UNITED STATES DISTRICT COURT 
 FOR THE EASTERN DISTRICT OF KENTUCKY


UNITED STATES OF AMERICA,

)


)


Plaintiff,

)


)


v.

)

)

THE COMMONWEALTH OF KENTUCKY;

)

Governor of the Commonwealth

)

of Kentucky; Secretary, Cabinet )

for Health and Family Services; )

Commissioner, Department of Mental )

Health and Mental Retardation

)

Services, Cabinet for Health

)

and Family Services; and Deputy )

Commissioner, Department of Mental )

Health and Mental Retardation

)

Services, Cabinet for Health and )

Family Services,

)

)


Defendants.

)


)


___________________________________)


Civil No. _______

COMPLAINT PLAINTIFF, THE UNITED STATES OF AMERICA (“Plaintiff”), by its undersigned attorneys, hereby alleges upon information and belief: 1. The Attorney General files this Complaint on behalf of the United States of America pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, to enjoin the named Defendants from egregiously and flagrantly depriving individuals housed in the Communities at Oakwood ("Oakwood") of rights, privileges, or immunities secured and protected by the Constitution and laws of the United States.

- 2 JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under 28 U.S.C. §§ 1331 and 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 1997a. 4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein. 5. Venue in the Eastern District of Kentucky is proper pursuant to 28 U.S.C. § 1391.
DEFENDANTS 6. Defendant Commonwealth of Kentucky owns and operates Oakwood and as such has responsibility for the services and supports provided to individuals residing at Oakwood. 7. Oakwood is a State facility for individuals with developmental disabilities. 8. Defendant Ernie L. Fletcher is the Governor of the Commonwealth of Kentucky and, in this capacity, he has responsibility for the operation of Oakwood. 9. Defendant Mark D. Birdwhistell is the Secretary of the Cabinet for Health and Family Services, which has responsibility for overseeing the operation of Oakwood.

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 10. Defendant John M. Burt is the Commissioner of the Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, which has responsibility for overseeing Oakwood. 11. Defendant Deputy Commissioner of the Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services has responsibility for overseeing Oakwood. 12. The individual Defendants named in paragraphs 8 through 11 above are officers of the Commonwealth of Kentucky and are sued in their official capacity only.
FACTUAL ALLEGATIONS 13. Defendants are legally responsible, in whole or in part, for the operation of Oakwood and for the health and safety of the persons residing in Oakwood. 14. Oakwood is an institution within the meaning of 42 U.S.C. § 1997(1). Oakwood provides care to individuals with developmental disabilities. 15. Defendants are obligated to operate Oakwood in a manner that does not infringe upon the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of individuals residing in Oakwood. 16. Defendants are obligated to provide treatment, supports, and services to individuals residing in Oakwood

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 consistent with the Americans with Disabilities Act and implementing regulations. 42 U.S.C. § 12101 et seq., 28 C.F.R. § 35.
17. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.
18. Individuals reside at Oakwood because they have been determined by Defendants to have significant developmental disabilities requiring extensive treatment, supports, and services.
19. Oakwood's supports and services substantially depart from generally accepted professional standards of care, thereby exposing individuals residing in Oakwood to significant risk and, in some cases, to actual harm.
20. Oakwood’s supports and services substantially depart from generally accepted professional standards of care in the following specific respects, among others:
a. the provision of adequate psychological and behavioral services;
b. the provision of adequate medical, dental, and nursing services;
c. the provision of adequate psychiatric services; d. the provision of adequate habilitation and therapy
services, including physical therapy, occupational therapy, speech and language therapy, and other forms of therapy, physical management, nutritional

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 services and related services; and
 e. the provision of adequate protections from harm, including abuse and neglect, staff-on-resident harm, resident-on-resident harm, and resident self-injury. 21. Oakwood’s supports and services substantially depart from generally accepted professional standards of care in the provision of sufficient numbers of adequately trained staff to render adequate treatment, supports, and services and to protect residents from harm, as outlined in paragraphs 19 and 20. 22. Defendants have failed and continue to fail to assess individuals residing in Oakwood to ascertain whether these individuals are receiving adequate treatment, supports, and services in the most integrated setting appropriate to their individual needs; that those individuals whom professionals determine should be placed in community programs are placed in such programs, when appropriate; and that these individuals are served in the most integrated setting appropriate to their needs.
VIOLATIONS ALLEGED COUNT ONE:
Violations of the Due Process Protections of the Fourteenth Amendment to the United States Constitution
23. The United States incorporates by reference the allegations set forth in Paragraphs 1 through 22 as if fully set forth herein.

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 24. The egregious and flagrant acts and omissions alleged in paragraphs 19 through 21 constitute a pattern or practice that violates the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of individuals residing in Oakwood. 25. Unless restrained by the Court, Defendants will continue to engage in the egregious and flagrant acts and omissions set forth in paragraphs 19 through 21 that deprive Oakwood residents of rights, privileges, or immunities secured or protected by the Constitution of the United States and federal law, and will cause irreparable harm to these residents.
COUNT TWO:
 Violations of the Americans with Disabilities Act
 26. The United States incorporates by reference the allegations set forth in Paragraphs 1 through 22 as if fully set forth herein. 27. The egregious and flagrant acts and omissions alleged in paragraph 22 violate the Americans with Disabilities Act and implementing regulations. 42 U.S.C. § 12101 et seq., 28 C.F.R. § 35. 28. Unless restrained by this Court, Defendants will continue to engage in the egregious and flagrant acts and omissions set forth in paragraph 22 that deprive Oakwood

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 residents of rights, privileges, or immunities secured and protected by federal law, and will cause irreparable harm to these residents.
PRAYER FOR RELIEF 29. The Attorney General is authorized under 42 U.S.C. § 1997a to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Court enter an order:
a. Declaring that the acts, omissions, and practices set forth in paragraphs 19 through 22 above constitute a pattern or practice of resistance to Oakwood’s residents’ full enjoyment of rights, privileges, or immunities secured or protected by the Constitution or laws of the United States, and that those acts, omissions and practices violate the Constitution and laws of the United States; and
b. Permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in paragraphs 19-22 above, and that this Court require Defendants to take such actions as will ensure that lawful conditions of institutionalization are afforded to Oakwood residents, including the provision of adequate treatment in the most integrated setting appropriate to their individual needs; and

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 c. Granting such other and further equitable relief as this Court may deem just and proper.
Respectfully submitted,
/s/ Alberto R. Gonzales THE HONORABLE ALBERTO R. GONZALES Attorney General of the United States

Dated:

August 31

, 2006

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AMUL R. THAPAR United States Attorney

/s/ Wan J. Kim WAN J. KIM Assistant Attorney General Civil Rights Division
/s/ Shanetta Y. Cutlar SHANETTA Y. CUTLAR Chief Special Litigation Section
/s/ Judy Preston JUDY PRESTON Deputy Chief Special Litigation Section
/s/ Mary R. Bohan MARY R. BOHAN Trial Attorney U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Washington, DC 20530-6400 (202) 514-6255 (202) 514-0212 (fax)

Dated:

August 31

, 2006

 
 UNITED STATES DISTRICT COURT FOR THE
 EASTERN DISTRICT OF KENTUCKY


UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

v.

)

)

THE COMMONWEALTH OF KENTUCKY, et al., )

)

Defendants.

)

)

____________________________________________)

Civil No. _______

Settlement Agreement

I. Jurisdiction and Parties

i. This case was instituted by the United States Department of Justice pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997.

ii. This Court has jurisdiction over this action pursuant to 28 U.S.C. § 1345.

iii. Venue is appropriate pursuant to 28 U.S.C. § 1391(b).

iv. The United States is authorized to institute this civil action by 42 U.S.C. § 1997a and has met all prerequisites for the institution of this civil action prescribed by the statute.

v. The Defendants are the Commonwealth of Kentucky (“Commonwealth”); Ernie L. Fletcher, Governor of the Commonwealth of Kentucky, in his official capacity only; Mark D. Birdwhistell, Secretary, Cabinet for Health and Family Services, in his official capacity only; John M. Burt, Commissioner, Department for Mental Health and Mental Retardation Services, in his official capacity only; and the Deputy Commissioner for the Department of Mental Health and Mental Retardation Services, in his official capacity only. The Defendants are ultimately responsible for operation of the Communities at Oakwood (“Oakwood”).

vi. Parties: This Agreement is by and between the United States Department of Justice (“DOJ”) and the Commonwealth of Kentucky (“Commonwealth”). The Commonwealth includes those government agencies, departments, entities, and persons involved at all relevant times in the management, oversight, and regulation of Oakwood and/or matters identified in Section II, “Subject Matter,” including those persons listed in paragraph v. above, in their official capacities.
vii. On June 22, 2001, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, notified the Governor of the Commonwealth of Kentucky, the Attorney General of the Commonwealth of Kentucky, the Secretary of the Cabinet for Health Services, and the Facility Director of Oakwood, of his intention to investigate allegations of unconstitutional and unlawful conditions at Oakwood pursuant to CRIPA.
viii. Following a thorough investigation, on November 7, 2002, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, informed the Governor of the Commonwealth of Kentucky, the Attorney General for the Commonwealth of Kentucky, the General Counsel for the Cabinet for Health Services of the Commonwealth of Kentucky, the Secretary of the Cabinet for Health Services, the Commissioner of the Department for Mental Health and Mental Retardation, and the Acting Facility Director of Oakwood that the Attorney General had reasonable cause to believe that persons residing in, or confined to, Oakwood were being subjected to egregious and flagrant conditions that deprived them of rights, privileges, and immunities secured by the Constitution or laws of the United States.
ix. The Commonwealth has voluntarily come forward with a Strategic Action Plan (“SAP”), which details methods by which the Commonwealth will operate Oakwood and provide services to residents of the facility. This SAP is incorporated into this Settlement Agreement (“Agreement”) as Exhibit A and, as such, is a fully enforceable order of this Court.
x. The parties to this Agreement share a common interest in seeking to protect the rights of those individuals with developmental disabilities living at Oakwood. In furtherance of the mutual commitments toward this interest, the parties have worked together to identify issues and provide solutions for ensuring that individuals with developmental disabilities living at Oakwood enjoy a safe and growth-oriented environment. This Agreement sets forth an agreed-upon manner for measuring and realizing these common interests.
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II. Subject Matter
This Agreement arises from an investigation performed by DOJ concerning conditions of confinement at Oakwood. The investigation was performed pursuant to CRIPA. DOJ issued its findings of fact on November 7, 2002.
i. Oakwood. Oakwood is an intermediate care facility for persons with developmental disabilities located in Somerset, Kentucky. At all times relevant herein, Oakwood was and is a state-operated facility.
ii. DOJ Investigation. The DOJ performed an initial on-site review of the conditions at Oakwood on November 5-9, 2001, with attention to the care and treatment of persons admitted to Oakwood. The investigation included reviews of facility records and interviews with administrators, staff, and residents.
iii. DOJ Findings. As a result of its investigation, the DOJ made findings, including the following:
1. Protection from Harm. a. The investigation found that Oakwood fails to protect its residents from harm due to abuse and mistreatment.
b. The investigation found that Oakwood fails to protect its residents from harm due to neglect or failing to maintain a safe environment.
2. Behavioral Services. a. The investigation found that persons with developmental disabilities receive inadequate care from Oakwood’s treatment teams.
b. The investigation found that Oakwood prepares inadequate individual support plans (“ISP”) for its residents.
c. The investigation found that Oakwood prepares inadequate behavioral support plans (“BSP”) for its residents.
d. The investigation found that Oakwood’s psychology staff fails to provide adequate behavior and psychology services to its residents.
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3. Psychiatric Services. The investigation found that Oakwood’s psychiatric services fall substantially below generally accepted professional standards of care.
4. General Medical Care. a. The investigation found that Oakwood provides inadequate preventative medical care designed to keep serious medical problems and disease from developing.
b. The investigation found that Oakwood has inadequate and incomplete communication and documentation systems.
c. The investigation found that Oakwood’s physician staff lacked sufficient training in the field of developmental disabilities.
d. The investigation found that Oakwood fails to provide adequate evaluation, diagnosis, and treatment for residents with seizure disorders.
5. Nursing Care. a. The investigation found that Oakwood’s nursing assessments and documentation, particularly those of acute illnesses and injuries, are incomplete, fragmented, inconsistent, and simply repeat prior assessments.
b. The investigation found that Oakwood’s nursing staff does not follow established standards and protocols regarding medication administration, resulting in an unacceptably high number of medication errors and consequent harm to residents.
c. The investigation found that the medical emergency response system at Oakwood falls below generally accepted professional standards of care and places the health and well-being of residents at risk of injury or death.
d. The investigation found that Oakwood staff engages in infection control practices that are outdated, unsafe, and ineffective for preventing the spread of infectious and contagious diseases, placing themselves and Oakwood residents at risk of harm.
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e. The investigation found that Oakwood’s nursing and direct care staff training programs are insufficient to protect its residents from harm and this is a major contributing factor to the inadequate nursing care provided at Oakwood.
f. The investigation found that Oakwood’s system for staffing nurses and direct care staff is inadequate and jeopardizes resident safety and quality of care.
6. Nutritional Management. The investigation found that Oakwood’s residents are not adequately managed during mealtimes; that residents lack adequate individual meal management plans; and that there is no interdisciplinary management connecting the resident’s nutritional management issues with his/her behavioral problems.
7. Physical Therapy. The investigation found that Oakwood does not provide sufficient physical therapy services to residents in need of such services.
8. Quality Improvement. The investigation found that the quality improvement program in existence at the time of the investigation was inadequate to address the crisis of care found to exist within the clinical services provided at Oakwood.
9. Serving Institutionalized Persons In The Most Integrated Setting Appropriate To Their Needs. The investigation found that Oakwood fails to accommodate persons who desire to live in the community in violation of the Commonwealth's obligations under Title II of the Americans with Disabilities Act, 42 U.S.C. § 12132 et seq., and the regulations promulgated thereunder, 28 C.F.R. § 35.130(d).
III. Understandings of Positions
i. The Commonwealth admits that, at the time of the DOJ investigation in 2001, the conditions at Oakwood may have violated the constitutional and/or statutory rights of its residents.
ii. DOJ acknowledges the Commonwealth’s efforts and progress in improving the quality of conditions and services at Oakwood since the findings letter was issued.
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iii. Nothing in this Agreement shall be construed as an acknowledgment or admission that the Commonwealth has not acted, or continues not to act, in full compliance with the United States Constitution or federal law.
iv. The provisions of this Agreement are a lawful, fair, adequate, and reasonable resolution of this investigation.
v. DOJ and the Commonwealth have engaged in good faith negotiations to reach an understanding in this Agreement. This Agreement memorializes the Commonwealth’s efforts to implement and maintain necessary improvements at Oakwood and to avoid protracted, contested litigation related to the DOJ CRIPA investigation.
vi. This Agreement is not intended to create any rights in any person or entity not a party to it.
IV. Strategic Plan for Enhancing Service Delivery
The Commonwealth shall implement and maintain implementation of this Agreement and the SAP for Oakwood. A copy of the SAP is attached as Exhibit A and incorporated fully by reference herein. The Parties mutually agree that the Agreement and the Commonwealth’s SAP are a thorough and complete plan of response to those findings identified by DOJ in Section II, Part iii of this Agreement. The Commonwealth’s obligations and a summary of the SAP follows:
i. Support for a Treatment Planning Process.
1. Treatment Planning. The Commonwealth shall implement a treatment planning process that allows for effective interdisciplinary work and encourages active participation by the individual, as appropriate to his/her functional status, and chosen family and friends. As contained in the SAP, the treatment planning process shall consist of an integrated treatment plan that integrates all assessments, develops supports and services based upon assessed needs, monitors systems for providing services and supports, and formulates evidence-based, empirically-validated treatment and training methods that comport with generally accepted professional standards. Emphasis shall be placed upon the creation of a treatment team assigned to each individual responsible for creating, implementing, monitoring, and updating an integrated treatment plan for each individual, including integrating all assessments, services, treatments, and supports. The treatment team membership shall include a treatment team leader
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responsible for the adequate functioning of each treatment team and implementation of the integrated treatment plan and shall reflect a consistent and enduring team of interdisciplinary caregivers as appropriate to the individual’s needs.
2. Holistic Assessment. The Commonwealth shall ensure that individuals are provided a holistic assessment of the individual’s needs and preferences, including an assessment of the individual’s psychosocial, behavioral, medical, and habilitation needs. Such assessments shall be revisited regularly and revised as needed given the individual’s circumstances.
3. Comprehensive Case Formulation. The Commonwealth shall develop and maintain comprehensive case formulations for each individual for the purpose of generating targeted and complete hypotheses about each individual’s status, course, treatment, and habilitation needs.
4. Need-Driven Planning. The Commonwealth shall focus treatment planning for each individual based upon the comprehensive assessment of the individual’s particular needs in all life areas (e.g., home living, community life, social life, health, wellness, work/education, and behavioral/psychiatric factors). The individual’s needs shall be updated in writing as warranted so that the individual’s objectives are identified in a manner that is realistic and attainable.
5. Monitoring of Plans. The Commonwealth shall routinely and systematically monitor treatment plans for individuals for implementation and effectiveness.
6. Transition Support. The Commonwealth shall develop and maintain a community transition plan as part of each resident's individual treatment plan.
ii. Integrate Discipline Specific Services.
Each of the professional disciplines listed below shall provide adequate assessments and services necessary to support an individualized interdisciplinary treatment planning process consistent with generally accepted professional standards.
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1. Psychiatric Services. The Commonwealth shall provide adequate and appropriate routine and emergency psychiatric and mental health services for the purpose of meeting the individualized needs of each resident, consistent with generally accepted professional standards. To this end, the Commonwealth shall ensure that psychiatric services are sufficient to meet the needs of each individual receiving psychotropic medications as well as those individuals who have or may have mental illness. Such services shall include the following:
a. Psychiatric Assessment. The Commonwealth shall perform a comprehensive psychiatric assessment for each individual with a mental health concern.
b. Psychotropic Medication Assessment. The Commonwealth shall make ongoing, timely, and documented psychiatric assessments of each individual receiving psychotropic medications.
c. Integrated Into Plan. The Commonwealth shall ensure that interdisciplinary treatment team functions are integrated into the individual’s treatment plan.
d. Integration Among Services. The Commonwealth shall ensure that psychiatric assessments are integrated with behavioral, neurological, and medical services for targeted treatment.
e. Psychiatric Staff. The Commonwealth shall provide an orientation and competency plan that promotes a system of adherence to standards of care on an ongoing basis.
f. Medication Management. The Commonwealth shall create and maintain an appropriate, safe, and effective medication management system.
2. Neurological Services. The Commonwealth shall ensure that individuals with seizure disorders are properly diagnosed, treated, and regularly monitored.
3. General Medical Care. The Commonwealth shall provide residents with adequate and appropriate preventative, routine, acute, and emergency health care, including neurological care, and dental care to meet the individualized needs of the residents, consistent with generally accepted professional standards. To this end, the Commonwealth agrees to do the following:
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a. Preventative Health Care. The Commonwealth shall provide residents with appropriate and timely preventative health care.
b. Routine and Emergency Health Care. The Commonwealth shall provide residents with appropriate and timely routine, emergency, and specialized health care.
c. Medication Use. The Commonwealth shall monitor medication use to ensure appropriateness, safety, and efficacy.
d. Physician Monitoring. The Commonwealth shall include physicians in the processes of monitoring medication use.
e. Mortality Review. The Commonwealth shall implement a formal mortality review process to provide specific recommendations to improve quality of care.
f. Dental Care. The Commonwealth shall provide timely and appropriate dental care.
g. Quality Management. The Commonwealth shall develop and maintain a medical quality management system.
4. Psychological and Behavioral Services. The Commonwealth shall provide adequate and appropriate psychological and behavioral services to meet the individualized needs of each resident, especially those with challenging behaviors, consistent with generally accepted professional standards. To this end, the Commonwealth agrees to do the following:
a. Sufficiency. The Commonwealth shall implement psychological and behavioral services that are sufficient to meet the needs of each individual in terms of general clinical/mental health, functional status, skills, and supports needed to exercise optimal autonomy or independence.
b. Positive Behavior Support. The Commonwealth shall develop and implement Positive Behavior Support (“PBS”) programs.
c. System Monitoring. The Commonwealth shall regularly monitor each individual’s skills training plan, supports provision, and PBS plan.
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d. Regression Prevention. The Commonwealth shall ensure that psychological services are sufficient to prevent or decelerate physical, functional, and psychological regression, and to ensure an individual’s reasonable safety, security, and freedom from receiving restrictive procedures, and undue bodily restraint.
e. Behavior Intervention Committee. The Commonwealth shall create and implement a Behavior Intervention Committee to review and approve any restrictive interventions for individuals.
5. Nursing Services. The Commonwealth shall ensure that Oakwood residents receive adequate and appropriate nursing care, including adequate and appropriate practices governing medication administration, emergency response, and infection control to meet the individualized needs of each resident, consistent with generally accepted professional standards. To this end, the Commonwealth agrees to do the following:
a. Sufficiency. The Commonwealth shall ensure that nursing services are sufficient to meet the need of its residents.
b. Performance Improvement. The Commonwealth shall implement and maintain a nursing performance improvement process.
6. Nutritional, Speech, Occupational, and Physical Therapy. The Commonwealth shall provide each resident with adequate and appropriate physical and nutritional management to meet the individualized needs of each resident, consistent with generally accepted professional standards. Furthermore, the Commonwealth shall provide each resident with adequate and appropriate occupational therapy, physical therapy, and speech therapy to meet the individualized needs of each resident, consistent with generally accepted professional standards. To this end, the Commonwealth agrees to do the following:
a. Sufficiency. The Commonwealth shall ensure that all individuals receive sufficient nutritional, speech, occupational, and physical therapy, as needed.
b. Performance Improvement. The Commonwealth shall implement and maintain a performance improvement plan to outline and measure goals for the delivery of nutritional, speech, occupational, and physical therapy services.
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iii. Risk Management.
1. Safe and Secure Environment. The Commonwealth shall provide a safe and secure environment to all individuals at Oakwood by protecting them from abuse, neglect, and other high-risk behaviors. To this end, the Commonwealth shall provide ongoing supervision of Oakwood residents in accord with generally accepted professional standards; adequate numbers of direct care staff necessary to manage and supervise clients in accordance with their individual program plans and to avoid extensive use of mandatory overtime and/or requiring direct care staff to perform support services to the extent that these duties interfere with the exercise of their primary direct client care duties; adequate and ongoing supervision of staff responsible for the direct care and treatment of Oakwood residents; and adequate training of direct care staff in all areas of the SAP for which they are responsible.
2. High-Risk Behavior. The Commonwealth shall identify thresholds for high-risk behavior and to ensure timely interventions to reduce ongoing risk.
3. Restraints. The Commonwealth shall promote a restraint-free environment by not using restraints as punishment or as part of a PBS plan, but allowing for the use of restraints only for medical emergencies or when there is immediate risk of harm to the individual or to others.
4. Criteria for Using Restraints. The Commonwealth shall promulgate and follow established criteria consistent with generally accepted professional standards for the use of restraints.
5. Restraint Procedures. The Commonwealth shall ensure that all staff members are competent in implementing restraint procedures.
6. Quality Management. The Commonwealth shall institute a quality management program on the use of restraints.
7. Risk Management System. The Commonwealth shall develop and implement an adequate risk management system, including an adequate management information system, to identify, track, monitor, and substantially reduce the incidents of harm due to abuse, neglect, and/or mistreatment, consistent with generally accepted professional standards.
8. Environmental Safety. The Commonwealth shall develop and implement a plan to provide Oakwood residents and staff with a safe and secure
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living and working environment, particularly in the common spaces, lavatories, and in areas frequented by residents with pica behaviors, selfinjurious behaviors, and aggressive behaviors.
iv. Quality Assurance.
1. Quality Assurance Program. The Commonwealth shall develop and implement quality assurance mechanisms consistent with generally accepted professional standards that enable the Commonwealth to comply fully with this Agreement and SAP, that timely and adequately detect problems with the provision of services and supports required under this Agreement and SAP, and that ensure appropriate corrective responses are implemented.
v. Community Transition.
In accordance with Title II of the Americans with Disabilities Act, 42 U.S.C. § 12132, et seq., and implementing regulation 28 C.F.R. § 35.130(d), the Commonwealth shall ensure that each Oakwood resident is served in the most integrated setting appropriate to meet their needs. To this end, the Commonwealth agrees to do the following:
1. Evaluation. The Commonwealth shall review and revise, as needed, its procedures, role, and function of Oakwood in serving its residents’ needs.
2. Transition Process. The Commonwealth shall implement and maintain a transition process that begins at admission and is an integral part of each individual’s treatment plan. The Commonwealth shall provide sufficient professional and support staff to implement fully this commitment to transition planning as an integral part of individual treatment planning.
3. Community Providers. The Commonwealth shall foster collaborative relationships with community providers, and provide sufficient additional community placements to ensure that each individual is served in the most integrated setting appropriate to his or her needs.
4. Available Services. The Commonwealth shall educate its residents, their families, and guardians regarding available community-based services.
5. Monitoring. The Commonwealth shall develop and implement systems to monitor services at community-based homes and ensure adequate staff training at such homes in order to protect residents from harm.
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Community-based homes are defined as those located outside the current geographic boundaries of Oakwood.
V. Implementation and Monitoring
i. The Commonwealth represents that it has implemented, or will implement, the policies and procedures summarized in Section IV of this Agreement and in the SAP.
ii. DOJ represents that it has reviewed the SAP and believes that the implementation of the Agreement, including the fully incorporated and enforceable SAP, will substantially and adequately address the issues raised by the DOJ CRIPA investigation.
iii. The Commonwealth represents that it will continually and periodically refine and revise the policies and procedures outlined in this Agreement and the SAP to assure compliance with the letter and spirit of this Agreement and the SAP. Upon request, DOJ shall be provided with copies and an opportunity to provide substantive comment upon any policies and procedures revised pursuant to this Agreement and the SAP.
iv. The Commonwealth represents that it has educated, or will educate, all employees at Oakwood with respect to the policies and procedures outlined in this Agreement and SAP. To this end, the Commonwealth warrants that all supervisory personnel, including both employees and consultants, shall sign a written statement that they have read and understand the terms of the Agreement and the SAP.
v. The Commonwealth shall maintain sufficient records to document its compliance with all terms of this Agreement and the SAP. The Commonwealth shall also maintain any and all records required by or developed under this Agreement and the SAP. DOJ shall have unrestricted access to and, shall, upon request, receive copies of any document and/or any databases relating to the implementation of this Agreement and the SAP. DOJ shall have unrestricted access to all staff and facilities, including private interviews with residents and staff, as necessary, to assess compliance with this Agreement and the SAP.
vi. The Commonwealth shall provide the DOJ, its staff, consultants and agents, with reasonable access to:
1. All buildings and facilities at Oakwood.
2. All staff having duties relating to Oakwood.
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3. All residents living at Oakwood, outside the presence of staff (unless the resident requests otherwise) consistent with this Agreement and the SAP.
4. Any records regarding Oakwood, its staff or residents.
5. Records of residents transitioned to community-based homes or other facilities, in order to evaluate compliance with the terms of this Agreement and the SAP.
vii. The Commonwealth shall designate contact agent(s) for ensuring that the Commonwealth adheres to the terms and conditions of this Agreement and the SAP.
viii. If the Commonwealth further subdivides Oakwood into smaller facilities and/or outsources any of the services covered under this Agreement and the SAP, this Agreement and SAP shall be fully applicable to, and binding upon, those subdivided facilities and/or outsourced services.
ix. The parties agree to the appointment of Nirbhay N. Singh, Ph.D., as the jointlyselected expert to monitor the Commonwealth's implementation of this Agreement and the SAP (the "Monitor"). The Monitor shall have full authority to independently assess, review, and report no less than semi-annually on the Commonwealth’s implementation of and compliance with the provisions of this Agreement and the SAP. The parties further agree that the Monitor may use consultants to aid in fulfilling the duties of the Monitor, under the same terms and conditions applicable to the Monitor. All reasonable costs and expenses of the Monitor, including the cost of any consultant to assist the Monitor, shall be borne by the Commonwealth. The Monitor shall simultaneously submit to DOJ a copy of any bill and/or request for payment made to the Commonwealth. The Monitor shall also submit to DOJ a copy of all payments made by the Commonwealth. In the event that Dr. Singh is unable to serve or continue serving as the Monitor, the Parties shall meet or otherwise confer within thirty (30) days of being notified of this eventuality to select a new Monitor. If the parties are unable to agree upon a selection, each Party shall submit two names, along with resumes or curricula vitae and cost proposals, to the Court and the Court shall appoint the Monitor from among the names submitted. The procedure described in this paragraph shall apply to all successor Monitors.
x. The overall duties of the Monitor and/or his/her designees shall be to observe, review, report findings, and make recommendations to the parties with regard to the implementation of the Agreement and the SAP. The Monitor shall regularly review the protections, services, and supports provided to residents in their residential settings and programs to determine the Commonwealth’s
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implementation of and compliance with this Agreement and the SAP. DOJ, the Monitor and/or his/her designees, may make both announced and unannounced inspections of the facility and of residential settings to which Oakwood residents are transitioned, in order to evaluate compliance with the terms of this Agreement and the SAP.
xi. The Monitor shall file with the Court, and also submit to the Commonwealth and to DOJ, a written report no less than every six months with regard to the Commonwealth’s implementation efforts and compliance with the Agreement and the SAP. The Commonwealth will take timely action to remedy any deficiencies cited by the Monitor.
xii. The Commonwealth shall notify the Monitor and DOJ immediately upon the death of any resident and/or any situation resulting in a resident being placed in imminent and/or immediate jeopardy that has caused or may cause severe injury to such Oakwood resident. The Commonwealth shall forward to the Monitor and DOJ copies of any completed incident reports related to deaths, autopsies and/or death summaries of residents, as well as all final reports of investigations of those incidents described in this subsection.
xiii. Except as required or authorized by the terms of this Agreement or the Parties acting together, or as authorized by a Court order, the Monitor shall not: issue public statements (at a conference or otherwise) or make findings with regard to any act or omission of the Commonwealth or its agents, representatives or employees, nor disclose to any person or entity, other than the Court or the Parties, any non-public information provided to the Monitor pursuant to this Agreement. Any press statement made by the Monitor regarding his/her employment must first be approved by the Parties. The Monitor shall not testify in any other litigation or proceeding with regard to any act or omission of the Commonwealth or any of its agents, representatives, or employees related to this case. The Monitor may testify in any case brought by either Party herein regarding the implementation, enforcement, or dissolution of this Agreement. Unless such conflict is waived in writing by the Parties, the Monitor shall not accept employment or provide consulting services that would present a conflict of interest with the Monitor’s responsibilities under this Agreement, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant, or such litigant’s or claimant’s attorney, in connection with a claim or suit against the Commonwealth or its departments, officers, agents or employees. The Monitor is not a state or local agency or an agent thereof, and accordingly the records maintained by the Monitor shall not be deemed public records subject to public inspection. Neither the Monitor nor any person or entity hired or otherwise retained by the Monitor to assist in furthering any provision of this Agreement shall be liable for any claim, lawsuit or demand arising out of the Monitor’s
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performance pursuant to this Agreement. This paragraph does not apply to any proceeding before a court related to performance of contracts or subcontracts for monitoring this Agreement.
VI. Compliance and Termination
i. This Agreement, and exhibits specifically referenced herein, shall constitute the entire integrated agreement of the Parties with respect to the DOJ CRIPA investigation. Except for the November 7, 2002 letter from the United States to the Commonwealth informing the Commonwealth that the United States had reasonable cause to believe that persons residing in or confined to Oakwood were being subjected to egregious or flagrant conditions that deprived them of rights, privileges, and immunities secured by the Constitution or laws of the United States, no prior or contemporaneous communications, oral or written, shall be relevant or admissible for purposes of determining the meaning of any provisions herein.
ii. If DOJ believes that the Commonwealth has failed to fulfill any obligation under this Agreement and SAP, DOJ will, prior to initiating any action to enforce the terms of this Agreement and SAP, give written notice to the Commonwealth of the claimed failure. Upon receipt of said written notice, the Commonwealth shall then have 60 days in which to cure the claimed failure, if necessary, and provide DOJ with sufficient proof of its cure. At the end of the 60 day period, in the event that DOJ determines that the failure has not been cured, DOJ may initiate any action against the Commonwealth to enforce this Agreement and SAP without further notice. However, in the case of an emergency posing an immediate threat to the health or safety of Oakwood’s residents, the United States may omit the notice and cure requirements herein, before seeking judicial action. If DOJ does not notify the Commonwealth of the Commonwealth’s failure to fulfill any obligation under this Agreement and SAP, such lack of notice shall not constitute a waiver of the Commonwealth’s underlying obligation.
iii. If, at any time, any Party to the Agreement and the SAP desires to modify it for any reason, that Party will notify the other party in writing of the proposed modification and the reasons therefor. The Parties shall meet and confer with regard to the proposed modification. The Parties may jointly petition the Court to adopt any such modification.
iv. No waiver of any of the terms of the Agreement and the SAP shall be valid unless it is in writing and signed by both Parties to the Agreement and the SAP.
v. This Agreement and the SAP will terminate five years after the effective date of the Agreement and the SAP, as defined in Part VI. ix. If the Parties agree that the Commonwealth and Oakwood officials are in compliance with each of the
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provisions of this Agreement and SAP earlier than five years from the effective date of the Agreement and the SAP, and have maintained compliance for at least one year, then the Agreement and the SAP may terminate at an earlier date. The burden will be on the Commonwealth and Oakwood officials to demonstrate such compliance. vi. To the extent that any of the legal authorities cited in the Agreement (e.g., federal statute, regulations or case law) are amended or superseded, this Agreement shall be amended accordingly. vii. The Commonwealth shall abide by all federal and state licensing requirements applicable to Oakwood and/or to any facility to which an individual residing at Oakwood is discharged. ix. This Agreement shall be effective on the first day of the month following the date of filing in a court of competent jurisdiction (“Effective Date”). Except where an earlier date is specified in this Agreement or the SAP, all provisions, objectives and/or action items shall be implemented within 36 months of the Effective Date of this Agreement. x. The Parties, by their signatures below, consent to entry of the foregoing Agreement as an order of the Court.
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FOR THE COMMONWEALTH OF KENTUCKY:


