2024-04-29T14:49:58-05:00 2023-06-30 440160260 FORVIS LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2022-07-01 560619359 GASTON MEMORIAL HOSPITAL INC GAST 7048342000 2525 COURT DRIVE 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 CAROMONT REGIONAL MEDICAL CTR DAVID O'CONNOR 2525 COURT DRIVE GASTONIA NC 28054 710174545 0 X WWW.CAROMONT.ORG X 1945 NC TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 14 10 4078 132 170803 72143 451028 437208 682507664 705072770 2772379 192832 3673742 4155598 689404813 709858408 1497469 1200577 0 0 270037481 290909667 0 0 0 360398787 358682059 631933737 650792303 57471076 59066105 730850666 838442096 506717452 443981255 224133214 394460841 TO PROVIDE COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. 0 0 612306469 1200577 704901967 CAROMONT HEALTH'S PHILOSOPHY OF CARE IS FOUNDED IN THREE DISTINCT WAYS. IT IS A HEALTH SYSTEM THAT INVESTS IN THE FUTURE OF HEALTHCARE FROM RESEARCH TO EDUCATION. IT IS AN ACTIVE COMMUNITY PARTNER, SUPPORTING AND DRIVING PROGRAMS THAT ENCOURAGE HEALTHIER LIFESTYLES. IT IS ALSO ADYNAMIC ORGANIZATION FOCUSED ON CONTINUOUS DAILY IMPROVEMENT, ADVANCED MEDICINE AND THE DELIVERY OF COMPASSIONATE, EXCEPTIONAL AND HIGHLY RELIABLE CARE. THE FISCAL YEAR ENDING JUNE 30, 2023 SAW CAROMONT HEALTH LIVING ITS VISION TO BE OUR COMMUNITY'S MOST TRUSTED HEALTHCAREPARTNER. THE COMPLETE 2023 COMMUNITY BENEFIT REPORT CAN BE FOUND AT WWW.CAROMONTHEALTH.ORG. 612306469 1 1 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 260 0 1 4078 1 1 1 0 0 0 0 0 0 0 0 0 1 0 X 14 10 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 PAYSEUR TREASURER AS OF 1/1/2023 1.00 1.00 X X 0 0 0 MR JEFFREY CASH CHAIR AS OF 1/1/2023 1.00 1.00 X X 0 0 0 REVPEARL BURRIS-FLOYD SECRETARY 1.00 40.00 X X 0 119248 0 MR BARRY POMEROY TREASURER THROUGH 12/31/2022 1.00 1.00 X X 0 0 0 DR JAY HENDLER CHIEF-OF-STAFF AS OF 1/22 1.00 40.00 X 0 492906 26481 DR HEALTH HIGH CHIEF-OF-STAFF ELECT AS OF 1/22 1.00 40.00 X 0 572492 34995 DR MICHEAL GASLIN PAST-CHIEF-OF-STAFF (NON-VOTING) STARTING 1/1/2022 1.00 1.00 X 22500 0 0 MR BOB HOVIS DIRECTOR 1.00 1.00 X 0 30589 0 MR JOSEPH DAVIS JR DIRECTOR 1.00 2.00 X 0 0 0 MR WILLIAM ANTHONY DIRECTOR 1.00 1.00 X 0 0 0 MS ANNETTE CARTER DIRECTOR 1.00 1.00 X 0 0 0 MS JANIE PEAK DIRECTOR 1.00 1.00 X 0 0 0 MR FRANK STEWART DIRECTOR 1.00 1.00 X 0 0 0 MR TOM EFIRD DIRECTOR 1.00 1.00 X 0 0 0 REVBENJAMIN HINTON DIRECTOR 1.00 1.00 X 0 0 0 MR JASON AUSTELL DIRECTOR 1.00 1.00 X 0 0 0 MR DAN BOYD DIRECTOR 1.00 1.00 X 0 0 0 MR JAY MCGRAW DIRECTOR 1.00 1.00 X 0 0 0 MR K CHRISTOPHER PEEK CEO 45.00 10.00 X 1558081 0 286732 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 45.00 10.00 X 884243 0 174464 MS LEIGH HICKMAN CLO/ASST. SEC. 45.00 10.00 X 465494 0 103464 MR DANNY WHARTON CHIEF OPERATING OFFICER 45.00 10.00 X 562270 0 122842 MS KATHLEEN BESSON SPECIAL ADVISOR TO CEO 45.00 10.00 X 687295 0 73014 DR TODD DAVIS EVP CHIEF PHYSICIAN EXECUTIVE 45.00 10.00 X 954616 0 186354 DR GEORGE ADCOCK III VP MEDICAL AFFAIRS 40.00 10.00 X 552436 0 121405 MR RICHARD BLACKBURN VP SUPPORT SERVICES 40.00 10.00 X 462254 0 114991 MS ROBIN LANG VP CHIEF INFORMATION OFFICER 40.00 10.00 X 503360 0 92832 MR FRANK MURPHY VP STRATEGY BUSINESS DEVELOPMENT 40.00 10.00 X 505337 0 107239 MS ASHLEY LONG VP CHIEF NURSING OFFICER 40.00 10.00 X 489380 0 64693 7647266 1215235 1509506 465 0 1 0 THE ROBINS AND MORTON GROUP 400 SHADES CREEK PARKWAY BIRMINGHAM AL 352465870 CONSTRUCTION MANAGEMENT 152041634 CROSS COUNTRY STAFFING PO BOX 404682 ATLANTA GA 303844682 TEMP PERSONNEL 56243005 SHC SERVICES INC PO BOX 677896 DALLAS TX 752677896 TEMP PERSONNEL 12777288 CUSTOM BUILDING SYSTEMS P O BOX 6280 GASTONIA NC 28056 CONSTRUCTION MANAGEMENT 4130749 MCMILLAN PAZDAN SMITH LLC PO BOX 537044 ATLANTA GA 303539450 CONSTRUCTION MANAGEMENT 3115444 82 423549 13659 437208 PATIENT SERVICE REVENUE 621500 702333384 702333384 ANCILLARY REVENUE 621500 2739386 2568583 170803 705072770 508969 508969 316137 -316137 -316137 -316137 CAFETERIA & VENDING INCOME 900099 2161773 2161773 MISCELLANEOUS REVENUE 900099 1893339 1893339 PHARMACY REVENUE 621500 60654 60654 39832 39832 4155598 709858408 704901967 170803 4348430 X 