2024-04-29T14:49:58-05:00 2023-06-30 440160260 FORVIS LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2022-07-01 561479699 GASTON MEMORIAL HOSPITAL FOUNDATION INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 DAVID O'CONNOR EVP, CFO 7048342000 2024-04-29 1 DAVID OCONNOR 999009999 1 AMY BIBBY P00445891 8282542254 2024-04-29 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 28054 1678812 0 X WWW.CAROMONT.ORG X 1985 NC TO ENGAGE AND INSPIRE OUR COMMUNITY TO SUPPORT CAROMONT HEALTH IN PROVIDING COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE 5 3 4 0 0 0 726948 1020867 0 0 1762248 657945 0 0 2489196 1678812 1159364 1074875 0 0 198004 294263 0 0 0 126416 183125 1483784 1552263 1005412 126549 26052596 27795692 30640 43136 26021956 27752556 X TO ENGAGE AND INSPIRE OUR COMMUNITY TO SUPPORT CAROMONT HEALTH IN PROVIDING COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE 0 0 1499070 1074875 SEE SCHEDULE OTHE MISSION OF THE CAROMONT HEALTH FOUNDATION IS TO ENGAGE AND INSPIRE THE COMMUNITY TO SUPPORT CAROMONT HEALTH BY PROVIDING COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. WHEN DONORS CHOOSE TO SUPPORT THE CAROMONT HEALTH FOUNDATION, THEIR CONTRIBUTIONS HELP FUND SCHOLARSHIPS, WORKPLACE DEVELOPMENT OPPORTUNITIES FOR EMPLOYEES AND LOCAL STUDENTS, AND GRANTS FOR LIFESAVING AND LIFE-CHANGING TREATMENTS. 1499070 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 1 0 1 4 1 0 0 0 0 0 0 0 0 0 0 0 0 X 5 3 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 NC X THE ORGANIZATION 7048342000 2525 COURT DRIVE GASTONIA NC 28054 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 1.00 54.00 X X 0 884243 174464 MS JANIE PEAK CHAIR 1.00 1.00 X X 0 0 0 DR GEORGE ADCOCK III SECRETARY 1.00 40.00 X X 0 552436 121405 MR BOB HOVIS DIRECTOR (THROUGH 12/31/22) 1.00 2.00 X 0 30589 0 MR JASON AUSTELL DIRECTOR (BEGININNG 01/01/23) 1.00 2.00 X 0 0 0 MR STEVEN WILSON DIRECTOR 1.00 2.00 X 0 0 0 MR K CHRISTOPHER PEEK CEO 1.00 54.00 X 0 1558081 286732 MS LEIGH HICKMAN CLO/ASST. SEC. 1.00 54.00 X 0 465494 103464 MS MARY GRACE BEAN DIRECTOR FOUNDATION 40.00 X 123954 0 0 123954 3490843 686065 1 0 1 0 0 559891 460976 1020867 596720 596720 61225 0 61225 61225 61225 1678812 0 0 657945 897517 897517 177358 177358 241422 241422 8400 8400 27166 27166 17275 17275 53193 53193 96888 96888 33044 33044 1552263 1499070 53193 0 343689 291489 8693 11893 10478 43444 20361257 21606226 5328479 5842640 26052596 27795692 30640 43136 30640 43136 X 20684784 21898022 5337172 5854534 26021956 27752556 26052596 27795692 126549 1604051 0 X X 0 1 X 1 0 X 3105598 1293604 1066885 726948 1020867 7213902 3105598 1293604 1066885 726948 1020867 7213902 716828 6497074 593590 510942 451329 624655 596720 2777236 791 791 9991929 0.65020 0.64360 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 5337172 369999 468312 298949 5876534 5600466 395644 -468977 188614 1347 5337172 6753405 629887 1142505 31476 2893855 5600466 3930785 2810378 147349 135107 6753405 