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OHA recommends CMS lift termination track after Unity Center fixes deficiencies

November 1, 2018

Legacy Emanuel, Unity’s parent, was set to lose certification

PORTLAND, Ore.--The Centers for Medicare & Medicaid Services is making a final determination regarding the federal agency’s certification of Unity Center for Behavioral Health in Portland, after the psychiatric hospital fixed deficiencies found during Oregon Health Authority investigations into safety issues.

The recommendation to lift the CMS "termination track" set to expire at the end of day Oct. 31 means Unity can continue receiving federal reimbursement for services provided to Oregon Health Plan clients until CMS issues its final decision. The determination will consider recommendations from the OHA Public Health Division Health Facility Licensing and Certification Program. The program’s surveyors inspect CMS-certified health facilities on behalf of the federal agency to ensure compliance with CMS’s Conditions of Participation.

"In recommending that the termination be rescinded, OHA surveyors informed CMS that Unity has sufficiently implemented an acceptable Plan of Correction that will allow it to meet CMS Conditions of Participation," said Dana Selover, M.D., manager of OHA’s Health Care Regulation and Quality Improvement Section, which administers the Health Facility Licensing and Certification Program. "The Plan of Correction has additional steps that the facility will use moving forward to ensure that patients will receive a level of care that meets state and federal standards."

A termination track is a period in which a health facility must correct deficiencies before CMS terminates the facility’s certification, effectively ending Medicare and Medicaid reimbursement for services.

In late August CMS had extended its termination track for Unity from Sept. 11 to Oct. 31 after the hospital implemented a plan to end an "immediate jeopardy" designation that had been placed on it in July. CMS concluded at the time that it would be difficult for the hospital to make necessary corrections by Sept. 11, but Unity was making progress and CMS wanted to provide additional time to develop and implement those corrections.

Unity was placed on the termination track in mid-May after OHA surveyors, on a site visit as part of a complaint investigation, found that an "immediate jeopardy" situation existed and that the facility was out of compliance with several conditions of participation. This determination followed observations, interviews with staff members and reviews of records that uncovered numerous hazards in the physical environment, and lack of patient supervision and clear protocols for response to medical emergencies. Hazards found during the survey reflected actual harm to patients, patient attempts at self-harm and suicide attempts.

The immediate jeopardy classification was removed several days later, after Unity submitted an abatement plan. However, in late July during another Unity site visit, OHA surveyors determined a second immediate jeopardy situation existed after finding continued hazards in the physical environment, continued lack of assessment and observation of patients at risk of harm. Surveyors remained at the hospital until an acceptable, written immediate jeopardy abatement plan was developed and implemented.

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 Media contact

Jonathan Modie

OHA External Relations

971-246-9139

phd.communications@dhsoha.state.or.us

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