2013-04-04T11:32:40-05:00 2012-06-30 560747981 DIXON HUGHES GOODMAN LLP 500 RIDGEFIELD COURT ASHEVILLE NC 28806 990 2011-07-01 560619359 GASTON MEMORIAL HOSPITAL INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 DAVID O'CONNOR 7048342000 2013-03-21 1 AMY BIBBY P00445891 8282542254 2011 2016-02-25 16:41:14Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 426092983 0 X WWW.CAROMONT.ORG X 1945 NC TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 14 12 3105 261 510357 38600 119286 1181292 405735809 416290990 41896 6070 5018302 8515831 410915293 425994183 257503 283868 0 0 163004927 169254959 0 0 0 214831055 218624236 378093485 388163063 32821808 37831120 332063801 360052108 307061339 326403841 25002462 33648267 TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. 0 0 363488761 283868 416789262 GASTON MEMORIAL HOSPITAL PROVIDES INPATIENT, OUTPATIENT, EMERGENCY, SURGICAL, WELLNESS AND PREVENTIVE CARE SERVICES TO THE RESIDENTS OF GASTON COUNTY AND SURROUNDING AREAS AT ITS 435 BED ACUTE CARE FACILITY.PLEASE SEE SCHEDULE O FOR A CONTINUATION OF OUR PROGRAM SERVICE ACCOMPLISHMENTS. 363488761 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 1 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 419 0 1 3105 1 1 1 0 0 0 0 0 0 0 0 0 X 14 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 H SPURGEON MACKIE JR 1.00 X X 0 0 0 SHEILA S REILLY PHD 1.00 X X 0 0 0 DR ROBERT D CROUCH 1.00 X X 0 0 0 M VINCENT QUINN 1.00 X X 0 0 0 MARY FRANCES FORRESTER 1.00 X 0 0 0 KELVIN C HARRIS MD 1.00 X 0 201000 18540 JAMES W BAILEY 1.00 X 0 0 0 JAMES R BEAM 1.00 X 0 0 0 RICHARD K CRAIG 1.00 X 0 0 0 MICKEY PRICE 1.00 X 0 0 0 SUSIE BROWN 1.00 X 0 0 0 DAVID ALLEN SMITH 1.00 X 0 0 0 W BARRY SMITH 1.00 X 0 0 0 DR RODNEY SMITH 1.00 X 0 0 0 DAVID O'CONNOR 40.00 X 569491 0 38816 MARIA LONG 40.00 X 432347 0 38015 RANDALL L KELLEY 40.00 X 0 0 0 DOUG LUCKETT 40.00 X 632444 0 24893 JERRY LEVINE 40.00 X 499821 0 9099 W K HARWELL 40.00 X 405621 0 36402 ANDREA K SERRA 40.00 X 316345 0 47908 MICHAEL R JOHNSON 40.00 X 328377 0 64465 ROWENA BUFFETT TIMMS 40.00 X 315687 0 29283 KATHLEEN BESSON 40.00 X 327712 0 58686 VALINDA L RUTLEDGE 0.00 X 766972 0 18607 STEVEN A RUBIN 0.00 X 230680 0 0 TERRY L JONES 0.00 X 318198 0 7463 5143695 201000 392177 130 1 1 0 MORRISON MANAGEMENT SPECIALISTS INC 3 WACHOVIA CENTER STE 3000 401 S CHARLOTTE NC 28202 FOOD SERVICES MANAGEMENT 4459749 SHARED (SIEMENS) MEDICAL SOLUTIONS 51 VALLEY STREAM PARKWAY MALVERN PA 19355 INFORMATION SYSTEMS 3236487 ARAMARK HEALTHCARE 10510 TWIN LAKES PARKWAY CHARLOTTE NC 28259 BIOMED SERVICES 3073394 GASTON ANESTHESIA ASSOCIATES 1550B UNION ROAD GASTONIA NC 28082 CRNA SERVICES 2176019 MCKESSON HBOC MCKESSON INFO SOLUTIONS PO BOX 98347 CHICAGO IL 606938347 INFORMATION SYSTEMS 1182433 50 1131072 50220 1181292 PATIENT SERVICES REVEN 621500 414247255 414247255 AUXILIARY INCOME 621500 1100647 602864 497783 PARTNERSHIP INCOME 541900 943088 930514 12574 416290990 104870 104870 98800 -98800 -98800 -98800 INFO SYSTEMS MEANINGFU 621500 3240391 3240391 PHARMACY REVENUE 621500 2501523 2501523 CAFETERIA & VENDING IN 722210 2112273 2112273 661644 536846 124798 8515831 425994183 416317479 510357 7985055 283868 283868 3100966 620193 2480773 50489 50489 132359758 121258848 11100910 6162628 5544975 617653 17776072 15994456 1781616 9805046 8822330 982716 429212 429212 1380808 1380808 153331 153331 189621 189621 37158158 33321983 3836175 606959 142502 464457 2598302 1318816 1279486 518422 518422 8484857 8484857 150687 95779 54908 700450 359983 340467 8921803 8921803 24485291 24485291 2832173 2832173 MEDICAL SUPPLIES 71746396 71746396 BAD DEBT 46253615 46253615 EQUIPMENT 5449852 5429921 19931 NC MEDICAID ASSESSMENT 5227709 5227709 1336590 1155519 181071 388163063 363488761 24674302 0 -5240 -4752 43641842 45721542 6558153 6266707 8288591 9982612 481869602 278352438 204909634 203517164 