In a letter received on November 7, 2018, the Centers for Medicare and Medicaid Services (CMS) has rescinded the termination “action” for Unity Center. This means CMS will reinstate Legacy Emanuel Medical Center’s Medicare “deemed” status through The Joint Commission, and remove the hospital from the State survey agency’s survey jurisdiction. This concludes the Oregon Health Authority investigation that began April 2018.

Our number one priority is, and has always been, the safety and well-being of our patients and staff at Unity Center for Behavioral Health. In service to that commitment, Unity Center staff and leaders have worked tirelessly over the last six months to implement the Plan of Correction. We have made significant improvements to our environment of care, and to our policies and practices.

To support implementation of the Plan of Correction, we’ve made notable staffing changes:

We’ve increased staffing levels and are actively recruiting to hire additional RNs. There are currently 53 open positions, which includes 20 full-time RN positions, 20 part-time RN positions and 7 on call/supplemental RN positions. 14 RNs have been hired with upcoming start dates, along with two behavioral health therapists, two PES behavioral health assistants and one pharmacy manager.

We have cross-trained Legacy Health nurses so that we have a backup pool of nurses that we can tap if needed. Charge RNs have been permanently relieved of patient care assignments to utilize more of their time and expertise to ensure consistent compliance with policies including medication administration and patient care documentation. In addition, we are aiming to hire two new harm reduction specialists by January 31, 2019 to support our continued commitment to safety.

Regarding changes to our practices and environment of care, we have made strides in several key areas:

We have modified our Environment of care to ensure patient safety, including placing stricter limits on the items that patients can bring into our environment of care, removing unsafe items from the facility, as well as modifications to patient rooms.

We have improved patient monitoring with changes to our infrastructure to address blind spots in patient care areas and documentation of our observation practices. We successfully implemented new monitoring practices based on patient needs.

We have improved patient care documentation including daily provider assessments for elevated suicide risk, and twice-daily nursing CSSRS (Columbia-Suicide Severity Rating Scale) assessments and Restraint and Seclusion documentation.

We have improved medication administration practices including daily audits of patient medication administration. One measure of improved medication practices is our utilization of patient and medication barcode scanning. Unity Center for Behavioral Health now has the highest rates of barcode utilization of all of Legacy Health’s six hospitals.

We have worked to create a culture of safety, through education and support for staff, many town hall meetings with staff and leadership, and a continued dialogue around safety.

Our work is not done. We are focused now on rebuilding capacity. One adult inpatient unit, 1E remains closed while we continue to recruit and hire new staff and RNs with the goal of eventually reopening 1E and operating at full capacity.

In addition to rebuilding capacity, we will continue to apply ourselves to the rigorous, consistent deployment of the changes we’ve made. We will remain vigilant and encourage staff to be our eyes and ears in every patient care setting and to raise any concerns they have about safety or care. We will continue to invest in and build a culture of safety that is pervasive in our behaviors, actions and words. And we will continue to look for opportunities to improve.

In the coming weeks and months, Unity Center leaders will be reaching out to our community partners to focus on building trust with the families, groups and agencies who count on us. We are grateful to our patients and their families for the privilege of providing them with quality care. We’re grateful to our staff for their hard work. We are grateful to our hospital partners for their support and to the OHA for their diligence.

Unity Center for Behavioral Health is committed to a strong partnership with our community and its leaders to support those among us who are suffering from mental illness or who are experiencing a behavioral health crisis.