IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF IOWA

UNITED STATES OF AMERICA
Plaintiff,
v.
THE STATE OF IOWAi THOMAS J. VILSACK, Governor of the State of Iowa

CIVIL NO.

Defendants.

COMPLAINT

PLAINTIFF, THE UNITED STATES OF AMERICA, by its undersigned

attorneys, hereby leges upon information and belief:

1. The Attorney General files this Complaint on behalf of

the United States America pursuant to the

1 Rights of

Institutionalized Persons Act, 42 U.S.C. § 1997, to enjoin the

named Defendants from depriving residents housed in the Glenwood

Resource Center (Glenwood) and the Woodward Resource Center

(Woodward) of rights, privileges, or immunit

secured and

protected by the Constitution and laws of the United States.

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 the Southern District of Iowa is proper

pursuant to 28 U.S.C. § 1391.

DEFENDANTS

6. Defendant State of Iowa owns and operates Glenwood and

Woodward. Glenwood is located in Glenwood, Iowa. Woodward is

located in Woodward, Iowa

7. Defendant Thomas J. Vilsack is Governor of the State of

Iowa. In his capacity as the State's chief executive, he is the

most senior official who is responsible for the operation of

Woodward and Glenwood.

FACTUAL ALLEGATIONS

8. Defendants are legally responsible, in whole or in

part, for the operation Glenwood and Woodward, for the

conditions each facility, and the health and safety of persons

confined or residing in both facilit

9. At all

evant times, Defendants acted or failed to

act, as alleged herein l under color of state law.

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10. Glenwood and Woodward are institutions within the

meaning of 42 U.S.C. § 1997(1).

11. Persons institutionalized at Glenwood and Woodward

suffer from mental disabilit that range from mild to profound.

12. Persons institutionalized at Glenwood and Woodward

include "qualified individual[s] with a disabili II for purposes

of the Americans with Disabil ies Act (ADA) and implementing

regulations. 42 U.S.C. § 12101

seg., 28 C.F.R. Part 35.

13. Defendants, and Glenwood and Woodward, are "public

entit[iesl" under the ADA and implementing regulations.

14. Defendants have failed and continue to fail to provide

adequate medical, nursing, neurological, psychological,

nutritional, habilitation, therapy, and psychiatric care services

to Glenwood and Woodward residents, to ensure that these

residents are

from undue and unreasonable restraint, and to

otherwise protect Glenwood and Woodward residents from harm.

15. Defendants have failed and continue to fail to assess

Glenwood and Woodward residents to ascertain whether residents of

these facil ies are receiving adequate treatment, supports, and

services in the most integrated setting appropriate to their

individual needs; that those individual residents whom

professionals determine should be placed in community programs

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are placed in such programs, when appropriate; and that the institution's residents are served in the most integrated setting appropriate to each resident's individual needs.
VIOLATIONS ALLEGED 16. The acts and omissions alleged in paragraphs 14 and 15 constitute a pattern or practice that violates Glenwood and Woodward residents' federal rights as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law. 17. The acts and omissions alleged in paragraph 15 violate the Americans with Disabilities Act and implementing regulations. 42 U.S.C. § 12101 et seq., 28 C.F.R. Part 35. 18. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions set forth in paragraphs 14-15 that deprive Glenwood and Woodward 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.
PRAYER FOR RELIEF 19. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Court enter an order permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those
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acting in concert or participation with them from continuing the

acts r omissions, and practices set forth in paragraphs 14-15 above, and that this Court require Defendants to take such

actions as will ensure lawful conditions of institutionalization

are afforded to

s of Glenwood and Woodward, including the

provision of adequate treatment in the most integrated setting

appropriate to their individual needs. The United States further

prays that this Court grant such other and further equitable

relief as it may

just and proper.

Respectfully submitted,

(,~GAoS. HC~ ROFT Attorney General of the United States

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United States Attorney Southern District Iowa U.S. Court House Annex Suite 286 Des Moines, Iowa 50309 2053 (515) 284-6257

Assistant Attorney General Civil Rights Division

Special Litigation Section

Dated: 11- 11

, JR.
Trial Attorneys United States Department Justice Civil Rights Division Special igation Section 950 Pennsylvania Avenue, N.W. Washington D.C. 20035 (202) 514-8103
I 2004.

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®f£ire nf tq.e JXttnrney ~eneral
~asqinstnn, ~.(1L 20530

CERTIFICATE OF THE ATTORNEY GENERAL

I, JOHN ASHCROFT, Attorney General of the United States,

certify that with regard to the foregoing Complaint,

States v.

I

complied with all subsections of 42 U.S.C.

§ 1997b(a) (1). I certify as well that I have complied with all

subsections of 42 U.S.C. § 1997b(a) (2). I further certi

pursuant to 42 U.S.C. § 1997b(a) (3), my belief that this action

by the Uni

States is of general public importance and will

mater ly

r the vindication of rights, privileges, or

immunities s

or protected by the Constitution and

of

the United States.

In addit

believe," set

action.

1

initiation of

certify that I have the "reasonable cause to

42 U.S.C. § 1997a, to

iate this

certify that all prerequisites to the

under 42 U.S.C. § 1997 have been met.

Pursuant to 42 U.S.C. § 1997a(c), I have pers

s

the foregoing Complaint. Pursuant to 42 U.S.C. § 1997b(b), I am

personally s

s Certificate.

Signed s Washington, D.C.

dayof~

,2004, at

~~ Attorney General of the United States

 
 IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF IOWA

UNITED STATES OF AMERICA
Plaintiff,
v.
THE STATE OF IOWA; THOMAS J. VILSACK, Governor of the State of Iowa

CIVIL NO.

Defendants.

SETTLEMENT AGREEMENT
The United States and the State of Iowa agree to settle this matter on the terms and conditions set forth below in this Settlement Agreement.
A. This case was instituted by the United States pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"),
42 u.s.c. § 1997.
B. This Court has jurisdiction over this action pursuant to
28 u.s.c. § 1345.
C. Venue is appropriate pursuant to 28 U.S.C. § 139l(b).
D. 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, provided, however, that if this agreement is never finalized, the State rese~ves the right to challenge the United States' authorization to institute this action.
E. The Defendants are the State of Iowa and the Honorable Thomas J. Vilsack, Governor of the State of Iowa, in his o f ficial capacity as Governor. Collectively, the Defendants shall hereinafter in the Settlement Agreement and Plan be referred to

as "the State." The collective residents of both the Woodward and Glenwood Resource Centers ("Resource Centers") will hereinafter in the Settlement Agreement be referred to as "residents."
F. Woodward and Glenwood are institutions covered by CRIPA and operated by the State to provide habilitation and other protections, supports and services to persons with me,ntal retardation and other developmental disabilities. The State has authority and responsibility for the operation of Woodward and Glenwood and is responsible for the implementation of this Settlement Agreement.
G. On March 22, 1999, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, notified the Governor of the State of Iowa, the Attorney General of the State of Iowa, the Director of the Iowa Department of Human Services, and the Superintendents of Woodward and Glenwood, of her intention to investigate allegations of unconstitutional and unlawful conditions at Woodward and Glenwood pursuant to CRIPA.
H. Following an investigation, on July 9, 2002, the Attorney General of the United States, by and through the Assistant Attorney General, Civil Rights Division, informed the Governor of the State of Iowa, the Attorney General of the State of Iowa, the Director of the Iowa Department of Human Services, and the Superintendents of Woodward and Glenwood that the Attorney General had reasonable cause to believe that persons residing in or confined to Woodward and Glenwood were being subjected to conditions that deprived them of their legal rights and of their rights, privileges, and immunities secured by the Constitution of the United States.
I. After notification of the initial investigation in 1999, and continuing from time to time thereafter, the State voluntarily undertook initiatives to address outstanding concerns with regard to the protections, services, and supports provided at Woodward and Glenwood.
J. The State has at all times denied that conditions at Woodward qnd Glenwood violate the constitutional or federal statutory rights of residents at Woodward and Glenwood. The State further maintains that it currently is adhering to many of the policies and practices set forth in the Plan, discussed in paragraph Q, that is incorporated herein by reference, and the
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State maintains that the fact that a particular policy or practice is included in the Plan is not to be construed as evidence by any person or party that the State is not following that policy or practice.
K. The State maintains that as a matter of State policy, the State has at all times aspired to provide a level of care to Woodward and Glenwood residents in excess of what it ~egards as a minimal level of care required by the Constitution and federal law.
L. The parties entering into this Settlement Agreement recognize the constitutional and legal interests of the residents of Glenwood and Woodward, and for the purpose of avoiding protracted and adversarial litigation, agree to the provisions set forth herein.
M. In entering into this Settlement Agreement, State officials do not admit any violation of the Constitution or of any law, and this Settlement Agreement and Plan may not be used as evidence of liability in any other civil or criminal proceeding.
N. The provisions of this Settlement Agreement are a lawful, fair, and appropriate resolution of this case.
0. This Settlement Agreement, voluntarily entered into, shall be entered by the United States District Court for the Southern District of Iowa.
P. This Settlement Agreement shall be applicable to and binding upon all of the parties, their officers, agents, employees, assigns, and successors.
Q. The parties jointly have agreed upon a plan (hereinafter called the "Plann), filed simultaneously herewith, to address outstanding concerns that impact or have impacted residents. The provisions of the Plan are incorporated in their entirety into this Settlement Agreement as if fully set forth, word-for-word, herein.
R. In order to monitor the State's implementation of the Settlemen~ Agreement, the United States and its consultative experts shall regularly conduct compliance reviews to ensure that the State has implemented and continues to implement all measures required by this Settlement Agreement. The United States shall make its consultative experts and agents available for technical assistance following such reviews. In order to assist in the implementation of the Plan, the United States recognizes that the
- 3-

Plan will require the retention of, and review by, consultative experts by the State.
S. The United States and its agents shall have the right to request, inspect, and review facility records, resident charts and other documents, conduct interviews with residents outside the presence of staff consistent with this Settlement Agreement (unless the resident requests otherwise), and observe. activities normally associated with providing protections, services, ·and supports to residents that are necessary to assess the State's compliance and/or implementation efforts with this Settlement Agreement and Plan. The United States will submit requests for documents in writing at or near the time of the request. The United States and its agents may obtain copies of all documents, records, and materials relevant to compliance and/or implementation of the Settlement Agreement and Plan. The State shall provide any requested documents, records and materials to the United States as soon as possible, but no later than within 20 business days of the request. At the discretion of the employee, any staff member may request that an attorney be present during an interview with a United States representative and/or agent. The United States may receive unsolicited calls or contacts from State personnel outside the presence of State representatives. The United States shall endeavor to interview employees onsite at the facility only after it provides reasonable notice to the State. However, nothing in this Settlement Agreement and Plan shall abridge the whistleblower rights of State employees or contractors under law or limit the ability of the United States to participate in related interactions with State employees or contractors. The United States agrees to provide the State with reasonable notice of any visit or inspection, although the parties agree that no notice shall be required in an emergency situation where the life, immediate health, or immediate safety of resident(s) is at issue. Such access shall continue until this action is dismissed.
T. Within 90 days from the Court's entry of this Settlement Agreement as an order, the State shall provide DOJ with an initial status report regarding its compliance with this Settlement Agreement. Within 180 days from entry of this order, the State shall provide DOJ with a second status report regarding its compl~ance with this Settlement Agreement. Within one year of the Court's entry of this Settlement Agreement, and wi t hin every 180 days thereafter (so long as this agreement remains in effect), the State shall provide DOJ with a status report regarding its compliance with this Settlement Agreement. Each status report shall provide:
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(1) a description of the State's status in complying with each and every provision of this Settlement Agreement and the steps taken to achieve compliance with each and every provision of this Settlement Agreement during the period since the last status report; and
(2) all relevant documents that demonstrate the State's compliance with this Settlement Agreement, .including, but not limited to, policies, procedures, protocols, training materials, and curriculum vitae.
U. (1) Except where there is an emergency situation where the life, immediate health, or immediate safety of resident(s) is at issue, if the United States maintains that the State has failed to carry out the requirements of this Settlement Agreement, the United States shall notify the State with specificity of any instance in which it maintains that the State has failed to carry out the requirements of this Settlement Agreement. With the exception of conditions or practices that pose an immediate and serious threat to the life, health, or safety of resident(s), the State shall have 30 days from the date of a deficiency notice from the United States to cure the claim of non-compliance before the United States may file any compliance motion with the Court. During this period, the parties shall coordinate and shall discuss areas of disagreement and attempt to resolve outstanding differences. If the parties reach an agreement that varies from the Plan, the new agreement shall be reduced to writing, signed, and filed with the Court for approval.
(2) If the parties fail to reach an agreement, the United States may seek specific performance of the Settlement Agreement and Plan in the first instance; however, if a Court Order for specific performance is issued, nothing shall limit the ability of the United States to seek other enforcement remedies in subsequent court submissions with regard to the Court's Order for specific performance.
(3) The United States agrees that in this case it will not seek a finding of, or sanction for, contempt against either the State of Iowa or any State officials unless an or der for specific performance has been entered and is thereafter violated in such a manner as : ~o make such a finding or sanctions appropriate.
V. The purpose of the Settlement Agreement and the incorporated Plan is that the State will be able to achieve desired outcomes for and provide the necessary protections, supports, and services to the residents of Woodward and Glenwood. The parties agree that the Settlement Agreement will be terminated and the case
-5-

dismissed four years and six months after the effective date of the Agreement. The Agreement may terminate at an earlier date if the parties agree that the State of Iowa is in substantial compliance with each provision of this Agreement, including the incorporated Plan, and the State has maintained compliance for at least 18 months. The burden shall be on the State of Iowa to demonstrate compliance. Noncompliance with mere technicalities, or temporary failure to comply during a period of oth.erwise sustained compliance shall not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained compliance shall not constitute substantial compliance.
W. Unless specified to the contrary elsewhere herein, in any compliance or other adversarial hearing prior to final dismissal of this action, the burden of proof will be on the party moving the Court.
X. All provisions of the Settlement Agreement and the incorporated Plan shall have ongoing effect until the final dismissal of this action. The Court shall retain jurisdiction of this action for all purposes under this Settlement Agreement until such time as the Settlement Agreement is terminated. Independent of the foregoing, if the United States and the State agree that either facility has achieved substantial compliance with each section of the Settlement Agreement and incorporated Plan, the parties shall file a joint motion to terminate this Settlement Agreement and Plan with respect to the facility that has achieved substantial compliance.
Y. The parties reserve the right to withdraw consent to this Settlement Agreement in the event that this Settlement Agreement is not approved by the Court in its entirety.
Z. There shall be no ex parte communications by either party with the Court. There shall be no ex parte communications by either party with the employees, experts, agents, or assigns of the other party that is inconsistent with this Settlement Agreement and Plan.
AA. The parties agree that any records produced pursuant to this Settlement Agreement and/or Plan may be shared only with the following: (1) the Court, including public submissions and filings; (2) any expert(s) or consultant(s) selected or retained by the parties pursuant to this Settlement Agreement and Plan; (3) all counsel of record in this matter; (4) staff and clerical
-6-

personnel involved in the preparation and review of the submissions and reports for counsel of record; and (5) United States and other governmental officials, as necessary, in order to carry out law enforcement responsibilities. All parties shall be responsible for maintaining the confidentiality of records in their possession. Submissions to the Court that contain identifying information of residents (such as their full name, address, or social security number) shall be filed wi.th the Court using pseudonyms or the residents' initials.
BB. All parties shall bear their own costs, including attorney fees.
CC. It is intended that the parties will pursue a problemsolving approach so that litigation and disagreements can be minimized and the energies of the parties can be focused on the task of meeting the needs of the residents and achieving the outcomes set forth in this Settlement Agreement. Absent an emergency condition, the United States agrees to attempt to confer with the State in a good faith effort to attempt to reach agreement regarding remedy of the alleged deficiencies. If the parties are not able to reach agreement, the United States may · seek enforcement of this Settlement Agreement and Plan from the Court consistent with this Settlement Agreement.
I I
Respectfully submitted,
FOR THE STATE OF IOWA:
THOMAS J Governor
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~d~1 THOMAS J. ILLER Attorney neral State of Iowa
puty Attorney General State of Iowa Hoover Building, 2~ Floor 1305 E. Walnut Street Des Moines, IA 50319 515/281-5164
-8-

FOR THE UNITED STATES:

United States Attorney Southern District of Iowa U.S. Court House Annex Suite 286 Des Moines, Iowa 50309-2053
(515) 284-6257

Assistant Attorney General Civil Rights Division

hief Special Litigation Section

0. TAYLOE, JR. GREGORY GONZALEZ Trial Attorneys United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave nue, N.W. Wa shington D.C. 20035
(202) 514 - 8103

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WHEREFORE, the parties to this action having agreed to the

provisions in the Settlement Agreement and Plan set forth above,

and the Court being advised in the premises, this Settlement

, Agreement and Plan are hereby entered a'#~~rder a ~ udg~

of this Court. It is so ordered, this

day of

v~

2004, at Des Moines, Iowa.

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IOWA STATE RESOURCE CENTERS PLAN
October 2004

TABLE OF CONTENTS

I. A. B.
c.
D. E.
F.
G. II. III.
A. B.
c.
D. IV.
A.
B. V.
A. B.
c.
VI. VII. VIII. IX. X. XI.

Definitions

1

Competency-Based Training

1

Restraint

1

Time Out

2

Behavior Support Plan

3

Individual Support Plan

3

Consistent With Current, Generally Accepted Professional Standards of 3 Care

Effective Date

4

Introduction

4

Protection from Harm

4

Restraint

4

Time Out

7

Abuse, Neglect and Incident Management

8

Quality Assurance

11

Integrated Protections, Services, Treatments and Supports

12

Interdisciplinary Teams

12

Integrated Support Plans

13

General Clinical Care

15

Supervision and Management

15

Minimum Common Elements of Clinical Care

15

At-Risk Individuals

16

Psychiatric Care and Services

17

Psychological Care and Services

20

Medical Care

22

Neurological Care

23

Nursing Care

24

Physical and Nutritional Management

25

A.

