2023-02-14T14:09:10-06:00 2022-03-31 910189318 MOSS ADAMS LLP 805 SW BROADWAY STE 1400 PORTLAND OR 97205 990 2021-04-01 930606316 SERENITY LANE SERE 5414842156 PO BOX 8549 COBURG OR 97408 BRIAN CARLIN CFO 5414842156 2023-02-13 1 BRIAN CARLIN 999009999 WENDY CAMPOS P00448102 5032421447 2023-02-13 3 AAL1 IAL1 2021 2023-03-07 01:45:13Z PETE KERNS PO BOX 8549 COBURG OR 97408 17333048 0 X WWW.SERENITYLANE.ORG X 1973 OR TO TRANSFORM LIVES THROUGH THE TREATMENT OF ADDICTION. 7 7 221 16 0 0 1190577 556278 15956847 16774468 2874 2302 0 0 17150298 17333048 0 0 0 0 8648575 9889915 0 0 104020 7835632 8386649 16484207 18276564 666091 -943516 7063382 7482725 8538531 9901390 -1475149 -2418665 TO TRANSFORM LIVES THROUGH THE TREATMENT OF ADDICTION. 0 0 17125191 16774468 TREATMENT OF CHEMICAL DEPENDENCY THROUGH INPATIENT, RESIDENTIAL, AND OUTPATIENT SERVICES. 17125191 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 17 0 1 221 1 0 0 0 0 0 0 0 0 0 0 0 0 X 7 7 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 OR X BRIAN CARLIN CFO 5412848617 PO BOX 8549 COBURG OR 97408 JOHN DUNPHY CHAIR 1.00 1.00 X X 0 0 0 JOHN LIPKIN VICE CHAIR 0.50 0.50 X X 0 0 0 DEAN HANSEN TREASURER 0.50 1.50 X X 0 0 0 TIM DANFORTH SECRETARY 0.50 0.50 X X 0 0 0 MARY CHAVIN MEMBER 0.50 0.50 X 0 0 0 DANA FLEMING MEMBER 0.50 0.50 X 0 0 0 REV JOHN KERNS MEMBER 0.50 0.50 X 0 0 0 SR JANE HIBBARD MEMBER 0.50 0.50 X 0 0 0 PETE KERNS PRESIDENT & CEO 1.00 41.00 X 0 145195 28108 JAMIE LOUIE-SMITH CFO 1.00 40.00 X 0 135435 19204 ERIC GEISLER DIRECTOR OF MEDICAL SERVICES 40.00 0.00 X 221803 0 15829 JOEL BREEN PSYCHIATRIST 24.00 0.00 X 130219 0 5941 CHARNKAMAL SINGH DIRECTOR OF IT SERVICES 40.00 0.00 X 107730 0 26424 MIGUEL ESTEVEZ PHYSICIAN 40.00 0.00 X 126740 0 12674 SUSAN NICHOLSON DIRECTOR, NURSING AND HOSPITAL SRVS 40.00 0.00 X 116460 0 18308 702952 280630 126488 5 0 1 0 SERENITY LANE HEALTH SERVICES PO BOX 8549 COBURG OR 97408 MANAGEMENT SERVICES 1300000 1 556278 556278 PATIENT SERVICES 621400 16774468 16774468 16774468 2302 2302 17333048 16774468 0 2302 247757 247757 7674159 7277602 310753 85804 314975 294688 18045 2242 1131307 1057335 73972 521717 494221 20878 6618 1300000 1300000 1500 1500 367999 264775 103224 350562 350562 805703 541414 255114 9175 1702360 1684810 17550 45185 43912 1092 181 11100 7976 3124 OVERHEAD ALLOCATION 1452506 1452506 BAD DEBT & CHARITY CARE 1040325 1040325 DIETARY SUPPLIES 472952 472952 TAXES AND LICENSES 322360 81883 240477 514097 510973 3124 18276564 17125191 1047353 