/s/ Ernie L. Fletcher ERNIE L. FLETCHER Governor Commonwealth of Kentucky

/s/ Mark D. Birdwhistell MARK D. BIRDWHISTELL Secretary Cabinet for Health & Family Services

/s/ John M. Burt JOHN M. BURT, Commissioner Department of Mental Health
& Mental Retardation Cabinet for Health & Family Services

/s/ Deputy Commissioner Deputy Commissioner Department of Mental Health
& Mental Retardation Cabinet for Health & Family Services

/s/ David E. Fleenor DAVID E. FLEENOR Deputy General Counsel Office of the Governor

Dated: August 31

, 2006

/s/ Wesley R. Butler WESLEY R. BUTLER General Counsel Cabinet for Health & Family Services

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FOR THE UNITED STATES:

/s/ Amul R. Thapar
AMUL R. THAPAR United States Attorney

Dated: August 31

, 2006

/s/ Wan J. Kim WAN J. KIM Assistant Attorney General Civil Rights Division
/s/ Shanetta Y. Cutlar SHANETTA Y. CUTLAR Chief Special Litigation Section
/s/ Judy Preston JUDY PRESTON Deputy Chief Special Litigation Section
/s/ Mary R. Bohan MARY R. BOHAN Attorney Special Litigation Section 950 Pennsylvania Avenue, NW U.S. Department of Justice Civil Rights Division Washington, DC 20035-6400 (202) 514-6255

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IT IS SO ORDERED.

DATED: ___________________, 2006

______/_s/______________________________ UNITED STATES DISTRICT JUDGE

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 U.S. Department of Justice
Civil Rights Division
Special Litigation Section - PHB 950 Pennsylvania Avenue, N.W. Washington, DC 20530
November 7, 2002
The Honorable Paul E. Patton Governor of the Commonwealth of Kentucky Office of the Governor 700 Capitol Avenue Suite 100 Frankfort, KY 40601
Re: Investigation of the Oakwood Developmental Center
Dear Governor Patton:
On June 22, 2001, we notified you, pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997, that we were investigating conditions of confinement at the Oakwood Developmental Center (“Oakwood”), a facility for individuals with developmental disabilities located in Somerset, Kentucky. On November 5-9, 2001, we conducted an on-site review of the care and treatment of individuals at Oakwood with experts in behavior management, and medical and nursing care. We reviewed numerous records and interviewed administrators, staff and residents. At an exit interview conducted on the last day of the tour, we verbally conveyed our preliminary findings to selected facility staff, counsel, and senior officials of the Kentucky Cabinet for Health Services. Consistent with the requirements of CRIPA, we are now writing to inform you of our findings.
At the outset, we wish to acknowledge and express our appreciation to the hardworking and committed staff of Oakwood and the Cabinet for Health Services officials for their assistance during our tour. At all times, Oakwood staff, Cabinet officials, and counsel were very cooperative and professional. We particularly recognize the commitment demonstrated by the Secretary of the Cabinet for Health Services, Marcia R. Morgan, who attended our exit conference, and the Commissioner of the Department of Mental Health and Mental Retardation Services, Margaret Pennington, who was present throughout our on-site review.

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Oakwood opened in 1972 as a residential facility for persons with developmental disabilities. It consists of 27 buildings on 200 acres. The facility is licensed to serve 420 individuals and has an average daily census of 394. Oakwood consists of 18 separate residential buildings, therapeutic and habilitative service areas, a medical services building that includes an infirmary, and administrative and support buildings. Each of the 18 residential buildings consists of two wings with approximately 12 beds each that are separated by a shared kitchen and laundry area. As of the time of our visit, the population of Oakwood consisted of approximately 249 men and 143 women ranging in ages from 19 to 67 years with the majority of residents between the ages of 22 and 46. The majority of residents (332) are persons with severe or profound mental retardation; approximately 52 residents use a wheelchair for mobility, seating, and/or positioning; approximately 190 of the residents receive antiepileptic medications; and 154 residents receive psychotropic medications.
Recently, Oakwood has initiated a plan to divide the institution into four separate facilities called communities. As this process was still being implemented during our tour, our letter evaluates Oakwood as a single facility.
Our findings, the facts supporting them, and the minimum remedial steps that we believe are necessary to correct constitutional deficiencies are set forth below. Residents of state-operated facilities have a right to live in reasonable safety and to receive adequate health care, along with habilitation, to ensure their safety and freedom from unreasonable restraint, prevent regression and facilitate their ability to exercise their liberty interests. See Youngberg v. Romeo, 457 U.S. 307 (1982). Similar protections are accorded by federal statute. See, e.g., Title XIX of the Social Security Act, 42 U.S.C. § 1396; 42 C.F.R. Part 483 (Medicaid Program Provisions). The State also is obliged to provide services in the most integrated setting appropriate to individual residents’ needs. Title II of the American with Disabilities Act (“ADA”), 42 U.S.C. § 12132 et seq.; 28 C.F.R. § 35.130 (d); see Olmstead v. Zimring, 527 U.S. 581 (1999).
As a brief summary, we find that Oakwood fails to provide adequate: (1) protection of its residents from harm due to abuse, mistreatment, neglect, improper use of restraints, pica behavior, and an overall lack of environmental safety; (2) behavioral and psychology services, including adequate treatment team meetings, individual and behavioral support plans, and training programs; (3) psychiatric services; (4) medical care, including neurological

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care; (5) nursing care; (6) staffing and staff training; (7) nutritional management; (8) physical therapy, and (9) quality assurance mechanisms designed to self-correct institutional problems.
I. PROTECTION FROM HARM
A. Abuse and Mistreatment
Oakwood fails to protect its residents from harm. There have been numerous and recurring incidents of abuse and mistreatment by staff members over the past several years. A serious example of abuse occurred on August 22, 2000, when an Oakwood staff member stomped on a resident’s head and rendered the resident unconscious. An internal facility investigation uncovered three further instances of this staff member physically abusing residents at Oakwood. Kentucky’s Office of the Inspector General, Division of Long Term Care found that “. . . the facility’s failure to develop and implement policies/procedures that prohibited continued employment of individuals who had allegations of substantiated abuse/neglect against them and the facility’s failure to develop/implement a system to evaluate client incident/accidents also presented imminent danger to the facility clients.”1 We concur in that assessment.2
In another example, a staff member was observed pushing, slapping, and cursing at a resident on a daily basis for approximately four months, from April to August, 2000. Oakwood’s internal investigation revealed that there was a “code of silence” among facility direct care staff regarding reporting allegations of abuse/neglect on other facility employees. Staff were afraid to report client abuse because of retaliation by other employees. Further, Kentucky’s Office of the Inspector General, Division of Long Term Care found that the facility failed to conduct a thorough investigation of the incidents after allegations of abuse relating to the same resident’s hip fracture were identified.3
1
 Complaint Intake Report, December 8, 2000.
2
 The Office of Attorney General for the Commonwealth of Kentucky has indicted three Oakwood staff members on felony charges of knowingly abusing or neglecting an adult for incidents of abuse occurring in the years 2000 and 2001.
3
 Complaint Intake Report, September 25, 2000.

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In addition to several substantiated reports of abuse and neglect, a high number of reported incidents of harm have occurred that present serious threats to resident safety but were unsubstantiated because the perpetrators could not be adequately identified. For example, a resident was beaten with a coat hanger but investigators could not confirm allegations identifying certain staff members.
Finally, the sheer volume of incident reports of harm is unacceptably high, especially recurring incidents with specific individuals over long periods of time. For example, from July to September, 2001, one resident in unit 117B, had 30 reported incidents of harm, another resident in unit 112A had 20 reported incidents of harm, a third resident in unit 104B had 16 reported incidents of harm. During the above three month period, we noted 24 residents with an unacceptably high number of recurring incidents of harm. Ms. Myers (Director of Performance Improvement and Quality Assurance) and Mr. Greene (Director of Administrative Services) agreed that the number of incidents of harm at Oakwood is a major problem and that immediate remedial steps should be taken to reduce such incidents to a minimum.
B. Neglect and Lack of Environmental Safety
Oakwood also fails to protect its residents from harm due to neglect and an overall lack of environmental safety. A particularly egregious example occurred from July, 2000 through our tour in November, 2001. On July 29, 2000, a resident collapsed in a bathroom. Facility staff pried open the resident’s clenched teeth and removed a large amount of fecal material from the resident’s mouth, whereupon he began breathing again. The resident was admitted to the hospital with a diagnosis of fecal aspiration pneumonia.
Previously, on July 11, 2000, the resident’s interdisciplinary team had met and agreed that due to the resident’s history of pica behavior (ingesting inedible foreign objects) he was inappropriately placed in his current residence. The team, however, made no further recommendation for his placement. In his Individual Support Plan (“ISP”), the team recommended that the resident receive direct supervision while inside and outside the cottage, and one-on-one supervision while eating and/or bathing. Despite the team’s recommendation for direct supervision, before the resident collapsed on July 29, 2000, staff were providing only indirect supervision for the resident while in the living unit. Staff in the living unit were apparently unaware of the treatment team’s reassessment of the resident in its July 11, 2000 meeting.

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Review of the records of pica incidents for the resident following the July 29, 2000 episode for the months of August and September, 2000, reveal at least 70 more attempted and/or actual incidents of pica behavior involving paper, trash, toilet paper, shoestrings, a washcloth, an ink pen, a sock, and fecal material. The logs noted that on September 25, 2000, the resident was again found with fecal material in his mouth. On October 6, 2000, the Centers for Medicare and Medicaid Services (“CMS”) issued a citation of immediate jeopardy with regard to the resident, citing Oakwood for inadequate supervision and failure of the interdisciplinary team to adequately reassess the resident’s active treatment program. On November 17, 2000, Oakwood submitted a Plan of Correction (“POC”) to address the concerns of CMS. In its POC, Oakwood stated that it would develop a special living unit for residents with pica behavior and transfer the resident into the new unit. In the interim, all current living unit staff were individually trained in the resident’s active treatment plan and the resident was placed on one-on-one supervision in his current living unit.
In April, 2001, the resident was placed in a special needs living unit designed for pica behavior. The resident’s Individual Support Plan (ISP), dated July 18, 2001, stated that placing the resident in a special needs cottage would decrease the resident’s incidents of pica due to environmental factors and supervision. However, while in the special needs unit from June through September 2001, the resident engaged in six episodes of significant pica behavior. On August 16, 2001, as the resident continued to engage in pica behavior, staff supervision was actually decreased to indirect supervision inside and outside the cottage.
On November 5, 2001, the week of our visit, the resident was admitted to the hospital with a possible bowel obstruction. Two days later, on November 7, 2001, five plastic gloves were removed from the resident’s stomach.4 Prior to surgery, staff were completely unaware of these pica incidents. Staff, however, admitted to observing on several occasions used gloves were left throughout the special needs living unit, including the resident’s
4
 On November 13-16, 2001, CMS conducted an abbreviated standard survey and as a result issued an another immediate jeopardy concerning the same resident for the same issues as outlined in the immediate jeopardy letter of October 6, 2000. CMS found that Oakwood did not adequately supervise clients to protect them from physical harm or report incidents of harm, neglect, or abuse.

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room. Staff failed to report several of the incidents of improper glove disposal to supervisors and those reported to supervisors remained unreported to the administration. Thus, effective environmental controls critical to operation of the special needs unit remained unenforced. Furthermore, as discussed later in this letter, no quality assurance mechanism exists to monitor the special needs unit to ensure that proper environmental controls are consistently implemented.
Staff neglect and unsafe conditions in the living units appear to be widespread across the facility. Incident reports are replete with instances of harm such as resident aggression, property destruction, self-injury and other behavioral problems. We reviewed numerous incidents of residents being chemically restrained due to aggression toward staff instead of being provided appropriate behavioral programming, along with cases of residents being victimized by other residents.
Pica continues to be a serious problem at the facility. We noted several incidents of residents eating fecal material. For example, on September 2, 2001, one resident picked up and placed in her mouth the bowel movement that another resident had dropped on the floor. There are also numerous documented instances of residents eating cigarette butts outside their homes. This problem has been identified to Oakwood by CMS and its own consultants. Still, during our visit we found numerous cigarette butts lying just outside the doors of many of the homes.
II. BEHAVIORAL SERVICES
An adequately functioning system of care and treatment for persons with developmental disabilities should have timely interdisciplinary treatment team meetings designed to create an overall plan of care for each resident in a facility, often referred to as an Individual Support Plan or ISP. The ISP should be based on adequate professional assessments of the individual and have objective, measurable outcomes that are reviewed and reassessed periodically. Residents with behavioral issues should also have a professionally generated behavior management plan, often called a Behavior Support Plan (“BSP”), that is integrated into the resident’s overall ISP. A facility should have sufficient professional staff to assess residents, formulate BSPs, attend treatment team meetings, train and monitor direct care staff in implementing the BSPs, take and assess data, and periodically modify the BSPs based on the collected data. We found Oakwood deficient in all major systemic categories related to behavioral services, including treatment team meetings, Individual Support Plans, Behavior Support Plans, and professional psychology services.