Minimum Common Elements of Physical and Nutritional Management

25

B.

Physical and Occupational Therapy

26

XII.

Communication

27

XIII. Habilitation, Training, Education & Skill Acquisition Programs

28

XIV. Serving Institutionalized Persons in the Most Integrated Setting

29

Appropriate to Their Needs

A.

Planning for Movement, Transition, and Discharge

29

B.

For Serving Persons Who Have Moved From the Resource Centers to

31

More Integrated Settings Appropriate to Their Needs

XV.

Recordkeeping and General Plan Implementation

32

II

I. Definitions:

A. Competency-Based Training

Competency-based training is a training approach geared to the attainment and demonstration of knowledge and skills to meet specified standards of performance. The elements required in a competency-based model are: information, demonstration, practice and evaluation. Competencies are specifically identified and explicitly defined in terms of specific information, concepts or skills, and criteria for successful completion of the training are established and can be objectively measured. Evaluation may consist of direct observation of skills, oral or written examination or some combination thereof, so long as the skills are objectively assessed.

B. Restraint

1. Chemical Restraint

Chemical restraint means any drug that:

a)

is administered to manage an individual's behavior in a way that reduces

the safety risk to the individual or others;

b)

has the temporary effect of restricting the individual's freedom of

movement; and

c)

is not a standard treatment for the individual's medical or psychiatric

condition.

2. Mechanical Restraint

Mechanical restraint means any device attached or adjacent to an individual's body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body. The term does not include mechanical supports used to achieve functional body position or proper balance.

3. Medical Restraint

Medical restraint is a health-related protection prescribed by a physician only where necessary during the conduct of a specific medical, including but not limited to dental, procedures, or only if necessary for protection during the time that a medical or dental condition exists, to prevent a person from inhibiting or undoing medical or dental treatment. Restraint does not include methods pursuant to written physician or dentist orders for maintaining position, or temporarily and physically stabilizing an individual for medical, dental, or diagnostic procedures.

4. Physical Restraint

Physical restraint is any approved manual method that restricts freedom of movement or normal access to one's body, contingent on maladaptive behavior. Physical restraint does not include brief, limited, and isolated use of:

a)

physical guidance and/or prompting techniques that are used to redirect

an individual or assist, support, or protect the individual during a

functional therapeutic or physical exercise activity;

b)

response blocking and brief redirection used to interrupt an individual's

limbs or body without the use of force so that the occurrence of

maladaptive behavior is prevented;

c)

holding, without the use of pressure or force, to calm or comfort, or hand

holding to escort from one area to another; and

d)

response interruption used to interrupt an individual's behavior using

approved techniques.

5. Emergency Restraint

Emergency restraint is the use of restraint:

a)

as an immediate response to an emergency safety situation that places the

individual or others at imminent and serious threat of violence or injury if

no intervention occurs;

b)

only after less restrictive measures have been determined to be

ineffective or not feasible; and

c)

when the restraint is not part of a program and contained in the

individual's Behavior Support Plan or when the restraint is not part of

written and documented medical restraint.

C. Time Out

Time out is the removal of an individual from a reinforcing or enjoyable environment to a neutral one in which reinforcement is not present, and which should be used only for a specified time. Time out may include having an individual:

a)

removed from an activity;

b)

leave the room altogether; or

c)

be placed in an unlocked room or other area from which egress is

prevented.

2

D. Behavior Support Plan (BSP)

A behavior support plan (BSP) is a comprehensive, individualized plan that addresses target behavior reduction and replacement behavior acquisition. It shall be developed consistent with current, generally accepted professional standards. The BSP contains intervention strategies designed to modify the environment, teach or increase adaptive skills and reduce or prevent the occurrence of target behaviors.

The BSP includes:

a)

The objective delineation of target behaviors, including baseline levels of

behavior;

b)

A comprehensive assessment oftarget behaviors, including integration of

assessment information from psychiatric, medical, and other disciplines;

c)

Training to acquire or increase replacement behaviors selected on the

basis of functional assessment and specific implementation procedures;

and

d)

Target behavior reduction strategies based on functional assessment and

specific implementation procedures.

The BSP is a component of the Individual Support Plan (ISP), which is designed to promote integration and provide opportunities for physical and social integration.

E. Individual Support Plan (ISP)

An Individual Support Plan (ISP) is the primary document setting out all of the protections, supports, and services to be provided to the individual. It is developed based on comprehensive assessments, consistent with current, generally accepted professional standards, by an interdisciplinary team that includes, whenever appropriate, the individual. It is a person-centered document that reflects the individual's preferences, strengths, needs and desires, and it integrates all services, supports, treatment plans, clinical care plans, and other interventions provided to or for the individual. Active treatment, supports and interventions along with a prioritized program plan with goals and objectives shall be a part of the ISP. An ISP shall identify methods to track and document progress toward the identified goals and objectives and shall document, track, and address barriers to moving toward integrated community living.

F. Consistent With Current, Generally Accepted Professional Standards of Care

A qualified professional's decision that does not so substantially depart from contemporary, accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such judgment, practice or standards.

3

G. Effective Date
The effective date hereof is October 1, 2004
II. Introduction
As part of an overall service delivery system, Glenwood State Resource Center and Woodward State Resource Center (collectively the "SRCs") provide care and treatment based upon evidence-based practices and empirically supported approaches designed to strengthen and support the individual's ability to function, to grow and develop in ways benefiting quality of life, to attain self-help and social skills, to minimize regression or loss of skills, and to provide for reasonable safety, security and freedom from undue bodily restraint, where possible.
III. Protection From Harm
SRCs shall provide individuals with a safe and humane environment and ensure that they are protected from harm.
A. Restraint
I . Effective immediately, the SRCs shall not place any individual in prone restraint.
2. By six months from the effective date hereof, the SRCs shall ensure that:
a) The use of a restraint is permissible only when less restrictive measures have been considered or attempted consistent with current, generally accepted professional standards of care; and
b) The restraint is used only pursuant to current, generally accepted professional standards and not used as punishment, as a substitute for treatment, training or habilitation programs, or for the convenience of staff.
3. By six months from the effective date hereof, the SRCs shall:
a) Review, revise, and develop as necessary policies, procedures, and protocols governing the use of restraints in behavioral and medical emergencies. This policy will define "approved" techniques for both safety purposes as well as emergency restraint. All staff responsible for the direct support of individuals will have successfully completed competency-based training.
b) Limit the use of all restraints, other than medical restraint, to emergency situations in which there is imminent risk of harm to the individual, or others. If medical restraints are required for routine medical or dental care for an individual, that person's individual support plan shall include treatments or strategies to minimize or eliminate need for restraint.
4

4. In furtherance of these goals, the interdisciplinary team serving each individual shall:
a) By one month from the effective date hereof, identify each individual who has had programmatic or emergency mechanical, physical, or chemical restraint during the past year.
b) By two months from the effective date hereof, for each person identified above, commence a formal, written, comprehensive functional assessment or analysis, and by 18 months from the effective date hereof, complete all such assessments or analyses consistent with generally accepted professional standards of care.
c) By six months from the completion of all assessments and analyses, for each person identified above, develop, implement, or review and revise the behavior support plan, based on that individual's particular strengths, specifying:
1. The objectively defined behavior to be treated that leads to the use of the restraint;
II. Alternative, positive adaptive behaviors to be taught to the individual to replace the behavior that initiates the use of the restraint, as well as other programs, where possible, to reduce or eliminate the use of such restraint;
111. Active treatment strategies that have been considered, that were attempted when appropriate, and that would not protect the person and/or others from harm; and
IV. The type of restraint authorized, the restraint's maximum duration, the designated approved restraint situation, and the criteria for terminating the use of the restraint.
5. The SRCs shall require that:
a) By eight months from the effective date hereof, no restraint shall be used that is prohibited by the individual's medical orders or Individual Support Plan;
b) Commencing by three months of the effective date hereof and fully implemented by 18 months from the effective date hereof, a physician, physician's assistant, nurse practitioner, or a Registered Nurse with training in application and assessment of restraint, shall conduct and document a face-toface examination of an individual within 30 minutes after the individual is placed in restraint;
c) Beginning immediately, as staffing levels permit, and with full implementation by eighteen months from the effective date hereof, staff trained in the application and assessment of restraint shall check the individual as soon as possible but no later than 15 minutes from the start of the restraint to review the application and consequence of restraint. A nurse or licensed health care
5

professional shall monitor and document vital signs, respiration, circulation and mental status of an individual in restraints at least every 30 minutes from the start of the restraint, except for medical restraint pursuant to a physician's order. In each instance of a medical restraint, the physician shall specify the schedule and type of monitoring required, consistent with current, generally accepted professional standards of care and the person's medical condition;
d) By one month from the effective date hereof, every restrained limb shall be released from restraint, examined for bruising and skin tears, and be exercised at least ten minutes every two hours;
e) By one month from the effective date hereof, every individual in restraint shall be provided a documented opportunity to eat at regular meal times, or as near such time as possible;
f) By one month from the effective date hereof, every individual in restraint shall be provided an opportunity to drink fluids and use a bed pan or toilet, as necessitated by the individual's needs, but not less frequently than every two hours;
g) By one month from the effective date hereof, an individual in mechanical or physical restraint, other than medical restraint, shall be under continuous one-toone supervisiOn;
h) By one month from the effective date hereof, every use of restraint shall be documented consistent with current, generally accepted professional standards of care;
i) By one month from the effective date hereof, an individual in restraint shall be released from restraint as soon as the individual does not pose an imminent risk of harm to any person, or as soon as the individual's treating physician determines, in the case of a medical restraint, that the restraint is no longer necessary;
j) By six months from the effective date hereof, the terms of the consent given for such restraint, except for emergency restraint, shall be set forth specifically in writing and shall include the name ofthe guardian or health care representative providing such consent, any limitations on the use of such restraint, and any risk associated with such restraint;
k) By eight months from the effective date hereof, the professional(s) responsible for the behavior support plan and the staff authorized to implement it shall be identified in the behavior support plan; and
I) By one year from the effective date hereof, the frequency and manner with which behavioral data are to be recorded by direct care staff shall be identified in the behavior support plan and shall be implemented.
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6. By one year from the effective date hereof, the SRCs shall review and revise, as appropriate, the behavior support plan of any individual placed in restraint, other than medical restraint, more than three times in any four-week period.
7. By six months from the effective date hereof, the SRCs shall ensure the regular practice of reviewing each use of restraint, other than medical restraint, and ascertaining the circumstances under which such restraint was used. The review shall take place within three business days of the start of each instance of restraint, other than medical restraint. Behavior support plans shall be revised, as appropriate.
8. By one year from the effective date hereof, the SRCs shall ensure that all direct care staff have successfully completed competency-based training in:
a) Restraint use;
b) How to properly redirect behaviors without resorting to undue use of restraint; and
c) How to provide adequate supervision to any individual in restraint.
B. Time Out
1. By six months from the effective date hereof, the SRCs shall eliminate, to the extent practicable, use of time out.
2. By one month from the effective date hereof, the SRCs shall ensure that use of time out is permissible only when:
a) Less restrictive measures have been considered or attempted; and
b) It does not substitute for treatment.
3. By one month from the effective date hereof, time out to a room or area from which egress is prevented only shall be used as part of a behavior support plan.
4. By one month from the effective date hereof, the SRCs shall ensure that time out is used only pursuant to current, generally accepted professional standards and not used as punishment, in lieu of training or habilitation programs, or for the convenience of staff.
5. By one year from the effective date hereof, the SRCs shall review, revise, as appropriate, and implement time out policies, procedures, and protocols that are consistent with current, generally accepted professional standards of care.
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C. Abuse, Neglect and Incident Management
The SRCs shall not tolerate abuse or neglect of individuals and shall continue to require that staff report abuse or neglect of individuals. All of the provisions in this subsection C shall be implemented by twelve months from the effective date hereof.
1. The SRCs shall review, revise, as appropriate, and implement incident management policies, procedures and practices that are consistent with current, generally accepted professional standards of care. Such policies, procedures and practices shall require:
a) A commitment that the SRC shall not tolerate abuse or neglect of individuals and that staff are required to report abuse or neglect of individuals.
b) The immediate reporting by staff to supervisory personnel and the Superintendent (or that official's designee) of serious incidents, including but not limited to death, abuse, neglect, and serious injury, and the prompt reporting by staff of these and all other unusual incidents, using standardized reporting.
c) Mechanisms to ensure that, when serious incidents such as allegations of abuse, neglect, and/or serious injury occur, SRC staff take immediate and appropriate action to protect the individuals involved, including removing alleged perpetrators from direct contact with individuals pending either the investigation's outcome or at least a well-supported, preliminary assessment that the employee poses no risk to individuals or the integrity of the investigation.
d) Competency-based training, at least yearly, for all staff on recogni zing and reporting potential signs and symptoms of abuse and/ or neglect. Such training also shall include recognizing and addressing precursors that may lead to abuse.
e) Notification of all staffwhen commencing employment and at least yearly of their obligation to report abuse and/or neglect to Resource Center and State officials. All staff persons who are mandatory reporters of abuse or neglect shall sign a statement that shall be kept with their personnel records evidencing their recognition of their reporting obligations. The SRCs shall not tolerate any mandatory reporter's failure to report abuse or neglect.
f) Mechanisms to educate and support individuals, relatives and personal or health representatives to identify and report unusual incidents, including allegations of abuse, neglect and/or mistreatment.
g) Posting in each living unit and day program site a brief and easily understood statement of individuals' rights, including information about how to actualize such rights and how to report violations of such rights.
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h) Procedures for referring, as appropriate, allegations of abuse and/or neglect to law enforcement.
i) Mechanisms to ensure that any staff person, individual, family member or visitor who in good faith reports an allegation of abuse or neglect is not subject to retaliatory action, including but not limited to reprimands, discipline, harassment, threats or censure, except for appropriate counseling, reprimands or discipline because of an employee's failure to report an incident in an appropriate or timely manner.
j) The timely and thorough investigation of all unusual incidents.
2. SRCs shall review, revise, as appropriate, and implement policies and procedures to ensure the timely and thorough conduct of investigations. Such policies and procedures shall:
a) Provide for the conduct of investigations of all deaths, as well as allegations of abuse, neglect, mistreatment, serious injury and theft. The investigations shall be conducted by qualified investigator(s) who have a background in working with people with developmental disabilities, including persons with mental retardation, and who are not within the direct line of supervision of the alleged perpetrator.
b) Ensure that only SRC staffwho have successfully completed competencybased training on the conduct of investigations be allowed to conduct investigations of all other unusual incidents.
c) Ensure that the facilities' investigations are coordinated with any investigations completed by law enforcement agencies so as not to interfere with such investigations.
d) Provide for the safeguarding of evidence.
e) Develop and implement standardized procedures and protocols for the conduct of investigations that are consistent with current, generally accepted professional standards of care. Such procedures and protocols shall require that:
1. Investigations commence within 24 hours or sooner, if necessary, of the incident being reported;
11. Investigations be completed within 5 business days of the incident being reported;
111. Each investigation shall result in a written report, including a summary of the investigation, findings and, as appropriate, recommendations for corrective action. The report's contents shall be sufficient to provide a clear basis
9

for its conclusion. The report shall set forth explicitly and separately:
a. Each allegation of wrongdoing investigated;
b. The name(s) of all witnesses;
c. The name(s) of all alleged victims and perpetrators;
d. The names of all persons interviewed during the investigation;
e. For each person interviewed, a report of the questions asked and answers given;
f. All documents reviewed during the investigation;
g. All sources of evidence considered, including previous investigations known to the SRCs, and their results, involving the alleged victim(s) and perpetrator(s);
h. The investigator's findings; and
1. The investigator's reasons for his/her conclusions.
3. The written report, together with any other relevant documentation, shall be reviewed by staff supervising investigations to ensure that the investigation is thorough and complete and that the report is accurate, complete and coherent. Any deficiencies or areas of further inquiry in the investigation and/or report shall be addressed promptly.
4. Whenever disciplinary or programmatic action is necessary to correct the situation and/or prevent reoccurrence, the SRCs shall implement such action promptly and thoroughly, and track and document such actions and the corresponding outcomes.
5. Records of the results of every investigation of abuse, neglect, and serious injury at each SRC shall be maintained in a manner that permits investigators and other appropriate personnel to easily access every investigation involving a particular staff member or individual.
6. Each SRC shall have a system to allow the tracking and trending of unusual incidents and investigation results. Trends shall be tracked by at least the following categories:
a) Type of incident;
b) Staff involved and staff present;
c) Individuals directly and indirectly involved;
10

d) Location of incident;
e) Date and time of incident;
f) Cause(s) of incident; and
g) Outcome of investigation.
7. Before permitting a staff person to work directly with any individual, the SRCs shall investigate the criminal history and other relevant background factors of that staff person, whether full-time or part-time, temporary or permanent, or a person who volunteers on a regular basis. Facility staff shall directly supervise volunteers for whom an investigation has not been completed when they are working directly with individuals living at the facility. The facility shall ensure that nothing from that investigation indicates that the staff person or volunteer would pose a risk of harm to individuals at the SRC.
D. Quality Assurance
By three months from the effective date hereof, the SRCs shall begin to develop/revise, and implement quality assurance mechanisms that enable the SRCs to comply fully with this Iowa State Resource Center Plan; that timely and adequately detect problems with the provision of adequate protections, services and supports and ensure that appropriate corrective steps are implemented; and that are otherwise consistent with current, generally accepted professional standards of care. By two years from the effective date hereof, the SRCs shall fully implement a quality assurance system that:
1. Tracks data with sufficient particularity to identify trends across, among, within and/or regarding:
a) Program Areas;
b) Living units;
c) Work shifts;
d) Protections, supports and services;
e) Areas of Care;
f) Individual staff; and/or
g) Individuals receiving services and supports.
2. Analyzes data regularly and, whenever appropriate, requires the development and implementation of corrective action plans to address problems identified through the quality assurance process. Such plans shall identify:
11

