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The death of a memory care resident who eloped undetected from a community in Oregon has prompted the state governor to call for an external audit of the state agency charged with overseeing senior living and care facilities, along with policies to bring “systemic changes.”

The call to action follows a report released in April by Oregon’s long-term care ombudsman in the wake of the death of resident Ki Soon Hyun. Two days after moving into Mt Hood Senior Living, a residential care and memory care community in Sandy, OR, Hyun was found in a wooded area outside the community. Police reports indicated that she succumbed to the cold weather overnight after wandering outside undetected.

Oregon Gov. Tina Kotek (D) has asked for an external review of the state Department of Human Services’ oversight of assisted living and residential care communities, adult foster homes and nursing facilities and directed the Governor’s Commission on Senior Services to provide policy recommendations to ensure resident safety. In response, the commission sent a list of initial recommendations, which include enacting “systemic changes” at ODHS. 

LeadingAge Oregon said it fully supports efforts to improve the safety and well-being of residents, asking that the association be included in any state discussions that arise from the external review. 

“Our inclusion will ensure that the perspectives of nonprofit and mission-driven care providers are considered and that any proposed changes are practical and effective,” LeadingAge Oregon CEO Kirstin Milligan told McKnight’s Senior Living. “It is imperative that any changes proposed to enhance the safety and well-being of residents are transparent and clear to consumers, providers and regulators, alike.”

Milligan said it’s important that the external review prioritize analyzing the state’s response and compliance with existing rules, regulations and policies before identifying potential changes. 

“A thorough examination and clear explanation of how current systems function and whether compliance is being met under the existing structure will provide a solid foundation for any improvements,” Milligan said, adding that LeadingAge Oregon will collaborate with all stakeholders to support safe, high quality care for residents. 

Red flags missed

ODHS’s Safety, Oversight and Quality program licenses community-based care facilities, including assisted living, residential care and memory care communities, adult foster homes and nursing facilities. 

In an April letter, the Governor’s Commission on Senior Services Chair Walter Dawson noted that the long-term care ombudsman’s report stated that the ODHS licensing unit “did not respond with effective urgency” and that the department potentially “did not recognize the seriousness of the numerous red flags” in Hyun’s death. 

Dawson said the commissions supported an audit of the state human services department in the hopes of improving the regulatory structures “to ensure the safety of all older adults” living in long-term care facilities.

In a June 10 response letter, Rachel Currans-Henry, the governor’s senior human services adviser, said that Kotek directed ODHS to conduct an external audit of its oversight practices. ODHS met with commission members to share updates on their progress in improving the oversight of licensed long-term care settings in the state.

“Ensuring the safety of our seniors is a priority, and it is critical that we have strong, effective regulatory systems and safety practices in order to protect residents in long-term care facilities,” Currans-Henry wrote, adding that Kotek asked the commission to provide recommendations for policy changes to ensure resident safety.

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