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Proposed Safety Fixes To Oregon State Hospital Facility Were ‘Unacceptable,’ Feds Say

State officials have proposed beefed-up improvements to patient care in Junction City and await a response from the Centers for Medicare & Medicaid Services.
The Oregon State Hospital campus in Junction City. | CHRISTIAN WIHTOL/THE LUND REPORT
June 13, 2022

Federal regulators who have threatened to decertify the Junction City campus of the Oregon State Hospital over safety concerns recently rejected the state’s proposed fixes as “generally unacceptable.” 

The federal Centers for Medicare & Medicaid Services required the psychiatric hospital to rewrite portions of its plan to address patient safety violations found at the facility ranging from suicide prevention to assaults and patient escapes.

Federal officials haven’t responded to the state’s revised plan submitted last week. But in a statement to The Lund Report, Superintendent Dolly Matteucci expressed confidence.

“This plan will ensure our services are meeting quality standards. We look forward to meeting the conditions of participation and resuming (certified) status.”

If the state doesn’t meet federal requirements, the Junction City campus runs the risk of losing its certification to receive federal funds on Aug. 3, the federal agency has warned.

The Oregon Health Authority runs the hospital, which has a main campus in Salem as well as the smaller campus housing in Junction City, which houses about 140 patients

Troubles Surfaced In December

Inspectors visited the facility in December after a patient escaped while on a group outing. They found multiple and systemic violations that jeopardized patient safety, such as a failure to internally investigate allegations of a patient-on-patient sexual assualt and failure to monitor a patient who attacked other patients in separate incidents just days apart. 

The inspectors worked for a different office of the Oregon Health Authority, which is deputized by the federal government to conduct health care facility inspections. Based on the inspection, federal regulators required improvements, issuing a May 5 “statement of deficiencies.

Nine days later, the state responded with a plan to address the problems noted by the federal government.

But in a May 25 email, a state inspector representing the federal agency notified hospital Superintendent Dolly Matteucci that the hospital’s proposed plan of correction needed more work and details. 

“It is noted and appreciated that since the survey the hospital has temporarily discontinued recreational off-grounds outings and has taken steps to eliminate the presence of unsafe and prohibited items in the patient (environment of care),” wrote  Karyn Thrapp, a patient safety surveyor in the email to hospital administrators. “However, the (plan of correction) has been determined to be generally unacceptable.”

The hospital, Thrapp added, needs to correct the following deficiencies in its initial plan of correction:

  • Rewriting vague language and terms that “seem to be specific” only to the state hospital. 
  • Corrective actions are “not clearly delineated for each deficiency,” the inspector wrote. For example, references to proposed policy and procedure revisions are “vague and do not reflect what changes are planned.”
  • Proposed staff training to correct violations are “not evident and clear for each deficiency,” the email said. “Some references to the type or groups of staff to be trained are unclear. There are no provisions for training during orientation of newly hired staff and provisions for ongoing training after the POC (plan of correction) correction date are inconsistent.”
  • The proposal’s plans for monitoring and auditing problem areas is “generally vague,” the email said. For example, the plan needs to include the number or percentage of cases to be reviewed, what type and how often. 

Federal regulators also found that the hospital, when it did give a percentage of case types it would review, didn’t identify a large enough share. “The sample size of 10% or 20% is not an adequate sample initially to ensure the hospital comes back into compliance,” the email said, adding that sample size would only be reasonable for long-term monitoring “after compliance is well established.”

Federal regulators also wanted clearer answers to how the hospital will ensure employees are adequately monitoring patients.

“How will staff observation, supervision of patients in all areas of the hospital and during transports on and off-units be

monitored to ensure patients are accounted for?” the email to hospital administrators asked. 

Federal officials also have other questions, such as how the hospital will monitor staff who are administering medications.

As for the December 2021 patient escape that started it all, federal officials still need more information.

“Are there plans for leadership staff or trained designees to systematically observe, monitor and document staff performance to ensure compliance, including during on and off campus outings?” the email asked.

The email also asked if there has been consideration of a systematic review of video recordings of activities, such as transports of patients on and off units, during dining and other activities to monitor and observe staff performance and compliance.

State Hospital Responds

Since receiving the “unacceptable” feedback, the state hospital has sent a revised plan to the federal agency intended to address the shortcomings, public records show. The federal agency hasn’t yet signed off on the second version of the draft plan.

It includes timelines for how quickly staff will be trained. For example, staff will be required to complete the new training within 21 days. Employees out on leave will have to complete the training within 14 days of their return.

For new employees, the plan calls for new employees to complete the training within six weeks as part of their orientation.

The goal is to train 100% of employees and when the hospital doesn’t keep pace with that, managers will need to develop plans for compliance and provide weekly updates. 

The revised plan is also longer – 50 pages instead of the 39 pages initially sent to the federal agency. It bolsters a variety of existing requirements in the initial plan.

For example, instead of a general requirement that the hospital will monitor and audit patient grievances to ensure that staff respond to them in the appropriate seven-day time frame, the revised plan adds more details. The plan now calls for compliance audits that sample for review about one out of every three grievances.

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1.