a) The actions that need to be taken to remedy and/or prevent the reoccurrence of problems;
b) The anticipated outcome of each action step; and
c) The person(s) responsible, and the time frame in which each action step must occur.
3. Disseminates corrective action plans to all entities responsible for their implementation, and:
a) Monitors and documents corrective action plans to ensure that they are implemented fully and in a timely manner, and that they have the desired outcome of remedying or reducing the problems originally identified; and
b) Modifies corrective action plans, as necessary, to ensure their effectiveness.
IV. Integrated Protections, Services, Treatments and Supports
The SRCs shall provide and implement an integrated Individual Support Plan (ISP) for each individual developed by an interdisciplinary team, that ensures that individualized protections, services, supports, and treatments are provided consistent with current, generally accepted professional standards of care.
A. Interdisciplinary Teams
By one year from the effective date hereof, the interdisciplinary team for each individual shall:
1. Provide services and supports that facilitate the individual's ability to exercise his/her choices and enhance his/her ability to develop independence and exercise selfdetermination.
2. Be facilitated by one person from the team who shall ensure that members of the team participate in assessing each individual, developing, monitoring and revising treatments, services, and supports.
3. Consist of the individual, the Qualified Mental Retardation Professional, other professionals dictated by the person's strengths, preferences, and needs, staff who regularly and directly provide services and supports to the person, and, as appropriate, the individual's family, guardian, advocates, attorneys, and other clinical staff.
4. Conduct comprehensive assessments, routinely and in response to significant changes in the individual's life, to determine the individual's strengths, preferences and needs, consistent with current, generally accepted professional standards of care.
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5. Ensure assessment results are used to develop, implement, and revise as necessary, an ISP that outlines the protections, services and supports to be provided to the individual.
B. Integrated Support Plans
The SRCs shall:
1. By three months from the effective date hereof, begin to review, revise as appropriate, and implement policies and procedures that provide for the development of integrated individual support plans (ISPs) for each individual, consistent with current, generally accepted professional standards of care, with full implementation by twelve months from the effective date hereof.
2. By two years from the effective date hereof, an ISP shall be developed and implemented for each individual that:
a) Identifies each individual's strengths, needs, preferences, and desires;
b) Addresses, in a manner building on the individual's preferences and strengths, each individual's prioritized needs, provides an explanation for any need or barrier which is not addressed, identifies the supports that are needed, and encourages community participation;
c) Specifies individualized, observable and/or measurable behavioral goals/objectives, the treatments or strategies to be employed, and the necessary supports to:
1. attain identified outcomes related to each preference;
11. meet needs; or
111. overcome identified barriers to living in the most integrated setting appropriate to his/her needs;
d) Integrates all protections, services and supports, treatment plans, clinical care plans, and other interventions provided for the individual;
e) Identifies the methods for implementation, time frames for completion, and the person(s) responsible;
f) Provides interventions, strategies, and supports that effectively address the individual's needs for services and supports and are practical and functional in the most integrated setting appropriate to meet the person's needs; and
g) Identifies the data to be collected and/or documentation to be maintained and the frequency of data collection in order to permit the objective analysis of the
13

individual's progress, the person(s) responsible for the data collection, and the person(s) responsible for the data review.
3. By three months from the effective date hereof, begin to ensure goals, objectives, anticipated outcomes, services, supports and treatments are coordinated in the ISP, and by two years from the effective date hereof ensure such coordination within the ISP.
4. Commencing by three months from the effective date hereof, and with full implementation within two years from the effective date hereof, ensure that each ISP is accessible, comprehensible and appropriate for the capabilities of the staff responsible for implementing it.
5. Commencing by three months from the effective date hereof, and with full implementation within two years from the effective date hereof, ensure that, unless otherwise expressly indicated, at least monthly, and more often as the needs of the individual dictate, the responsible interdisciplinary team member(s) for each program or support included in the ISP, review(s) and analyze(s) the data and other information necessary to assess the progress and efficacy of current interventions. If there is a lack of expected progress and/or a significant change in the individual's status has occurred, the interdisciplinary team shall meet to determine if the ISP needs to be modified, and shall modify the ISP as appropriate.
6. Commencing by three months from the effective date hereof, and with full implementation within one year from the effective date hereof, ensure the ISP for school-age students is coordinated with the development of the Individualized Educational Programs (IEPs) to ensure they are consistent and/or compatible.
7. Upon completion of the revised policies and procedures, require all staff responsible for the development and implementation of individuals' ISPs to successfully complete related competency-based training. Training of existing staff shall be completed within 18 months hereof. Once this initial training is completed, the State shall require all staff successfully to complete related competency-based training commensurate with their duties upon their initial employment and on an ongoing, asneeded basis, with refresher training provided at least every 12 months thereafter. Such training shall include training on all policies and procedures and, for staff responsible for implementing ISPs, on the implementation of individuals' individualized plans.
8. By three months from the effective date hereof, each SRC shall designate one person who shall ensure that appropriate training and technical assistance is provided to teams responsible for the development and implementation ofiSPs, and to provide quality assurance oversight for the revised individual planning process.
9. To the fullest extent as soon as possible, but no later than 24 months from the effective date hereof, ensure that interdisciplinary teams have a caseload permitting them to perform the steps set forth in Section B.
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10. Commencing within six months from the effective date hereofwith full implementation by 18 months from the effective date hereof, develop and implement quality assurance processes to ensure that the ISPs developed are consistent with current, generally accepted professional standards and are implemented in an appropriate and timely manner. Whenever problems are identified, develop and implement plans to remediate the problems.

V. General Clinical Care

A. Supervision and Management

The SRCs shall provide supervision and management of clinical services and shall implement an organizational structure to provide integrated clinical services (general medicine, psychology, psychiatry, nursing, dentistry, pharmacy, physical therapy, speech therapy, dietary and occupational therapy) consistent with current, generally accepted professional standards of care.

1. By six months from the effective date hereof, SRCs shall begin to implement a clinical services peer review system, which shall be implemented fully by two years from the effective date hereof.

2. By one year from the effective date hereof, the appropriate clinician shall review recommendations from non-SRC clinicians. The review and documentation shall include whether or not to adopt the recommendations and, if adopted, how to integrate the recommendation into the individual's overall health care plan.

B.

Minimum Common Elements of Clinical Care

1.

By six months from the effective date hereof, SRCs shall begin to provide

preventive, routine, specialized and emergency clinical services consistent with

current, generally accepted professional standards of care, with full

implementation by two years from the effective date hereof. The SRCs shall

require that:

a) Individuals' needs shall be timely detected through assessments or evaluations that are performed on a regular basis and performed in response to developments or changes in an individual's status, consistent with current, generally accepted professional standards ofcare;

b) Diagnoses shall be consistent with current, generally accepted professional standards of care;

c) Treatments and interventions shall be consistent with current, generally accepted professional standards of care;

d) Clinical indicators by which efficacy oftreatments and interventions shall be measured shall be specified consistent with current, generally accepted professional standards of care;

15

e) A system shall be established and maintained to monitor the health status of individuals consistent with current, generally accepted professional standards of care; and

f) Treatments and interventions shall be modified in response to clinical indicators, consistent with current, generally accepted professional standards of care.

2.

By six months from the effective date hereof, the SRCs shall begin to establish

and implement integrated clinical services policies, procedures, and protocols

consistent with current, generally accepted professional standards of care, with

full implementation by two years from the effective date hereof.

C. At-Risk Individuals

The SRCs shall identify individuals whose health or well-being is at risk by implementing a risk screening, assessment and management system consistent with current, generally accepted professional standards of care. At a minimum this will include: use of an enteral tube; dysphagia; aspiration or aspiration pneumonia; upper airway obstruction; obesity or underweight status; unplanned weight change; epilepsy or seizures; gastroesophageal reflux disease; use of a colostomy or ileostomy; osteoporosis; multiple fractures; decubitus ulcers; injury to self or others from behavioral problems; multiple falls within a one-year period; tracheotomy; ventilator dependence; and/or any other acute or chronic condition that places an individual at health risk.

The SRCs shall also:

1. By one year from the effective date hereof, design and implement a risk assessment and management system, and establish criteria for identification of individuals at risk, consistent with current, generally accepted professional standards of care.

2.

By one year from the effective date hereof, screen individuals on a regular basis,

consistent with current, generally accepted professional standards of care to

determine their at-risk status.

3.

Perform an interdisciplinary assessment of services and supports after an

individual is identified as at-risk and in response to changes in an at-risk

individual's condition, as measured by established at-risk criteria. In each

instance, the interdisciplinary team will start the assessment process as soon as

possible but within five working days.

4.

By one year from the effective date hereof, establish and implement within 30

days of the interdisciplinary assessment an individualized services and supports

plan for each individual, as appropriate, to meet needs identified by the

interdisciplinary assessment, including preventive interventions to minimize the

condition of risk, except that the SRCs shall take more immediate action when

16

the risk to the individual warrants. Such plans shall be integrated into the ISP and shall include the clinical indicators to be monitored and the frequency of monitoring.

VI. Psychiatric Care and Services

By six months from the effective date hereof, SRCs shall begin to provide psychiatric services by a qualified professional consistent with current, generally accepted professional standards to individuals who require such services, with full implementation by two years from the effective date hereof.

1.

By six months from the effective date hereof, the SRCs shall ensure that no

individual shall receive psychotropic medication without having been evaluated

and diagnosed consistent with current, generally accepted professional standards

of care.

2. By six months from the effective date hereof, SRCs shall ensure that psychotropic medication plans developed and implemented by SRC staff are consistent with current, generally accepted professional standards of care. Psychotropic medications shall not be used as punishment; as a substitute for a treatment program; in the absence of a psychiatric diagnosis, neuropsychiatric diagnosis, or specific behavioral-pharmacological hypothesis; or for the convenience of staff.

3.

Commencing within three months ofthe effective date hereof and fully

implemented by eighteen months from the effective date hereof, SRCs shall

ensure that:

a) A nurse will observe for a minimum of 60 minutes following administration of a chemical restraint and will document the individual's response and notify a physician of adverse effects; and

b) A physician, physician's assistant, nurse practitioner, or a Registered Nurse with training in the administration and assessment of chemical restraint shall conduct and document a face-to-face examination of an individual within 30 minutes after the individual is administered a chemical restraint. A physician shall conduct a face-to-face assessment within 24 hours. The psychiatrist shall assess the effects of the chemical restraint by reviewing the use of the chemical restraint on the psychiatrist's next working day.

c) If pre-sedation is to be used for routine medical or dental care for an individual, that person's individual support plan shall include treatments or strategies to minimize or eliminate the need for pre-sedation, and the use of pre-sedation shall be appropriately coordinated with other medications, supports and services, and monitored and assessed, consistent with generally accepted professional standards of care.

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4. By one month from the effective date hereof, each SRC shall employ a minimum of one full-time equivalent board certified or board eligible psychiatrist(s) to ensure the provision of services necessary for implementation of this section of the plan.

5. By six months from the effective date hereof, the SRCs shall begin to develop and implement protocols to reach a psychiatric diagnosis, consistent with current, generally accepted professional standards of care, with full implementation within one year from the effective date hereof.

6. By six months from the effective date hereof, the SRCs shall begin to develop and implement a protocol, consistent with current, generally accepted professional standards of care, to screen each individual upon admission for possible psychiatric disorders and ensure that identified individuals, including all individuals admitted with a psychiatric diagnosis or prescribed psychotropic medication, receive a comprehensive psychiatric assessment and evaluation according to the protocols above, with full implementation within one year from the effective date hereof.

7. By six months from the effective date hereof, the SRCs shall begin to develop and implement a protocol to screen each individual residing at each facility for possible psychiatric disorders and ensure that individuals with possible psychiatric disorders receive a comprehensive psychiatric assessment and evaluation according to the protocols above, and diagnoses are consistent with the current DSM or neuropsychiatric criteria, and/or a specific behavioralpharmacological hypothesis with full implementation within one year from the effective date hereof.

8. By two years from the effective date hereof, the SRCs shall develop and implement a system to integrate pharmacological treatments with behavioral and other interventions through combined assessment and case formulation.

a)

Before a proposed behavior support plan is implemented, the

interdisciplinary team, including the psychiatrist, shall determine the least

intrusive and most positive interventions to treat the behavioral or

psychiatric condition, and whether the individual will best be served

primarily through behavioral, pharmacology, or other interventions, in

combination or alone. Consideration should be given to the relative risk,

contraindications, types of interventions and interaction effects. If it is

concluded that the individual is best served through use of psychotropic

medication, the ISP must also specify non-pharmacological treatment,

interventions or supports to address signs and symptoms in order to

minimize need for psychotropic medication to the degree possible.

b)

Before the non-emergency administration of psychotropic medication,

the interdisciplinary team, including the psychiatrist, primary care

physician and nurse, shall determine whether the harmful effects of the

individual's mental illness outweigh the possible harmful effects of

18

psychotropic medication and whether reasonable alternative treatment strategies are likely to be less effective or potentially more dangerous than the medications.

c)

When psychotropic medication is prescribed as part of an ISP, the

psychiatrist shall ensure the treatment plan for the psychotropic

medication includes:

1. a diagnosis consistent with current DSM, or neuropsychiatric criteria, and/or a specific behavioral-pharmacological hypothesis;

11. the objective signs/symptoms which will be used to evaluate effectiveness of the medication and how these will be measured; and

llJ. the expected time line for the therapeutic effects of the medication to occur.

9. By six months from the effective date hereof, the SRCs shall begin to ensure that the interdisciplinary team, including the psychiatrist, provides ongoing monitoring of the psychiatric treatment identified in the treatment plan as often as necessary, based on the individual's current status and/or changing needs, but no less often than quarterly, with full implementation within two years from the effective date hereof.

The monitoring shall consist of a mental status examination, including face-toface assessment; an assessment of diagnostic criteria to ensure that medications are appropriate, prescribed at the lowest, most effective dose, and specifically matched to a clinically justifiable diagnosis; a review of behavior program data; a review of side effects of medication; a review of adverse drug reactions; a review of drug/drug interactions; a review of the general health status of the individual; an assessment of the psychotropic medication against identified signs/symptoms; and a reassessment of symptoms, diagnoses and treatment.

10. By one year from the effective date hereof, the SRCs shall develop and implement a facility-level review system to monitor as often as necessary, based on the individual' s current status and/or changing needs, but at least monthly, the prescriptions of two or more psychotropic medications from the same general class (e.g., two antipsychotics, two antidepressants, two stimulants, etc.) to the same individual as well as the prescription of a total of three or more psychotropic medications to the same individual, and to ensure that the use of such medications is clinically justified, consistent with current, generally accepted professional standards of care.

11. By one year from the effective date hereof, the SRCs shall develop and implement a system consistent with current, generally accepted professional standards of care for monitoring, detecting, reporting and responding to side

19

effects of psychotropic medication as determined by the physician, based on the individual's current status and/or changing needs, but at least quarterly.
12. By one month from the effective date hereof, the SRCs shall obtain informed consent or proper legal authorization (except in the case of an emergency) from guardians and/or health care representatives, prior to administering psychotropic medications or other restrictive procedures.

VII. Psychological Care and Services

By six months from the effective date hereof, the SRCs shall begin to provide individualized services and comprehensive programs developed by qualified professionals consistent with current, generally accepted professional standards of care, to promote the growth, development and independence of all individuals, to minimize regression and loss of skills, and to ensure reasonable safety, security, and freedom from undue use of restraint, with full implementation by three years from the effective date hereof.

1. The SRCs shall maintain at each facility a qualified director of psychology who is responsible for maintaining a consistent level of psychological care throughout the facility.

2. By six months from the effective date hereof, SRCs shall begin to establish a psychology peer review system to review behavior support plans, with full implementation by two years from the effective date hereof.

3. Commencing within one month from the effective date hereof and with full implementation within twelve months from the effective date hereof, the SRCs shall develop and implement standard protocols for data collection, including methods to monitor and review the progress of each person in meeting the goals of the individual's behavior support plan.

a)

Data collected pursuant to these protocols shall include information

about target and replacement behaviors and conditions under which

they occur, including, where appropriate, the frequency, intensity and

duration ofbehaviors.

b)

Data collected pursuant to these protocols shall be reviewed at least

monthly by qualified professionals to assess progress and to modify

behavior support programs where the individual has shown no

measurable progress over a period of time.

c)

These protocols shall include methods for assessing the reliability of

data collection and, as necessary, correcting data collection procedures.

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4. By one month from the effective date hereof, the SRCs shall develop and implement standard psychological assessment protocols, consistent with current, generally accepted professional standards of care, that allow for the identification of:

a)

medical, psychiatric, environmental or other reasons for target

behaviors; and

b)

other psychological needs that may require intervention, including but

not limited to, physical or severe emotional abuse or Post Traumatic

Stress Disorder.

5. By one year from the effective date hereof, the SRCs shall ensure that psychological assessments are based on current, accurate, and complete clinical and behavioral data.

6. By eighteen months from the effective date hereof or one month from the individual's admittance to an SRC, whichever date is later, and thereafter as often as needed, the SRCs shall complete a psychological assessment of each individual pursuant to the standard psychological assessment protocols established by the facilities.

7. By one month of the assessment required in VI.6, above, those individuals needing psychological services shall receive such treatment, consistent with current, generally accepted professional standards of care. Documentation shall be provided in such a way that progress can be measured to determine the efficacy of treatment.

8. By one month from the date of the individual's psychological assessment, the SRCs shall develop and implement an individual behavior support plan for each person who is exhibiting behaviors that constitute a risk to the health or safety of the individual or others or serve as a barrier to learning and independence and have been resistant to less formal interventions. The behavior support plan shall include:

a)

specification ofbehavior(s) for which the plan is being developed;

b)

procedures for measuring outcomes;

c)

relevant assessment information;

d)

relevant replacement behaviors that are consistent with the overall goals

of the individual's program;

e)

a description of interventions to be used to reduce problem behavior and

to strengthen alternative behavior;

f)

procedures to facilitate generalization and maintenance; and

21

g)

information relevant to competency-based training and monitoring for

staff implementing the plan.

Documentation regarding the plan's implementation shall be gathered and maintained in such a way that progress can be measured to determine the efficacy of treatment.

