U.S. v. Wisconsin

MR-WI-001-002 I N THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OP WISCONSIN
UNITED STATES OF AMERICA, Plaintiff,

DOC NO REG'D/FILED
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JWSKUPNiEWiTZ CLERK US OIST COURT
WO OF WI

v.
THE STATE OF WISCONSIN; the Honorable TOMMY G. THOMPSON, Governor of the State of Wisconsin; JOSEPH S. LEEAN, Secretary of the Department of Health & Family Services; JAMES HUTCHISON, Superintendent of the Southern Wisconsin Center for the Developmentally Disabled; and STEVE WATTERS, Acting Superintendent of the Central Wisconsin Center for the Developmentally Disabled,

Civil Action No.
'97 0 0231

Defendants.

COMPLAINT 1. The Attorney General of the United States brings this action on behalf of the United States of America, pursuant to the Civil Rights of Institutionalized Persons Act of 1980 ("CRIPA"), 42 U.S.C. §§ 1997-1997J, to enjoin the named Defendants from depriving persons residing at the Southern Wisconsin Center for the Developmentally Disabled ("SWC") in Union Grove, Wisconsin, and the Central Wisconsin Center for the Developmentally Disabled ("CWC") in Madison, Wisconsin, of rights, privileges or immunities secured or protected by the laws and Constitution of the United States.

JURISDICTION, STANDING AND VENUE 2. This Court has jurisdiction over this action pursuant to 28 U.S.C. § 1345. 3 . The United States has standing to maintain this action pursuant to 42 U.S.C. § 1997a. 4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein. 5. Venue in the United States District Court for the Western District of Wisconsin is proper pursuant to 28 U.S.C. § 1391.
DEFENDANTS 6. Defendant STATE OF WISCONSIN ("State") owns and operates SWC and CWC ("the institutions"), facilities housing individuals with mental retardation or other developmental disabilities. Some of the individuals are also elderly and mentally ill. 7. Defendant TOMMY G. THOMPSON is the Governor of the State of Wisconsin, and, in this capacity, heads the Executive Branch of the State's government and, among other duties, reviews and approves budget requests submitted by Executive Branch agencies regarding the institutions. He selects and appoints the Secretary of the Department of Health and Family Services. 8. Defendant JOSEPH S. LEEAN is the Secretary of the Department of Health and Family Services and, in this capacity,
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exercises administrative control of, and responsibility for, the institutions.
9. Defendant JAMES HUTCHISON is the Superintendent of SWC, and is responsible for the administration and day-to-day operations of SWC.
10. Defendant STEVE WATTERS is the Superintendent of CWC, and is responsible for the administration and day-to-day operations of CWC.
11. The individual Defendants named in paragraphs 7, 8, 9 and 10 above are officers of the Executive Branch of the State of Wisconsin and are sued in their official capacities.
12. SWC and CWC are institutions as that term is defined in 42 U.S.C. §1997(1) (A), (1) (B) (i) and (1) (B) (v) .
13. Persons residing at the institutions are individuals with mental retardation or other developmental disabilities, and some of the individuals are also elderly and mentally ill. Persons residing at the institutions are "qualified individual [s] with a disability" under the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C. §§ 12101, 12131.
14. The State of Wisconsin and the Wisconsin Department of Health and Family Services are "public entities" under Title II of the ADA, 42 U.S.C. § 12131.
15. Defendants are legally responsible, in whole or in part, for the operation of and conditions at the institutions, as well as for the care and treatment of persons residing at those institutions.
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16. At all relevant times, Defendants have acted or failed to act, as alleged herein, under color of state law.
FACTUAL ALLEGATIONS 17. Defendants have failed and are continuing to fail to provide reasonably safe conditions and to ensure the reasonable safety and personal security of the institutions' residents. 18. Defendants have failed and are continuing to fail to provide adequate medical care and related services, including psychiatric care, to the institutions' residents. 19. Defendants have failed and are continuing to fail to ensure that residents of the institutions are free from undue or unreasonable restraint. 20. Defendants have failed and are continuing to fail to ensure that chemical and physical restraints are administered to residents at the institutions by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff. 21. Defendants have failed and are continuing to fail to ensure that medications are prescribed and administered to residents at the institution by appropriately qualified professionals in keeping with accepted professional standards, and are not used as punishment, in lieu of treatment, or for the convenience of staff. 22. Defendants have failed and are continuing to fail to provide the institutions' residents with that level of training
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necessary to protect the residents' liberty interests, including their right to training sufficient to ensure their safety and freedom from undue restraint.
23. Defendants have failed and are continuing to fail to provide a sufficient number of adequately trained staff to render the essential care, treatment and training outlined above in paragraphs 17 through 22 as required by the laws and Constitution of the United States.
24. Defendants have failed and are continuing to fail to maintain professionally based recordkeeping and record review systems to ensure that resident records contain accurate, up-to-date and relevant information necessary to enable staff to provide adequate care, treatment, and training to the institutions' residents.
25. Defendants have failed and are continuing to fail to ensure that citizens living at the institutions are adequately evaluated for community placement, that those individual residents who professionals determine should be placed in community programs are placed in such programs, and that all residents are served in the most integrated setting appropriate to each resident's individual needs.
26. Defendants have failed and are continuing to fail to meet the requirements of the Americans with Disabilities Act of 1990, 42 U.S.C. §§ 12101 et. seq. , and the regulations promulgated pursuant thereto, by excluding the citizens living at the institutions, by reason of their disability, from participation
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in or by denying them the benefits of services, programs, or activities, or by subjecting them to discrimination, and by failing to administer services, programs, and activities in the most integrated setting appropriate to their needs.
VIOLATIONS ALLEGED 27. The acts and omissions alleged in paragraphs 17 through 26 infringe upon the residents' legal rights and substantive liberty interests and constitute resistance to their full enjoyment of rights, privileges or immunities secured or protected by the laws and Constitution of the United States, and deprive the institutions' residents of such rights, privileges or immunities. 28. Unless restrained by this Court, Defendants will continue to engage in the conduct and practices set forth in paragraphs 17 through 26 that deprive residents of the institutions of rights, privileges, or immunities secured or protected by the laws and Constitution of the United States, and cause irreparable harm to those residents.
PRAYER FOR RELIEF 29. The Attorney General is authorized under 42 U.S.C. § 1997a to seek only equitable relief. WHEREFORE, the United States prays that this Court enter an order permanently enjoining Defendants, their agents, employees, subordinates, successors in office, and all those acting in
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concert or participation with them from continuing the acts, practices and omissions at the institutions set forth in paragraphs 17 through 26, and to require Defendants to take such action as will bring Defendants into compliance with federal law and provide constitutional conditions of care to persons who presently reside at the institutions. The United States further
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prays that this Court grant such other and further equitable relief as it may deem just and proper.
Respectfully submitted,

JANET RENO Attorney General of the
lited States

5iPEGGY/M' LAUTENS CHH&GER
United States Attorney
Western Dist. of Wisconsin

feSBELLE KATZ PINZ^ER Acting Assistant Attorney General Civil Rights Division

THOMAS P. SCHNEIDER United States Attorney Eastern Dist. of Wisconsin

STEVEN H. ROSENBAUM Chief Special Litigation Section

ROBINSUE FROHBOESE Deputy Chief Special Litigation Section
3
ROBERT C. BOWMAN RICHARD J. FARANO Senior Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 10th & Pennsylvania Ave., N.W. Washington, D.C. 20530 (202) 514-6253 (202) 307-3116

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CERTIFICATE OF THE ATTORNEY GENERAL

I, Janet Reno, Attorney General of the United States, certify that with regard to the foregoing Complaint, I have 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 certify, pursuant to 42 U.S.C. § 1997b(a)(3), my belief that this action by the United States is of general public importance and will materially further the vindication of rights, privileges, or immunities secured or protected by the laws and Constitution of the United States.

I further certify that I have "reasonable cause to believe" set forth in 42 U.S.C. § 1997a to initiate this action. Finally, I certify that all prerequisites to the initiation of suit under 42 U.S.C. §§ 1997-1997J have been met.

Pursuant to 42 U.S.C. § 1997a(c), I have personally signed the foregoing Complaint. Pursuant to 42 U.S.C. § 1997b(b), I am personally signing this Certificate.

Signed this v?_ day of / I'tArf*/*_ at Washington, D.C.

, 1997

JANET RENO ^Attorney General x of the United States

 
 U.S. Department of Justice Civil Rkhts Division

Orfzjt: of ike Asstsuwt Antv-r.tr- Of-fczi
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. . -. . . . .
U.S. v. Wisconsin

The Honorable Tommy G. Thompson
Governor State of Wisconsin State Capitol Room 115 East Madison, WI 53707

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Re: Southern and Central Wisconsin Centers for the Developmentallv Disabled

Dear Governor Thompson:

By earlier correspondence, we advised you of this Department's intent to investigate conditions at the Southern Wisconsin Center for the Developmentally Disabled ("SWC"), in Union Grove, and the Central Wisconsin Center for the Developmentally Disabled ("CWC"), in Madison, pursuant tc the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1937 e_t seer. Following investigative tours of both facilities by the United States' attorneys andits experts, we sent the Secretary of the Wisconsin Department of Health and Social Services ("DHSS"), Mr. Gerald Whitburn, on July IS,1333, at his request, a summary of the information obtained during the course of our review of the facilities ("1993 Summary" or "Summary"). Our experts found serious deficiencies in a number of areas at both facilities.

We informed appropriate state officials that we providedth; summary to DHSS in order that DHSS might evaluate this information and begin to take corrective measures, as necessary. Pursuant to our responsibilities under CR.IPA, we also informed these officials of our need to re-evaluate the conditions at the facilities in light of DHSS's contention that the deficiencies cited in the Summary had been fixed or did not exist.

Accordingly, on April 18-IS, 1994, we re-toured SW <=._._ o:: April 11-12, 1994 and April 20-21, 1994, we re-toured CWC. Consistent with statutory requirements, we are now writing to inform you of our findings. We regret to advise you that we found numerous conditions at both facilities that violate the constitutional rights of the residents there. In addition, o t h facilities are not in full compliance with the Americans with Disabilities Act of 1990, 42 'S.S.C.§ 12101 ez sea. , Section 534
Act of 1973, 29 U.S.C. § 794et sec., and

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the substantive provisions of Title XIX of the Social Securitv Act, 42 U.S.C. §*139S et sea.
Under the Fourteenth Amendment and relevant federal statutes, residents of state-operated facilities for the developmental!;/ disabled and rr.entally retarded have a rich- ::, inter alia, adequate medical care, reasonably safe conditions, and training, including such training as to protect each resident's safety and liberty interests and permit each resident an opportunity to function as independently as their individual handicapping conditions permit. Programs must be provided tc teach adaptive behaviors, including self-help skills, communication, social skills, and skills to enhance'independence, that are essential to the physical and mental health and safety of residents. In addition, individuals with developmental disabilities r.ust be provided services in community-based programs where appropriate. ;/
The facts disclosed during the course of our investigations that support cur findings of unconstitutional conditions ar.d violations of federal statutory rights at SWC and CWC are se: forth below.
1/ See, e.g.. Title il of the Americans with Disabilities Act ("ADA"), 42 U.S.C. § 12132 e_t seq. (and implementing regulations, 28 C.F.R. 35.130(b)(l), and 23 C.F.R. 35.13 0(d)); Section 5:4 of the Rehabilitation Act of 1973, 25 U.S.C. § 794 e_t sea. ; Title XIX of the Social Security Act, 42 U.S.C. § 1396 et sea, (and implementing regulations," 42 C.F.R. § 483.420 - 480); Your.cbera v. Romeo, 457 U.S. 307 (1932); United States v. Tennessee, Nc. 92-2062, slip op. (W.D. Tenn. Feb. 17, 1994); Halderman v. Pennhurst State School & Hospital, No. 874-134 5, slip op. (I.D. Pa. March 29, 19 94) ; Jackson v. Fort Stanton Hoso. & Trair.ir.c School, 757 F. Supp. 1243 (D.N.M. 1990), rev'd in part on ether grounds, 954 F.2d 980 (10th Cir. 1992); Thomas S. bv Brooks v. Flaherty, 699 F. Supp. 1173 (W.D.N.C. 1938), aff'd, 902 F.2i 2 50 (4th Cir.), cert . denied, 493 U.S. 951 (1990); Clark v. Coher.. 613 F. Supp. 634 (E.D. ?a. 1935), aff'd, 794 F.2d 79 (3d Cir. 19 35) , cert . denied, 475 U.S. 962 (1935); Garv W. v. Louisjar.a, 43 7 F. S H O D . 1209, (E.D. La. 1575).

