2011-04-06T08:44:03-05:00 2010-06-30 DIXON HUGHES PLLC 500 Ridgefield Court Asheville NC 28806 990 2009-07-01 560619359 GASTON MEMORIAL HOSPITAL INC GAST 7048342000 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 DAVID O'CONNOR 7048342000 2011-03-30 1 Amy Bibby 8282542254 2009 2016-02-24 21:20:13Z DAVID O'CONNOR 2525 COURT DRIVE PO BOX 1747 GASTONIA NC 280531747 383769132 0 X WWW.CAROMONT.ORG X 1945 NC To provide exceptional health care to the communities we serve. 14 11 3091 192 925418 140661 455641 373678 363285894 378127914 104775 112375 4408753 5155165 368255063 383769132 42500 88799 0 158413435 157119443 0 0 189145978 200992995 347601913 358201237 20653150 25567895 296184905 324420647 314205955 314318521 -18021050 10102126 To provide exceptional healthcare to the communities we serve. 0 0 337036111 88799 378216050 CAROMONT HEALTH PROVIDES INPATIENT, OUTPATIENT, EMERGENCY, AND SURGICAL SERVICES TO THE RESIDENTS OF GASTON COUNTY AND SURROUNDING AREAS AT ITS 435-LICENSED BED HOSPITAL, GASTON MEMORIAL HOSPITAL. PLEASE SEE SCHEDULE O FOR A CONTINUATION OF OUR PROGRAM SERVICE ACCOMPLISHMENTS. 337036111 1 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 1 288 0 3091 1 1 1 0 0 0 0 0 0 0 0 14 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 NC X X DAVID O'CONNOR 7048342000 2525 COURT DRIVE GASTONIA NC 28054 James R Beam 1.00 X 0 0 0 H Spurgeon Mackie Jr 1.00 X 0 0 0 Dr Robert D Crouch 1.00 X 0 0 0 Richard K Craig 1.00 X 0 0 0 Mary Frances Forrester 1.00 X 0 0 0 Kelvin C Harris MD 1.00 X 0 225445 18524 William K Gary Sr 1.00 X 0 0 0 James H Howard Jr 1.00 X 0 0 0 Sheila S Reilly PhD 1.00 X 0 0 0 Barry M Pomeroy 1.00 X 0 0 0 Mickey Price 1.00 X 0 0 0 Dr Kathy Drum 1.00 X 0 0 0 David Allen Smith 1.00 X 0 0 0 Dr H Clayton Thomason III 1.00 X 27900 0 0 Johnathan D Williams MD 1.00 X 30000 0 0 Vincent Quinn 1.00 X 0 0 0 Robert H Blalock Jr 1.00 X 0 0 0 Wayne F Shovelin 40.00 X 1972052 0 712653 David O'Connor 40.00 X 579283 0 174861 Maria Long 40.00 X 355765 0 121679 Valinda L Rutledge 40.00 X 257892 0 43500 Terry L Jones 40.00 X 632609 0 206916 JAMES D Huber 40.00 X 540103 0 158668 STEVEN A RUBIN 40.00 X 372256 0 129844 W K HARWELL 40.00 X 375060 0 166459 ANDREA K SERRA 40.00 X 319224 0 117066 MICHAEL R JOHNSON 40.00 X 225386 0 32995 SHARILYN J REESE 40.00 X 215723 0 23375 DAVID S MCSWAIN 40.00 X 207913 0 23504 LAURA W SWANSON 40.00 X 179839 0 13646 RICHARD C BLACKBURN 40.00 X 183050 0 29258 6474055 225445 1972948 104 0 1 0 SHARED (SIEMENS) MEDICAL SOLUTIONS 51 VALLEY STREAM PARKWAY MALVERN PA 19355 INFORMATION SYSTEMS 4568728 MORRISON MANAGEMENT SPECIALISTS INC 3 WACHOVIA CENTER STE 3000 401 S CHARLOTTE NC 28202 FOOD SERVICES MANAGEMENT 4100943 ARAMARK CTS 12483 COLLECTIONS CENTER DRIVE CHICAGO IL 60693 BIOMED SERVICES 2306054 GASTON ANESTHESIA ASSOCIATES PO BOX 601713 CHARLOTTE NC 28260 CRNA SERVICES 1867323 REHABCARE GROUP 7733 FORSYTH BLVD STE 1700 ST LOUIS MO 63105 OP REHAB SERVICES 1376032 51 172894 200784 373678 PATIENT SERVICES REVEN 621500 376617160 376180414 436746 PARTNERSHIP INCOME 541900 800617 764619 35998 IMAGING REVENUE 621500 428637 428637 LINEN/LAUNDRY 541900 97200 73163 24037 NURSING OUTREACH 621500 87504 87504 96796 96796 378127914 111538 111538 837 837 837 837 CAFETERIA & VENDING IN 722210 2255812 2255812 PHARMACY REVENUE 621500 2076656 2076656 DISCOUNTS & REBATES 621500 481068 481068 341629 35703 305926 5155165 383769132 377719267 925418 4750769 88799 88799 10239710 2864392 7375318 127597 127597 119305641 114890068 4415573 18036801 16470656 1566145 9409694 8558798 850896 5251589 5251589 2192896 31133 2161763 158855 158855 23922 23922 27705287 25126483 2578804 881379 133438 747941 2442474 1789358 653116 247094 247094 8718047 8715894 2153 102367 57999 44368 533641 268905 264736 9285762 9285762 26706067 26706067 2627482 2627482 UBI TAX -5415 -5415 MEDICAL SUPPLIES 66616455 66529460 86995 BAD DEBT 40397974 40397974 EQUIPMENT 5201236 5163868 37368 RECRUITING 968469 850247 118222 937414 853048 84366 358201237 337036111 21165126 0 -14801 -3285 35522404 33966858 4975910 5676105 7006967 7706644 477025151 269748931 208555162 207276220 3110334 17892 306912 349220 2311646 2311646 34410371 67119347 296184905 324420647 45447702 34757005 225406834 219898498 43351419 59663018 314205955 314318521 X -18021050 10102126 -18021050 10102126 296184905 324420647 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 23922 23922 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Annual dues were paid to the North Carolina Hospital Association and the American Hospital Association, of which $23,922 was determined to be expenditures used in lobbying activities by these organizations. 1654070 1654070 260481793 107501851 152979942 203290825 157712158 45578667 11598463 4534922 7063541 207276220 PREPAID PENSION OBLIGATION 26368035 DEFERRED FINANCING COSTS 5941413 OTHER RECEIVABLES 3754574 457B PLAN ASSETS 3169112 DEFERRED CHARGE - INTEREST RATE SWAP 27886213 67119347 457B PLAN LIABILITY 3169112 ESTIMATED 3RD PARTY SETTLEMENTS 28584396 CAPITAL LEASE OBLIGATION 23294 INTEREST RATE SWAP LIABILITY 27886216 59663018 383769132 358201237 25567895 2555281 2555281 28123176 381751209 -2017923 -2017923 383769132 0 383769132 358201237 0 358201237 0 358201237 Part XI, Line 8 - Other Adjustments: EQUITY TRANSFER: -16869616. RESTATEMENT OF INTEREST SWAP: 19424897. Part XII, Line 2d - Other Adjustments: FOUNDATION TRANSFER: -2017923. 1 1 1 X 1 X 1 1 1 0 1 1 13481041 13481041 0.04240 59098761 45226075 13872686 0.04370 830248 754731 75517 0.00020 73410050 45980806 27429244 0.08630 891846 2390 889456 0.00280 922681 5000 917681 0.00290 3922430 3422139 500291 0.00160 261074 261074 0.00080 5998031 3429529 2568502 0.00810 79408081 49410335 29997746 0.09440 623913 623913 0.00200 623913 623913 0.00200 0 13775512 874183 118789448 100267511 18521937 X 1 1 GASTON MEMORIAL HOSPITAL INCORPORATED