9. By six months from the effective date hereof, the SRCs shall begin to ensure that behavior support plans are written so that they can be understood and implemented by direct care staff, with full implementation within two years from the effective date hereof.

10. By six months from the effective date hereof, the SRCs shall begin to ensure that direct care staff successfully complete competency-based training on the overall purpose and objectives ofthe specific behavior support plans for which they are responsible and how to implement behavior support plan and training procedures, with full implementation within two years from the effective date hereof.

11. By six months from the effective date hereof, SRCs shall begin to revise and update each individual's behavior support plan whenever necessary, with full implementation within two years from the effective date hereof.

12. Beginning within six months from the effective date hereof, with full implementation within three years from the effective date hereof, the SRCs shall:

a)

Maintain a 1:30 ratio of psychologists with specialized training in

subjects such as applied behavior analysis and positive behavior supports

to provide services for the general population. Specialized training may

include coursework or training provided as part of employment; and

b)

Maintain one (1) psychology assistant for every psychologist.

VIII. Medical Care

The SRCs shall ensure that the individuals they serve receive routine, preventive, and emergency medical and dental care consistent with current, generally accepted professional standards. The SRCs shall ensure that individuals with health problems are identified, assessed, diagnosed, and treated consistent with current, generally accepted professional standards of care.

1. The SRCs shall maintain a medical director responsible for medical care, consistent with current, generally accepted professional standards.

2. By two years from the effective date hereof, the SRCs shall establish and maintain a medical peer review system.

3. By three months from the effective date hereof, the SRCs shall begin to maintain a medical quality improvement process that collects data relating to the quality of

22

medical services; assesses these data for trends; initiates outcome-related inquiries; identifies and initiates corrective action; and monitors to ensure that remedies are achieved, with full implementation within two years from the effective date hereof.
4. By three months from the effective date hereof, the SRCs shall maintain a system to track and address errors in the administration of medication.
5. By three months from the effective date hereof, the SRCs shall establish those policies and procedures that ensure provision of medical care consistent with current, generally accepted medical standards.
IX. Neurological Care
The SRCs shall ensure that individuals with a neurological diagnosis are treated and monitored by a neurologist consistent with current, generally accepted standards of care.
1. By three months from the effective date hereof, the SRCs shall ensure that each individual admitted with a neurological diagnosis is evaluated by a neurologist within thirty (30) days.
2. By three months from the effective date hereof, the SRCs shall ensure that standard seizure management plans are developed and implemented consistent with current, generally accepted professional standards of care.
3. By three months from the effective date hereof, the SRCs shall ensure that a neurologist evaluates each individual having a seizure disorder diagnosis at least annually and more frequently as necessary.
4. By three months from the effective date hereof, the SRCs shall ensure that those individuals having seizures significantly refractory in terms of each individual circumstance receive neurological intervention consistent with current, generally accepted professional standards of care.
5. By three months from the effective date hereof, the SRCs shall ensure that each person receiving anticonvulsant medications is monitored for side effects consistent with current, generally accepted professional standards of care.
6. By three months from the effective date hereof, the SRCs shall minimize the use of older anticonvulsant medications with greater side effects in favor of those with fewer side effects consistent with each individual's circumstances.
7. By three months from the effective date hereof, the SRCs shall ensure that each person who has remained seizure free for more than two years is evaluated by a neurologist to determine the continued appropriateness of any anticonvulsant medication treatments that person is receiving.
23

8. By three months from the effective date hereof, the SRCs shall ensure that the neurologist and psychiatrist coordinate the use of medications, through the interdisciplinary team process, when they are prescribed for both seizures and a mental health disorder.
X. Nursing Care
The SRCs shall ensure that individuals receive nursing care consistent with current, generally accepted professional standards of care. Nurses shall document nursing assessments, identify health care problems, notify physicians of health care problems, monitor, intervene, and keep appropriate records of the individuals' health care status. The SRCs shall:
1. By one year from the effective date hereof, in addition to the ISP reviews, update nursing assessments of the nursing care needs of each individual on a quarterly basis and more often as needed.
2. By six months from the effective date hereof, begin to update nursing diagnoses and nursing care plans to address each individual's health care needs on a quarterly basis or more often and as needed, with full implementation within two years from the effective date hereof. Plans shall be integrated into individuals' ISPs.
3. By six months from the effective date hereof, begin to establish nursing assessment and reporting protocols for medical conditions consistent with current, generally accepted professional standards of care, with full implementation within one year from the effective date hereof.
4. By six months from the effective date hereof, begin to develop and implement a system of recording clinical indicators of risk consistent with current, generally accepted professional standards of care, with full implementation within one year from the effective date hereof. Plans and progress shall be discussed with the interdisciplinary team at regularly scheduled integrated reviews.
5. By three months from the effective date hereof, begin to implement a system consistent with current, generally accepted professional standards of care, to monitor and document the progress of individuals on a regular basis, and modify nursing interventions, as appropriate, with full implementation within two years from the effective date hereof.
6. By three months from the effective date hereof, begin to implement procedures for the administration of medications in a manner consistent with current, generally accepted nursing standards of care and provide the necessary supervision and training to minimize medication errors, with full implementation within one year from the effective date hereof.
24

XI. Physical and Nutritional Management

A.

Minimum Common Elements of Physical and Nutritional Management

The SRCs shall provide each individual with physical and nutritional management care consistent with current, generally accepted professional standards of care. By three years from the effective date hereof, the SRCs shall maintain at each facility an interdisciplinary physical and nutritional management team to address individuals' physical and nutritional management needs. The physical and nutritional management team should consist of a registered nurse, physical therapist, occupational therapist, dietician, speech pathologist, and, as needed, a medical doctor. All members of the team should have specialized training or experience demonstrating competence in working with individuals with complex physical and nutritional management needs. The SRCs shall identify each individual who has a physical or nutritional management problem and provide such individuals with appropriate interventions and supports. The SRCs shall:

1. Ensure that, beginning six months from the effective date hereof, and with full implementation within three years from the effective date hereof, the interdisciplinary physical and nutritional management team shall assess each individual having physical and nutritional management problems to identify the causes of such problems.

2. By six months from the effective date hereof, begin to maintain and implement adequate mealtime, oral hygiene, and oral medication administration plans ("mealtime and positioning plans") for individuals who cannot feed themselves, require positioning assistance associated with swallowing activities, have difficulty swallowing, or who are at risk of choking and/or aspiration (collectively, individuals having "physical or nutritional management problems"), which plans shall address feeding and mealtime techniques, and positioning of the individual during mealtimes and other activities that are likely to provoke swallowing difficulties, with full implementation within three years from the effective date hereof.

3. By three months from the effective date hereof, ensure staff engage in mealtime practices that do not pose an undue risk of harm to any individual. Individuals shall be in proper alignment during and after meals or tube feedings, with full implementation within six months from the effective date hereof.

4. By six months from the effective date hereof, begin to develop and implement positioning plans for each non-ambulatory individual with physical or nutritional management problems, with full implementation within three years from the effective date hereof.

5. By six months from the effective date hereof, begin to ensure that staff responsible for individuals with physical or nutritional management problems have successfully completed competency-based training in how to implement the

25

mealtime and positioning plans that they are responsible for implementing, with full implementation within three years from the effective date hereof.

6. By six months from the effective date hereof, begin to monitor the implementation of mealtime and positioning plans to ensure that the staff demonstrates competence in safely and appropriately implementing such plans, with full implementation within three years from the effective date hereof.

7. By six months from the effective date hereof, begin to develop and implement a system to monitor the progress of individuals with physical or nutritional management difficulties, and revise interventions as appropriate, with full implementation within three years from the effective date hereof.

8. By six months from the effective date hereof, evaluate each individual fed by a tube to ensure that the continued use of the tube is medically necessary. Where appropriate, implement a plan to return the person to oral feeding.

B. Physical and Occupational Therapy

The SRCs shall provide individuals in need of physical therapy and occupational therapy with services that are consistent with current, generally accepted professional standards of care to enhance their functional abilities. The SRCs shall:

I. By eighteen months from the effective date hereof, conduct occupational and physical therapy screenings of all individuals residing at each facility. Ensure that individuals identified with therapy needs, including functional mobility, receive a comprehensive assessment consistent with current, generally accepted professional standards of care. By six months from the effective date hereof, the SRCs shall begin to implement the following with full implementation by three years from the effective date hereof:

a)

Comprehensive occupational therapy assessments, as needed, that shall

consider significant medical issues and health risk indicators, in

accordance with generally accepted standards of practice, including but

not limited to scoliosis and/or deformities; posture; upper extremity

function, including muscle tone and range of motion; transfer status; and

positioning options;

b)

Comprehensive physical therapy assessments, as needed, that shall

consider: significant medical issues and health risk indicators in

accordance with generally accepted standards of practice, including but

not limited to scoliosis and/or deformities; lower extremity function,

including muscle tone, range of motion and trunk control; and

c)

Wheeled mobility assessments, as needed, that shall incorporate the

components ofoccupational and physical therapy screenings and shall

involve interdisciplinary team members. The assessments shall ensure

that the wheelchair and positioning are promoting appropriate body

26

alignment and functional health status, as determined by applicable factors including but not limited to respiration rates; lung sounds; trunk flexibility; trunk balance; and skin integrity.

The assessments shall ensure that, for individuals with physical or nutritional management problems, the wheelchair and positioning seek to mitigate the occurrence of aspiration and positioning is integrated into the daily, 24-hour schedule.

2. By three years from the effective date hereof, SRCs shall develop and implement, as part of the ISP, occupational, physical therapy, and nutritional management plans consistent with current, generally accepted professional standards of care. The plans shall address:

a)

Individualized interventions;

b)

Objective, measurable outcomes;

c)

Positioning devices and/or other adaptive equipment; and

d)

For individuals who have regressed, interventions to minimize further

regressiOn.

3. By three years from the effective date hereof, ensure that staff responsible for implementing occupational and physical therapy plans of care, and physical and nutritional management plans of care, have successfully completed competencybased training in implementing such plans of care.

4. By three years from the effective date hereof, SRCs shall develop and implement a system to monitor and address:

a)

The status of individuals in need of occupational and physical therapy;

b)

The condition, availability and appropriateness of physical supports and

adaptive equipment; and

c)

The treatment interventions that address the occupational therapy,

physical therapy, and physical and nutritional management needs ofeach

individual.

XII. Communication

The SRCs shall provide adequate and timely speech and communication therapy services, consistent with current, generally accepted professional standards of care, to individuals who require such services. The SRC shall:

1. By eighteen months from the effective date hereof, provide a speech language pathologist, with specialized training or experience demonstrating competence in

27

subjects related to augmentative and alternative communication, to conduct assessments, develop and implement programs, provide stafftraining, and monitor the implementation of programs.

2. By six months from the effective date hereof, begin to develop and implement a screening and assessment process designed to identify individuals who would benefit from the use of alternative and/or augmentative communication systems, with full implementation within three years from the effective date hereof.

3. By six months from the effective date hereof, begin to ensure that the communication plans of individuals who would benefit from alternative and/or augmentative communication systems address their communication needs in a manner that is functional and adaptable to a variety of settings, with full implementation within three years from the effective date hereof. Plans shall be reviewed and revised, as needed, but at least annually.

XIII. Habilitation, Training, Education & Skill Acquisition Programs

The SRCs shall provide individuals with adequate habilitation, including but not limited to individualized training, education, and skill acquisition programs developed and implemented by interdisciplinary teams to promote the growth, development and independence of all individuals, to minimize regression and loss of skills, and to ensure reasonable safety, security, and freedom from undue use of restraint.

The SRCs shall:

1. By two years from the effective date hereof, conduct annual assessments, with quarterly reviews, of individuals' preferences, strengths, skills, needs, and barriers to community integration, in the areas of living, working and engaging in leisure activities.

2. By three years from the effective date hereof, use the information gained from the assessment and review process to develop, integrate, and revise programs of training, education, and skill acquisition to address each individual's needs. Such programs shall:

a)

Be current, individualized, and integrated with other supports and

serv1ces;

b)

Incorporate the person's preferences and strengths;

c)

Specify individualized, observable and/or measurable goals/objectives,

the strategies to be employed, and the necessary supports to attain

identified outcomes, in sufficient detail to enable staff to appropriately

implement the programs.

d)

Include interventions, strategies and supports that effectively address the

individual's needs for services and supports and that are practical and

28

functional in the most integrated setting consistent with the individual's needs.

e)

Include to the degree possible training opportunities in community

settings; and

f)

Identify the data to be collected and/or documentation to be maintained,

the frequency of data collection, in order to permit the objective analysis

of the individual's progress, the person(s) responsible for the data

collection, and the person(s) responsible for the data review.

3. By three years from the effective date hereof, ensure that all direct care staff have successfully completed competency-based training on the implementation of habilitation programs, including but not limited to training, education and skill acquisition programs.

4. Ensure that, unless otherwise expressly indicated, at least monthly, and more often as the needs ofthe individual dictate, the responsible interdisciplinary team member(s) for each program or support included in the ISP, review(s) and analyze(s) the data and other infonnation necessary to assess the progress and efficacy of current interventions; and if:

a)

there is a lack of expected progress; and/or

b)

significant change in the individual's status has occurred, then the

interdisciplinary team shall meet to determine if the ISP needs to be

modified, and shall modify the ISP as appropriate.

5. By three months from the effective date hereof, begin to develop and implement quality assurance processes to ensure that the habilitation, training, education and skill acquisition programs developed are consistent with current, generally accepted professional standards and are implemented in an appropriate and timely manner. Whenever problems are identified, develop and implement plans to remediate the problems, with full implementation within two years from the effective date hereof.

XIV. Serving Institutionalized Persons in the Most Integrated Setting Appropriate to Their Needs

A. Planning for Movement, Transition, and Discharge

The SRCs shall take action to encourage and assist people to move to the most integrated settings consistent with the determinations ofprofessionals that community placement is appropriate, that the transfer is not opposed by the individual, that the transfer is consistent with the individual's ISP, and the placement can be reasonably accommodated, taking into account the statutory authority of the State, the resources available to the State, and the needs of others with mental disabilities.

29

The SRCs shall provide adequate assessments, transition planning and discharge procedures for individuals who live at SRCs. The SRCs shall:

1. By one year from the effective date hereof, review, revise, as appropriate, and implement policies, procedures and practices related to transition and discharge processes. Such policies, procedures and practices shall require that:

a)

The ISP team will identify the major barriers to the individual's

movement to the most integrated setting appropriate to the individual's

needs at least annually, and more frequently as appropriate, and shall

identify, implement and document strategies to overcome such barriers.

If changes in the identified barriers are noted, the ISP team shall revise its

strategies for overcoming the barriers, as appropriate. The ISP team also

will identify and attempt to resolve, on a timely basis, outstanding

concerns of the individual, or the individual's guardian or legal

representative, regarding discharge and transition.

b)

The ISP team will identify in each individual's ISP the protections,

services and supports that need to be provided to ensure safety and the

provision of adequate habilitation in the most integrated appropriate

setting based on the individual's needs.

c)

When the most integrated setting is identified to appropriately meet an

individual's needs and the individual is accepted for and agrees to service

in that setting, then the Team shall develop and implement a transition

plan in a timely manner. Such a plan shall:

1. Specify the actions that need to be taken by the SRC, including informing the county or, as appropriate, Department ofHuman Services staff, of the proposal for the individual to move, requesting assistance in implementing the transition plan, and coordinating the transition plan with provider staff.

11. Specify the SRC positions responsible for these actions, and the time frames in which such actions are to be completed; and

111. The SRCs shall invite and encourage the active participation of the county case manager as a member of the individual's ISP team

2. By 18 months from the effective date hereof, ensure that staff responsible for the development and implementation of the individual's ISP shall successfully complete related competency-based training upon employment, and refresher training at least every twelve months thereafter. Such training shall address all policies and procedures on the development and implementation ofiSPs, as well as, as appropriate, implementation of the individual's specific plans.

3. By one year from the effective date hereof, when the individual is accepted for and agrees to service in a new setting, promptly review the comprehensive assessment, transition plan and proposed supports with the individual and, as
30

appropriate, the guardian or legal representative to facilitate their decisionmaking regarding the new setting.
4. By one year from the effective date hereof, ensure that each individual leaving an SRC to live in a community setting shall have a current comprehensive assessment of needs and supports completed or updated within 30 days prior to the individual's leaving.
5. Ensure that the supports identified in the comprehensive assessment that are determined through professional judgment to be essential to the person's health and safety shall be in place at the transitioning person's new home before the person's departure from the SRC. The absence of those supports identified as non-essential to health and safety shall not be a barrier to transition.
6. Develop and implement quality assurance processes to ensure that the transition plans developed are consistent with generally accepted professional standards of care and are implemented. Whenever problems are identified, develop and implement plans to remedy the problems.
7. Develop and implement a system to collect, aggregate, and analyze data related to the identified barriers. On an annual basis, use such information to produce a comprehensive assessment ofbarriers and provide this information to the Mental Health, Mental Retardation, Developmental Disabilities, and Brain Injury Commission and other appropriate agencies. If this information indicates action that the State can take to overcome barriers, taking into account the statutory authority of the State, the resources available to the State, and the needs of others with mental disabilities, a plan will be developed by the State and appropriate steps taken.
B. For Serving Persons Who Have Moved From the Resource Centers to More Integrated Settings Appropriate to Their Needs
Within 60 days of the individual's placement or within 60 days of the comprehensive assessment that follows placement, the supports called for in the individual's latest comprehensive assessment will be in place and if not yet in place, a specific plan to provide the outstanding supports will be fully implemented within 90 days. The State also shall provide adequate oversight and monitoring mechanisms to ensure that community placement settings are safe and appropriate and that services and supports identified through comprehensive assessments are provided for individuals leaving the SRCs' intermediate care facility for persons with mental retardation program.
31

XV. Recordkeeping and General Plan Implementation

By one month from the effective date hereof, the SRCs shall begin to establish and maintain a unified record for each individual consistent with current, generally accepted professional standards, with full implementation within three years from the effective date hereof.

1. By two years from the effective date hereof, the SRCs shall review and revise, as appropriate, all policies, protocols and procedures as necessary to implement this plan.

