2015-11-23T19:23:48-06:00 2015-03-31 910189318 MOSS ADAMS LLP 975 OAK STREET SUITE 500 EUGENE OR 97401 990 2014-04-01 930606316 SERENITY LANE SERE 5414842156 PO BOX 8549 COBURG OR 97408 MIKE DYER PRESIDENT AND CEO 5414842156 2015-10-28 1 WENDY CAMPOS P00448102 5416861040 2014 2016-04-25 22:37:26Z X MIKE DYER PO BOX 8549 COBURG OR 97408 14075192 0 X WWW.SERENITYLANE.ORG X 1973 OR TREATMENT OF THE DISEASE OF CHEMICAL DEPENDENCY 8 8 193 8 0 0 5975 5199 13057459 14067467 2385 2526 0 0 13065819 14075192 0 0 0 0 8266577 8381849 0 0 335078 4877524 5432858 13144101 13814707 -78282 260485 4800783 4677701 3871570 3485376 929213 1192325 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 13171042 14067467 TREATMENT OF CHEMICAL DEPENDENCY THROUGH INPATIENT AND RESIDENTIAL SERVICES. 13171042 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 1 193 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 1 1 1 1 0 OR X DUSTIN STAPLETON 5412848617 91320 NORTH COBURG INDUSTRIAL WAY 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 40.00 X 0 168915 47330 DUSTIN STAPLETON VP OF FINANCE/ADMINISTRATION 1.00 40.00 X 0 107904 28788 KAREN WILLOCK VP OF CLINICAL SERVICES 1.00 40.00 X 0 97569 4878 RONALD SCHWERZLER MEDICAL DIRECTOR 40.00 X 198768 0 26492 MICHAEL SCHWARTZ DOCTOR 40.00 X 191358 0 26122 LARRY BRADLEY VP OF DEVELOPMENT 40.00 X 156602 0 7830 JOSH BOLTON CHIEF INFORMATION OFFICER 40.00 X 107256 0 5363 653984 374388 146803 4 0 1 0 0 5199 5199 PATIENT SERVICES 621400 14067467 14067467 14067467 2526 2526 14075192 14067467 0 2526 620192 455760 164432 5630128 5317629 113166 199333 268697 259298 9399 1351425 1305543 45882 511407 472406 22939 16062 1300000 1300000 8050 8050 181832 169679 12153 535860 535600 260 549273 525218 24055 1105130 1104600 530 69108 61270 7838 25386 25191 195 DIETARY SUPPLIES 440281 440281 CHARITY CARE 404012 404012 LAB FEES 229008 229008 BAD DEBT EXPENSE 164803 163522 1281 420115 402025 18090 13814707 13171042 308587 335078 2655 2655 2742403 1650274 1884076 2774488 171649 249908 0 376 4800783 4677701 3871570 3485376 3871570 3485376 X 929213 1192325 929213 1192325 4800783 4677701 260485 2627 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 1 322 352268 352268 0.02780 322 352268 352268 0.02780 157 7612 244909 244909 0.01930 1 51164 51164 0.00400 158 7612 296073 296073 0.02330 158 7934 648341 648341 0.05110 0 163522 0 1 0 1 1 SERENITY LANE 616 E 16TH AVENUE EUGENE OR 97401 X SERENITY LANE 1 0 0 1 X X X X X X X 12 1 0 0 1 X WWW.SERENITYLANE.ORG X 0 0 1 X X X X 1 1 1 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 WENDY H PARK, PMHCNS-PP, PH.D, CLINICAL SUPERVISOR OF MENTAL HEALTH SERVICES FOR THE UNIVERSITY OF OREGON HEALTH CENTER AND CANDACE LANGHOUSE, PEACEHEALTH HUMAN RESOURCES AT SACRED HEART MEDICAL CENTER. 