2525 COURT DRIVE GASTONIA NC 28054

X X X 6 OUTPATIENT CLINICS; 3 DIAGNOSTIC CENTERS Part I, Line 3c: Regardless of income, assets are also used to determine if a patient qualifies for Charity. The 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 accounted for. All costs are from the system, no cost to charge ratios were used in the calculations. Part I, Line 7g: These costs do not include any amounts associated with a physician's clinic. Part I, Line 7f: $40,397,973 Bad Debt Expense removed from total expenses prior to calculating Percent of Total Expense. Part III, Line 4: Allowances for uncollectible accounts are computed based on statistical information from current and prior years' experience. The System grants credit to patients without collateral, substantially all of whom are from the surrounding area.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, Lines 2 and 3 - Charges written off to charity/bad debt in the Emergency Room are subject to means testing. If the patient qualifies Schedule H Part VI Page 2 under the charity care policy the account is written off. The reminder of the hospital is subject to application for charity and if no application is filed, the unpaid amount becomes bad debt. The uninsured qualifying patient % in the ER was applied to the remainder of the hospital to determine the amount of bad debt that could have been charity. The amount was at the charge level, and the cost to charge ratio for the internally costed bad debt was used to determine the cost associated with those charges. Part III, Line 8: The Medicare Cost report standard costing methodology is followed when filing the cost report. This is a step down methodology that applies the average patient cost to Medicare patients, thus understating the true cost. Part III, Line 9b: The policy does contain 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 policy: Charity - 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.Expired Patients - Patients, including out of county residents, who have died, have no estate, and have no responsible spouse are deemed to have no income for the purpose of determining Charity Care eligibility. Part I, Line 6a: The organization community benefit report made available to the public contains community benefits for all related organizations to the hospital. Part VI, Line 2: At CaroMont Health, we are in love with life. That love of life is a dynamic force that is making its way from each employee and volunteer in our organization out into our community-touching the lives of every person we serve. Community priorities are established through a number of mechanisms: a. 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. b. Patient satisfaction data is analyzed to determine where and/or how services need to be improved. c. 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. d. 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. e. Gaston Memorial Hospital through the Gaston County Healthcare Commission in conjunction with the Gaston County Health Department conducts a Community Assessment every four years. The most recent study was Fall, 2008). 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. f. 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 organization notifies patients by distributing brochures and/or verbal communication with staff that include, Registrars, Financial Counselors, and Benefit Eligibility Specialists.The organization has developed a program to assist uninsured and underinsured community members with enrollment in public programs. Seven employees assist individuals with enrollment in Medicaid, NC Health Choice, Medicare, Crime Victims program, food stamps, vocational rehab, public housing, Wal-Mart prescription program, meals on wheels and adult services at DSS. In FY2010, the cost of this program was $403,387. Part VI, Line 4: The organization's primary service area is Gaston County, North Carolina. Its secondary service area includes the counties of Cleveland and Lincoln in North Carolina and York in South Carolina. The primary service area is urban with an estimated population of 208,958 in 2009. There are no other acute care hospitals in Gaston County. For the fiscal year ended June 30, 2010, Medicaid patients comprised 17.2% of the hospital's gross charges and Uninsured patients comprised 7.8% of the hospital's gross charges. According to the U.S Census Bureau, 15.1% of the persons in Gaston County were below poverty level in 2008. According to the U.S. Department of Health and Human Services, there are two medically underserved service areas in Gaston County. Part VI, Line 5: