 3788620 7671770 2045057 5626713 1023903 377967 463406 262328 372927 2500531 74835 74835 10247136 0.54910 0.57620 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 750985 1505133 100784 7680 6513 2342709 40686 750000 -39463 238 750985 30235 15043 -1785 2807 40686 1.00000 0 0 0 MACKIE SCHOLARSHIP FUND 39753 SHOVELIN SCHOLARSHIP FUND 2302957 2342710 4264796 670453 3594343 1264996 -7046 1257950 4852293 4862067 1264996 1264996 3597071 667725 667725 4264796 2728 0 2728 667725 667725 670453 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS AND CANCER ASSISTANCE. 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, 2011 AND 2010, RESPECTIVELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: EQUITY TRANSFER -7,046. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 667,725. PART XIII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS 667,725. 1 GASTON FAMILY HEALTH SERVICES 991 WEST HUDSON BOULEVARD GASTONIA NC 28054 581958398 501(C)(3) 480778 FMV 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) 150000 FMV CASE MANAGER, CARE NAVIGATOR AND PROGRAM COORDINATOR REIKI EDUCATION INC PO BOX 298 PINEVILLE NC 28134 412275839 501(C)(3) 6000 FMV SYMPTOM MANAGEMENT CLINIC UNITED WAY OF GASTON COUNTY 200 EAST FRANKLIN BLVD GASTONIA NC 28052 560653356 501(C)(3) 10000 FMV GENERAL ASSISTANCE ALLIANCE CHILDREN AND YOUTH PO BOX 1695 GASTONIA NC 28053 561471862 501(C)(3) 10000 FMV HARVESTING FOR HEALTHY YOUTH ASSISTANCE 5 NURSING EDUCATION SCHOLARSHIP 5 7680 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 1 1 0 0 0 1 1 0 0 VALINDA L RUTLEDGE 0 577086 0 316937 0 182402 0 3613 0 35021 0 1115059 0 30281 DAVID O'CONNOR 0 322191 0 135109 0 235272 0 7350 0 32470 0 732392 0 81255 MARIA LONG 0 240185 0 107347 0 140056 0 7350 0 26304 0 521242 0 54573 WAYNE F SHOVELIN 0 0 0 0 0 5914978 0 0 0 0 0 5914978 0 472568 PART I, LINES 4A-B WAYNE F. SHOVELIN, FORMER CEO PARTICIPATED IN A SUPPLEMENTAL SALARY CONTINUATION RETIREMENT PLAN. GROSS PAYMENTS FOR 2010 WERE $5,914,978. PLEASE REFER TO THE SCHEDULE O DISCLOSURE FOR PART VI, SECTION B, LINE 15 FOR MORE DETAIL. PART I, LINE 6 CERTAIN CAROMONT MEDICAL GROUP INC. PHYSICIAN'S COMPENSATION PACKAGES ARE BASED ON THE INDIVIDUAL PHYSICIAN'S NET RESULTS FROM OPERATIONS AS CALCULATED BASED SOLEY ON HIS/HER NET CHARGES LESS HIS/HER ALLOCABLE SHARE OF CLINIC OVERHEAD COSTS. 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 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 HOSIPIAL, 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. COMPENSATION FOR ALL OTHER EXECUTIVES IS ESTABLISHED THROUGH PERFORMANCE EVALUATION, COMPARISON WITH COMPARABLE MARKET DATA AND DETERMINATION BY THE CEO OF ACCEPTABLE SALARY RANGE AND PERCENTILE RANKING. ALL COMPENSATION DECISIONS FOR EXECUTIVES ARE RECOMMENDED BY THE CEO AND APPROVED BY THE COMPENSATION COMMITTEE. FULL COLLECTED COMPENSATION INFORMATION AND ANY COMPENSATION OPINIONS PROVIDED DURING THESE PROCESSES WILL BE KEPT WITH THE COMPENSATION COMMITTEE OR BOARD MINUTES, AS APPLICABLE. IN 2009, THE BOARD OF DIRECTORS, BY AND THROUGH THE COMPENSATION COMMITTEE, CONDUCTED TWO DETAILED REVIEWS OF THE RETIREMENT BENEFIT TO BE PAID TO ITS RETIRING CEO. IN CONDUCTING THESE REVIEWS, THE COMPENSATION COMMITTEE WORKED THROUGH AN EVALUATION OF THE RETIRING CEO'S PERFORMANCE DURING HIS 33-YEAR TENURE WITH THE ORGANIZATION. THE COMPENSATION COMMITTEE CONCLUDED THAT IN THE AREAS OF FINANCE AND QUALITY MEASURES, THE RETIRING CEO'S PERFORMANCE CONSISTENTLY EXCEEDED EXPECTATIONS AND HAS POSITIONED CAROMONT HEALTH AS A LEADER IN THE REGION. HIS PERFORMANCE IN THE AREA OF PATIENT SATISFACTION HAS, IN THE MISSION-CRITICAL AREA OF EMERGENCY SERVICES, EXCEEDED THE BOARD OF DIRECTOR'S EXPECTATIONS. OVERALL, AND OVER THE ARC OF HIS CAREER AT CAROMONT, THE RETIRING CEO'S LEADERSHIP HAS LED CAROMONT HEALTH FROM A MERE COMMUNITY HOSPITAL INTO A REGIONAL HEALTHCARE POWERHOUSE. THE COMMITTEE CONCLUDED THAT HIS LEADERSHIP HAD OUTPERFORMED THE REGION AND FULFILLED THE COMMUNITY'S DESIRE TO KEEP ITS HEALTHCARE SYSTEM UNDER LOCAL CONTROL, THEREBY JUSTIFYING HIS RETIREMENT PAYMENT AS FAIR AND REASONABLE COMPENSATION FOR OUTSTANDING PERFORMANCE. FORM 990, PART VI, SECTION C, LINE 18 THE ORGANIZATION'S FORM 990 IS MADE AVAILABLE TO THE PUBLIC UPON REQUEST AND ON WWW.GUIDESTAR.ORG. 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: 1,264,996. EQUITY TRANSFER -7,046. TOTAL TO FORM 990, PART XI, LINE 5: 1,257,950. 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 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1