2017-02-06T17:26:15-06:00 2016-03-31 910189318 Moss Adams LLP 975 Oak Street Suite 500 Eugene OR 97401 990 2015-04-01 930606316 Serenity Lane SERE 5414842156 PO Box 8549 Coburg OR 97408 MIKE DYER PRESIDENT AND CEO 5414842156 2017-02-01 1 Wendy Campos P00448102 5416861040 2017-01-30 2015 2021-01-29 14:40:06Z MIKE DYER PO Box 8549 Coburg OR 97408 13646515 0 X WWW.SERENITYLANE.ORG X 1973 OR TREATMENT OF THE DISEASE OF CHEMICAL DEPENDENCY 8 8 204 8 0 0 5199 19622 14067467 13623774 2526 3119 0 0 14075192 13646515 0 0 0 0 8381849 8588776 0 0 406161 5432858 5476419 13814707 14065195 260485 -418680 4677701 4419923 3485376 3641858 1192325 778065 PROVIDING A HEALING ENVIRONMENT IN WHICH CHEMICALLY DEPENDENT INDIVIDUALS AND THEIR FAMILIES DISCOVER AN ENHANCED QUALITY OF LIFE THROUGH LONG-TERM RECOVERY FROM ADDICTIONS. 0 0 13558361 13623774 TREATMENT OF CHEMICAL DEPENDENCY THROUGH INPATIENT AND RESIDENTIAL SERVICES. 13558361 1 0 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 31 0 1 204 1 0 0 0 0 0 0 0 0 0 0 X 8 8 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 1 1 1 0 OR X DUSTIN STAPLETON 5412848617 1 SERENITY LANE 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 Mike Kehoe Treasurer 0.50 0.50 X X 0 0 0 Kate Kloos Secretary 0.50 0.50 X X 0 0 0 Larry Olsen Member 0.50 0.50 X 0 0 0 Rev John Kerns Member 0.50 0.50 X 0 0 0 Tim Danforth Member 0.50 0.50 X 0 0 0 Cindy Weinhold Member 0.50 0.50 X 0 0 0 Mike Dyer President & CEO 1.00 41.00 X 0 185135 28519 Dustin Stapleton VP of Finance/Administration 1.00 41.00 X 0 110534 28664 Karen Willock VP of Clinical Services 1.00 41.00 X 0 99900 4995 Ronald Schwerzler Medical Director 40.00 X 184230 0 25585 Larry Bradley VP of Development 40.00 X 156571 0 7829 Michael Schwartz Doctor 40.00 X 116196 0 9903 Josh Bolton Chief Information Officer 40.00 X 107158 0 5358 564155 395569 110853 4 0 1 0 0 19622 19622 Patient Services 621400 13623774 13623774 13623774 3119 3119 13646515 13623774 0 3119 310586 146282 82152 82152 6077009 5907457 169552 265051 256999 8052 1396358 1355916 40442 539772 518058 6971 14743 1300000 1300000 11550 11550 335126 308411 26715 501643 501643 645478 617348 28130 793609 793334 275 69064 61864 7200 35508 35059 449 Charity Care 480375 480375 DIETARY SUPPLIES 452329 452329 TAXES AND LICENSES 232722 226132 6590 LAB FEES 183672 183672 435343 413482 21861 14065195 13558361 100673 406161 2655 318503 1650274 1240938 2774488 2485301 249908 374348 376 833 4677701 4419923 3485376 3641858 3485376 3641858 X 1192325 778065 1192325 778065 4677701 4419923 -418680 4420 0 X 0 1 X 1 0 X 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 HAVE 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 STATEMENTS. 1 1 0 0 1 1 0 1 1 278 474409 474409 0.03460 278 474409 474409 0.03460 105 1952 200913 200913 0.01470 1 67274 67274 0.00490 106 1952 268187 268187 0.01960 106 2230 742596 742596 0.05420 1 119674 0 1 1 1 1 Serenity Lane 1 Serenity Lane 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 15 1 0 0 1 X WWW.SERENITYLANE.ORG X 1 15 1 WWW.SERENITYLANE.ORG 0 0 1 X X X 0 1 X X X 1 X X 1 X X 1 X X X X X 0 X 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 Candace Langhouse, PeaceHealth Human Resources at Sacred Heart Medical Center; Edwin Schneider, RPh, Professional Recovery Network President; and Christopher J. Hamilton, PhD, MPA, Monitoring Programs, Program Direction, Reliant Behavioral Health. SERENITY LANE Part V, Section B, Line 11: Prioritization of health needs and services in the community. SERENITY LANE Part V, Section B, Line 22d: CHARGES TO FAP ELIGIBLE PATIENTS ARE DETERMINED BASED ON FINANCIAL NEED ON A CASE BY CASE BASIS. 