104020 146519 173384 3618824 4499883 2972162 2438503 325877 370955 7063382 7482725 8538531 9901390 8538531 9901390 X -1475149 -2418665 -1475149 -2418665 7063382 7482725 -943516 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 X PART X, LINE 2: SERENITY LANE HEALTH SERVICES, SERENITY LANE, AND SERENITY LANE HEALTH SERVICES FOUNDATION ARE NOT-FOR-PROFIT ORGANIZATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE AND ARE EXEMPT FROM FEDERAL INCOME TAXES. SERENITY LANE HEALTH SERVICES, SERENITY LANE, AND SERENITY LANE HEALTH SERVICES FOUNDATION HAVE ALSO BEEN CLASSIFIED AS ENTITIES THAT ARE NOT PRIVATE FOUNDATIONS WITHIN THE MEANING OF THE INTERNAL REVENUE CODE. ACCORDINGLY, NO PROVISION HAS BEEN MADE FOR INCOME TAXES IN THE CONSOLIDATED FINANCIAL STATEMENTS PURSUANT TO ASC 740, INCOME TAXES. THE ORGANIZATION GENERALLY EVALUATES ANY UNCERTAIN TAX POSITIONS CONSISTENT WITH THE ACCOUNTING AND DISCLOSURE REQUIREMENTS OF ASC 450, CONTINGENCIES. THE ORGANIZATION DID NOT HAVE ANY UNCERTAIN TAX POSITIONS IN CONNECTION WITH THESE CONSOLIDATED FINANCIAL STATEMENTS. 1 1 1 X 1 X 1 1 0 0 143195 143195 0.00820 7307547 5490005 1817542 0.10420 7450742 5490005 1960737 0.11240 51755 51755 0.00300 18717 18717 0.00110 70472 70472 0.00410 7521214 5490005 2031209 0.11650 1 831427 1 1 1 1 SERENITY LANE 91150 COBURG INDUSTRIAL WAY COBURG OR 97408 WWW.SERENITYLANE.ORG 40-0992 X SPECIAL INPATIENT CARE FACILITY SERENITY LANE 1 0 0 1 X X X X X X X 21 1 0 0 1 X WWW.SERENITYLANE.ORG X 0 0 1 X 200.000000000000 300.000000000000 X X 1 1 X X X 1 X SEE LINE 16J STATEMENT X SEE LINE 16J STATEMENT X SEE LINE 16J STATEMENT X X X X X 1 X 1 X X X X X 1 X 0 0 SERENITY LANE PART V, SECTION B, LINE 5: THE HOSPITAL CONSULTED WITH RESPECTED COMMUNITY MEMBERS AND INCLUDED THEIR COMMENTARY IN THE COMMUNITY HEALTH NEEDS ASSESSMENT. THE HOSPITAL CONSULTED WITH DR. KATE MARSHALL, INSTRUCTOR OF MEDICAN AT OREGON HEALTH SCIENCES UNIVERSITY; KEVIN GRAVES, INTERVENTIONIST AT THERE IS HOPE INTERVENTIONS, AND BRITTANY FERRELL, MPH, A CLINICIAN AT A MISSION FOR MICHAEL. THE HOSPITAL ALSO CONSULTED WITH LANE COUNTY PUBLIC HEALTH, DESCHUTES COUNTY, THE OREGON HEALTH AUTHORITY, TRILLIUM LANE COUNTY AND THE OREGON MEDICAL GROUP. SERENITY LANE PART V, SECTION B, LINE 11: COORDINATION OF PATIENT CARE WITH PEACE HEALTH-RIVERBEND; LIAISON WITH GOVERNMENTAL DEPARTMENTS, MEDICAL CENTERS, AND SUBSTANCE USE TREATMENT CENTERS TO MEET THE HEALTH AND SAFETY NEEDS OF ITS TREATMENT COMMUNITY; EXPANDED EVIDENCE-BASED