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A. Treatment Team Meetings
The treatment team meetings, designed to formulate, discuss and update resident ISPs and BSPs, are inadequate. Treatment teams are disorganized, often lack key professional personnel, and fail to identify and/or discuss progress toward concrete, identifiable goals. The training and clinical objectives discussed at the meetings are vague and demonstrate a mindset that residents are at Oakwood, not for short term skills development and ultimate discharge, but for long term care and maintenance.
B. Individual Support Plans
The ISPs of Oakwood residents are insufficient. The ISPs fail to outline the overall vision for the residents while at Oakwood, discuss and integrate resident strengths and weaknesses, or formulate specific goals with defined training objectives to achieve such goals. In general, the ISPs at Oakwood are generic, repetitive across residents, and infrequently updated.
C. Behavior Support Plans
Oakwood fails to provide adequate behavior management for its residents, even though many of them have a history of high-risk behavioral problems. Almost half of the Oakwood residents that need a behavioral plan have none. Of the plans that exist, most are ineffective. The majority of the resident records examined showed individuals admitted for short-term skills training but not receiving any short term training or skills development and, instead, remaining at Oakwood for an extensive period of time while developing severe behavioral problems. For example, according to one resident’s chart, he was admitted for “refinement of self-help skills, personal hygiene skills, and to develop appropriate leisure-time activities, communication skills, and socialization skills.” While at Oakwood, this resident deteriorated into multiple behavioral problems including aggression and pica behavior. His BSP and ISP, however, still indicate the same training goals as they did more than twenty years ago. This resident’s case is not an isolated example.
1. Restraint Use
As resident behavior has become increasingly difficult to manage due to lack of adequate behavior management, Oakwood staff have resorted to increased use of physical and chemical restraints even though all of the Oakwood psychologists interviewed stated that restraints and other aversive or restrictive procedures such as helmets and mittens are unnecessary and unwarranted. The continued use of restraints and aversive procedures to control

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behavioral problems for the convenience of staff and in place of effective active treatment constitutes active harm to the residents of Oakwood.
2. Training Programs
Oakwood fails to provide adequate training programs for its residents. A large number of residents do not have day programs and remain idle most of the day engaging in self-stimulation and other problematic behaviors. For example, one resident we observed engages in self-injury and aggression and has a program for these behaviors. However, the behavior program contains no out-of-home component in his daily routine. He remains in the unit without any meaningful activities all day. The residents who do have day programs often engage in meaningless activities designed only to keep them busy. Contributing to the problem of inadequate day programs and recreational activities for the residents is the lack of adequate transportation and an efficient system for accessing the limited transportation options that do exist.
3. Pica Behavior
As discussed earlier, Oakwood fails to provide adequate behavior plans and training programs for its residents with pica behavior. Oakwood has yet to provide any systematic intervention or training to address this problem.
D. Psychology Services
The current psychology staff are unable to provide adequate behavior and psychology services to Oakwood residents given their case loads and other administrative responsibilities. Oakwood has two clinically trained psychologists, one with a caseload of 84 residents and the other with a caseload of 68 residents, which is simply too high to provide adequate services given the behavioral needs of the residents. While the full time psychology staff is overextended, Oakwood underutilizes its part-time clinical psychologist who works four hours per week, has experience in neuropsychology, but has no patient-care duties. Oakwood’s four behavioral analysts also have caseloads that do not permit adequate evaluation and treatment of Oakwood residents.
Given the extensive caseloads, psychology staff is unable to adequately train or monitor the direct care staff in implementing the behavior programs they develop. Many of the direct care staff we interviewed were unfamiliar with the residents or their programs. Other staff who knew the residents did not know the resident’s behavior plan and were unable to communicate what to do

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if a resident exhibited a behavior covered by his or her plan. In addition to direct care staff being unfamiliar with behavior plans, supervisors were also unfamiliar with the plans. For example, we observed one resident hitting his head, which was very red and swollen. A direct care staff merely stated “R. don’t hit your head” as she walked past him; six other direct care staff failed to intervene. He continued hitting himself. Finally, a staff member from the psychology department took the resident outside and then brought him back inside. The resident continued to hit himself the whole time. He hit himself a total of 27 times without adequate intervention while we were observing the unit.
Compounding the lack of oversight and training by the psychology staff is the inadequate orientation and follow up training on behavioral interactions given to direct care staff. New staff are given only two hours of training on behavioral interactions with no evaluation made as to their competency to apply such skills on the living units. Consequently, many direct care staff demonstrate little behavioral skills when working with individuals with challenging behaviors. During the tour, we often observed staff providing negative reinforcement to individual residents with behavior problems instead of active treatment.
III. PSYCHIATRIC SERVICES
Psychiatric services at Oakwood fall substantially below accepted professional standards of care. A significant problem currently exists with the diagnoses of psychiatric disorders. More than 50 percent of the diagnoses are no longer correct. Many of the diagnoses upon admission were in error and have yet to be corrected or updated. Furthermore, a number of Oakwood residents are receiving psychotropic medications without any psychiatric diagnosis. This is unacceptable practice.
Currently, about 42 per cent of Oakwood residents are treated with psychotropic medications, an unusually high number for a facility such as Oakwood. Oakwood is using psychotropic medications to treat the behavioral problems of residents in place of adequate behavioral treatment plans. We noted a number of Oakwood residents on psychotropic medications without any behavior support plan. Many residents are on medication solely by default because other treatment methods for their severe challenging behaviors have not proven effective. It violates professional standards to use drugs in lieu of appropriate and effective behavioral treatment. In addition, many residents are on multiple psychotropic drugs without adequate clinical justification in their charts for such polypharmacy. Currently about 60 per cent of those on psychotropic medication are on such polypharmacy. The

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Oakwood psychiatrists agreed that polypharmacy, especially the use of three or more drugs, is problematic both in terms of drug interactions and adverse effects on residents.
Oakwood lacks a peer-review system for psychiatric care (and for physician services in general), which is an essential component of an effectively functioning clinical services. Further, Oakwood lacks an adequately functioning Pharmacy and Therapeutics Committee, a critical function in monitoring and correcting important quality of care issues, especially in the important and currently deficient area of psychotropic medication use. The existing Pharmacy and Therapeutics Committee fails to adequately: (1) address psychopharmacology issues such as the prevalence and patterns of psychotropic drug prescriptions; (2) conduct peer review of drug prescription practices of individual physicians; (3) monitor use of specific medications for given indications; and (4) improve rational psychopharmacotherapy at the facility. Given the current inadequate state of psychopharmacology practice at Oakwood, the lack of the above Committee functions is a serious gap in psychiatric services.
A collateral problem is the lack of a functional system for assessing Tardive Dyskinesia (“TD”) and other movement disorders,5 or for system-wide monitoring of the side effects of psychotropic medications. An effective system for assessing TD is important because TD and other involuntary movement disorders often result from prescribed psychotropic medication, especially typical antipsychotics. However, Oakwood has no records on the prevalence of serious side effects from the use of psychotropic medications and no policy or procedure for assessing such involuntary movement disorders such as TD. An example of the problem of a lack of an adequate system for assessing serious side effects of psychotropic medications occurred in a treatment team meeting we attended. Partway through the meeting, various staff members commented on the resident’s tendency to self-stimulate herself by rubbing her thumb and fingers together called pill-rolling. Staff suggested they ought to find something more functional for her to do with her fingers. However, the behavior of pill-rolling is a clear sign of Tardive Dyskinesia. TD, as the root of the problem, was not discussed until the end of the meeting when a new physician brought up TD as a possible explanation of the problem. No one,
5
 Tardive dyskinesia is a syndrome which involves involuntary movements such as tongue thrusting or facial grimacing caused by side effects of certain drugs, including antipsychotic medications (Haldol) and other dopamine antagonists. The condition may be reversible if recognized in the earliest stages by stopping the offending drug.

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including the nurses, direct care staff, and behavior analysts had considered TD before, though the resident had been at the facility for years and had apparently been evidencing the behavior for some time.
Finally, the psychiatric and psychology staff admitted that they have not been adequately trained in integrating behavioral and psychopharmacological treatments necessary to appropriately treat many of the Oakwood residents with psychiatric diagnoses.
IV. MEDICAL CARE
A. General Medical Care
Oakwood provides inadequate medical care, especially preventative care designed to keep serious medical problems and disease from developing. The lack of close monitoring and adequate preventive measures can cause harm to Oakwood residents. For example, a resident with a history of constipation was sent to the emergency room of a local hospital for evaluation of severe constipation and possible bowel obstruction. Even though she had been receiving multiple bowel medications, the date of her last bowel movement was not known. She was admitted to the hospital for chronic colonic inertia and a urinary tract infection. Within a few days of admission, she died due to sepsis; her autopsy revealed a markedly dilated bowel. In another example, one resident suffered nine fractures over the course of two years from 1998-2000 before Oakwood finally evaluated her for osteoporosis and began treatment for severe osteoporosis.
Bowel and bladder disorders have been identified as a recurrent medical issues in residents at Oakwood. In a review of the charts of residents who died while at Oakwood, all of the autopsy reports indicated dilated colons. Despite this pattern, Oakwood does not perform screening colonoscopies unless the resident presents symptoms of rectal bleeding or gastrointestinal symptoms. Regular use of screening colonoscopy comports with professional standards of care in evaluating colon complaints, including detecting and preventing cancer. Still, Oakwood fails to document bowel elimination in a resident’s chart and has not developed protocols regarding the use of laxatives or enemas in the event that a patient does not have a bowel movement within a designated period of time. In one instance, a resident’s primary care physician observed that the resident’s seizure activity was closely connected to the resident’s fecal impaction; nevertheless, no data existed in the resident’s chart regarding bowel movements. A staff member told the doctor that any information that does exist on bowel movements was kept locked in the medication cart. Keeping data locked in the medication cart not only prevents easy

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recording of this important information but is useless to a medical care provider reading the medical chart for information on bowel habits.
The medical care of Oakwood residents is further compromised by inadequate communication between medical professionals. When Oakwood residents are referred to the hospital emergency room and to private medical specialists, information concerning the resident is frequently incomplete and unreliable. It is not uncommon to find in a patient’s chart consultant notes such as, “There is no lab work here for comparison,” or “The caretaker with the patient has no information regarding his past medical history.” Oakwood physicians do not always send a note to the consulting specialist as to their medical concerns, nor do they routinely discuss their concerns with the consultant. Often, a non-medical staff fills out the referral note to the consultant. The lack of direct physician to physician communication regarding Oakwood residents greatly compromises the adequacy of medical care provided at Oakwood.
Documentation in Oakwood’s medical charts is incomplete and often illegible. The Medical Director is listed in each chart as the patient’s physician even though he is not the primary care physician for any patient. Physician progress notes often do not provide periodic documentation of acute problems, diagnostic evaluations, or therapeutic interventions. Such documentation is critical for determining whether medical treatment is effective. Furthermore, the medical charts fail to contain an easily accessible active problem list or chronic problem list necessary to provide adequate diagnosis and treatment. For example, the physician of one resident could not determine from the chart whether the client had a previous surgery. Oakwood referred the resident to a gastroenterologist because of weight loss with a concern that she might be experiencing gall bladder disease. It was later learned that she had her gall bladder removed in the past, most likely while she was a resident of Oakwood.
A critical component of an adequate medical service delivery system is a properly functioning mortality review process. Although Oakwood has a mortality review committee, the committee’s review process is inadequate. The goal of a mortality review committee is to understand the cause of death and make necessary changes in policies and practices to prevent future suffering and possible deaths. Oakwood’s own mortality review policies and procedures reflect the above goal in stating that the purpose of a mortality review is to “identify preventive measures and opportunities for improvement at the provider and systems level.” However, the mortality review committee does not implement its own mortality review policies and procedures. All of the mortality

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reviews from January 2000 to November 2001 were incomplete and missing important information, even though these are required under Oakwood’s internal policy. Conclusions or recommendations for improvement in care were generally lacking and, if they were present at all, did not result in any policy change or followup. With regard to one resident, the mortality review committee did not even know the cause of the resident’s death at the time of the review.
Finally, current physician staff at Oakwood lack sufficient training in the field of developmental disabilities. Of the four new physicians hired, only one has had training or previous experience diagnosing and treating patients with developmental disabilities. Although in September, 2001, Oakwood completed its Medical Best Practices Guidelines, which outlines protocols for the treatment of common medical problems for person with developmental disabilities, at the time of our visit in November, 2001, none of the physicians were aware of the contents of these guidelines and some were not even aware that the guidelines existed.
B. Neurological Care
Oakwood fails to provide adequate evaluation, diagnosis, and treatment for residents with seizure disorders. Insufficient staffing, inadequate communication between physicians, and poor follow up treatment are significant contributing factors to the lack of adequate neurology services. Neurology consults are required to provide minimally adequate neurological care. Such consults are needed to evaluate the necessity of anticonvulsant medications as well as to decide when to taper these medications to minimize harmful side effects. Fifty percent of the nearly 400 residents at Oakwood have a diagnosis of seizure disorder. Until November 2001, however, Oakwood had only one consulting neurologist who provided neurology services for ten to fifteen residents per month. No policy exists to give guidance as to which residents take priority for evaluation. During the week of our visit, Oakwood added the part-time services of a second neurologist who held his first clinic during that week for nine residents. His ability to evaluate and treat Oakwood residents with seizure disorders was significantly compromised by the failure of Oakwood’s primary care physicians to communicate adequately the reason for the referral to neurology and to answer questions about the patient. Not one primary care physician attended the Neurology Clinic when we observed the clinic. For many of the residents attending the clinic, Oakwood did not send a staff member who could describe the client’s seizures or medical history. For example, one resident was referred for an evaluation of “spells.” Staff, however, could not describe the spells to the

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neurologist. The consultants’ expertise was not fully utilized, both in evaluating the clients and in educating the professional staff at Oakwood.
The lack of adequate, timely evaluation, diagnosis, and treatment of residents’ neurological needs causes many Oakwood residents to remain on powerful anticonvulsant medications with potentially severe side-effects and dangerous adverse reactions to other drugs. This is especially true in the case of older anticonvulsant medications (such as Phenobarbital and Dilantin), which many Oakwood residents continue to take. The use of older anticonvulsants is causing many adverse effects as observed in the neurology clinic we attended, including gum disease, gait problems resulting in a significant number of falls, and further cognitive dysfunction. Such harm could be avoided by closer monitoring by a qualified neurologist and adjustment of medications.
Furthermore, our record review revealed that 40 Oakwood residents continue to be treated for seizures, in many cases with more than one anti-convulsant drug, despite not having a single seizure for significant periods of time. For example, we examined one resident diagnosed with a seizure disorder whose last seizure was in 1976. Even though no one knew the resident’s type of seizure disorder, and the information was not apparent from the resident’s chart, the resident remained on Depakote three times daily. A neurologist did not evaluate him until September 17, 2001, when he was admitted to an acute care hospital due to unexplained unresponsiveness. The hospital conducted an EEG but the results of the test were not in his chart upon returning to Oakwood and no follow up with a neurologist had occurred. In another example, a resident was admitted to Oakwood in 1979 with a diagnosis of a seizure disorder. His last seizure was in 1992. He takes Dilantin and Phenobarbital, yet no record exists of him ever being evaluated by a neurologist. On August 5, 2001, a physician had written an order for an evaluation by a neurologist, but at the time of our visit no evaluation had occurred.
V. NURSING CARE
A. Nursing Assessments and Documentation
Nursing assessments and documentation, particularly those of acute illnesses and injuries, are incomplete, fragmented, inconsistent and simply repeat prior assessments. For example, when one resident complained of chest pains, the nurse only documented his vital signs, that his skin was “cool to the touch” and that he was able to talk with staff. A full nursing cardiac and respiratory assessment should have been conducted and documented, including evaluating the presence, strength and

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regularity of pulses, breath sounds and breathing patterns. When another resident’s blood pressure was measured at 158/110, the nurse made no mention in her note of this unusually high blood pressure reading, and did not conduct an appropriate physical assessment.
Nursing assessments are not adequately integrated into the ISPs. By Oakwood policy and under minimum professional standards of nursing care, a Health Care Plan (“HCP”) is to be initiated upon admission. The HCP should also be integrated into a resident’s ISP and periodically updated throughout the year to reflect changes in the goals and outcomes of nursing care for each resident. Not only are HCPs not properly integrated into the ISP process, many residents have no HCP at all. The lack of HCPs and HCP integration into the ISP process at Oakwood decreases continuity of care and results in inconsistencies of treatment that delay desired nursing outcomes. For the HCPs that do exist, the nursing goals and outcomes are updated only once per year. Of the 21 HCPs we reviewed, only three were reviewed or updated prior to the annual evaluation. Active treatment is an ongoing process and such infrequent evaluation of the nursing needs of the residents fails to properly reflect a resident’s progress toward identified nursing goals and outcomes.
In addition, participation by the nurses in the interdisciplinary team (“IDT”) meetings that give rise to the ISP is inadequate and their role is not clearly defined. The nurse, therefore, does not play an integral role in the overall care and desired treatment outcomes of the resident. Nurses are not proactive and do not advocate to benefit the resident at the team meetings. The nurse rarely provides information obtained from nursing assessments and does not share nursing diagnoses that the IDT needs to address and possibly incorporate into the ISP. Finally, the nurse does not participate in the IDT group discussions for ideas to solve residents’ problems.
Inadequate documentation by Oakwood nurses also prevents timely and appropriate medical and nursing care. Flowsheets and logs are undated and show gaps in documentation. Nurses are inconsistent in their use of the DAP format (i.e., Diagnosis, Analysis and Plan) in noting resident conditions. Even where notes are placed in the DAP format, they are incomplete, fail to describe the health event, and prevent appropriate, adequate followup on identified problems. The seizure record in use at Oakwood is vague and requires too much subjective judgment. For example, the nurse is to indicate “light” or “heavy” seizure on the form, but there is no criteria on the form or in the nursing seizure protocol to define such terms. Nursing progress notes are disconnected and do not flow from shift to shift resulting in

- 16 
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failure to followup on identified problems. A nursing progress note should fully describe the problem, and each subsequent note should address the problem until resolution. Reviewed Oakwood charts fell below such standard of care. The inadequate nursing documentation is a function of the poor quality of the Oakwood medical charts in general. The entire chart is confusing, hard to follow, and in no logical order. Such poor medical records fail to promote prioritizing problems and developing appropriate treatment strategies to maximize desired outcomes.
B. Medication Administration
The nursing staff at Oakwood does not follow established standards and protocols regarding medication administration resulting in an unacceptably high number of medication errors and consequent harm to residents. We reviewed numerous incident reports that demonstrated that nurses often administer medication to the wrong resident. The number of pills found lying on the floors of the living units also indicates that the nurses are failing to ensure that residents are actually taking the medications. In a survey completed on October 12, 2001, CMS also noted these problems regarding medication errors. None of the nurses we interviewed were either aware of the CMS survey conclusions or of the problem of unidentified medications found on the living unit floors; the nurses stated that medication errors were rare at Oakwood. We observed nurses administering medications and several took no steps to ensure that the medications were swallowed.
Several factors contribute to the unacceptably high rate of medication errors at Oakwood. First, nurses are routinely assigned multiple housing units and made responsible for a number of residents exceeding the number that may be safely managed. Second, due to high nursing turnover rates and frequent staffing shortages, new nurses or nursing staff reassigned from other cottages are unfamiliar with resident identities. Third, nurses are insufficiently trained on safe medication administration practices and their ability to properly administer medications are inadequately evaluated. For example, with regard to administering psychotropic medications, Oakwood has no competency based assessments to evaluate nurses on the proper use of new analytical tools to measure possible symptoms of tardive dyskinesia, a harmful side-effect of psychotropic drug usage. Oakwood’s use of videotapes to evaluate competency in medication administration does not effectively ensure that safe practice is occurring. Fourth, the medication error reporting system is ineffective and fails to promote safe nursing care. Oakwood has no formal system in place to track adequately medication error data and provide detailed analysis such as problem identification, plans for

- 17 
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improvements, implementing changes, and evaluating the effect of changes. Finally, poor communication at all levels of the nursing staff regarding medication error data and the serious problem of underreporting of medication errors at Oakwood further exacerbates the lack of an effective system to evaluate medication error data. There are no regular forums at Oakwood in which aggregate data on medication errors from within or across communities is shared with nursing staff. Such poor communication and underreporting of medication error data is a function of a reporting system that focuses on blaming and punishing nursing staff for medication errors while ignoring the deeper systemic nature of the problems surrounding medication administration.
C. Medical Emergencies
The medical emergency response system at Oakwood falls below accepted standards of care and places the health and well being of residents at risk of injury and death. The current protocol at Oakwood is overly broad and vague, and does not provide clear expectations for staff during a medical emergency. Staff responding to an emergency have no idea as to the severity and immediacy of the emergency or the type of medical emergency equipment that may be needed. For example, the protocol does not define a medical emergency (a Code 300), does not list any examples of emergencies, and does not indicate when staff should call a medical emergency. The protocol fails to identify which staff should respond to a Code 300, and does not specify the role staff should play. Although not directed by the protocol, in practice, Code 300's are called whenever a nurse is needed (whether for treatment of a laceration, a long seizure, or cardiac arrest). When a Code 300 is called, all nurses from all four communities must respond. The result is that nursing staff must abandon medical duties to respond to numerous non-emergent situations. Such use of nursing staff is inefficient and places other residents of the facility at risk as their medical staff leaves to respond to an open call for medical help that often is not an emergency requiring all staff.
Furthermore, information concerning medical emergencies is documented inadequately on a regular incident report form. Oakwood needs to establish a separate code for life threatening emergencies, clearly define the response team members and their respective duties, and designate a nurse to record and document accurately the event.

- 18 
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Finally, nurse training with regard to medical emergencies is inadequate. For example, protocol directs that a nurse may administer I.V. medications, but nurses are given no formal training on I.V. medication administration. If a physician is not present at the emergency (which occurs especially on evening and night shifts), an unskilled nurse may have to delay providing emergency medication until an Emergency Medical Technician or physician arrives. This delay of potentially critical treatment places residents at risk of severe injury or even death.
D. Infection Control
Oakwood staff engage in infection control practices that are outdated, unsafe, and ineffective for preventing the spread of infectious and contagious diseases, placing themselves and Oakwood residents at risk of harm. The Oakwood Infection Control Manual is at least three years old and fails to reflect the most recent accepted professional standards of care, especially in the critical areas regarding current guidelines for Bloodborne Pathogens and Tuberculosis. Throughout our visit, we witnessed instances of unsafe and unacceptable infection control practices, particularly with regard to staff failing to wash hands or change gloves before touching or assisting multiple residents during eating, toileting, and dressing. Finally, Oakwood lacks a full time person to direct the infection control process. Accountability for developing and overseeing infection control practices is distributed among other professional staff rendering the system fragmented and inefficient. Such a fragmented system fails to collect, organize and report sufficient data to assess trends and/or performance improvement opportunities within or across the Oakwood living units.
E. Training
Oakwood’s nursing and direct care staff training programs are insufficient to protect its residents from harm and is a major contributing factor to the inadequate nursing care provided at Oakwood. In addition to a lack of an adequate nursing training program, the training provided is not competency based. Nurses are not evaluated on whether they are capable of actually performing the skills presented in training. Oakwood merely has employees and supervisors sign a checklist acknowledging attendance and that the employee understands the skills presented. Nurses must be evaluated on their competency to perform critical nursing tasks (especially with regard to high risk nursing skills such as inserting and maintaining I.V.’s and suctioning). A mere checklist is inadequate. Furthermore, Oakwood does not provide sufficient, ongoing, competency based training that should be conducted at regularly established intervals throughout the year.