1200317 1200317 260 260 4896754 4896754 232847118 213547337 19299781 7978506 7166488 812018 29681943 26661044 3020899 15505346 13927279 1578067 1115616 1115616 820533 820533 207000 207000 28000 28000 23 23 100666560 96530151 4136409 2215810 490970 1724840 5850764 4425054 1425710 3160721 3160721 7104879 7104879 128503 75147 53356 553327 276200 277127 7947826 7947826 38582724 38582724 2281503 2281503 MEDICAL SUPPLIES 112780454 112780454 UBI TAX 77576 77576 BAD DEBT 60862433 60862433 MEDICAID ASSESSMENT FEE 7604111 7604111 6693696 6565955 127741 650792303 612306469 38485834 0 1 5 64795343 83316902 11497614 12723915 7185216 5054592 1069817651 447508007 461851798 622309644 72361185 18663032 113159509 96374006 730850666 838442096 145635796 132406624 263486757 250284717 97594899 61289914 506717452 443981255 X 127925123 339071374 96208091 55389467 224133214 394460841 730850666 838442096 X 59066105 668 111260854 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 1 0 0 0 0 1 156172 0 1 48516 204688 0 PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $48,516 WAS DETERMINED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. THE ORGANIZATION HAD AN ADDITIONAL $156,172 IN LOBBYING COSTS FOR FISCAL YEAR 2023. LOBBYING REGISTRATION IS IN THE NAME OF CAROMONT HEALTH, INC. LOBBYING EXPENDITURES ARE REPORTED ON THE GASTON MEMORIAL HOSPITAL, INC FORM 990. 12061 12061 12061 12061 10190 1941 70 12061 10310 228 348 10190 10049 655 394 10310 1.00000 0 0 8963536 8963536 448796910 227538206 221258704 10174688 9335873 838815 294168885 203507238 90661647 307713632 7126690 300586942 622309644 NET PENSION ASSET/DEFERRAL 76550096 DEFERRED FINANCING COSTS 709829 OTHER RECEIVABLES 7307227 DEFERRED CHARGE-INTEREST RATE SWAP 4844223 SBITA 6962631 96374006 ESTIMATED 3RD PARTY SETTLEMENTS 56366885 INTEREST RATE SWAP LIABILITY 4844223 PENSION DEFERRED INFLOW 78806 61289914 X 766689034 668 6376837 6377505 760311529 23 -50453144 -50453121 709858408 596306684 6376837 6376837 589929847 23 60862433 60862456 650792303 PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR ONCOLOGY MEDICATIONS FOR INDIGENT PATIENTS. 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 2D - OTHER ADJUSTMENTS: EXPENSES IN REVENUES 3,187. PROVIDER RELIEF FUNDS 6,373,650. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 60,862,433. INTERCOMPANY TRANSFER FROM AFFILIATE -111,315,577. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES IN REVENUES 3,187. PROVIDER RELIEF FUNDS 6,373,650. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 60,862,433. 1 1 1 X 1 X 1 1 0 1 1 14095747 14095747 0.02390 102574097 84385518 18188579 0.03080 116669844 84385518 32284326 0.05470 2564146 5655 2558491 0.00430 3106679 161752 2944927 0.00500 562315 133469 428846 0.00070 1294685 1294685 0.00220 7527825 300876 7226949 0.01220 124197669 84686394 39511275 0.06690 3503304 3503304 0.00590 3503304 3503304 0.00590 60862433 3752595 89954496 105427598 -15473102 X 1 1 1 1 CAROMONT REGIONAL MEDICAL CENTER 2525 COURT DRIVE GASTONIA NC 28054 X X X 3 DIAGNOSTIC IMAGING CENTERS AND 6 OP SERIVCE CENTER CAROMONT REGIONAL MEDICAL CENTER 1 0 0 1 X X X X X X X X 21 1 0 1 1 X WWW.CAROMONTHEALTH.ORG X WWW.GASTONGOV.COM/DEPARTMENTS/HEALTH-AND-HUMAN-SERVICES X X 1 21 1 HTTPS://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/FY21_PRESENTATION_CHNA-(1).PDF 0 1 X 200.000000000000 200.000000000000 X X X X 1 1 X X X X 1 X SEE DISCLOSURE X SEE DISCLOSURE X SEE DISCLOSURE X X X X X X 1 X 0 X X X X X 1 X 0 0 CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 5: GASTON COUNTY COMMUNITY HEALTH ASSESSMENT WAS CONDUCTED BY THE FOLLOWING PARTNERS: THE GASTON COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, GASTON TOGETHER, UNITED WAY OF GASTON COUNTY, CAROMONT HEALTH, AND STAKEHOLDER ORGANIZATIONS. THE ASSESSMENT INCLUDES THE COLLECTION AND ANALYSIS OF EXISTING STATISTICAL DATA, QUALITY OF LIFE SURVEY DATA COLLECTED DIRECTLY FROM RESIDENTS AND INPUT FROM COMMUNITY FOCUS GROUPS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 6B: THE HOSPITAL CONDUCTED THEIR CHNA WITH THE FOLLOWING ORGANIZATIONS: GASTON COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES, CAROMONT HEALTH, GASTON TOGETHER, THE UNITED WAY OF GASTON COUNTY AND REPRESENTATIVES OF OTHER STAKEHOLDER ORGANIZATIONS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 7D: PARTNERING AGENCIES PRESENTED THE CHNA AT WORKSHOPS, MEETINGS AND ON AGENCY WEBSITES TO ENCOURAGE COMMUNITY STAKEHOLDERS TO USE THEM TO ENHANCE THE WELLBEING OF GASTON COUNTY AND ITS RESIDENTS. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 11: CAROMONT HEALTH PRIORITIES (2019-2021) ARE TO PROACTIVELY MANAGE MENTAL HEALTH ISSUES IN PRIMARY CARE OFFICES THROUGH THE HIRE OF MORE LCSWS, ENHANCE OPIOID AND PRESCRIPTION DRUG ABUSE INTERVENTION AND MANAGEMENT PROTOCOLS AND TO IMPROVE ACCESS TO AFFORDABLE HEALTH FOOD IN LOW INCOME COMMUNITIES THROUGH WORK WITH LOCAL STAKEHOLDERS. THE IMPLEMENTATION PLAN AND PRIORITIES FOR THE MOST RECENT CHNA WERE SET IN NOVEMBER 2022. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 13B: REGARDLESS OF INCOME, ASSETS ARE ALSO USED TO DETERMINE IF A PATIENT QUALIFIES FOR CHARITY. BELOW IS THE VERBIAGE FROM THIS POLICY: EXEMPT ASSETSTHE PRIMARY RESIDENCE ON UP TO ONE ACRE OF LAND, ONE AUTOMOBILE FOR EACH WORKING AGED ADULT, AND OTHER ASSETS, INCLUDING BUT NOT LIMITED TO, RETIREMENT FUNDS, INVESTMENTS AND OTHER FINANCIAL ASSETS, CASH VALUE OF LIFE INSURANCE POLICIES, AND EQUITY IN PROPERTY OR REAL ASSETS, TOTALING UP TO $25,000 ARE ALSO EXEMPT FROM CONSIDERATION AS ASSETS IN DETERMINING CHARITY CARE ELIGIBILITY. ANNUAL INCOME FROM PROPERTY OF REAL ASSETS WILL BE DEDUCTED FROM THE AMOUNT OF EQUITY IN THE ASSET WHEN CALCULATING THE EXEMPTION. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 15E: CAROMONT HEALTH HAS A TEAM DEDICATED TO EDUCATING AND/OR ASSISTING PATIENTS WITH OTHER STATE OR GOVERNMENT AGENCIES THAT MAY BE A SOURCE OF ASSISTANCE. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 16J: PLAIN LANGUAGE BROCHURES ARE DISTRIBUTED AT REGISTRATION SITES. FINANCIAL COUNSELORS PROACTIVELY COMMUNICATE VERBALLY OR IN WRITING PRIOR TO SERVICE FOR SCHEDULED VISITS AND IN-HOUSE, AND/OR AFTER SERVICE TO THOSE MOST LIKELY TO REQUIRE FINANCIAL ASSISTANCE. VERBIAGE IS ALSO ON THE PATIENT BILLING STATEMENT. SPANISH INSTRUCTIONS ON WEBSITE AND IN PERSON INTERPRETER STAFF AVAILABLE TO ASSIST. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 18E: COLLECTION ACTIONS ARE TAKEN AFTER REASONABLE EFFORTS HAVE BEEN MADE TO DETERMINE PATIENT'S ELIGIBILITY FOR ASSISTANCE. CAROMONT REGIONAL MEDICAL CENTER PART V, SECTION B, LINE 20E: PLAIN LANGUAGE BROCHURES AT REGISTRATION SITES. PROACTIVELY COMMUNICATING VERBIALLY AND/OR IN WRITING TO SCHEDULED PATIENTS PRIOR TO SERVICE. COMMUNICATING IN-HOUSE, DURING SERVICE, OR AFTER SERVICE TO THOSE MOST LIKELY TO QUALIFY FOR ASSISTANCE. PART V, SECTION B, LINE 16A THE PLAIN LANGUAGE SUMMARY AND CHARITY CARE APPLICATION CAN BE FOUND USING THE LINKS BELOW:PLAIN LANGUAGE SUMMARY: HTTP://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/REGISTRATION_CHARITYCAREPOLICYCHARITY CARE APPLICATION: HTTP://WWW.CAROMONTHEALTH.ORG/DOCUMENTS/CHARITY-CARE-APPLICATION-ENGLISH PART I, LINE 3C: FREE CARE IS PROVIDED TO PATIENTS WITH A FPG OF 200% OR LESS. ALL OTHER PATIENTS RECEIVE AN INSURANCE DISCOUNT BASED ON THEIR INDIVIDUAL INSURANCE PLAN AGREEMENT OR AN UNINSURED DISCOUNT FOR SELF PAY PATIENTS. UNINSURED DISCOUNTS ARE COMPARABLE TO OUR INSURANCE DISCOUNTS.REGARDLESS OF INCOME, ASSETS ARE ALSO USED TO DETERMINE IF A PATIENT QUALIFIES FOR CHARITY. BELOW IS THE VERBIAGE FROM THIS POLICY:EXEMPT ASSETSTHE PRIMARY RESIDENCE ON UP TO ONE ACRE OF LAND, ONE AUTOMOBILE FOR EACH WORKING AGED ADULT, AND OTHER ASSETS UP TO $25,000 INCLUDING BUT NOT LIMITED TO, RETIREMENT FUNDS, INVESTMENTS AND OTHER FINANCIAL ASSETS, CASH VALUE OF LIFE INSURANCE POLICIES, AND EQUITY IN PROPERTY OR REAL ASSETS ARE ALSO EXEMPT FROM CONSIDERATION AS ASSETS IN DETERMINING CHARITY CARE ELIGIBILITY. ANNUAL INCOME FROM PROPERTY OF REAL ASSETS WILL BE DEDUCTED FROM THE AMOUNT OF EQUITY IN THE ASSET WHEN CALCULATING THE EXEMPTION.PART 1, LINE 6A:COMMUNITY BENEFIT REPORT: THE ORGANIZATION'S COMMUNITY BENEFIT REPORT MADE AVAILABLE TO THE PUBLIC CONTAINS COMMUNITY BENEFITS FOR ALL RELATED ORGANIZATIONS TO THE HOSPITAL. PART I, LINE 7: THE COSTING