Oregon State Hospital System – CRIPA Review 2006

Results of the 2006 U.S. Department of Justice review of conditions and practices at the Salem and Portland campuses of the Oregon State Hospital

READ – full PDF document as a 47 page letter to Governor Ted Kulongski


The U.S. Department of Justice (USDOJ) Civil Rights Division is responsible under the 1997 Civil Rights of Institutionalized Persons Act (CRIPA) for investigating conditions and practices at public psychiatric institutions. USDOJ regularly conducts reviews of such institutions throughout the United States to ensure protection of the constitutional and federal statutory rights of patients with mental illness who are being treated in public institutions.

During November 2006 USDOJ investigated conditions and care practices at the Salem and Portland campuses of the Oregon State Hospital (OSH). The inquiry included on-site interviews of administrative staff, mental health care providers and patients. Investigators also examined the physical living conditions at the two facilities and reviewed hundreds of documents including policies and procedures, incident reports, and medical and mental health records.

Following that review, USDOJ provided a report in January 2008 to the Oregon Department of Human Services (DHS) advising DHS of USDOJ’s findings. The report, per CRIPA requirements, includes recommended remedial steps for OSH to take to correct any reported deficiencies.

USDOJ stated in its report that “It is apparent that many OSH staff genuinely are concerned for the well-being of the persons in their care. These staff members display admirable dedication and undertake significant efforts to provide appropriate treatment and improve the lives of OSH patients.”

However, USDOJ found deficiencies in five general areas:

  • Adequately protecting patients from harm,
  • Providing appropriate psychiatric and psychological care and treatment,
  • Use of seclusion and restraints in a manner consistent with generally accepted professional standards,
  • Providing adequate nursing care,
  • Providing discharge planning to ensure placement in the most integrated settings.

The next section provides more details about these findings and OSH’s actions to remedy the identified deficiencies.

Findings and responses

Inadequate protection of patients from harm


  • There is widespread patient-against patient assault, unchecked self-injurious behavior, and a high rate of falls.
  • The housing units contain environmental hazards, some of which pose risks of serious injury, illness and death.
  • OSH’s ability to address patient safety is hampered by inadequate incident management and quality assurance systems.


Thus far, OSH has taken the following actions to better protect patients from harm:

  • Received approval and $458.1 million in funding from the 2007 Oregon Legislature to replace OSH with two new, state-of-the-art psychiatric hospitals. The hospitals will be located in Salem (opening in 2011) and Junction City (opening in 2013). Many of the recommendations in the USDOJ report will be addressed with the opening of these new facilities.
  • Received $9.3 million from the January 2006 Legislative Emergency Board to boost hospital staffing and speed patient discharges. The money was earmarked to hire 30 new staff members, move 71 patients into community-based programs, and renovate the Portland OSH campus to create bed space for patients who had been living in the most-dilapidated building on the Salem campus.
  • Implemented a Continuous Improvement Plan process that includes actions to address patient safety.
  • Implemented The Joint Commission (for the accreditation of health care organizations) 2008 National Patient Safety Goals.
  • Educated all staff on Professional Assault Crisis Training (ProACT).
  • Created an electronic critical incident and medication error reporting system.
  • Improved critical incident review and response/improvements follow-up.
  • Expanded a falls reduction program hospital-wide.
  • Supported mandatory pain reduction training for all licensed staff.
  • Revised and implemented dangerousness risk assessments hospital-wide.
  • Continued seclusion/restraint reduction efforts.
  • Promoted a non-violence campaign hospital-wide.
  • Trained all management leadership in Trauma-Informed Care.
  • Completed fire drills and extinguisher checks as scheduled.
  • Trained all staff in asbestos awareness, safe equipment operations, and use of personal protective equipment.
  • Cataloged all asbestos in the facility and certified staff in asbestos abatement.
  • Met all Occupational Safety and Health Administration requirements.

Lack of appropriate psychiatric and psychological care and treatment


  • Psychiatric practices at both campuses lack adequate assessments and diagnoses, behavioral management services, and medication management.
  • Patients do not receive comprehensive treatment planning that integrates assessment and input from mental health professionals representing a variety of disciplines.

Thus far, OSH has taken the following actions to improve mental health care and treatment:

  • Entered into a two-year agreement with Oregon Health & Science University (OHSU) to add a chief psychiatrist, six additional psychiatrists/physicians and one research assistant to the Salem OSH campus to improve patient care.
  • Implemented a Continuous Improvement Plan process that includes actions to address mental health care and treatment.
  • Increased active, centralized treatment services at the Portland OSH facility and completed plans to implement this at the Salem OSH campus in August 2008.
  • Established a consumer-run Empowerment Center.
  • Implemented evidence-based practice of Relapse Prevention hospital-wide.
  • Implemented evidence-based practice individual and group therapies.
  • Supported Certified Alcohol and Drug Counselor (CADC) training for mental health credentialed staff.
  • Provided Dual Diagnosis Anonymous (mental health and addictions) groups.
  • Created Community Reintegration Program for addictions, which supports community transitions, employment and education.
  • Established best-practice, self-help coping skills training, Recovery International, hospital-wide.
  • Expanded vocational and educational services hospital-wide.
  • Implemented a medication accuracy and interaction verification system.
  • Created involuntary medication procedures to protect patients’ rights.
  • Enhanced physician peer review for completeness and quality of assessments and diagnosis, and evidence-based prescribing.
  • Improved behavior support plans.
  • Improved physician recruitment.
  • Renewed all hospital and residential licenses with the State of Oregon.
  • Addressed The Joint Commission findings and received continued conditional accreditation.
  • Received continued certification by Centers for Medicaid and Medicare Services (CMS).

Inappropriate use of seclusion and restraints


Inappropriate use of seclusion and restraints

Inappropriate use of seclusion and restraints