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F. Staffing Systems
Oakwood’s system for staffing nurses and direct care staff is inadequate and jeopardizes resident safety and quality of care. Oakwood lacks a computerized information system, and at the time of our tour, was unable to present to us complete data as to staffing minimums, ratios of nursing and direct care staff to residents, and actual staff in attendance (as opposed to scheduled). Such a disorganized staffing system creates a high risk for inaccuracy and miscalculations, and makes it impossible to generate meaningful, essential reports that are necessary for appropriate staffing analyses of trends, gaps, and/or imbalances in staffing, and to ensure minimal staffing requirements are being met throughout Oakwood.
Compounding the inability to access critical staffing information is the lack of any centralized organization of staffing. Staffing organization is fragmented and logged manually within the separate communities even though nursing staff may be shared across communities if needed. Each community director is responsible for all staffing needs (nursing and direct care staff) of the community. However, the director of nursing for each community still determines the nursing schedules and there is little coordination between the director of nursing and the community director.
Furthermore, Oakwood’s attempt to allocate nursing staff across the communities fails to take into account the particular needs of the residents within the different communities. For example, Willow Run has the most fragile residents but has the least number of nurses resulting in the unacceptable situation that the community with the greatest need has the worst staff to resident ratio. As a result of the lack of staffing organization, incomplete staffing data, and fragmentation of staffing analysis, Oakwood is unable to determine any staffing minimums for its communities for nursing across shifts and days of the week. Indeed, the deficiencies left us unable to determine whether Oakwood has sufficient numbers of nurses or direct care staff to safely conduct its operations. However, we do find that current nursing and direct care staff, even if sufficient in raw numbers, is inadequately deployed to give appropriate care and protect Oakwood residents from harm.
VI. NUTRITIONAL MANAGEMENT
Residents are not adequately managed during mealtimes. Many residents do not have an adequate individual meal management plan (“MMP”). We observed several residents without MMPs, with problems swallowing and coughing, with foods and liquids coming

- 20 
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out of their mouths due to poor head positioning, and drinking and eating too fast, with no staff monitoring them. Furthermore, residents with MMPs are not being adequately managed. We observed several instances of staff not following the MMPs and placing residents at significant risk of choking, and/or aspiration. A major concern across the MMPs was residents eating too fast. We observed several residents with identified choking risks and specific instructions to eat slowly, eating much too quickly with staff failing to intervene or even acknowledge the problem. One of the residents, after finishing eating, proceeded to cough for over thirty minutes. The other resident guzzled liquid so fast that it was pouring out of his mouth. The direct care staff had no response and, in fact, was not even observing the resident. In a third example, a resident with a strong history of aspiration pneumonia had instructions to be fed slowly, one bite/sip at a time. We observed the direct care staff feeding him one bite after the other without waiting for the resident to swallow each bite. Such manner of feeding is a major health risk for this individual.
Compounding the problem is the lack of adequate staffing and the unpleasant eating environment. With food being served at different times during the meal due to lack of staff, many residents wait 20 minutes or more to receive cold food and begin yelling, talking loudly, and banging on tables.
Finally, often nutritional management issues are related to a resident’s behavioral problems, but Oakwood has no interdisciplinary management committee that meets at regular intervals to discuss the nutrition management needs of the residents, the current meal plan, or changes needed to the meal plan. We observed several residents whose behavioral problems impacted their nutritional management program. In one example, a direct care staff was having difficulty feeding a resident because of his self-injurious behavior of banging his head to the point that his forehead was red, bruised and knotted. The staff member, however, did not acknowledge the self-injurious behavior, or provide any intervention or prompts to cease such behavior, but merely kept trying to feed the resident.
VII. PHYSICAL THERAPY
Oakwood does not provide sufficient physical therapy services to residents in need of such services. Physical therapy is critical to the residents of Oakwood in order to maintain gross motor skills, joint range of motion, gait training, and posture. Oakwood does not, for example, have a positioning program which is critical for proper swallowing, adequate digestion, and otherwise proper nutritional management. The lack of a positioning program

- 21 
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contributes to the inadequate nutritional management discussed above.
Many of the residents at Oakwood remain in wheelchairs without a specific medical indication that such confinement is necessary. Confining clients unnecessarily to wheelchairs greatly increases their risk of osteoporosis, atrophy, scoliosis, skin breakdown, and muscle weakness over time. We observed that many of the residents confined to wheelchairs have the potential to walk but have not received adequate physical therapy services to enable them to do so. The physical therapy department recognizes the need to “get people out of wheelchairs,” but little appears to have been done to achieve this goal.
Furthermore, the direct care staff ultimately responsible for much of the physical therapy needs of the residents are inadequately trained. Oakwood provides new direct care staff with only two hours of training on transfers, positioning, and handling pressure ulcers and such training does not involve competencybased evaluations of the direct care staff. Due to their high case loads, the physical therapists also do not have sufficient time to conduct ongoing training of direct care staff necessary to ensure that physical therapy programs are being adequately implemented. The physical therapists concentrate mainly on the most egregious cases, leaving many residents with physical therapy needs untreated.
Finally, due to inadequate staffing of the physical therapy department, the physical therapists have only been able to attend a small minority of interdisciplinary team meetings and, consequently, have been unable to effectively present to other Oakwood professionals the physical therapy needs of the great majority of residents. In one team meeting we observed, the physical therapist in attendance stated that staff should work with the resident on ambulation skills; the Director of Nursing for that community questioned the need for such training and stated, “She gets along pretty fast by crawling.”
VIII. QUALITY IMPROVEMENT
Although Oakwood currently has a quality improvement (“QI”) program, it is inadequate to address the crisis of care found to exist within the clinical services provided at Oakwood. The current program is too limited to provide adequate monitoring and improvement of critical areas of care and treatment of Oakwood residents. Oakwood lacks a systematic approach to recognizing and resolving many of the problems outlined in this findings letter. In the critical area of protecting residents from harm and abuse, Oakwood does not have a risk management system that integrates

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risk investigations, outcomes, and remediation. There is no formal feedback system so that clinicians and administrative staff are informed of gaps in services with remedial actions taken. For example, in the critical area of pica behavior, we noted that one resident had a history of severe pica behavior having swallowed batteries, screws, razor blades, pennies, and nuts and bolts, among many other items. We reviewed this resident’s incident reports for the last week of August and the month of September, 2001, and found five separate incidents of harmful pica behavior. On August 23 he swallowed 6 “A” batteries; on August 26 he swallowed 4 “A” batteries; on August 28 he swallowed 2 metal matchbox cars; on September 1 he swallowed another battery; and on September 27 he swallowed a large toenail clipper. Ever since his admission on December 9, 1999, this resident has been engaging in harmful pica behavior and has had to be treated for chronic esophageal ulcers caused by chemical and mechanical irritation from pica items. Oakwood has failed to provide appropriate clinical interventions to prevent such instances of pica behavior from reoccurring. Aside from the obvious harm and neglect caused by the serious lack of clinical intervention for this resident, Oakwood’s quality improvement program has failed to monitor and prevent the above serious pattern of harmful pica instances. An effective risk management system would have prevented the recurrence of such incidents through a monitoring, feedback, training, treatment, and accountability system.
Oakwood’s QI system also fails to ensure that safe, appropriate nursing care is provided to residents. Although the nursing performance areas monitored under the current QI system are appropriate and important (i.e., documentation; gastrostomy tube/jejunoscopy tube use; medication errors; infection control and seizure management), the goals are not objective and measurable, thus precluding any reliable assessment of improvement in care at Oakwood. For example, simply providing training to nurses on the use of tube feeding does not indicate improvement. Root causes of problems need to be identified, evaluated and addressed directly. Nursing administrators need to actually obtain baseline data on problem areas such as aspiration, intolerance during feeding, and rates of infection at tube sites, and then review outcome data to identify whether improvement has actually occurred. As previously discussed, in the area of medication administration, there exists a similar failure to identify root causes of problems. Oakwood needs to collect and analyze baseline data regarding medication administration, analyze the current processes, recommend changes, and design a plan to monitor outcomes after changes are made.

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Finally, compounding the inadequate quality improvement program is Oakwood’s total lack of a management information system. Oakwood does not have an integrated, system-wide clinical database for all residents. An effective support and services system cannot be managed without a responsive and efficient management information system.
IX. SERVING INSTITUTIONALIZED PERSONS IN THE MOST INTEGRATED SETTING APPROPRIATE TO THEIR NEEDS
Individuals who desire to live in the community and who reasonably can be accommodated are denied an adequate opportunity to do so in violation of Kentucky’s obligations under Title II of the Americans with Disabilities Act, 42 U.S.C. § 12132 et seq., and the regulations promulgated thereunder, 28 C.F.R. § 35.130 (d). The Commonwealth of Kentucky is responsible for providing appropriate accommodations and services in the community for residents of Oakwood and should take active steps toward such goals.
The current administration of Oakwood informed us that Oakwood was originally designed to serve people for a maximum of three years, but residents’ stays have been continuously extended. Many residents, however, are able and desire to move into the community. Individuals at Oakwood with whom we spoke, from direct care staff to professional staff, including the new director of the facility, stated that with appropriate supports and services the great majority of individuals at Oakwood can and should be served in the community. It is clear from interviews with staff and reviews of resident records, however, that Oakwood is being operated as a long-term residence. Admissions to Oakwood are frozen and the yearly census is relatively unchanged signifying that very few residents of Oakwood are being discharged into less restrictive settings. Treatment teams function to make individuals fit the long term institutional culture rather than prepare them for community living. At the time of our tour, discharge or transition planning was inadequate. The limited number of plans in place did not specify critical information such as time lines, transition activities, and monitoring requirements prior to and after discharge.
During our investigation, we noted that the ISPs of several residents stated a preference to live in the community. While onsite, a number of residents approached us and stated their desire to live outside the facility. For example, one resident told us of her strong desire to live in a group home near her mother in another city in northern Kentucky. This resident came to Oakwood when she was nine years old and remains at the age of 44. Her goal is to live in the community in a group home. Her physician

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noted that she has good communication skills and can live in the community with minimal supports; she works on a regular basis. Oakwood explained that her father opposes any community placement. Oakwood, however, has provided her father with no choice counseling or explored other options to fulfill her express wish to live outside of Oakwood. The above resident’s situation is not uncommon.

X. MINIMUM REMEDIAL MEASURES

To remedy the deficiencies discussed above and to protect the constitutional and federal statutory rights of Oakwood residents, the Commonwealth of Kentucky should implement the minimum remedial measures set forth below.

A. Protection From Harm

Oakwood residents should be adequately protected from harm due to abuse and/or neglect and provided a safe and secure living environment. Specifically, Oakwood should:

1.

Develop and implement an adequate risk management

system, including an adequate management

information system, to identify, track, monitor,

and substantially reduce the incidents of harm due

to abuse and neglect.

2.

As part of the risk management system, develop and

implement an adequate incident management plan to

substantially reduce the number of overall

incidents occurring at Oakwood, particularly the

number of incidents due to resident aggression,

self-harm, and unknown causes

3.

Develop and implement policies and procedures that

clearly define and detail the consequences of

abuse, neglect, and nonreporting incidents of harm

at Oakwood.

4.

Develop and implement a plan to provide Oakwood

residents and staff with a safe and secure living

and working environment.

5.

Adequately train all staff on identifying,

reporting, and managing incidents of harm, abuse,

and/or neglect, including training on client rights

and consequences of violating client rights.

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-

B. Behavioral Services

An adequate array of comprehensive individualized behavior programs and services should be provided to Oakwood residents. Such behavior programs and services should be developed by qualified professionals consistent with accepted professional standards and provide a safe, functional and stable living environment, prevent regression, and facilitate the growth, development, and independence of every Oakwood resident. To this end, Oakwood should:

1.

Identify and plan for the training needs of Oakwood

residents by conducting a comprehensive and timely

interdisciplinary functional assessment for each

Oakwood resident that uses a systematic and

reliable method for assessing the impact of the

physical environment on the resident.

2.

Based upon adequate assessments, develop and

implement individualized behavior programs to

reduce or eliminate harmful behaviors by replacing

them with more appropriate functional behaviors and

useful skills.

3.

Have a qualified professional timely develop,

implement and monitor a professionally based,

individualized skills training program for each

resident containing appropriate skills development

designed to enable each resident to grow and

develop and learn useful adaptive skills.

4.

Develop and implement adequate active treatment

programs for all residents engaging in pica

behavior.

5.

Develop and implement a policy on use of restraints

(physical, mechanical, and chemical) that is

consistent with accepted professional standards of

care.

6.

Develop and implement a professionally based,

individually appropriate data collection system to

measure and review relevant information about

maladaptive behaviors and the conditions under

which they occur, including, where appropriate, the

frequency, intensity, and duration of the

behaviors.

7.

Develop and implement meaningful day programs for

all Oakwood residents based upon their assessed

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needs and designed to pre-empt maladaptive behaviors.

8.

Treatment team meetings should focus on writing

treatment plans that actively develop skills needed

in the community, that serve to enhance the quality

of the resident’s life, that accurately reflect who

is making decisions, and that provide

justifications for recommendations.

9.

Write Individual Support Plans in terms of

measurable outcomes where goals and objectives are

to be achieved in a reasonable amount of time and

be community focused. Treatment teams should be

held accountable for monthly progress on each

objective for resident’s under their care and

supervision.

10.

Provide sufficient staffing, particularly direct

care staff, to develop and implement all Individual

and Behavior Support plans and services in an

adequate manner.

11.

Provide counseling to an individual and his/her

parent or guardian on available community living

options to assist them in making choices regarding

living preferences.

12.

Develop and implement a training program to improve

and expand the skills of all psychology staff in

behavioral management.

13.

Provide adequate psychology staffing and services.

14.

Develop and implement a plan to require

psychologists and psychiatrists to integrate

treatments.

15.

Develop and implement guidelines for clinical

services that are focused on the specific needs of

persons with developmental disabilities and on

measurable outcomes.

16.

Develop and implement a staff development program

to train staff in the appropriate care and

treatment of residents at Oakwood, including but

not limited to, implementing behavioral and active

treatment programs (all staff should know and be

able to implement a behavior support plan for

residents under his or her care and/or

- 27 -

supervision), the proper functioning of the interdisciplinary treatment team process, the effects and side-effects of medications, life safety issues, recognizing seizures, environmental safety, and data collection.

C. Psychiatric Services

Residents should be provided adequate and appropriate psychiatric and mental health services in accordance with accepted professional standards, when needed. To this end, Oakwood should:

1.

Retain adequate psychiatry consultation hours to

meet the needs of its residents.

2.

Develop and implement standard psychological and

psychiatric assessment and interview protocols for

reliably reaching a psychiatric diagnosis for

individuals with mild and moderate mental

retardation and standard protocols for individuals

with severe and profound mental retardation.

3.

Undertake a thorough psychiatric evaluation/workup

of all individuals currently residing at Oakwood,

provide a current, clinically justifiable diagnosis

for each individual, and remove all diagnoses that

are not clinically justified.

4.

Ensure that psychotropic medications are only used

in accordance with accepted professional standards

and not used for behavior control in place of a

training program or for the convenience of staff.

5.

Provide a particularized justification for

polypharmacy if more than one drug is prescribed

for the same indication.

6.

Monitor the use of each psychotropic medication

against identified markers or target variables and

evaluate its effect and reassess diagnoses and

treatments as appropriate.

7.

Develop and implement a plan to assess, treat, and

monitor Tardive Dyskinesia (TD) and other movement

disorders on a regular basis and adequately train

medical and nursing staff to reliably assess TD and

other movement disorders.

- 28 -

8.

Develop and implement an adequate Pharmacy and

Therapeutics Committee with, at a minimum, the

following responsibilities

a. Develop and implement policies and practice guidelines for the use of psychotropic medications for psychiatric disorders in the residents at Oakwood;

b. Monitor prevalence and patterns of psychotropic drug prescriptions at Oakwood;

c. Provide peer-review and guidance for prescribing medications; and

d. In concert with the psychology staff, develop and implement a plan to teach psychiatrists and behavior analysts to integrate their treatments.

D. General Medical Care

Individuals with health problems should be promptly identified, assessed, diagnosed, treated, monitored and, as monitoring indicates, reassessed, diagnosed and treated, consistent with current professional standards of care, including with documentation adequate to withstand clinical scrutiny. To this end Oakwood should:

1.

Establish a formal medical peer-review system.

2.

Establish an adequate mortality review process that

identifies and implements any possible improvements

in the care of the clients and recommendations for

change.

3.

Adequately document all medical services, including

identifying the name of the patient’s primary care

physician, recording the results of diagnostic

evaluations at the time they are reviewed, and

developing a current and chronic problem list.

4.

Have medical staff receive, at least annually,

adequate education and training regarding the

special needs of patients with developmental

disabilities.

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-

5.

Establish a medical quality assurance program that

collects data relating to the quality of medical

services, assesses such data for trends, identifies

corrective action; and monitors to ensure that

appropriate remedies are achieved.

6.

Establish uniform medical care policies and

protocols to ensure the consistent provision of

medical care. Such policies and protocols should

include protocols for the treatment of common

medical problems, such as severe

constipation/obstipation, bowel obstruction, and/or

urinary tract infection, and preventive care

protocols that require adequate screening and

periodic checkups for general medical conditions

and conditions specific to persons with

developmental disabilities.

E. Neurologic Care

Individuals with a neurologic disorder diagnosis should be treated and regularly monitored by a neurologist, according to current professional standards of care, including with documentation adequate to withstand clinical scrutiny, to ensure that treatment and medication are appropriate. To this end, Oakwood should:

1.

Provide sufficient neurological care to meet the

identified neurological needs of Oakwood residents

and retain a sufficient number of qualified

neurologists to deliver adequate neurological

services.

2.

Ensure adequate communication between the

neurologist and the primary care physician and

other involved staff members.

3.

Evaluate promptly each Oakwood resident with a

diagnosis of seizure disorder to determine if they

have been properly diagnosed and, where necessary,

provide appropriate, effective treatment of all

such disorders.

4.

Reassess the need for antiseizure medication for

those who have not had a seizure for two or more

years.

5.

Require that a neurologist evaluate every patient

with a seizure disorder at least annually.

- 30 -

6.

Develop and implement standard seizure treatment

objectives and rationalize anticonvulsant

medication prescription practices.

7.

Implement a facility-wide, monthly side-effects

monitoring system specifically for anticonvulsant

medications.

F. Nursing Care

Residents should receive adequate nursing care. Nurses should perform their responsibilities in keeping with accepted professional standards of care by adequately identifying health care problems, notifying physicians of health care problems, and monitoring and intervening to prevent and reduce health care problems. To this end, Oakwood should:

1.

Conduct annually an adequate, comprehensive nursing

assessment based upon an appropriate diagnosis for

Oakwood residents and document such comprehensive

assessment in a resident’s chart.

2.

Conduct follow-up nursing assessments as needed

and/or as identified in the comprehensive

assessment to appropriately treat Oakwood

residents.

3.

Develop and implement adequate and appropriate

comprehensive nursing care plans based upon

accepted standards of care for nursing process.

Such comprehensive nursing care plans should be

integrated with the Individual Support Plan and

reviewed and updated monthly.

4.

Develop and implement an adequate chart and

documentation system that includes an adequate

seizure management record with objective and

defined criteria that appropriately describe the

nature of the seizure, and adequate progress notes

that record information chronologically from shift

to shift and by issue from beginning to resolution.

5.

Develop and implement a competency-based training

program to train Oakwood nurses in implementing and

documenting the nursing care process (including

adequate diagnosis, comprehensive

assessment/analysis, plan development, and

integration into Individual Support Plans), and in

adequate medication administration practices.

- 31 -

6.

Clearly define the role and expectations of nurses

as members of the Interdisciplinary Team and during

Individual Support Plan meetings.

7.

Develop and implement an adequate system of

medication administration that accords with

professional standards of care and includes, at a

minimum, the following:

a. Administering the correct medications to the patient properly identified to receive such medications;

b. Ensuring that residents are actually taking their medications;

c. Adequately recording, monitoring and tracking medication error data, including aggregating data across all living units and levels of nursing staff; and

d. Identifying specific problems with medication administration from the medication error data and implementing corrective measures.

8.

Develop and implement an adequate emergency

response system that contains the following:

a. Detailed definitions of medical emergencies that clearly differentiate between life threatening and non-life threatening emergencies;

b. An outline of the responsibilities of all emergency response personnel;

c. Nursing procedures for using emergency equipment and medications; and

d. Competency based training for all staff involved in medical emergencies with periodic practice drills.

9.

Develop and implement an adequate infection control

system, including an infection control manual,

based upon professionally accepted standards of

infection control practices, particularly during

mealtimes; and train all staff on such infection

control practices.

- 32 
-

10.

Develop and implement an adequate uniform staffing

system to ensure adequate numbers of nursing and

direct care staff on the living units. Such

staffing system should:

a. Adequately assess the individual staffing needs of all Oakwood communities based upon variables other than mere census, such as acuity of residents living in a particular facility;

b. Ensure that nursing and direct care staff are adequately allocated and deployed across all shifts and communities 24 hours per day, seven days per week, particularly third shift nurses for all communities; and

c. Generate reports that present a complete facility wide staffing analysis on a daily basis as well as designated periodic intervals for the purpose of trend analysis.

G. Nutritional Management

Residents should be provided adequate and appropriate nutritional management, particularly for those individuals with feeding and swallowing problems. To this end, Oakwood should:

1.

Have an interdisciplinary team of oral motor

specialists comprehensively assess each individual

who has a nutritional management problem and/or is

at risk of aspiration to identify the causes for

the nutritional management problem, and take all

appropriate steps to ameliorate the individual's

feeding and swallowing problems, including

developing and implementing an individualized

feeding and positioning plan, and train staff in

how to implement the plans.

2.

Develop and implement a system to monitor the

progress of the Oakwood residents who have feeding

and swallowing problems.

3.

Ensure sufficient staffing to adequately develop

and implement nutritional management, feeding and

positioning plans for Oakwood residents.

- 33 
-

H. Physical Therapy

Individuals having physical disabilities, including, but not limited to, those in wheelchairs or experiencing walking difficulties, should be assessed regularly for their physical therapy needs and adequacy of their supports, particularly after a significant change in their physical status. All residents with identified physical therapy needs should be treated according to accepted professional standards of care. Such physical therapy assessments and treatment should be documented in resident charts. To this end, Oakwood should:

1.

Provide physical therapy and physical therapy

planning for each resident in need of physical

therapy interventions.

2.

Ensure that therapeutic positioning is adequate to

support physical needs and is reviewed regularly to

ensure proper implementation.

3.

Ensure that staff involved in therapeutic

positioning receive sufficient competency-based

training on therapeutic positioning, particularly

in addressing scoliosis, mealtime needs, and

functional seating.

4.

Integrate physical therapy into the

interdisciplinary team process, especially with

regard to the nutritional management team.

I. Quality Improvement

Oakwood should develop and implement a Quality Improvement Plan that includes collecting data on staff performance in critical areas of resident care and treatment on a quarterly basis to provide for effective trend analysis and remediation.

J.

Serving Institutional Persons in the Most

Integrated Settings Appropriate to Their Needs

Individuals with developmental disabilities should be provided services in the most integrated setting appropriate to their needs. In particular, the Commonwealth should:

1.

Develop a more comprehensive plan for community-

based services for those individuals whom

professionals have determined could be served in

the community.

- 34 
-

2.

Develop and implement an adequate system to monitor

community-based programs to ensure program adequacy

and the full implementation of each individual's

habilitation plan.

3.

Every facility resident should be professionally

assessed to determine whether continued placement

in the facility constitutes the most integrated

setting appropriate to meet the individual’s needs.

More particularly, Oakwood should:

a. Develop and implement comprehensive, formal guidelines, policies and procedures for transition planning;

b. Assess the most appropriate setting and support needs for each individual and periodically update the assessments for individuals who remain at the facility for extended periods of time; and

c. If it is determined that a more integrated setting would appropriately meet the individual's needs, promptly develop and implement, with appropriate consent, a transition plan that specifies actions necessary to ensure a safe, successful transition from the facility to a more integrated setting.
* * * * *

The cooperative approach taken by the officials of the Commonwealth of Kentucky and Oakwood has been both appreciated and productive. We understand that officials are aware of and acknowledge many of the problems discussed in this letter. We are encouraged to note that Oakwood, its staff, and State officials are committed to changing Oakwood and look forward to continue working cooperatively with Oakwood and Commonwealth officials in addressing the concerns outlined in this letter. To this end, we will forward our expert consultants' reports under separate cover. Although their reports are their work and do not necessarily represent the official conclusions of the Department of Justice, their observations, analyses and recommendations provide further elaboration of relevant concerns, and offer practical assistance in addressing them.

- 35 
-
In the unexpected event that the parties are unable to reach a resolution regarding our concerns, we are obligated to advise you that the Attorney General may initiate a lawsuit pursuant to CRIPA, to correct deficiencies or to otherwise protect the rights of Oakwood residents, 49 days after the receipt of this letter. 42 U.S.C. § 1997b (a)(1). Accordingly, we will soon contact Commonwealth officials to discuss in more detail the measures that the Commonwealth must take to address the deficiencies identified herein.
Sincerely,
/s/ Ralph F. Boyd
Ralph F. Boyd, Jr. Assistant Attorney General
cc: The Honorable Ben Chandler Attorney General Commonwealth of Kentucky
Michael Wright, Esq. Assistant Attorney General Health Care Fraud Unit Commonwealth of Kentucky
The Honorable Marcia R. Morgan Secretary of the Cabinet for Health Services Commonwealth of Kentucky
The Honorable John Walker
 General Counsel
 Cabinet for Health Services 
 Commonwealth of Kentucky

The Honorable Margaret Pennington Commissioner, Department of Mental Health and Mental
Retardation Services
Denise Micheletti
 Acting Facility Director
 Oakwood Communities

Gregory F. Van Tatenhove United States Attorney Eastern District of Kentucky

 
 Memorandum of Understanding

l. Preamble

Following a thorough investigation, on November 7, 2002, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, informed the Commonwealth of Kentucky that the Attorney General had reasonable cause to believe that persons residing in or confined to the Communities of Oakwood ("Oakwood"), were being subjected to conditions that deprived them of rights, privileges, and immunities secured by the Constitution or laws of the United States. The Commonwealth has voluntarily come forward with a Strategic Action Plan ("the SAP"), which details methods by which the Commonwealth will operate Oakwood and provide services to residents ofthe facility. The parties to this Memorandum of Understanding share a common interest in seeking to protect the rights of those citizens with mental retardation living at Oakwood. In furtherance of the mutual commitments toward this interest, the pa11ies have worked together to identify issues and provide solutions for ensuring that Kentucky's citizens with mental retardation living at Oakwood enjoy a safe and growth oriented environment. This Memorandum of Understanding sets forth an agreed upon manner for measuring and realizing these common interests.

JI. Scope

A.

Parties. This Memorandum of Understanding ("Memorandum") is by and between the

United States of America (''United States") and the Commonwealth of Kentucky

("Commonwealth"). For purposes ofthe Memorandum, Commonwealth includes those

government agencies, departments, entities and persons, in their individual and official

capacities, involved at all relevant times in the management, oversight and regulation of

the matters identified in Paragraph 8 of this Section "Subject Mauer".

B.

Subject Matter. This Memorandum arises from an investigation perfOrmed by the

United States Department ofJustice ("the DOJ"), concerning conditions ofconfinement

at Oakwood. The investigation was performed pursuant to the Civil Rights of

Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. The DOJ issued its findings

of fact on November 7, 2002.

i.

Oakwood. Oakwood is an intermediate care facility for persons with

mental retardation located in Somerset, Kentucky. At all times relevant herein,

Oakwood was and is a state-operated facility.

ii.

DOJ Investigation. The DOJ perfOrmed an initial on-site review of

the conditions at Oakwood on November 5-9, 2001, with attention to the care

and treatment of persons admitted to the facilities. The investigation included

reviews of facility records and interviews with administrators, statT and

residents.

