Governor's Panel Concludes Review of Oregon State Hospital Policies on Patient Abuse
Panel Recommends Changes to Reduce Risk for Patients
(Salem, Ore.) – Governor Ted Kulongoski today announced that he has received the final report of the expert panel convened at his request to review Oregon State Hospital (OSH) policies on patient abuse. OSH Administration, the Office of Investigations and Training within the Department of Human Services, and the Oregon State Police have already started working on implementation of the panel’s recommendations that can be achieved within existing resources and that do not require legislative authority.
The panel, led by the governor’s senior advisor Stephen Schneider, did not find any pattern of continuing sexual abuse at the hospital or evidence of failure of the responsible parties to respond promptly and appropriately to allegations. However, the panel identified significant gaps in current policy and procedure, communication among state agencies and training of OSH staff as issues needing to be addressed. Accordingly, the panel submitted multiple recommendations to mitigate risk and address public concern for the safety and well-being of OSH patients.
“We must ensure that the state is providing the best possible care to Oregonians with mental illness and that we are doing everything we can so that all of those in custody at the Oregon State Hospital are treated fairly and with respect,” said the Governor. “I am pleased that the State Hospital, the Office of Investigations and Training, and the State Police are moving forward to implement many of the recommended changes.”
The panel’s recommendations fall under the following general headings:
- Changes to the existing decision tree for abuse allegation process. The panel recommends multiple changes to improve the process that occurs when the OSH Superintendent receives an allegation that an OSH patient has been abused or neglected by an OSH employee.
- Improved communication and coordination among primary agencies regarding abuse cases. The panel suggests that OSH, the Office of Investigations and Training (OIT), the Oregon State Police (OSP), and the Marion and Multnomah County district attorneys’ offices convene an interagency committee to create a working protocol among the agencies that establishes a more coordinated, efficient and effective system for OSH abuse and neglect case assignment and investigation.
- Dedicated OSP investigator assigned to OSH abuse and neglect cases. Recognizing existing funding constraints, the panel recommends that the Oregon Department of Human Services explore the possibility of a dedicated law enforcement investigator to the OSH for the purposes of expediting abuse and neglect cases.
- Changes to the OSH new employee hiring and contractor screening processes. The panel recommends several enhancements to the Hospital’s current hiring and contractor screening practices, including the addition of specific questions in an employee application process relating to whether an individual has been investigated previously for abuse or neglect; limits on direct client contact until completion of an FBI background check, and improved cross-data system reporting among different DHS clusters, including child welfare, adult protective services, provider licensure and regulation, and OIT.
- Improvements to staff training and evaluation. The panel recommends requiring significantly more than the current 1.25 hours of training on abuse and neglect; including competency testing to ensure that staff attain a minimum level of proficiency before client contact is approved; and requiring continuing education regarding abuse and neglect as well as re-testing as mandatory components of OSH employment.
- Quality assurance/annual review. The panel recommends that OSH include a review of its patient abuse and neglect policies and procedures as part of its Annual Continuing Quality Improvement Review.
- Facilities study. The panel recommends that a facilities study take place. The Legislature and the Governor recently approved funding to evaluate the future of the OSH facility, which this panel recommends include an assessment relating to the issue of improving client safety.
- Creation of external advisory group. The panel recommends that OSH create an external advisory group, including OIT, OSP, patients, staff and community members, to review issues relating to hospital protocol and policies regarding patient abuse and neglect.
On September 21, the Governor sent a letter to Department of Human Services Director Gary Weeks calling for a review of the policies and protocol in place at the Oregon State Hospital to identify, report and respond to allegations of abuse and patient mistreatment. After receiving the initial DHS report, the governor directed Schneider to review and evaluate the information - in consultation with a select group of experts in public safety, abuse and neglect reporting and investigation, and mental health service delivery and administration - to determine whether the policies and procedures currently in place at the State Hospital are effective.
State Hospital Report Review Panel Members:
Garfield de Bardelaben, Ph. D., Interpersonal Relations International, LLC
Walt Beglau, Marion County District Attorney
Christopher J. Krenk, MSW, President and Chief Executive Officer, Albertina Kerr Centers
Melinda Mowery, RN, MS, Mental Health Director, Clackamas County Mental Health Program
Norwood Knight-Richardson, M.D., Director, Public Psychiatry Training Program, Oregon Health Sciences University
Laurie Powers, Ph.D., Professor, Regional Research Institute for Human Services, Portland State University
Mary Oschwald, Ph.D., Research Assistant Professor, Regional Research Institute for Human Services, Portland State University
Stephen Schneider, Senior Advisor to Governor Ted Kulongoski
Media Contact:
Marian Hammond, (503) 378-6169
Anna Richter Taylor, (503) 378-6496
Bob Nikkel, DHS, (503) 945-9708
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