Gaston Memorial Hospital Foundation:The Gaston Memorial Hospital Foundation (a subsidiary of CaroMont Health) was established in 1985. The primary purpose of the Foundation is to provide funding for health care projects and services within the Health Care System and in the community. The Foundation also solicits and receives donations and administers two scholarship funds for students pursuing health related careers. In addition to the Foundation utilizing its investment earnings for donations, CaroMont Health donates up to 10% of its operating income to the GMH Foundation each year. Gaston Memorial Hospital Foundation actively supports Gaston Family Health Services (GFHS), a federally qualified healthcare clinic providing medical and dental services to the uninsured and underinsured population of Gaston County. This clinic is important to assuring that the uninsured and underinsured have access to health care in Gaston County. During fiscal year 2010, the Foundation donated $480,778 to GFHS. CaroMont Health is committed to assisting GFHS in providing for these patients who might otherwise go without primary care services. Gaston Community Healthcare Commission:In 1992 the Gaston Community Healthcare Commission (GCHC) was established with Gaston Memorial Hospital as a sponsoring organization. The GCHC has been a certified Healthy Carolinian Task Force since 1994. 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. As a designated Healthy Carolinian Task Force, initiatives have to be coordinated by a Board that is representative of the community, and document the impact that its initiatives have on health status. Since 1998, the following organizations have had a permanent position on the GCHC: Gaston Memorial Hospital, Gaston County Health Department, Gaston/Lincoln/Cleveland Mental Health Authority, Gaston Family Health Services, Gaston County Department of Social Services, Gaston County School System, Gaston College and Gaston Emergency Medical Services. The 25 member GCHC Board directed the activities of seven initiatives that were undertaken to improve health status. These efforts focused on improving the health of children, assisting residents of all ages to make better life styles choices, and improving access and decreasing the cost of medical services. During 2003 the GCHC was transferred to Gaston Together. Gaston Together allows the GCHC to have broader exposure in the community, and greater ability to seek grants to assist with the implementation of the numerous initiatives, while taking a broader advocacy position for addressing local health issues. The GCHC has been identified as the point organization for addressing health issues as a part of Gaston County's Vision 2012. Vision 2012 is a collaborative effort between Gaston County and the Gaston County Chamber of Commerce to implement initiatives for addressing economic development, infrastructure development, housing, safety, social/arts, and health issues. All of these actions have resulted in a stronger Board and community involvement for GCHC in order to continue to address health related issues. Workforce Development:CaroMont Health identifies and fills the health care provider needs of the community. The physician recruitment department is led by a Director of Physician Recruiter who oversees the Department of Physician Services, recruits physicians and physician extenders as needed and maintains open communication with all those involved in recruitment process.Enviromental Improvements:CaroMont Health has made great strides to become more eco-friendly. Some of these improvements include: a. Recycling 300,000 lbs of cardboard b. Recycling 990,205 lbs of office paper c. Recycling 190,000 lbs of metal d. Recycling fluorescent Lamps e. Began Plastic bottle recycling 2009 - estimated volume 5000lbs f. Established internal office paper collection system g. Began rechargeable battery recycling program h. Donated 100's of pc's and monitors to local schools and churches (reduced need to destroy) Part VI, Line 6: EVENTSHealthcare Career Day:CaroMont Health holds this an annual event for middle and high school students who are interested in a career in healthcare. During this fair, students have the opportunity to interact with CaroMont Health professionals and learn about their particular careers. Departments who are take part include Respiratory Care, Surgical Services, Rehab Services, Imaging Services, and Pharmacy, Food and Nutrition Services, and others. Over 100 students typically attend this event from all over Gaston County.CaroMont Health Heart Walk:This is an annual charity event sponsored by CaroMont Health is held to raise money for the Heart Society of Gaston County. The purpose of the Heart Walk charity event is to:(1) Increase awareness of cardiovascular disease and promote a heart healthy lifestyle by encouraging exercise. (2) Collect monetary donations to support the programs of the Heart Society of Gaston County which include medication assistance for persons with heart disease, cholesterol and blood pressure screenings for the public and cardiovascular health education programs for school children and the public.More than 400 walkers turned out for the May 2010 event where more than $14,000 was raised for the cause.Commissioner's School of Excellence:Each summer, the Gaston County Board of Commissioner funds a two-week residential experience for rising 10th graders at Belmont Abbey College. The Commissioners' School of Excellence (CSE) offers a variety of hands-on activities and seminars designed to help participants better understand Gaston County, and their own roles as future leaders. During this two-week session, some of these students who have expressed an interest in health care visit the hospital for a tour of the facility and to learn more about prospective careers. They get to interact with health care professionals in the Laboratory, Food and Nutrition Services and Imaging Services. Camp Summer Breeze is a week-long day camp for children with asthma. It combines traditional camp activities with asthma education in a medically supervised environment. The camp is held at Camp Rotary in western Gastonia. The July 2009 camp had 20 campers and junior volunteers. Children who cannot afford the tuition are given scholarships, and no campers have ever been turned away. Campers are given daily instruction on managing their disease, including hands-on training in how to properly measure their peak flows, proper inhaler use, and helpful breathing techniques.The CaroMont Candlelight 8K was held in October 2009 to raise money to provide prescription medications to patients via HealthNet Gaston. It was a "fall festival" event, which included an eight kilometer road race and a two mile fun run. Both began and ended on CaroMont's campus. This event received the endorsement of the Gastonia City Council, as well as cooperation and in-kind support from the NC Department of Transportation and the Gastonia Police Department. With more than 50 CaroMont employee volunteers and 700 runners, the event raised nearly $21,000 for HealthNet Gaston.The CaroMont Cancer Center held several programs and events for Breast Cancer Survivors including a Pink Ribbon Luncheon with a panel of experts to answer questions about Breast Health; Pink Ribbon Club which is a support group for survivors; Pink Ribbon Dinner and Expo that offers an educational session and expo of "pink ribbon" merchandise. The Annual Prostate Screening is held at Gaston Memorial Hospital every year. Men who fall within the screening guidelines as indicated by the American Cancer Society are eligible for a free screening that includes a digital rectal exam and Prostate Screening Assessment. The men are also provided with prostate education and prevention. 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. Other strategic partners involved with this initiative include community physicians, Gaston County Department of Social Services, Gaston County Health Department, and other local leaders. Flu Prepardeness:CaroMont Health provided significant community leadership and service during the H1N1 flu pandemic of 2009-2010. Numerous CaroMont Health staff members were recruited to provide vaccinations for Gaston County school children, and to staff community vaccination clinics. CaroMont employees - including nurses, medical assistants and security personnel - contributed nearly 500 hours for these vaccination clinics. In addition, CaroMont provided in-kind support for planning and coordinating with our community partners. In February 2010, Gaston County Commissioners presented commendations to CaroMont Health, Gaston County Health Department, Gaston College, Gaston County Schools, and Gaston Emergency Management Services for "outstanding contributions protecting the health of the people of Gaston County during the 2009 H1N1 flu response."HEALTH PROFESSIONS EDUCATIONStudents from more than twenty-five colleges and universities ranging from two-year programs to traditional four-year programs to Masters level programs receive all or part of their clinical training at various Health Care System facilities. Disciplines include: nursing, counseling, occupational therapy, clinical pastoral education, respiratory therapy, paramedic - basic and emergency medical technicians, laboratory technology, medical office administration, physical therapist assistant, phlebotomy, radiographic technology, recreational therapy, therapeutic recreation, health services and information management, nurse midwifery, family nurse practitioner, neonatal nursing, communication sciences and disorders, cardiovascular interventional technology, radiation therapy, social work, pharmacy, and physical therapy. In 2002, the Hospital established a partnership with the University of North Carolina - Charlotte ("UNCC") School of Nursing entitled CaroMont Health and the University of North Carolina at Charlotte Student Partnership. This partnership provides funding for a clinical facilitator and class supplies and has allowed UNCC to increase its class enrollment by ten nursing school students in their junior and senior years. The students have a classroom at the Hospital and clinical rotations take place throughout CaroMont Health.CASH AND IN-KIND CONTRIBUTIONSThe organization makes contributions to many community agencies. In FY2010, cash donations were made to over 30 community groups and/or events. In addition, the organization allows classroom space to be used by community groups and donates medical supplies and office supplies to various local and international organizations. Part VI, Line 7: CaroMont Health's vision is to be a nationally recognized leader and valued partern in promoting individual health and vibrant communities. 