The Unity Center is a psychiatric emergency room operated by Legacy Health in Portland, Oregon. It has several local hospital partners, including Kaiser, Adventist, and OHSU – which closed their psychiatric units when Unity opened in the Spring of 2017 and now send all persons in mental health crisis to Unity for triage, rapid care, and inpatient treatment. In the opening / closings there was a small net loss in hospital beds for people with acute mental illness in the area.
Unity employs a Psychiatric Emergency Service (PES) model meant to allow more people access to rapid care. The PES is a large open room for about 40 patients, with comfortable chairs and quick access to clinical staff. The PES has been criticized by current and former staff, visiting clinicians, mental health advocates, and by state and Federal agencies for being dangerous to both staff and patients. A report from Oregon OSHA (see below) found staff logs of over 500 patient – on – staff assaults at Unity in it’s opening year. From the OSHA report in April 2018 until an investigation by the Oregon Health Authority was revealed by Unity staff whistle-blowers on July 30 Unity was silent – not transparent as promised – on safety issues.
Providence Hospital is the inpatient care alternative which accepts Medicaid for people with mental illness in Multnomah County. Cedar Hills Hospital has very limited access to people in Medicaid.
NEW – Statement of Deficiencies and Plan of Corrective Action for Unity Center DHHS Medicaid and Oregon Health Authority, issued JULY, 2018 (PDF)
Statement of Deficiencies and Plan of Corrective Action for Unity Center DHHS Medicaid and Oregon Health Authority, issued MAY, 2018 (PDF)
Latest News Articles – click the title links to read full articles
State recommends dropping decertification threat for Portland mental health facility – KATU.com, November 2, 2018
The Oregon Health Authority Thursday recommended that the federal government drop the threat of taking away Medicare and Medicaid certification for Northeast Portland’s Unity Center for Behavioral Health.
OHA officials launched an investigation into Unity’s operations after receiving a complaint last February that patients and staff were endangered by practices inside the facility.
Imperiled Portland psychiatric ER receives state’s OK – Oregonian, November 1, 2018
Portland’s main psychiatric facility will likely keep a key federal certification, said state officials Thursday.
Unity Center for Behavioral Health was on track to lose federal funding after state health investigators found that the facility routinely allowed patients to hurt themselves, physically and sexually assault each other and escape. Nurses and staff gave patients the wrong medications in the wrong amounts, according to state documents.
A statement and timeline of the investigation into Unity Center for Behavioral Health released Friday evening said that the investigation, based on a Feb. 19 complaint, revealed “numerous hazards in the physical environment, a lack of patient supervision and lack of clear protocols for response to medical emergencies. Hazards observed … reflected actual harm to patients, patient attempts at self-harm and suicide attempts.”
At least two patients died of preventable causes, according to the Oregon Health Authority, which has investigated and monitoring Unity.
A patient committed suicide at the Unity Center for Behavioral Health two months after state investigators informed the psychiatric hospital that it was failing to safeguard patients, according to findings from the latest inspection released Monday.
But a Thursday morning announcement said that Unity officials have made enough progress toward fixing its problems that it no longer is on a track to be terminated from Medicare and Medicaid reimbursements.
Nurse says Legacy Health punished him for speaking out about problems at Unity – Oregonian, October 23, 2018
A Unity Center for Behavioral Health employee claims he has been punished by the center’s leaders for his public criticism of the facility’s operations.
Christopher Lambert filed a civil rights complaint Oct. 10 with the Oregon Bureau of Labor and Industries.
Lambert was a nurse at Unity when it opened in February 2017. Over the next year and a half, he said he identified and reported issues of patient-on-patient violence, patient-on-staff violence, sexual assault and self-harm by patients.
Unity Center slapped with whistleblower’s complaint – Portland Tribune – October 22, 2018
A whistleblower who alerted state health care officials about hazardous and neglectful conditions for patients at Legacy Health’s Unity Center for Behavioral Health has quit and filed a complaint claiming the hospital system’s management retaliated against him for raising concerns.
Filed by longtime Legacy nurse Christopher S. Lambert, the complaint to the state Bureau of Labor and Industries makes new allegations about how the Portland-based hospital system has responded to the investigation by the Oregon Health Authority, the one Lambert helped spark. Specifically, it suggests that Legacy management sought to punish him after he complained of safety issues, and also sought to cover up problems on more than one occasion by keeping him from talking to state investigators.