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SOUTHEP-N WISCONSIN CENTER
I. Medical Care is Dangerously Deficient.
A. Medical staff is insufficient.
The 19 93 Summary containing our medical expert's conclusions stated that he "found an inadequate number of medical and nursing professionals at SWC which impairs medical care and treatment services." 1553 Summary at 5. The Summary went on to point out that:
The number of physicians is inadequate to serve che needs of SWC's 537 developmentally disabled residents, -.any of whom present difficult clinical problems. During cur investigative tour, SWC only employed 3.5 FTE [full-timeequivalent] physicians, including its part-time Medical Director -- a medical staff half the size of CWC's.
Id. The Summary further noted that "[t]he lack of physicians results in excessive caseloads, a concern mirrored by interviewed staff. These caseloads average approximately 179 residents per physician." Id. The Summary proceeded to detail the deficient medical care at SWC that was, in large part, due to the inadequate staffing.
Despite the gravity and scope of the deficiencies expressed to DKSS in the 1993 Summary as arising from the lack of medical staff, as well as SWC staff's own concerns about the inadequate medical coverage, DKSS has not increased the medical staff. Although the resident census has decreased somewhat over the last two years, the physician to resident ratio has remained unacceptably high -- over 160 residents per physician. As SWC staff recognize, this ratio is substantially above the minimum standard ratio for this population of one physician to 10G residents. Similarly, the numbers of full-time-equivalent registered nurses and licensed practical nurses have not increased significantly. This lack of adequate numbers cf trained medical staff at SWC continues to contribute to the grossly inadequate medical care being provided to SWC residents.
5 . Seizure menitorir.a and management is inadequate .
SWC has over 300 residents with seizure disorders. SWl's monitoring and management of these disorders are seriously deficient. The deficiencies identified by our medical expert: are again attributable, in large part, to the lack of adequate medical staff and of sufficient consultant hours. The number cf hours presently being provided by the neurologist consultant: is entirely inadequate given the number of residents with seizure disorders. Presidents OP. anticonvulsant medications are kept on the same dosages and the sar.e medications for years, despite

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strong evidence that the medications are no longer necessary and, in some cases, are causing serious and unintended side-effec:s. In addition, in some of these cases, the lab reports indicate that the residents have not been en therapeutic doses of an anticonvulsant for years. Thus, these residents are being kepi on medications that are doing them no good, and potentially great harm. Although the effectiveness of subtherapeutic doses car. be documented for a minority of seizure patients, no such documentation exists in the charts of these SWC residents.
In one representative case, a resident is listed as having a possible seizure disorder and is on the anticonvulsant Phenytoin. According to the resident's record, he has not had a seizure since 1988, except for one possible incident in 1992 which was believed to be a cardiac event rather than a seizure. The resident was diagnosed with dementia which, according to the pharmacist's note, is possibly due to the Phenytoin. The pharmacist suggested discontinuing the medication. However, despite this recommendation, and the fact that this resident has apparently been seizure free for at least six years and is suffering dementia possibly due to the medication, the resident was still on the medication at the time of our tours. Moreover, the lab reports indicate that the Phenytoin in his blood has been subtherapeutic for at least two years. There is no indication that the physicians have taken any measures to increase his doses to a therapeutic level, and no documentation that they purposely maintain his dosage at this level because they have determined that subtherapeutic doses are effective for this resident. In sum, SWC physicians simply continue to prescribe dosages and medications which are not benefiting this resident and other residents, but which may be causing them substantial harir..
Also, it is well-accepted by medical professionals that seizures should be treated with only one anticonvulsant whenever possible (monotherapy), and that the unnecessary prescription of additional anticonvulsants (polypharmacy) subjects patients to the risks of serious side-effects and may affect the patient's cognitive functions, sedating or otherwise hindering the patient's ability to function. Our medical expert found several examples of polypharmacy with no adequate justification for the practice. In several cases, residents with well-controlled seizures are being given three anticonvulsants, the side-effects of one or more of which may be causing or exacerbating the residents' behavior problems. Although SWC's Medical Directive #27 correctly notes that residents treated with Phenytoin and Phenobarbital should be switched to alternative anticonvulsants whenever possible, this directive is not being carried out.

C. Diagnosis and treatment of illnesses fail to comport with -renerallv accented professional standards.
As we noted in the 1933 Summary, the lack of adequate also impacts on the quality of basic medical care.
During our latest tours, the United States' medical expert identified a number of residents who have medical problems that the medical staff failed to identify and treat appropriately in a timely manner. Medical progress notes are brief and do not contain much information about a physical exam and changes in clinical findings. In cases where clinical symptoms were identified or illnesses diagnosed, there is an absence of close monitoring and follow-up on abnormal tests thereafter.
In one representative case, a resident had such a severe skin infection (cellulitis) of his penis and scrotum that he required an in-dwelling catheter to drain his bladder. He v=s seen by a dermatologist who recommended that he be referred to a urologist if he was not better in one week. Our expert could find no documentation in his chart that he was ever seen by a urologist. Three weeks later lab results showed a moderate amount of blood and a high white blood cell count in his urine (indicating possible infection). There is no evidence that a physician acknowledged these abnormal results. Despite obvious and continuing signs of serious infection, the resident was not treated for the infection for over two months. The treatment, when it came, was too late, and the resident died from sepsis or a blood infection.
"D. Monitoring and follow-up of medical care residents receive at contract hospitals are insufficient.
Institutions such as SWC have an obligation to ensure that medical care they contract for is adequate. SWC documents and our discussions with medical staff indicate that SWC had serious concerns about the quality of medical care provided to residents sent out to a local hospital. These sources also indicate that the Medical Director intended to review the possibility of contracting with another hospital. Nevertheless, residents continue to be sent to this hosnital and continue to be harmed by the grossly substandard care provided there.
A particularly egregious example is the case of one 27-year-old resident who was sent to the hospital for surgery of a perforated duodenum. After surgery, he broke out of his restraints and caused his surgical wound to re-open. A second surgery was required to close the wound. Following this surgery, however, the hospital decided to immobilize the resident by administering a drug co oaralvze him. The drug is so powerful that it can arrest breathing. Accordingly, the hospital also gave him. a surgical tracheostomy and put him on a ventilator. The resident was left paralyzed and on a ventilator for three •

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weeks until his wound healed. The tracheostomy was then removed. This procedure represents an exceedingly gross departure frtaccepted standards of post-operative care. At a minimum, SW" administrators and medical staff should have been closely monitoring his care and should have prevented these procedures.
In another case, a 26-year-old resident was transported from SWC to the emergency room by ambulance because of severe respiratory arrest. Ke was treated and returned to SWC. Cr. the afternoon of the same day he was in severe respiratory arrest again and was transported back to the emergency room. He required oxygen by mask, and a blood gas test suggested early respiratory failure. The hospital physician diagnosed upper respiratory infection and again sent the resident back to SV-'i. At 1:00 A.M. that night, the resident died. The failure of SWi's physicians and the hospital's physicians to diagnose and prcteriy treat the resident's life-threatening medical condition represents seriously deficient medical practice.
E. Emercencv care is lackinc.
SWC relies on local 911 emergency medical technicians :: provide advanced emergency care and transport to the communityhospital for further care. Although some reliance on outside local emergency medical support is warranted, SWC is insufficiently prepared to handle emergency conditions that may occur before local emergency medical technicians can arrive. Emergency equipment on various wards is locked up and difficult to access rapidly. In addition, the last emergency drill was held "in 19S1. Finally, no staff physician has Advanced Life Support training.
F. Medical record-keeoina is seriously deficient.
The 1SS3 Summary detailed several ways in which the medical record-keeping practices were deficient. As the Summary noted, "all of [these deficiencies] contribute to valuable treatment information being lost." Summary at 11. These same types cf deficiencies were found repeatedly in the documents our experts reviewed during the latest tours. Our medical expert found the records so poor that he had difficulty in locating or tracking medical care. In addition to the specific problems in documentation and follow-up already described in sections A through D above, our medical expert generally found that physician notes are infrequent and often do not have a entry. Usually there is no documentation or clinical summar-v in the physician notes when residents were transferred to the Infirmary.
Adequate medical documentation and record-keeping is essential to crovide adeauate medical care. Medical

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documentation and record-keeping at SWC continue to be seriousl deficient
II. The Administration and Monitoring of Psychotropic Medications Are Grossly Deficient and Psychiatric Services in General are Inadequate.
The 1933 Summary pointed out that "[o]ne of the most significant consequences of this staffing shortage is inappropriate medication practices." Id. at S. The Summary stated that S W C s substantial reliance on psychotropic medications, absent adequate documented rationales for their use, strongly suggests that they are "being prescribed as chemical restraints to control behavior rather than to treat psychiatric illness." Id. The Summary also observed that "SWC's medication practices are also inextricably•related to shortfalls in psychiatric services." Id.
The most recent review by our medical and psychology experts confirms that these deficiencies still persist. Our medical expert found several cases where residents continued to suffer the ill-effects of psychotropic medications, including behavioral side-effects and potentially permanent neurological damage, despite any clear indication in the records that the residents continued to need the medications. In several cases where residents were actually seen by consultants, the consultants noted the severe effects the medications were having on the individuals and/or questioned the need for the medications and recommended that they be discontinued. But the recommendations were "ignored, with no explanation as to why.
For example, one resident, diagnosed with severe mental retardation, a behavior disorder, and autism, was prescribed the psychotropic Haldol. The resident exhibited extrapyramidal symptoms ("EPS"), which can evidence a frequently permanent and debilitating condition caused by continued use of certain neuroleptics such as Kaldol. Initial consultations by a psychiatrist and a gastroenceroicgist were done in 1SB9. The gastroenterologist recommended no psychotropic medications due to adverse affects ov.the resident's distended bowels. A neurology consultant in February 1993 also noted the symptoms of EPS and recommended reducing the Kaldoi. Although there were several notes in the resident's record recommending that an updated psychiatric consultation be obtained, none was obtained until 1994 -- five years after the initial consult. Although this resident had two serious and potentially permanent complications, bowel distent ion and EPS, from the psychotropic medication, there was a five year delay in an appropriate follow-up consultation.
In another case, a 35-year-old resident has been on Stelazine since 1933, despite the fact that there is no adequate documentation of a psychiatric or behavior disorder dia gnosis

