2011-04-06T08:44:03-05:00 2010-06-30 DIXON HUGHES PLLC 500 Ridgefield Court Asheville NC 28806 990 2009-07-01 561455630 CAROMONT HEALTH SERVICES CARO 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 DAVID O'CONNOR 7048342000 2011-03-29 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 11386665 0 X WWW.CAROMONT.ORG X 1984 NC To provide exceptional health care to the communities we serve. 3 2 179 0 0 0 3631 11849339 11381235 14 2642 1785 11851981 11386665 0 0 5179064 5132473 0 0 4847352 4890741 10026416 10023214 1825565 1363451 12954619 12299079 532401 439587 12422218 11859492 To provide exceptional healthcare to the communities we serve. 0 0 9149524 11381235 SEE SCHEDULE O.The vision of CaroMont Health is to be a nationally recognized leader and valued partner in promoting individual health and vibrant communities.CaroMont Health Services, Inc. participates in the CaroMont Health mission by providing outpatient surgical care through the CaroMont Specialty Surgery Center and personal nursing care and maintenance through Courtland Terrace Nursing Home. 9149524 1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 29 0 179 1 0 0 0 0 0 0 0 0 0 3 2 0 0 0 0 0 0 0 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 Kelvin C Harris MD 1.00 X X 0 225445 18524 Mary Frances Forrester 1.00 X 0 0 0 Richard K Craig 1.00 X 0 0 0 Wayne F Shovelin 1.00 X 0 1972052 712653 Valinda L Rutledge 1.00 X 0 257892 43500 David O'Connor 1.00 X 0 579283 174861 Maria Long 1.00 X 0 355765 121679 Patricia Anderson 40.00 X 35823 0 1608 35823 3390437 1072825 0 0 1 0 REHABCARE GROUP INC 7733 FORSYTH BLVD STE 1700 ST LOUIS MO 63105 pHYSICAL THERAPY 677797 1 3631 3631 OUTPATIENT SERVICES 621400 11043358 11043358 PROGRAM SERVICE INVEST 900099 337877 337877 11381235 14 14 CAFETERIA 900099 1785 1785 1785 11386665 11381235 0 1799 37431 37431 4075310 3545898 529412 65472 56470 9002 625232 540656 84576 329028 283790 45238 19400 19400 52 52 1209001 1169031 39970 296 246 50 113880 68406 45474 274323 267465 6858 5617 791 4826 15578 6639 8939 767102 767102 37062 37062 MEDICAL SUPPLIES 2074154 2074154 BAD DEBT 224991 224991 EQUIPMENT RENTAL & MAIN 128396 128386 10 MISCELLANEOUS 19826 14436 5390 EDUCATION 1063 1063 10023214 9149524 873690 0 1468 3163 745356 479728 185143 154395 19171 8229 18899647 9915732 9390755 8983915 2565000 2565000 47726 104649 12954619 12299079 532401 439587 532401 439587 X 12422218 11859492 12422218 11859492 12954619 12299079 X 0 1 1 X 0 X 13933306 5493674 8439632 4829754 4291054 538700 136587 131004 5583 8983915 INVESTMENT IN ADVANCED HOME CARE, INC PURSUANT TO NAME CHANGE AND MERGER 2565000 F 2565000 11386665 10023214 1363451 8 -1926185 -1926177 -562726 11158646 8 -228027 -228019 11386665 0 11386665 9795187 0 9795187 228027 228027 10023214 Part XI, Line 8 - Other Adjustments: EQUITY TRANSFER TO AFFILIATE: -1926185. Part XII, Line 2d - Other Adjustments: BAD DEBT: -224991. EXPENSES INCLUDED IN REVENUE: -3036. Part XIII, Line 4b - Other Adjustments: BAD DEBT: 224991. EXPENSES INCLUDED IN REVENUE: 3036. 1 X X X X X 0 1 0 0 0 1 1 0 0 Kelvin C Harris MD 0 161539 0 61856 0 2050 0 18524 0 0 0 243969 0 0 Wayne F Shovelin 0 642828 0 394994 0 934230 0 577417 0 135236 0 2684705 0 922287 Valinda L Rutledge 0 145002 0 112500 0 390 0 31876 0 11624 0 301392 0 0 David O'Connor 0 311111 0 121980 0 146192 0 135558 0 39303 0 754144 0 132040 Maria Long 0 204730 0 71010 0 80025 0 91791 0 29888 0 477444 0 78135 Part I, Line 4a Wayne F. Shovelin, CEO participates in a Supplemental Salary Continuation Retirement Plan. Gross payments for 2010 were $5,914,998. 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 B, line 11 The organization's Form 990 is reviewed by the Audit Finance Investment committee of the Board of Directors prior to presentation to the full Board before the Form is 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 on 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 Vice President/General Counsel and the Corporate Compliance Officer. The President shall make the Board of Directors aware of any actual conflicts of interest. Form 990, Part VI, Section B, line 15 The CEO, CFO/Assistant Treasurer and General Counsel/Assistant Secretary are compensated for their services by 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 dialogue with the CEO, 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 a process of dialogue between the CEO and the executive, 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 19 At this time, the organization's governing documents and conflict of interest policy are not made available to the public. The organization's financial statements are made available upon request. FORM 990, PART V AND PART VII COMMON PAYMASTER 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 2525 Court Drive Gastonia NC 28054 581636959 MEDICAL SERVICES NC 501(c)(3) Line 11B, II N/A Gaston Memorial Hospital Foundation Inc 2527 Court Drive Gastonia NC 28054 561479699 FOUNDATION NC 501(c)(3) Line 9 N/A CaroMont Medical Group Inc 2528 Court Drive Gastonia NC 28054 561479712 MEDICAL GROUP NC 501(c)(3) Line 9 N/A Hospice of Gaston County Inc 2529 Court Drive Gastonia NC 28054 581341530 Hospice Care NC 501(c)(3) Line 7 N/A Gaston Memorial Hospital Inc 2530 Court Drive Gastonia NC 28054 560619359 HOSPITAL NC 501(c)(3) Line 3 N/A Gaston Emergency Physicians Inc 2531 Court Drive Gastonia NC 28054 562209423 Supporting Organization NC 501(c)(3) Line 11A, I N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1