METHODOLOGY USED IS A COST ACCOUNTING SYSTEM. ALL PATIENT SEGMENTS ARE INCLUDED. THIS SYSTEM ASSIGNS DIRECT COSTS TO SUPPLIES, PROCEDURES, ROUTINE AND SPECIALTY ROOM RATES BASED ON THE DEPARTMENT OF ORIGINATION. FIXED COSTS ARE ALLOCATED BASED ON STATISTICAL BASIS. THESE COSTS ARE THEN AGGREGATED AT THE PATIENT LEVEL AND TABULATED BY PAYOR TYPE. THE RATIO OF COST TO CHARGE METHOD IS NOT MATERIALLY USED IN THE COST ACCOUNTING SYSTEM. PART I, LN 7 COL(F): 60,862,433 BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES PRIOR TO CALCULATING PERCENT OF TOTAL EXPENSE. PART I, LINE 7H: CAROMONT HEALTH IS INVOLVED IN APPROXIMATELY 40 RESEARCH STUDIES, APPROXIMATELY 55% OF WHICH ARE CLINICAL TRIALS COOPERATIVE GROUP PROGRAM STUDIES SPONSORED BY THE NATIONAL CANCER INSTITUTE (NCI). CAROMONT HEALTH ALSO PARTICIPATES IN DRUG AND DEVICE STUDIES SPONSORED BY VARIOUS PHARMACEUTICAL, BIOTECHNOLOGY, AND DEVICE COMPANIES, AS WELL AS UNFUNDED ONCOLOGY, NURSING AND PHARMACY RESEARCH STUDIES. PART II, COMMUNITY BUILDING ACTIVITIES: CAROMONT HEALTH'S RECRUITMENT OF PHYSICIANS, ADVANCED CARE PRACTITIONERS, NURSING AND CLINICAL STAFF, AND BUSINESS AND SUPPORT STAFF EXTENDS INTO THE FIVE COUNTIES THE SYSTEM SERVES AND IS DRIVEN BY THE CHANGING POPULATION OF THE REGION AND THE SPECIFIC HEALTH NEEDS OF PATIENTS. THE SYSTEM'S GOAL IS TO BE PRO-ACTIVE AND ANTICIPATORY SO THAT THE HEALTH CARE NEEDS OF THE COMMUNITY ARE MET IN A QUALITY-DRIVEN AND CONVENIENT MANNER. ADDITIONALLY, CAROMONT HEALTH OFFERS A FULL PROGRAM FOCUSED ON JOB COMPETENCY TRAINING AND PROFESSIONAL DEVELOPMENT OPPORTUNITIES FOR EMPLOYEES AT ALL LEVELS OF THE ORGANIZATION AND ROBUST EDUCATION PARTNERSHIPS WITH PUBLIC SCHOOLS, CAREER TECH PROGRAMS, AND COLLEGES AND UNIVERSITIES TO DEVELOP CAREER PATHWAYS FOR STUDENTS. PART III, LINE 2: CHARGES FOR SERVICES PROVIDED IN THE EMERGENCY DEPARTMENT ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING. CHARGES FOR SERVICES PROVIDED ELSEWHERE IN THE HOSPITAL ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING AND/OR APPLICATIONS FILED BY THE PATIENTS. IF NO MEANS TESTING IS DONE AND NO APPLICATION IS FILED, THE UNPAID AMOUNT IS WRITTEN-OFF TO BAD DEBT. THE % OF PATIENTS QUALIFYING FOR CHARITY IN THE EMERGENCY DEPARTMENT WAS APPLIED TO THE REMAINDER OF THE HOSPITAL TO DETERMINE THE % OF BAD DEBT PATIENTS WHO COULD HAVE BEEN CHARITY. PART III, LINE 3: EXCLUDED ALL EMERGENCY ROOM PATIENT ACCOUNTS THAT ARE SCREENED BY OUR REAL TIMESOFTWARE, ALL OTHER ACCOUNTS THAT HAD A CHARITY INDICATOR TO SHOW CHARITY WAS CONSIDERED AND ALL OTHER ACCOUNTS WITH A NOTE IN THE ACCOUNT HISTORY THAT CHARITY WAS CONSIDERED. AFTER EXCLUSIONS THERE REMAINED $7,505,190 THAT WENT TO BAD DEBT AND WE ESTIMATED 50% COULD POSSIBLY HAVE BEEN CHARITY IF ALL REQUIREMENTS WERE MET BY THE PATIENT. PART III, LINE 2: CHARGES WRITTEN OFF TO BAD DEBT WERE TABULATED AT THE PATIENT LEVEL AND ARE REPORTED AT THE AMOUNT CHARGED TO PATIENTS. ACCOUNTS ARE RESERVED AS BAD DEBT BASED ON AN ACCOUNTS RECEIVABLE AGING METHODOLOGY. WHEN ACCOUNTS ARE SENT TO A COLLECTION AGENCY, THEY ARE WRITTEN OFF THE ACCOUNTS RECEIVABLE SYSTEM. ANY SUBSEQUENT COLLECTIONS ON THE ACCOUNTS ARE POSTED AS RECOVERIES AND REDUCE THE EXPENSE. ALL UNINSURED PATIENTS RECEIVE A DISCOUNT ON THEIR BILL, WHICH IS RECORDED AS A CONTRACTUAL ADJUSTMENT. THE AMOUNT OF THE UNINSURED DISCOUNTS ARE EXCLUDED FROM BAD DEBT EXPENSE. PART III, LINE 3: CHARGES FOR SERVICES PROVIDED IN THE EMERGENCY DEPARTMENT ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING. CHARGES FOR SERVICES PROVIDED ELSEWHERE IN THE HOSPITAL ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING AND/OR APPLICATIONS FILED BY THE PATIENTS. IF NO MEANS TESTING IS DONE AND NO APPLICATION IS FILED, THE UNPAID AMOUNT IS WRITTEN-OFF TO BAD DEBT. THE % OF PATIENTS QUALIFYING FOR CHARITY IN THE EMERGENCY DEPARTMENT WAS APPLIED TO THE REMAINDER OF THE HOSPITAL TO DETERMINE THE % OF BAD DEBT PATIENTS WHO COULD HAVE BEEN CHARITY. PART III, LINE 4: THE ORGANIZATION'S FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE ON BAD DEBT EXPENSE. BAD DEBT EXPENSE IS REPORTED AS A DEDUCTION FROM PATIENT REVENUE. PART III, LINE 1: THE ORGANIZATION