9873 8152 380625 439199 2311646 2311646 65968677 91809838 332063801 360052108 39454843 39871306 213332101 207464861 54274395 79067674 307061339 326403841 X 24995463 33640118 6999 8149 25002462 33648267 332063801 360052108 X 37831120 -29185315 X X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 189621 189621 0 EXPLANATION OF LOBBYING ACTIVITIES: PART II-B, LINE 1: ANNUAL DUES WERE PAID TO THE NORTH CAROLINA HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, OF WHICH $25,275 WAS DETERMINED TO BE EXPENDITURES USED IN LOBBYING ACTIVITIES BY THESE ORGANIZATIONS. AN ADDITIONAL $164,346 IN LEGAL FEES WERE PAID FOR LOBBYING EXPENDITURES. 6999 1500 221 571 8149 6513 966 480 6999 1.00000 0 0 341972 341972 264712414 124040880 140671534 5206433 4752848 453585 197264696 149558710 47705986 14344087 14344087 203517164 PREPAID PENSION OBLIGATION 41484454 DEFERRED FINANCING COSTS 4443036 OTHER RECEIVABLES 5960144 457B PLAN ASSETS 4838369 DEFERRED CHARGE - INTEREST RATE SWAP 34779242 457F PLAN ASSETS 304593 91809838 457B PLAN LIABILITY 4838369 ESTIMATED 3RD PARTY SETTLEMENTS 39145470 INTEREST RATE SWAP LIABILITY 34779242 457F PLAN LIABILITY 304593 79067674 425994183 388163063 37831120 -64 -29185251 -29185315 8645805 350555255 -64 -75438864 -75438928 425994183 0 425994183 341909450 0 341909450 46253613 46253613 388163063 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: THE ORGANIZATION'S ENDOWMENT FUNDS ARE USED FOR ONCOLOGY MEDICATIONS. 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, 2012 AND 2011, RESPECTIVELY. PART XI, LINE 8 - OTHER ADJUSTMENTS: INTERCOMPANY TRANSFER TO AFFILIATE -27,147,201. CHANGE IN VALUE OF INTEREST RATE SWAP -2,038,050. TOTAL TO SCHEDULE D, PART XI, LINE 8: -29,185,251. PART XII, LINE 2D - OTHER ADJUSTMENTS: BAD DEBT -46,253,613. CHANGE IN VALUE OF INTEREST RATE SWAP -2,038,050. INTERCOMPANY TRANSFERS -27,147,201. PART XIII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT 46,253,613. 1 1 1 X 1 X 1 1 1 0 1 1 12241895 12241895 0.03580 65004753 56888511 8116242 0.02370 137484 122641 14843 0.00000 77384132 57011152 20372980 0.05950 1142432 10140 1132292 0.00330 1760822 1760822 0.00510 603262 151773 451489 0.00130 893824 893824 0.00260 4400340 161913 4238427 0.01230 81784472 57173065 24611407 0.07180 998773 998773 0.00290 998773 998773 0.00290 1 14686473 1021512 126364371 113446447 12917924 X 1 1 1 1 GASTON MEMORIAL HOSPITAL INCORPORATED

2525 COURT DRIVE GASTONIA NC 28054

X X X 4 DIAGNOSTIC IMAGING CENTERS AND 6 OP SERIVCE CENTER GASTON MEMORIAL HOSPITAL INC 1 1 1 200.000000000000 1 300.000000000000 1 X X X X 1 1 X X X X 1 0 1 X 0 0 PART I, LINE 3C: 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 (1) 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 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 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. NO COST TO CHARGE RATIOS WERE USED IN THE CALCULATIONS. PART I, L7 COL(F): 46,253,615 BAD DEBT EXPENSE REMOVED FROM TOTAL EXPENSES PRIOR TO CALCULATING PERCENT OF TOTAL EXPENSE. PART I, LINE 6A: THE ORGANIZATION COMMUNITY BENEFIT REPORT MADE AVAILABLE TO THE PUBLIC CONTAINS COMMUNITY BENEFITS FOR ALL RELATED ORGANIZATIONS TO THE HOSPITAL. RESEARCH ACTIVITIES: PART I, LINE H CAROMONT HEALTH IS INVOLVED IN APPROXIMATELY 75 RESEARCH STUDIES, APPROXIMATELY HALF 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 NURSING AND PHARMACY RESEARCH STUDIES. PART II: WORKFORCE DEVELOPMENT - CAROMONT HEALTH'S RECRUITMENT OF PHYSICIANS INTO THE FIVE COUNTIES THE SYSTEM SERVES IS DRIVEN BY THE CHANGING LANDSCAPE OF HEALTHCARE REFORM. THE SYSTEM RECRUITS BASED ON IDENTIFIED COMMUNITY HEALTHCARE NEEDS. THE SYSTEM'S GOAL IS TO BE PRO-ACTIVE AND ANTICIPATORY SO THAT THE HEALTHCARE NEEDS OF THE COMMUNITY ARE MET IN A QUALITY DRIVEN AND CONVENIENT MANNER. PART III, LINE 4: THE SYSTEM DESCRIBED IN PART 1 LINE 7 WAS USED FOR