2. By three months from the effective date hereof, the SRCs shall begin to implement additional quality assurance procedures to ensure a unified record for each person consistent with current, generally accepted professional standards, with full implementation within three years from the effective date hereof.

a)

The quality assurance procedures shall include random review of the

unitied record of at least 15 individuals every month; and

b)

The SRCs shall monitor all deficiencies identified in each review to

ensure that adequate corrective action is taken to limit possible

reoccurrence.

3. By three months from the effective date hereof, the SRCs shall routinely utilize such records in making care, medical treatment and training decisions, with full implementation within three years from the effective date hereof.

4. Unless otherwise specified herein, each provision of this Pl an shall be implemented by no later than three years from the effective date hereof.

32

~ U.) ~~
KEVIN W. CONCANNON Director Iowa Department of Human Services Hoover Building, 51h Floor 1305 E. Walnut St. Des Moines, IA 50319 515-281-5452
. / / ; ~//?
1- z~f!~~
MICHAEL DAVIS Superintendent Woodward Resource Center 1251 3341h St. Woodward, lA 50276 515-438-2600
Z:~o~
Acting Superintendent Glenwood Resource Center 711 S. Vine St. Glenwood, lA 51534 712-527-2252
Date: October u_, 2004
33

 
 Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 1 of 6

IN THE"UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF IOWA

UNITED STATES OF AMERICA

) Civil No. 4:04 CV-00636 REL-RAW

)

)

" Plainti f f ,- .

}

)

Notice of Information

)

Regarding Memorandum of

v.

)

Agreement at Woodward

) .' Resource Center

)

THE STATE OF IOWAi

)

CHESTER CULVER, Governor

)

of the State of Iowa

}

}

Defendants.

)

---------------------------}

COME NOW the Plaintiff, the United States of America,. and

the Defendants, the State of Iowa, et. al., and provide the

following notice to the Court regarding the termination of the
"
consent decree with respect to Woodward Resource Center, stating:

1. On November 24, 2004, the Court entered a Settlement

Agreement and the Iowa State Resource Plan (\\SRC Plan"),' which

was incorporated by reference into the Settlement Agreement

(collectively, \\court orders"). The SRC Plan required the State

and WRC to take measures to improve conditions in a number of

areas at. WRC. 1

2. The effective date of the SRC Plan was October 1, 2004

(SRC Plan, Paragraph I.G). The SRC Plan established timetables

. .' ,,"
: ...

1

The Settlement Agreement and SRC plan also concern .

conditions at the Glenwood Resource Center (\\GRC") in Glenwood,

Iowa. However, this Notice does not concern GRC.

Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 2 of 6

by which the State and WRe were to implement the requirements of

the SRe Plan.

3. All requirements of the SRe Plan were to be implemented

three ..years. from .the effective date of the SRe Plan, .meaning that.'

..: :.:

the SRe Plan was to be fully implemented by October 1, 2007.

4. The Settlement Agreement calls for the court orders to

terminate four and one-half years from the effective date of the court orders, which will be April 1, 2009 (Settlement Agreement ~

Paragraph V) .

5. Since entry of the court orders, the United States has

diligently monitored the status of the State's compliance with

implementation of the terms of the SRe Plan and,has determined

that WRe is in substantial compliance with the SRe Plan.

6. . .In particular, WRe has achieved substantial compliance

with .the SRe's provisions regarding: protecting residents from

harmj developing integrated protections, services, treatments and

supports; clinical care; psychiatric care; psychological care;

medicalcarei neurological care; nursing carei physical and

nutritional management ("PNM"); communication services;

habilitation, training, education and skill acquisition services;

planning for movement, transition and discharge; and the

development of recordkeeping systems. Notably, the facility has implemented excellent pr~tection from harm measures, quality

2

Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 3 of 6
assurance systems, medical services, and interdisciplinary team practices. Its efforts to place persons into the most integrated settings appropriate to their needs are robust and yet careful . and respectful. In. the area of behaviora1 supports and services,.
: '. '
the facility is in the process of developing cutting-edge interventions, and in the area of PNM services, it has successfully (albeit recently) implemented an unusually sophisticated and capable system of care. Undergirding many of these systems and programs is an electronic recordkeeping system of remarkable capacity.
8. The time of continued Court oversight from October 2007 to April 2009 was intended to ensure that, once compliance with the SRC Plan had been achieved, WRC would maintain this compliance for over a year, and in doing so, demonstrate that implementation of the Plan's provisions was sustained and integrated into the .operations of WRC.
9. The United States' determination is that WRC came into substantial compliance with all of the PNM service requirements in approximately February 2009. Thus, WRC has not yet demonstrated sustained substantial compliance in this area. Accordingly, the parties have agreed that the United States may continue to monitor PNM services for an additional year, in
3

Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 4 of 6
connection with the United States' monitoring of compliance activities at GRC.
10. The terms of this agreement are set forth in a .. - Memorandum. of Agreement that .was· executed by the parties. For
the Court's information, a copy of the MOA is attached hereto as Attachment A.
11. The MOA is not offered as an order of the Court, but . ... .
represents a private agreement between the United States and the State of Iowa.
12. The key provisions of the MOA are that: a) the United States may continue to monitor PNM services at WRC for a period of one year; b) the substantive terms of the MOA are the same requirements as those set forth in Section XI of the SRC Plan, and Section XI is incorporated by reference into the MOAi . and c) should PNM services at WRC decline during the term of the MOA, the parties will collaborate on the development of measures to improve PNM services.
13. The United States continues its compliance monitoring at GRC. 14. Counsel for the State of Iowa has reviewed this Notice and consents to its submission.
4

Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 5 of 6

Respectfully submitted,
Counsel for the United States
LORETTA KING Acting Assistant Attorney General Civil Rights Division
SHANETTA Y. CUTLAR Chief Special Litigation Section

" ,,' .
:', .

CHRISTOPHE Assistant Unite
States Attorne U.S. Courthouse Second Floor 110 E. Court Avenue Des Moines, Iowa 50309 (515) 284 6222

. O. TAY OE, JR., Specia Counsel VERLIN DEERINWATER Senior Trial Attorney Special Litigation Section Civil Rights Division 601 D St. NW - Room 5024 Washington, DC 20004 verlin.deerinwater@usdoi .gov Tel.: (202) 514-6260 Fax.: (202) 514-6273

",

,",.

, ',

5

Case 4:04-cv-00636-REL-RAW Document 21 Filed 04/01/09 Page 6 of 6

CERTIFICATE OF SERVICE

I hereby certify that on ~ /,

, 2009 I caused the

foregoing to be served on the following by electronic mail:

GRETCHEN WITTE KRAEMER Assistant Attorney General State of Iowa Hoover State Office Building Des Moines, IA 50319 (202) 514-6260

CHRISTOP HAGEN Assist nt nited
States torney U.S. Cou thouse Annex Second Floor 110 E. Court Avenue Des Moines, Iowa 50309 (515) 284-6222

;: '

."

,<

;.'

6

 
 Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 1 of 6

MEMORANDUM OF AGREEMENT BETWEEN THE UNITED STATES AND THE STATE OF IOWA REGARDING THE WOODWARD RESOURCE CENTER

i

I. INTRODUCTION

I
I.

1. This Memorandum of Agreement ("MOA") is entered into by the United

States and the State of Iowa ("State") to address certain conditions at the Woodward

Resource Center ("WRC") in Woodward, Iowa.

2.

On November 24, 2004, the Court entered a Settlement Agreement and

the Iowa State Resource Plan ("SRC Plan"), which was incorporated by reference into

the Settlement Agreement. The SRC Plan required the State and WRC to take measures to improve conditions in a number of areas at WRC. 1

3.

The effective date of the SRC Plan was October 1, 2004 (SRC Plan,

Paragraph I.G). The SRC Plan established timetables by which the State and WRC

were to implement the requirements of the SRC Plan.

4.

All requirements of the SRC Plan were to be implemented three years

from the effective date of the SRC Plan, meaning that the SRC Plan was to be fully·

implemented by October 1,2007.

The Settlement Agreement and SRC Plan also concern conditions at the Glenwood Resource Center ("GRC") in Glenwood, Iowa. However, this MOA does not · concern GRC.
1
Attachment A Page 1 of 6

Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 2 of 6
5. The Settlement Agreement calls for the Settlement Agreement to terminate four and one-half years from the effective date of the SRC Plan, which will be April 1, 2009.
6. Since entry of the Settlement Agreement, the United States has diligently monitored the status of the State's implementation of the terms of the SRC Plan.
7. The United States' most recent compliance tour of WRC took place on February 9 - 10, 2009. As of the tour, the United States determined that WRC achieved substantial compliance with all the requirements of the SRC Plan.
8. In particular, WRC has achieved substantial compliance with the SRC's · provisions of: protecting residents from harm; developing integrated protections, services, treatments and supports; clinical care; psychiatric care; psychological care; · medical care; neurological care; nursing care; physical and nutritional management ("PNM"); communication services; habilitation, training, education and skill acquisition services; planning for movement, transition and discharge; and the development of recordkeeping systems. Notably, the facility has implemented excellent protection from
harm measures, quality assurance systems, medical services, and interdisciplinary team practices. Its efforts to place persons into the most integrated settings appropriate to their needs are robust and yet careful and respectful. In the area of behavioral supports and services, the facility is in the process of developing cutting-edge interventions, and in the area of PNM services, it has successfully (albeit recently) implemented an unusually sophisticated and capable system of care. Undergirding many of these systems and programs is an electronic recordkeeping system of remarkable capacity.
2
Attachment A Page 2 of 6

Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 3 of 6
9. The time of continued Court oversight from October, 2007 to April 1, 2009 was intended to ensure that, once compliance with the SRC Plan had been achieved, WRC would maintain compliance for over a year, and in doing so, demonstrate that its improvements and remedial steps were sustained and integrated into the operations of WRC.
10. However, because PNM services only recently came into substantial compliance, WRC has not yet demonstrated sustained compliance in this area. Accordingly, the parties have agreed that the United States may continue to monitor PNM services for an additional year, in connection with the United States' monitoring of compliance activities at GRC. II. SUBSTANTIVE TERMS OF MOA
11. Accordingly: .A) The United States may continue to monitor PNM services at WRC until
April1, 201 0; B) The substantive terms of the PNM services of this MOA shall be the same
requirements as those set forth in Section XI of the SRC Plan, and Section XI is hereby incorporated by reference; and C) Should PNM services at WRC decline during the term of this MOA, the State and WRC shall collaborate with the United States on the development of measures to improve PNM services to the point where services meet the requirements of the PNM Plan.
3
Attachment A Page 3 of 6

Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 4 of 6
Ill. IMPLEMENTATION OF THE MOA 12. This MOA will be effective on the date it is fully executed by the parties. 13. The United States, together with its expert consultants and agents may,
with reasonable no~ice to the State, tour WRC to assess compliance with this MOA. 14. Within a ·reasonable time in advance of the tour, the United States shall
identify any expert consultants it plans to use on the tour. 15. The United States and its attorneys, expert consultants, and agents shall
have reasonable access to the facilities, documents, records, residents, and employees of WRC upon reasonable notice to the State for the purpose of confirming sustained compliance with the SRC and compliance with this MOA. Such access shall continue until this MOA is terminated as set forth in paragraph 18 below.
16. Throughout the duration of the MOA, the United States and its expert consultants and agents will maintain the confidentiality of WRC residents' medical and personal information, to the fullest extent allowed by law.
17. The United States will make its experts available for verbal exit conferences during any tour. Preliminary findings will be shared at that time.
18. This MOA will terminate on April1, 2010. 19. All parties shall bear their own costs, including attorneys' fees, related to assessing compliance with this MOA.
IV. DISPUTE RESOLUTION
20. The parties will work in good faith to meet the terms of this MOA and maintain the goal of ensuring appropriate care for the residents of the WRC.
4
Attachment A Page 4 of 6

Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 5 of 6

21. This MOA is binding upon the parties, by and through their officials, agents, employees, assigns, and successors.
22. If the State fails to comply with this MOA in whole or in part, the United States retains the right to seek appropriate judicial relief in federal court if, after thirty (30) days prior written notice to the State of the breach, the State has failed to cure such. breach during the thirty (30) day period. Nothing in this MOA shall be construed to preclude the State from asserting any legal defense or theory in any legal proceeding. V. MODIFICATION OF THE MOA
23. If, at any time, any party to this MOA desires to modify it for any reason, that party will notify the other party in writing of the proposed modification and the reasons therefore. No modification will occur unless there is written agreement by the parties. AGREED TO: FOR THE UNITED STATES:
ANETTAY. CUTLAR hief Special Litigation Section

CHRISTOP Assistant United States Attorney U.S. Courthouse Ann x Second Floor
110 E. Court Avenue
Des Moines, Iowa 50309
I/t/1 J Dated: '-/

BENJA IN 0. TAY OE, JR., Special Counsel VERLIN DEERINWATER Senior Trial Attorney Special Litigation Section Civil Rights Division 601 D St. NW - Room 5024 Washington, DC 20004
5
Attachment A Page 5 of 6

Case 4:04-cv-00636-REL-RAW Document 21-2 Filed 04/01/09 Page 6 of 6
\
,., I

FOR THE STATE OF IOWA:

. ·. ' ·.~ ·
. . ::!.

..

. Eugene I. Gessow

·,;

Director

Department of Hurnan Services

Hoover Building

Des Moines, lA 50319

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 Case 4:04-cv-00636-REL-RAW Document 23 Filed 05/13/10 Page 1 of 2

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF IOWA

UNITED STATES OF AMERICA

)

Civil No. 4:04-CV-00636-REL-RAW

)

Plaintiff,

)

)

Notice of Information

v.

)

)

THE STATE OF IOWA;

)

CHESTER CULVER, Governor

)

of the State of Iowa

)

)

Defendants.

)

_____________________ )_________________________________________

COME NOW the Defendants and provide the following Notice to inform the Court of the status of consent decree activities at the Woodward Resource Center (WRC) and Glenwood Resource Center (GRC).

1. As this Court is aware, the State of Iowa entered into a consent decree with the U.S. Department of Justice (DOJ) to improve care for the clients of the two State Resource Centers (SRC), GRC and WRC.

2. Woodward Resource Center attained substantial compliance with the consent decree. The consent decree expired as to WRC in April, 2009.

3. Glenwood Resource Center attained substantial compliance with the consent decree. The consent decree expired as to GRC in April, 2010.

4. The consent decree and related oversight is terminated.

5. DOJ has reviewed and consents to this submission.

Respectfully submitted,

THOMAS J. MILLER Attorney General of Iowa

/s/Gretchen Witte Kraemer AT0004358 Assistant Attorney General Second Floor Hoover State Office Building Des Moines, IA 50319
1

Case 4:04-cv-00636-REL-RAW Document 23 Filed 05/13/10 Page 2 of 2
gkraeme@dhs.state.ia.us Tel.: (515) 281-6707 Fax: (515) 281-7219 Service via electronic mail to the following on May 13, 2010. CHRISTOPHER HAGEN Assistant United States Attorney U.S. Courthouse Annex Second Floor 110 E. Court Avenue Des Moines, Iowa 50309 (515) 284-6222 BENJAMIN O. TAYLOE, JR VERLIN DEERINWATER Attorneys Special Litigation Section Civil Rights Division 601 D St. NW - Room 5024 Washington, DC 20004 (202) 514-8103
2

 
 Case: 4:04-cv-636 As of: 07/25/2012 01:40 PM CDT 1 of 3
U.S. District Court Southern District of Iowa (Central) CIVIL DOCKET FOR CASE #: 4:04−cv−00636−REL−RAW

TERMED

United States of America v. STATE OF IOWA et al Assigned to: Senior Judge Ronald E. Longstaff Referred to: Magistrate Judge Ross A. Walters Cause: 28:1331 Federal Question: Other Civil Rights
Plaintiff

Date Filed: 11/18/2004 Date Terminated: 11/24/2004 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Christopher D Hagen−AUSA U S Attorney's Office 110 E Court Ave Ste 286 Des Moines, IA 50309 515−473−9300 Fax: 515 473−9282 Email: usaias.nefcivil@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Benjamin O Tayleo United States Department of Justice Civil Rights Division 950 Pennsylvania Avenue NW Washington, DC 20035 202−514−8103 ATTORNEY TO BE NOTICED

Gregory Gonzalez United States Department of Justice Civil Rights Division 601 D Street N.W. Washington, DC 20035 202 305 2941 Fax: 202 514 6903 Email: gregory.gonzalez@usdoj.gov TERMINATED: 12/22/2008 ATTORNEY TO BE NOTICED

Robert A. Koch U S DEPT OF JUSTICE CIVIL DIVISION 950 PENNSYLVANIA AVE NW WASHINGTON, DC 20530 202−305−2302 Fax: 202−514−6903 Email: Robert.Koch@usdoj.gov ATTORNEY TO BE NOTICED

V. Defendant State of Iowa

represented by Gretchen Witte Kraemer ATTORNEY GENERAL OF IOWA HOOVER STATE OFFICE BLDG SECOND FLOOR 1305 EAST WALNUT STREET DES MOINES, IA 50319 515 281 6707

Case: 4:04-cv-636 As of: 07/25/2012 01:40 PM CDT 2 of 3

Fax: 515 281 7219 Email: gkraeme@dhs.state.ia.us LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gordon E Allen DRAKE UNIVERSITY LEGAL CLINIC 2400 UNIVERSITY AVE DES MOINES, IA 50311−4505 515 271 2773 Fax: 515 271 4000 Email: allen.gordy@gmail.com TERMINATED: 03/07/2008

Defendant Thomas J Vilsack

represented by Gretchen Witte Kraemer (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Gordon E Allen (See above for address) TERMINATED: 03/07/2008

Date Filed 11/18/2004 11/18/2004
11/18/2004 11/18/2004 11/24/2004 12/09/2004 03/07/2008
03/07/2008 03/27/2008 04/03/2008

