Oregon State Hospital makes ‘significant’ improvements, is now in compliance with patient care and safety standards

SALEM, Ore. (KTVZ) -- The Oregon State Hospital has made notable changes in regards to patient care and safety after a sentinel event in March of 2025. The hospital is now in compliance with Centers for Medicare and Medicaid Services (CMS) standards for patient care and safety.

Some of the notable improvements include:

• Increased collaboration to identify interventions to prevent or reduce the time a patient is in seclusion or restraint
• Implementation of a video monitoring team to provide additional support of in-person assessment of patients in seclusion or restraint
• Improved coordination on treatment care planning to mitigate and prevent falls and seclusion or restraint events 

Centers for Medicare and Medicaid Services revisited the Oregon State Hospital Salem campus on January 6th and 7th to confirm and review the hospital’s execution of the corrective actions. 

Read the full release from Oregon Health Authority, below:

After making significant improvements to patient care and safety, Oregon State Hospital is in compliance with Centers for Medicare and Medicaid Services (CMS) patient care and safety standards and is no longer at risk of losing eligibility to participate in the CMS reimbursement program. 

The hospital implemented comprehensive corrective actions in response to a March 2025 sentinel event. CMS surveyors conducted a revisit of the OSH Salem campus on Jan. 6 and 7 to review the hospital’s implementation of the corrective actions.  

In a letter received late Wednesday, CMS notified OSH that based on the revisit findings and recommendations, it is “rescinding the termination action.” The letter also officially declared OSH in “substantial compliance,” which is how CMS notifies a hospital that it is no longer under added scrutiny and is returning to a normal survey cycle, and restored its “deemed status.” This enables the hospital to continue billing for reimbursement, based on its continued accreditation by The Joint Commission, an independent regulatory body that sets quality care and safety standards.  

“CMS’s decision affirms the significant progress staff have made to strengthen patient care and safety. I am proud of this team and tremendously grateful for this organization’s hard work – and we’re clear-eyed that this milestone is not the finish line,” said Sejal Hathi, M.D., MBA, director of Oregon Health Authority. “Our charge now is to hardwire these gains into everyday practice through continued cultural and operational change, so that every patient, every day, receives safe, high-quality, therapeutic care.”  

OSH provides psychiatric treatment for people from across Oregon who are in need of hospital-level mental health treatment who are traditionally marginalized, stigmatized and underserved, including many people with co-occurring disorders and those impacted by structural racism, and disproportionally represented in the criminal justice system.   

Audits and continuing education on the implemented corrective actions helped the hospital sustain the changes which included:  

• Increased collaboration to identify interventions to prevent or reduce the time a patient is in seclusion or restraint
• Implementation of a video monitoring team to provide additional support of in-person assessment of patients in seclusion or restraint
• Improved coordination on treatment care planning to mitigate and prevent falls and seclusion or restraint events 

“This is a milestone that every caregiver has worked hard to achieve with the understanding that our work does not stop with CMS compliance,” said Jim Diegel, OSH interim superintendent. “Over the past 10 months, teams across the hospital have worked diligently to not only implement corrective actions specific to the CMS findings, but to strengthen OSH’s systems around quality assurance and performance improvement to create lasting change. This includes a new chief patient safety officer position to formalize our ongoing work to ensure strategic focus on continuous improvements to patient care and safety.”  

The hospital will continue to implement and audit its corrective actions to ensure sustained compliance as part of its commitment to ongoing improvement.  

This recent decision by CMS means the hospital returns to a routine cycle of surveys to ensure compliance with standards centered on patient safety and quality of care.