justifying the use of the drug. Stelazine is a powerful neuroleptic with significant side-effects, and its use, ever, for individuals with diagnosed psychiatric disorders, is generally discouraged in favor of newer, safer and more efficacious drugs. A consulting neurologist in 1992 noted that the resident had "IPS due to Scelazir.e." The neurologist continued the Stelazine, however, because a prior reduction had reportedly increased behavior problems. Yet, there is no adequate documentation zi this increase or any evidence that staff attempted to determine whether the perceived increase may have been the simple result of the resident's increased activity level due to the resident :.o: being as sedated by the Stelazine. Moreover, there is little evidence of any recent behavior problems. Also, our expert could find no documentation indicating that consideration had been given to switching to another medication in order to reduce the EPS problem.
In yet another case, a 45-year-old resident was diagnosed with "intermittent explosive disorder" by the psychiatric consultant in 1933, and was put on Mellaril and Tegretol. In 1993, the resident was rushed to the emergency room after choking on a meatball. In June 1993, a feeding consultant recommended reducing or discontinuing the Mellaril because it could be creating or exacerbating the resident's swallowing disorder. There is no documentation that this resident has received a psychiatric consultation since the one in 1988, and the last reduction in the dosage of Mellaril occurred in 1990. This absence of even routine monitoring of this resident by a psychiatrist is a gross deviation from professional standards, and is especially egregious given the identified potential danger of Mellaril for this resident.
Although SWC issued medical directives in 1988 that attempt to set a standard for psychiatric care, the medical records indicate that these directives are not being followed.
In cases where the presence or absence of behaviors and potential symptoms of psychiatric problems are actually documented by staff, they are not addressed and the existing treatments are simply continued. For example, one resident's aggressive behavior escalated dramatically (i.e., in three consecutive months the incidents of aggression went from 4 5 to 142 to 1 8 3 ) , but there is no evidence that the resident w-a=s seen by a psychiatrist or that SWC staff considered changing the resident's psychotropic medication. In another case, the attending physician noted that a resident on three anticonvulsants for a seizure disorder and Meliaril for a behavior disorder had no behavior problems for 16 months. Despite this long record of controlled behavior there was n: documented attempt to reduce the dosage of Mellaril.

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SWC is engaging in the use of chemical restraints by failing co ensure that psychotropic medications are prescribed and administered to SWC residents in keeping with accepted professional standards, and are not used in lieu of treatment, or for the convenience of staff. At SWC, psychotropic medications are used in lieu of proper assessment and analysis of the individual's behavior problem, especially when the behavioral treatment programs are ineffective. For example, the facility doubled one resident's psychotropic medication in response to che individual's increased aggression and temper tantrums. This resident did not have an active behavioral treatment prograrr. other than a generic reinforcement program and redirection. Further, there was no data to support the use of such a program for the treatment of his chronic behavior problems. In many cases at SWC, the facility psychologists have largely abdicated their responsibility to provide•adequate and appropriate treatment, relying too heavily on pharmacological intervention and the consulting psychiatrist to place individuals on higher doses of neuroieptics, the effectiveness of which is often questionable in the treatment of individuals with problem behaviors.
For those dually diagnosed individuals who need both behavioral programming and medication for their mental illness, ic is extremely important that the two treatments are integrated properly. Accurate and reliable behavioral data is particularly important when behavioral programs are combined with pharmacological treatment. In addition, written programs r.ust show that the psychologist, psychiatrist and physician have discussed the probable consequences of the combined treatments. However, at SWC, the level of integration of behavioral and pharmacological interventions is minimal. The mere fact that SWC has combined che use of aversive procedures with neuroleptic medication reveals a lack of knowledge of the interaction between these two treatment modalities. In addition, the SWC psychologists needlessly justify the use of psychotropic medication because they misunderstand the significance of their own observations of the individual's behavior.
A number of residents have serious behavior problems and medical disorders that require close supervision by staff. On coo many occasions there has been an absence of that supervision. In a few of these cases, residents who have well-knowr. and documented swallowing disorders or pica behavior require emergencv medical care or surgery because they have choked en food or ingested an inedible object.
In-.one case that indicates the absence of close supervision, a 63-vear-oid resident had been diagnosed with a cait disorder

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that leads tc frequent fails. The physical therapist reported that she needed one person to assist with her walking. Despite this recommendation, the resident was seen in the emergency room for trauma a::er a fall, and accordingly to the treating physician's r.ote, the resident had fallen 62 times that day.
Other incident reports detail a variety of unexplained and serious incidents and injuries at SWC. Many of these incidents and injuries reflect the inadequacy of the institutional environment in which these residents are kept. While some cf these incidents and injuries were accidental, many were r.o:. Moreover, S W C s documentation indicates that a number of residents may have suffered injuries at the hands of SWC staff. Finally, residents with dangerous and sometimes life-threatening problems requiring closs supervision by staff do not receive such supervision.
IV. Psychology Services Substantially Depart from Accepted Professional Standards.
In addition to the deficiencies in psychology services already addressed above, our psychology expert also found chat essential aspects of S W C s psychology services depart substantially from accepted professional standards. These findings are consistent with those outlined in our 1S93 Summarv.
A. Behavioral programs are inadequate.
The State is failing to provide the residents of SWC with adequate individualized behavioral programming to ensure and protect the SWC residents' safety and liberty interests.
SWC has custody of a large number of residents with serious maladaptive behaviors such as physical aggression, pica, self-injurious behavior and agitation. Behavior problems pose physical and emotional risks to the individual and to other residents and staff. Individuals living in an institution like SWC must be protected from physical injury and psychological harm stemming from behavior problems.
An individualized behavioral treatment program, devised and implemented according to currently accepted professional standards, can reduce ana eliminate these maladaptive behaviors. However, the behavioral treatment programs currently utilized at SWC do not comport with accepted professional standards. Cur consultant psychologist found that SWC residents are being subjected to harm and unreasonable risk of injury due to major deficiencies in the assessment of residents and in the development, implementation and monitoring of resident behavioral programs. As a result, the State is failing to provide reasonably safe conditions and to ensure the reasonable safety and personal security of the SWC residents.

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Ail behavioral programs must be based upon an adequate assessment of resident need, including the need to develoc programs to address maladaptive behaviors. At every stage of the assessment, analysis and treatment of an individual's behavior problems, SWC is failing to meet accepted professional practices. For example, the SWC psychology staff is unfamiliar with necessary functional assessment procedures, instruments and methods; the current assessment scale utilized at the facility, and the documentation of the rationale and development of the behavioral treatment programs are inadequate. The little descriptive analysis that is undertaken at SWC is poorly documented with little factual data. In none of the forty cases reviewed by cur expert psychologist did the SWC staff appropriately determine the function of the resident's behaviors or adequately plan a systematic method of addressing the problem behaviors. Without utilizing generally accepted assessment techniques, interventions at SWC are selected simply by trial and error. This is inadequate and represents a substantial departure from generally accepted practice for the development of behavioral programs.
The inadequacies in the development and implementation of behavioral programs at SWC have deprived the residents of effective treatment for their maladaptive behaviors and violated their right to a safe environment. For example, the inadequate behavioral intervention process at SWC caused one resident's aggression to increase dramatically from 103 incidents per month in 1992 to 25? incidents per month in 1993. Further, this individual's self-injurious behavior increased from 32 incidents per month in 1952 to 124 incidents per month in 1993. Had this resident's treatment been appropriately changed in 1992 when it was clear that it was ineffective, he may not have been subjected to an increasing rate of aggression and self-injury.
SWC does not effectively or actively treat its residents' behavior problems. Many individual residents with maladaptive behaviors have been forced to endure the same ineffective behavioral program for years even though they are still engaging in the behaviors that were initially targeted in the original program. For example, it took over five years to "control" the self-injury of one client even though his behavioral treatment included restraints and medication. When changes in behavior take this long, it is questionable whether the changes are actually attributable to the efficacy of the behavioral treatment program. Another resident, who continues to eat inedible objects (pica behavior) has been on the same ineffective program to treat this behavior for over seven years. Needless to say, this behavior can be extremely dangerous. The psychologists at SWC have used generic pica programs with only minor individual variations. They have cade no effort to vigorously treat pica with craven behavioral orocedures. The crocrams also do not stoo

- 12 -
the individual from exhibiting the behavior in the natural
Further, the programs are not sufficiently monitored ar.d revised as appropriate. At SWC, there is no facility-wide system of reliable behavior data collection. What data is collected is not checked or reviewed in a timely fashion. For example, behavioral data is checked only once a month and reviewed by the team only once a quarter. This does not comport with accected professional practices which call for daily data review. In addition, the SWC behavioral programs typically do not assess the programs' side effects and do not assess the generality or durability of the behavior change.
B. Training programs are inadequate.
The State is also failing to provide SWC residents with that level of individualized training as is necessary to enhance functioning, and facilitate growth, development, and independence. In the absence of such programs, residents dr not develop the skills necessary to exercise any degree of independence and they remain totally dependent on staff to meet all their needs.
It is generally accepted in the field today that training programs should not focus on the acquisition of meaningless, rote or otherwise isolated skills, but rather should focus on the acquisition of functional skills across a range of settings, people, and target behaviors so as to produce comprehensive iife-'styie changes for the individual. However, at SWC, the training programs do not meet currently accepted professional standards. The SWC training programs are designed to enhance isolated, specific, discrete skills rather than to produce the acquisition of functional skills. Further, the training is conducted in discrete, artificial and sequestered training sessions. Thus, the SWC training programs render it unlikely that the individual will maintain and generalize the taught skill in the natural environment.
C. Restraint usaae is excessive.
The State is failing to ensure that SWC residents are free from undue or unreasonable restraint. Because behavioral • interventions at SWC are developed largely on the basis of trial and error, many interventions prove unsuccessful leading to an excessive reliance on a variety of restrictive procedures to gain control over problem behaviors. The majority of behavioral programs at SWC employ some form of restrictive procedure. Typical formal restrictive procedures used at SWC include: timeout (locked and unlocked), mandatory forced compliance time-cut, fencing•mask, and physical restraint. These restrictive procedures are neither functionally the least aversive nor the

- 13 -
most effective for each individual. As a result, the SWC treatment programs have not produced socially significant changes in the residents' behavior and ability to function as normalIv as possible.
Even though some positive, nor.-aversive components are used in programming at SWC, they are ineffective and are no: designed to teach safe and socially acceptable behaviors for the individuals who continue to engage in severe behavior problems, often for years. As a result, emergency restraints often must be used to compensate. For example, during one twelve-month period, a SWC resident was placed in emercrencv restraint 27 times. This total does not even include the physical restraints that are used as part of his program. There are a great many other SWC individuals who have been subjected to repeated emergency restraints. Allowing individuals to engage in high rates of severe problem behaviors that require excessive applications of emergency restraints cannot be justified, and the use of these restraints should prompt the treatment team to revise the individual's behavioral treatment..
V. SWC's Institutional Environment Fails to Meet the Needs of the Residents .
In providing care and services to individuals with developmental disabilities, it is essential to furnish them wich an acceptable and responsive environment that ensures safety, and promotes learning and their own social well-being. Such environments are functional and provide a setting for an enhanced quality of life for the individuals. Currently accepted professional scandards require that an acceptable and responsive environment is the least restrictive alternative, is stable, safe and engaging, and operates to teach and maintain functional skills, to reduce or pre-empt the occurrence of behavior problems. However, the living environment at SWC meets none of these requirements.
The environment at SWC is not fully functional for its residents and may be the cause of some of their problem behaviors. Ironically, it is the presence of these behavior problems that can actually decrease or delay the individuals' opportunities to live in the community. On our tour of SWC, many residents were not interacting with each other, staff, training materials or their environment generally. In one case reviewed by our psychology expert, SWC did not provide one particular individual with consistent application of his prescribed behavioral intervention and an SWC staffer acknowledged thai greater success would likely be achieved with this individual in a more specialized and individualized living environment. As discussed earlier, the mere face that the facility has been unable to effectively treat its residents' behavior crobier;

