CMS Approves Oregon State Hospital Plan of Correction

Posted on February 6, 2024

Salem, Ore.- The Centers for Medicare and Medicaid Services (CMS) has approved the Oregon State Hospital (OSH) Plan of Correction (PoC). The plan details how the hospital is responding to findings that it was deficient in areas related to the secure medical transport of justice-involved patients.

CMS surveyors visited OSH in September and October 2023 after a patient’s unauthorized leave while in secure transport restraints. At the time, OSH worked closely with CMS and successfully implemented corrective actions to remove an “immediate jeopardy” finding. The current PoC builds off of that extensive work.

Based on the CMS report, the plan is divided into the following four categories: transportation of patients, incident response, trainings and documentation. Examples of areas for improvement which OSH is addressing includes:

  • policies and procedures for staff training to ensure patient safety and security and the safety of others during justice-involved patient transport and restraint/seclusion use
  • elopement prevention to ensure the safe and appropriate care of patients
  • alternatives or less restrictive interventions to restraints and seclusion and clear documentation that other interventions were ineffective
  • improvements to quality assurance processes and management structures

“The safety of patients and employees will benefit from the ongoing refinements and additional enhancements included in the PoC,” said OSH Superintendent Dolly Matteucci. “Enhanced policies, more specific trainings, clear expectations and data driven evaluations create a foundation for individual and collective success.”

The PoC includes policy and procedure review and updates, attestation and training, and audits. Each section will have audits that will continue in a regular cadence, culminating in annual reviews once sufficient progress has been documented.

Beginning Feb. 25, surveyors representing CMS may return to validate that OSH has successfully implemented the PoC.

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