# Docket Text
1 COMPLAINT against all defendants, filed by United States of America. Rule 16 Notice of Dismissal set for 3/18/2005. Notice of Dismissal for lack of Service deadline set for 3/18/2005.(Hagen, Christopher) (Entered: 11/18/2004)
2 MOTION for Settlement/Settlement Conference Motion for Approval of Proposed Settlement Agreement by United States of America. Responses due by 12/6/2004 (Attachments: # 1Settlement Agreement # 2Iowa State Resourse Centers Plan)(Hagen, Christopher) Modified on 11/19/2004, added descriptions to attachments (bp, ). (Entered: 11/18/2004)
3 MEMORANDUM in Support re 2 MOTION for Settlement/Settlement Conference Motion for Approval of Proposed Settlement Agreement filed by United States of America. (Hagen, Christopher) (Entered: 11/18/2004)
Judge Ronald E. Longstaff and Ross A. Walters added. (bp, ) (Entered: 11/18/2004)
4 SETTLEMENT AGREEMENT ORDERED BY JUDGE LONGSTAFF AND FILED by United States of America. (Hagen, Christopher) (Entered: 11/24/2004)
5 ORDER allowing case to be closed administratively but the Court retains jurisdiction to enforce the Order of November 24, 2004. Entered by Ronald E. Longstaff on 12/9/2004. (dsg) (Entered: 12/09/2004)
6 Joint MOTION for Entry of Stipulation for Supplemental Relief Motions referred to Ross A. Walters. by United States of America, STATE OF IOWA, Thomas J Vilsack. Responses due by 3/24/2008 (Attachments: # 1 Proposed Order)(Hagen, Christopher) (Entered: 03/07/2008)
7 NOTICE of Appearance by Gretchen Witte Kraemer on behalf of STATE OF IOWA (Kraemer, Gretchen) (Entered: 03/07/2008)
8 MOTIONS REFERRAL − NO DOCUMENT − 6 Joint MOTION for Entry of Stipulation for Supplemental Relief. Motion referred to Ronald E. Longstaff. (sc) (Entered: 03/27/2008)
9 ORDER granting 6 Stipulated motion for supplemental relief. Signed by Senior Judge Ronald E. Longstaff on 4/1/2008. (sk, ) (Entered: 04/03/2008)

Case: 4:04-cv-636 As of: 07/25/2012 01:40 PM CDT 3 of 3

07/14/2008
07/17/2008 07/22/2008 08/07/2008 08/11/2008 10/30/2008 12/22/2008 12/22/2008
03/09/2009 03/30/2009 03/30/2009 04/01/2009 06/30/2009 05/13/2010

10 Joint MOTION for Entry of Plans of Correction as an Order Motions referred to Ross A. Walters. by United States of America, STATE OF IOWA, Thomas J Vilsack. Responses due by 8/4/2008 (Attachments: # 1 Attachment 1, # 2 Attachment 2)(Hagen, Christopher) (Entered: 07/14/2008)
11 MOTIONS REFERRAL − NO DOCUMENT − 10 Joint MOTION for Entry of Plans of Correction as an Order Motions referred to Ronald E. Longstaff. (don) (Entered: 07/17/2008)
12 ORDER granting 10 Motion for entry of plans of correction. Signed by Senior Judge Ronald E. Longstaff on 7/17/2008. (sk, ) Modified on 8/13/2008 (sk, ). (Entered: 07/22/2008)
13 NOTICE by STATE OF IOWA *** Report filed under entry 14 *** Notice of Information Regarding Plans of Correction (Attachments: # 1 Notice of Manual Filing)(Kraemer, Gretchen) Modified on 8/11/2008 (don, ). (Entered: 08/07/2008)
14 STATUS REPORT by STATE OF IOWA Part of entry 13 . (Attachments: # 1 part 2) (don) (Entered: 08/11/2008)
15 NOTICE by State of Iowa filed with consent of the US DOJ (Attachments: # 1 Exhibit WRC, # 2 Exhibit GRC Letter, # 3 Exhibit GRC Chart)(Kraemer, Gretchen) (Entered: 10/30/2008)
16 MOTION to Substitute Attorney for the Plaintiff. Motions referred to Ross A. Walters. by United States of America. Responses due by 1/8/2009 (Koch, Robert) (Entered: 12/22/2008)
17 TEXT ORDER: ORDER granting 16 motion for leave to withdraw. Mr. Gonzalez's appearance may be terminated and Mr. Koch shall be shown as proceeding on behalf of the United States. Entered by Magistrate Judge Ross A. Walters on 12/22/2008. (klw) (Entered: 12/22/2008)
18 NOTICE by State of Iowa (Attachments: # 1 Exhibit, # 2 Exhibit, # 3 Exhibit)(Kraemer, Gretchen). (Entered: 03/09/2009)
19 TEXT ORDER: IT IS ORDERED that the motion filed March 9, 2009 seeking to have the documents filed under seal is hereby granted. Signed by Senior Judge Ronald E. Longstaff on 3/30/2009. (dsg) (Entered: 03/30/2009)
20 Sealed Document. (Attachments: # 1 Exhibit)(Kraemer, Gretchen) (Entered: 03/30/2009)
21 NOTICE by United States of America (Attachments: # 1 Memorandum of Agreement)(Hagen, Christopher) (Entered: 04/01/2009)
22 NOTICE by State of Iowa, Thomas J Vilsack (Attachments: # 1 Exhibit, # 2 Exhibit)(Kraemer, Gretchen) (Entered: 06/30/2009)
23 NOTICE by State of Iowa (Kraemer, Gretchen) (Entered: 05/13/2010)

 
 Investigation of Woodward State Resource Center and Glenwood State Resource Center (... Page 1 of 21
July 9, 2002
The Honorable Thomas J. Vilsack Governor of Iowa State Capitol Building Des Moines, IA 50319
Re: Investigation of Woodward State Resource Center and Glenwood State Resource Center
Dear Governor Vilsack:
On March 22, 1999, we notified you, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997, that we were investigating conditions at two state-operated facilities for the developmentally and mentally disabled: the Woodward State Hospital-School (subsequently renamed Woodward Resource Center) (Woodward) in Woodward, Iowa, and the Glenwood State HospitalSchool (subsequently renamed Glenwood Resource Center) (Glenwood), in Glenwood, Iowa. In November 1999, and again in April and May 2001, we visited both facilities. At an exit interview conducted on the last day of each facility visit, we verbally conveyed our preliminary findings to counsel and senior Department of Human Services and facility officials. Consistent with the requirements of CRIPA, we are now writing to apprise you of our findings.
As a threshold matter, we wish to acknowledge, and express our appreciation for, the extensive cooperation and assistance provided to us by the administrators and staff of these two facilities. We hope to continue to work with the State of Iowa and officials at Woodward and Glenwood in the same cooperative manner in addressing the problems that we found. Further, we note that both facilities are staffed predominately by dedicated individuals who are genuinely concerned for the well-being of the persons in their care.
We conducted our investigation by reviewing medical and other records relating to the care and treatment of individuals at these two facilities; interviewing administrators, staff and residents; and conducting on-site surveys of the facilities. Our findings are supported by the assessments contained in our expert consultants' reports.
At the time of our 2001 visits, the Woodward census was approximately 280 residents and the Glenwood census was approximately 385 residents. At both facilities, residents' mental disabilities range from mild to profound. They possess diverse abilities and functional levels. Some residents are more reliant on staff to assist them in meeting their daily needs, while others are much more independent and capable of making decisions for themselves. There are a number of individuals at each facility who have developed maladaptive behaviors. Many of them have seizure disorders, ambulation issues or other health care needs. A significant portion of Glenwood's population is medically fragile. More than half of each facility's residents have been diagnosed as having one or more psychiatric disorders.
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 Americans 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).

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Investigation of Woodward State Resource Center and Glenwood State Resource Center (... Page 2 of 21
Both Woodward and Glenwood excel in various respects, many of which are discussed below. In particular, each facility has taken innovative, aggressive steps to become a resource for the surrounding community. Woodward's general medical care is good, on the whole, as is Glenwood's nutrition management program. In other areas, however, such as Woodward's use of restraints, Glenwood's general medical care and both facilities' psychiatric and psychological care and community placement programs, they do not provide constitutionally or statutorily mandated levels of care. Our findings, the facts supporting them, and the minimum remedial steps that we believe are necessary are set forth below.
I. RESTRAINTS AND RESTRICTIVE PROCEDURES
A. Woodward
From April 2000 through March 2001, an average of 56 Woodward residents each spent about 18 hours in mechanical and manual restraints each month, according to Woodward's "monthly restraint reports." Some individuals, such as RI and DM, were repeatedly restrained for more than 300 hours a month, as part of behavior management programs. A number of Woodward residents, such as EK, DS, PN, and ED, were regularly placed in four- and five-point restraints in excess of 10 hours a month. Also, residents such as HC, GG and JP occasionally have been immobilized in a so-called "papoose board," either during medical procedures or as part of a behavior program.
Separately, and over the same period, an unreported percentage of Woodward residents were placed in helmets, jumpsuits and mittens for approximately 870 hours each month, according to Woodward's "monthly behavioral intervention reports." The latter three devices, though classified as behavioral interventions, are also restraints; they were used in response to behavioral issues to restrain individuals from accessing parts of their bodies.
Totaling together the hours that are identified in the "monthly restraint reports" during the months from April 2000 to March 2001 and the separate tally for the same period of hours in restraints identified in the "behavioral intervention reports," about 56 Woodward residents each spent approximately 33 hours in restraints per month.
The use of restraints at Woodward places individuals at risk of harm. First, the prevalence of their use indicates that restraints are substituting for needed behavioral supports; individuals are physically or mechanically prevented from engaging in challenging behaviors instead of receiving effective treatment to address the cause of those behaviors. Although restrictive interventions may be appropriate in true emergency situations, their use as a long-term behavioral intervention is not appropriate. The generally accepted practice is that nonrestrictive interventions are an effective alternative when they are based on proper assessments and correctly designed and implemented. Further, restrictive interventions do not generally improve behaviors.
This point is illustrated by RI, who spent at least ten hours a day in restraints for virtually every day of the 12-month period reviewed. RI's records show that he is subjected to restraints because he engages in pica. His records show no evidence that potential medical or nutritional conditions that can lead to pica were ever considered, and his records indicate that behavioral causes of his condition have not been correctly assessed. His records show that, possibly as a consequence of these deficiencies, his behavior support plan has had no impact on his pica.
Seventy-eight Woodward residents have restraints or time out (the latter of which involves removing an individual from an environment and conditioning his/her freedom of movement on certain behaviors)

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as part of their behavior support plan. This means that each of these individuals' behavior support plans permits the use of specific restrictive interventions if they engage in certain behaviors. Our investigation was unable to locate any evidence showing that the use of these restrictive interventions has produced clinically significant positive changes in the behavior of these individuals. In other words, they are not getting better for having been restrained, isolated or otherwise physically restricted. Certainly, long-term use of restrictive interventions on these seventy-eight individuals would constitute a significant departure from generally accepted standards of care.
Second, Woodward's extensive use of restraints means that individuals with diminished comprehension, some of whom have been sexually or physically abused and suffer from Post Traumatic Stress Disorder, are subjected to the significant psychological harm that comes from being physically held down or restrained.
Finally, Woodward's residents regularly are physically injured in restraints. Woodward incident reports from 1999 and 2001, the two years for which we have such data, identify numerous individuals suffering multiple abrasions, open wounds, floor burns, reddened areas and bruises while in restraints. Although the cause of injury is sometimes unclear, and the frequency of injury while in restraints appears to be decreasing, the reports indicate an on-going pattern of physical harm due to restraint use. This harm can be most severe. In March of 2001, D.D. (1), a forty-five-year-old Woodward resident, died after being placed in three-point restraints. The primary cause of death, according to the State Medical Examiner's autopsy report, was "compressional/positional asphyxia[] occurr[ing] during physical restraint by other individuals." Accordingly, D.D.'s death was classified as a homicide; no criminal charges have been brought.
Woodward direct care staff receive training on restraint use, as well as periodic de-escalation training. D.D.'s death, involving the incorrect use of restraints in the presence of five staff members, demonstrates that staff are inadequately trained, or possibly noncompliant with training.
Interviews by facility security personnel of each of the five staff members who witnessed or participated in restraining D.D. show that he was placed on a hard surface on his stomach, although he had a behavior plan that specified that his restraints were to be applied while he was "sitting down or lying face up," and risk of asphyxiation is usually heightened by placing an individual face down. Further, according to Woodward's investigation, staff immobilized D.D.'s head with pressure in a manner not authorized in his behavior plan nor otherwise authorized or taught at Woodward. Finally, staff did not continually observe and assess D.D.'s physical condition. When interviewed by facility security personnel, none of the five staff persons showed an appreciation for or awareness of these deficiencies.
Woodward's use of restrictive procedures, apart from restraints, is also problematic. For instance, as of April 2001, the facility maintained electronic tracking devices on at least three people to monitor their movements while at the facility. Electronic tracking for these three individuals had no therapeutic value. In fact, they are used as substitutes for therapeutic treatment. That is, they are used for the convenience of staff, not for the care of individuals. This is incompatible with the State's obligation to provide minimally adequate supports to ensure freedom from undue restraint. Youngberg, 457 U.S. at 324.
Since our 2001 tour, Woodward's administration has stated that the facility is taking extensive measures to reduce the use of restraints and restrictive procedures, along with the associated harms. These steps reportedly include retraining staff, revising restraint policies, and expanding use of alternative responses. The representations of remedial action are encouraging, but Woodward's problems in this area have been longstanding; actual results will provide the best measure of its progress.

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Investigation of Woodward State Resource Center and Glenwood State Resource Center (... Page 4 of 21
B. Glenwood
Glenwood has achieved a substantial decline in the frequency of occurrences in which restraints and restrictive procedures are used, as measured from August 1999 to May 2001. However, these impressive results appear to be diminished by data from January 2000 to February 2001, indicating that the collective, total time that individuals spend in restraints and time out has remained fairly constant. Together, these data suggest that, while individuals are restrained less often, they spend more time in restraints, per occurrence, than before. Although Glenwood has made significant progress in this area, its work is not complete, as it appears that individuals are restrained for excessive periods of time.
II. PSYCHIATRIC AND BEHAVIORAL SERVICES
A. General Psychiatric Services
1. Psychiatric Assessments
Minimum standards of care dictate that the psychiatric diagnosis of each individual be justified in a generally accepted professional manner. At both Woodward and Glenwood, psychiatric assessments were not performed to substantiate current diagnoses in any formal or consistent manner. In general, the documentation reflects an inadequate psychiatric evaluation of Woodward's and Glenwood's residents. This is a serious concern, given that both facilities have diagnosed well over one-half of their residents as having psychiatric disorders.
To take an example, one of AB's diagnoses is Borderline Personality Disorder. Her chart does not identify which markers of this disorder she exhibits. Nor does it otherwise set forth the basis upon which this disorder, which requires significant cognitive ability to manifest itself, could be present in an individual with profound mental retardation and very limited expressive skills.
2. Psychiatric Diagnoses
The average facility for individuals with mental retardation has a prevalence of psychiatric disorders well below 50 percent. By comparison, Woodward has diagnosed approximately 85 percent, and Glenwood approximately 60 percent, of their respective populations as having psychiatric disorders. It would be noteworthy if the epidemiology of Woodward's and Glenwood's residents varied so significantly from the average facility. In fact, however, many of these diagnoses are dated, unsubstantiated or incorrect. For example, at Woodward, RDW was diagnosed with Conduct Disorder, notwithstanding that RDW is 55-years-old and Conduct Disorder is not found in adults, with or without a mental disability. Numerous Woodward and Glenwood residents were diagnosed with Intermittent Explosive Disorder when their psychological reports specify other causes of their problem behaviors.
3. Psychotropic Medications
Approximately 68 percent of Woodward's population and 60 percent of Glenwood's population were receiving psychotropic drugs. Often, the justification for continued use of psychotropic medication was staff recommendations, not empirically supported decisions justifying a need for the medication. At both facilities, the unjustified use of multiple psychotropics to address the same condition was common, as was the practice of administering psychotropics to treat undiagnosed conditions. Further, psychotropics regularly were administered without an indication as to what symptoms are targeted or whether the medication is successful. Finally, the facilities have individuals who have received psychotropics for years without any clinically significant improvement.