- 14 -
through treatment programs indicates that the State is not providing an acceptable living environment for them.
SWC does not provide the least restrictive living environment for its residents because it does not provide functionally fewer restrictions than they would experience in -he community. ?:r example, one resident is forced to endure restricted access to his personal clothing simply because cf a peer's maladaptive behavior. Another resident is denied access to his bedroom merely because a peer is destructive. SWC alst does not provide increased opportunities for work, educational and leisure activities available to their non-disabled peers.
In addition, SWC does not provide most of its residents with a stable environment. Some SWC annual program reviews note that some individuals' maladaptive behaviors manifest themselves in response to changes in their routine at the facility. These behaviors are further exacerbated by the acknowledged inconsistency in the delivery of habilitative services at SWC. Even SWC staff have noted this in the resident records.
SWC is an isolated, self-contained environment which necessarily separates its residents with disabilities fro- the rest of society. As a result, the facility fails to provide its residents treatment in an environment that permits contacts with society and its mainstream social institutions, demands indeoendent functioning and permits the exercise of judgment an contact with family members. The State must provide these disabled residents an opportunity to participate in or benefit from'aids, benefits and services equal to that afforded to ethers outside the institution; more specifically, to those provided to other individuals with disabilities in the State's established community-based programs. The residents are entitled to aids, benefits and services that are as effective in affording the- the equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement as those served in community-based programs. By confining residents with disabilities at SWC, the State is failing to provide such services in the least separate, most integrated setting as reauired by the Americans with Disabilities Act of 1990, 42 U.S.C. § 12IC1 et. sea. , and section 504 of the Rehabilitation Ace of 1973, 23 U.S.C. § 794 e_t sea.
The cases reviewed by our consultant indicate that all cf the SWC residents could be successfully placed in the community if provided with adequate supports. The SWC staff acknowledge this fact in the individual annual program review reports.

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Keeping individuals in an institution who have been determined to be capable of living in the community cannot be justified. V
VI. Remedial Measures.
In order to remedy these deficiencies and ensure that the rights of SWC residents are protected, the following remedial measures need to be implemented promptly.
a. Hire, train and deploy adequate numbers of trained medical care staff, including physicians and nurses, to meet the medical needs of the residents. Each physician generally should not have a case load exceeding 100 residents. Increase the number of hours of consulting and contract professionals, especially those for neurology and psychiatry, to a level sufficient to provide adequate care. Ensure that enough adequately trained medical professionals, including pharmacists, are employed to institute appropriate quality assurance mechanisms, especially to oversee the prescription, administration and monitoring of psychotropic and ar.ticcr.vulsant medications, the timely treatment and follow-up on medical problems and the care provided residents sent to local hospitals.
b. Provide adequate and timely medical care, including appropriate services to meet the acute, chronic and emergency medical care needs of residents. Residents on psychotropic or anticonvulsant medications should be evaluated to determine the appropriateness of their prescriptions and whether these medications are being prescribed and monitored in accordance with accepted professional standards. Psychotropic medications must not be used as punishment, in lieu of a training program, for behavior control, without an adequate rationale and a psychiatric or neuropsychiatric diagnosis, or for the convenience of staff. Residents must not be kept on anticonvulsant medications (or
1/ See, e.g., Halderman v. Pennhurst State School & Hospital, No. 74-1345, slip op. at 1, 4-9 (E.D. Pa. March 29, 1334); Jackson v. Fore Stanton Koso. & Training School, 757 F. Supp. 1243, 1310-13 (D.N.M. 1990), rev'd in part on other grounds, 95 4 F.2d 930 (10th Cir. 1992); Thomas S. v. Flaherty, 639 F. Sure. 1173, 1204 (W.D.N.C. 19S8), aff'd, 902 F.2d 250 (4th Cir.), cert denied, 493 U.S. 951 (1990); Clark v. Cohen, 613 F. Supp. =. 4, 704 and n.13 (S.D. Pa. 1985), aff'd, 794 F.2d 79 (3d Cir. 1=55), cert. denied, 479 U.S. 952 (1936) (all finding a Fourteenth Amendment right to community services where a professional has determined that an institutionalized mentally retarded client should be served in the community); see also ADA, 42 U.S.C. § 12132 e_t sea. (including implementing regulations, e. c. , 23 C.F.R. 35.13C(b) (1) (ii) ; 23*C.F.R. 35.130(b) (1) (iii) ; and 25 C.F.R. 35.130(d)); Section 504 of the Rehabilitation Act cf 1973, 29 U.S.C. § 794 et sec-

- 16 -
inappropriate doses of those medications) that serve no therapeutic purpose or are otherwise contraindicated.
c. Medical staff should receive adequate training in emergency medical care. Emergency care policies and procedures, including the frequency of emergency drills and the location of emergency equipment, must be evaluated to ensure that they are sufficient to provide adequate emergency care. An emergency care committee or other quality assurance mechanism should review =11 clinical interventions and ensure all staff are properly trained, and all emergency equipment is operable and readily accessible.
d. Medical records must be kept in a fashion sufficient to allow medical professionals to provide adequate and timely care. An adequate system must be developed for tracking and monitoring seizure disorders, and medical staff, as well as direct care staff, should be adequately trained in seizures and seizure documentation. SWC staff must consistently utilize an appropriate and uniform method and seizure record for recording seizure activity in residents. This record should be kept in one consistent place in the chart. Physicians should write periodic summaries in resident charts which contain, at a minimum, treatment goals, goal progress, and plans for future treattme
e. SWC must employ and deploy sufficient staff, properly trained, to ensure residents are supervised and adequately protected fro- harm.
All residents must be evaluated to determine their individual strengths and weaknesses and to develop appropriate individualized training programs, including behavior management and skill acquisition programs. Immediate attention must be given to residents with self-injurious, physically abusive and other destructive behaviors by identifying them and providing necessary training on a priority basis. Such interdisciplinary evaluations should review the individual's training needs, utilizing a written descriptive functional analysis for those individuals with problem behaviors, and assess the efficacy of chemical and physical restraints. Such programs should address and develop appropriate strategies to promote the physical, mental, behavioral, and social skills of each resident and permit each resident to function as independently as possible. Such programs must be consistently implemented and procedures developed to ensure appropriate review and revision.
g. SWC must develop and implement a professionally based, individually appropriate data collection system to measure relevant information about problem behaviors and the conditions under which they occur, including, where appropriate, the frequency, intensity, and duration of the behaviors, and review the data in a timely manner.

- 17 -
h. SWC must have a qualified professional develop ar.d implement a professionally based, individualized training program for each resident teaching functional skills and provide each individual with an adequate number of hours of training. The professional must document the rationale and development of the program, and must routinely test hypotheses.
i. SWZ must ensure that restraints, chemical and physical, including emergency restraints and time-out, are used only pursuant to accepted professional standards and that they are never used as punishment, in lieu of training programs, or for the convenier.ee of staff.
j. Immediate steps must be taken to develop and implement an overall plan to significantly reduce the size of the facility and to place residents in appropriate, less restrictive, community-based programs. There should be an immediate ban en the admission of children, except in emergency circumstances, and children should be prioritized for placement in alternate, community-based programs. In the meantime, residents should receive training to assist in their placement and transition co the community-based living arrangements. Presidents should also be adequately assessed to identify services necessary to meet their needs in the community.
Large, congregate residential institutions have been demonstrated to be ill-equipped to provide the care, education, and training needed to promote the growth and development of developmentaliy disabled and mentally retarded persons. See, e.c. ; Halderr.an v. Pennhurst State School & Hospital, No. 741345, slip op. at 1, 4-9 (E.D. Pa. March 23, 1994) . The national trend is to serve these individuals in appropriate, alternative community-based programs and facilities which can meet their individual needs. Given the gravity and scope of our experts' findings regarding the deficient care provided at SWC, we must recommend the development of more appropriate settings and services for the residents of SWC.

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CENTRAL WISCONSIN" CENTER
I. Medical Care Is Deficient:.
The 1993 Summary outlines the concerns of the United States' medical expert regarding CWC's emergency care and the lack cf adequate numbers of nurses at the time of the United States' review in 1952. !/ In our most recent review, our medical expert found some favorable aspects of the medical care beir.g provided at CWC, including the competence and professior.alisrr. cf the Medical Director and some local medical consultants, and the changes CWC instituted to address some of the United States' earlier criticisms of emergency care. However, our most recent review revealed that critical aspects of medical care at CWC substantially depart from professional standards of care.
A. Emercencv and critical care is deficient.
As outlined briefly in the 1993 Summary, the United States' previous medical expert found problems in CWC's medical emergency response. Our medical expert's recent review of medical care at CWC indicates that the primary concern addressed in the 1933 Summary regarding CWC's cardio-pulmonary resuscitation ("C?R") and Do Not Resuscitate ("DNR"} policies and practice have been largely ameliorated by CWC taking appropriate actions to clarify those policies and change practice.
However, our recent review revealed areas of emergen care that"represent substantial departures from professional practice. Our medical expert observed several instances where crucial emergency equipment was kept in locations that were not immediately accessible and that were sometimes locked. In one instance, a resident with a tracheostomy tube was observed without a replacement tube at the bed side. Staff had to leave the room and retrieve a replacement tube from a closet in the hall located about 100 feet away. Tubes that become plugged or extruded can immediately compromise the patient's ability to breath. Because such problems with tracheostomy tubes are not unusual, as evidenced by CWC's own documentation, it is a serious breach of generally accepted professional practice not to have spare tracheostomy tubes at the bedside. At the conclusion cf our tour, we informed the Medical Director and the Superintendent of the immediate life-threatening potential of this deficiency.
]_/ During our most recent tour in IS 54, the Director cf stated that CWC had not increased the nursing staff since review -in IS92.