111.

DOJ Findings. As a result of its investigation, the DOJ made

findings, including the following:

J. Protection from Harm.
a. The investigation found that Oakwood failed to protect its residents from harm due to abuse and mistreatment. b. The investigation found that Oakwood failed to protect its residents from harm due to neglect or failing to maintain a safe environment.
2. Behavioral Services.
a. The investigation found that persons with developmental disabilities receive inadequate care from Oakwood's treatment teams.
b. The investigation found that Oakwood prepares inadequate individual support plans (ISP) for its residents. c. The investigation found that Oakwood prepares inadequate behavioral support plans (BSP) for its residents. d. The investigation found that Oakwood's psychology staff failed to provide adequate behavior and psychology services to its residents.
3. Psychiatric Services. The investigation found that Oakwood's psychiatric services fell substantially below generally accepted professional standards of care.
4. General Medical Care.
a. The investigation found that Oakwood provided inadequate preventative medical care designed to keep serious medical problems and disease from developing.
b. The investigation found that Oakwood had inadequate and incomplete communication and documentation systems. c. The investigation found that Oakwood's physician staff lacked sufficient training in the field of developmental disabilities.
d. The investigation found that Oakwood fails to provide adequate evaluation, diagnosis and treatment for residents with seizure disorders.
5. Nursing Care.
a. The investigation found that Oakwood's nursing assessments and documentation, particularly those of acute illnesses and injuries, were incomplete, fragmented, inconsistent and simply repeat prior assessments.
b. The investigation found that Oakwood's nursing staffdid not follow established standards and protocols regarding medication administration resulting in an unacceptably high number of medication errors and consequent harm to residents.

2

c. The investigation found that the medical emergencyrcsponse system at Oakwood fell below generally accepted professional standards ofcare and places the health and well being ofresidents at risk of injury or death.
d. The investigation found that Oakwood staff engaged in infection control practices that were outdated, unsafe, and ineffective for preventing the spread of infectious and contagious diseases, placing themselves and Oakwood residents at risk of harm.
e. The investigation found that Oakwood's nursing and direct care staff training programs were insufficient to protect its residents from harm and was a major contributing factor to the inadequate nursing care provided at Oakwood.
f. The investigation found that Oakwood's system for staffing nurses and direct care staff was inadequate and jeopardized resident safety and quality of care.
6. Nutritional Management. The investigation found that Oakwood's residents were not adequately managed during mealtimes; that residents lacked adequate individual meal management plans; and that there was no interdisciplinary management connecting the resident's nutritional management issues with his/her behavioral problems.
7. Physical Therapy. The investigation found that Oakwood did not provide sufficient physical therapy services to residents in need of such servtces.
8. Quality Improvement. The investigation found that the quality improvement program in existence at the time of the investigation was inadequate to address the crisis of care found to exist within the clinical services provided at Oakwood.
9. Serving Institutionalized Persons In Ihe Most Integrated Setfing Appropriate To Their Needs. The investigation found that Oabvood fails to accommodate persons who desire to live in the community in violation ofCommonwealth's obligations under Title II of the Americans with Disabilities Act, 42 U.S.C. § 12132 et seq., and the regulations promulgated thereunder, 28 C.F.R. § 35.!30(d).

C.

Understandings of Positions.

1.

Commonwealth admits that, at the time of the DOJ investigation in

200 I, the conditions at Oakwood may have violated the constitutional and/or

statutory rights of its residents.

ii.

United States acknowledges Commonwealth's efforts and progress

in improving the quality of conditions and services at Oakwood since the

findings letter was issued.

3

111.

United States acknowledges that full implementation of the SAP will

meet the requirements of this MOU.

IV. Nothing in this Memorandum shall be construed as an acknowledgment or admission by United States that Commonwealth has acted, or continues to act, in full compliance with the United States Constitution or federal law.

v.

The provisions of this Memorandum are a lawful, fair, adequate and

reasonable resolution of this investigation.

vi.

United States and Commonwealth have engaged in good faith

negotiations to reach an understanding in this Memorandum. This

Memorandum memorializes Commonwealth's efforts to implement and

maintain necessary improvements at Oakwood and to avoid protracted,

contested litigation related to the DOJ investigation. The Memorandum of

Understanding and the SAP, which is fully incorporated by reference in this

Memorandum, are an integrated document and contain the entire agreement

between the parties.

VII.

This Memorandum is not intended to create any rights in any person

or entity not a party to it.

III.

Actions by the Parties

A.

Strategic Plan for Enhancing Service Delivery. Commonwealth has created and

agrees to implement and maintain its Strategic Action Plan for Oakwood. A copy ofsaid

SAP is attached hereto and incorporated herein by reference as Exhibit" A". The Parties

mutually agree that Commonwealth's SAP is a thorough and complete plan of response

to those findings identified by United States in Section II, Paragraph H., Part iii of this

Memorandum. The Commonwealth's obligations and a summary of the SAP follows:

1.

Support for a Treatment Planning Process.

1. Treatment Planning Commonwealth agrees to implement a treatment planning process that allows for effective interdisciplinary work and encourages active participation by the individual, as appropriate to his/her functional status, and chosen family and friends. As contained in the SAP, the treatment planning process shall consist of an integrated treatment plan that integrates all assessments, develops supports and services based upon assessed needs, monitors systems for providing services and supports, and formulates evidence-based, empiricallyvalidated treatment and training methods that comport with generally accepted professional standards. Emphasis shall be placed upon the creation of a treatment team assigned to each individual responsible for creating, implementing, monitoring and updating an integrated treatment

4

plan for each individual, including integrating all assessments, services, treatments and supports. The treatment team membership shall include a treatment team leader responsible for the adequate functioning of each treatment team and implementation of the integrated treatment plan and shall reflect a consistent and enduring team of interdisciplinary caregivers as appropriate to the individual's needs.
2. Holistic Assessment. Commonwealth agrees to ensure that individuals are provided a holistic assessment of the individual's needs and preferences, including an assessment of the individual's psychosocial, behavioral, medical and habilitation needs. Such assessments shall be revisited regularly and revised as needed given the individual's circumstances.
3. Comprehensive Case Formulation. Commonwealth agrees to develop and maintain comprehensive case formulations for each individual for the purpose of generating targeted and complete hypotheses about each individual's status, course, treatment and habilitation needs. 4. Need-Driven Planning. Commonwealth agrees to focus treatment planning fOr each individual based upon the comprehensive assessment of the individual's particular needs in all life areas (e.g., home living, community life, social life, health, wellness, work/education, and behavioral/psychiatric factors). The individual's needs shall be updated in writing as warranted so that the individual's objectives are identified in a manner that is realistic and attainable.
5. Monitoring ofPlans. Commonwealth agrees that the treatment plans for individuals shall be routinely and systematically monitored for implementation and effectiveness.
6. Transition Support. Commonwealth agrees to develop and maintain a community transition plan as part ofeach resident's individual treatment plan.

11.

Integrate Discipline Specific Services.

Each of the professional disciplines listed below shall provide adequate assessments and services necessary to support an individualized interdisciplinary treatment planning process consistent with generally accepted professional standards.

1. Psychiatric Services. Commonwealth shall provide adequate and
appropriate routine and emergency psychiatric and mental health services for the purpose of meeting the individualized needs of each resident,
consistent with generally accepted professional standards. To this end, Commonwealth agrees to ensure that psychiatric services arc sufficient
to meet the needs of each individual receiving psychotropic medications
as well as those individuals \vho have or may have mental illness and for w·hich medication is indicated. Such services shall include the following:

5

a. Psychiatric Assessment. Commonwealth agrees to perform a comprehensive psychiatric assessment for each individual \Vith a mental health problem. b. Psychotropic Medication Assessment. Commonwealth agrees to make ongoing, timely and documented psychiatric assessments of each individual receiving psychotropic medications. c. Integrated To Plan. Commonwealth agrees to ensure that interdisciplinary treatment team functions are integrated into the individual's treatment plan. d. Integration Among Services. Commonwealth agrees to ensure that psychiatric assessments are integrated with behavioral, neurological and medical services for targeted treatment. e. Psychiatric Staff Commonwealth agrees to provide an orientation and competency plan that promotes a system of adherence to standards of care on an ongoing basis. f. Medication Management. Commonwealth agrees to create and maintain an appropriate, safe and effective medication management system. 2. Neurological Services. Commonwealth agrees to ensure that individuals with seizure disorders are properly diagnosed, treated and regularly monitored. 3. General Medical Care. Commonwealth shall provide residents with adequate and appropriate preventive, routine, acute, and emergency health care, including neurological care, and dental care to meet the individualized needs of the residents, consistent with generally accepted professional standards. To this end, Commonwealth agrees to the following: a. Preventative Health Care. Commonwealth agrees to provide residents with appropriate and timely preventative health care. b. Routine and Emergency Health Care. Commonwealth agrees to provide residents with appropriate and timely routine, emergency and specialized health care. c. Medication Use. Commonwealth agrees to monitor medication use to ensure appropriateness, safety and efficacy. d. Physician Monitoring. Commonwealth agrees to include physicians in the processes of monitoring medication use. e. Mortality Revie\V. Commonwealth agrees to implement a formal mortality rev1cw process to provide specific recommendations to improve quality of care. f. Dental Care. Commonwealth agrees to provide timely and appropriate dental care. g. Quality Management. Commonwealth agrees to develop and maintain a medical quality management system. 4. Psychological and Behavioral Services. Commonwealth shall provide adequate and appropriate psychological and bchaYioral
6

services to meet the individualized needs ofeach resident, especially those with challenging behaviors, consistent with generally accepted professional standards. To this end, Commonwealth agrees to the following:
a. Sufficiency. Commonwealth agrees to implement psychological and behavioral services that are sufficient to meet the needs of each individual in terms of general clinical/mental health, functional status, skills and supports needed to exercise optimal autonomy or independence.
b. Positive Behavior Support. Commonwealth agrees to develop and implement Positive Behavior Support ("PBS") programs. c. System Monitoring. Commonwealth agrees to regularly monitor each individual's skills training plan, supports provision, and PBS plan.
d. Regression Prevention. Commonwealth agrees to ensure that psychological services are sufficient to prevent or decelerate physical, functional and psychological regression, and to ensure an individual's reasonable safety, security and freedom from receiving restrictive procedures and undue bodily restraint. c. Behavior Intervention Committee. Commonwealth agrees to create and implement a Behavior Intervention Committee ("BIC") to review and approve any restrictive interventions for individuals.
5. Nursing Services. Commonwealth shall ensure that Oakwood residents receive adequate and appropriate nursing care, including adequate and appropriate practices governing medication administration, emergency response, and infection control to meet the individualized needs of each resident, consistent with generally accepted professional standards. To this end, Commonwealth agrees to the following:
a. Sufficiency. Commonwealth agrees to ensure that the nursing services are sufficient to meet the need of its residents. b. Performance Improvement. Commonwealth agrees to implement and maintain a nursing perfOrmance improvement process.
6. Nutritional, Speech, Occupational and Physical Therapy. Commonwealth shall provide each resident with adequate and appropriate physical and nutritional management to meet the individualized needs of each resident, consistent with generally accepted professional standards. furthermore, Commonwealth shall provide each resident with adequate and appropriate occupational therapy, physical therapy, and speech therapy to meet the individualized needs ofeach resident, consistent with generally accepted professional standards. To this end, Commonwealth agrees to the following:
a. Sufficiency. Commonwealth agrees to ensure that all individuals receive sufficient nutritional, speech, occupational
7

and physical thcmpy, as needed.
b. Performance Improvement. Commonwealth agrees to implement and maintain a performance improvement plan to outline and measure goals for the delivery of nutritional, speech, occupational and physical therapy services.

111.

Risk Management.

I. Safe and Secure Environment. Commonwealth agrees to provide a safe and secure environment to all individuals at Oakwood by protecting them from abuse, neglect and other high-risk behaviors. 2. High-Risk Behavior. Commonwealth agrees to identify thresholds for high-risk behavior and to ensure timely interventions to reduce on-going risk.
3. Restraints. Commonwealth agrees to promote a restraint-free environment by not using restraints as punishment or as part of a PBS plan, but allowing for the use of restraints only for medical emergencies or when there is immediate risk of harm to the individual or to others. 4. Criteria for Using Restraints. Commonwealth agrees to promulgate and follow established criteria consistent with generally accepted professional standards for the use of restraints. 5. Restraint Procedures. Commonwealth agrees to ensure that all staff members are competent in implementing restraint procedures. 6. Quality Management. Commonwealth agrees to institute a quality management program on the use of restraints. 7. Risk A1anagement System. Commonwealth shall develop and implement an adequate risk management system, including an adequate management information system, to identif)', track, monitor, and substantially reduce the incidents of harm due to abuse, neglect, and/or mistreatment, consistent with generally accepted professional standards.

IV.

Quality Assurance.

1. Quality Assurance Program. Commonwealth shall develop and implement quality assurance mechanisms consistent with generally accepted professional standards that enable Oakwood to comply fully with this Memorandum and SAP, that timely and adequately detect problems with the provision of services and supports required under this Memorandum and SAP, and that ensure appropriate corrective responses are implemented.

v.

Community Transition.

In accordance with Title II of the Americans with Disabilities Act, 42 U.S.C. § 12132, and implementing regulation 28 C.F.R. § 35.130(d), Commonwealth

8

shall ensure that each Oakwood resident is served in the most integrated setting appropriate to meet their needs. To this end, Commonwealth agrees to the following:
1. Evaluation. Commonwealth agrees to review and revise, as needed, its procedures, role and function of Oakwood in serving its residents' mental retardation needs.
2. Transition Process. Commonwealth agrees to implement and maintain a transition process that begins at admission and is an integral part of each individual's treatment plan.
3. Community Providers. Commonwealth agrees to foster collaborative relationships with community providers, and address the need for additional community placements. 4. Available 5iervices. Commonwealth agrees to educate its residents, their families and guardians regarding available community-based services.

B.

Representations of Implementation.

1.

Commonwealth represents that it has implemented, or will implement,

the policies and procedures summarized in Section Ill, Paragraph A of this

Memorandum and more fully set out in Exhibit ''A."

u.

Commonwealth represents that it has provided to the DOJ copies of

Exhibit "A."

Ill.

United States represents that it has reviewed Exhibit ''A" and believes

that its implementation will substantially and adequately address the issues

raised by the DOJ investigation.

iv.

Commonwealth represents that it \Viii continually and periodically

refine and revise the policies and procedures outlined in Exhibit "A" to assure

compliance with the letter and spirit of this Memorandum and its attachments.

Upon request, United States shall be provided with copies and an opportunity

to provide substantive comment upon any policies and procedures revised

pursuant to the SAP.

v.

Commonwealth represents that it has educated, or will educate, all

employees at Oakwood with respect to the policies and procedures outlined in

Exhibit "A."

VI.

Commonwealth shall maintain sufficient records to document their

compliance with all terms of this Memorandum and SAP. Commonwealth

shall also maintain any and all records required by or developed under this

Memorandum and SAP. The United States shall have unrestricted access to

and, shall, upon request, receive copies of any document and/or any databases

9

relating to the implementation of this Memorandum and SAP. The United States shall have unrestricted access to all staff and facilities, including private interviews with residents and staff~ as necessary to assess compliance with this Memorandum and SAP.

v11.

Commonwealth agrees to provide the DOJ, its stan: consultants and

agents, with reasonable access to:

I. All buildings and facilities at Oakwood; 2. All staff having duties relating to Oakwood; 3. All residents living at Oakwood, outside the presence of staff (unless
the resident requests otherwise) consistent with this Memorandum and SAP; and
4. Any records regarding Oakwood, its staff or residents.

viii. Commonwealth designates Rebecca Cecil as its contact agent for ensuring that the Commonwealth adheres to the terms and conditions of this Memorandum and SAP.

JX.

If Commonwealth further subdivides Oakwood into smaller facilities

and/or out sources any of the services covered under this Memorandum and

SAP, this Memorandum and SAP shall be fully applicable to and binding upon

those subdivided facilities and/or outsourced services.

x.

The parties agree to the appointment of Dr. Nirbhay N. Singh, Ph.D.,

as the jointly-selected expert to monitor the Commonwealth's implementation

of this Memorandum and SAP (the "Monitor"). The Monitor shall have full

authority to independently assess, review, and report semi-annually on the

Commonwealth's implementation of and compliance with the provisions of

this Memorandum and the SAP. The parties further agree that the Monitor may

usc consultants to aid in fulfitling the duties of the Monitor, under the same

terms and conditions applicable to the Monitor. All reasonable costs and

expenses of the Monitor, including the cost of any consultant to assist the

Monitor, shall be borne by Commonwealth.

xi.

The overall duties of the Monitor and/or his/her designees shall be

to observe, review, report findings, and make recommendations to the parties

with regard to the implementation of the Memorandum and SAP. The Monitor

shall regularly review the protections, services, and supports provided to

residents in their residential settings and programs to determine the

Commonwealth's implementation of and compliance with this Memorandum

and SAP. The Monitor and/or his/her designees, may make both announced

and unannounced inspections of the facility.

10

xu.

The Monitor shall submit to Commonwealth and to DOJ a written

report every six months with regard to the Commonwealth's implementation

efforts and compliance with the Memorandum and SAP. The Commonwealth

will take timely action to remedy any deficiencies cited by the Monitor, without

waiting for the Monitor's report to be finalized.

XIII.

Commonwealth shall notify the Monitor immediately upon the

death of any resident, and shall forward to the Monitor copies of any completed

incident reports related to deaths, autopsies and/or death summaries of

residents, as well as all final reports of investigations that involve residents.

IV.

Terms and Conditions

A.

This Memorandum, and exhibits specifically referenced herein, shall constitute the entire

integrated agreement of the parties. No prior or contemporaneous communications, oral

or written, shall be relevant or admissible for purposes ofdetermining the meaning ofany

provisions herein. If United States believes that Commonwealth has failed to fulfill any

obligation under this Memorandum and SAP, United States will, prior to initiating suit

against Commonwealth, give written notice to Commonwealth of the claimed failure.

Upon receipt of said written notice, Commonwealth shall then have sixty (60) days in

which to cure the claimed failure, if necessary, and provide United States \Vith sufficient

proof of its cure. At the end of the sixty (60) day period, in the event United States

determines that the failure has not been cured, United States may initiate suit against

Commonwealth without further notice. United States commits to work in good faith

with Commonwealth to avoid litigation. IIO\vcver, in the case of an emergency posing

an immediate threat to the health or safety of Oakwood's residents, United States may

omit the notice and cure requirements herein, before seeking judicial action.

B.

If, at any time, any party to the Memorandum and SAP desires to modify it for any

reason, that party will notify the other party in writing of the proposed modification and

the reasons therefor. No modification \viii occur unless there is written agreement by the

parties.

C.

No waiver of any of the terms of this Memorandum and SAP shall be valid unless it is

in writing and signed by all parties to the Memorandum and SAP.

D.

This Agreement and SAP will terminate four years after the effective date of the

Agreement and SAP. If the parties agree that Commonwealth and Oakwood officials

arc in compliance with each of the provisions of this Agreement and SAP earlier than

four years from the effective date of the Agreement and SAP, and have maintained

compliance for at least one year, then the Agreement and SAP may terminate at an earlier

date. The burden will be on Commonwealth and Oakwood officials to demonstrate such

compliance.

II

IL

To the extent that any of the legal authorities cited in the Memorandum (e.g., federal

statute, regulations or case law) are amended or superceded, this Memorandum shall be

amended accordingly.

F.

This Memorandum shall be effective on the date it is signed by all parties.

:ier+-fav< , Dated thisd{1_5~day of

2004.

FOR THE UNITED STATES:
/s/ Gregory F. Van Tatenhove
GREGORY F. VAN TATENHOVE United States Attorney Eastern District ofKentueky

/s/ R. Alexander Acosta
R. ALEXANDER ACOSTA Assistant Attorney General Civil Riehts Division
/s/ Bradley J. Schlozman
DLEY J Deputy Assis Attorney General Civil RU(hts Division
/s/ Shanetta Y. Cutlar
/chief ii{jANETTA Y CUTLAR
Special Litigation Section
/s/ Elizabeth Johnson
ELIZABETH JOHNSON WILLIAM G. MADDOX MARY R. BOHAN Attorneys Special Litigation Section

12

FOR THE COMMONWEALTH OF KENTUCKY,

/s/ Ernie Fletcher
:;:elffirf: FLEift'HER. Governor Commonwealth of Kentd:ekv_

/s/ James W. Holsinger
/urMES IV. l!Of}fNGERJR;lfb (A";cretary
Cabinet for Health & Family Services

/s/ Mark D. Birdwhistell
/ MARKD BIRDvmrs"'T"'E:o-LL;---Undersccretary for Health Cabinet for Health & Family Services

/s/ David E. Fleenor
D~ AV= ID- E. - FL~ EEN~ O- R -·-WESLEY R. BUTLER Office of Legal Services Cabinet for Health & Family Services

/s/ Rebecca J. Cecil

/s/ Pat Wear, II

Deputy Undersecretary for Health Cabinet for Health & Family Services

Depm1ment for Mental I-Icalth & Mental Retardation
Cabinet for Health & Family Services

I )'

Exhibit A Strategic Action Plan The Communities at Oakwood

. . -,G..",..:,· .'o.,,:_,....,a..,-,.r_,i: ' .-.·+:-S·.:.tl,..·-!'2::·):· .~;:~:·:'' ·::P_·::.O:_:,:_R:-;:~T. ::~o::'n 2Z:\i1_'~:r:iu'}it;;?&j:T~. M~-\;E;~(-N.. E~ :: l-~ l:~L.,...·A:/;N'<t·N_:.\J'-N?::\I:SJ~1:~\l~iD~R{;:O1~:~C~~!.E\!,S~~sS.:>····••·
Objective 1. Treatment planning process allows for effective interdisciplinary work with active participation by individuals.

Action Items

A. Invite the individual and chosen family/friends to participate.

B.

Ensure that supervisor,

the core treatment team is composed of, at a direct care staff(DCS), transition facilitator,

minimum, the team leader/QMRP, and a health care representative.

psychologist,

home

manager/program

C.

Ensure that the individual functional status.

participates

sufficiently,

i.e.,

provides

meaningful

mput,

in

the

planning

process,

depending

on

his/her

D. E. F.

Ensure that the team prepares the ind1viduals to advocate Take appropriate steps to include the individual's family Ensure that each team member knows and is responsible

for themselves, ensures that they have meaningful input in their
and friends as an integral part of the treatment planning process. for the care of the individual.

treatment

plan.

G. Ensure that treatment team membership is consistent and enduring.

H.

Ensure that treatment planning conference (TPC) occurs within 24 hours of a plan of Life), 14 days, 28 days, 42 days, 56/60 days, and monthly thereafter. The fourth quarterly review will serve as the annual review.

new admission (initial Quarterly reviews will

treatment plan), at 7 days (initial include quality oflife assessments.

I.

Ensure case of

that each team emergency.

meets

at

a

regularly

scheduled

time,

and

this

meeting

takes

precedence

over

any

competing

assignment,

except

in

J.

Ensure that if a team member is unable to meeting, and the information is presented

attend, s/he provides Mitten information to the members at the meeting.

to

the

treatment

team

leader/QMRP

prior

to

the

K. L.

Ensure Ensure

that that

each team

team has a structure to review all the individual's issues relevant to treatment members are trained in the /principles and practice of treatment planning.

plannmg

in

the

meeting

time.

M. Review, revise and implement current treatment planning form and procedures.

Implementation Plan 1. Assess current treatment plalllling process and forms.

Target Date (projected) Aug 04 to Nov 04

2. Develop a procedure for treatment planning process and revise forms.

Dec 04 to May 05

3. Develop a plan to train staff.

June 05 to Jul 05

4. Train staff (pilot).

Aug 05 to Oct 05

5. Train staff(facility wide).

Nov 05 to Jun 06

6. Develop outcome measures.

Jul 06 to Dec 06

7. Assess outcomes.

Jan 07 ongoing

8. Outcomewrelated quality improvement

Jul 07 ongoing

Objective 2. An interdisciplinary holistic assessment drives the treatment planning process

Action Items

A. Ensure that there is a holistic assessment protocol for all new admissions.

B.

Ensure that the holistic assessment individual needs and preferences.

includes

all

relevant

psychosocial,

behavioral,

medical

and

habilitation

issues,

as

dictated

by

C.

Ensure that the holistic diagnostrc formulatiOn

assessment provides sufficient information to and differential diagnosis Will be documented

reach the most reliable diagnoses m the psychtatnc evaluation.

and

differential

diagnoses.

The

D.

Ensure that the case scheduled treatment

formulation provides the basis for disciplinewspecific assessments. rlanning conferences (TPCs) as additional information is gathered.