PART III LINE 2. TOTAL CHARGES AND THE CHARGES WRITTEN OFF TO BAD DEBT WERE TABULATED AT THE PATIENT LEVEL. THE DETAILED COST OF THE PATIENT WAS MULTIPLIED BY THE RATIO OF CHARGES WRITTEN OFF/TOTAL CHARGES PER PATIENT TO ASSIGN THE COST TO THE PATIENT. BECAUSE OF THIS COST BASED METHOD, DISCOUNTS AND PAYMENTS WOULD BE THE DIFFERENCE BETWEEN THE TOTAL CHARGES AND THE CHARGES WRITTEN OFF TO BAD DEBT.RATIONALE FOR PART III, LINE 3: CHARGES FOR SERVICES PROVIDED IN THE EMERGENCY DEPT ARE EVALUATED FOR CHARITY BASED ON MEANS TESTING. CHARGES FOR SERVICES PROVIDED ELSEWHERE IN THE HOSPITAL ARE EVALUATED FOR CHARITY BASED ON APPLICATIONS FILED BY PATIENTS. IF NO APPLICATION IS FILED, THE UNPAID AMOUNT IS WRITTEN-OFF TO BAD DEBT. THE % OF PATIENTS QUALIFYING FOR CHARITY IN THE EMERGENCY DEPT WAS APPLIED TO THE REMAINDER OF THE HOSPITAL TO DETERMINE THE % OF BAD DEBT PATIENTS WHO COULD HAVE BEEN CHARITY. THE BAD DEBT WRITE-OFFS WERE CONVERTED TO COST USING THE METHODOLOGIES DESCRIBED ABOVE.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 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 ALSO 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. 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:GASTON MEMORIAL HOSPITAL OFFERS MEDICAL SERVICES FREE OR AT A REDUCED RATE THROUGH THE CHARITY CARE PROGRAM. DETERMINATION OF FULL OR PARTIAL CHARITY CARE WILL BE BASED ON THE PATIENT'S INCOME, FAMILY SIZE, AND ASSETS. POTENTIAL ELIGIBILITY EXISTS ONLY AFTER REIMBURSEMENT EFFORTS FROM ALL OTHER THIRD PARTY RESOURCES, FEDERAL, STATE, AND LOCAL ASSISTANCE PROGRAMS HAVE BEEN EXHAUSTED. GASTON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 11H: TOTAL CHARGES ARE THE SAME FOR ALL. PATIENT AMOUNT DUE IS ZERO OR A TIERED DISCOUNT FOR CHARITY ELIGIBLE PATIENTS BASED ON WHAT WAS CHECKED. GASTON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 13G: BROCHURES AT REGISTRATION SITES. PROACTIVELY COMMUNICATING VERBALLY OR IN WRITING TO SCHEDULED PATIENTS PRIOR TO SERVICE. COMMUNICATING IN-HOUSE, DURING SERVICE, OR AFTER. GASTON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 15E: COLLECTION ACTIONS ARE TAKEN AFTER REASONABLE EFFORTS HAVE BEEN MADE TO DETERMINE PATIENT'S ELIGIBILITY FOR ASSISTANCE. GASTON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 16E: COLLECTION ACTIONS ARE TAKEN AFTER REASONABLE EFFORTS HAVE BEEN MADE TO DETERMINE PATIENT'S ELIGIBILITY FOR ASSISTANCE. GASTON MEMORIAL HOSPITAL, INC. PART V, SECTION B, LINE 17E: BROCHURES AT REGISTRATION SITES. PROACTIVELY COMMUNICATING VERBALLY OR IN WRITING TO SCHEDULED PATIENTS PRIOR TO SERVICE. COMMUNICATING IN-HOUSE, DURING SERVICE, OR AFTER. PART VI, LINE 2: CAROMONT HEALTH ESTABLISHES COMMUNITY PRIORITIES THROUGH A NUMBER OF MECHANISMS:- LEADERSHIP OPINIONS ARE SOUGHT TO HELP IDENTIFY NEEDED SERVICES IN THE COMMUNITY. TELEPHONE SURVEYS ARE CONDUCTED ON A PERIODIC BASIS TO GATHER OPINIONS FROM RESIDENTS IN THE SERVICE AREA; THE MOST RECENT STUDY WAS COMPLETED IN THE SPRING OF 2009.- PATIENT SATISFACTION DATA IS ANALYZED TO DETERMINE WHERE AND/OR HOW SERVICES NEED TO BE IMPROVED.- SERVICE AREA DATA (VITAL STATISTICS, DEMOGRAPHICS AND UTILIZATION) ARE ANALYZED FOR TRENDS. THIS INFORMATION IS COORDINATED WITH PUBLIC HEALTH DATA TO DETERMINE VOIDS AND SERVICE AREA HEALTH PROBLEMS.- FINDINGS FROM COMMUNITY SURVEYS/REPORTS PUBLISHED BY OTHER ORGANIZATIONS (UNITED WAY, CHAMBER OF COMMERCE, PARTNERSHIP FOR CHILDREN, GASTON COUNTY, ETC.) ARE GATHERED AND REVIEWED FOR PERTINENCE TO COMMUNITY HEALTH PROBLEMS.