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In addition, CWC is attempting to provide emergency/critical medical care tc seriously ill residents without the requisite resources. Residents in need of acute care are sent to a Special Care Unit at CWC. However, this Unit is not adequately equipped to care for these residents. For example, residents admitted with acute respiratory difficulties are at risk because the CWC does not provide standard diagnostic and monitoring tools such as "stat" blood cases or adequate cardiopulmonary monitoring. CWC also does not provide "code sheets" with pre-determined doses of emergency drugs on the individual charts in case of emergencies. CWC also does not conduct mock emergency drills. During the last year, there were several deaths due to respiratory conditions and many acute transfers due to respiratory problems. It is our expert's opinion that the proper treatment of some of these individuals was unnecessarily delayed because they were first sent to the Special Care Unit -- where their condition deteriorated sufficiently for them to be sent on to an acute care hospital. Because CWC is not prepared to properly care for residents with acute medical problems, residents admitted tc the Unit are at great risk.
B. Diagnosis and treatment of illnesses fail to comport with cenerallv accepted professional standards.
Our medical expert identified a number of cases where residents had medical problems that the medical staff did net diagnose and treat appropriately in a timely manner. In several cases, CWC staff failed to recognize the seriousness of illnesses and to expeditiously transfer the residents to an acute care facility. The unreasonable delays in providing proper care resulted not only in harm to these residents, but, in some cases, contributed to their ultimate death.
For example, a routine urinalysis for one resident on 4/2/92 indicated a potentially serious problem with glucose metabolism. However, there was no follow-up evaluation or repeat urinalysis. Exactly 10 months later, on 2/2/93, the staff reported "...abnormal breathing, lethargic and sleepy." A too brief physician note on 2/23/93 remarks on the resident's abnormal breathing and a very fruity smell that "may be due to a metabolic problem." Blood tests revealed signs consistent with a diagnosis of a life-threatening metabolic acidosis. However, the physician diagnosed dehydration only and treated the resident with hydration. The next day the staff reported the resident was "unresponsive," and a physician note at an unspecified time stated "...no change. Will check glucose." Later that day, the resident was rushed to the emergency room where the resident required intensive resuscitation. The medical staff at CWI failed to provide a generally accepted level of professional practice by delaying transfer of a resident with obvious signs of life-threatening metabolic acidosis and dehydration.

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In another case, a resident had a prolonged seizure, but her record made no notation of the type of seizure or the duration -two factors that are important to know when treating seizure disorders. She was transferred to the Special Care Unit at CWC, and her blood pressure rose dramatically, a classic symp-om cf brain injury. She had another prolonged seizure and was described as unresponsive and with an even higher blood pressure. CWC delayed transferring her to an acute care hospital for -wo days after the first prolonged seizure. Despite subsequent treatment at ~he hospital after transfer, she died of diffuse swelling and herniation of the brain due to uncontrolled seizures. The staff's failure to accurately record her seizures, to appropriately monitor her blood pressure and to act upon her symptoms represent substantial departures from professional practice. The increasing blood pressure indicated increasing intracranial pressure and should have prompted early transfer co the hospital.
In another case, a resident developed all of the apparent symptoms of severe pulmonary infection. Despite her physical condition, her expressions of pain and her continuing deterioration, CWC medical staff waited almost two weeks before transferring her to the hospital. She died at the hospital, where she was given morphine to ease her pain. Because CWC medical staff did not transfer the resident sooner, the resident did not get close monitoring of her respiratory distress and suffered unnecessarily.
One 50-year-old male was first reported as having red sores on his scrotu- on 8/12/92. It was treated as an infection, but did not resolve. Subsequent entries in his medical record noted various treatments over the next nine months. On 5/11/93, the resident was finally referred to a dermatologist who did a biopsy that showed a low grade carcinoma that required surgery.
In another case, a resident was admitted to the local hospital for severe dehydration. The hospital discharged the resident back to CWC despite the fact the resident still had an alarmingly high sodium level. it is standard practice to discharge a patient only after the blood chemistries have returned to the normal range. The resident required readmissior. to the hospical two days later and subsequently died from cardiac decompensation. This case represents not only CWC medical staff's failure to recognize or appropriately act upon life-threatening symptoms, but also their failure to adequately monitor and coordinate the care residents are receiving at outside facilities.

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C. Seizure monitorir.c and management is inadequate.
In addition to the deficiencies described above, our medical expert found that seizure management generally is inadequate. Documentation of seizures and seizure management is particularly substandard. Medical records poorly track residents' seizure activity and fail to clearly describe any medical plans, monitoring or interventions. In several cases, residents are on multiple anticcnvulsants (sometimes as many as four and five) with no adequate explanation in the residents' records supporting their use and the necessity of this polypharmacy. Even for t: es e residents with apparently difficult to control seizures, whoscases one would expect medical staff to be following with greater attention to detail, our experc had difficulty finding seizure records in the resident's charts, even with the help of the medical records supervisor.
Our expert also found that physicians' progress notes and plans for seizure management were written only sporadically and often without sufficient detail, making it very difficult tc follow the course and plan of treatment. Given the complexity of the seizure disorders for a number of the residents at CWC, standard practice would require more organized tracking of seizures, a thoughtful and organized treatment plan with a periodic update, and review of seizure medications and blood levels.
D. Medical record-keeoincr is seriouslv deficient .
make clearr, CWC is extremely poor, a condition that adversely impacts upon the medical care being received by CWC residents. In addition to the deficiencies in record-keeping discussed above, our medical expert found that it was extremely difficult to locate medical information or track medical care in the residents' medical charts. Charts contained an excessive amount of very outdated reports and entries. For example, many charts had lab reports and physical exam notes that go back 10 to 15 years. On the other hand, charts were missing a lot of important recent information, or the documents containing the information were misfiled in the record.
Physicians' and nurses' progress notes were poorly organized, difficult to follow, and, too often, cryptic. Physician progress notes were infrequent and often did not have a time of entry. The nurses, physicians and direct care staff all use the progress note sections, but often without a title or other indication of the author or discipline making the note. It is generally an accepted practice in multi-disciplinary progress
•io=rly document the discipline of the author of the is generally accepted practice that there be a clinical summary in the physician notes and a

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new physical examination when residents are transferred to a special care unit. This does not appear to be standard practice at CWC. These problems and the lack; of organization in the progress notes make it very difficult, if not impossible, for CWC medical staff to adequately monitor and manage chronic problems. This leads to fragmented care and lack of follow-up on chronic and serious medical disorders.
II. Psychiatric Services and the Administration and Monitoring of Psyche,rooic Medications Are Inadequate.
The number of hours provided by the contract psychiatrist is entirely inadequate to meet the needs of CWC's population. According to the contract psychiatrist, he presently provides just twelve hours per week of psychiatric services, which he spends not only on patient quarterly reviews but attending several CWC committees, and state-wide review boards. This leaves very little time for him to spend in individual patient evaluations (other than the quarterly reviews) or direct one-to-one patient contact. In fact, when asked, neither the psychiatrist, nor the psychology director, could remember the last time the psychiatrist had conducted an individual assessment or work-up.
As stated earlier, for dually diagnosed individuals who need both behavioral programming and medication for their mental illness, it is extremely important that the two treatments be integrated properly, and that accurate and reliable behavioral data are kept and utilized in determining treatment. In addition, written programs must show that the psychologist, psychiatrist and physician have discussed the probable consequences of the combined treatments. However, at CWC, the level of integration of behavioral and pharmacological interventions is limited. For example, CWC is treating pica with increased medication even though it is not clear that medication is at all effective in controlling pica. The very fact that changes in learned behavior are often used as the basis for making changes in medication prescriptions shows that CWC is far from running fully integrated behavioral and psychopharmacoicgical programs. This problem is exacerbated by the lack of adequate psychiatrist hours.
These deficiencies contribute, in large part, to CWC's inappropriate use of medications, including their use as chemical restraints. At CWC, psychotropic medications are used in lieu of proper assessment and analysis of the individual's behavior problem, leading to inappropriate and escalating use of these medications -- especially when the behavioral treatment programs are ineffective. Just as at SWC, CWC psychologists abdicate their responsibility to provide adequate and appropriate treatment to the residents by relying too heavily on the consulting c-svehiatrist and medications to affect behaviors.

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This is especially troubling giver, that the effectiveness of these medications is often questionable for individuals with problem behaviors.

III. Residents Are Subjected to Harm Due to Inadequate Suoervi sion .

As with SWC discussed above, a number of residents at CWC

have serious behavior problems and medical disorders that require

close supervision by staff. The records reviewed by our exp erts

reveal a number of that supervision.

occasions where there has been For example, two residents who

waenreabsienncceoedof

health had been identified as having "fast feeding" or "stuffing"

behaviors. Eoth residents' compulsive eating disorders had been

repeatedly documented by staff, and notes had been entered in

both charts that they required close supervision and training to

prevent stuffing. Unfortunately, CWC did not provide sufficient

supervision or training to prevent the residents from stuffing

food, and CWC did not provide emergency medical care to'prevent

the residents from massively aspirating the food and subsequently

choking to death. The emergency care provided in both of t ese instances essentially consisted of calling 911. Although th

emergency technicians arrived and attempted intubation, it w

too little, too late. These preventable deaths represent

deficits in supervising residents, as well as the inadequacy

relying too heavily on 911 for respiratory emergencie s.

These two events were not isolated instances. In 1933-1994:, there have been at least 10 occasions when residents have been sent to the emergency room because they aspirated edible or inedible objects.

IV. Psychology Services Substantially Depart from Accepted Professional Standards.

Our psychology expert found that essential aspects of CWC's psychology services deparc substantially from accepted professional standards. Again, our expert's findings largely echo those articulated in our 1993 Summary. Although CWC is to be commended for seeking assistance from a variety of outside psychology consultants since cur review in 1992, the fruits of those contacts have yet to be realized.

A. Behavioral procrams are inadequate.

The State is failing to provide the residents of CWC with adequate individualized behavioral programming to ensure and protect the CWC residents' safety and liberty interests.

Manv CWC residents have serious maladaotive behaviors such as physical aggression, biting, property destruction, throwing furniture, cica, self-injurious behavior and agitation. Behavior

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problems such as these pose physical and emotional risks to the individual and to other residents and staff. CWC residents have a right to be protected from physical injury and psychological harm stemming from behavior problems.
As articulated earlier, individualized behavioral treatment programs which are appropriately devised and implemented, car. reduce and eliminate these maladaptive behaviors. However, cur consultant psychologist found that CWC is subjecting its residents to harm and unreasonable risk of injury because of the major deficiencies in the behavioral assessment of residents, and in the development, implementation and monitoring of resident behavioral programs. Although the CWC psychologists are actively planning to change the content and process of writing behavior treatment plans, nonetheless, the majority of current behavioral treatment programs utilized at CWC do not comport with accepted professional standards. As a result, the State is failing tc provide reasonably safe conditions, and to ensure the reasonable safety, personal security and liberty interests of the CWC residents.
CWC is failing to meet accepted professional practices in a number of ways. As an initial matter, the facility staff utilizes an inadequate assessment scale. The CWC staff also take little hard data to test their hypotheses on the functions cf individual target behaviors. In fact, in none of the 34 cases our consultant reviewed, did the staff systematically test its hypothesis or the presumed motivation in deriving behavioral treatment. As a result, for example, CWC provided one resident with 'a behavioral intervention that actually reinforced his selfinjury. Further, the CWC staff does not sufficiently engage in a descriptive analysis of the individual behavior. As a result, CWC develops interventions that are typically based on trial and error. Unfortunately, all indications point to the conclusion that CWC's trial failures exceed their trial successes. For example, one individual has engaged in pica behavior for manyyears without any successful short or long term intervention despite many and varied attempts often using unproven methods.
Another serious and pervasive problem at CWC is the minimal documentation cf the rationale and development of the behavioral treatment plans. Poor documentation means that it is difficult to determine why certain procedures were selected over others as the treatment of choice. For example, one boy's aggressive behavior was documented for over six years without remission, and yet the staff's rationale for treatment was never fully explicated. In this period of time, not only did CWC fail to adequately treat his aggression and thereby fail to protect the individual and other residents from the results of that aggression, but CWC also subjected him to repeated time-out and physical restraint. In addition, insufficient documentaticn often results in a behavioral assessment that is not mear.ir.rfui .