The

case

formulation

is

revised

at

regularly

2

Implementation Plan

Target Date (projected)

1. Develop a treatment planning procedure for holistic assessments.

Dec 04 to May 05

2. Develop a plan to train staff.

Jun 05 to Jul 05

3. Train staff (pilot).

Aug 05 to Oct 05

4. Train staff (facility wide).

Nov 05 to Jun 06

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jut 07 ongoing

Objective 3. Treatment planning is based on a comprehensive case formulation for each individual

Action Items
A Derive case formulations from analyses of the information gathered from holistic and discipline-specific assessments, including diagnosis and differential diagnoses.
B. Case formulations should include a review of pertinent history, predisposing, precipitating and perpetuating factors, present status and previous treatment history.
C. Consider bio-medical, psychosocial, and psycho-educational factors, as appropriate, for each category in #2 above.
D. Consider moderating factors (e.g., age, gender, culture) and mediating factors (e.g. treatment adherence and medication issues) for each category in item B above, that may impact the outcomes of interventions.
E. The content of the case formulation should enable the generation of hypotheses about each individual's status, course, treatment and habilitation needs.
--·

3

Implementation Plan 1. Develop a treatment planning procedure for case formulation.

Target Date (projected) Dec 04 to May 05

2. Develop a plan to train staff.

Jun 05 to Jul 05

3. Train staff (pilot).

Aug 05 to Oct 05

4. Train staff (facility wide).

Nov 05 to Jun 06

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

Objective 4. Treatment planning is driven by individualized needs and leads to improvement in each individuals' quality of life

Action Items
A. Develop a list of the individual's needs that follow from the holistic and discipline-specific assessments, diagnoses and differential diagnoses, and case formulation.
B. Ensure that the needs address all important life areas (e.g., home living, community life, social life, health and wellness, work/education, and behavioral/psychiatric factors), and incorporates the individual's life goals-wishes, visions, aspirations and dreams.
C. Update the individual's needs at treatment team conferences to reflect their changing functional status (i.e., new identified needs are added or current needs modified if desired outcomes are not achieved).
D. Develop intervention objectives for all identified needs. Needs can be prioritized depending on the discharge criteria and the individual's functional status.
E. Ensure that the objectives address treatment (i.e., for a disease or disorder), habilitation (i.e., skills and supports) and

4

enriclunent (e.g., quality of life activities).
F. Write the objectives in behavioral, observable, or measurable terms.
G. Write objectives that are realistic and attainable (i.e., relevant to each individual's level of functioning). H. Establish a clear timeline for the achievement of each objective. I. Update the objectives to reflect the individual's changing needs J. Ensure that there are interventions that relate to each objective. K. Ensure that the interventions utilize strengths of the individual, family, friends, care providers and the system of care, as
applicable.
L. For each intervention, specify who is going to do what to facilitate the individual to meet his or her needs as specified in the objective.
M. Ensure that the interventions are aligned with increasing personal independence, choice and enhanced quality of life. N. Develop new interventions to facilitate attainment of new objectives when the old objectives are achieved. 0. Ensure that each plan addresses, tracks and provides supports against risks/dangers, as clinically appropriate.

Implementation Plan

Target Date (projected)

1. Develop a treatment planning procedure for needs, objectives and interventions.

Dec 04 to May 05

2. Develop a plan to train staff.

Jun 05 to Jul 05

3. Train staff (pilot).

Aug 05 to Oct 05

4. Train staff (facility wide).

Nov 05 to Jun 06

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 06 ongoing

7. Outcome-related quality improvement.

--·

--

Jul 07 ongoing

-··

---

5

Objective 5. Treatment plans are routinely and systematically monitored for implementation and effectiveness

I

Action Items

A. Monitor treatment plan implementation routinely and systematically.

B. Implement interventions appropriately throughout the individual's day.

'

C. Ensure that Implementation of interventions reflect the individualized nature of the treatment plan.

D.

Review, at least monthly at the TPC, in producing the desired outcomes.

the

needs,

objectives

and

interventions

identified

in

the

individual's

treatment

plan

for

effectiveness

E. Review more frequently if there are changes in the individual's status or significant newly identified needs. F. Encourage the mdividual (or guardian, if applicable) to participate in the review process commensurate with the individual's level of
functioning.

G. Ensure that the review process includes an assessment of progress related to community transition, as appropriate. H. Base progress reviews and revision recommendations on data collected as specified in the treatment plan.

Implementation Plan

Target Date (projected)

1. Develop a monitoring instrument for treatment plans

Jan 06 to Mar 06

2. Monitor plans.

Apr 06 ongoing

3. Develop outcome measures.

Jul 06 to Dec 06

4. Assess outcomes

Jan 07 ongoing

5. Outcome-related quality improvement.

--

-

Jul 07 ongoing

6

Objective 6. Develop a system to support successful community transition

Action Items

A. Develop community transition plan as part of the initial treatment plan.

B. Ensure that the criteria for community transition are individualized in behavioral, observable or measurable terms.

C. Provide educational opportunities for individuals and families/guardians to facilitate community transition.

D. Increase the number of community-based experiences available to individuals and families/guardians.

E.

Increase interface with local and state agencies vocational services to facilitate items C & D.

including

department

of

mental

health

and

mental

retardation,

community

providers,

Implementation Plan

l. Revise Oakwood Community Transition protocol.
2. Implement revised Oakwood Community Transition Protocol.

3. Develop outcome measures.

4. Assess outcomes.

5. Outcome-related quality improvement.

L__

---

---

--

--

-

Target Date (projected) Jan 05 to Jun 05

Jul 05 ongoing

Jan 06 to Jun 06

Jul 06 ongoing

Jan 07 ongoing

--

-

-

7

Psychiatric services are sufficient to meet the needs ofeach individual receiving psychotropic medications as well as each individual who has or may have mental illness andfor which medication is indicated.

assessment

A.

Ensure that assessment mcludes givers and other team members.

a

thorough

history

of presenting

problem

from

the

individual,

if possible,

family,

if appropriate,

care

B. Ensure that assessment addresses the course and setting within which the symptoms occur.

C. Ensure that assessment recognizes the functional significance of behavior.

D. E.

Ensure that assessment addresses relevant bio-medical, psychosocial and psycho-educational issues. Ensure that assessment reviews and critically examines diagnostic conclusions made in the past.

F. G.

Ensure that assessment reviews relevant medical and neurological Ensure that the psychiatric formulation integrates past and present and behavioral interventions.

pathways as they affect history and response to

psychiatric current and

condition of the individual. past pharmacological, psychosocial

H. Ensure that the diagnoses are stated in accord with DSM-IV-TR.

I. J. K.

Ensure that the documented justification of the diagnoses is in accord with DSM-IV TR.

Ensure Ensure

that that

there is documentation diagnoses identified as

of differential diagnoses during initial diagnostic formulation and thereafter, rule out or deferred are finalized within 60 days of the initial .diagnosis.

as

indicated.

I.

a procedure for psychiatric senrices.

Jul 05

8

3. Develop a monitoring instrument.

Jul 05 to Aug 05

4. Monitor psychiatric documentation.

Sep 05 ongoing

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jan 07 ongoing

Objective 2. Provide ongoing and timely psychiatric assessments of each individual receiving psychotropic medications and document in progress notes

Action Items
A. Ensure that progress notes provide a specific account of psychiatric symptoms under treatment and changes in the individual's status.
B. Complete progress notes within time frames appropriate to the status of each individual but no less frequently than quarterly. C. Ensure that progress notes document a summary of the prev10us interval, including the contextual basis of the symptoms.
D. Ensure that progress notes document changes m medications when warranted and the rationale for these changes. E. Ensure that progress notes document monitoring of risks associated with drug treatments.
F. Ensure that progress notes indicate and update diagnoses with justification.
G. Ensure that progress notes address results of scales used for monitoring side effects of medications (e.g., DISCUS/MOSES/an AED rating scales) and document changes in treatment, as appropriate.
H. Explain rationale for any polyphannacy in a progress note.
I. Ensure that progress notes recognize and recommend psycho·social treatment, as clinically indicated, and address the individual's response to this intervention.

Implementation Plan I. Develop a treatment planning procedure for holistic assessments.
--

Target Date (projected) Dec 04 to May 05

9

2. Develop a plan to train staff. 3. Train staff (pilot).

Jun 05 to Jul 05
I
Aug 05 to Oct 05

4. Train staff (facility wide).

Nov 05 to Jun 06

5. Develop outcome measures. 6. Assess outcomes.

Jul 06 to Dec 06
I
Jan 07 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

'

Objective 3. Psychiatric services are integrated in the interdisciplinary treatment team functions

Action Items
A. Ensure that the psychotropic medication plan is developed by the psychiatrist in consultation with appropriate members of the team. B. Ensure that the psychiatrist attends treatment team meetings for individuals who require psychiatric services. C. Ensure that the interdisciplinary case formulations and treatment plans are aligned with psychiatric diagnostic formulation and treatment.

Implementation Plan

Target Date (projected)

I. Develop a procedure for psychiatric services.

Jan 05 to Jun 05

2. Implement procedure.
3. Develop a monitoring instrument.

Jul 05 ongoing
'
Jul 05 to Aug 05

4. Monitor psychiatric documentation

--

Sep 05 ongoing

10

5. Develop outcome measures.

Jan 06 to Jun 06

6. Assess outcomes.

Jul 06 ongoing

7. Outcome-related quality improvement.

Jan 07 ongoing

Objective 4. Psychiatric and behavioral services are integrated

Action Items
A. Ensure that the psychiatrist reviews proposed behavioral plans/interventions to ensure they are consistent with psychiatric assessments and permit evaluation of the impact of drug treatment.
B. Document that psychiatric disorders targeted for treatment are distinguished from learned behavior and that integrated treatments are provided if there is overlap.
C. Exchange data at least monthly between the psychiatrist and behavioral psychologist to update diagnoses and understand the nature of
behaviors/ needs targeted for treatment.

Implementation Plan 1. Develop a procedure for psychiatric services.

Target Date (projected) Jan 05 to Jun 05

2. Implement procedure.

Jul 05 ongoing

3. Develop a monitoring instrument.

Jun 05 to Aug 05

4. Monitor psychiatric documentation.

Sep 05 ongoing

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

II

7. Outcome-related quality improvement.

Jul 07 ongoing

Objective 5. Psychiatric and neurological services are integrated

Action Items
A. Document that psychiatric and neurological services recognize and address the benefits and risks of medications used by the other treatment modality.
B. Document that differential diagnosis, diagnostic work up and treatments established by each service recognize the other modality's
contribution to the individual's clinical status.
C. Ensure that psychiatry has access to consultations by a movement disorders specialist in those cases that reqUire clarification of diagnosis and refinement of treatment.

Implementation Plan l. Develop a procedure for psychiatric services.

Target Date (projected) Jan 05 to Jun 05

2. Implement procedure

Jul 05 ongoing

3. Develop a monitoring instrument.

Jun 05 to Aug 05

4. Monitor psychiatric documentation

Sep 05 ongoing

5. Develop a system to assess outcomes. 6. Assess outcomes. 7. Outcome-related quality improvement.

---

Jul 06 to Dec 06
'
Jan 07 ongoing
Jul 07 ongoing.
I

12

Objective 6. Psychiatric and medical services are integrated

Action Items

A Ensure that the psychiatrist attends medical staff meetings and participates and/or receives feedback from the Pharrmacy and

Therapeutics (P&T) Committee regarding psychotropic medication use.

B. Document that psychiatric and medical services recognize and address the benefits and risks of treatments used by the other

I

modality.

Implementation Plan 1. Develop a procedure for psychiatric services. 2. Implement procedure. 3. Develop a monitoring instrument.

Target Date (projected)

lao 05 to Jun 05

' '

Jul 05 ongoing

Jul 05 to Aug 05

4. Monitor psychiatric documentation. 5. Develop outcome measures. 6. Assess outcomes.

Sep 05 ongoing Jul 06 to Dec 06 Jan 07 ongoing

7. Outcome-related quality improvement. Objective 7. Facility ensures orientation and competency of psychiatric staff

Jul 07 ongoing
i I

Action Items
A Provide an orientation and competency plan for psychiatric staff that ensures adequate orientation to policies and procedures and outlines performance expectations.
B. Establish a peer review/competency evaluation system to ensure adherence to standards of care on an ongoing basis.

13

Implementation Plan

Target Date (projected)

l. Develop an orientation and competency plan for medical staff.

Jan 05 to Jun 05

2. Revise current medical peer review system.

Jul 05 to Dec 05

3. Develop outcome measures.

Jul 06 to Dec 06

4. Assess outcomes.

Jan 07 ongoing

5. Outcome-related quality improvement.

Jul 07 ongoing

Objective 8. There is an appropriate, safe and effective medication management system

Action Items

A. Ensure that psychotropic medications are used as part of an interdisciplinary plan of care. The psychiatrist provides input to the treatment team and obtains data from the team from the team regarding the use of medications.
B. Ensure that psychotropic medication use is based on a complete diagnostic assessment or a behavioral pharmacological hypothesis relevant to the assessment.

C. Ensure proper match between diagnosis and medications.

D. Follow appropriate informed consent procedures.

E. Delineate and measure specific index/target behaviors.

F. Systematically review on at least a monthly basis psychotropic medication use by treatment teams to ensure proper indications and optimal use.

G. Monitor potential harmful effects of psychotropic medications on individual's functioning in a systematic manner. H. Utilize a recognized scale for monitoring tardive dyskinesia.

I. Integrate quality oflife measures in the treatment team's review of medication effects and side effects using a validated rating

scale.

--

-

14

Implementation Plan

Target Date (projected)

l. Develop a treatment planning procedure for psychotropic medication review.

Dec 04 to May 05

2. Develop a plan to train staff.

Jun 05 to Jul 05

3. Train staff (pilot).

Aug 05 to Oct 05

4. Train Staff (facility wide).

Nov 05 to Jun 06

5. Develop outcome measures.

Jun 06 to Dec 06

6. Assess outcomes.

Jan 06 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

NEUROLOGICAL SERVICES

Objective 1. All individuals with seizure disorders are properly diagnosed, treated and regularly monitored

Action Items

A. Ensure that all individuals diagnosed with seizure disorders receive at least an annual neurological assessment by a neurologist.

B.
c.

Ensure that individuals with refractory seizures (10 or more seizures per year) are evaluated by an epileptologist. Follow all individuals with refractory seizures more closely than those with fewer seizures.

D. Ensure accurate and timely recording of seizures with adequate information to provide seizure management.

E. Base the use of anticonvulsant medications on reliable diagnostic work up to determine seizure type.

F. Document the rationale for the use of all anticonvulsant medications.

G. Document that, when clinically appropriate, individuals have been transitioned, or considered for transition from the older to the newer anticonvulsants.

H. Evaluate all individuals who have been seizure free for two years to determine the need for continued anticonvulsant medications.

15

!. Document risks and benefits of continued AED treatment.
J. Consider individuals who have failed appropriate medication trials for vagal nerve stimulator implants or surgical treatment, if
appropriate.
K. Monitor the cognitive, motor and behavioral adverse effects of anticonvulsant medications. L. Identify all individuals receiving anticonvulsant medications and record seizure frequency and type, and medication types and doses. M. Ensure that seizure management protocol includes thresholds for referral to epileptology and standards/approach in the withdrawal of
medications for seizure free individuals.
N. Develop and implement a protocol for emergency management of status epilepticus. 0. Train staff to ensure consistency in recording the required infonnation related to seizure activity.
P. Ensure ongoing and effective communications between neurologist and primary care physician and other treatment team members
regarding neurological status of the individual and the risks and benefits of neurological treatment.

Implementation Plan

Target Date (projected)

]. Revise current epilepsy management procedure.

Jan 05 to Jun 05

2. Implement revised procedure.

Jul 05 ongoing

3. Develop a monitoring instrument.

Jul 05 to Aug 05

4. Monitor neurological documentation.

Sept 05 ongoing

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

16

GENERAL MEDICAL CARE

Objective 1. Individuals receive appropriate and timely preventative health care

Action Items
A. Screen for hearing and vision, as needed.
c.B. Provide age and gender-specific cancer screening in accord with American Cancer Society recommendations. Provide annual EKGs for individuals age fifty or greater and earlier as indicated by a medical condition (e.g. cardiovascular disease or routine treatment with thioridazine or mesoridazine).
D. Provide timely PPD testing to assess tuberculosis risk. E. Conduct laboratory testing of serum drug levels, complete blood counts, serum electrolytes, lipids and glucose and liver functions, as
indicated prior to and during treatment with certain anticonvulsant, mood stabilizing and antipsychotic medications. F. Provide timely immunizations for all individuals. G. Provide sickle cell screening for all African American individuals. H. Implement protocol for individuals at risk for constipation/impaction. I. Provide screening of thyroid function and cervical spine radiographs for individuals with Down's syndrome.
J. Implement protocol for management of individuals at risk for dysphagia. K. Implement protocol for preventative screening with bone mineral density for individuals at risk of osteoporosis, including postmenopausal
women and individuals receiving long-term treatment with phenytoin. L. Implement protocol for management of individuals at risk of skin break down.

Implementation Plan 1. Revise current preventive management procedures and implement reVJSlOn.

Target Date (projected) Jan 05 to Jun 05

2. Implement revised procedures. 3. Develop a monitoring instrument.

Jul 05 ongoing Jul 05 to Aug 05

4. Monitor medical documentation.

Sep 05 ongoing

17

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

Objective 2. Individuals receive appropriate and timely routine, emergency and specialized care

Action Items
A. Implement a procedure that ensures timely and adequate initial and ongoing assessments of physical status and treatment interventions and ensures timely and adequate emergency response.
B. Organize medical records in a manner that allows relevant information to be easily identified and utilized in making timely treatment decisions.
C. Ensure that current and updated medical problem list identifies all relevant acute and chronic problems to serve as a tracking log. D. Ensure that physician progress notes document history, subjective complaints, examination findings, diagnosis of the problem and a plan
of care.
E. Ensure that the annual medical summary includes a physical examination, summary of current status, significant medical events, treatments provided and response to treatment in the past year, and a future plan of care.
F. Ensure that the annual summary addresses relevant problems identified on the problem list. G. Ensure that individuals receive consultations by specialists as appropriate.

Implementation Plan I. Revise current procedure on medical attention to individuals.

Target Date (projected) Jan 05 to Jun 05

2. Implement revised procedure.

Jul 05 ongoing

3. Develop monitoring instrument.

Jul 05 to Aug 05

18

4. Monitor Medical documentation.

Sep 05 ongoing

5. Develop outcome measures.

Jul 06 to Dec 06

6. Assess outcomes.

Jan 07 ongoing

7. Outcome-related quality improvement.

Jul 07 ongoing

Objective 3. Medication use is monitored for appropriateness, safety and efficacy of medication use

Action Items
A. Implement procedure for reporting adverse drug reactions (ADRs); procedure includes likely cause, probability scale, severity scale and thresholds for intensive case analysis of serious reactions.
B. Conduct intensive case analysis for serious ADRs.
c Report adequate numbers of ADRs.
D. Implement current guidelines for the use of all medications. E. Implement system for drug utilization evaluation (DUE), with priorities for high risk, high frequency medications. F. Identify practitioner and group trends, based on ADRs and DUE as applicable. G. Provide educational activities based on identified trends, as applicable. H. Implement a system of medication variance reporting (MVR) that addresses ali categories of potential and actual variances (e.g.,
prescription, transcription, ordering, dispensing, administration and documentation). I. Train clinicians in the proper use ofMVR data collection tool.
J. Analyze MVR data for trends and performance improvement activities. K. Monitor high risk uses of medications (e.g., polypharmacy, long-term benzodiazepine use, long-term use of anticholinergics, conventional
antipsychotic use and long-term use of antipsychotics for unlabeled indications).

Implementation Plan

1. Revise current structure and function ofPhannacy and Therapeutics Committee.

--·

--··

Target Date (projected)
'
August 04 to Dec 04
I
I

19

2. Revise current adverse drug reaction (ADR) instrument and procedure.

3. Revise system for tracking and trending ADR data.

4. Implement revised ADR system.

5. Develop individualized guidelines for psychotropic medications.

6. Revise current drug utilization evaluation (DUE) system based on new guidelines.

7. Implement revised DUE system.

8. Revise current medication variance reporting (MVR) instrument and procedure.

9. Revise system for tracking and trending MVR data.

10. Implement revised MVR system.

11. Develop thresholds for intensive case analysis (ICA) based on ADR and MVR data. 12. Implement ICA system.

13. Develop procedures and a monitoring system for high-risk medication uses.

14. Monitor high risk medication uses.

15. Develop a system to assess outcomes.

---

--

Aug 04 to Dec 04

Jan 05 to Jun 05

Jul 05 ongoing

Aug 04 to Mar 05

Jan 05 to Mar 05

Apr OS ongoing

Aug 04 to Dec 04

Jan 05 to Jun 05

Jul 05 ongoing

Aug 04 to Dec 04

Jan 05 ongoing

Apr 05 to Jun 05

Jul 05 ongoing

--

Jan 06 to Jun 06

20

16. Assess outcomes. 17. Outcome·related quality improvement.

Jul 06 ongoing
I
Jan 07 ongoing

Objective 4. Physicians are included in the processes of monitoring medication use

Action Items
A. Ensure that physicians regularly attend, participate m and receive feedback from the Pharmacy and Therapeutics (P&T) Committee reviews and data analyses.
B. Include physicians in the development and updates of medication guidelines. C. Implement procedure requiring pharmacists to communicate medication alerts with the prescribing physician. D. Document in a centralized log all medication alerts.

Implementation Plan

Target Date (projected)

I. Revise current medical peer review system.

Jul 05 to Dec 05

2. Revise current physician orientation and competency evaluation plans.

Jul 05 to Dec 05

3. Revise current medication alert system and implement revision.

Jan 05 to Mar 05

Objective 5. Formal Mortality Review Process Provides Specific Recommendations to Improve Quality of care

Action Items

A. Conduct a final mortality review within 45 days of each individual's death.

B. Ensure that the comprehensive mortality review includes review and discussion of all supporting documentation.
c. Ensure that the mortality review generates recommendations for remedial action when appropriate.

D. Conduct external independent review of mortality findings; provide recommendations based on this external review, as appropriate.

:

E. Implement recommendations as appropriate; track and analyze all recommendations to identify trends and provide remedial action as

needed.

'

21

Implementation Plan

I

I. Revise current system for Mortality Reviews.

I

2 Develop outcome measures.

3. Assess outcomes.

4. Outcome-related quality improvement.

Objective 6. Timely and appropriate dental care is provided

Action Items
A. Implement protocols for dental/oral hygiene care; routinely review protocols and revise as needed. B. Conduct annual dental assessments, or more frequently based on individual's needs.
c. Ensure that dental perfonnance improvement process monitors dental/oral hygiene assessments, treatments and documentation.
D. Monitor preventative care programs to decrease use of pre-sedation restraints.

Implementation Plan

Target Date (projected)

I. Develop a procedure for dental care.

Jun 05 to Dec 05

2. Develop outcome measures.

Jun 06 to Dec 06

3. Assess outcomes.

Jan 07 ongoing

4. Outcome-related quality improvement.

---

--

-

Jul 07 ongoing.

--

----

22

Objective 7. There is a medical quality management system

Action Items

'

A. Develop a medical peer review process with clear perfonnance criteria, feedback loop and corrective follow up action.

c.B. Include in the system any patterns and trends identified by the P&T Committee regarding medication use. Utilize patterns and trends for educational and perfonnance improvement purposes

Implementation Plan l. Revise current Medical Peer Review system (same as Goal II Psychiatric Services Objective 7).

Target Date (projected) Jul 05 to Dec 05

2. Develop outcome measures.

Jun 06 to Dec 06

3. Assess outcomes.

Jan 07 ongoing

4. Outcome·related quality improvement.

Jul 07 ongoing

PSYCHOLOGICAL AND BEHAVIORAL SERVICES

Objective 1. Psychological and behavioral services are sufficient to meet the needs of each individual in terms of general clinicaUmental health, functional status, and skills and supports needed to exercise optimal autonomy or independence.

