Systems Improvement Agreement

Western State Hospital and the Department of Social and Health Services have entered into a Systems Improvement Agreement with the Centers for Medicare and Medicaid Services to improve patient treatment and overall safety.  This page is devoted to providing information and updates on the activities and progress to address the issues that require correction and improvement.  Please check periodically as information is updated. 

Western State Hospital  - Updates and Information


July 9, 2018


Western State Hospital (WSH) loses its Centers for Medicare & Medicaid Services (CMS) Certification July 9, 2018.  In absence of that certification, the Department of Social and Health Services (DSHS) implemented the following plan that goes into effect immediately to ensure continuity of operations related to regulatory oversight.

  1. Governing Body is expanding to include representation outside of the DSHS Behavioral Health Administration and may include external agencies.
  2. Residential Care Services (RCS) will supervise investigation of reports alleging abuse (including sexual abuse), neglect and financial exploitation. As necessary, RCS will adopt emergency rules containing mandatory reporting requirements.
    1. RCS will sample all WSH Administrative Reports of incidents for fidelity to required RCS mandatory reporting requirements. The finding of this sampling will be reported to external monitors (per #3 below).
    2. Other reporting to the Washington State Department of health related to individual practitioner’s findings, Board of Pharmacy and food continues as before.
  3. External monitoring to a CMS standard of care and continues quality improvement in patient care.
    1. DSHS will contract with Clinical Services Management, LLC to monitor adherence to CMS standard through survey and auditing of Western State Hospital.

Along with this oversight plan, DSHS and the hospital remain focused on increasing patient safety, compliance with documentation, being good stewards of taxpayer dollars and working towards the governor’s vision of a new, better way to treat mental illness in Washington.


June 26, 2018 - On Monday, June 25, 2018, Western State Hospital learned from the Centers of Medicaid and Medicare Services that it had met all but four of the 26 conditions of participation required to remain federally funded.

Below, please find the letter and the statement of deficiencies noted in the May 2018 survey done by CMS.

June 25, 2018 - Western State Hospital learned today that it did not meet all conditions of participation by the Centers for Medicare Medicaid Services.

See our full release here. See the notice from CMS here


11/3/2017 - CMS grants second Systems Improvement Agreement to Western State Hospital - Second SIA


9/1/2017 - CMS has extended the Systems Improvement Agreement with Western state Hospital for an additional 30 days. In July, a 60-day extension was given which would have ended Sept. 3. CMS and DSHS entered into the original agreement in June 2016 to fix systemic operating problems at the hospital and restore the focus on patient treatment and overall safety. In May 2017, CMS conducted a follow-up survey that covered all areas of the hospital operations.

Western will use this extension to continue making forward progress and its work with CMS on next steps for the hospital. During the extension, the hospital continues to be certified by CMS and maintain its eligibility for federal funding.


07/12/2017 - The Department of Social and Health Services (DSHS) submitted its plan of correction for Western State Hospital (WSH) to the Centers for Medicare and Medicaid Services (CMS) today, July 11, 2017. The agency's plan of correction is contained in the below documents.

The submittal of the plan of correction is just the first step in a process. CMS will review the plan and may provide additional guidance regarding next steps. Although CMS could accept the plan as written, it may require changes or adjustments to the plan, or other actions it deems necessary.

Plan of Correction Document 1

Plan of Correction Document 2

Plan of Correction Document 3

Plan of Correction Document 4


6/30/2017 - The Department of Social and Health Services (DSHS) announced that Western State Hospital has been provided an extension to the Systems Improvement Agreement (SIA) from the Centers for Medicare and Medicaid Services (CMS).

The CMS survey, conducted in May 2017, was an extremely rigorous review by 23 experienced surveyors. It covered all areas of hospital operations and lasted nearly three weeks. Their feedback was provided to the Department on June 28, 2017 in a Form 2567 Statement of Deficiencies.

Read the letter from CMS, the 2567 and the 60-day extension in their entirety here:

June 28, 2017 Letter from CMS

2567 Document 1

2567 Document 2

2567 Document 3

2567 Document 4

SIA Extension


1/13/2017 - Preliminary Recommendations from the Select Committee on Quality Improvement in State Hospitals (Select Committee)


8/30/2016 - Systems Improvement Agreement Update to the Select Committee on Quality Improvement in State Hospitals (6/30/2016).

6/8/2016 -

Western State Hospital welcomes Sean Murphy to the position of Chief of Safety and Security for Western State Hospital.


6/1/2016 -

 Western State Hospital welcomes Jocelyn “J” Hofe as the hospital’s new Director of Emergency Management. J has more than 33 years of leadership experience in public safety, emergency management and incident response.


6/3/2016 - News Release: CMS agreement supports Western State Hospital’s journey to provide safer, higher-quality care