- GASTON MEMORIAL HOSPITAL THROUGH THE GCHC IN CONJUNCTION WITH THE GASTON COUNTY HEALTH DEPARTMENT CONDUCTS A COMMUNITY ASSESSMENT EVERY FOUR YEARS. THE MOST RECENT STUDY WILL HAVE CONCLUDE IN THE FALL OF 2012. THIS ASSESSMENT GATHERS OPINIONS AND IS COMBINED WITH PUBLIC HEALTH DATA TO DETERMINE THE TOP FOUR COMMUNITY-WIDE HEALTH ISSUES. SERVICE AREA STRENGTHS, WEAKNESSES AND OPPORTUNITIES ARE USED AS A BASIS FOR ESTABLISHING COMMUNITY PRIORITIES. ALL THIS INFORMATION IS USED TO ESTABLISH ORGANIZATIONAL PRIORITIES, IDENTIFY AGENCIES AND ORGANIZATIONS TO BE INVOLVED IN RESOLVING COMMUNITY ISSUES, AND IMPLEMENT PROGRAMS TO RESOLVE IDENTIFIED ISSUES. GOALS, OBJECTIVES AND STRATEGIES ARE ESTABLISHED AND THE PROGRESS IS EVALUATED ON AN ANNUAL BASIS.- BOARD MEMBERS, SENIOR MANAGEMENT AND DEPARTMENT DIRECTORS ARE INVOLVED IN NUMEROUS ORGANIZATIONS. THROUGH THIS NETWORK OF RELATIONSHIPS, FURTHER INFORMATION ABOUT THE COMMUNITY AND THE NEEDS OF AREA RESIDENTS AND ORGANIZATIONS ARE USED IN THE DEVELOPMENT OF PROGRAMS AND SERVICES AVAILABLE THOUGH CAROMONT HEALTH. PART VI, LINE 3: THE PROCESS IS CONSISTENT. ATTEMPTS TO INFORM PATIENTS ARE MADE AS SOON AS POSSBLE (PRIOR TO, TIME OF, DURING, OR AT DISCHARGE) BUT CERTAINLY PRIOR TO THIRD PARTY PLACEMENT FOR COLLECTION. PATIENTS ARE NOTIFIED IN SEVERAL WAYS ABOUT THEIR ELIGIBILITY FOR ASSISTANCE. BROCHURES ARE DISTRIBUTED AND VERBAL COMMUNICATION BETWEEN STAFF AND PATIENT IS PROACTIVE. IN ADDITION, THE HOSPITAL HAS HIRED STAFF TO ASSIST UNINSURED AND UNDERINSURED PATIENTS WITH ENROLLMENT IN VARIOUS PUBLIC PROGRAMS, INCLUDING MEDICAID. PART VI, LINE 4: GASTON COUNTY, WHICH IS THE COUNTY LOCATED TO THE WEST OF THE CHARLOTTE NC, IS THE HOSPITAL'S PRIMARY MARKET. LINCOLN, CLEVELAND, AND MECKLENBURG COUNTIES ARE THE HOSPITAL'S SECONDARY MARKET. THERE ARE NO OTHER ACUTE CARE HOSPITALS IN THE PRIMARY SERVICE AREA. ACCORDING TO THE U.S. CENSUS BUREAU, GASTON COUNTY HAD A POPULATION OF 207,031 (2011), A MEDIAN HOUSEHOLD INCOME OF $43,253 (2006-2010), AND 16.6% PERSONS BELOW POVERTY LEVEL (2006-2010). DURING FISCAL YEAR 2012, 8.4% OF THE HOSPITAL'S GROSS CHARGES WERE FROM UNINSURED PATIENTS AND 16.2% WAS FROM MEDICAID PATIENTS. PART VI, LINE 5: COMMUNITY HEALTHOUR COMMUNITY HEALTH INITIATIVES ARE FOCUSED PRIMARILY ON DISEASE PREVENTION AND BETTER MANAGEMENT OF CHRONIC ILLNESSES. THAT INCLUDES WORKING WITH LOCAL EMPLOYERS ON INNOVATIVE PROGRAMS AND COLLABORATING WITH OUR HEALTH CARE NEIGHBORS. THROUGH INNOVATION AND A FOCUS ON COMMUNITY WELLNESS, CAROMONT HEALTH IS DETERMINED TO MAKE UPCOMING CHANGES IN HEALTHCARE TO HAVE A POSITIVE IMPACT ON THE PEOPLE WE SERVE. TOBACCO CESSATION PROGRAMIN ORDER TO PROVIDE A HEALTHY ENVIRONMENT FOR OUR PATIENTS, FAMILIES AND STAFF, CAROMONT HEALTH AND ITS AFFILIATE CAMPUSES HAVE BEEN TOBACCO-FREE SINCE JANUARY 2007. IN FEBRUARY 2011, CAROMONT RECEIVED THE "GOLD STAR STANDARD HOSPITALS" DESIGNATION FROM NORTH CAROLINA PREVENTION PARTNERS FOR EXCELLENCE IN OUR EMPLOYEE TOBACCO CESSATION PROGRAMS. ALL EMPLOYEES WHO USE TOBACCO MAY PARTICIPATE IN A "QUIT PROGRAM", WHICH PROVIDES THEM WITH INCENTIVES IF THEY QUIT USING TOBACCO AND REMAIN TOBACCO-FREE FOR AT LEAST SIX MONTHS.GASTON COUNTY HEALTH SUMMITCAROMONT HEALTH HOSTED A HIGH PROFILE, PUBLIC CONVERSATION ABOUT THE HEALTH OF OUR COMMUNITY DURING THE 2011 GASTON COUNTY HEALTH SUMMIT, WHICH WAS HELD IN LATE MARCH. THE EVENT BROUGHT TOGETHER LEADERS FROM ORGANIZATIONS AND BUSINESSES SUCH AS CAROMONT HEALTH, COMMUNITY HEALTH PARTNERS, GASTON COMMUNITY HEALTHCARE COMMISSION, GASTON COUNTY DEPARTMENT OF SOCIAL SERVICES, GASTON COUNTY HEALTH DEPARTMENT, GASTON FAMILY HEALTH SERVICES, PATHWAYS, PHARR YARNS AND THE YMCA. ATTENDEES DISCUSSED WHERE OUR COMMUNITY STANDS IN TERMS OF HEALTH, INCLUDING WAYS TO IMPROVE HEALTH AND THE RELATIONSHIP BETWEEN BUSINESSES AND A COMMUNITY'S HEALTHCARE PROVIDERS. THE GASTON COUNTY HEALTH COALITION'S GOAL IS TO IMPROVE THE HEALTH STATUS OF OUR COMMUNITY, PARTICULARLY IN TERMS OF CHRONIC DISEASE MANAGEMENT. COMMUNITY CONVERSATIONS SUCH AS THE GASTON COUNTY HEALTH SUMMIT ARE HELPING DIVERSE GROUPS WORK TOGETHER TO MEET THOSE GOALS.HEALTHNET GASTONHEALTHNET GASTON (HNG) IS A PROGRAM DESIGNED TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES TO LOW-INCOME, UNINSURED RESIDENTS OF GASTON COUNTY. ITS SERVICES INCLUDE: A MEDICAL HOME/PRIMARY CARE PHYSICIAN SERVICES, SPECIALTY PHYSICIAN SERVICES, MEDICATION ASSISTANCE, CASE MANAGEMENT/HEALTH COACHING ACTIVITIES, AND HOSPITAL SERVICES. HNG OPERATES THROUGH THE LEADERSHIP AND COLLABORATION OF ITS FOUR FOUNDING STRATEGIC PARTNERS, INCLUDING: GASTON MEMORIAL HOSPITAL, GASTON FAMILY HEALTH SERVICES, COMMUNITY HEALTH PARTNERS, GASTON COMMUNITY HEALTH CARE COMMISSION. OTHER STRATEGIC PARTNERS INVOLVED WITH THIS INITIATIVE INCLUDE COMMUNITY 241 PHYSICIANS, GASTON COUNTY DEPARTMENT OF SOCIAL SERVICES, GASTON COUNTY HEALTH DEPARTMENT, AND OTHER LOCAL LEADERS.COMMUNITY HEALTH IMPROVEMENT ADVOCACYCAROMONT HEALTH HAS SIGNIFICANTLY IMPACTED ITS COMMUNITY IN PROVIDING MANY DIFFERENT HEALTH IMPROVEMENT PROJECTS, GROUPS, EVENTS, EDUCATION PROGRAMS, ETC. PART VI, LINE 6: CAROMONT HEALTH IN GASTONIA, NORTH CAROLINA IS A REGIONAL, INDEPENDENT, NOT-FOR-PROFIT HEALTH CARE SYSTEM. IT ENCOMPASSES GASTON MEMORIAL HOSPITAL WITH 435-BEDS; COURTLAND TERRACE, A 96-BED SKILLED NURSING FACILITY; GASTON HOSPICE WHICH INCLUDES THE 12-BED ROBIN JOHNSON HOUSE INPATIENT FACILITY, AND CAROMONT MEDICAL GROUP, A NETWORK OF 44 PRIMARY AND SPECIALTY PHYSICIAN OFFICES. CAROMONT HEALTH'S VISION IS TO BE A NATIONALLY RECOGNIZED LEADER AND VALUED PARTNER IN PROMOTING INDIVIDUAL HEALTH AND VIBRANT COMMUNITIES.CAROMONT HEALTH HAS 3 OFF-SITE IMAGING LOCATIONS, 2 SAME-DAY SURGERY CENTERS AND 1 OCCUPATIONAL MEDICINE CLINIC.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. REPORTS FILED WITH STATES PART VI, LINE 7 NC 1 AMERICAN HEART ASSOCIATION 222 SOUTH CHURCH STREET SUITE 303 CHARLOTTE NC 28202 135613797 501(C)(3) 25000 COMMUNITY ASSISTANCE BELMONT ABBEY COLLEGE 100 BELMONT-MT HOLLY ROAD BELMONT NC 28012 560547498 501(C)(3) 5100 COMMUNITY ASSISTANCE CLEVELAND COMMUNITY COLLEGE 137 SOUTH POST ROAD SHELBY NC 28152 560848556 501(C)(3) 24268 COMMUNITY ASSISTANCE COMMUNITY FOUNDATION OF GASTON COUNTY 1201 E GARRISON BLVD GASTONIA NC 28053 581340834 501(C)(3) 36500 COMMUNITY ASSISTANCE DANIEL STOWE GARDENS 6500 SOUTH NEW HOPE ROAD BELMONT NC 28012 208362933 501(C)(3) 20000 COMMUNITY ASSISTANCE GASTON HOSPICE 258 E GARRISON BLVD GASTONIA NC 28054 581341530 501(C)(3) 5000 COMMUNITY ASSISTANCE GASTON REGIONAL CHAMBER 601 W FRANKLIN BLVD GASTONIA NC 28053 560232990 501(C)(6) 15300 COMMUNITY ASSISTANCE LIFE IN THE CAROLINAS 7804 FAIRVIEW ROAD CHARLOTTE NC 28226 262693974 N/A 5000 COMMUNITY ASSISTANCE THE MCADENVILLE FOUNDATION INC 100 MAIN STREET MCADENVILLE NC 28101 560623961 501(C)(3) 11000 COMMUNITY ASSISTANCE MONTCROSS AREA CHAMBER OF COMMERCE PO BOX 368 BELMONT NC 28012 560710166 501(C)(6) 6500 COMMUNITY ASSISTANCE MOUNT HOLLY COMMUNITY DEVELOPMENT FOUNDATION 1068 SOUTH MAIN STREET MT HOLLY NC 28120 200738339 501(C)(3) 100000 COMMUNITY ASSISTANCE MOUNT HOLLY FARMER'S MKT 120 OAKLAND STREET MT HOLLY NC 28120 260464156 N/A 5200 COMMUNITY ASSISTANCE THE SCHIELE MUSEUM 1500 E GARRISON BLVD GASTONIA NC 28054 560770432 501(C)(3) 25000 COMMUNITY ASSISTANCE 9 4 ONCOLOGY PHARMACY ASSISTANCE 9 571 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 1 1 X X X X X 1 0 0 0 0 1 1 0 0 KELVIN C HARRIS MD 0 161597 0 39403 0 0 0 5103 0 13437 0 219540 0 0 DAVID O'CONNOR 332181 0 182565 0 54745 0 9800 0 29016 0 608307 0 0 0 MARIA LONG 274556 0 150300 0 7491 0 7350 0 30665 0 470362 0 0 0 DOUG LUCKETT 408322 0 195743 0 28379 0 2450 0 22443 0 657337 0 0 0 JERRY LEVINE 315104 0 162887 0 21830 0 0 0 9099 0 508920 0 0 0 W K HARWELL 237700 0 112114 0 55807 0 0 0 36402 0 442023 0 0 0 ANDREA K SERRA 189939 0 95298 0 31108 0 5799 0 42109 0 364253 0 0 0 MICHAEL R JOHNSON 238694 0 62460 0 27223 0 7350 0 57115 0 392842 0 0 0 ROWENA BUFFETT TIMMS 175619 0 115975 0 24093 0 4641 0 24642 0 344970 0 0 0 KATHLEEN BESSON 213542 0 91460 