Action Items
A. Contribute to a holistic assessment of each individual admitted to Oakwood. B. Undertake discipline·specific assessments, as needed, with regard to general clinical/mental health, functional status, and skills and
c. supports needed to exercise optimal autonomy or independence as specified in an individual's treatment plan. Ensure integration of psychological with other treatment modalities, including psychiatry, neurology, nursing, medical and health care, and other services as needed by an individual.
D. Ensure that skill~_ training and support_programs are aligned with the peeds of the in~jvidual as docul'l}ented in the indj_yidual's treatment__

23

plan and that the training is provided in functional contexts.
E. Use a Positive Behavior Supports approach to behavioral mterventions. F. Write positive behavioral support plans or strategies at a level that can be easily understood and implemented by direct care staff. G. Adequately document their assessments, rationale for their interventions, implementation of interventions, and individual-specific
outcomes.
H. Train all staff in the principles of Positive Behavior Support and support the staff in implementing positive behavior support plans with a high degree (90+%) of fidelity.
I. Develop, Implement and supervise a facility-wide incentive system that is habilitation focused and involves each individual, to the extent possible, given their functional status, in determining how the incentive system will be individualized in terms of the individual's needs. Individualization of the individual's incentives will be reviewed during the regularly scheduled treatment planning conferences.

Implementation Plan

Target Date (projected)

l. Revise current Behavioral Intervention protocol to incorporate positive behavioral supports.

Jul 04 to Oct 04

2. Train BA/Psych and IDT members on revised Behavior Supports protocol.

Nov 04 to Mar 05

3. Implement Behavior Supports protocol.

Jan 05 ongoing

4. Develop operational procedures for Positive Behavior Supports referral, assessment and intervention.
5. Pilot new operational procedures.

Feb 05 to Jul 05 Aug 05 to Dec 05

6. Develop outcome measures.

Nov 05 to Dec 05

7. Assess outcomes of pilot.

Jan 06 to Mar 06

8. Finalize Positive Behavioral Supports protocol incorporating new operational procedures.

Apr 06 to Jun 06

24

9. Assess outcomes.

July 06 ongoing

10. Outcome·related quality improvement.

Jan 07 ongoing

ll. Evaluate and refine positive behavior supports milieu. (Action Item I only).

Jan 07 ongoing

Objective 2. Positive Behavior Support programs are developed and implemented

Action Items
A. Ensure that the goals of intervention/team process include: a. The individual's treatment team is involved in the assessment and intervention process b. Broad goals of intervention are determined (e.g., improved functioning, greater participation in activities, enhanced social skills, etc).
c. A specific behavior of concern is defined in clear, observable and measurable terms (i.e., what the individual says or does that staff find problematic).
d. Baseline estimate of the behavior is established in terms of objective measures (e.g., rate, frequency, duration, intensity, etc).

B. Ensure that the functional assessment/gathering infonnation includes:
a. Pertinent records are reviewed (e.g., meeting notes, anecdotal records, evaluations, previous interventions, etc). b. Functional assessment interviews are conducted with people (e.g., individual, parents and family members, therapists and direct
care staff, teachers, etc) who often interact with the individual within different settings and activities. c. Direct observations are conducted across relevant circumstances (e.g., multiple settings, over time) and by more than one observer. d. Other assessment tools (e.g., rating scales, checklists) are used to produce objective information regarding events preceding and
followmg the behavior of concern, as well as ecological and motivational variables that may be affecting the individual's behavior.
'· Additional assessments (e.g., ecological, sleep, medication effects, curricular, etc) are conducted, as needed, to determine broader variables affecting the individual's behavior.

c. Ensure that the functional assessment/summary statements include:

a. Patterns are identified from the data collected that include (i) circumstances in which the behavior was most and least likely to

occur (e.g., when, where, and with whom) and (ii) specific functions the behavior appeared to serve for the individual (i.e., what

the individual gets or avoids by engaging in the behaviors of concern).

b. Broader variables (e.g., activity patterns, curriculum, et0_that may be affecting the individual's behavior are identified.

J

25

c. Patterns are summarized into written summary statements or hypotheses. These statements are clear, concise, and based on data.

D. Ensure that the Positive Behavior Support Plan (PBS plan) includes:
a. Intervention strategies are clearly linked to the functional assessment information (summary statements/hypotheses)
b. The individual's treatment team designs a positive behavior support plan (PBS plan) that includes: c. Description of the behavior, patterns identified through the functional assessment, and goals of intervention d. Modifications to the social or physical environment that may prevent the behavior and/or increase the likelihood of alternative
appropriate behavior(s)
e. Specific behaviors (skills) to be taught and/or reinforced that will: (a) achieve the same function as the behavior of concern, and (b) allow the individual to cope more effectively with his/her circumstances, and
f. Strategies for managing consequences so that reinforcement is (i) maximized for positive behavior, and (ii) minimized for behavior of concern.
g. Goals of intervention and specific replacement behaviors/skills are incorporated into the mdividual' s overall treatment plan. h. If necessary to insure safety and rapid de-escalation of the individual's behavior of concern, crisis management procedures and
criteria for the1r use are determined and documented.
1. Everyone working with the individual on a regular basis is familiar with the PBS plan and implements its strategies with high degree of fidelity.

E. Ensure that implementation, monitoring and evaluation includes:

a. Implementation of the PBS plan is monitored to msure that strategies are used consistently across intervention settings
b. Objective information is collected to evaluate the effectiveness of the PBS plan. This information includes:

1. Decreases in problem behavior.

H. Increases in replacement skills and/or alternative behaviors.

Ill. Achievement of broader goals.

IV. Durability of behavior change.

c. The ind1vidual 's treatment team reviews, at scheduled Treatment Plan Conferences (TPCs), the individual's progress and makes necessary adjustments to the PBS plan, as needed.

Implementation Plan

Target Date (projected)

1. Revise current Behavioral Intervention protocol to incorporate positive behavioral supports.

Jul 04 to Oct 04

26

2. Train BNPsych and IDT members on revised Behavior Supports protocol.

Nov 04 to Mar 05

3. Implement Behavior Supports protocol.

Jan 05 ongoing

4. Develop operational procedures for Positive Behavior Supports referral, assessment and intervention.
5. Pilot new operational procedures.

Feb 05 to Jul 05 Aug 05 to Dec 05

6. Develop outcome measures.

Nov 05 to Dec 05

7. Assess outcomes of pilot.

Jan 06 to Mar 06

8. Finalize Positive Behavioral Supports protocol incorporating new operational procedures.

Apr 06 to Jun 06

9. Assess outcomes.

July 06 ongoing

10. Outcome-related quality improvement.

Jan 07 ongoing

Objective 3. There is a psychological and behavioural service system that regularly monitors each individual's skills Training plans, supports provision and positive behavior support plan

Action Items
A. Ensure that the direct care staff is consistently and reliably implementing skills training programs, supports provision and behavior support plans.
B. Ensure that the skills training programs, supports provision and behavior support plans are effective and producing training
and treatment outcomes as specified in each individual's treatment plan.
c Provide timely reviews and modifications to skills training programs, support provision and positive behavior support plans
where the individual is not making progress.
D. Develop an adequate system to track the use of restrictive procedures, the use of emergency procedures, and the implementation and monitoring of positive behavior support plans.

27

Implementation Plan

Target Date (projected)

I. Assess staff knowledge of principles of Positive Behavior Support (post-test).

Jan 05 to Mar 05

2. Develop and provide appropriate follow-up training for staff on principles of Positive Behavior Supports.
3. Develop outcome measures.

Apr 05 to Sep 05 (ongoing thereafter) Jan 06 to Mar 06

4. Assess outcomes.

Apr 06 ongoing

5. Outcome-related quality improvement.

Oct 06 ongoing

Objective 4. Psychology services are sufficient to prevent or decelerate physical, functional and psychological regression, and to ensure an individual's reasonable safety, security and freedom from receiving restrictive procedures and undue bodily restraint

Action Items
A. Identify each individual who sustains or causes frequent injuries or is at risk of serious hann due to his or her behaviors (e.g., self-injury, aggression).
B. Prioritize these individuals for intensive intervention, where appropriate, through skills training, provision of supports, positive behavioral support plans and other treatment modalities.
c. Reduce and eliminate the use of restrictive procedures except in medical emergencies and when an individual poses an
immediate danger to self or others.

Implementation Plan l. Revise current Risk Management procedures.

Target Date (projected) Aug 04 to Dec 04

2. Revise the Abuse Neglect procedures.

Aug 04 to Dec 04

28

3. Revise current Incident Management procedures.

Aug 04 to Dec 04

4. Implement revised procedures.

Jan 05 to Dec 05

5. Develop outcome measures.

Jan 06 to Mar 06

6. Assess outcomes.

Apr 06 ongoing

7. Outcome-related quality improvement.

Oct 06 ongoing

Objective 5. A Behavior Intervention Committee (BIC) is used to review and approve any restrictive interventions

Action Items
A. Ensure that the BIC consists of a standing committee consisting ofthe best clinician from: psychology (chair), psychiatry, pharmacy, nursing and a community representative.
B. Ensure that the BIC meets in a timely manner to review all restrictive interventions submitted to it for review and approval.
c Ensure that the BIC has a standard protocol for reviewing the need for and approval of all restrictive interventions that include any
restrictive Procedures.

Implementation Plan

Target Date (projected)

1. Establish BIC membership.

Jun04

2. Develop standard protocol for review of all Behavioral Support Plans, including those involving restrictive procedures.
3. Develop monitoring instrument for BIC reviews.

Aug 04 to Jan 05 Feb 05 to Mar 05

4. Monitor BIC reviews.

Apr 05 ongoing

29

5. Develop outcome measures

Jan 06 to Mar 06

6. Assess outcomes.

Apr 06 ongoing

7. Outcome-related quality improvement.

Oct 06 ongoing

NURSING SERVICES

Objective 1. Nursing services are sufficient to meet the needs of all individuals

Action Items A. Conduct initial nursing assessments within 24 hours of new admissions. The assessments include monitoring of health care indicators (e.g. vital signs, lung sounds, bowel sounds and oxygen saturation levels, and acute and chronic illnesses/injuries. B. Conduct ongoing nursing assessments on a quarterly basis, and more frequently based on individual's needs. C. Implement nursing interventions, whenever needed, especially for the following conditions:
a. when an individual sustains an injury;
b. when an individual is restrained,
C. for the ongoing care of an individual's tracheotomy tube, d. when an individual has a skin care and/or positioning and/or nutritional, and/or physical augmentation plan, e. when an individual has or is at risk of developing constipation and/or impaction, pressure ulcer, choking/dysphagia,
osteoporosis, significant weight loss/gain, or other identified risks, or f. when an individual is enterally fed. D. Implement a protocol to document changes in the health status of individuals and communicate these changes to the medical staff in a manner that reflects the urgency of the problem. E. Implement a system to document an individual's status when the individual is transferred to another health care setting (for treatment and/or testing and/or consultation) and upon the individual's return. F. Implement procedure for the safe administration of medications, investigation and documentation of variances, and corrective action, including supervision and training.

30

Implementation Plan l. Develop a timeline to review/revise nursing practice procedures.

Target Date (projected) Aug 04 to Dec 04

2. Develop/revise nursing practice procedures.

Jan OS to Dec OS

3. Revise current Medication Variance Reporting instrument and procedure (same as Goal II General Medical Care Objective 3).

Aug 04 to Dec 04

4. Revise infection control procedures.

Sep 04 to Dec 04

Objective 2. There is a nursing performance improvement process

Action Items

A. Implement a system to regularly monitor the individual's healthcare outcomes and modify nursing interventions based on individual's needs.

B.

Provide competency based training to nursing staff in the performance of their functions, including role in the interdisciplinary process and active treatment, assessments and interventions, documentation and performance ofDISCUS/MOSES/AED scales.

Implementation Plan

Target Date (projected)

l. Revise current nursing competency plan.

Aug 04 to Dec 05

'

2. Develop outcome measures for nursing practices.

Jan 06 to Jun 06

3. Develop outcome measures for infection control practices.

Jan 06 to Jun 06

I

4. Assess outcomes of nursing practices.

Jul 06 ongoing

31

5. Assess outcomes of infection control practices.

Jul 06 ongoing

6. Outcome-related quality improvement.

Jan 07 ongoing

NUTRITIONAL, SPEECH, OCCUPATIONAL AND PHYSICAL THERAPY

Objective 1. All individuals receive nutritional, speech, occupational and physical therapy, as needed

Action Items A. Identify and provide interdisciplinary assessments for individuals in need of nutritional, speech, occupational and physical therapy in a timely manner. B. Ensure that the assessments include, but are not limited to, likely causes, diagnoses, relevant health care issues, risk indicators and baseline measurements, as appropriate.
c. Implement an action plan derived from analysis of the infonnation gathered in the assessments to meet the needs of
individuals and improve their quality of life. D. Ensure that the analysis and action plans provide strategies to minimize or remediate concerns/risks. E. Implement a protocol to: a) provide preventive care for individuals to promote healthy body weight and b) provide therapeutic
interventions to attain optimal weight. The interventions shall be tailored to the severity of the problem as measured by BMI and/or other tools. F. Train and provide oversight of staff to assist individuals to eat safely and appropriately. Monitor individual functional outcomes. G. Implement a therapeutic positioning program to ensure optimal positioning for individuals and promote individuals' highest functional level of mobility. H. Provide competency-based training and oversight of staff to utilize appropriate lifting and transfer teclmiques. I. For those individuals identified at risk of choking/aspiration, provide competency-based training and oversight of staff to assist them with proper head alignment and other techniques to minimize risk during such activities as eating, drinking, toothbrushing, dental examination, medication administration, and bathing.
J. Implement a protocol to document and monitor caloric, protein, water and/or fluid intake requirements on individuals who are
receiving a prescribed therapeutic regimen. K. Ensure that individuals receive enteral nutrition only when medically necessary and, where appropriate, return the individual

32

to oral intake. L. Provide competency-based training and oversight of staff to assist individuals receiving enteral feeding with proper postural
alignment.

Implementation Plan l. Revise current therapeutic services protocoL

Target Date (projected) Aug 04 to Dec 04

2. Implement new therapeutic services protocol including positioning,
wellness and enteral nutrition.
3. Revise current competency based training systems.
4. Implement revised competency based training systems.

Jan 05 to Dec 05

i

Jan 05 to Dec 05

I

Jan 06 to Jun 06

Objective 2. There is a performance improvement process for above services

Action Items A. Implement functional outcome goals and expectations that are measurable to document results of therapy interventions.
c.B. Modify therapy interventions that fail to achieve desired goals. Implement a performance improvement process that identifies patterns and trends, provides feedback to staff and utilizes patterns and trends for education and performance improvement.

Implementation Plan 1. Develop outcome measures.

Target Date (projected) Jan 06 to Jun 06

2. Assess outcomes.

Jul 06 ongoing

3. Outcome-related quality improvement.

Jan 07 ongoing

33

-
GOAL III: RISKMANAGEMENT. " <::"' ' ., '•
Objective I. Oakwood provides safe and secure environment to all individuals. Protect individuals from abuse, neglect and other high risk behaviors (e.g. aggression, self-harm, falls, etc)
Action Items A. Delineate guidelines and responsibilities for reporting, responding and resolving allegations of abuse and neglect. B. Ensure that all staff understands what constitutes abuse and neglect, are required to inunediately report witnessed or suspected abuse and neglect and the consequences of failure to report. C. Initiate abuse and neglect investigations no later than 24 hours from the date of reporting, and concluded as soon as practicable. D. Take immediate measures to protect the safety and welfare of the individual, including removal of the staff involved from direct care (pending outcome of investigation) and procuring timely health care for any injuries resulting from the incident. E. Collect and/or preserve all physical evidence as early in the investigation as possible. F. Ensure that the investigators are qualified and trained to communicate effectively with individuals who are not easy to understand (or utilize additional resources, if needed), interview witnesses and obtain needed information, and submit a report of the findings with documentary evidence. G. Report all allegations of abuse and neglect arc to appropriate outside agencies. H. Ensure that if abuse and/or neglect is substantiated, staff involved shall receive appropriate disciplinary action according to State guidelines. I. Enter abuse and neglect data into a central database within the facility. J. Implement a consistent set of procedures for what constitutes minor and major incidents/injuries and how they should be reported. K. Employ consistent approach for the logging and tracking of minor and major incidents/injuries. L. Document client-to-client altercations that create risk of harm or harm to identify the cause of the incident, the location, who was affected or involved, and nature and severity of the injury. Ensure that data is entered into a central database within the facility. M. Document staff injuries resulting from client assaults or physical interventions and enter data into a central data base within the facility. N. Document other high risk behaviors such as falls, elopements, any aggressive behavior reg_(ifdless of injury and enter data into
34

a central database within the facility.
0. Develop and implement a data system to identify individuals at increased risk of abuse, neglect and other high risk behaviors,
specify contributing factors for each individual and implement individualized interventions.

Implementation Plan I. Revise current Risk Management procedures.

Target Date (projected) Aug 04 to Dec 04

2. Revise current Abuse Neglect procedures.

Aug 04 to Mar 05

3. Revise current Incident Management procedures.

Aug 04 to Jun 05

4. Implement revised procedures.

Jan 05 to Dec 05

5. Develop outcome measures.

Jan 06 to Jun 06

6. Assess outcomes. 7. Outcome~related quality improvement.

Jul 06 ongoing Jan 07 ongoing

Objective 2. Oakwood has identified thresholds for high risk behavior and ensures timely interventions to reduce ongoing Risk

Action Items
A. Implement a procedure that outlines risk management thresholds (i.e. different levels of high risk behavior) and provides a framework for timely specified interventions, including reviews/revisions of the treatment plan to reduce the level of risk. The interventions are tailored to the level of risk.
B. Monitor staff adherence to the time frames and levels of interventions specified in the procedure.

35

Implementation Plan I. Revise current Risk Management procedures.

Target Date (projected) Aug 04 to Dec 04

2. Revise current Abuse Neglect procedures.

Aug 04 to Mar 05

3. Revise current Incident Management procedures.

Aug 04 to Jun 05

4. Implement revised procedures.

Jan 05 to Dec 05

5. Develop outcome measures.

Jan 06 to Jun 06

6. Assess outcomes.

Jul 06 ongoing

7. Outcome-related quality improvement. Objective 3. Oakwood has a restraint free environment

Jan 07 ongoing

Action Items

A.

Ensure that restraints are not used as punishment, plans, or for the convenience of staff.

in

lieu

of skills

training,

supports

provision,

and

positive

behavior

support

c.B. Ensure that restraints are used only for medical emergencies or when there is immediate risk of harm to self or others.

Ensure that restraints are frequency of a behavior.

not

used

as

part

of any

positive

behavior

support

plans

or

a

learning-based

contingency

to

reduce

the

D. Prohibit the use of standing PRN orders for chemical restraints.

E Develop a staff culture that promotes a restraint free environment.

36

Implementation Plan

Target Date (projected)

1. Revise current Behavioral Intervention Policy and Procedure to fully incorporate positive behavioral supports.
2. Train BA!Psych on revised Behavioral Intervention Policy and Procedure.

Jun 04 to Dec 04 Jun 04 to Dec 04

3. Assess staff knowledge of positive behavior supports and provide additional training as needed. 4. Develop outcome measures.

Jan 05 to Jun 05 (ongoing thereafter)
Jan 06 to Jun 06

5. Assess outcomes.

Jul 06 ongoing

6. Outcome-related quality improvement.

Jan 07 ongoing

Objective 4. When restraints are used, their use meets established criteria
Action Items A Ensure that there is immediate notification of an on-site supervisor upon the use of any restraints. B. Ensure that there is notification of and approval by a psychologist and/or nurse if any restraint is applied for longer than one hour and upon each hour thereafter.
c. Ensure timely assessment by a nurse to ensure the restraint is being safely applied and is reasonably tailored to the individual's
behavior. D. Provide continuous monitoring of the individual while restrained to ensure safety; monitoring and documentation by a nurse or
supervisor of vital signs, and mental status of the individual every hour the individual is restrained; every restrained limb shall be released from restraint, examining it for bruising and skin tears, and exercising at least 10 minutes every hour; the restrained individual shall be provided an opportunity to eat, drink fluids and toilet as needed; provide every individual in restraint with continuous one-to-one supervision. E. Release an individual from restraint as soon as the individual is determined not to pose an inunediate danger to the physical safety of self or others.
F. Ensure a review (and documentation) by psychology of the use of a restraint withjp 24 hours of the a22lication of the restraint_

37

G. Undertake a comprehensive review by the individual's treatment team if an individual receives three or more restraints within a 30-day period. This meeting shall take place on the first working day following the third restraint. The team shall make specific, written recommendations and shall document these recommendations in the individual's record, and shall make changes in the individual's skills training and support plan, as indicated.
H. Document each use of mechanical, physical, and/or chemical restraint, including the exact type of restraint or procedure used, as well as the length of time it was used. Documentation of each use ofrestraint shall be kept in the individual's file and in a central location in the facility.

Implementation Plan

Target Date (projected)

I. Review/revise emergency intervention procedures.

Aug 04 to Dec 04

2. Implement revised emergency intervention procedures.

Jun 05 to Dec 05

3. Review/revise system to assess outcomes.

Jan 06 to Jun 06

4. Assess outcomes.

Jul 06 to Dec 06

5. Outcome-related quality improvement.

Jan 07 ongoing

Objective 5. All staff are competent in implementing restraint procedures

Action Items
A. Provide competency-based training to all staff who may be responsible for implementing unplanned mechanical, physical, or chemical restraints.
B. Ensure that staff use mechanical, physical, or chemical restraints with fidelity.

38

Implementation Plan

Target Date (projected)

1. Review/revise emergency intervention procedures.

Aug 04 to Dec 04

2. Implement revised emergency intervention procedures.

Jun 05 to Dec 05

3. Review/revise system to assess outcomes.

Jan 06 to Jun 06

4. Assess outcomes.

Jul 06 ongoing

5. Outcome-related quality improvement.

Jan 07 ongoing

Objective 6. There is a quality management program
Action Items A. Produce a risk management written report on a quarterly basis which tracks and analyzes patterns and trends of incidents and injuries, including, but not limited to, abuse and/or neglect, client-client altercations, staff injuries, falls, elopements, restraints and client aggression. B. The risk management report/review provides recommendations to reduce the risks.
c. Patterns and trends are identified and utilized for education/training and other performance improvement activities.

Implementation Plan

Target Date (projected)

1. Revise current Risk Management procedures.

Aug 04 to Dec 04

2. Revise current Abuse Neglect procedures.

Aug 04 to Mar 05

3. Revise current Incident Management procedures.

Aug 04 to Jun 05

39

4. Implement revised procedures. 5. Develop outcome measures. 6. Assess outcomes. 7. Outcome-related quality improvement.

Jan 05 to Dec 05 Jan 06 to Jun 06 Jul 06 ongoing Jan 07 ongoing

40

GOALIV: CQ~MUNI']'Y ']'JMl'ISITIO~ '

. ~ -,. ·,- .-

,,

Objective I. The Commonwealth of Kentucky DMHMRS will review and revise its procedures, as needed, regarding the role and functions of its facilities that serve individuals with mental retardation and developmental disabilities ("developmental centers")

Action Items
A. Department for Mental Health and Mental Retardation Services (DMHMRS) will review and revise current procedures regarding the role and functions of its developmental centers, including the following considerations: a. Will the developmental centers continue to function as ICF/MR facilities? b. Will the developmental centers need to be downsized to an optimal population level? What will be the optimal size? c. What kinds of individuals will be served at the developmental centers? d. Will the developmental centers be used as community resource centers? What will be the nature of the resource centers?
B. Will the developmental centers be developed as centers of excellence, linked to universities and other educational institutions, that fosters quality research, training of professionals, and provision of specialized services to the community?
C. DMHMRS will implement its revised procedures in its developmental centers. D. DMHMRS will monitor and enforce adherence to its procedures by the developmental centers. E. DMHMRS will review and realign its current Medicaid Waiver Program to address the increasing need for community
placements.

I Implementation Plan I. Revise Kentucky Community Transition Process.

I Target Date (projected) Jan 05 to Dec 05

2. Implement revised KY Community Transition Process.

Jan 06 to Jun 06

3. Develop outcome measures.

Jul 06 to Dec 06

41

4. Assess outcomes.

Jan 07 to Jun 07

5. Outcome-related quality improvement.

Jul 07 ongoing

Objective 2. Oakwood has a transition process that begins at admission and is an integral part of each individual's treatment plan

Action Items
A. Enhance Oakwood's professional culture and align its procedures that focuses on community integration.
B. Develop community transition plans for each individual at admission and update these plans at treatment plan conferences as
needed.
C. Develop discharge criteria in terms of skills and supports the individual will need to display that will enable the individual to successfully transition to an identified community placement commensurate with their needs.
D. Link the discharge criteria to skills training and supports provision.
E. Actively collaborate with community providers to facilitate community transition within reasonable timeframes. F. Ensure that the Community Transition Coordinator informs an individual's treatment team of any identified barriers to
community placement. G. Document efforts by the individual's treatment team and/or the Community Transition Coordinator to overcome or resolve
these barriers.
H. Develop and implement follow-up supports and services for 12 months to ensure successful community placement. I. Develop and implement a quality assurance system that identifies vulnerabilities to community placement failures and uses the
data to develop ways by which Oakwood and treatment teams can anticipate and overcome these vulnerabilities with regard to specific individuals.

