By Anastasia Mason, Salem Statesman Journal,

10 hours ago

The Centers for Medicare and Medicaid Services has told the state of Oregon that it could stop providing Medicare payments to the Oregon State Hospital beginning August 4 if deficiencies found at the hospital after a patient death in March are not corrected.

CMS surveyors found hospital staff reported being "coached" on how to respond to them and said corrections put into place were stopped and returned to their previous practices after CMS found the hospital in compliance, according to the 245-page report the hospital released June 11. CMS sent the report to the hospital on May 22, a spokesperson said.

Gov. Tina Kotek called for the replacement of the hospital's chief medical officer and interim superintendent, Dr. Sara Walker, following the death, saying later "it became apparent that we needed to have a fresh start at the state hospital."

Walker had been in the superintendent role since the March 2024 retirement of Dolly Matteucci. Dave Baden, the deputy director of policy and programs for OHA, was appointed as acting superintendent to replace Walker, before James Diegel was scheduled to start June 4.

The report notes hospital staff who spoke with CMS indicated "numerous warnings and problems were brought to the attention of hospital executive leadership by department, program, and unit leaders. Those concerns were largely ignored and dismissed."

According to the statement of deficiencies, "multiple reports" mentioned the hospital's superintendent/chief medical officer, who at the time was Walker, as dismissing those concerns.

A federal judge on June 6 found the state in contempt of court for failing to comply with an order that required people deemed unable to defend themselves in court to be admitted to the hospital within a week. The judge also called for the state to be fined $500 a day for every person who is still waiting to be admitted after that 7-day period.

Kotek told reporters on June 9 that "being fined on a daily basis is not the best use of taxpayer dollars" and estimated the state could rack up fines of $250,000 to $500,000 a month.

"I feel like we're making progress," Kotek said. "And the judge, I think, just ran out of patience with us."

The hospital is no longer in immediate jeopardy status, which would mean it was at risk of losing certification necessary to receive federal funding, a spokesperson for the hospital said. Serious patient safety events have put the hospital into immediate jeopardy status multiple times in recent years.

An OSH spokesperson said the hospital will resubmit a plan of correction to CMS on June 13 after a prior submission was rejected. That plan will incorporate elements of a stabilization plan requested by Kotek, Baden said.

CMS will then make an unannounced visit to see if those changes have been made. Potentially stopping Medicare payments could come further down the line.

Feedback from employees included claims that there is an "empathy problem" at the psychiatric hospital and that staff with the least training and experience were assigned to units with patients in need of the most care.

“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.

OHA Director Dr. Sejal Hathi is on maternity leave.

CMS surveyors also found that hospital bylaws were outdated, with some medical protocols appearing to have last been reviewed in 2016 or earlier.

Some of the hospital's policies and procedures, including educational presentations and demonstration videos presented to staff, were unclear or did not provide straightforward explanations for use of seclusion and restraints.

Surveyors also determined a patient had been “accidentally” locked in a seclusion room overnight. The report stated that the safety of eight patients in seclusion was not properly ensured, citing multiple falls. Other safety failures included patients in seclusion having access to objects including items with sharp edges and “an altered patient toothbrush that they used for self-harm.”

A previous report from CMS found that the patient who died in March had fallen in seclusion.

Anastasia Mason covers state government for the Statesman Journal. Reach her at [email protected] or 971-208-5615.

This article originally appeared on Salem Statesman Journal: Oregon State Hospital reverted to prior practices after feds found it in compliance