COMPLIES WITH THE REPORTING REQUIREMENTS OF GASB. STATEMENT NO. 15 IS NOT APPLICABLE. PART III, LINE 8: THE MEDICARE COST REPORT STANDARD COSTING METHODOLOGY WAS FOLLOWED WHEN FILING THE COST REPORT. THIS IS A STEP DOWN METHODOLOGY THAT APPLIES THE AVERAGE PATIENT COST TO MEDICARE PATIENTS. THE COST REPORT DOES NOT ALLOW HOSPITALS TO REPORT ALL OPERATING COSTS. BECAUSE OF THESE TWO ISSUES, THE MEDICARE COST REPORT METHODOLOGY UNDERSTATES THE TRUE COST OF TREATING MEDICARE PATIENTS. WE HAVE USED COSTING METHOD TO DETERMINE TOTAL COSTS RELATED TO THE MEDICARE PROGRAM AND ALL OF THE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BEFEFIT AS THIS REPRESENTS THE TRUE COST OF ADMINSTERING THE PROGRAM PART III, LINE 9B: THE POLICY CONTAINS PROVISIONS ON THE COLLECTION PRACTICES TO BE FOLLOWED FOR PATIENTS WHO ARE KNOWN TO QUALIFY FOR CHARITY CARE OR FINANCIAL ASSISTANCE. BELOW IS VERBIAGE FROM THE CHARITY POLICY:CAROMONT REGIONAL MEDICAL CENTER OFFERS MEDICAL SERVICES FREE OF CHARGE THROUGH THE CHARITY CARE PROGRAM. DETERMINATION OF CHARITY CARE WILL BE BASED ON THE PATIENT'S INCOME, FAMILY SIZE, AND ASSETS. POTENTIAL ELIGIBILITY EXISTS ONLY AFTER THE REIMBURSEMENT EFFORTS FROM ALL OTHER THIRD PARTY RESOURCES, FEDERAL, STATE, AND LOCAL ASSISTANCE PROGRAMS HAVE BEEN EXHAUSTED. PART VI, LINE 2: EVERY 3 YEARS, CAROMONT HEALTH ESTABLISHES COMMUNITY PRIORITIES THROUGH A NUMBER OF MECHANISMS:1. LEADERSHIP OPINIONS ARE SOUGHT TO HELP IDENTIFY NEEDED SERVICES IN THE COMMUNITY VIA PARTNERSHIPS WITH THE GASTON COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES, LOCAL NON-PROFIT ORGANIZATIONS FOCUSED ON HEALTH IMPROVEMENT IN OUR COMMUNITIES AND OTHER HEALTH-FOCUSED ENTITIES. CAROMONT HEALTH ALSO WORKS WITH COMMUNITY AGENCIES TO CONDUCT COMMUNITY NEEDS ASSESSMENTS AND QUALITY OF LIFE SURVEYS EVERY TWO TO THREE YEARS. 2. PATIENT SATISFACTION DATA, HEALTH TRENDS, AND CARE OUTCOMES ARE ANALYZED TO DETERMINE WHERE AND/OR HOW SERVICES SHOULD TO BE EXPANDED OR IMPROVED.3. SERVICE AREA DATA (VITAL STATISTICS, DEMOGRAPHICS AND UTILIZATION) ARE ANALYZED FOR GROWTH AND HEALTH TRENDS. THIS INFORMATION IS COORDINATED WITH PUBLIC HEALTH DATA TO DETERMINE OPPORTUNITIES AND VOIDS IN HEALTHCARE SERVICE.4. FINDINGS FROM COMMUNITY SURVEYS/REPORTS PUBLISHED BY OTHER ORGANIZATIONS (DEPARTMENT OF HEALTH AND HUMAN SERVICES, GASTON COUNTY GOVERNMENT, ECONOMIC IMPACT AND DEVELOPMENT GROUPS, ETC.) ARE GATHERED AND REVIEWED FOR PERTINENCE TO COMMUNITY HEALTH PROBLEMS.5. BOARD MEMBERS, SENIOR LEADERS AND SYSTEM MANAGEMENT ARE INVOLVED IN NUMEROUS ORGANIZATIONS IN THE COMMUNITY. THROUGH THIS NETWORK OF RELATIONSHIPS, INFORMATION ABOUT THE COMMUNITY AND THE NEEDS OF AREA RESIDENTS AND ORGANIZATIONS IS USED IN THE DEVELOPMENT OF PROGRAMS AND SERVICES AVAILABLE THROUGH CAROMONT HEALTH. PART VI, LINE 3: THE ORGANIZATION INFORMS AND EDUCATES THE PATIENTS ABOUT THEIR ELIGIBILITY FOR ASSISTANCE IN SEVERAL WAYS. A CHARITY AND FINANCIAL SUMMARY IS ON OUR WEBSITE. BROCHURES ARE DISTRIBUTED IN THE EMERGENCY ROOM AND ALL OTHER REGISTRATION SITES. SPECIFICALLY TRAINED STAFF (FINANCIAL COUNSELORS AND BENEFIT ELIGIBILITY SPECIALISTS) PROACTIVELY MAKE CONTACT WITH PATIENTS PRIOR TO, AT TIME OF SERVICE, AND/OR AFTER DISCHARGE TO DISCUSS ELIGIBILITY FOR MEDICAID, OTHER INSURANCE/PROGRAM BENEFITS, OR CHARITY CARE, AND TO OFFER ASSISTANCE WITH THE APPLICATIONS. THE COMMUNICATION IS ATTEMPTED AS SOON AS POSSIBLE. WRITTEN COMMUNICATION IS MADE PRIOR TO COLLECTION AGENCY PLACEMENT. PART VI, LINE 4: GASTON COUNTY, COVERING 355.9 SQUARE MILES IN THE SOUTHERN PORTION OF THE PIEDMONT REGION OF NORTH CAROLINA, IS THE ORGANIZATION'S PRIMARY MARKET. LINCOLN, CLEVELAND AND PARTS OF WESTERN MECKLENBURG COUNTY, AS WELL AS YORK COUNTY, SOUTH CAROLINA, MAKE UP THE HEALTH SYSTEM'S SECONDARY MARKET. ACCORDING TO THE U.S. CENSUS BUREAU'S REPORT FROM JULY 1, 2022, GASTON COUNTY HAD AN ESTIMATED POPULATION OF 234,215, A MEDIAN HOUSEHOLD INCOME OF $56,819 AND 14.9% OF PERSONS IN POVERTY. RACE AND ETHNIC DEMOGRAPHICS STATE THAT 75.4% OF THE POPULATION IDENTIFY THEMSELVES AS WHITE, 19.5% AS BLACK OR AFRICAN AMERICAN, 8.9% AS HISPANIC, 2.5% AS TWO OR MORE RACES, AND 1.8% AS ASIAN. PART