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For example, CWC provided one resident: with two different informal CWC staff assessments of his behavior, which produced two markedly different motivational explanations. Without documented data, it would be difficult for any CWC psychologist to determine the most appropriate intervention plan for this individual. Consequently, CWC has provided this resident with a treatment plan that does not bear much relationship to either assessed motivation. Inadequate documentation of the rationale and development of behavior treatment plans also typically result in the use of restraint and medication when they are not necessary. This is common at CWC. For example, CWC has placed one individual on medication and in elbow restraints for hundreds of hours a month even though the staff has failed to provide her with a formal functional analysis and is collecting behavioral data at an inappropriate, unrepresentative time. Her monthly time in restraints, in hours for IS93, are as follows for elbow splints: 118, 137, 151, 149, 132, 113, 160, 1S3, 159, 170, 151 and 143; and for the supine positioner: 375, 322, 362, 354, 325, 302, 364, 343, 338, 313, 581 and 575. In addition, her behavioral treatment plan provides for increased medication in response to increased behaviors.
Also, there is widespread inconsistent implementation and application of the behavioral programs at CWC rendering success unlikely. Inconsistent delivery of programming services explains why CWC routinely fails to successfully redirect or eliminate the residents' maladaptive behaviors.
CWC does not timely evaluate the effects of behavioral and psychopharmacoiogical treatment programs. It is generally accepted that behavioral data should be checked daily to ascertain trends and patterns in response to treatment or other factors. However, CWC staff check data formally only once every month, and then review it only at the three month team meetings. This is unjustifiable. Even though some CWC psychologists indicated that they checked data on a more frequent basis, there was no indication in the residents' charts that the psychologists modified individual programs as a result. Consequently, residents are often left on a regimen of restraint and/or medication for an unjustifiably long period of time without adequate monitoring.
In none of the cases reviewed by our consultant was there evidence that CWC adequately provided programming that would enable the individual to maintain and generalize any behavior changes made. As a result, any "successes" are unlikely to have a lasting positive impact on the individual's life outside a clinical setting.
In sum, the inadequacies in the development and implementation of behavioral programs at CWC have deprived the residents of effective treatment for their maladaotive behaviors

- 26 -
and violated their liberty interests and their right to a safe environment. This is clearly inadequate and represents a substantial departure from generally accepted practice for the development cf behavioral programs.
B. Training programs are inadequate.
As discussed above for SWC, the State is also failing ;c provide CWC residents with that level of individualized training as is necessary to enhance functioning, and facilitate grow:':., development, and independence. Similarly, contrary to accepted professional standards, the CWC training programs are principally designed to enhance isolated, specific, discrete skills rather than to produce the acquisition of meaningful, functional skills that may produce socially significant changes in the lives cf the individuals. As at SWC, the training is conducted in discrete, artificial and sequestered training sessions, making it unlikely that the individual will maintain and generalize the taught skill in the natural environment.
C. Restraint usage is excessive.
The State is failing to ensure that CWC residents are free from undue or unreasonable restraint. As discussed above, CWC routinely engages in the use of restraint to attempt to control its residents' maladaptive behaviors. In fact, the majority of behavior treatment programs at CWC use some form of restrictive procedure. For example, in just the first six months of 1S33, one CWC resident was restrained in a wheelchair 130 times for about IIS hours and in a geri-chair 479 times for about 2SG hours. Allowing an individual like this to engage in high rates of severe problem behaviors that require excessive use of restraint cannot be justified under any condition. There are other examples of restraint at CWC: another resident has been subjected to time-out, physical holds, restraint in a wheelchair, and the use of hand-mitts in unsuccessful attempts to prevent her pica behavior; another individual was subjected to time-out and physical restraint for years in an unsuccessful attempt to gain control of his aggression; and yet another individual has been placed in restraints for hundreds of hours per month in an unsuccessful attempt to control her self-injury. Given that this individual spends most of her day in restraints, there is little likelihood that she is actually learning.
Because behavioral interventions at CWC are developed largely on the basis of trial and error, many interventions prove unsuccessful leading to an excessive reliance on a variety of restrictive procedures to gain control over problem behaviors. In short, the excessive use of physical restraints and tiir.e-out are indications that the CWC behavior treatment programs are ineffective. Ostensibly, one of the reasons individuals are olaced in institutions is for soecialized treatment, but, as the

- 27 -
examples noted above illustrate, the institution is unable to provide such treatment.
V. CWC's Ir.siitutiional Environment Fails to Meet the Needs cf the Residents .
CWC fails co provide the individuals with developmental disabilities residing there with an acceptable and responsive environment that ensures safety, and promotes learning and their own social well-being. Accepted professional standards require that an acceptable and responsive environment is the least restrictive alternative, is stable, safe and engaging, and operates to teach and maintain functional skills, and to reduce or pre-empt the occurrence of behavior problems. The living environment at CWC does not meet these requirements.
The environment at CWC is not fully functional for its residents and rr.ay be the cause of some of their problem behaviors. For example, many CWC residents are not interacting with available materials indicating that the environment is nofunctional for them. This produces adverse results such as the self-stimulating and abusive behavior our expert observed a number of idle residents engaging in. In addition, CWC has been unable thus far to systematically teach and maintain functional skills for its residents facility-wide. CWC also does not provide most of its residents with a stable environment characterized by order, predictability and continuity. Further, the prevalence of individuals with behavior problems at the facility not only poses risk of harm, but also interferes with the individual's learning and habilitation, and decreases an individual's opportunity to live in the community. As discussed earlier, the fact that the facility has been unable to effectively treat its residents' behavior problems through treatment programs indicates that CWC is not providing an acceptable living environment for them.
Living at CWC also does not provide the residents of the facility with functionally fewer restrictions than they would experience in the community, and in fact, denies them opportunities to participate in work, educational and leisure activities available to their non-disabled peers. For example, some residents are restricted in their access to their own personal property because the CWC staff locks doors in an effort to safeguard clothing or other personal objects from being damaged. CWC, like SWC, is an isolated, self-contained environment which necessarily separates its residents with disabilities from the rest of society. As a result, the facility fails to provide its residents treatment in an environment that permits contacts with society and its mainstream social institutions, demands independent functioning and permits the exercise.of judgment and contact with family members. As stated earlier, the State must provide its residents with disabilities

- 23 -
an opportunity to participate in or benefit from aids, ber.e and services equal to that afforded to others outside the institution; more specifically, to those provided to other individuals with disabilities in the State's community-base programs. The residents are entitled to aids, benefits and services that are as effective in affording them the equal opportunity to obtain the same result, to gain the same ben or to reach the same level of achievement as those served in community-based programs. By confining residents with disabilities at CWC, the State is failing to provide such services in the least separate, most integrated setting as required by the Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 e_t sea. , and section 504 of the Rehabilitaticn Act of 1973, 29 U.S.C. § 794 et sea.
The cases reviewed by our consultant indicated that all of the CWC residents could be successfully placed in the community if provided with adequate supports. The CWC staff acknowledge this in the individual annual program review reports. We must reiterate that keeping individuals in an institution who have been determined to be capable of living in the community cannot be justified.
VI. Remedial Measures.
In order to remedy these deficiencies and ensure that the rights of CWC residents are protected, the following remedial measures must be implemented promptly.
'a. Adequately train and drill medical staff to ensure they provide appropriate emergency medical care. Emergency care policies and procedures, including the frequency of emergencydrills and the location of emergency equipment, must be evaluated to ensure that they are sufficient to provide adequate emergency care. An emergency care committee or other quality assurance mechanism should review all emergency clinical interventions and ensure all staff are properly trained, and all necessary emergency equipment is present, operable and easily accessible. The role and resources of the Special Care Unit ("SCU") should be evaluated, and the criteria for resident admission and retention on this unit adjusted to ensure that critically ill residents who cannot be adequately cared for on the SCU are immediately transported to an acute care hospital.
b. Provide adequate and timely medical care, including appropriate services to meet the acute, chronic and emergency medical care needs of residents. Train and deploy adequate numbers of medical care staff, including physicians and nurses, to meet the medical needs of the residents. Increase the r.urier of hours of consulting and contract professionals, especially those for psychiatry, to a level sufficient to provide adequate care. Ensure that enough adequately trained medical

- 29 -
professionals, including pharmacists, are employed to institute appropriate quality assurance mechanisms, especially to oversee the prescription, administration and monitoring of psychotrcpic and anticonvulsant medications, the timely treatment and follow-up on medical problems and the care provided residents sent to local hospitals.
c. Residents on psychotropic or anticonvulsant medications should be evaluated to determine the appropriateness of their prescriptions and whether these medications are being prescribed and monitored in accordance with accepted professional standards. Psychotropic medications must not be used as punishment, in lieu of a training program, for behavior control without an adequate rationale and a psychiatric or neuropsychiatric diagnosis, or for the convenience of staff. Residents must not be kept on anticonvulsant medications (or inappropriate doses of those medications) that serve no therapeutic purpose or are otherwise contraindicated.
d. Medical records must be kept in a fashion sufficient to allow medical professionals to provide adequate and timely care. Physicians should write periodic summaries in resident charts which contain, at a minimum, treatment goals, goal progress, ar.d plans for future treatment. Staff writing in the interdisciplinary notes must clearly identify themselves, transcribe the accurate date and time, and provide clear and accurate information. An adequate system must be developed for tracking and monitoring seizure disorders, and medical staff, as well as direct care staff, should be adequately trained in seizures and seizure documentation. CWC staff must consistently utilize an appropriate and uniform method and seizure record for recording residents' seizure activity. This record should be kept in one consistent place in the chart.
e. CWC must employ and deploy sufficient staff properly trained to ensure residents are supervised and adequately protected from harm.
f. All residents must be evaluated to determine their individual strengths and weaknesses and to develop appropriate individualized training programs, including behavior management and skill acquisition programs. Immediate attention must be given to residents with self-injurious, physically aggressive an; other destructive behaviors by identifying them and providing necessary training on a priority basis. Such interdisciplinary evaluations should review the individual's training needs, utilizing a written descriptive functional analysis for those individuals with problem behaviors, and assess the efficacy of chemical and physical restraints. Such programs should address and develop appropriate strategies to promote the physical, mental, -behavioral, and social skills of each resident and perrr.i each resident to function as independently as possible. Such

- 30 -
programs must be consistently implemented and procedures developed to ensure appropriate review and revision..
g. CWC must develop and implement a professionally based, individually appropriate data collection system to measure relevant information about problem behaviors and the conditions under which they occur, including, where appropriate, the frequency, intensity, and duration of the behaviors, and review the data in a timely manner.
h. CWC must have a qualified professional develop and implement a professionally based, individualized training program for each resident teaching meaningful functional skills and provide each individual with an adequate number of training hours. The professional must document the rationale and development of the program, and .must routinely test hypotheses.
i. CWC must ensure that restraints, chemical and physical, including emergency restraints and time out, are used only pursuant to accepted professional standards and that they are never used as punishment, in lieu of training programs, or for the convenience of staff.
j. Immediate steps must be taken to develop and implement an overall plan to significantly reduce the size of the facility and to place residents in appropriate, less restrictive, community-based programs. There should be an immediate ban or. the admission of children, except in emergency circumstances, and children should be prioritized for placement in alternate, community-based programs. In the meantime, residents should receive training to assist in their placement and transition to the community-based living arrangements. Given the gravity ana scope of our experts' findings regarding the care provided at CWC, we must recommend the development of more appropriate settings and services for the residents of CWC.
Pursuant to CRIPA, the Attorney General may initiate a lawsuit to correct deficiencies at an institution or otherwise to protect the rights of its residents 49 days after appropriate officials have been advised of the relevant violations of law. 42 U.S.C. § IS97b(a) (1). Therefore, we anticipate hearing from you as soon as possible, but no later than 49 days after the date of this letter, with any response you may have to our findings and a description of the specific steps you have taken or intend to take to implement each of the remedies described above for each facility.. If you do not respond within the stated time period, we must: consider initiating an action to remedy the unconstitutional conditions we have identified. In your response, please address your willingness to enter into a judicially enforceable agreement to memorialize any agreement we may subsequently reach regarding this matter.

