Oregon State Hospital's Junction City campus submits draft improvement plan to keep federal funds
In early May, state inspectors found serious concerns at the Oregon State Hospital's Junction City campus, such as failures to take steps to protect patients from physical harm, and demanded administrators submit a corrective action plan within 10 days or risk losing the hospital’s Medicare and Medicaid certification.
The 39-page draft plan, which was submitted May 14, includes proposed fixes such as hiring a campus administrator, organizational improvements, updated guidelines preventing patients from having sexual contact, staff training, and an updated list of contraband for suicide prevention, among others, according to records the Register-Guard received from the Oregon Health Authority.
A spokesperson for the hospital said in an email that the plan was a draft and the final plan will be submitted to the Centers for Medicare and Medicaid Services by Monday, June 6.
OSH provides psychiatric treatment for adults from throughout the state who need hospital-level mental health treatment. The hospital has two campuses: a main campus in Salem and a second campus in Junction City. The Junction City location serves people who have been civilly committed, were voluntarily committed by a guardian, or have been committed under a guilty except for insanity plea to criminal behavior related to their mental illness.
The findings that prompted the need for a corrective plan stem from an inquiry into an incident last year when a patient, who was found guilty except for insanity on charges of arson and aggravated harassment, walked away from an outing in Eugene. However, the investigation’s scope broadened to many incidents documented at the Junction City campus in December 2021 and January 2022.
The review was conducted by surveyors that are part of Oregon Health Authority’s Public Health Division. These surveyors review complaints at hospitals and other health care facilities in Oregon on behalf of federal regulators. The state hospital is eligible to receive federal Medicare and Medicaid payments as long as it remains in compliance with federal requirements.
Investigators’ 134-page report painted a picture of a facility that routinely failed to safeguard patients even after unsafe conditions had been documented. The lapses put patients in danger from other patients, resulting in at least one alleged sexual assault and physical attacks, inspectors alleged. The review cites the hospital for deficiencies in the areas of compliance with law, patient rights, form and retention of records and patient safety. It states that the hospital failed to provide adequate preventative measures that created actual harm for patients including failure to prevent patient-to-patient sexual contact, sexual assault and physical altercations as well as failure to prevent patient suicide attempts and self-harm.
The surveyors identified federal and state compliance ranging from the lack of a permanent, onsite administrator to manage the Junction City campus on a daily basis, to shortcomings in documenting follow-up reviews after patient-to-patient altercations.
More of the proposed fixes include:
The OSH Grievance Policy will be reviewed and updated to require written unit grievance responses to be completed and provided to the grievant within seven days, with some exceptions.
Off-grounds outings will remain on hold until the plan of correction is implemented.
When off-campus activities resume, security staff will be retrained with a specific emphasis on handoff communication, transport ratios, physical supervision and post-outing documentation.
Some staff will have to attend trainings, such as one meant to help prevent patient-to-patient altercations. There will be audits and evaluations to make sure patients are safe and staff complete the required trainings.
The Contraband and Prohibited Items policy will be updated to prevent patients from getting materials that could be used for suicide.
A new incident review process will be developed.
Data will be separated between the two OSH campuses.
In the May 14 emailed Plan of Correction to CMS, Oregon State Hospital’s Director of Quality Management, Kimberly Ross, said implementation is underway. The draft plan says many of the identified “deficiencies,” including that lack of an onsite administrator, should be corrected by June 14.
Contact reporter Tatiana Parafiniuk-Talesnick at Tatiana@registerguard.com or 541-521-7512, and follow her on Twitter @TatianaSophiaPT.
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This article originally appeared on Register-Guard: Oregon State Hospital proposes improvements to keep federal funds