VI, LINE 5: COMMUNITY HEALTH INITIATIVES ARE FOCUSED ON DISEASE PREVENTION AND MANAGEMENT OF CHRONIC ILLNESS. THAT INCLUDES WORKING WITH EMPLOYERS ON INNOVATIVE PROGRAMS AND COLLABORATING WITH HEALTH CARE NEIGHBORS, MANAGING ILLNESS WITHIN THE HEALTH SYSTEM'S WORKFORCE AND INTENSE FOCUS ON SUCCESSFUL CARE COORDINATION FOR PATIENTS WITH CHRONIC DISEASE. ADDITIONALLY, CAROMONT HEALTH PROVIDES NEARLY $1 MILLION ANNUALLY IN SPONSORSHIP AND GRANT SUPPORT FOR LOCAL NON-PROFITS, COMMUNITY PROGRAMS AND SERVICES, AND OTHER COMMUNITY INITIATIVES AIMED AT IMPROVING THE HEALTH OF THE COMMUNITY. ACTING AS A TRUSTED HEALTHCARE PARTNERS, CAROMONT HEALTH SEEKS TO PROVIDE CARE AND SUPPORT TO ALL MEMBERS OF THE COMMUNITY. PART VI, LINE 6: ESTABLISHED IN 1946, CAROMONT REGIONAL MEDICAL CENTER IS A 476-BED, NOT-FOR-PROFIT ACUTE CARE FACILITY OFFERING COMPREHENSIVE INPATIENT HOSPITAL SERVICES. CAROMONT REGIONAL MEDICAL CENTER IS THE ANCHOR OF CAROMONT HEALTH, A HEALTH CARE SYSTEM WITH FIVE AFFILIATE COMPANIES INCLUDING A NETWORK OF MORE THAN 60 PRIMARY AND SPECIALTY CARE LOCATIONS. PART VI, LINE 7, REPORTS FILED WITH STATES NC 1 KINTEGRA HEALTH 991 WEST HUDSON BLVD GASTONIA NC 28052 581958398 501(C)(3) 213727 0 COMMUNITY ASSITANCE GASTON BUSINESS ASSOC PO BOX 7 GASTONIA NC 28052 560232990 501(C)(3) 121700 0 COMMUNITY ASSITANCE COMMUNITY FOUNDATION 1201 E GARRISON BLVD GASTONIA NC 28054 581340834 501(C)(3) 100000 0 COMMUNITY ASSITANCE GASTON COUNTY SCHOOLS PO BOX 1397 GASTONIA NC 280531397 566001032 501(C)(3) 62700 0 COMMUNITY ASSITANCE DANIEL STOWE BOTANICAL GARDEN 6500 S NEW HOPE RD BELMONT NC 28012 208362933 501(C)(3) 25000 0 COMMUNITY ASSITANCE HEART SOCIETY OF GASTON COUNTY INC 1201 EAST GARRISON BLVD GASTONIA NC 28054 561330921 501(C)(3) 18150 0 COMMUNITY ASSITANCE CANCER SERVICES OF GASTON COUNTY INC 306 SOUTH COLUMBIA ST GASTONIA NC 28054 561164253 501(C)(3) 15000 0 COMMUNITY ASSITANCE MONTCROSS AREA CHAMBER OF COMMERCE PO BOX 368 BELMONT NC 28012 560710166 501(C)(6) 14460 0 COMMUNITY ASSITANCE THE CATHERINE PHARR CARSTARPHEN PO BOX 1939 MCADENVILLE NC 28101 560623961 501(C)(3) 12500 0 COMMUNITY ASSITANCE CATAWBA RIVERKEEPER 715 N CHURCH ST CHARLOTTE NC 28220 562034780 501(C)(3) 12000 0 COMMUNITY ASSITANCE UNITED WAY P O BOX 2597 GASTONIA NC 28052 560653356 501(C)(3) 10560 0 COMMUNITY ASSITANCE BOYS AND GIRLS CLUB OF GREATER GASTON PO BOX 23 GASTONIA NC 28053 561419498 501(C)(3) 10000 0 COMMUNITY ASSITANCE CHERRYVILLE CHAMBER OF COMMERCE INC PO BOX 305 CHERRYVILLE NC 28021 560635698 501(C)(3) 10000 0 COMMUNITY ASSITANCE CITY OF MOUNT HOLLY PO BOX 406 MOUNT HOLLY NC 28120 566001295 GOVERNMENTAL 10000 0 COMMUNITY ASSITANCE COVENANT VILLAGE 1351 ROBINWOOD RD GASTONIA NC 28054 561210103 501(C)(3) 10000 0 COMMUNITY ASSITANCE DOWNTOWN BELMONT DEVELOPMENT ASSOCIATION PO BOX 431 BELMONT NC 28012 474333734 501(C)(3) 10000 0 COMMUNITY ASSITANCE GASTON COMMUNITY FOUNDATION 1201 E GARRISON BLVD GASTONIA NC 28053 581340834 501(C)(3) 10000 0 COMMUNITY ASSITANCE HOLY ANGELS FOUNDATION 660 WILKINSON BLVD BELMONT NC 28012 561762654 501(C)(3) 10000 0 COMMUNITY ASSITANCE MARCH OF DIMES INC 1550 CRYSTAL DRIVE PO BOX GA 18819 131846366 501(C)(3) 10000 0 COMMUNITY ASSITANCE THE LEUKEMIA AND LYMPHOMA SOCIETY PO BOX 22443 RYE BROOK NY 100872443 135644916 501(C)(3) 10000 0 COMMUNITY ASSITANCE MEDASSIST OF MECKLENBURG 4428 TAGGART CREEK RD SUITE 101 CHARLOTTE NC 282085400 562018957 501(C)(3) 7500 0 COMMUNITY ASSITANCE CITY OF GASTONIA PO BOX 1748 GASTONIA NC 28053 566000227 GOVERNMENTAL 7000 0 COMMUNITY ASSITANCE GASTON COUNTY EDUCATION FOUNDATION PO BOX 1397 GASTONIA NC 28053 561764830 501(C)(3) 6000 0 COMMUNITY ASSITANCE CITY OF LOWELL 101 WEST FIRST ST LOWELL NC 28098 566003509 GOVERNMENTAL 5500 0 COMMUNITY ASSITANCE GASTON COUNTY FAMILY YMCA 201 SOUTH CLAY STREET GASTONIA NC 28052 560655420 501(C)(3) 5000 0 COMMUNITY ASSITANCE CITY OF BESSEMER CITY 125 EAST VIRGINA AVE BESSEMER CITY NC 28016 566001177 GOVERNMENTAL 10000 0 COMMUNITY ASSISTANCE 26 0 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. SCHEDULE I, PART III THE PURPOSE OF THE GERTRUDE CLINTON HEALTH CAREERS SCHOLARSHIP IS TO ENCOURAGE MEDICAL AND HEALTH-RELATED PROFESSIONALS