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 palliative care facility, CaroMont Medical Group, a network of primary and specialty physician offices in five counties and two states, and CaroMont Specialty Surgery, a freestanding ambulatory surgery center. NC 1 GASTONIA GRIZZLIES PO BOX 177 GASTONIA NC 28053 421554288 N/A 5500 FMV COMMUNITY ASSISTANCE COMMUNITY FOUNDATION OF GASTON COUNTY 991 W HUDSON BLVD GASTONIA NC 28052 581340834 501(C)(3) 15000 FMV COMMUNITY ASSISTANCE GASTONIA DOWNTOWN DEVELOPMENT CORP PO BOX 2396 GASTONIA NC 28053 560840699 501(C)(3) 5500 FMV COMMUNITY ASSISTANCE GASTON COUNTY FAMILY YMCA 615 WEST FRANKLIN BLVD GASTONIA NC 28052 560655420 501(C)(3) 7500 FMV COMMUNITY ASSISTANCE 3 1 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: OTHER ORGANIZATIONS THAT RECEIVE GRANT FUNDS MAY BE REQUIRED TO SUBMIT MONTHLY REPORTS THAT ARE MONITORED BY MANAGEMENT AND/OR THE BOARD OF DIRECTORS. ALL GRANTS DECISIONS ARE DOCUMENTED. X X X 1 1 X X X X X 0 1 0 0 0 1 1 0 0 Kelvin C Harris MD 0 161539 0 61856 0 2050 0 0 0 18524 0 243969 0 0 Wayne F Shovelin 642828 0 394994 0 934230 0 577417 0 135236 0 2684705 0 922287 0 David O'Connor 311111 0 121980 0 146192 0 135558 0 39303 0 754144 0 132010 0 Maria Long 204730 0 71010 0 80025 0 91791 0 29888 0 477444 0 78135 0 Valinda L Rutledge 145002 0 112500 0 390 0 31876 0 11624 0 301392 0 0 0 Terry L Jones 317938 0 102793 0 211878 0 145175 0 61741 0 839525 0 194604 0 JAMES D Huber 282610 0 105745 0 151748 0 126760 0 31908 0 698771 0 148138 0 STEVEN A RUBIN 220154 0 87145 0 64957 0 81654 0 48190 0 502100 0 53423 0 W K HARWELL 209766 0 79742 0 85552 0 85931 0 80528 0 541519 0 77812 0 ANDREA K SERRA 183620 0 73870 0 61734 0 77183 0 39883 0 436290 0 59535 0 MICHAEL R JOHNSON 195465 0 27397 0 2524 0 32995 0 0 0 258381 0 0 0 SHARILYN J REESE 187419 0 27146 0 1158 0 23375 0 0 0 239098 0 0 0 DAVID S MCSWAIN 177095 0 0 0 30818 0 23504 0 0 0 231417 0 0 0 LAURA W SWANSON 176807 0 0 0 3032 0 13646 0 0 0 193485 0 0 0 RICHARD C BLACKBURN 146401 0 20050 0 16599 0 29258 0 0 0 212308 0 0 0 Part I, Line 1a Travel for Companions - If a spouse or companion is expected to attend an event, it must be approved in advance and the expenses of the spouse or companion will be treated as taxable compensation and added to the employee's W2 or a 1099 will be issued at the end of the calendar year. During FY 2010 this benefit was provided to the CEO and some board members. Tax indemnification and gross-up payments - Reimbursement for certain taxable benefit costs (i.e. cell phones) will be grossed up for any tax obligations. 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 2010 this benefit was provided to the CEO and CFO. Part I, Line 4a Wayne F. Shovelin, CEO participates in a Supplemental Salary Continuation Retirement Plan. Gross payments for 2010 were $5,914,998. Please refer to the Schedule O disclosure for Part VI, Section B, Line 15 for more detail. Part I, Line 6 Certain CaroMont Medical Group Inc. Physician's Compensation packages are based on the individual physician's net results from operations as calculated based soley on his/her net charges less his/her allocable share of clinic overhead costs. Executive Incentive Compensation Plan for all key employees based on the achievement of annual Business Objectives and Financial Performance of the consolidated system. Manager Incentive Plan based on consolidated corporate and individual performance goals. NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HVF7 2003-01-23 120000000 NEW CONSTRUCTION, PURCHASE CAPITAL EQUIPMENT, PARTIAL ADVANCE REFUNDING 0 0 NORTH CAROLINA MEDICAL CARE COMMISSION 521309402 65820HA94 2008-01-01 118400000 RENOVATION OF HOSPITAL, PURCHASE OF CAPITAL EQUIPMENT, CURRENT REFUNDING 0 0 120405450 21 4642069 96734224 2007 0 1 1 1 118628201 17871 2471189 29562598 2009 1 0 1 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 1 0.00000 0.00000 0.00000 1 0 1 1 MERRILL LYNCH CAPITAL SERVICES 31.600000000000 0 0 0 0 1 1 MERRILL LYNCH DERIVATIVE PRODUCTS 21.000000000000 0 0 0 LUCINDA DAVIS FAMILY MEMBER OF DIRECTOR, JAMES BEAM 54150 COMPENSATION AS EMPLOYEE 0 BARBARA WILLIAMS FAMILY MEMBER OF DIRECTOR, JOHNATHAN WILLIAMS 35963 COMPENSATION AS EMPLOYEE 0 GENA POMEROY FAMILY MEMBER OF DIRECTOR, BARRY POMEROY 37484 COMPENSATION AS EMPLOYEE 0 CAROLINA ORTHAPAEDIC & SPORT MEDICINE CENTER PA ENTITY MORE THAN 5% OWNERSHIP BY CLAYTON THOMAS, III 242296 AGREEMENT FOR PROVISION OF IMAGING SERVICES TO THE ORGANIZATION 0 Form 990, Part VI, Section B, line 11 The organization's Form 990 is reviewed by the Audit Finance Investment Committee of the Board of Directors prior to presentation to the full Board before the Form is filed with the IRS. Form 990, Part VI, Section B, line 12c Each applicable employee and director shall fully and truthfully complete a questionnaire concerning potential and actual conflicts of interest annually. Such questionnaire shall identify