Oregon State Hospital Receives CMS Statement Of Deficiencies -06/11/25
June 11, 2025
Contact: Amber Shoebridge, Amber.shoebridge@oha.oregon.gov, 503-931-9586
Oregon State Hospital receives CMS statement of deficiencies
(Salem, Ore.) – Oregon Health Authority (OHA) and Oregon State Hospital (OSH) are responding to a statement of deficiencies from Centers for Medicare and Medicaid Services (CMS), following an April survey.
The deficiencies identified in the report relate to the hospital’s policies and procedures around patients’ rights and the responsibilities of its governing body to ensure patients receive safe and appropriate care.
“This report is a clarion call for the need for the immediate changes being implemented now that will have impact to assure that patients at OSH are safe and receiving the care they need and deserve,” said OHA Deputy Director Dave Baden, who was named OSH acting superintendent on April 11. “Sustained and ongoing cultural changes at the hospital will take time. We need to improve our processes in support of not only patients in seclusion or high-risk patients, but every patient at OSH.”
The statement of deficiencies, which cites instances of system-level failures, comes after CMS surveyors visited OSH after placing the hospital in immediate jeopardy (IJ) which could have resulted in the hospital losing CMS participation eligibility. The hospital put in place corrective actions, which led to CMS lifting the IJ status on May 12, 2025.
Hospital staff have worked to implement crucial improvements to the care and monitoring of patients in seclusion and restraint as well as high-risk patients. Other changes include innovations like transitioning three patient units into psychiatric intensive care units in April to improve care and interventions.
“The culture at OSH must change if we hope to ensure accountability and provide the highest quality of care for every person admitted to OSH. There is no other option,” said OHA Acting Director Kris Kautz.
“Our PoC will include strategies from our stabilization plan; many of which have already been implemented,” Baden said. “Two key changes implemented in the past few weeks are designed to provide more support for unit staff and leaders who are responsible for the daily care of patients. That’s our pause on telework for patient-facing staff and managers and mandatory rounding or visits to units by OSH leaders. The goal is increased visibility and improved communication between leadership and staff, as well as patients.”
The stabilization plan was released on April 30. It includes strategies to improve patient daily care and safety specific to three objectives: to decrease the likelihood of sentinel events (events that can lead to harm, injury or death), to improve OSH’s function as a 24/7 hospital, and to provide staff with clearer direction and empowerment to keep patients safe.
The statement of deficiencies can be found on the OSH website. The document has been redacted. As a medical provider and a HIPAA-covered entity, OSH is prohibited by federal and state privacy law from sharing a patient’s protected health information.
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