IN THE FIELD OF HUMAN SERVICES TO PRACTICE THEIR SPECIALTIES AT CAROMONT REGIONAL MEDICAL CENTER OR IN GASTON COUNTY. X X 1 0 X X X X X 0 1 0 0 0 1 1 0 0 MR K CHRISTOPHER PEEK CEO 948458 0 411971 0 197652 0 263009 0 23723 0 1844813 0 158940 0 DR TODD DAVIS EVP CHIEF PHYSICIAN EXECUTIVE 639674 0 215244 0 99698 0 162631 0 23723 0 1140970 0 84067 0 MR DAVID O'CONNOR EVP/CFO/ASST. TREASURER 580745 0 194511 0 108987 0 150741 0 23723 0 1058707 0 86689 0 MS KATHLEEN BESSON SPECIAL ADVISOR TO CEO 441172 0 190076 0 56047 0 65149 0 7865 0 760309 0 0 0 MR DANNY WHARTON CHIEF OPERATING OFFICER 413333 0 108937 0 40000 0 111221 0 11621 0 685112 0 33564 0 DR GEORGE ADCOCK III VP MEDICAL AFFAIRS 387244 0 110038 0 55154 0 97727 0 23678 0 673841 0 46463 0 MR FRANK MURPHY VP STRATEGY BUSINESS DEVELOPMENT 356731 0 100892 0 47714 0 92563 0 14676 0 612576 0 39975 0 DR HEALTH HIGH CHIEF-OF-STAFF ELECT AS OF 1/22 0 369474 0 201762 0 1256 0 11703 0 23292 0 607487 0 0 MS ROBIN LANG VP CHIEF INFORMATION OFFICER 355253 0 98653 0 49454 0 81329 0 11503 0 596192 0 41655 0 MR RICHARD BLACKBURN VP SUPPORT SERVICES 319323 0 89898 0 53033 0 100573 0 14418 0 577245 0 0 0 MS LEIGH HICKMAN CLO/ASST. SEC. 362901 0 101731 0 862 0 87394 0 16070 0 568958 0 0 0 MS ASHLEY LONG VP CHIEF NURSING OFFICER 278560 0 72725 0 138095 0 54784 0 9909 0 554073 0 0 0 DR JAY HENDLER CHIEF-OF-STAFF AS OF 1/22 0 427874 0 61083 0 3949 0 12200 0 14281 0 519387 0 0 PART I, LINE 1A THE ORGANIZATION HAS A POLICY TO ADDRESS WHEN SPOUSAL TRAVEL IS PERMITTED AND PAYS CLUB DUES FOR THE PRESIDENT/CEO FOR BUSINESS PURPOSES AS PART OF THE EMPLOYMENT CONTRACT. PART I, LINE 4B THE FOLLOWING INDIVIDUALS RECEIVED DEFERRED COMPENSATION ALLOCATIONS FROM THE FILING ORGANIZATION FROM A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP): DAVID O'CONNOR - $ 111,541 TODD DAVIS, MD - $ 123,431 K. CHRISTOPHER PEEK - $ 223,809 LEIGH HICKMAN - $ 55,268 DANNY WHARTON - $ 80,141 GEORGE ADCOCK III - $ 59,779 ROBIN LANG - $ 53,595 FRANK D. MURPHY - $ 54,811 ASHLEY LONG - $ 30,070 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. CERTAIN CAROMONT MEDICAL GROUP, INC. PHYSICIAN'S COMPENSATION PACKAGES ARE BASED ON THE INDIVIDUAL PHYSICIANS NET RESULTS FROM OPERATIONS AS CALCULATED BASED SOLELY ON HIS/HER NET CHARGES LESS HIS/HER ALLOCABLE SHARE OF CLINIC OVERHEAD COSTS. A NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2003-01-23 120000000 SEE PART VI 0 0 0 B NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2019-11-19 41460000 SEE PART VI 0 0 0 C NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 2021-02-10 129092857 SEE PART VI 0 0 0 A 22200000 123594002 5150936 1256069 3386000 91583288 22217709 2005 0 1 1 1 B 5770000 41460000 0 1 1 1 C 705000 129453813 1064190 110133176 18256447 2023 0 0 0 0 A 0 0 1 1 1 1 0.00130 0.00130 0 1 0.00110 0 1 B 0 0 0 0 0.00100 0.00100 0 0 1 C 0 0 0 0 0.00000 0.00000 0 0 1 A 0 0 0 1 1 1 MERRILL LYNCH CAPITAL SERVICES 31.600000000000 1 0 0 0 1 B 0 0 0 0 1 0 0 0 1 C 0 0 0 0 1 0 0 0 1 A 1 B 0 C 0 DATE REBATE COMPUTATION PERFORMED ISSUER NAME: NORTH CAROLINA MEDICAL CARE COMMISSION DATE THE REBATE COMPUTATION WAS PERFORMED: 12/05/2017 SCHEDULE K SUPPLENTAL INFORMATION THREE 501(C)(3) ORGANIZATIONS WITHIN THE PARENT-SUBSIDIARY CONTROLLED GROUP BENEFIT FROM THE BONDS AS FOLLOWS: GASTON MEMORIAL HOSPITAL, INC. (56-0619359) CAROMONT HEALTH, INC. (58-1636959) CAROMONT HEALTH SERVICES, INC. (56-1455630) CAROMONT REGIONAL MEDICAL CENTER HOLDS THE LIABILITY FOR THE BONDS, PER AUDITED FINANCIAL STATEMENTS. SCHEDULE K, PART I, COLUMN (F); DESCRIPTION OF PURPOSE: ISSUE A - THE SYSTEM USED THE PROCEEDS FROM THESE BONDS FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO, A NEW WOMEN'S CENTER AND PARKING DECK, RENOVATIONS TO EXISTING FACILITIES, AND EQUIPMENT. IN ADDITION, PROCEEDS WERE USED TO REFUND IN ADVANCE OF THEIR MATURITIES $17,000,000 IN PRINCIPAL AMOUNT OF THE SERIES 1998 HOSPITAL REVENUE BONDS. ISSUE B - ON NOVEMBER 19, 2019 THE BANK EXCHANGED THE 2018 TAXABLE BONDS FOR FIXED RATE TAX-EXEMPT BONDS (THE "2019 TAX-EXEMPT BONDS") ISSUED BY THE NCMCC. THIS EXCHANGE OF THE SERIES 2018 BONDS FOR THE SERIES 2019 TAX-EXEMPT BONDS CONSTITUTES A CURRENT