TREATMENT OFFERINGS IN OUR RESIDENTIAL FACILITY; OFFERED TELEHEALTH FOR ALL OUTPATIENT PROGRAMMING IN RESPONSE TO THE COVID-19 PANDEMIC; EXPANDED MENTAL HEALTH SERVICES; ADDICTION LECTURES BY DR. ERIC GEISLER, DIRECTOR OF MEDICAL SERVICES AT SERENITY LANE, TO STAKEHOLDERS. SERENITY LANE PART V, SECTION B, LINE 16J: THE FAP, FAP APPLICATION, AND FAP PLAIN LANGUAGE SUMMARY ARE AVAILABLE AT HTTPS://SERENITYLANE.ORG/ADMISSIONS/COSTS-AND-INSURANCE-INFO/FINANCIAL-ASSISTANCE-POLICY/ 7 1 - SERENITY LANE 1050 PRICE ROAD ALBANY OR 97322 OUTPATIENT REHAB FACILITY 2 - SERENITY LANE 920 SW EMKAY DRIVE BEND OR 97702 OUTPATIENT REHAB FACILITY 3 - SERENITY LANE 10920 SW BARBUR BLVD PORTLAND OR 97219 OUTPATIENT REHAB FACILITY 4 - SERENITY LANE 2575 NW KLINE STREET ROSEBURG OR 97471 OUTPATIENT REHAB FACILITY 5 - SERENITY LANE 960 LIBERTY STREET SE STE 120 SALEM OR 97302 OUTPATIENT REHAB FACILITY 6 - SERENITY LANE 4211 WEST 11TH AVENUE EUGENE OR 97402 OUTPATIENT REHAB FACILITY 7 - SERENITY LANE 12662 SE STARK STREET SUITE A PORTLAND OR 97233 OUTPATIENT REHAB FACILITY PART I, LINE 3C: AS REPORTED ON SCHEDULE H, PART V, LINE 13, THE ORGANIZATION ALSO USES INSURANCE STATUS TO DETERMINE ELIGIBILITY FOR FREE OR DISCOUNTED CARE. PART I, LINE 7: CHARITY CARE COST IS ESTIMATED BASED UPON A PRO-RATA PERCENTAGE OF TOTAL PATIENT SERVICE COSTS TO TOTAL PATIENT SERVICE REVENUES.COMMUNITY SERVICES AND EDUCATION ARE TRACKED BY EVENT OR ACTIVITY WITH DIRECT COST BEING ACCUMULATED. PART I, LN 7 COL(F): ESTIMATED AT GROSS REVENUES PRIOR TO DISCOUNTS AND PAYMENTS. PART III, LINE 2: ESTIMATED AT 1-2% OF GROSS REVENUES, LESS PRIOR ACCOUNTS WRITTEN-OFF BUT COLLECTED IN THE CURRENT PERIOD. PART III, LINE 3: IF PATIENT APPLIES FOR FINANCIAL ASSISTANCE AND PROVIDES PROPER DOCUMENTATION, THEN BALANCES ARE WRITTEN-OFF TO CHARITY CARE (NOT BAD-DEBT EXPENSE) WHICH IS NETTED WITH GROSS REVENUES. NO DETERMINATION OF THOSE WHO MAY QUALIFY FOR FINANCIAL ASSISTANCE IS MADE UNLESS PROPER INFORMATION IS SUPPLIED AND ASSISTANCE IS REQUESTED. PART III, LINE 4: ACCOUNTS RECEIVABLE ARE CARRIED AT THEIR ESTIMATED COLLECTIBLE AMOUNTS. IN THE NORMAL COURSE OF BUSINESS, THE ORGANIZATION EXTENDS UNSECURED CREDIT TO THIRD PARTY PAYORS AND PRIVATE PARTIES. THE ORGANIZATION PROVIDES FOR AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND AN ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS THAT IS BASED UPON REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION, EXISTING ECONOMIC CONDITIONS, AND CONTRACT