- 31 -
We look forward to working with you to resolve this matter in a reasonable and practical manner. If you or your staff has any questions, please feel free to contact Robert Bowman, at 202514-6*253, or Richard Farano, at 202-514-3116.
Sincerely,
Deval L. Patrick Assistant Attorney General
Civil Rights Division
cc: The Honorable James Doyle Attorney General State of Wisconsin
Mr. Gerald Whitburn Secretary Dept. of Health & Social Services
Mr. Jarr.es H u t c h i n s o n S uoe r in tende nt Southern Wisconsin Center
Mr. Gerald Dymond Superintendent Central Wisconsin Center
The Honorable Peggy Laugenschlager United States Attorney Western District of Wisconsin
The Honorable Thomas Schneider United States Attorney Eastern District of Wisconsin

 
 U.S. v. Wisconsin

•--• 'J v

l !•• ••• ••••• • • ••••! !•••
MR-WI-001-003
IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN

"' ' '' ~'

UNITED STATES OF AMERICA, Plaintiff,
v. THE STATE OF WISCONSIN, £_£.
Defendants.

Jo:iepn V/. Skupr.icwkz, Clerk u. i>.District Court
of Wisconsin
Civil Ac£ipny:

SETTLEMENT AGREEMENT I . INTRODUCTION
A. This case was i n s t i t u t e d by the to the Civil Rights of I n s t i t u t i o n a l i z e d Persons Act, 42 U.S.C. § 1997.
B. This Court has j u r i s d i c t i o n over these actions pursuant to 28 U.S.C. § 1345.
C. Venue i s appropriate pursuant to 2 8 U.S.C. §§ 1391 and 1392 .
D. The United States i s authorized to i n s t i t u t e t h i s c i v i l action by 42 U.S.C. § 1997a and has met a l l the p r e r e q u i s i t e s for the i n s t i t u t i o n of this c i v i l action prescribed by the s t a t u t e .
E. The p l a i n t i f f is the United States of America. F. The defendants include: the State of Wisconsin,- Joseph S. Leean, Secretary of the Department of Health & Family Services; James Hutchison, Superintendent of the Southern Copy of this document has been provided to: AUSA Cameli and AAG Victor t h i s 10th day of April, 1997. By : QA- OU^>V
Deputy Clerk

Wisconsin Center for the Developmentally Disabled ("SWC"), in Union Grove, WI; and Steve Watters, Acting Superintendent of the Central Wisconsin Center for the Developmentally Disabled ("CWC"), in Madison, WI.
G. The individual defendants who are officers of the Executive Branch of the State of Wisconsin have authority and responsibility for the operation of SWC and CWC ("the Centers") and are sued in their respective official capacities.
H. The parties agree that the care, conditions and training of the developmentally disabled citizens residing at the Centers ("the residents") implicate rights that are secured and protected by the laws and Constitution of the United States. The parties entering into this Settlement Agreement recognize these statutory and constitutional interests, and for the purpose of avoiding protracted and adversarial litigation, agree to the provisions set forth herein.
I. In entering into this Settlement Agreement, defendants do not admit any violation of law and this Settlement Agreement may not be used as evidence of a violation of law in any other civil proceeding. The defendants maintain that the care, treatment and services provided at the Centers meet or exceed all applicable legal standards, and far exceed the constitutional minimums at issue in legal actions of this nature. The United States maintains that the care, treatment and services provided at the Centers continue to violate the constitutional and federal statutory rights of the individuals residing in these
- 2-

institutions. The defendants contend that they are currentlyadhering to some of the policies and practices required by this Agreement. The fact that a particular policy or practice is included as a requirement in this Agreement is not to be construed for any purpose by any person or forum as evidence that the defendants are or are not currently following that policy or practice. This Settlement Agreement is enforceable only by the parties hereto, and only in the manner herein provided.
J. The provisions of this Settlement Agreement are a lawful, fair and appropriate resolution of this case.
K. In all cases, the defendants agree to provide adequate care, treatment and services consistent with the requirements of Youngberg v. Romeo. 457 U.S. 307 (1982). To the extent any provision of this Agreement relating to the provision of care, treatment or services requires that any action be taken or thing be done to a level of quality or in an amount that is not otherwise specified or quantified in the Agreement, that provision shall be interpreted consistent with the "professional judgement" standard enunciated in Youngberg. In particular, all qualifying terms used in this Agreement, including but not limited to "medically indicated," "adequate" or "timely" shall be interpreted to mean that level, quality, amount or timeliness of care, treatment or services that is consistent with the "professional judgment" standard enunciated in Youngberg. However, the "professional judgment" standard enunciated in Youngbercr in no way relieves the defendants of any obligation to
- 3-

meet specific requirements of federal law, including but not limited to regulations of the Health Care Financing Administration governing Intermediate Care Facilities for the Mentally Retarded.
L. This Settlement Agreement, voluntarily entered into, shall be filed by the United States with the United States District Court for the Western District of Wisconsin at the same time as the summons and complaint in this matter are filed, and shall be entered by the Court and shall be enforceable as an order of this Court pursuant to the procedures provided herein. The parties acknowledge that venue is proper in this Court and that this Court retains jurisdiction over the Centers to the extent and pursuant to the procedures provided in this Settlement Agreement. This Settlement Agreement is legally binding on and judicially enforceable by the parties pursuant to the procedures provided herein and it shall be applicable to and binding upon all of the parties, their officers, agents, employees, assigns, and successors. II. M^nTHAL CARS
A. Defendants will ensure that the Centers1 residents . receive adequate preventive, chronic, routine, acute, and
emergency medical care. To this end, at a minimum, the Centers will continue to maintain a full time equivalent ("FTE") primary care physician to resident ratio of at least 1:120 commencing no later than April 1, 1997. For the purpose of calculating this ratio, each Center Medical Director shall be considered to work
- 4-

at that proportion of one FTE that his or her primary care
patient case load bears to the average patient case load of a FTE
primary care physician at the Center. Within 120 days from the
entry of this Settlement Agreement, the Centers1 primary care
physicians will:
1. Conduct annual comprehensive evaluations of a l l residents who are due for their regular annual evaluations,-
2. Determine what specialized medical services are required for the residents for whom they are responsible and timely provide or arrange for such services whenever necessary to evaluate'or treat the individual's medical problems;
3 . Participate in the development of an integrated medical plan of care for each resident to address any chronic medical problems of that individual, as part of the annual comprehensive medical evaluation of that individual;
4. Adequately review each resident's medical status and progress in response to his or her medical plan of care as often as is medically indicated given the resident's particular medical condition and needs,-
5 . Review and adequately respond to all recommendations of outside medical specialists, including regular consultants, and laboratory' findings, if medically indicated, documenting what action has been taken and the reasons therefor, including, if action is recommended by a physician specialist within his or her field of expertise and is not taken, the reason (s) for not acting upon the recommendations or findings, or seeking a second opinion;
6. Maintain formal relationships to coordinate care with medical personnel at acute care hospitals and to review the care residents receive at these hospitals,- implement a protocol requiring staff at the Centers to obtain from the hospitals a timely, adequate record of the diagnosis, course of treatment at the hospitals, and prescribed treatment; perform a re-admission assessment and write orders specifying the individual's follow-up care after an individual is returned from the hospital; record in the individual's medical record any treatment rendered or recommendations made by hospital staff during the individual's hospital stay; and
7 . Implement peer review at each facility to review a random sample of not less than 10% of a l l residents' medical
- 5-

charts annually, in order to evaluate and make recommendations regarding the medical care provided these residents.
B. pmp-raency care - Defendants shall provide all staff physicians, registered nurses ("RNs"), licensed practical nurses ("LPNs"), supervisors, and direct care employees who regularly provide services on-grounds at the Center, with annual training in procedures for seeking assistance in case of emergency; and shall provide systematic, periodic training in emergency procedures, including the proper way to administer cardiopulmonary resuscitation, to a number of staff sufficient to ensure that these services are always readily available to all residents. Thereafter, defendants shall evaluate, through the use of emergency drills held at least annually on each unit and for each shift, the competence of all participating staff to perform adequately, document such evaluations and provide such additional training as the evaluations indicate are necessary to ensure staff competence in emergency procedures. Defendants will ensure necessary medication and equipment to be used in case of emergency are easily accessible to qualified staff in each residential unit. Within 30 days of each medical emergency, the Medical Director shall select a quality assurance committee with a membership that is appropriate to the nature of each emergency to review the emergency to assess whether the actual response was timely and adequate, and make and disseminate any recommendations for improving the emergency response. The Medical Director shall develop and oversee the implementation of a protocol or written guidelines for conducting such reviews and
- 6-

making recommendations. The medical director, a staff physician, and a nurse at each Center shall be members of that Center's committee, along with any other individuals deemed appropriate by the Centers. An "emergency," within the meaning of this section, includes status epilepticus, respiratory arrest or any other sudden, life-threatening event or condition.
The CWC Short Term Care Unit, formerly used as an inpatient hospital unit, will no longer be used for these purposes. This unit may be used for evaluation services for community residents with developmental disabilities, rehabilitation for CWC residents returning from surgery or other hospitalization, short-term services such as continuous oxygen for respiratory ailments or fluid therapy for mild dehydration for CWC residents when the attending physician concludes that hospitalizaticn is not medically necessary, or hospice care for CWC residents with terminal conditions where such care cannot be provided on the resident's living unit. Inpatient hospital treatment of CWC residents shall be provided at a local hospital.
C. Training for medical staff - Upon the entry of this Settlement Agreement, defendants shall, periodically but not less than once annually, obtain the services of expert medical specialists of the Centers' choice who shall train the Center's primary care physicians and registered nurses in the assessment, diagnosis, treatment and monitoring of medical problems typically associated with persons with developmental disabilities. Topics covered within the first year following the entry of this
- 7-