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. 10 SERENITY LANE 1050 PRICE RD ALBANY OR 97322 OUTPATIENT REHAB FACILITY SERENITY LANE 4305 NE THURSTON VANCOUVER WA 98662 OUTPATIENT REHAB FACILITY SERENITY LANE 601 NW HARMON BEND OR 97701 OUTPATIENT REHAB FACILITY SERENITY LANE 10920 BARBUR BVD PORTLAND OR 97219 OUTPATIENT REHAB FACILITY SERENITY LANE 12662 SE STARK PORTLAND OR 97233 OUTPATIENT REHAB FACILITY SERENITY LANE 1800 NW 167TH PL BEAVERTON OR 97006 OUTPATIENT REHAB FACILITY SERENITY LANE 2575 NW KLINE ROSEBURG OR 97471 OUTPATIENT REHAB FACILITY SERENITY LANE 1885 FISHER RD SALEM OR 97305 OUTPATIENT REHAB FACILITY SERENITY LANE 4211 WEST 11TH EUGENE OR 97402 OUTPATIENT REHAB FACILITY SERENITY LANE 2133 CENTENNIAL PLAZA EUGENE OR 97401 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): X PART III, LINE 4: THE ORGANIZATION UTILIZES THE ALLOWANCE METHOD TO ACCOUNT FOR BAD DEBTS BASED UPON EVALUATION OF ACCOUNTS RECEIVABLE, ANALYSIS OF HISTORICAL DATA AND EXISTING ECONOMIC CONDITIONS. THE ORGANIZATION PROVIDES AN ALLOWANCE FOR DOUBTFUL ACCOUNTS AND FOR ADMINISTRATIVE ADJUSTMENTS THAT IS BASED UPON REVIEW OF OUTSTANDING RECEIVABLES, HISTORICAL COLLECTION INFORMATION AND EXISTING ECONOMIC CONDITIONS. DISCOUNTS AND PAYMENTS ARE APPLIED TO PATIENT ACCOUNTS PRIOR TO RECORDING ANY BAD DEBT EXPENSE. 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 SURVEYS5. 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 0 0 0 0 0 0 0 0 0 MIKE DYER PRESIDENT & CEO 0 168915 0 0 0 0 0 28446 0 18884 0 216245 0 0 RONALD SCHWERZLER MEDICAL DIRECTOR 198768 0 0 0 0 0 9938 0 16554 0 225260 0 0 0 MICHAEL SCHWARTZ DOCTOR 191358 0 0 0 0 0 9568 0 16554 0 217480 0 0 0 LARRY BRADLEY VP OF DEVELOPMENT 156602 0 0 0 0 0 7830 0 0 0 164432 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. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS REVIEWED BY THE CEO, VP OF FINANCE/ADMIN AND THE FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION B, LINE 12C THROUGH A CONFLICT OF INTEREST STATEMENT FILLED OUT AND SIGNED PERIODICALLY FORM 990, PART VI, SECTION B, LINE 15 CEO COMPENSATION IS SET BY THE BOARD OF DIRECTORS USING DATA FROM COMPARABLE ORGANIZATIONS. VICE PRESIDENT'S COMPENSATION IS SET BY THE CEO USING THE SAME METHOD. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST SERENITY LANE HEALTH SERVICES 2133 CENTENNIAL PLAZA EUGENE OR 97401 943113708 ADMINISTRATIVE SERVICE AND SUPPORT FOR SERENITY LANE OR 501(C)(3) 509(A)(3) TYPE I SERENITY LANE 0 SERENITY LANE HEALTH SERVICES FOUNDATION 2133 CENTENNIAL PLAZA EUGENE OR 97401 461684147 FINANCIAL SUPPORT FOR SERENITY LANE OR 501(C)(3) 509(A)(3) TYPE I SERENITY LANE 0 0 0 0 1 1 0 0 0 0 0 1 0 1 1 0 1 0 0 0 SERENITY LANE HEALTH SERVICES K 792724 CASH SERENITY LANE HEALTH SERVICES M 1300000 CASH