RATES WITH THIRD PARTY PAYORS. ACCOUNTS RECEIVABLE WITH THIRD PARTY PAYORS ARE GENERALLY DUE BASED UPON SUBMISSION OF THE CLAIM. THE MAJORITY OF RECEIVABLES FROM PRIVATE PARTIES ARE FINANCED OVER 18-36 MONTHS AS DETERMINED AT THE TIME OF DISCHARGE. NO NONCURRENT PORTION IS SEGREGATED AS ESTIMATION IS DIFFICULT AND NOT RELIABLE. IF THE NONCURRENT PORTION COULD BE REASONABLY ESTIMATED, SUCH CLASSIFICATION MAY HAVE A MATERIAL EFFECT ON THE CURRENT PORTION OF ASSETS; HOWEVER, IT WOULD NOT CHANGE THE OVERALL FINANCIAL POSITION OF THE ORGANIZATION. FINANCE CHARGES ARE CALCULATED AT 18% PER ANNUM AND SECURITY ARRANGEMENTS, IF ANY, VARY WITH THE FINANCIAL CIRCUMSTANCES OF THE PRIVATE PARTIES. MANAGEMENT DETERMINES NONACCRUAL OF INTEREST ON DELINQUENT ACCOUNTS RECEIVABLE ON AN ACCOUNT-BY-ACCOUNT BASIS BASED UPON HISTORICAL COLLECTION INFORMATION AND FINANCIAL CIRCUMSTANCES OF THE PRIVATE PARTY. MANAGEMENT DETERMINES AND EVALUATES PAST DUE BALANCES ON AN ACCOUNT-BY-ACCOUNT BASIS, AND IF AMOUNTS BECOME UNCOLLECTIBLE, THEY WILL BE WRITTEN-OFF WHEN THE DETERMINATION IS MADE.THERE WAS NO CHANGE IN THE METHODOLOGY USED BY THE ORGANIZATION TO ESTIMATE THE ALLOWANCE FOR DOUBTFUL ACCOUNTS AND THE ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS IN THE CURRENT YEAR. PART III, LINE 9B: IF THE PATIENT REQUESTS CONSIDERATION AND PROVIDES THE REQUESTED AND APPROPRIATE SUPPORT, FINANCIAL ASSISTANCE IS PROVIDED. PART VI, LINE 2: IN ADDITION TO THE COMMUNITY HEALTH NEEDS ASSESSMENT SERENITY LANE DOES THE FOLLOWING TO ADDRESS THE HEALTH CARE NEEDS OF THE COMMUNITY:1. THE BOARD IS MADE UP OF HIGHLY RESPECTED MEMBERS OF THE COMMUNITY REPRESENTING DIFFERENT ASPECTS, SUCH AS DOCTORS, HUMAN RESOURCE DIRECTORS, PRIESTS, ETC...2. SERENITY LANE STAYS IN CONTACT WITH NUMEROUS REPRESENTATIVES OF THE COMMUNITY, SUCH AS POLICE OFFICERS AND ELECTED REPRESENTATIVES. THE ORGANIZATION ALSO MAINTAINS CONTACT WITH OTHER PROFESSIONALS SERVICING THE ALCOHOL AND DRUG ABUSE ARENA INCLUDING AN ANNUAL AWARDS BANQUET SPONSORED AND ORGANIZED BY SERENITY LANE THAT RECOGNIZES OTHERS IN THE COMMUNITY THAT HAVE A SIGNIFICANT IMPACT IN THIS ARENA.3. SERENITY LANE HAS AN INTERNAL QUALITY ASSURANCE LICENSED STAFF TO PERFORM ROUTINE INSPECTIONS OF OTHER SIMILAR FACILITIES TO ENSURE THE ORGANIZATION IS UP TO DATE WITH THE LATEST PROCESSES AND TECHNOLOGY.4. SERENITY LANE PERFORMS ANNUAL PATIENT SURVEYS.5. SERENITY LANE ACCUMULATES PATIENT DATA BY GEOGRAPHICAL LOCATION WHICH HELPS ALIGN SERVICES WITH THE CURRENT