DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Western Division of Survey and Certification
Seattle Regional Office
701 Fifth Avenue, Suite 1600
Seattle, WA 98104

March 24, 2017

Michael Uradnik, Administrator
Cascade Behavioral Hospital
12844 Military Road South
Tukwila, WA 98168
Re:

CMS Certification Number 50-4011
Conditions of Participation Not Met
Termination Date Extended to May 15, 2017

Dear Mr. Uradnik:
Between the dates of March 7-10, 2017, the State Of Washington (State survey agency) conducted a
revisit survey at Cascade Behavioral Hospital. The survey team did not find the facility to be in
substantial compliance with the Medicare Conditions of Participation.
The deficiencies identified are cited in the enclosed Statement of Deficiencies and Plan of Correction
Form CMS 2567. The deficiencies limit the capacity of Cascade Behavioral Hospital to furnish services
of an adequate level and quality.
To avoid potential termination action, CMS must receive and approve a credible allegation of
compliance within 10 calendar days of the date of this letter. Complete your plans of correction in
the space provided on the CMS Form 2567.
Please send your plans of correction to (1) the State Survey Agency and (2) to CMS to the attention of
Karen Roe at:
CMS_RO10_CEB@cms.hhs.gov
Or, when not emailed, fax to 443.380.7537
An acceptable plan of correction, which includes acceptable completion dates, must contain the
following elements:
• Plan of Correction for each specific deficiency cited.
• Procedure/process for implementing the acceptable plan of correction for each deficiency
cited.
• Monitoring and tracking procedures to ensure the plan of correction is effective and that
specific deficiencies cited remain corrected and/or in compliance with the regulatory
requirements.

 Page 2 – Cascade Behavioral Hospital
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Address process improvement and demonstrate how the facility has incorporated
improvement actions into its Quality Assessment and Performance Improvement (QAPI)
program. Address improvement in systems to prevent the likelihood of re-occurrence of the
deficient practice.
A completion date for correction of each deficiency cited.
The plan must include the individual responsible for implementing the acceptable plan
of correction with signature and title.

Thank you for your cooperation in this matter. If you have any further questions, please contact my staff
by email at CMS_RO10_CEB@cms.hhs.gov, attention Karen Roe.
Sincerely,

Julius P. Bunch Jr., Manager
Division of Survey, Certification & Enforcement
Regional Office - Seattle

cc:

Washington Department of Health

THIS SERVES AS OFFICIAL NOTICE SENT VIA EMAIL OR FACSIMILE PURSUANT TO 42 CFR §488. NO HARD COPY TO FOLLOW.