9 1 - Serenity Lane 1050 Price Road Albany OR 97322 Outpatient Rehab Facility 2 - Serenity Lane 4305 NE Thurston Way Vancouver WA 98662 Outpatient Rehab Facility 3 - Serenity Lane 601 NW Harmon Boulevard Bend OR 97701 Outpatient Rehab Facility 4 - Serenity Lane 10920 Barbur Boulevard Portland OR 97219 Outpatient Rehab Facility 5 - Serenity Lane 12662 SE Stark Street Portland OR 97233 Outpatient Rehab Facility 6 - Serenity Lane 1800 NW 167th Place Beaverton OR 97006 Outpatient Rehab Facility 7 - Serenity Lane 2575 NW Kline Street Roseburg OR 97471 Outpatient Rehab Facility 8 - Serenity Lane 1885 Fisher Road Salem OR 97305 Outpatient Rehab Facility 9 - Serenity Lane 4211 West 11th Avenue Eugene OR 97402 Outpatient Rehab Facility Part I, Line 3c: PATIENTS WHO REQUEST FINANCIAL ASSISTANCE ARE ASKED TO COMPLETE A FINANCIAL STATEMENT DESCRIBING THEIR SOURCES OF INCOME AND ALL EXPENSES. EACH DETAIL OF EACH APPLICATION IS REVIEWED AND A DECISION IS MADE WHETHER TO PROVIDE A CHARITY CARE DISCOUNT WITHIN THE FINANCIAL CAPABILITIES OF ORGANIZATION. 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: NEARLY ALL COMMUNITIES IN THE STATE OF OREGON AND VANCOUVER, WA. CONSTITUENTS SERVED ARE THE WORKING MEN AND WOMEN AND THEIR FAMILIES. 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. X 1 1 1 0 0 0 0 0 0 0 0 Mike Dyer President & CEO 0 185135 0 0 0 0 0 9257 0 19262 0 213654 0 0 Ronald Schwerzler Medical Director 184230 0 0 0 0 0 9212 0 16373 0 209815 0 0 0 Larry Bradley VP of Development 156571 0 0 0 0 0 7829 0 0 0 164400 0 0 0 Part I, Line 1a COUNTRY CLUB DUES ARE PAID ON BEHALF OF THE PRESIDENT & CEO. THE COUNTRY CLUB IS USED FOR BUSINESS MEETINGS AND FOR DEVELOPMENT AND FUNDRAISING PURPOSES. Part I, Line 4a Michael Schwartz received a severance payment in the amount of $35,000. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the President/CEO, VP of Finance/Administration and the finance committee of the board of directors. Form 990, Part VI, Section B, line 12c THE CONFLICT OF INTEREST POLICY REQUIRES A STATEMENT FILLED OUT AND SIGNED PERIODICALLY. Form 990, Part VI, Section B, line 15 PRESIDENT/CEO COMPENSATION IS SET BY THE BOARD OF DIRECTORS USING DATA FROM COMPARABLE ORGANIZATIONS. VICE PRESIDENT COMPENSATION IS SET BY THE PRESIDENT/CEO USING THE SAME METHOD. Form 990, Part VI, Section C, line 19 UPON REQUEST SERENITY LANE HEALTH SERVICES PO Box 8549 Coburg OR 97408 943113708 ADMINISTRATIVE SUPPORT FOR SERENITY LANE OR 501(c)(3) Line 11a, I SERENITY LANE 0 SERENITY LANE HEALTH SERVICES FOUNDATION PO Box 8549 Coburg OR 97408 461684147 FINANCIAL SUPPORT FOR SERENITY LANE OR 501(c)(3) Line 11a, I SERENITY LANE 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 13000000 CASH SERENITY LANE HEALTH SERVICES E 1000000 CASH SerENITY LANE HEALTH SERVICES K 317724 CASH serENITY LANE HEALTH SERVICES M 1300000 cASH