NEED. PART VI, LINE 3: PATIENTS WITHOUT ADEQUATE RESOURCES ARE DIRECTED TO THE BUSINESS OFFICE TO APPLY FOR FINANCIAL ASSISTANCE. PART VI, LINE 4: CONSTITUENTS SERVED ARE THE WORKING MEN AND WOMEN AND THEIR FAMILIES IN NEARLY ALL COMMUNITIES IN THE STATE OF OREGON. PART VI, LINE 5: PROVIDING COMMUNITY EDUCATION AND RESOURCES REGARDING THE DISEASE OF CHEMICAL DEPENDENCY. THIS IS DONE THROUGH PARTICIPATION IN CONFERENCES, EDUCATING EMPLOYERS, NEWS ARTICLES AND OTHER COMMUNITY OUTREACH PRACTICES. PART VI - STATE FILING OF COMMUNITY BENEFITY REPORT: SERENITY LANE IS NOT AN ACUTE CARE HOSPITAL AND NOT SUBJECT TO THE COMMUNITY BENEFIT REPORT IN OREGON WHERE WE OPERATE. 0 0 0 0 0 0 0 0 0 ERIC GEISLER DIRECTOR OF MEDICAL SERVICES 219803 0 2000 0 0 0 9143 0 6686 0 237632 0 0 0 PETE KERNS PRESIDENT & CEO 0 145195 0 0 0 0 0 7729 0 20379 0 173303 0 0 JAMIE LOUIE-SMITH CFO 0 133435 0 2000 0 0 0 6401 0 12803 0 154639 0 0 PART I, LINE 3 PRESIDENT/CEO COMPENSATION IS SET BY THE SERENITY LANE HEALTH SERVICES BOARD OF DIRECTORS (A RELATED ORGANIZATION) USING DATA FROM COMPARABLE ORGANIZATIONS. FORM 990, PART VI, SECTION A, LINE 2 REVEREND JOHN KERNS (BOARD MEMBER) HAS A FAMILY RELATIONSHIP AS THE BROTHER OF PETE KERNS (CEO AND PRESIDENT). FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS REVIEWED BY THE PRESIDENT/CEO, CHIEF FINANCIAL OFFICER AND THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY REQUIRES A PERIODIC STATEMENT BE COMPLETED AND SIGNED. FORM 990, PART VI, SECTION B, LINE 15 PRESIDENT/CEO COMPENSATION IS SET BY THE BOARD OF DIRECTORS USING DATA FROM COMPARABLE ORGANIZATIONS. CFO COMPENSATION IS SET BY THE PRESIDENT/CEO USING DATA FROM COMPARABLE ORGANIZATIONS. COMPENSATION WAS LAST DETERMINED IN THIS MANNER DURING 2020. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. SERENITY LANE HEALTH SERVICES PO BOX 8549 COBURG OR 97408 943113708 ADMINISTRATIVE SUPPORT FOR SERENITY LANE OR 501(C)(3) LINE 12B, II N/A 0 SERENITY LANE HEALTH SERVICES FOUNDATION PO BOX 8549 COBURG OR 97408 461684147 FINANCIAL SUPPORT FOR SERENITY LANE OR 501(C)(3) LINE 12A, I SERENITY LANE HEALTH SERVICES 0 0 0 0 1 1 0 0 0 0 0 1 0 1 1 1 1 0 0 0 SERENITY LANE HEALTH SERVICES D 11853314 LOAN BALANCE SERENITY LANE HEALTH SERVICES E 1000000 LOAN GUARANTEE SERENITY LANE HEALTH SERVICES K 1061100 CASH SERENITY LANE HEALTH SERVICES M 1300000 CASH SERENITY LANE HEALTH SERVICES N 1452506 CASH SERENITY LANE HEALTH SERVICES O 1302792 CASH SERENITY LANE HEALTH SERVICES P 903087 CASH