Lambert’s complaint comes even as Legacy officials are scrambling to be removed from a “termination track” that would block it from receiving federal funds if the problems at Unity Center are not cleared up by Oct. 31. A state inspection earlier this month discovered a new round of problems at Unity — problems that Legacy says it has already addressed.
DOWNLOAD – Scott Lambert’s BOLI complaint (PDF)
Suicide At Unity Shows Mental Health Center Has Long Way To Go – The Lund Report, September 11, 2018
Two months after state investigators warned officials at Portland’s only psychiatric ER they could lose federal certification, a woman who was known to be suicidal killed herself.
State finds new problems at Unity Center; Legacy vows improvements – Portland Tribune, September 11, 2018
Newly released state report says continued failures resulted in successful patient suicide, other issues.
Portland mental health center failed to stop suicide after problems surfaced, report says – Oregonian, September 11, 2018
A patient died by suicide at the Unity Center for Behavioral Health two months after state investigators informed the psychiatric hospital that it was failing to safeguard patients, according to findings from the latest inspection released Monday.
The suicide and other problems illustrate the Unity Center’s seeming slowness to fix serious lapses.
Unity Center hires more staff as it address deficiencies in psychiatric care – Portland Business Journal, September 6, 2018 (paywalled)
The psychiatric hospital received a deadline extension to fix safety concerns at the Portland facility
Multnomah reviewing 1,200 reports of abuse of mentally ill adults since last year – Portland Tribune, September 6, 2018
Unity Center confirms 2 deaths, wants to be free of investigation in September – Oregonian, September 6, 2018
The president of Unity Center for Behavioral Health said Wednesday he expects the metro area’s troubled mental health hospital to remain open and fix serious safety problems this month.
“The Unity Center is critical to the community and I can assure you on behalf of our leadership team, our staff at the four organizations, we are 100 percent committed to its success,” Trent Green said in an interview Wednesday.
Portland’s Unity Center wins reprieve to fix problems in care for mentally distressed – Portland Tribune, September 5, 2018
The federal government has extended its deadline for Legacy Health to fix what a complaint claimed was a “hell hole” created for some of the region’s most vulnerable people at the Unity Center for Behavioral Health in Portland, the region’s psychiatric emergency facility that opened last year.
The federal government had previously given Legacy until Sept. 11 to address what a recent state report depicted as a woeful and unsafe situation for patients at Unity. Investigators found that, time after time, reported instances of patient abuse and neglect were ignored or downplayed by staff or management at Unity — contrary to the safety-first picture that Legacy officials had long publicly portrayed to local officials. In some cases, unsafe conditions created an “immediate jeopardy” for patients, investigators found.
Portland’s psychiatric ER has 7 more weeks to fix serious safety problems – Oregonian, September 4, 2018
Portland’s imperiled psychiatric center has seven more weeks before it could lose a crucial federal certification.
The Oregon Health Authority confirmed Tuesday that Unity Center for Behavioral Health has until Oct. 31 to fix significant safety issues.
The federal Centers for Medicare and Medicaid Services last month gave Unity officials a second list of problems to fix and extended the time Unity has to make improvements. It previously faced a deadline of Sept. 11.
County’s failures with Unity warrant an outside review – op ed from The Oregonian, August 26, 2018
Discrepancies led to county managers placed on leave – Portland Tribune, August 21, 2018
A closer look at how the review into Unity Center complaint-handling gathered steam.
Multnomah County Suspends 2 Managers After Failing to Investigate Complaints About Unity – Lund Report, August 20, 2018
After reports surfaced about the lack of follow-up on reports of abuse at the Unity Center for Behavioral Health in Northeast Portland, a top-level county manager takes action.
Multnomah County puts 2 administrators on leave over handling of health care complaints – Oregonian, August 20, 2018
Multnomah County examines how it handled complaints about Unity – Oregonian, August 17, 2018
County managers on leave over failure to investigate Unity Center – Portland Tribune, August 16, 2018
MHASD Director David Hidalgo suspended pending County audit of Unity Center – August 16, 2018 (PDF)
New review, audit to ask: Who’s watching Unity? – Portland Tribune, August 14, 2018
Violence at Unity Center for Behavioral Health Draws Financial Questions
The Lund Report, August 13, 2018
Critics say financial incentives influenced the center’s decision to use a “living room style” of intake area which critics say invites attacks.
Embattled mental healthcare facility says it has a plan for change – Oregon Business, August 8 2018
Trent Green, president of Unity Behavioral Health Care, outlines new strategy following lawsuits and investigations into patient safety.