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Investigation of Woodward State Resource Center and Glenwood State Resource Center (... Page 5 of 21
There are strong indications that psychotropics are prescribed at both facilities to address staff complaints about individuals with challenging behaviors, that is, prescribed for the convenience of staff. Physicians at Glenwood have openly expressed concern about being pressured in this regard.
Polypharmacy (that is, the use of multiple drugs to treat the same indication), while possibly appropriate in some circumstances, always should be justified. None of the reviewed Woodward and Glenwood charts reflecting polypharmacy provided any written justification as to why multiple medications were used to target the same condition. Certainly, no basis was provided showing how multiple psychotropic medications work synergistically or separately to address the same problem.
Some individuals, such as Woodward's CD, have developed medication-related seizures and, nevertheless, have been placed on other medications that facilitate the onset of seizures. Some Woodward residents, such as RI and DAP, have received powerful psychotropic medications that have not demonstrably improved their psychiatric or behavioral problems but have caused them to develop seizures and other permanent physical side effects.
With regard to seizures and other serious permanent side effects of psychotropic drug use, the 90Day Psychotropic Medication Review and the side effect assessments at Woodward and Glenwood have not provided residents with adequate protection, as the above examples confirm. For data derived from side effect assessment tools to be meaningful, they must be read in connection with other clinical data, including but not limited to, the state of the disorder, the psychotropic dosage levels and durations of use, and available treatment alternatives. The charts do not evidence that such factors are uniformly considered when assessing side effects.
Chart review also indicates multiple instances in which drugs are administered for conditions for which no identified diagnosis has been made. At Woodward, CD receives Luvox each day for signs and symptoms of depression, including difficulty sleeping. Although CD's chart states "diagnosis is reviewed and appears appropriate at this time," nowhere does the diagnosis include the depression for which she receives daily medication. AB also receives Luvox for probable depression but does not have a diagnosis of depression. DJ receives Paxil to address depression and pain but does not have a diagnosis of depression; nor does the chart provide an explanation of the pain that is being medicated.
There are also repeated instances in which drugs are administered without any indication of what condition is targeted or whether the drug in question is providing effective treatment. For instance, at Woodward, RP is on Trilafon, but his chart does not indicate why, what results are expected, or whether this medication is providing effective treatment. At Glenwood, there is no indication in BOT's pharmacological and behavioral program what, in particular, the psychotropic medications that he/she receives are addressing and what effects these drugs are having.
The foregoing examples raise grave concerns regarding the use of psychotropics at both facilities, although it should be noted that the Woodward charts reviewed in 2001 also reflect an effort to decrease and discontinue the use of unnecessary psychotropic medication. These reductions appear to be wellconsidered, and are done with care, taking into account the effects on the individual and the views of staff. Nevertheless, a great amount of work is required in this area, as the health and well-being of many residents are endangered.
4. Treatment Outcomes Monitoring
At both facilities, residents with psychiatric disorder diagnoses frequently are poorly monitored for treatment outcomes. In this regard, there are numerous instances in which psychotropic medications are

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Investigation of Woodward State Resource Center and Glenwood State Resource Center (... Page 6 of 21
not reassessed after having been administered for several years with a lack of significant behavioral change. The facilities' ability to monitor treatment outcomes is further compromised by the instances, noted above, in which psychotropic drugs are prescribed without a corresponding diagnosis and/or without identifying the targeted markers of the underlying psychopathology that is being treated. Glenwood's lack of institution-wide audits, reviews or summary reports regarding psychotropic medication use is another factor diminishing its ability to monitor treatment outcomes.
5. Pharmacy and Therapeutics Oversight
Typically, the Pharmacy and Therapeutics ("P&T") Committee provides leadership on drug prescriptions at a facility, examines the rationale for the use of polypharmacy, checks on medication errors, provides information on advances in medication, and evaluates data on side effects of medication, especially movement disorders. Woodward's P&T Committee is not performing these necessary functions. It does not assess general patterns and prevalence of psychotropic drug prescriptions. Glenwood does not even have a P&T Committee or another entity performing these functions. This constitutes a major gap in minimally adequate care services.
6. Informed Consent
In numerous instances when, presumably, the parent or legal guardian is not available or has not responded to requests for authorization, both facilities' superintendents have authorized the use of restraints and psychotropic medications for individuals, without having been appointed guardian. Federal regulation of facilities such as Woodward and Glenwood requires that there be written informed consent of the individual, parents (if the individual is a minor) or legal guardian. 42 C.F.R. § 483.440 (f) (3)(ii). The lack of informed consent regarding the use of psychotropic medications also runs afoul of the Due Process Clause of the Fourteenth Amendment. See Washington v. Harper, 494 U.S. 210, 221 (1990).
B. Psychological Services
Considerable, well-intended, efforts are made at both facilities to collect psychological data. Nevertheless, the behavioral data used in forming assessments is often inaccurate or incomplete in important respects. To some extent, this results from burdening direct care staff with excessive, unfocused, behavioral data recording requirements. In any event, as a psychologist noted in the case of Woodward's CD, the behavioral data at both facilities are often unreliable.
Further, assessments and findings regarding the function of behaviors are regularly overstated, inadequately substantiated or incomplete. As a result, they, too, are frequently unreliable. For instance, BK's chart, at Woodward, does not identify the signs and symptoms supporting the findings of obsessive compulsive disorder and pervasive developmental disorder. Without substantiation, the results of the functional assessment of Woodward's CD were interpreted to show that self injury occurred most often when CD could not escape noise, notwithstanding data showing that her highest rate of self injury occurred when she was alone.
Without explanation, in the case of Woodward's RI, certain results from a Functional Analysis Screening Tool ("FAST") were discounted as being "an artifact of the assessment instrument," while other results from the same instrument were fully credited. At Glenwood, each reviewed Behavior Development Plan contains the identical statement that "possible medical, psychiatric or other motivations" were considered and ruled out, but none of these plans points to data supporting this assessment. The relevant records indicate that psychologists at both facilities are prone to accept the

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findings from FAST ratings selectively, apparently to justify assessments.
Compounding the questionable utility of the facilities' psychological assessments is the use of stale data. BLT's treatment program, at Woodward, was written based on an assessment made sixteen months earlier. If underlying aspects of BLT's behavior had changed in the interim, the treatment plan's therapeutic value would be questionable. LJ's current treatment plan, again at WRC, is based on FAST data now two years old. Her problem behaviors have continued at a high level, suggesting that reliance upon such old data is not appropriate.
As for psychological treatments, both facilities are heavily invested in the development of elaborate behavior support plans. These plans, however, frequently do not appear to be appropriate. For instance, if an individual, such as Woodward's CD, is injuring herself as a means of receiving stimulation and attention, as the behavioral hypothesis for her suggests, then placing her in restraints is unlikely to be an effective treatment, because restraining her does not teach her alternative, socially appropriate ways of behaving. Further, the psychiatrist's report suggests that her behaviors may have more to do with psychiatric illness than a failure to learn appropriate behaviors.
Similar examples were found at Glenwood. BOT's behavior development plan contains the unsubstantiated statement found in other charts that "possible medical, psychiatric or other motivations for the target behavior have been considered." It also claims to have taken into account BOT's pharmacological treatment, although why he is receiving drugs, what they are specifically targeting and what effect they are actually having on him were not considered or, at least, not in a manner permitting meaningful review.
Moreover, the complexity of BOT's plan, involving seven different interventions, jeopardizes its feasibility. This problem is typical of many of the behavior support plans at both facilities. While perhaps appropriate for the study of a discrete behavior in a laboratory setting, they require an unrealistic level of sophistication and time commitment from direct care staff. More fundamentally, they are not, as a general matter, measurably improving the lives of Woodward and Glenwood residents. In other words, they often provide ineffective treatment.
C. Integration of Pharmacological and Behavioral Plans
Combined assessment and case formulation should occur to develop an integrated behavioral and psychopharmacological treatment and, at a minimum, ensure that related treatments do not conflict. To a large extent, however, this does not take place at either facility. The psychiatric care and behavioral care of Woodward's and Glenwood's residents are largely uncoordinated, to the point that practitioners of each discipline develop assessments, diagnoses and treatments without integrating or even considering those of the other discipline. In the context of these facilities, this failure makes many important treatment decisions essentially arbitrary.
Woodward's BLT receives psychotropic medication daily to treat depression, but nothing in her chart indicates that this fact was considered to be important in the preparation of her behavior support plan. The behavior support plan of Woodward's CD notes that she has seizures approximately bi-monthly, but this fact is not mentioned in the psychiatric consultation, not even in reference to her daily medication with Seroquel, a drug that lowers seizure thresholds. JP and BOT of Glenwood present similar problems, outlined above.
Many of these cases were provided by Woodward and Glenwood as examples of the integration of pharmacological and behavioral treatments, but they do not indicate an appreciation of what such

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integration entails. Further, there is a significant lack of proper case formulation, even apart from considerations of psychopharmacological treatment. In fact, there is a lack of integration at the diagnostic level, as when a psychiatrist diagnoses an individual with a psychiatric disorder such as Intermittent Explosive Disorder and a psychologist irreconcilably finds that behavioral motivations account for the same disorder.
In this regard, approximately 83 percent of all individuals at Woodward who have a complete behavior support plan are also on psychotropic medication for essentially the same target behaviors. The percentages appear to be similar at Glenwood. It further appears that the psychologists writing these behavior development plans give little consideration to any significant contribution that psychiatric disorders may make to the targeted behaviors. In effect, each facility's psychologists and psychiatrists independently provide treatment for the same behaviors. These independent treatments, as implemented, largely have not been effective; most of the individuals subjected to them are burdened with behavioral problems or psychiatric disorders that are unimproved. The failure of the facilities' psychiatrists and psychologists to collaborate effectively has contributed to these results.
III. GENERAL MEDICAL CARE
A. Woodward
The information that we have seen indicates that, exclusive of the psychiatric issues addressed above, Woodward is providing good general medical care to its residents.
Three full-time physicians provide medical services at Woodward, one of whom serves as medical director. Two of these three physicians have been at Woodward for more than twenty years. The third arrived in 1993. With supplemental support from an outside physician, Woodward doctors provide twenty-four-hour on-site coverage. In short, Woodward residents have the benefit of immediately available physician services, provided by doctors who, for the most part, are well-acquainted with the individuals whom they are treating.
Woodward medical services are also well-supported by specialists at McFarland clinic, in Ames, Iowa. McFarland physicians see Woodward residents on a same-day basis, if necessary. They also travel to the facility to conduct at least seven separate clinics, each of which occurs once or twice a month, except for the quarterly dermatology and ophthalmology clinics.
Although the facility should consider expanding its preventive care guidelines to address issues particular to its aging population, such as bone marrow screening, the guidelines currently in place are comprehensive. They include screening for vision, hearing and dental care, physical side effects screening for individuals on psychotropic medications, cervical spine radiographs for individuals having Downs Syndrome, immunization schedules, mammogram protocols, and bone mineral density testing on post menopausal women.
B. Glenwood
About 40 percent of Glenwood's 386 residents are medically fragile; that is, in addition to having mental retardation, these individuals are nonambulatory, require a gastric feeding tube, have uncontrolled seizures or have severe osteoporosis. Seven Glenwood residents died between January 2000 and January 2001. Six of these deaths involved individuals under 50.
At the time of our latest visit Glenwood residents received general medical services from four full-

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time physicians, with another due to start shortly thereafter. Glenwood's physicians appear to be competent and dedicated. Nevertheless, especially in light of the number of medically fragile residents, Glenwood's general medical services are not properly equipped to provide necessary care.
Facilities that regularly provide general medical services to a population such as Glenwood's, with significant numbers of medically fragile residents, typically have a medical director, or an equivalent position, who reports directly to the superintendent and is responsible for maintaining a consistent level of adequate medical care throughout the facility. Although Woodward's population is less medically needy, it has a medical director. Glenwood does not. In fact, Glenwood's administration repeatedly has involved itself in medical care decisions that are properly the responsibility of the facility's physicians, a troubling activity that would not likely occur if a competent medical director were in place.
Further, although it is standard professional practice to maintain a formal peer review system as a quality assurance tool and a means to ensure the provision of consistent medical care, Glenwood has no such system.
It is also standard practice in facilities like Glenwood to have a medical quality assurance program that monitors the quality of services the facility delivers and makes recommendations for improvement. Glenwood has no such program. Further, as noted above, it is also the norm to have a Pharmacy and Therapeutics ("P&T") Committee that, among other responsibilities, provides leadership on drug prescriptions at a facility, examines the rationale for the use of polypharmacy, checks on medication errors, and provides information on drug development. At Glenwood, there is no such committee.
Finally, although it is standard practice in facilities such as Glenwood to establish medical care policies and protocols to ensure the consistent provision of adequate medical care, Glenwood has none. Although, in some instances, it uses standing orders, these do not define the problem to be treated, guide in assessing a patient, set forth necessary steps if the condition does not improve with medication or treatment given, or identify trigger points for physician notification and intervention.
The absence of the foregoing components of adequate medical oversight has jeopardized the medical care of Glenwood's residents. In the case of at least one individual, JW, it has contributed to morbidity and mortality. Without appropriate medical protocols, Glenwood nurses lacked clear guidance when to notify physicians regarding JW's condition. The delays in assessing, diagnosing and treating his pneumonia contributed to the onset of sepsis and his death. The absence of a peer review system and a medical quality assurance program prevented Glenwood from identifying the delays after the fact and correcting the underlying problems, so that they could be avoided in the future.
IV. NEUROLOGIC CARE
A. Woodward
Neurology services are provided by two epileptologists from the McFarland clinic. Every Woodward resident having a seizure disorder diagnosis is evaluated. Each such resident is reevaluated on an annual basis regardless of seizure frequency, thereby preventing an asymptotic individual from remaining unnecessarily on an anticonvulsant for a prolonged period of time. Currently, no Woodward resident with epilepsy is receiving older barbiturates such as Phenobarbital or Mysoline. The facility is clearly attempting to eliminate consumption of unnecessary anticonvulsant medications. However, as discussed at § II.A.3 above, certain Woodward residents' seizure problems have been worsened by psychotropic medications, and greater coordination between neurologic and psychiatric care services is warranted.

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B. Glenwood
As a general matter, erroneous diagnoses of epilepsy in mentally handicapped persons are common because of difficulties inherent in assessing their neurological conditions. In light of this problem, good medical practice necessitates that each individual who is admitted with a neurological diagnosis to a facility such as Glenwood be thoroughly evaluated by a neurologist at admission. Thereafter, individuals with a confirmed neurologic disorder who are receiving anticonvulsant medications should be regularly monitored by a neurologist for appropriateness of treatment and medication.
Glenwood has a well-qualified neurologist on staff. However, he has an extensive non-neurology caseload. Apparently, his other duties, at least in the past, have prevented him from examining at admission each individual arriving at the facility with a neurological disorder diagnosis. Also, he does not regularly monitor individuals on anticonvulsants to ensure that their treatment is effective and their medication appropriate. Further, notwithstanding that about 40 percent of Glenwood's residents receive anticonvulsant medications, the facility has not established a formal neurology clinic, nor developed standard treatment objectives or anticonvulsant prescribing practices. Consequently, the likelihood is substantial that many Glenwood residents are receiving ineffective neurological treatment or are unnecessarily exposed to potentially harmful drugs.
V. NUTRITION MANAGEMENT
Each facility has created a nutrition management team composed of speech and language pathologists, occupational therapists, nurses, dieticians and physical therapists or physical therapist aides. Glenwood's team also includes physicians and a dentist. At Woodward, physicians participate only on an as-needed basis.
The facilities have used the services of a consultant who is well-credentialed in assessing and treating individuals with dysphagia. The consultant has provided instruction to therapists and has conducted evaluation clinics.
At both facilities, instructions regarding the dining or feeding of specific individuals, including photographs of proper placements, are kept at the dining table.
A. Woodward
At Woodward, direct care staff receive four hours of training regarding problems associated with dysphagia but no other mandatory formal training in mealtime procedures. Much of the other nutritionrelated training that is provided is not competency based, and some staff assist with meals without having received individual-specific training. Additional staff training is apparently contemplated but is not yet in place.
Woodward has also not implemented a screening program for individuals having nutrition management needs. Nor has it fully evaluated each resident identified as high risk in nutrition and provided appropriate mealtime plans for them.
B. Glenwood
Glenwood's speech and language therapists provide competency based training to direct care staff. Glenwood has developed standard operating procedures regarding food temperature and consistency, a list of preferred feeders, oral motor treatment protocols, and off-campus dining protocols. The protocols

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and procedures are kept in a manual that is readily available in each house.
Glenwood's nutrition management team meets weekly and operates a continuous quality improvement plan in conjunction with food services. Further, charts are reviewed randomly and data on dysphagia and respiratory incidents are reviewed and evaluated to ensure continuous quality improvement.
Glenwood's team is proactive in providing care. Every Glenwood resident is screened at least once to determine his or her risk level. Individuals are regularly assessed, according to risk, during mealtimes.
The level and quality of Glenwood's training, interdisciplinary participation, data tracking and assessment, treatment, monitoring, and quality assurance in the area of nutrition management are commendable.
VI. PHYSICAL AND OCCUPATIONAL THERAPY
A. Woodward
Woodward residents are not receiving adequate physical therapy to meet their needs. The reviewed charts showed insufficient physical therapy involvement and scant physical therapy care planning. Although Woodward has a physical therapy aide and a part-time physical therapist on contract, it had, at the time of our latest visit, no physical therapist on staff. This raises concerns regarding the adequacy of staffing and of supervision for Woodward's physical therapy aide.
For occupational therapy, by contrast, Woodward has enlisted the aid of rehabilitation technicians from the University of Iowa to assist in developing effective positioning and repositioning of its nonambulatory residents. These technicians have also used state-of-the-art computer mapping of nonambulatory individuals to identify potential pressure sore areas and permit timely, preventative care of these areas. At the time of our tour, there had been no recent pressure-sore related hospitalizations from Woodward.
Wheelchairs and assistive devices at Woodward, as a general matter, were well-maintained and properly fitted for the individual using them.
B. Glenwood
Glenwood's physical and occupational therapy programs are good. In particular, Glenwood has the capability to fashion and extensively modify supports and assistive devices. These devices are wellmaintained and assessed regularly to ensure proper fit with the individual using them.
Separately, Glenwood provides excellent hydrotherapy services to its residents. Its hydrotherapy facility is an impressive asset. It enables many nonambulatory individuals to walk with assistance in water or otherwise manipulate and relax stiffened body parts. It is also a significant resource for behavioral treatment.
VII. PROTECTION FROM HARM
A. Woodward
Over an extended period of time, Woodward has made steady progress in reducing the number of

