2011-04-06T08:44:03-05:00 2010-06-30 DIXON HUGHES PLLC 500 Ridgefield Court Asheville NC 28806 990 2009-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 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 2356788 0 X WWW.CAROMONT.ORG X 1985 NC To provide exceptional health care to the communities we serve. 3 2 0 0 0 0 1628015 774819 0 227135 242605 0 1855150 1017424 1025820 480778 0 0 0 0 1807 9195 1027627 489973 827523 527451 8377524 11182026 140000 70000 8237524 11112026 To provide exceptional healthcare to the communities we serve. 0 0 480949 480778 3035347 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. Gaston Memorial Hospital Foundation actively supports Gaston Family Health Services (GFHS), a private non-profit corporation providing medical and dental services to the uninsured and underinsured population of Gaston County. During fiscal year 2010, the Foundation donated $480,778 to help cover the cost of their physicians. This clinic is important to assuring that the uninsured and underinsured have access to health care in Gaston County. CaroMont Health is committed to assisting GFHS in providing for these patients who might otherwise go without primary care services. 480949 1 1 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 0 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 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 X James R Beam 1.00 X 0 0 0 Mary Frances Forrester 1.00 X 0 0 0 David Allen Smith 1.00 X 0 0 0 James Howard Jr 1.00 X 0 0 0 Mickey Price 1.00 X 0 0 0 Sheila Reilley 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 121619 0 3164992 1052633 0 0 1 0 0 23519 751300 774819 262328 262328 1319641 1339364 -19723 -19723 -19723 1017424 0 0 242605 480778 480778 9024 9024 OTHER EXPENSE 171 171 489973 480949 9024 0 3 8145279 10163963 191555 267078 40687 750985 8377524 11182026 140000 70000 140000 70000 X 8196837 10361040 40687 750986 8237524 11112026 8377524 11182026 X 0 1 1 X 0 X 1795062 1547946 7205 1553180 774819 5678212 1795062 1547946 7205 1553180 774819 5678212 572790 5105422 979834 1023903 377967 463406 262328 3107438 74835 74835 8860485 0.57620 0.63620 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 40686 750000 -39463 238 750985 30235 15043 -1785 2807 40686 1.00000 0 0 0 CANCER FOUNDATION FUND 6513 MACKIE SCHOLARSHIP FUND 36119 SHOVELIN SCHOLARSHIP FUND 708353 750985 1017424 489973 527451 329128 2017923 2347051 2874502 2874502 329128 2017923 2347051 527451 489973 489973 1017424 0 0 0 489973 489973 489973 Part V, Line 4: Description of Intended Use of Endowment Funds: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS AND CANCER ASSISTANCE. Part XI, Line 8 - Other Adjustments: EQUITY TRANSFER: 2017923. Part XII, Line 2d - Other Adjustments: TRANFER OF EQUITY FROM HOSPITAL: 2017923. Part XII, Line 4b - Other Adjustments: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS: 489973. Part XIII, Line 4b - Other Adjustments: EXPENSES NETTED AGAINST REVENUE ON FINANCIAL STATEMENTS: 489973. 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 1 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 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 91731 0 29888 0 477384 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. CaroMont Health 2525 Court Drive Gastonia NC 28054 581636959 MEDICAL SERVICES NC 501(c)(3) Line 11B, II N/A CaroMont Health Services 2526 Court Drive Gastonia NC 28054 561455630 OUTPATIENT SERVICES NC 501(c)(3) Line 3 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 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0