the employee's obligation to immediately make the President aware in writing of any potential or actual conflicts on interest as they may arise and contain said employee's agreement to abide by all terms and conditions of this policy as a condition of retaining their position. Such questionnaires shall be reviewed annually by the Vice President/General Counsel and the Corporate Compliance Officer. The President shall make the Board of Directors aware of any actual conflicts of interest. Form 990, Part VI, Section B, line 15 The CEO, CFO/Assistant Treasurer and General Counsel/Assistant Secretary are compensated for their services by CaroMont Health, Inc. The compensation of all CaroMont executives for each year is established by the Compensation Committee of the CaroMont Health Board of Directors, based on guidance and opinions provided by an independent, third-party compensation consultant. Board members who serve on the Compensation Committee are independent and free of any conflict of interest. Any Compensation Committee member who develops a conflict of interest during his/her term with respect to the discussion of any executive's compensation leaves the meeting and does not participate in the discussion or decision-making by the remaining independent members of the Compensation Committee. The Compensation Committee retains jurisdiction over the total compensation package for executives and reviews executive benefits and perquisites as well as total cash compensation. Compensation for the CEO is established through a process of dialogue with the CEO, comparison with comparable market data and determination by the Compensation Committee of acceptable salary range and percentile ranking. All compensation decisions for the CEO are recommended by the Compensation Committee and approved by the Board of Directors. Compensation for all other executives is established through a process of dialogue between the CEO and the executive, comparison with comparable market data and determination by the CEO of acceptable salary range and percentile ranking. All compensation decisions for executives are recommended by the CEO and approved by the Compensation Committee. Full collected compensation information and any compensation opinions provided during these processes will be kept with the Compensation Committee or Board minutes, as applicable. In 2009, the Board of Directors, by and through the Compensation Committee, conducted two detailed reviews of the retirement benefit to be paid to its retiring CEO. In conducting these reviews, the Compensation Committee worked through an evaluation of the retiring CEO's performance during his 33-year tenure with the organization. The Compensation Committee concluded that in the areas of finance and quality measures, the retiring CEO's performance consistently exceeded expectations and has positioned CaroMont Health as a leader in the region. His performance in the area of patient satisfaction has, in the mission-critical area of emergency services, exceeded the Board of Director's expectations. Overall, and over the arc of his career at CaroMont, the retiring CEO's leadership has led CaroMont Health from a mere community hospital into a regional healthcare powerhouse. The Committee concluded that his leadership had outperformed the region and fulfilled the community's desire to keep its healthcare system under local control, thereby justifying his retirement payment as fair and reasonable compensation for outstanding performance. Form 990, Part VI, Section C, line 19 At this time, the organization's governing documents and conflict of interest policy are not made available to the public. The organization's financial statements are made available upon request. 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. SCHEDULE K, PART II, LINE 5: BOND (A) CREDIT ENHANCEMENT INSURANCE: $ 3,386,000 OTHER ISSUANCE COSTS: 1,256,069 BOND (B) CREDIT ENHANCEMENT INSURANCE: $ 1,553,717 OTHER ISSUANCE COSTS: 917,472 FORM 990, PART III, LINE 4A STATEMENT OF PROGRAM SERVICE ACCOMPLISHMENTS: The vision of CaroMont Health is to be a nationally recognized leader and valued partner in promoting individual health and vibrant communities. STRATEGY AND OBJECTIVES: CaroMont Health undertakes a comprehensive assessment of its services every three to five years 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 2010 objectives related to activities to improve the health of the community, including: 1. Develop an aggressive growth strategy to include - Leverage existing vertical and horizontal integration - Identify and establish partnerships to create compelling value proposition 2. The Focus of CaroMont Health's Growth Strategy - Enhance brand presence in key secondary market locations - Expand access points for care: - Portals for new referrals - Emphasize urgent and primary care (right care, right place, right time) - Design to provide coordinated and accountable care - Link cross-referrals, interventions, health management and wellness - Utilize e-technology, 24/7 connectivity and relationship-building - Create a 'personally remarkable' individualized care experience In addition, several of CaroMont Health's business objectives focused on improving the