State finds patients endangered at Legacy’s Unity Center – UPDATED
Oregon Health Authority investigation finds problems at Unity Center, Legacy’s regional mental health facility
Portland Tribune – August 3, 2018
The Oregon Health Authority has given Legacy Health’s Unity Center for Behavioral Health in Northeast Portland until Sept. 11 to fix problems that have jeopardized patient safety.
OHA issued its first public statement late Friday after a scathing investigation report found “several issues that jeopardized patient safety.”
Serious safety problems plague Portland’s premier mental health center, state investigation shows
Oregonian – August 3, 2018
State investigators have placed Portland’s premier psychiatric crisis center on notice that it could lose its federal certification as early as next month unless it fixes widespread safety problems.
The threat of pulling the certification is a rare regulatory move and could imperil Unity Center for Behavioral Health’s operation.
The notice follows a series of inspections by state investigators and two findings that Unity had placed patients and employees in “immediate jeopardy.”
In the first few pages of a 105-page list of issues at Unity released Friday to The Oregonian/OregonLive, Oregon Health Authority investigators found that the center had bathroom doors that enabled patients to attempt suicide, blind spots in areas where cameras monitored patient safety and patients able to run away when supervisors were supposed to be watching.
Unity Center certification at risk as OHA documents suicide attempts, patient self-harm (PDF)
Portland Business Journal – August 3, 2018
Unity Center partially reopens to new mental health patients
Oregonian – August 2, 2018
Unity Center closure: open floor plan, ‘under-medicated’ patients among chief concerns
Portland Business Journal – August 1, 2018
Unity Center reopening as investigation wraps up
Portland Tribune – August 2, 2018
Emergency Departments Step Up After Portland’s Psychiatric ER Turns Patients Away
The Unity Center for Behavioral Health started turning most patients away on Saturday.
The Lund Report – August 1, 2018
A ‘hell hole’: Unity Center closes to new patients
KOIN.com – July 31, 2018
Unity Center closes to new EMS patients due to safety concerns
Portland Tribune – July 30, 2018
Breaking News: Unity Center for Behavioral Health Care Diverts Ambulances
The Oregon Health Authority is investigating the center, which has been plagued with problems since opening a year and a half ago.
The Lund Report – July 30, 2018
Portland’s main psychiatric ER bars most new patients during state investigation
Oregonian – July 30, 2018
The Unity Center for Behavioral Health, Portland’s 1 ½-year-old psychiatric emergency room, is no longer accepting most new patients while it works to address problems raised by a state investigation into employee and patient safety.
In a move that could cause backups at hospital emergency rooms, the 100-bed center has told ambulances and area hospitals to no longer bring or refer patients to Unity.
The facility will still accept walk-in patients only for now, said Legacy Health spokesman Brian Terrett.
Terrett said he isn’t sure how long the suspension will last. Unity is using the time to train nurses on new safety protocols, he said. He did not specify what those protocols are.
A matter of degree: Can head of Portland’s flagship crisis center be called a doctor?
Oregonian – July 21, 2018
As vice president of Unity Center for Behavioral Health, [Chris] Farentinos has described herself as a “physician” in testimony before state lawmakers. She has routinely answered to “Dr.” at multiple public speaking engagements. Her employer has repeatedly referred to her as “Dr. Chris Farentinos” on its website, Facebook and in public presentations.
But Farentinos isn’t a licensed doctor in the United States and never has been.
Woman who set self on fire in Portland park remembered as ‘brilliant and tortured’ artist
Oregonian – June 22, 2018
Woman who set self on fire in Portland park remembered as ‘brilliant and tortured’ artist
Oregonian – June 22, 2018
“Chloe was brilliant and rarely got a chance to show it,” friend AJ Luxton said in an email. “She created enchanting video games, she built things, she volunteered with Habitat for Humanity after Hurricane Katrina, she taught herself to read despite severe dyslexia.”
Sagal was a game developer and artist who struggled with mental illness for many years. Her friends say she loved dogs, forged authentic weapons and made haunting music when she was able to. They say she was proud of her Romani heritage and an active socialist.
What happened to Sagal at Unity has not been publicly disclosed.
“Due to federal privacy protection regulations for patients, we are unable to confirm any information related to any patient at Unity Center,” Unity spokeswoman Kristin Whitney said by email.