0 22710 0 6676 0 52010 0 386398 0 0 0 VALINDA L RUTLEDGE 338137 0 260451 0 168384 0 6750 0 11857 0 785579 0 0 0 STEVEN A RUBIN 55249 0 0 0 175431 0 0 0 0 0 230680 0 0 0 TERRY L JONES 0 0 0 0 318198 0 0 0 7463 0 325661 0 0 0 PART I, LINE 1A HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES - A PERCENTAGE OF PERSONAL USE OF DUES PAYMENTS FOR MEMBERSHIP IN A HEALTH OR FITNESS CLUB OR A SOCIAL OR RECREATIONAL CLUB WILL BE ADDED TO THE EMPLOYEE'S W-2 AT THE END OF THE CALENDAR YEAR. DURING FY 2012 THIS BENEFIT WAS PROVIDED TO THE CEO AND CFO. PART I, LINE 3 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. PART I, LINE 4A DURING THE YEAR THE ORGANIZATION PAID SEVERANCE PAYMENTS TO A FORMER OFFICER AND FORMER KEY EMPLOYEES IDENTIFIED BELOW. STEVEN A. RUBIN, FORMER KEY EMPLOYEE $174,972 TERRY L. JONES, FORMER KEY EMPLOYEE $318,198 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. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HVF7 2003-01-23 120000000 SEE PART VI 0 0 0 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HG64 2008-01-31 118400000 SEE PART VI 0 0 0 800000 123594002 5150936 1256069 3386000 91583288 22217709 2005 0 1 1 1 24630000 118649797 610174 917471 1553717 28952424 86616011 2009 1 0 1 1 0 0 1 1 1 1 0.00010 0.00000 0.00010 1 0 0 1 1 1 1 0.00010 0.00010 0.00020 1 0 1 1 MERRILL LYNCH CAPITAL SERVICES 31.600000000000 1 1 0 0 0 0 0 1 MERRILL LYNCH DERIVATIVE PRODUCTS 21.000000000000 1 1 0 0 1 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) GASTON MEMORIAL HOSPITAL, INC. HOLDS THE LIABILITY FOR THE BONDS, PER AUDITED FINANCIAL STATEMENTS. PART I, LINE A, COLUMN (C): THIS BOND ISSUE INCLUDES TWO CUSIPS MATURING ON THE SAME DATE: 65820HVG5 AND 65820HVF7. 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, ISSUED ON AUGUST 27, 1998. ISSUE B - THE SYSTEM USED THE PROCEEDS FROM THE BONDS FOR VARIOUS CAPITAL IMPROVEMENTS, INCLUDING, BUT NOT LIMITED TO, THE RENOVATION OF CERTAIN FLOORS OF THE PATIENT TOWER, RENOVATION OF THE DAY OF SURGERY UNIT, INSTALLATION OF FIRE SPRINKLERS IN NON-SPRINKLED AREAS, AND THE UPGRADE OF LIFE SAFETY AND CRITICAL POWER. IN ADDITION, THE HOSPITAL USED THE PROCEEDS TO REFUND THE AGGREGATE PRINCIPAL AMOUNT OF THE SERIES 1995 REVENUE BONDS, ISSUED ON NOVEMBER 15, 1995, IN THE AMOUNT OF $41,210,000 AND TO REFUND THE AGGREGATE PRINCIPAL AMOUNT OF THE SERIES 1998 REVENUE BONDS, ISSUED ON AUGUST 27, 1998, IN THE AMOUNT OF $49,710,000. PART II, LINE 3 COLUMN A, INVESTMENT EARNINGS INCLUDED IN TOTAL PROCEEDS OF ISSUE: LINE 3 COLUMN (A) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 3,594,002. PART II, LINE 3 COLUMN B, INVESTMENT EARNINGS INCLUDED IN TOTAL PROCEEDS OF ISSUE: LINE 3 COLUMN (B) INCLUDES THE TOTAL INVESTMENT EARNINGS ON BOND PROCEEDS IN THE AMOUNT OF $ 249,798. 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. PART IV, LINES 2 AND 3A, COLUMN (B): THE SERIES 2008 BONDS WERE ORIGINALLY ISSUED AS VARIABLE BONDS BEARING INTEREST AT WEEKLY RATES. CAROMONT HEALTH, INC. ENTERED INTO INTEREST SWAP AGREEMENTS TO HEDGE ITS INTEREST RISK WITH RESPECT TO A PORTION OF THE SERIES 2008 BONDS. ON SEPTEMBER 1, 2010, THE SERIES 2008 BONDS WERE CONVERTED TO FIXED INTEREST RATES TO MATURITY. HOWEVER, THE INTEREST RATE SWAPS WERE NOT TERMINATED IN CONNECTION WITH SUCH FIXED RATE CONVERSION AND REMAIN IN EFFECT. PART IV, LINE 3C, COLUMN (B): THIS BOND ISSUE HAS TWO HEDGE TERMS: 11.0 YEARS AND 21.0 YEARS. LUCINDA DAVIS FAMILY MEMBER OF DIRECTOR, JAMES BEAM 50489 COMPENSATION AS EMPLOYEE 0 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 BOARD OF DIRECTORS SHALL CONSIST OF FOURTEEN (14) MEMBERS, ALL OF WHOM SHALL BE THE MEMBERS OF THE BOARD OF DIRECTORS OF CAROMONT HEALTH, INC., AND ALL OF WHOM SHALL BE 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 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 HOSPITAL, 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. THE PROCESS FOR DETERMINING COMPENSATION FOR EXECUTIVE DIRECTORS AND 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. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -64. INTERCOMPANY TRANSFER TO AFFILIATE -27,147,201. CHANGE IN VALUE OF INTEREST RATE SWAP -2,038,050. TOTAL TO FORM 990, PART XI, LINE 5: -29,185,315. PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM LAST YEAR. STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS: FORM 990, PART III, LINE 4A CAROMONT HEALTH IN GASTONIA, NORTH CAROLINA IS A REGIONAL, INDEPENDENT, NOT-FOR-PROFIT HEALTH CARE SYSTEM. IT ENCOMPASSES GASTON MEMORIAL HOSPITAL WITH 435-BEDS; COURTLAND TERRACE, A 96-BED SKILLED NURSING FACILITY; GASTON HOSPICE WHICH INCLUDES THE 12-BED ROBIN JOHNSON HOUSE INPATIENT FACILITY, AND CAROMONT MEDICAL GROUP, A NETWORK OF 44 PRIMARY AND SPECIALTY PHYSICIAN OFFICES. CAROMONT HEALTH'S VISION IS TO BE A NATIONALLY RECOGNIZED LEADER AND VALUED PARTNER IN PROMOTING INDIVIDUAL HEALTH AND VIBRANT COMMUNITIES. CAROMONT HEALTH IS THE HEALTH CARE PROVIDER OF CHOICE FOR GASTON, LINCOLN AND CLEVELAND COUNTIES. THESE ARE RAPIDLY GROWING COMMUNITIES AND WE INTEND TO GROW WITH THE COMMUNITIES WE SERVE. CAROMONT HEALTH IS THE ONLY HEALTH CARE SYSTEM IN GASTON COUNTY WITH ACUTE CARE BEDS FOR THE FORESEEABLE FUTURE. WE CONTINUE TO ATTRACT TOP MEDICAL PROFESSIONALS FROM AROUND THE COUNTRY, WHILE RETAINING SOME OF THE AREA'S BEST PHYSICIANS AND NURSES. WE CONTINUE TO FORM INNOVATIVE COLLABORATIONS TO UPGRADE OUR TECHNOLOGY, CREATING BETTER OUTCOMES FOR OUR PATIENTS AND BETTER MANAGEMENT OF TIME AND MONEY. AND WE WILL CONTINUE TO PLAN NEW FACILITIES AS OUR COMMUNITY CONTINUES TO GROW. OUR GROWING COMMUNITY BRINGS WITH IT CHANGE IN TERMS OF DEMOGRAPHICS, AS WELL AS INFRASTRUCTURE NEEDS. AT THE SAME TIME, THE NATION'S HEALTH CARE INFRASTRUCTURE IS ON THE VERGE OF A SYSTEMIC OVERHAUL WITH FAR-REACHING IMPLICATIONS. FORTUNATELY, CAROMONT IS FOCUSED ON THE FUTURE AND TAKING STEPS TO PREPARE FOR ANTICIPATED CHANGES. WE BELIEVE THAT WE ARE WELL-POSITIONED, NOT ONLY TO EMBRACE THE COMING INNOVATIONS IN OUR NATION'S HEALTH CARE SYSTEM, BUT TO ACTUALLY AFFECT CHANGE THAT WILL BRING ABOUT A HEALTHIER, MORE VIBRANT COMMUNITY. MISSION AND VISION CAROMONT HEALTH'S MISSION IS TO PROVIDE EXCEPTIONAL HEALTH CARE TO THE COMMUNITIES WE SERVE. OUR VISION IS TO BE A NATIONALLY RECOGNIZED LEADER AND VALUED PARTNER IN PROMOTING INDIVIDUAL HEALTH AND VIBRANT COMMUNITIES. WE HOLD THE FOLLOWING VALUES FOR CAROMONT HEALTH. EACH IS IMPORTANT AND THEIR ORDER REFLECTS NO PARTICULAR HIERARCHY. AS WE HONOR THESE VALUES DAILY, OUR COMMITMENT TO OUR MISSION IS UNWAVERING. -QUALITY PATIENT CARE - WE STRIVE TO BE A LEADER IN PROVIDING QUALITY PATIENT CARE IN A SAFE AND FAMILY CENTERED ENVIRONMENT. -RESPECT FOR THE INDIVIDUAL - WE RESPECT EACH PERSON'S DIGNITY, RIGHT TO PRIVACY, AND DIVERSE BELIEFS. WE TREAT OTHERS AS WE WOULD LIKE TO BE TREATED. -INTEGRITY - WE WILL BE GUIDED BY WHAT IS RIGHT. -OPEN AND RESPONSIBLE COMMUNICATION - WE EMPHASIZE LISTENING, RESPONSIVENESS AND MUTUAL UNDERSTANDING. -PRIDE OF OWNERSHIP - WE BELIEVE EACH PERSON IS EMPOWERED FOR ACTION AS NEEDED AND MUST ASSUME PERSONAL RESPONSIBILITY AND ACCOUNTABILITY. -CUSTOMER SERVICE AND PATIENT SATISFACTION- WE ARE COMMITTED TO THE HIGHEST LEVEL IN BOTH ENDEAVORS. -FISCAL RESPONSIBILITY - WE KNOW THAT THE SOUND USE OF ALL RESOURCES IS FUNDAMENTAL TO OUR SUCCESS. -TEAMWORK- WE ARE PARTICIPATIVE AND WORK COOPERATIVELY. THE WELLBEING OF OUR PATIENTS IS DEPENDENT ON THE CONTRIBUTIONS OF ALL. -INNOVATION - WE ENCOURAGE NEW IDEAS, OPENNESS TO CHANGE, AND CREATIVITY. CAROMONT HEALTH QUALITY: -HEALTH GRADES CLINICAL EXCELLENCE RECIPIENT -GOLD STAR STANDARD HOSPITAL FOR TOBACCO CESSATION EFFORTS -U.S. NEWS AND WORLD REPORT'S BEST HOSPITALS AWARD -BECKER'S HOSPITAL REVIEW TOP COMMUNITY