quality of care provided to our patients. Examples are: - Support continued development of a "safety net" program to provide "medical home" and medical services to qualified uninsured residents of Gaston County. - Complete requirements for JCAHO Certification for Disease- Specific Care Certification Program for Joint, Stroke, Heart Failure, Inpatient Diabetes, and Hip and Knee Replacement. - Participating in, and/or sponsoring/cosponsoring 10 or more healthcare related community events or programs that contribute to improving the health and wellness status of the communities we serve. - Participating in at least 48 speaking engagements or promotions regarding various CaroMont Health services and programs. - Conduct or participate in wellness health screenings within the community and/or places of employment. - Assess the benefit of establishing a Level III Trauma Program based on community need and physician input. - Enhance/expand the scope of our cardiovascular service - Develop a multi-disciplinary representation of physician councils to facilitate physician leadership development, provide a forum for evaluating and aligning new services, enhance care coordination, sharpen our focus and streamline the health care operating system. 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. Other strategic partners involved with this initiative include community several physicians, Gaston County Department of Social Services, Gaston County Health Department, and other local leaders. During fiscal year 2010, the hospital provided $8,761,805 and the employed physicians provided $680,715 of uncompensated care to the HNG patients. UNITED WAY: CaroMont Health is a pace setter organization for United Way and in fiscal year 2010, employees pledged $157,877 to United Way. Since 1990, CaroMont Health has donated a 10% match of the United Way employee pledges to the employee hardship fund on an annual basis. Funds are distributed to CaroMont Health employees who experience an unforeseen catastrophic event (for example; fire, serious accident, etc.) during the year. GASTON COMMUNITY HEALTHCARE COMMISSION: In 1992 the Gaston Community Healthcare Commission (GCHC) was established with Gaston Memorial Hospital as a sponsoring organization. The GCHC has been a certified Healthy Carolinian Partnership since 1994. 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. Since 1998, the following organizations have had a permanent position on the GCHC: Gaston Memorial Hospital, Gaston County Health Department, Pathways, Gaston Family Health Services, Gaston County Department of Social Services, Gaston County School System, Gaston College, United Way, Gaston Regional Chamber, Medical Society, and Gaston Emergency Medical Services. The 25 member GCHC Board directed the activities of seven initiatives that are undertaken to improve 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. During 2003 the administration of the GCHC was transferred to Gaston Together. Gaston Together allows the GCHC to have broader exposure in the community, build greater volunteer participation, and greater ability to seek grants to assist with the implementation of their numerous initiatives, while taking a broader advocacy position for addressing local health issues. The GCHC has been identified as the point organization for addressing health issues as a part of Gaston County's Vision 2020. Facilitated by Gaston Together, Vision 2020 is a collaborative community effort to implement initiatives addressing economic development, infrastructure development, housing, safety, social/arts, and health issues to position Gaston County for the future. All of these actions have resulted in a stronger Board and community involvement for GCHC in order to continue to improve the health status of the residents of Gaston County. CaroMont Health has significantly impacted its community in providing many different health improvement projects, groups, events, education programs, etc. HEALTH INSURANCE ENROLLMENT PROGRAMS: Gaston Memorial Hospital has developed a program to assist uninsured and underinsured community members with enrollment in public programs. Seven employees assist individuals with enrollment in Medicaid, NC Health Choice, Medicare, Crime Victims program, food stamps, vocational rehab, public housing, Wal-Mart prescription program, meals on wheels and adult services at DSS at an annual cost of $403,387. The primary service area of CaroMont Health is Gaston County in North Carolina. However, because of the regional nature of multiple services and/or programs that are provided through the organization, we provide a substantial amount of health care services to residents outside Gaston County. These out of county residents primarily come from Cleveland and Lincoln Counties in North Carolina, as well as York and Cherokee Counties in South Carolina. In fiscal year 2010, Gaston Memorial Hospital provided over $72 million of uncompensated care services to patients who had no insurance representing 7.8% of total services provided. In addition, the hospital provided over $159 million in services to Medicaid patients, representing 17.2% of the total services provided. No funding is received by CaroMont Health from Gaston County to provide this uncompensated care. Services are provided to all Gaston County residents, regardless of their ability to pay. All programs are funded from excess working capital. On occasion grants are received from The Duke Endowment, local foundations, federal or state agencies for specific programs, such as assistance with the start-up of parish nurse ministries, assistance with bioterrorism readiness, and the Breast Health Navigator position. Community priorities are established 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. - 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. 