Luxton, who spoke to Sagal on Monday over the phone, said Sagal “spent two days sitting in triage at the Unity Center; she was never properly hospitalized.”
“I had visited the Unity Center with her in March 2017 for about half an hour, and we had given them my information to keep on file as an emergency contact,” Luxton added, “so I also theoretically could have been contacted while she was there Saturday or Sunday.”
But Luxton was not notified and didn’t know Sagal had been taken to Unity until Monday.
LISTEN – Assault Reports Spark Concerns About Portland Mental Health Facility
– OPB.org, April 4, 2018
Assault reports spark concerns about mental health facility – Portland Tribune, April 3, 2018
Some say ‘outpatient’ model at mental health facility isn’t safe, endangering both staff and patients.
Unity Center for Behavioral Health in Portland fined by OSHA – KPTV.com, March 20, 2018
State fines Unity mental health $1,650 after workers suffer hundreds of assaults, Oregonian, March 20, 2018
State workplace regulators have fined the Unity Center for Behavioral Health $1,650 for failing to take steps to prevent future assaults on employees by patients struggling with mental illness.
Oregon fines mental health hospital $1.6k for failing to protect workers from patient assaults, Becker’s Hospital Review, March 19, 2018
During an investigation of the mental health facility, which was launched after numerous employees reported being assaulted by patients, the Oregon Occupational Safety and Health Division found Unity violated four safety rules and regulations. In particular, the behavioral health center failed to properly log, document and investigate the roughly 300 assaults on staff members by patients.
In addition, OSHA documented an ‘uneasy culture’ at the behavioral health center in the investigation. During interviews, some employees said they didn’t report minor assaults, like a punch to the face, because they feared they would be viewed negatively by the administration. Other employees told OSHA no safety measures were implemented after reports of assaults, according to Oregon Live.
OSHA Investigation of Unity Center – 500 Assaults
The Oregon Occupational Health and Safety Administration (Oregon OSHA) finished an investigation of patient – on – staff assaults at Unity Center for Behavioral Health, Legacy Hospital’s ambitious gateway for people with acute mental illness in the Portland metro area.
READ THE OSHA INVESTIGATION- Citation and Notification of Penalty (PDF)
The report was mentioned in an earlier news story, see Two Unity mental health nurses say violent patients choked staff, broke bones, Oregonian February 18, 2018.
The OSHA investigation states staff at Unity reported over 500 assaults from patients since the facility starting tracking assaults in the March of 2017. Unity opened in January 2017.
OHSA found three “serious” violations and fined the billion-dollar-a-year corporation $1,650. Violations included not recording assaults in a log, and not investigating or evaluating assaults. The investigation also includes many cogent and reasonable recommendations for Unity to adopt.
READ – Oregon OSHA dings Unity Center for unreported assaults, Portland Tribune, March 19, 2018
READ – Unity Center for Behavioral Health in Portland fined by OSHA, KPTV.com, March 20
READ – State Fines Unity Mental Health After Workers Assaulted, AP Wire, March 20
READ – Oregon fines mental health hospital $1.6k for failing to protect workers from patient assaults, Becker’s Hospital Review, March 20
READ – Unity Mental Health Fined After Workers Assaulted, KXL.com, March 20
READ – State fines mental health center after workers assaulted, KTVZ.com, March 20
READ – State fines Unity mental health $1,650 after workers suffer hundreds of assaults, Oregonian, March 20
READ (paywall) – Unity Center fined by state regulators for unreported assaults on employees, Portland Business Journal, March 20
Patient – on – staff assault in a psychiatric inpatient unit is often a sign of poorly trained or oriented staff, understaffing, staff misunderstanding acuity of patients during intake, poor planning around discharge or transportation, inability to monitor patients, limited engagement, lack of experienced medical oversight, poor communications technology (panic buttons), restrictive setting or misuse of seclusion and restraint.
The result of patient – on – staff assaults left unaddressed by the facility can be overmedication, a higher level of security both in the structure of the facility and by staff members, fearfulness of patients from staff, and less care.
Left unstated in the OSHA report – and outside of their scope of work – are a set of remaining questions, such as, how many patient – on – patient assaults occurred? How many staff – on – patient assaults occurred? How many arrests have occurred at Unity? What did Unity – starting in March 2017 when they began to record assaults – do to address assaults by patients – on – staff? What additional training was provided to staff? How often is seclusion – a locked room – used to punishment patients for behavior? How often is physical restraint used at Unity? Were patients who were assaultive barred from returning to Unity in the future? How often is medication increased after an assault at the direction of a non-physician? Does Unity provide “trauma informed care” as advertised? What structural or policy changes have been made to address assault? And mostly – why should patients seek help from Unity in the future?