REFUNDING OF THE SERIES 2018 BONDS AND PROVIDES CAROMONT WITH INCREMENTAL INTEREST COST SAVINGS. ISSUE C - ON JANUARY 21, 2021, THE NORTH CAROLINA MEDICAL CARE COMMISSION ISSUED $105,260,000 OF SERIES 2021A AND SERIES 2021B HOSPITAL REVENUE BONDS ("SERIES 2021 BONDS"). THE $40,950,000 SERIES 2021A BONDS ARE TAX-EXEMPT FIXED RATE BONDS THAT MATURE FEBRUARY 1, 2036 AND THE $64,310,000 SERIES 2021B BONDS ARE TAX-EXEMPT PUT BONDS THAT MATURE FEBRUARY 1, 2051. THE INTEREST RATE FOR THE NEW BONDS IS 5%. THE PROCEEDS WILL BE USED BY THE SYSTEM FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO, A NEW FOUR-STORY, APPROXIMATELY 140,000 SQUARE FOOT CRITICAL CARE TOWER ON THE HOSPITAL CAMPUS AND TO PAY THE FEES AND EXPENSES INCURRED IN CONNECTION WITH THE SALE AND ISSUANCE OF THE BONDS. SCHEDULE K, PART II, LINE 3 COLUMN (A): LINE 3 COLUMN (A) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 3,594,002. SCHEDULE K, PART II, LINE 3 COLUMN (C): LINE 3 COLUMN (C) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 360,956. SCHEDULE K, PART II, LINE 11; OTHER SPENT PROCEEDS: OTHER SPENT PROCEEDS INCLUDE DEPOSITS MADE INTO A REFUNDING ESCROW ACCOUNT ALONG WITH INTEREST EARNED ON THE ACCOUNT, BOTH OF WHICH WERE SUBSEQUENTLY USED TO PAY PRINCIPLE AND INTEREST ON THE REFUNDED BONDS. SEE THE RESPONSE FOR PART I, COLUMN (F) FOR DETAILS. 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 CONSISTS OF FOURTEEN (14) MEMBERS, ALL OF WHOM ARE THE MEMBERS OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH, INC., AND ALL OF WHOM ARE APPOINTED BY THE BOARD OF DIRECTORS OF CAROMONT HEALTH. 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. 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. PURSUANT TO THE COMMITTEE CHARTER FOR THE COMPENSATION COMMITTEE OF THE BOARD, THE BOARD OF DIRECTORS APPROVES THE EXECUTIVE COMPENSATION PHILOSOPHY, WHICH ESTABLISHES THE PARAMETERS FOR ALL EXECUTIVE COMPENSATION DECISIONS. THE BOARD OF DIRECTORS DELEGATES ALL COMPENSATION DECISIONS FOR ALL EXECUTIVES TO THE COMPENSATION COMMITTEE, PROVIDED SUCH DECISIONS ARE CONSISTENT WITH THE COMPENSATION PHILOSOPHY. BOARD APPROVAL MUST BE OBTAINED WHEN COMPENSATION DECISIONS DEVIATE FROM THE COMPENSATION PHILOSOPHY. A MAJORITY OF 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. FORM 990, PART IX, LINE 11G HOSPITALIST FEES: PROGRAM SERVICE EXPENSES 10,731,277. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 10,731,277. PHYSICIAN LEADERSHIP FEES: PROGRAM SERVICE EXPENSES 238,138. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 238,138. INTEGRATION & PERFORMANCE IMPROVEMENT FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 1,022,374. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,022,374. CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 70,814,221. MANAGEMENT AND GENERAL EXPENSES 1,620,995. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 72,435,216. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 6,259,093. MANAGEMENT AND GENERAL EXPENSES 397,073. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 6,656,166. PROFESSIONAL SERVICES: PROGRAM SERVICE EXPENSES 8,303,143. MANAGEMENT AND GENERAL EXPENSES 14,468. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,317,611. CONSULTING FEES: PROGRAM SERVICE EXPENSES 121,056. MANAGEMENT AND GENERAL EXPENSES 948,605. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,069,661. LICENSE FEES: PROGRAM SERVICE EXPENSES 63,223. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 63,223. TAX EXEMPT BOND FEES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 132,894. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 132,894. FORM 990, PART XI, LINE 9: INTERCOMPANY TRANSFER FROM AFFILIATE 111,315,577. AUXILIARY NET ASSET ADJUSTMENT -54,723. PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM LAST YEAR. 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 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 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 7 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 COUNTY PO BOX 1578 GASTONIA NC 280531578 566000300 GOVERNMENT ADMINISTRATION NC N/A 0 0 0 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1