3835087 74346 172984 151632 3835087 1.00000 0 0 0 SHOVELIN SCHOLARSHIP FUND 3416123 HUDSON NURSING SCHOLARSHIP FUND 301745 BUCCI SCHOLARSHIP FUND 5385 WOMEN OPTIMIZE WELLNESS FUND 329982 EMPLOYEE SCHOLARSHIP FUND 131172 DAMORE SCHOLARSHIP FUND 40633 ONCOLOGY SCHOLARSHIP FUND 14308 SELF SCHOLARSHIP 35982 COVID19 304360 INVESTMENTS CARE FIRST FUND 647513 INVESTMENTS CLINICAL RESEARCH FUND 18856 INVESTMENTS IN COURTLAND 72467 INVESTMENTS AUX SCHOLARSHIP 460355 WOODY FAMILY SCHOLARSHIP 31147 WORKFORCE SCHOLARSHIP 5177 GEORGE WASH HALL SCHOLARSHIP 25685 NEXT GENERATION SCHOLARSHIP 1750 5842640 X 2189949 1604051 1604051 585898 53193 1039721 1092914 1678812 459349 0 459349 53193 1039721 1092914 1552263 PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR SCHOLARSHIPS. 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, 2023 AND 2022. PART XI, LINE 4B - OTHER ADJUSTMENTS: GRANTS IN REVENUES 1,038,356. EXPENSES IN REVENUES 1,365. PART XII, LINE 4B - OTHER ADJUSTMENTS: GRANTS IN REVENUES 1,038,356. EXPENSES IN REVENUES 1,365. 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 560619359 501(C)(3) 423549 0 COMMUNITY ASSISTANCE GASTON COLLEGE FOUNDATION 201 HIGHWAY 321 SOUTH DALLAS NC 28034 237079454 501(C)(3) 44500 0 COMMUNITY ASSISTANCE CANCER SERVICES OF GASTON COUNTY 306 S COLUMBIA STREET GASTONIA NC 28054 561164253 501(C)(3) 30000 0 COMMUNITY ASSISTANCE BACKPACK WEEKEND FOOD PROGRAM PO BOX 551030 GASTONIA NC 28055 471591744 501(C)(3) 17000 0 OPERATIONAL SUPPORT HEART SOCIETY OF GC 1201 EAST GARRISON BLVD GASTONIA NC 28054 561330921 501(C)(3) 15000 0 OPERATIONAL SUPPORT GASTON COLLEGE 201 HIGHWAY 321 SOUTH DALLAS TX 28034 237079454 501(C)(3) 150000 0 COMMUNITY ASSISTANCE 7 0 SCHOLARSHIPS 30 177357 SHOVELIN, BUCCI, HUDSON AND MACKIE NURSING SCHOLARSHIPS 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. 0 1 0 0 0 0 1 0 0 MR K CHRISTOPHER PEEK CEO 0 948458 0 411971 0 197652 0 263009 0 23723 0 1844813 0 158940 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 0 580745 0 194511 0 108987 0 150741 0 23723 0 1058707 0 86689 DR GEORGE ADCOCK III SECRETARY 0 387244 0 110038 0 55154 0 97727 0 23678 0 673841 0 46463 MS LEIGH HICKMAN CLO/ASST. SEC. 0 362901 0 101731 0 862 0 87394 0 16070 0 568958 0 0 PART I, LINE 3 COMPENSATION PAID TO CEO OF CAROMONT HEALTH, INC. WAS PAID BY CAROMONT REGIONAL MEDICAL CENTER, A RELATED ORGANIZATION. CAROMONT REGIONAL MEDICAL CENTER UTILIZED THE FOLLOWING METHODS TO DETERMINE APPROPRIATE COMPENSATION FOR CEO THAT HAD INFLUENCE OVER THE ORGANIZATION'S ACTIVITIES: - COMPENSATION COMMITTEE - INDEPENDENT COMPENSATION CONSULTANT - WRITTEN EMPLOYMENT CONTRACTS - COMPENSATION SURVEY OR STUDY - APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS BY RELATED ORGANIZATION CAROMONT REGIONAL MEDICAL CENTER FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 111,541 K. CHRISTOPHER PEEK - $ 223,809 DR. GEORGE ADCOCK III - $ 59,779 LEIGH HICKMAN - $ 55,268 PART I, LINE 6 EXECUTIVE INCENTIVE COMPENSATION PLAN FOR ALL KEY EMPLOYEES BASED ON THE ACHIEVEMENT OF ANNUAL BUSINESS OBJECTIVES WHICH INCLUDE A FINANCIAL GOAL ATTRIBUTABLE TO OPERATING MARGIN. 