Two Unity mental health nurses say violent patients choked staff, broke bones
Oregonian, February 13, 2018
Two former nurses at the new Unity Center, touted as the city’s more humane alternative for people in mental health crisis, have filed a pair of $1 million lawsuits, claiming they were fired from their jobs after complaining about their safety.
Registered nurses John Stough and Cindy Olivares say in the suits that the Unity Center for Behavioral Health in Northeast Portland doesn’t have enough security guards to deal with patients who lash out.
A Multidisciplinary Model for Emergency Psychiatric Care
Oregon health systems team up to integrate care for behavioral health patients
Hospital & Health Networks – November 2017
Cops Insist On Bringing Guns into Portland’s New Mental Health Hospital
Portland Mercury, May 24, 2017
Some See That As Cause for Concern in a City That’s Seen Past Tragedy
READ – Oregon State Hospital policy on weapons on campus (PDF)
Portland Mercury, May 10, 2017
A Brand New Mental Health Center Aims to Revolutionize Care in Portland. It Faces Dizzying Challenges.
Medical leaders at Unity Center announced
Press Release from OHSU – April 15, 2016
Reports and Press Releases from Legacy / Unity
Summary of Deficiencies – July, summarized by Legacy (PDF)
July Unity Center Plan of Correction Summary. Plan submitted to the Oregon Health Authority – August 2018 (PDF)
July Unity Plan of Correction – complete 89 pages (PDF)
Summary of Deficiencies – May, summarized by Legacy (PDF)
May Unity Center Plan of Correction Summary. Plan submitted to the Oregon Health Authority – June 2018 (PDF)
May Unity Plan of Correction – complete 77 pages (PDF)
Public Records Requests
On May 23, 2018 the Mental Health Association of Portland made a public records request of Multnomah County for records on “All substantiated and inconclusive investigations of abuse to patients at Unity Center for Behavioral Health.” The County replied on May 25, “After a thorough search of our files, the Department of County Human Services and the Health Department did not locate records responsive to your request.”
We resubmitted the public records request again on May 31, slightly rephrasing our request, this time for, “All investigations of patients at Unity Center for Behavioral Health.” The County responded on June 11 asking for payment for finding records for us, and later in the day we were sent a report of a single investigation from 2017 – no reports were available for 2018.
READ – Multnomah County Health Department Abuse Investigation and Protective Services Report, July 6, 2017 (PDF)
On August 23 a senior County staffer told us more records had been uncovered and could be had for the asking. We asked, and on September 18, 2018 we received three documents about investigations of patient abuse of Unity by Multnomah County.
Cindy Scherba termination announcement 1 2017, about January 26, 2017
Fundraising – 2014
Listen to the show:
Fundraising – 2016
Job Announcements – 2015
Job Announcements – 2016
[Undated]: Announcement that Unity is actively recruiting for the position of Director Unity Services (#16-0257).To apply, go to http://www.legacyhealth.org/careers and specify job #16-0257. For additional information, contact Debbie Schoenheinz, Senior Recruitment Consultant, at 503-415-5718. AA/EOE/Disabilities/Veterans
[Undated]: Announcement that Unity is actively recruiting for the position of Unity Director of Patient Care Services (#15-3674). For more information on this position, please contact Debbie Schoenheinz at 503-415-5718. AA/EOE/Disabilities/Veterans
Public Presentations – 2015
Public Presentations – 2016
Newsletter – 2016
Oct. 30, 2015: PowerPoint presentation by Oregon Health Authority, Office of Health Analytics, re Hospital Performance Metrics Advisory Committee/Metrics and Scoring Committee Joint Behavioral Health Learning Session (PDF, 94 pages)
Crisis Walk In Center Work Group – Scope of Work, Mental Health Association of Portland, April 2013
Unity Community Engagement flyer, PPT, February 2016
Legacy Behavioral Health ProjectMeeting with Advocates – Meeting Minutes, January 2015
Unity Transitions of Care – Sub-groups, member roster – April 25, 2016
Advisory Committee – 2016
Advisory Meeting for Unity Center Agenda, April 2015
Advisory meeting for Unity Center contact list for patient advocates, no date
Unity Advisory Council Meeting Minutes, April 27, 2016
Transport Committee – 2016