Implementation Plan
l. Revise Oakwood Community Transition protocol.

Target Date (projected) Jan 05 to Jun 05

2. Implement revised Oakwood Community Transition Protocol.

Jul 05 to Dec 05

42

3. Develop a system to assess outcomes.

Jun 06 to Dec 06

4. Assess outcomes.

Jan 06 ongoing

5. Outcome-related quality improvement.

Jul 07 ongoing

Objective 3. Oakwood has collaborative relationships with community providers

Action Items

A. Increase strategic alliances with community provider organizations.

B. Increase interface with local health, education, and social and vocational services.

I

c. Assist community organizations to develop or increase community-based services, including housing, employment, and social

support services.

Implementation Plan

Target Date (projected)

1. Revise Oakwood Community Transition protocol. 2. Implement revised Oakwood Community Transition Protocol.

Jan 05 to Jun 05
.
Jul 05 to Dec 05

3. Develop outcome measures.

Jun 06 to Dec 06

4. Assess outcomes.

Jan 07 ongoing

5. Outcome-related quality improvement.

Jul 07 ongoing

Objective 4. Individuals, families, guardians and staff are educated about community based services
Action Items A. Provide educational events for individuals and their families regarding the new treatment planning system and the community

43

transition planning system.
B. Increase educational events for the individuals, families/guardians and staff regarding community-based services.
C. Provide placement fairs, tours, and make other information available to individuals, their families/guardians and staff to familiarize themselves with community placement alternatives.
D. Educate individuals and their families/guardians about community placement options available to them through the waiver
program.
E. Identify and address the concerns and fears of individuals, families/guardians regarding community placement of specific Individuals.

Implementation Plan

Target Date (projected)

1. Revise Oakwood Community Transition protocol.

Jan 05 to Jun 05

2. Implement revised Oakwood Community Transition Protocol.

Jut 05 to Dec 05

3. Develop outcome measures.

Jun 06 to Dec 06

4. Assess outcomes.

Jan 07 ongoing

5. Outcome-related quality improvement.
H:\Stralegic Plan Implementation Plan draft 8-1 J-04#3ElSabaawi2.doc

·--··-··

Jul 07 ongoing

44

 
 Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 1 of 8
U.S. District Court Eastern District of Kentucky (Frankfort) CIVIL DOCKET FOR CASE #: 3:06−cv−00063−KKC

CLOSED

USA v. Commonwealth of Kentucky et al Assigned to: Judge Karen K. Caldwell Cause: 42:12101et seq. − Americans with Disabilities Act
Plaintiff

Date Filed: 08/31/2006 Date Terminated: 09/13/2006 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

USA

represented by Mary Regina Bohan U.S. Department of Justice − 4926 Civil Rights Division 950 Pennsylvania Avenue, NW Patrick Henry Building, Room 4926 Washington, DC 20530 202−514−6255 Fax: 202−514−6273 Email: mary.bohan@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

William Granville Maddox U.S. Department of Justice − Civil Rights Division Employment Litigation Section 950 Pennsylvania Ave NW Patrick Henry Bldg Room 4908 Washington, DC 20530 202−514−6255 Fax: 202−514−0212 Email: william.maddox@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

V.
Defendant
Commonwealth of Kentucky as Owner and Operator of Oakwood − Oakwood

represented by Fredrick Ryan Keith Kentucky Cabinet for Health and Family Services Office of Legal Services 275 E Main St 5W−B Frankfort, KY 40621 502−564−7062 Fax: 502−564−7091 Email: ryan.keith@ky.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Johann Frederick Herklotz Wellman, Nichols &Smith, PLLC 444 Lewis Hargett Circle Suite 170 Lexington, KY 40503 859−368−8116 Fax: 859−368−8221 Email: hherklotz@wnsattorneys.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 2 of 8

Defendant Governor of the Commonwealth of Kentucky Governor Ernie Fletcher − Ernie Fletcher
Defendant Secretary of the Cabinet for Health and Family Services Mark D. Birdwhistell, Secretary − Mark Birdwhistell

Kerry B. Harvey U.S. Attorney's Office, EDKY 260 W. Vine Street Suite 300 Lexington, KY 40507−1612 859−233−2661 Email: kerry.harvey@usdoj.gov TERMINATED: 06/04/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Wesley R. Butler Barnett, Benvenuti &Butler, PLLC 489 E Main St Suite 300 Lexington, KY 40507 859−226−0312 Fax: 859−226−0313 Email: wes.butler@bbb−law.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
D. Brent Irvin Cabinet for Health &Family Services − Frankfort Office of Legal Services 275 E. Main Street 5W−A Frankfort, KY 40621 502−564−7905 Fax: 502−564−7573 Email: brent.irvin@ky.gov ATTORNEY TO BE NOTICED
represented by Fredrick Ryan Keith (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Johann Frederick Herklotz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kerry B. Harvey (See above for address) TERMINATED: 06/04/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED
D. Brent Irvin (See above for address) ATTORNEY TO BE NOTICED
represented by Fredrick Ryan Keith (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Johann Frederick Herklotz (See above for address)

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 3 of 8

LEAD ATTORNEY ATTORNEY TO BE NOTICED

Kerry B. Harvey (See above for address) TERMINATED: 06/04/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED

D. Brent Irvin (See above for address) ATTORNEY TO BE NOTICED

Defendant
Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services John M. Burt, Commissioner − John Burt

represented by Fredrick Ryan Keith (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Johann Frederick Herklotz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Kerry B. Harvey (See above for address) TERMINATED: 06/04/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED

D. Brent Irvin (See above for address) ATTORNEY TO BE NOTICED

Defendant
Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services

represented by Fredrick Ryan Keith (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Johann Frederick Herklotz (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Kerry B. Harvey (See above for address) TERMINATED: 06/04/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED

D. Brent Irvin (See above for address) ATTORNEY TO BE NOTICED

Date Filed 08/31/2006
08/31/2006

# Docket Text
1 COMPLAINT, filed by USA. (Attachments: # 1 Civil Cover Sheet and Case Assignment# 2 Certificate of the Attorney General Hon. Alberto R. Gonzalez)(CBD) (Entered: 08/31/2006)
2 JOINT MOTION for Entry of Settlement Agreement by USA, Commonwealth of Kentucky (Attachments: # 1 Proposed Order for Entry of Settlement Agreement# 2

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 4 of 8

08/31/2006 09/13/2006 09/13/2006
12/13/2006 12/14/2006
12/14/2006 05/31/2007 06/01/2007 06/14/2007 06/14/2007

Tendered Settlement Agreement# 3 Tendered Exhibit A to Settlement Agreement − Pgs 1−74 Action Plan# 4 Tendered Exhibit A to Settlement Agreement − Pgs 75−104 Action Plan)(CBD) (Entered: 08/31/2006)
***MOTION SUBMITTED TO CHAMBERS of Caldwell for review: 2 JOINT MOTION for Entry of Settlement Agreement by USA and Commonwealth of Kentucky (CBD) (Entered: 08/31/2006)
3 PROPOSED ORDER FOR ENTRY OF SETTLEMENT AGREEMENT: Judgment shall be entered in this matter pursuant to the terms and conditions of the Settlement Agreement and its Exhibit A, the fully incorporated and enforceable Strategic Action Plan. This Court will retain jurisdiction over the case in accordance with the terms of the Settlement Agreement and its Exhibit A, the fully incorporated and enforceable Strategic Action. Signed by Judge Karen K. Caldwell. (AKR)cc: COR (Entered: 09/13/2006)
4 SETTLEMENT AGREEMENT by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, USA, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services. (Filed pursuant to Order of Court 3 ) (Attachments: # 1 Exhibit A − Pages 1 − 74 of Action Plan# 2 Exhibit A − Pages 75 − 104 of Action Plan)(AKR) (Entered: 09/13/2006)
5 NOTICE OF FILING by USA Notice of Filing October 2006 Monitor's Report (Attachments: # 1 Monitor's Rpt Pt 1# 2 Part 2# 3 Part 3# 4 Part 4# 5 Part 5)(Bohan, Mary) Additional attachment(s) added on 12/14/2006 (Dearborn, Christy). (Entered: 12/13/2006)
NOTICE OF DEFICIENCY and NOTICE OF DOCKET MODIFICATION TO Mary Bohan re 5 Notice of Filing; Error 1: Pages 17−60 Part 1 and all pages of Parts 2−8 of Monitor's Report were sideways; Error by attorney; Correction: Clerk has rotated the pages and entered the corrected documents as seperate attachments; At the browse screen within ECF, attorney should always open and view each PDF document before proceeding with the filing. Error 2: Parts 2, 3, and 4 of Monitor's Report exceeded the 2MB size limit; Entry made by attorney; Correction: Clerk has seperated the PDF images into less than two (2) megabyte segments. Counsel is reminded that large documents may not upload properly to ECF or download within a reasonable amount of time, therefore, documents over 2 megabytes must be broken down into 2 megabytes, or less. Error 3: main document was scanned instead of converted into PDF format directly from the native word application. All pleadings created with a word application shall be converted to PDF format using PDF conversion software rather than being scanned. Error 4: attorney has failed to "type" name on the signature line.; The name of the Filing User under whose login and password the document is submitted must be preceded by an "s/" and typed in the space where the signature would otherwise appear. No further action required by counsel as to this entry. (cc: COR) (CBD) (Entered: 12/14/2006)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 5 Notice of Filing of Monitor's Report. (CBD) (Entered: 12/14/2006)
6 NOTICE by USA Notice of Substitution of Counsel (Bohan, Mary) (Entered: 05/31/2007)
***FILE SUBMITTED TO CHAMBERS of Caldwell for review: 6 Notice of Substitution. (CBD) (Entered: 06/01/2007)
7 NOTICE by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services Notice of Substitution of Counsel (Herklotz, Johann) (Entered: 06/14/2007)
***Attorney Johann Frederick Herklotz for Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 5 of 8

06/15/2007 06/15/2007
12/27/2007 12/28/2007 06/25/2008

Services and Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services added pursuant to QC re: 63 . (AKR) (Entered: 06/15/2007)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 7 Notice of substitution of counsel on behalf of defendants. (AKR) (Entered: 06/15/2007)
8 NOTICE OF FILING by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services Notice of Filing Court Monitor Report 2, April, 2007 (Attachments: # 1 Exhibit Court monitor report pages 1 − 19# 2 Exhibit Court monitor report pages 20 − 39# 3 Exhibit Court monitor report pages 40 − 59# 4 Exhibit Court monitor report pages 60 − 79# 5 Exhibit Court monitor report pages 80 − 99# 6 Exhibit Court monitor report pages 100 − 119# 7 Exhibit Court monitor report pages 120 − 139# 8 Exhibit Court monitor report pages 140 − 159# 9 Exhibit Court monitor report pages 160 − 179# 10 Exhibit Court monitor report pages 180 − 199# 11 Exhibit Court monitor report pages 200 − 219# 12 Exhibit Court monitor report pages 220 − 239# 13 Exhibit Court monitor report pages 240 − 259# 14 Exhibit Court monitor report pages 260 − 279# 15 Exhibit Court monitor report pages 280 − 299# 16 Exhibit Court monitor report pages 300 − 319# 17 Exhibit Court monitor report pages 320 − 339# 18 Exhibit Court monitor report pages 340 − 359# 19 Exhibit Court monitor report pages 360 − 379# 20 Exhibit Court monitor report pages 380 − 393)(Herklotz, Johann) Modified text in italics to better describe pleading on 6/18/2007 (Ratliff, Kay). (Entered: 06/15/2007)
9 NOTICE OF FILING Court Monitor Report #3 by USA (Attachments: # 1 Court Monitor Report #, Dated December 16, 2007)(Maddox, William) Modified text w/ better desciption on 12/28/2007 (CBD). (Entered: 12/27/2007)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 9 Notice of Filing Court Monitor Report #3 (CBD) (Entered: 12/28/2007)
10 NOTICE OF FILING by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services Notice of Filing Court Monitor Report 4, May 2008 (Attachments: # 1 Exhibit Court Monitor Report pages 1 to 13, # 2 Exhibit Court Monitor Report pages 14 to 25, # 3 Exhibit Court Monitor Report pages 26 − 51, # 4 Exhibit Court Monitor Report pages 52−71, # 5 Exhibit Court Monitor Reponrt pages 72 − 91, # 6 Exhibit Court Monitor Report 92−111, # 7 Exhibit Court Monitor Report pages 112−131, # 8 Exhibit Court Monitor Report pages 132−151, # 9 Exhibit Court Monitor Report pages 152−171, # 10 Exhibit Court Monitor Report pages 172−191, # 11 Exhibit Court Monitor Report pags 192−211, # 12 Exhibit Court Monitor Report pages 212−231, # 13 Exhibit Court Monitor Report pages 232−251, # 14 Exhibit Court Monitor Report 252−271, # 15 Exhibit Court Monitor Report pages 272−291, # 16 Exhibit Court Monitor Report pages 292−311, # 17 Exhibit Court Monitor Report pages 312−331, # 18 Exhibit Court Monitor Report pages 332−351, # 19 Exhibit Court Monitor Report pages 352−371, # 20 Exhibit Court Monitor Report pages 372−391, # 21 Exhibit Court Monitor Report pages 392−411, # 22 Exhibit Court Monitor Report pages 412−431, # 23 Exhibit Court Monitor Report pages 432−451, # 24 Exhibit Court Monitor Report pages 452−471, # 25 Exhibit Court Monitor Report 472−491, # 26 Exhibit Court Monitor Report pages 492−511, # 27 Exhibit Court Monitor Report pages 512−519)(Harvey, Kerry) (Additional attachment(s) added on 6/26/2008: # 28 CORRECT Exhibit Court Monitor Report pgs1−13, # 29 CORRECT Exhibit Court Monitor Report pgs14−25, # 30 CORRECT Exhibit Court Monitor Report pgs26−51, # 31 CORRECT Exhibit Court Monitor Report pgs52−71, # 32 CORRECT Exhibit Court Monitor pgs72−91, # 33 CORRECT Exhibit Court Monitor Report pgs92−111, # 34 CORRECT Exhibit Court Monitor Report pgs112−131, # 35 CORRECT Exhibit Court Monitor Report pgs132−151, # 36 CORRECT Exhibit Court Monitor Report pgs152−171, # 37 CORRECT Exhibit

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 6 of 8

06/25/2008 06/26/2008 01/05/2009
01/06/2009 06/15/2009
06/16/2009 06/04/2010

Court Monitor Report pgs172−191, # 38 CORRECT Exhibit Court Monitor Report pgs192−211, # 39 CORRECT Exhibit Court Monitor Report pgs212−231, # 40 CORRECT Exhibit Court Monitor Report pgs232−251, # 41 CORRECT Exhibit Court Monitor Report pgs252−271, # 42 CORRECT Exhibit Court Monitor Report pgs272−291, # 43 CORRECT Exhibit Court Monitor Report pgs292−311, # 44 CORRECT Exhibit Court Monitor Report pgs312−331, # 45 CORRECT Exhibit Court Monitor Report pgs332−351, # 46 CORRECT Exhibit Court Monitor Report pgs352−371, # 47 CORRECT Exhibit Court Monitor Report pgs372−391, # 48 CORRECT Exhibit Court Monitor Report pgs392−411, # 49 CORRECT Exhibit Court Monitor Report pgs412−431, # 50 CORRECT Exhibit Court Monitor Report pgs432−451, # 51 CORRECT Exhibit Court Monitor Report pgs452−471, # 52 CORRECT Exhibit Court Monitor Report pgs472−491, # 53 CORRECT Exhibit Court Monitor Report pgs492−519) (AKR). (Entered: 06/25/2008)
Attorney Update. Attorney Kerry B. Harvey for Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky and Secretary of the Cabinet for Health and Family Services added. (AKR) (Entered: 06/26/2008)
NOTICE OF DOCKET MODIFICATION TO K. Harvey re 10 Notice of Filing Court Monitor Report ; ERROR: ALL pages of all exhibits were sideways; Entry by attorney; CORRECTION: Clerk has rotated the pages and entered the documents as separate attachments; At the browse screen within ECF, the Attorney should always open and view each PDF document before proceeding with the filing; No further action required by counsel. cc: COR (AKR) (Entered: 06/26/2008)
11 NOTICE OF FILING by USA Court Monitor Report 5 (Attachments: # 1 Court Monitor Report 5 Pages 1 − 40, # 2 Court Monitor Report 5 Pages 41−80, # 3 Court Monitor Report 5 Pages 81 − 120, # 4 Court Monitor Report Pages 121 − 160, # 5 Court Monitor Report 5 Pages 161 − 200, # 6 Court Monitor Report 5 Pages 201 − 240, # 7 Court Monitor Report 5 Pages 241 − 280, # 8 Court Monitor Report 5 Pages 281 − 320, # 9 Court Monitor Report 5 Pages 321 − 360, # 10 Court Monitor Report 5 Pages 361 − 400, # 11 Court Monitor Report 5 Pages 401 − 440, # 12 Court Monitor Report 5 Pages 441 − 480, # 13 Court Monitor Report 5 Pages 480 − 487)(Maddox, William) (Entered: 01/05/2009)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 11 Notice of Filing Court Monitor Report 5. (AKR) (Entered: 01/06/2009)
12 NOTICE OF FILING "Court Monitor Report 6, May, 2009" by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services (Attachments: # 1 Exhibit Report Pages 1−40, # 2 Exhibit Report Pages 41−80, # 3 Exhibit Report Pages 81−120, # 4 Exhibit Report Pages 121−160, # 5 Exhibit Report Pages 161−200, # 6 Exhibit Report Pages 201−240, # 7 Exhibit Report Pages 241−280, # 8 Exhibit Report Pages 281−320, # 9 Exhibit Report Pages 321−360, # 10 Exhibit Report Pages 361−400, # 11 Exhibit Report Pages 401−440, # 12 Exhibit Report Pages 441−480, # 13 Exhibit Report Pages 481−519)(Harvey, Kerry) Modified by adding text "Court Monitor Report 6, May, 2009" to better describe pleading on 6/16/2009 (AKR). (Entered: 06/15/2009)
***FILE SUBMITTED TO CHAMBERS of Karen Caldwell for review: 12 Notice of Filing Court Monitor Report 6, May, 2009. (AKR) (Entered: 06/16/2009)
13 NOTICE of Appearance by Fredrick Ryan Keith on behalf of Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 7 of 8

06/04/2010 06/04/2010 06/04/2010 12/13/2010
12/15/2010

the Cabinet for Health and Family Services (Keith, Fredrick) (Entered: 06/04/2010)
14 NOTICE OF FILING of "Court Monitor Report 8, April 2010" by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services (Attachments: # 1 Exhibit Pages 1 − 160, # 2 Exhibit Pages 161 − 321, # 3 Exhibit Pages 322 − 482, # 4 Exhibit Pages 483 − 636)(Keith, Fredrick) Modified text for better description on 6/4/2010 (CBD). (Entered: 06/04/2010)
Attorney Update. Attorney Kerry B. Harvey terminated. Substituted by F. Ryan Keith per DE 13 . (CBD) (Entered: 06/04/2010)
NOTICE OF DOCKET MODIFICATION TO Frederick Keith re 14 Notice of Filing; Error: attachments were insufficiently described as "Exhibit." Entry by attorney; Correction: the Clerk renamed the attachments. Attachments must be adequately described. Example: Exhibit A (incorrect); Exhibit A Affidavit of John Doe (correct.) No further action required by counsel. cc: COR (CBD) (Entered: 06/04/2010)
15 NINTH STATUS REPORT Court Monitor Report 9 by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services. (Attachments: # 1 Exhibit Court Monitor Report 9 PART 1, # 2 Exhibit Court Monitor Report 9 PART 2, # 3 Exhibit Court Monitor Report 9 PART 3, # 4 Exhibit Court Monitor Report 9 PART 4, # 5 Exhibit Court Monitor Report 9 PART 5, # 6 Exhibit Court Monitor Report 9 PART 6, # 7 Exhibit Court Monitor Report 9 PART 7, # 8 Exhibit Court Monitor Report 9 PART 8, # 9 Exhibit Court Monitor Report 9 PART 9, # 10 Exhibit Court Monitor Report 9 PART 10, # 11 Exhibit Court Monitor Report 9 PART 11, # 12 Exhibit Court Monitor Report 9 PART 12, # 13 Exhibit Court Monitor Report 9 PART 13, # 14 Exhibit Court Monitor Report 9 PART 14, # 15 Exhibit Court Monitor Report 9 PART 15, # 16 Exhibit Court Monitor Report 9 PART 16, # 17 Exhibit Court Monitor Report 9 PART 17, # 18 Exhibit Court Monitor Report 9 PART 18, # 19 Exhibit Court Monitor Report 9 PART 19, # 20 Exhibit Court Monitor Report 9 PART 20, # 21 Exhibit Court Monitor Report 9 PART 21, # 22 Exhibit Court Monitor Report 9 PART 22, # 23 Exhibit Court Monitor Report 9 PART 23, # 24 Exhibit Court Monitor Report 9 PART 24, # 25 Exhibit Court Monitor Report 9 PART 25)(Keith, Fredrick) (Entered: 12/13/2010)
16 SEVENTH STATUS REPORT Court Monitor Report 7 October 2009 by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services. (Attachments: # 1 Exhibit Court Monitor Report 7 October 2009 − Part 1, # 2 Exhibit Court Monitor Report 7 October 2009 − Part 2, # 3 Exhibit Court Monitor Report 7 October 2009 − Part 3, # 4 Exhibit Court Monitor Report 7 October 2009 − Part 4, # 5 Exhibit Court Monitor Report 7 October 2009 − Part 5, # 6 Exhibit Court Monitor Report 7 October 2009 − Part 6, # 7 Exhibit Court Monitor Report 7 October 2009 − Part 7, # 8 Exhibit Court Monitor Report 7 October 2009 − Part 8, # 9 Exhibit Court Monitor Report 7 October 2009 − Part 9, # 10 Exhibit Court Monitor Report 7 October 2009 − Part 10, # 11 Exhibit Court Monitor Report 7 October 2009 − Part 11, # 12 Exhibit Court Monitor Report 7 October 2009 − Part 12, # 13 Exhibit Court Monitor Report 7 October 2009 − Part 13, # 14 Exhibit Court Monitor Report 7 October 2009 − Part 14, # 15 Exhibit Court Monitor Report 7 October 2009 − Part 15, # 16 Exhibit Court Monitor Report 7 October 2009 − Part 16, # 17 Exhibit Court Monitor Report 7 October 2009 − Part 17, # 18 Exhibit Court Monitor Report 7 October 2009 − Part 18, # 19 Exhibit Court Monitor Report 7 October 2009 − Part 19, # 20 Exhibit Court Monitor Report 7 October 2009 − Part 20, # 21 Exhibit Court Monitor Report 7 October 2009 − Part

Case 3:06-cv-63 As of: 07/25/2012 03:25 PM EDT Page 8 of 8

08/08/2011 08/08/2011
08/09/2011 09/28/2011
09/28/2011 09/29/2011

21, # 22 Exhibit Court Monitor Report 7 October 2009 − Part 22, # 23 Exhibit Court Monitor Report 7 October 2009 − Part 23, # 24 Exhibit Court Monitor Report 7 October 2009 − Part 24, # 25 Exhibit Court Monitor Report 7 October 2009 − Part 25)(Keith, Fredrick) (Entered: 12/15/2010)
17 NOTICE of Appearance by D. Brent Irvin on behalf of Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services (Irvin, D.) (Entered: 08/08/2011)
18 NOTICE OF FILING by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services (Attachments: # 1 Exhibit Court monitor report No. 10, part 1, # 2 Exhibit Court monitor report 10, part 2, # 3 Exhibit court monitor report 10, part 3, # 4 Exhibit court monitor report 10, part 4, # 5 Exhibit court monitor report 10, part 5 of 5)(Irvin, D.) (Entered: 08/08/2011)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 18 Notice of Filing Court Monitor Report No. 10. (AKR) (Entered: 08/09/2011)
19 NOTICE by Commissioner, Department of Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Commonwealth of Kentucky, Deputy Commissioner of the Mental Health and Mental Retardation Services in the Cabinet for Health and Family Services, Governor of the Commonwealth of Kentucky, Secretary of the Cabinet for Health and Family Services, USA (Attachments: # 1 Proposed Order of Final Dismissal)(Irvin, D.) (Entered: 09/28/2011)
***FILE SUBMITTED TO CHAMBERS of Judge Caldwell for review: 19 Notice of Final Dismissal. (AKR) (Entered: 09/28/2011)
20 ORDER OF FINAL DISMISSAL: this case is dismissed. Signed by Judge Karen K. Caldwell on 9/29/2011.(AKR)cc: COR (Entered: 09/29/2011)