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 IS CAROMONT HEALTH, INC., A NORTH CAROLINA NOT-FOR-PROFIT CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF DIRECTORS SHALL CONSISTENT OF 5 MEMBERS, ALL OF WHO ARE APPOINTED BY THE BOARD OF DIRECTORS OF THE SOLE MEMBER. TWO MEMBERS OF THE BOARD OF CAROMONT HEALTH SHALL BE MEMBERS OF THE BOARD. TWO MEMBERS SHALL BE MEMBERS OF CAROMONT'S SENIOR LEADERSHIP TEAM AND RECOMMENDED BY THE CEO. ONE MEMBER SHALL BE A COMMUNITY MEMBER RECOMMENDED BY THE CEO. 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 11B THE ORGANIZATION'S FORM 990 WAS REVIEWED BY THE AUDIT FINANCE INVESTMENT COMMITTEE OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH PRIOR TO PRESENTATION TO THE FULL BOARD BEFORE THE FORM WAS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C MEMBERS OF THE BOARD OF DIRECTORS, MEMBERS OF SENIOR LEADERSHIP, ANY PHYSICIAN HOLDING A LEADERSHIP OR ADMINISTRATIVE POSITION WITHIN THE ORGANIZATION, DIRECTORS, RESEARCH STUDY PERSONNEL, MANAGERS AND ALL STAFF MEMBERS OF THE PURCHASING AND MARKETING DEPARTMENTS AND ANY OTHER DEPARTMENT DEEMED TO HAVE MATERIAL DECISION MAKING RESPONSIBILITIES ON BEHALF OF CAROMONT HEALTH SHALL FULLY AND TRUTHFULLY COMPLETE A QUESTIONNAIRE CONCERNING POTENTIAL AND ACTUAL CONFLICTS OF INTEREST ANNUALLY. SUCH QUESTIONNAIRE SHALL IDENTIFY THE INDIVIDUAL'S OBLIGATION TO IMMEDIATELY MAKE THE CORPORATE COMPLIANCE OFFICER AWARE IN WRITING OF ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST AS THEY MAY ARISE AND CONTAIN SAID INDIVIDUAL'S AGREEMENT TO ABIDE BY ALL TERMS AND CONDITIONS OF THIS POLICY AS A CONDITION OF RETAINING THEIR POSITION. SUCH QUESTIONNAIRES ARE REVIEWED ANNUALLY BY THE CHIEF LEGAL OFFICER AND THE CORPORATE COMPLIANCE OFFICER. QUESTIONNAIRES SUBMITTED BY DIRECTORS ARE REVIEWED ANNUALLY BY THE NOMINATING COMMITTEE OF THE BOARD. FORM 990, PART VI, SECTION B, LINE 15 THE CEO, CFO, COO, CPE AND CHIEF LEGAL OFFICER ARE COMPENSATED FOR THEIR SERVICES BY CAROMONT REGIONAL MEDICAL CENTER, 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. A MAJORITY OF THE BOARD MEMBERS WHO SERVE ON THE COMPENSATION COMMITTEE ARE INDEPENDENT AND ALL ARE FREE FROM 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 DOES NOT PARTICIPATE IN THE DISCUSSION OR DECISION-MAKING BY THE REMAINING 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 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. PART XII, LINE 2C THE PROCESS FOR THIS HAS NOT CHANGED FROM THE PRIOR YEAR. FORM 990, PART V AND PART VII 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 INC 2525 COURT DRIVE GASTONIA NC 28054 581636959 MEDICAL SERVICES NC 501(C)(3) LINE 12B, 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 10 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 0 1 1 0 0 0 0 0 1 0 0 1 0 1 0 1 1 1 1