Report on Deficiencies at the Oregon State Hospital – CMS 2022

May 5, 2022

Oregon State Hospital Junction City
29398 Recovery Way
Junction City, OR 97448

Re: CMS Certification Number:
Conditions of Participation Not Met
Removed Deemed Status
90-day Termination Track

READ – full formatted version of this 134 page report (PDF)

Dear Administrator:

On January 17, 2022, the Oregon Health Authority (State survey agency) completed a complaint survey
at your facility. The deficiencies cited limit the capacity of Oregon State Hospital Junction City to
furnish services of an adequate level and quality. The deficiencies identified are as follows and are
listed on the enclosed Statement of Deficiencies and Plan of Correction (Form CMS – 2567).

Fed – A – 0020 – 482.11 – Compliance With Laws
Fed – A – 0022 – 482.11(b) – Licensure Of Hospital
Fed – A – 0043 – 482.12 – Governing Body
Fed – A – 0115 – 482.13 – Patient Rights
Fed – A – 0118 – 482.13(a)(2) – Patient Rights: Grievances
Fed – A – 0122 – 482.13(a)(2)(ii) – Patient Rights: Grievance Review Time Frames
Fed – A – 0123 – 482.13(a)(2)(iii) – Patient Rights: Notice Of Grievance Decision
Fed – A – 0144 – 482.13(c)(2) – Patient Rights: Care In Safe Setting
Fed – A – 0145 – 482.13(c)(3) – Patient Rights: Free From Abuse/harassment
Fed – A – 0263 – 482.21 – Qapi
Fed – A – 0286 – 482.21(a), (c)(2), (e)(3) – Patient Safety
Fed – A – 0385 – 482.23 – Nursing Services
Fed – A – 0395 – 482.23(b)(3) – Rn Supervision Of Nursing Care
Fed – A – 0438 – 482.24(b) – Form And Retention Of Records
Fed – A – 0700 – 482.41 – Physical Environment
Fed – A – 0701 – 482.41(a) – Maintenance Of Physical Plant
Fed – A – 0750 – 482.42(a)(3) – Infection Control Surveillance, Prevention
Fed – A – 1640 – 482.61(c)(1) – Treatment Plan

To participate as a provider of services in the Medicare and Medicaid Programs, a facility must meet all of the Conditions of Participation established by the Secretary of Health and Human Services. When a facility is found to be out of compliance with the Medicare Conditions of Participation, The Social Security Act Section 1866(b) authorizes the Secretary to terminate a facility’s Medicare provider agreement because the facility no longer meets the requirements for participation as a provider of services in the Medicare program. 42 CFR § 489.53 authorizes the Centers for Medicare and Medicaid Services to terminate Medicare provider agreements when a provider no longer meets the Conditions of Participation.

This letter is to inform you the Centers for Medicare and Medicaid Services (CMS) has determined that Oregon State Hospital Junction City no longer meets the conditions for participation as a provider of services in the Medicare program established under Title XVIII of the Social Security Act. Consequently, Oregon State Hospital Junction City’s participation in the Medicare program may be terminated on 08/03/2022 if deficiencies have not been corrected.

Your deemed status with TJC is removed and you are placed under the State’s survey jurisdiction. Your deemed status will be restored when you get back in substantial compliance with Medicare regulatory requirements. The finding that the Oregon State Hospital Junction City is not in compliance with the Conditions of Participation does not affect your facility’s TJC accreditation, its Medicare payments, or its current status as a participating provider in the Medicare program. However, you are required to submit an acceptable plan of correction regarding these deficiencies. After the approved plan of correction has been implemented, and we have found that all of the Medicare Conditions of Participation are met, we will discontinue the state’s survey jurisdiction. A copy of this letter is being forwarded to TJC and the Department Of Human Services.