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incidents of injury occurring each month. Further, the proportion of all injuries requiring treatment by a physician has also decreased, especially in 2000 and 2001. Woodward's use of restraints has artificially contributed to this decline, in that restraints suppress the behavior without correcting it. Nevertheless, the long-term downward trend in incidents shows that, as a general matter, the facility has achieved significant improvement in this area. That more work remains to be done is evident in the death of D.D. while in restraints, as discussed above at § I.A.
B. Glenwood
Glenwood's monthly incident reports show that certain types of harmful incidents, such as those requiring emergency room admission, appear with sufficient frequency and regularity to warrant analysis of their root cause. A review of relevant records and interviews at the facility surfaced nothing to indicate that such an analysis had been undertaken. Further, there do not appear to be any systematic analyses in terms of other variables that may predict when, where and in whose presence these incidents occur, so that steps could be taken to reduce or prevent them.
Similarly, the Risk Management Committee regularly identifies instances where review of certain restraint use is warranted, but there is little to indicate that a review is, in fact, undertaken with its conclusions reported to the committee. For instance, the February 28, 2001 committee minutes read, "Discussed [SJ] use of helmet for six times or 150 minutes. Kim and Dick will follow up on the emergency restraint." However, the minutes of successive meetings make no mention of this issue.
The issue of adequate quality assurance and prevention from harm arises in still other contexts. At a minimum, as noted above, Glenwood lacks a Pharmacy and Therapeutics ("P&T") Committee and a medical peer-review committee, or the equivalents, to ensure that problematic trends in treatment and care of individuals are detected and addressed, and it does not track facility-wide psychotropic medication use. Glenwood also had no method, as of the time of our visit, to track errors in the administration of medications and identify corrective actions. Finally, following our tour, we received credible allegations that two Glenwood staff have sexually abused residents. A facility investigation as to one staff person was inconclusive, but noted that, on prior occasions, he had been found with facility residents in questionable circumstances. Criminal charges are pending against the other staff member. These allegations raise issues regarding, among other things, the adequacy of staff supervision. In summary, Glenwood lacks important and necessary safeguards to adequately protect its residents from harm.
VIII. HABILITATION
Both facilities have taken steps to improve the habilitation and training (also known as active treatment) provided to their residents. While significant, their efforts are incomplete, and the available data suggest that, certainly as to Woodward and probably as to Glenwood, residents are not receiving appropriate habilitation.
Woodward and Glenwood follow, to an extent, an Essential Lifestyle Planning ("ELP") model, which is typically used to identify and address habilitation objectives, as well as reasonable supports, that will help the individual attain an appropriate lifestyle of his or her choosing. Both facilities have done well in using the ELP model to determine individuals' likes, dislikes, preferences, and strengths. However, neither facility has succeeded in assimilating this information into planning the individual's habilitation.
For example, according to his Woodward ELP, BJ's favorite activities involve models, cars, tools and music, but Woodward's habilitation objectives for this resident focus almost exclusively on perceived

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deficiencies, such as "Will not engage in disruptive behavior; Will not engage in thinking errors, and Will tell time." To a great extent, the facilities ignore individuals' life interests and goals when planning their habilitation and focus instead on the facilities' objectives, which tend toward adapting the individual to life in an institution.
Furthermore, whatever the habilitation objectives may be, the available data indicate that Woodward largely has been unable to achieve them, and nothing that we have seen indicates that Glenwood has fared better. Woodward data show that there is limited meaningful engagement in habilitation. In the vast majority of cases, the habilitation failed to produce "on-task" behavior (that is, the behavior which the habilitation is intended to manifest) during the six-month period commencing September 2000. Similarly, a sample of learning-based programs showed that, in August 2000, no progress was made in the majority of them.
IX. SERVING INSTITUTIONALIZED PERSONS IN THE MOST INTEGRATED SETTINGS APPROPRIATE TO THEIR NEEDS
Facility records indicate that, over a 15-month period ending in March 2001, Woodward had outplaced only 18 residents, 2 of whom were transferred to Glenwood, and had identified an additional 2 as suitable for placement. Similarly, for the same period, Glenwood had outplaced only 19 residents, although it had identified an additional 32 residents as suitable for placement. Individual staff members have made considerable effort to facilitate appropriate community placement opportunities, but the facilities, themselves, have not implemented adequate steps regarding assessments of individuals, consultations with guardians and family members, identification of appropriate supports and settings, and planning of the transition process. Consequently, individuals who desire to live in the community and who reasonably can be accommodated there are denied an adequate opportunity to do so. This is not in accordance with the State'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).
As a threshold matter, neither facility has established protocols ensuring that individuals are adequately assessed to determine the most integrated setting appropriate for their wants and needs. Consequently, treatment professionals' assessments of individuals have been haphazard or altogether absent. Although both facilities make effective use of the Essential Lifestyle Planning ("ELP") model to determine individuals' wants and preferences, neither has implemented the ELP model, or any other approach, to consistently and timely identify the most reasonably suitable environment for the individual, the individual's preferences in that regard, and the accompanying supports for living there.
Second, as discussed above, both facilities have failed to translate individuals' goals, wants and needs into adequate habilitation. More particularly, with a few significant exceptions, the focus of habilitation has been on behavioral issues.
Third, although family members and guardians, of course, will play prominent roles in decisions about living arrangements, the facilities have halted consideration of community placement for certain individuals, based on perceived objections of persons other than the individual, herself. At the same time, the facilities have failed regularly to inform family and guardians about available supports that have helped individuals with significant disabilities succeed in the community. A decision to stay in or leave an institution is not meaningful if it is not informed.
Finally, though Glenwood is making significant progress in this area, the timeliness, consistency and completeness of transition and community placement planning are problematic at both facilities. Current planning in these areas is informal. At Woodward, it often occurs either shortly before formal discharge

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or, in some cases, following an individual's move. Glenwood has engaged in several months of appropriate planning for some individuals, such as SJ, JS and EF. Other Glenwood plans, for JC and LK, for instance, appear to be incomplete and somewhat hurried. Not surprisingly, the latter two individuals returned to Glenwood. At both Glenwood and Woodward, the lack of a formalized transition and community placement planning process at the organizational and individual levels needlessly subjects the success of community placements to chance.
Separately, Glenwood had, as of March 2001, 27 residents under the age of 18. Ten of them were 12 or younger. Record review indicates that many of these children came to Glenwood because of a lack of available in-home supports. As discussed below, Glenwood has aggressively expanded its capability to provide community support services. It should consider linking this expanded capability with a targeted effort to assist in returning to the community those children in its care who can do so with reasonable support.
X. COMMUNITY SUPPORT SERVICES
Both facilities are making efforts to serve as community resources and have developed an array of community support services, including campus and in-home respite care, thirty-day assessment services and other diagnostic and evaluation services, in-home supported living and family services, consultations for family and community providers, and waiver-funded group homes. Glenwood has made particular efforts in this regard, locating a community school and a residence for the elderly on its grounds. Some of the elderly residents have become involved in foster grandparent and senior companion programs, which are excellent examples of creative and effective community outreach.
In general, all of these services have helped to somewhat integrate the facilities themselves into the community. They also have enabled some individuals to continue living in the community. The facilities' efforts in this regard are commendable.
XI. RECORD KEEPING
Maintaining accurate, complete and workable records for every institutionalized person is difficult but fundamentally important. Record management at both facilities is strikingly poor. Consequently, individuals are needlessly exposed to risk of harm.
A. Woodward
From the first page of documentation, there were errors of fact in every one of the numerous patient charts and client records that one of our consultants reviewed. The charts were full of documentation errors, specific documents were hard to find, information was missing, and even Woodward's staff had difficulty helping him locate information and documentation. Meaningful record quality assurance is nonexistent, and the numerous deficiencies suggest a lack of concern for detail.
B. Glenwood
Here, too, the records were full of errors, and specific consult records and notes were very difficult to locate. Further, there is frequently a significant lag time between when a note is dictated or written and when it is placed in the chart. Much of the writing in progress notes in the charts is illegible, and the notes are not consistently dated, timed and signed. Again, these problems indicate poor to nonexistent quality assurance and oversight and a lack of care of detail.

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XII. MINIMUM REMEDIAL MEASURES
To remedy the deficiencies discussed above and to protect the constitutional and federal statutory rights of Woodward and Glenwood residents, Iowa promptly should implement the minimum remedial measures set forth below. These apply to both facilities unless otherwise indicated.
A. Restraints and Restrictive Controls
Any device or procedure that restricts, limits or directs a person's freedom of movement (including, but not limited to, mechanical restraints, physical/manual restraints or time out procedures) ("Restrictive Controls") should be permissible only as a last resort. More specifically, the facilities should:
1. Eliminate use of mechanical restraints from all behavior plans and programs and limit use of mechanical restraints to true emergency situations.
2. Eliminate prone holds in all circumstances.
3. Eliminate use of all other Restrictive Controls except:
(a) when active treatment strategies have been considered and attempted and would not protect the person or others from harm, or prevent property damage; (b) other less intrusive or restricted methods have been ineffective; and (c) as a planned intervention in approved behavior support plans, or on an emergency basis, when an unexpected crisis situation occurs in which a person's behavior poses an immediate risk of harm to self or others.
4. Provide all direct care staff with competency based training on emergency restraint use.
5. Develop and implement a policy on restraints and restrictive measures that comports with current professional standards.
6. Convene an interdisciplinary team to review and revise, as appropriate, the behavior support plan of any individual placed in mechanical restraints more than three times in a one-month period.
B. Psychiatric Services
No resident should receive psychotropic medications without having first been thoroughly evaluated and diagnosed according to current professional standards of care, including with sufficient documentation to withstand clinical scrutiny. More particularly, the facilities should:
1. Develop 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. Use these protocols to assess each person upon admission for possible psychiatric disorder(s).
2. Undertake a thorough psychiatric evaluation/workup of all individuals currently residing at each facility, provide a clinically justifiable current diagnosis for each individual, and remove all diagnoses which cannot be clinically justified.

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3. As to all residents residing at the facilities receiving psychotropic medications, undertake a new psychiatric consult to ensure that all such medications are appropriate and are specifically matched to current, clinically justifiable diagnoses.
4. Ensure that each psychotropic medication is prescribed in its optimal therapeutic range.
5. If more than one drug is prescribed for the same indication, provide a particularized justification at the mechanism level for the polypharmacy, and eliminate all polypharmacy that cannot be justified at the mechanism level.
6. In all prescriptions and psychiatric consults, specify the marker or target variables for each drug and the expected time line for the effects to be evident. Monitor the use of each such medication against the markers or target variables that have been identified to evaluate its effect. Reassess diagnoses and treatments as appropriate.
7. Ensure that, where psychotropic medications are used, ongoing consideration is given to the potential impact of the individual's other medications, and the impact on other aspects of the individual's health.
8. Ensure that psychiatry hours at each facility are sufficient to enable the psychiatrists to provide adequate services.
9. Fully integrate pharmacological treatments with behavioral and other interventions.
10. Obtain informed consent or proper legal authorization prior to administering psychotropic medications and other invasive treatments.
C. Psychological Services
Behavioral data used in forming psychological assessments should be current, accurate and complete; behavioral assessments should be complete and substantiated; treatments should be geared toward improving the individual's quality of life, and all of the foregoing should be implemented according to current professional standards of care, including with documentation sufficient to withstand clinical scrutiny. More particularly, the facilities should:
1. Develop standard protocols for efficient, accurate collection of behavioral data, including relevant contextual information.
2. Develop standard psychological assessment and interview protocols. Ensure in these protocols that possible medical, psychiatric or other motivations for target behaviors are considered.
3. Use these protocols to ensure that functional assessments and findings about behaviors are adequately substantiated, current and complete. In this regard, ensure that other potential functions have been assessed and excluded.
4. Ensure that behavioral plans are written at a level that can be understood and implemented by direct care staff.
5. Ensure that outcomes of behavioral plans include fundamental objectives, such as

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reduction in use of medication, enhanced learning opportunities, and greater community integration.
6. Ensure that outcomes are frequently monitored, and that assessments and treatments are reevaluated promptly if target behaviors do not improve.
7. Ensure that the psychologist:individual ratio is adequate to support both individuals needing behavior programs and the facility's general population.
D. Integration of Pharmacological and Behavior Plans
Combined assessment and case formulation should occur to develop and implement an integrated behavioral and psychopharmacological treatment and, at a minimum, ensure that related treatments do not conflict. More particularly, the facilities should ensure that:
1. Psychiatric disorders or conditions that require primary, or adjunctive psychopharmacological treatment, are distinguished from essentially learning-based behavior problems that require behavioral or other interventions. Expressly identify those that have overlap. Provide appropriate, integrated treatment.
2. Behavior development plans reflect an assessment, in a manner that will permit clinical review, of medical condition(s), psychiatric treatment and the use and impact of psychotropic drugs.
E. General Medical Care
Individuals with health problems should be promptly identified, assessed, diagnosed, treated, monitored and, as monitoring indicates is necessary, reassessed, diagnosed and treated, consistent with current professional standards of care, including with documentation adequate to withstand clinical scrutiny. More specifically, Glenwood should:
1. Retain a well-qualified medical director who would be responsible for maintaining a consistent level of adequate medical care throughout the facility.
2. Establish a formal medical peer-review system.
3. Establish a medical quality assurance program that:
(a) actively collects data relating to the quality of medical services; (b) assesses these data for trends; (c) initiates inquiries regarding problematic trends and possible deficiencies; (d) identifies corrective action; and (e) monitors to ensure that appropriate remedies are achieved.
4. Establish a system to track errors in the administration of medicine.
5. Establish uniform medical care policies and protocols to ensure the consistent provision of medical care.
6. Monitor and analyze facility-wide psychotropic medication use so that policies,

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procedures and drug prescribing practices can be based on reliable quantitative data.
F. Neurologic Care At Glenwood
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 the treatment and medication are appropriate. More particularly, Glenwood should:
1. Ensure that each individual who is admitted with a neurological diagnosis is thoroughly evaluated by a neurologist at admission.
2. Develop and implement standard seizure treatment objectives and anticonvulsant medication prescription practices.
3. Ensure that a well-qualified neurologist thoroughly evaluates every resident having a seizure disorder diagnosis and reviews all people with seizure disorders to ascertain a goodness-of-fit among assessment, diagnosis and treatment.
4. Implement a facility-wide, monthly side-effects monitoring system specifically for anticonvulsant medications.
5. Minimize use of older anticonvulsant medications, such as barbiturates and hydantoins, in favor of newer ones having fewer cognitive, behavioral and physical side effects.
G. Nutrition Management At Woodward
All facility residents should be assessed for swallowing difficulties. Residents having swallowing difficulties should be supported with appropriate nutritional supports. More particularly, the facilities should:
1. Conduct facility-wide screening for all residents not already identified as having nutrition management needs.
2. Fully evaluate each individual identified as nutritionally high-risk and develop and implement mealtime plans for each such individual.
3. Ensure that residents identified as nutritionally high-risk are regularly re-assessed.
4. Develop and implement formal, competency-based staff training on mealtime procedures, supplemented with quality assurance monitoring of mealtimes.
5. Ensure that only staff who have demonstrated competency with an individual's mealtime plan provide assistance to that individual.
H. Physical Therapy at Woodward
In accordance with current professional standards of care, each individual having physical disabilities, including but not limited to those in wheelchairs or experiencing walking difficulties, should be assessed regularly, and should be assessed promptly after a significant change in physical status, to

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identify and address physical therapy needs and the adequacy of supports. The assessment should be documented in a manner adequate to support clinical review. More particularly, Woodward 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 competency-based training on therapeutic positioning, particularly in addressing scoliosis, mealtime needs, and functional seating.
I. Protection from Harm
Incidents involving injury and unusual incidents should be reliably and accurately reported and investigated, with appropriate follow-up. More particularly, the facilities should:
1. Ensure that incidents involving injury and unusual incidents are tracked and analyzed to identify root causes.
2. Ensure that analyses are transmitted to the relevant disciplines and direct-care areas for responsive action, and responses are monitored to ensure that appropriate steps are taken.
3. Ensure that assessments are conducted to determine whether root causes have been addressed and, if not, ensure that appropriate feedback is provided to the responsible disciplines and direct-care areas.
J. Habilitation
Habilitation and training should be provided to prevent regression and unreasonable restraint and improve the ability of individuals to exercise their liberty interests. More particularly, the facilities should:
1. Develop and implement individualized habilitation programming directly matched to the individual's goals, interests, needs, and lifestyle preferences.
2. Formalize planning protocols, policies and procedures for use throughout the facilities.
3. Provide staff training on the development of individualized plans and their implementation.
4. Monitor and analyze the efficacy of the individualized planning and implementation process. Each individualized plan should have outcome measures that specify action steps and/or training strategies, and related target dates and responsible staff. Revise programming, as appropriate, based on outcomes.
K. Serving Institutionalized Persons In The Most Integrated Settings Appropriate To Their Needs
Every facility resident should be professionally assessed to determine whether continued placement

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in the facility constitutes the most integrated setting appropriate to meet the individual's needs. More particularly, the facilities should:
1. Develop and implement comprehensive, formal guidelines, policies and procedures for transition planning. These should include, at a minimum, target dates, measurable outcomes, training and transition strategies, and responsible staff.
2. Assess the specific characteristics of the most appropriate setting and support needs for each individual at each facility. Assessments (for new admissions) should be done at admission. Periodically update the assessments for individuals who remain at the facility for extended periods of time.
3. 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 names and positions of those responsible for these actions, and corresponding time frames.
4. Ensure that consent decisions are fully informed.
L. Record Keeping
Individual records should be accurate, current, complete and organized in a manner allowing relevant information to be quickly identified. More particularly, the facilities should:
1. Implement quality assurance/fidelity review procedures to ensure, through frequent, random reviews, that individuals' medical charts and other records are accurate, complete and current. Where the review identifies record keeping deficiencies, these should be monitored to ensure that adequate corrective action is taken to limit their reoccurrence.
* * * * *
The collaborative approach that the parties have taken thus far has been productive, as both Glenwood and Woodward have exhibited improvements since our investigation began. We hope to be able to continue working with the State in an amicable and cooperative fashion to resolve our outstanding concerns regarding these facilities.
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 the relevant concerns, and offer practical assistance in addressing them. We hope that you will give this information careful consideration and that it will assist in facilitating a dialogue swiftly addressing areas requiring attention.
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 Woodward and Glenwood residents, 49 days after the receipt of this letter. 42 U.S.C. § 1997b (a)(1). Accordingly, we will soon contact State officials to discuss in more detail the measures that the State must take to address the deficiencies identified herein.

http://www.usdoj.gov/crt/split/documents/ia_findings_wsrc_gsrc.htm

6/4/2007

Investigation of Woodward State Resource Center and Glenwood State Resource Cente... Page 21 of 21
Sincerely,
Ralph F. Boyd, Jr. Assistant Attorney General
cc: The Honorable Thomas Miller Attorney General State of Iowa
Dr. Michael J. Davis Superintendent Woodward State Resource Center
Dr. William Campbell Superintendent Glenwood State Resource Center
Ms. Jessie Rasmussen Director Iowa Department of Human Services
Steven M. Colloton, Esq. United States Attorney Southern District of Iowa
1. We have assigned random initials to the Woodward and Glenwood residents mentioned herein to protect their privacy. In a separate transmittal, we are providing a schedule through which these individuals can be identified.

http://www.usdoj.gov/crt/split/documents/ia_findings_wsrc_gsrc.htm

6/4/2007