HOSPITAL AWARD, 2011 -CARECHEX #1 IN NC FOR CORONARY BYPASS SURGERY, HEART ATTACK TREATMENT, HEART FAILURE TREATMENT, AND PNEUMONIA CARE -COMMISSION ON CANCER (COC) OUTSTANDING ACHIEVEMENT AWARD (OAA), 2011 -HEALTHIEST EMPLOYER AWARD BY CHARLOTTE BUSINESS JOURNAL, 2012 -THOMSON AND REUTERS 50 TOP CARDIOVASCULAR HOSPITAL, 2012 -THOMPSON AND REUTERS 100 TOP HOSPITAL, 2012 -PREMIER ALLIANCE QUALITY ADVISOR TOP PERFORMER AWARD -HEALTH GRADES DISTINGUISHED HOSPITAL AWARD FOR CLINICAL EXCELLENCE, 2012 -HEALTH GRADES EXCELLENCE AWARD FOR EMERGENCY MEDICINE, 2012 -HEALTH GRADES AMERICAS 100 BEST FOR CARDIAC CARE, CARDIAC SURGERY, SPINE SURGERY, WOMEN'S HEALTH, 2012 -LEAPFROG HOSPITAL SAFETY SCORESM GRADE A FOR PATIENT SAFETY, 2012 -BECKER'S HOSPITAL REVIEW 100 BEST COMMUNITY HOSPITAL, 2012 CAROMONT HEALTH STRATEGY AND OBJECTIVES: CAROMONT HEALTH UNDERTAKES A COMPREHENSIVE ASSESSMENT OF ITS SERVICES EVERY YEAR TO DETERMINE STRATEGIC CHANGES REQUIRED TO ADDRESS THE CHANGING HEALTHCARE ENVIRONMENT, AND THUS THE OVERALL PROGRAM DIRECTIONS THAT NEED TO BE PURSUED. ON AN ANNUAL BASIS, GOALS AND OBJECTIVES ARE ESTABLISHED THAT WILL ALLOW PROGRESS TOWARDS THE DESIRED DIRECTION. MANY OF CAROMONT HEALTH'S FISCAL YEAR 2012 STRATEGIES AND OBJECTIVES WERE CREATED TO IMPROVE THE HEALTH OF THE COMMUNITY. CAROMONT HEALTH HAS SIGNIFICANTLY IMPACTED ITS COMMUNITY IN PROVIDING MANY DIFFERENT HEALTH IMPROVEMENT PROJECTS, GROUPS, EVENTS, EDUCATION PROGRAMS, ETC. INCLUDING THE FOLLOWING: HEALTHNET GASTON: HEALTHNET GASTON (HNG) IS A PROGRAM DESIGNED TO PROVIDE COMPREHENSIVE HEALTH CARE SERVICES TO LOW-INCOME, UNINSURED RESIDENTS OF GASTON COUNTY. ITS SERVICES INCLUDE: A MEDICAL HOME/PRIMARY CARE PHYSICIAN SERVICES, SPECIALTY PHYSICIAN SERVICES, MEDICATION ASSISTANCE, CASE MANAGEMENT/HEALTH COACHING ACTIVITIES, AND HOSPITAL SERVICES. HNG OPERATES THROUGH THE LEADERSHIP AND COLLABORATION OF ITS FOUR FOUNDING STRATEGIC PARTNERS, INCLUDING: GASTON MEMORIAL HOSPITAL, GASTON FAMILY HEALTH SERVICES, COMMUNITY HEALTH PARTNERS, GASTON COMMUNITY HEALTH CARE COMMISSION. UNITED WAY: CAROMONT HEALTH IS A PACE SETTER ORGANIZATION FOR UNITED WAY AND IN FISCAL YEAR 2012. GASTON COMMUNITY HEALTHCARE COMMISSION: IN 1992 THE GASTON COMMUNITY HEALTHCARE COMMISSION (GCHC) WAS ESTABLISHED WITH GASTON MEMORIAL HOSPITAL AS A SPONSORING ORGANIZATION. THE PURPOSE OF THIS ORGANIZATION IS TO DEVELOP A WORKABLE COMMUNITY-WIDE AGENDA THROUGH A PROBLEM SOLVING NETWORK OF ORGANIZATIONS AND INDIVIDUALS TO IMPROVE HEALTH STATUS OF GASTON COUNTY RESIDENTS. AS A CERTIFIED HEALTHY CAROLINIAN PARTNERSHIP, INITIATIVES ARE BASED ON THE MOST RECENT COMMUNITY HEALTH ASSESSMENT, COORDINATED BY BOARD THAT IS REPRESENTATIVE OF THE COMMUNITY, AND DOCUMENT THE IMPACT THAT THESE INITIATIVES HAVE ON HEALTH STATUS. THESE EFFORTS FOCUS ON IMPROVING THE HEALTH OF CHILDREN, ASSISTING RESIDENTS OF ALL AGES TO MAKE HEALTHIER LIFE STYLES CHOICES, IMPROVING ACCESS TO MEDICAL CARE, AND DECREASING THE COST OF MEDICAL SERVICES. CAROMONT HEALTH HEART WALK: THIS IS AN ANNUAL EVENT TO RAISE MONEY FOR THE GASTON HEART SOCIETY. IT IS A ONE MILE FUN WALK ON THE CAROMONT HEALTH CAMPUSES. PATIENT ADVOCACY - MEDICAID ELIGIBILITY DEPARTMENT (PATIENT FINANCIAL SERVICES): GASTON MEMORIAL HOSPITAL HAS DEVELOPED A PROGRAM TO ASSIST UNINSURED AND UNDERINSURED COMMUNITY MEMBERS WITH ENROLLMENT IN PUBLIC PROGRAMS. COMMON PAYMASTER 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 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 GASTON MEMORIAL HOSPITAL FOUNDATION INC 2527 COURT DRIVE GASTONIA NC 28054 561479699 FOUNDATION NC 501(C)(3) LINE 9 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 EMERGENCY PHYSICIANS INC 2531 COURT DRIVE GASTONIA NC 28054 562209423 SUPPORTING ORGANIZATION NC 501(C)(3) LINE 11A, I CAROMONT HEALTH INC 0 0 1 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1