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. Health Professionals Education: CaroMont Health provides over $925,113 for the following educational activities: Precepting - UNCC, GWU, Queens AD, CPCC, Kaplan, CUSP (Admin.Support) CUSP (Administrative Support) Pharmacy Practice Residency (Pharmacy) Preceptor - GC Dietary (Administrative Support) Preceptor - California College of Health Sciences (Admin Support) Preceptor - ASU (Administrative Support) Preceptor MOC - UNCC (Administrative Support) Precepting/Mentor (Pharmacy) Precepting - Pharmacy -Wingate College Student (Pharmacy) Preceptor - Gardner Webb University (Administrative Support) Coordinated Nursing Assistant Instructor Orientation (Education Svcs) Precepting - Wingate College Student (Pharmacy - March - April 2010) Pharmacy Student #2 Mentoring - Wingate (Pharmacy) Pharmacy Student Mentoring-UNC Student #2 (Pharmacy) Pharmacy Student Mentoring-UNC Student #1 (Pharmacy) New Graduate Welcome Receptions (Administrative Support) Preceptor - Queens (Administrative Support) Pharmacy Student #1 Mentoring - Wingate (Pharmacy) Preceptor - Certified Clinical Medical Asst (Administrative Support) Lincoln-Cleveland Nurses Celebration (Executive Offices) Coordinated Gaston City Schools Allied Science Education Program (Education Services) Gaston Co Education Foundation BOD (Executive Offices) IC Training (Administrative Support) Financial contributions and in-kind contributions totaling $742,201 cover a wide array of community events and activities such as: Gaston Regional Chamber Economic Development Dept Dues (Exec. Offices) Daniel Stowe Botanical Gardens Holiday Lights (Executive Offices) Gaston County Family YMCA (Marketing) Gaston Regional Chamber Annual Dues (Executive Offices) Community Foundation Sponsorship for Simms Award (Exec. Offices) Boys Scouts of America (Marketing) NC Chamber Annual Membership (Executive Offices) Mt. Holly Springfest (Marketing) Gaston Regional Chamber (Marketing) Gaston Literacy Council Inc. (Marketing Gaston Chamber Salute to Manufacturing (Marketing) First Friday Focus-Gaston Regional Chamber (Marketing) March of Dimes Ambassador Avenue Sponsor (Marketing) Heart Society's 2010 Heart Ball Patron Level Donation (Marketing) Bessemer City Chamber Annual membership (Execuitve Offices) Heart Society 2010 Golden Heart Award Sponsor (Marketing) Gaston Chamber 2009 Economic Forecast Luncheon ( Marketing) Gaston Regional Chamber 2010 Planning Retreat (Marketing) Gastonia Jaycees (Marketing) Advanced Home Care Infusion Services (Patient Care) Gastonia Civitan Club Dues (Executive Offices) Advanced Home Care Annual Charity Golf (GMH) Belmont Abbey Corporate Annual membership (Executive Offices) Montcross Area Chamber of Commerce (Marketing) Catawba River Womens Group (Marketing - FY2010) United Way Women's Luncheon Table Sponsor (Marketing) South Point High School Baseball Tournament Sponsor Gastonia Grizzlies Annual Baseball Camp Sponsorship Gastonia Grizzlies HMI Sponsored Grizzly Baseball Camp Classroom space for Community Groups (Education Services) Samaritan's Purse - donation of medical supplies (Housekeeping) Framed Artwork to Junior League of Gaston County (Housekeeping) Giveaways for Cleveland County Fair (Marketing) Hand sanitizers to Taste of Gaston Event (Marketing) Refreshments for Cancer Center holiday concert (Marketing) Ink pens to Living Well after Lung Cancer program (Marketing) Personal Computer to Gaston County YMCA (Information Systems) Community Building Activities - Staff provide time and expertise to Workforce Development - Physician Recruitment. FORM 990, PART V AND PART VII COMMON PAYMASTER THE FILING ORGANIZATION USES A RELATED ORGANIZATION FOR ITS PAYROLL FUNCTION. ALL W-2S ARE FILED BY THE COMMON PAYMASTER. HOWEVER, AMOUNTS PAID BY THE COMMON PAYMASTER ARE TREATED AS IF PAID DIRECTLY BY THE ORGANIZATION FOR WHICH SERVICES ARE PERFORMED. CaroMont Health 2525 Court Drive Gastonia NC 28054 581636959 MEDICAL SERVICES NC 501(c)(3) Line 11b, II N/A CaroMont Health Services 2526 Court Drive Gastonia NC 28054 561455630 OUTPATIENT SERVICES NC 501(c)(3) Line 3 N/A Gaston Memorial Hospital Foundation Inc 2527 Court Drive Gastonia NC 28054 561479699 FOUNDATION NC 501(c)(3) Line 9 N/A CaroMont Medical Group Inc 2528 Court Drive Gastonia NC 28054 561479712 MEDICAL GROUP NC 501(c)(3) Line 9 N/A Hospice of Gaston County Inc 2529 Court Drive Gastonia NC 28054 581341530 Hospice Care NC 501(c)(3) Line 7 N/A Gaston Emergency Physicians Inc 2531 Court Drive Gastonia NC 28054 562209423 Supporting Organization NC 501(c)(3) Line 11a, I N/A 0 0 0 0 0 0 0 0 1 0 0 1 0 1 1 1 1 1