Settlement Agreement shall include: (1) neurologic disorders, including seizures and specifically the prescription of medication to control seizures; (2) orthopedic and physiatric conditions; (3) gastroenterologic disorders, and physical and nutritional management; and, (4) behavioral and psychiatric disorders, including the psychopharmacologic treatment of such disorders, and side effects of behavior modifying medication. Thereafter, topics covered shall be at the discretion of the medical director. Defendants shall document that such training occurred, including maintaining a list of those in attendance as well as clinical areas covered.
In addition, all newly hired medical staff shall attend an orientation course which covers, at a minimum, the four topic areas listed above. Again, defendants shall document that such training occurred. The trainers for this orientation course may include qualified Center medical staff.
D. Neurology consultations and seizure management Defendants will provide adequate neurology care, including routine, chronic, and emergency seizure management to all individuals with epilepsy at the Centers. The defendants shall, within 120 days from the entry of this Settlement Agreement, implement and ensure the following:
1. A board certified neurologist(s) shall perform a comprehensive assessment for each resident receiving anticonvulsant medication as often as is medically indicated given the medical condition of the resident to determine whether the medication treatment is justified; defendants shall mair.-ain the number of hours of neurology care provided by board certified neurologists at the Centers and request outside neurology consults as needed;
- 8-

2. The neurologist(s) at the Centers shall timely evaluate, diagnose and recommend treatment for residents who are referred to them by primary care physicians, and examine and recommend treatment, as often as is medically indicated for residents receiving anticonvulsant medications;
3. In performing these duties, the neurologist(s) shall confer with the referring primary care physician and, if medically indicated, with the assigned psychiatrist, and timely record notes in the resident's medical records that reflect the neurological assessment, diagnosis, recommended course of treatment, and results,-
4. For each individual currently receiving anticonvulsant medication, the neurologist(s) , in concert with the Center's medical professionals, shall evaluate whether the type of medication is appropriate and effective for the type of seizure and is consistent with the principles of monotherapy or rational polypharmacy, representing the fewest number of medications medically indicated for effective seizure management. It is understood between the parties that adherence to these principles does not necessarily rule out use of some newer anticonvulsants that are intended as add-on medications. The neurologist shall ensure that residents are not kept on anticonvulsants that serve no therapeutic purpose and are not maintained on supertherapeutic or subtherapeutic levels of anticonvulsants for prolonged periods without adequate documentation of the neurologist's professional judgment that such level is medically indicated;
5. The Centers will employ systems for the recording of every seizure of each resident including information on: (a) the date and time of the onset of the seizure; (b) the duration of the seizure; (c) a description of the seizure,- (d) an indication as to whether or not the individual is conscious or unconscious, and the duration of any period(s) of unconsciousness; (e) any medical or other steps taken to control the seizure; and (f) the individual's response to the intervention;
6. The Centers will provide training programs to ensure that all staff, including nursing and direct care staff, shall be trained in how to recognize a seizure, describe the seizure and length of time it lasts and record that information in the resident's record,- and
7. Defendants will utilize a quality assurance process to ensure that all seizures are being appropriately documented and evaluated.
- 9-

E. psychiatric: care and treatment: - The defendants will
provide adequate routine and emergency psychiatric and mental
health services to residents who need such services.
Psychotropic medication shall not be used as punishment, in lieu
of a training program, for behavior control, in lieu of a
psychiatric or neuropsychiatric diagnosis, or for the convenience
of staff. To these ends, defendants shall within 180 days from
the entry of this Settlement Agreement, unless otherwise noted:
1. Continue to employ and utilize a board certified or board eligible consulting psychiatrist(s) with experience treating developmentally disabled individuals at SWC at least 40 hours per week, and at CWC at least 24 hours per week; ensure that the consulting psychiatrist (s) , among other responsibilities, is involved in the coordination of mental health services in the facility, and is responsible for ensuring that residents with mental health concerns receive an initial comprehensive psychiatric assessment, diagnosis, treatment plan, quarterly treatment plan update, and psychotropic review at least quarterly in connection with the regular quarterly evaluation of care of each resident; ensure that the psychiatrist(s) formulate and sign a diagnosis or diagnoses, considering differential diagnoses where appropriate, and employing DSM-IV criteria and terminology,-
2. The psychiatrists shall, upon request of the inter-disciplinary team ("IDT") or at the psychiatrists' own request, serve on the IDT of any resident whose individual plan of service includes the use of behavior modifying medication or for whom such has been recommended;
3. Ensure that the psychiatrist(s) adequately review the current medication regimen of each individual to determine whether the type and dosage of the medication is indicated by the resident's needs, and recommend any changes in the medication regimen; ensure that the psychiatrist (s) consults with the assigned psychologist to determine whether the existing behavior management program is indicated by the resident's needs and whether different programs or interventions could be developed to address the resident's target behaviors and/or symptoms so as to reduce or eliminate the need for psychotropic medications; ensure that the psychiatrist (s) consults with the resident's primary care physician, psychologist, nurse, and other appropriate members of the resident's IDT, to determine whether the harmful effects of the resident's mental illness outweigh the possible
- 10 -

harmful side effects of the psychotropic medication and whether all reasonable alternate treatment strategies are likely to be ' less effective or potentially more dangerous than the medication, and require that the psychiatrist document his or her evaluation results and conclusions. This review, consultation and documentation shall be performed in connection with the regular quarterly review of each resident, or more often if indicated by the resident's needs,-
4. Ensure that the psychiatrist (s) develop and sign as part of each resident's quarterly review process (or more often if indicated by the resident's needs) an overall treatment plan for each resident with a diagnosis of mental illness with a description of clear, objective and measurable short-term, intermediate and long range goals and objectives for each resident including time frames for the achievement of each;
5. Develop and implement a system that requires the psychiatrist (s), when prescribing a psychotropic medication for behavior modification, to specify in the medical record the behavior (s) that initiate(s) the use of the behavior-modifying medication, and that requires the psychologist and the treatment team (including the psychiatrist) to specify in the medical record, where appropriate, the behavior (s) to be taught to the resident to replace the behavior (s) that initiate (s) the use of the medication or other programs to be used to reduce or eliminate the use of the medication; utilize psychotropic medications for behavioral control purposes only in the context of a treatment plan for a mental illness or psychiatric disorder that is based upon data that is sufficiently reliable to meet the treatment needs of the residents; avoid use of psychotropic medication unless specific justification exists and is documented in the individual's medical record; and
6. Ensure that each resident is receiving benefit from the treatment once it has begun, by adequately monitoring the treatment, conducting quarterly reviews of each resident's working diagnosis, ensuring that the psychiatrist participates in such reviews, ensuring that decisions about the efficacy of treatment are based on objective data and by documenting the results of such reviews in the resident's medical chart.
F. Defendants have organized and will continue to convene a
committee ("the Psychotropic Medication Review Committee"), the
purpose of which is ensure that psychotropic medications are used
appropriately in the Centers and the members of which are
appropriate to achieve this purpose.
- 11 -

G. Medication - Within 180 days from the entry of this
Settlement Agreement, defendants shall take all reasonable
measures to ensure that prescription medications are adequately
prescribed for and administered to residents, including that such
medications not be used as punishment, in lieu of a habilitation
program, or for the convenience of staff. The defendants will:
1. Administer prescription medication only upon order of a physician and behavior modifying medication only upon order of a physician after consultation with a psychiatrist, except in the case of any psychiatric emergency in which the resident's behavior escalates to the point where the resident or others are put at risk, in which case consultation must be had with the Center's psychiatrist no later than the psychiatrist's next regularly scheduled work day, but in no event more than 72 hours after the order;
2. Establish procedures to review the drug regimen of each resident every 30 days, except in cases where the prescribing physician has adequately justified in the resident's medical record that less frequent review is adequate, require that no prescription is valid for more than 90 days;
3. Utilize an adequate system for detecting, reporting and responding to any medication side effects, and medication errors; and
4. Develop and implement a quality assurance procedure whereby every six months a pharmacist performs a comprehensive review of anticonvulsant and psychotropic medications used for each resident; a copy of the review will be included in each resident's medical record and shall include at least the following information: the current and prior prescriptions, dosage and dates of prescription changes; any recent and prior lab results testing therapeutic blood levels for each medication; for residents on anticonvulsant(s), each resident's seizure history, and for residents on psychotropic(s), the current -and, if different, prior -- psychiatric diagnosis or diagnoses justifying use of the psychotropic(s); any relevant recommendations or plans by medical personnel or consultants contained in the record relating to prescription of the medication(s) ; observations of side-effects contained in the record; and relevant observations or recommendations of the reviewer, if any. To the extent the required information consists of historical information for each resident, such information shall be recorded for that period of time for which
- 12 -

it would be useful for purposes of medical diagnosis and treatment of the particular resident.
III. PSYCHOLOGICAL SERVICES. TRAINING PROGRAMS AND RESTRAINTS
A. The defendants will provide at the Centers
individualized habilitative services and training programs, which
are developed by qualified professionals, to facilitate the
growth, development, and independence of every resident, and to
reduce or eliminate risks to personal safety, provide protection
from harm, reduce or eliminate undue use of restraint, and
prevent regression. To this end, defendants shall, within 12
months from the entry of this Settlement Agreement, unless
otherwise provided herein:
1. Employ sufficient FTE psychologists to meet the needs of the residents, and to that end maintain a ratio at each Center of at least one FTE psychologist to 25 residents requiring behavior management programs (provided that nothing in this paragraph may be construed to prohibit psychologists from treating additional residents not requiring behavior management programs);
2. Consult with a nationally recognized consultant in psychological services for persons with severe developmental disabilities to develop and help implement behavior data collection systems that maximize reliability of data collection in a clinical setting and that measure relevant information about challenging and other behavior(s) and the conditions under which they occur, including, where appropriate, the frequency, intensity, severity, and duration of the behavior(s);
3. Conduct an adequate inter-disciplinary assessment of each resident to determine the individual's need for training,to that end, a psychologist shall:
a. Conduct an adequate descriptive analysis of the individual's challenging behavior (s) using rating scale instruments that are in general use in the professional field; such descriptive analysis shall be written, adequately documented and data-based;
b. Develop an hypothesis regarding the cause of
the challenging behavior(s] that is individualized for the
particular client; such an hypothesis shall be written, adequately documented and data-based;
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c. Conduct a functional analysis, or functional assessment provided a professional shall adequately document why a functional analysis is unnecessary, in the individual's natural settings so as to best tailor an adequate intervention for each of the individual's challenging behavior(s); such an analysis shall be written, adequately documented and data-based; and
d. Document the rationale and reasons for the development and implementation of a particular training program;
4. Have a qualified professional develop a professionally based, individualized training program for each resident based on the findings of the individual's assessment, ensure that the training program is implemented over time and revised when necessary, and provide each resident with an adequate number of hours of training to enable the resident to develop behavior(s) designed to reduce risks to personal safety, afford protection.from harm, provide freedom from restraints that are not necessary to protect the resident or others from harm, prevent regression or deterioration of skills, facilitate growth, development and independence, and teach functional, adaptive skills,- ensure that adequate programs are maintained and generalized across settings, that training programs that seek to teach skills are taught in functional settings and under conditions that skills are to be used, and that behavior reduction programs and skills training programs are integrated and written in conjunction with one another;
5. Develop and implement training programs that contain the following:
a. Training objectives developed by an appropriately constituted IDT and based upon assessments and evaluations required above; for those individuals identified as exhibiting maladaptive behavior(s), a behavior management component which identifies the specific behavior(s) to increase and decrease, procedures for staff to follow to decrease the occurrence of the problem behavior(s), the alternative behavior(s) that will be taught, and environmental changes to promote the development of positive, adaptive behavior(s);
b. Instructional methods to be utilized by those with responsibility for implementing the program; such methods shall emphasize positive approaches and behavioral interventions which promote functional skill development and socially accepted behaviors in the individual;
c. An adequate training schedule to be followed to reach the identified objective (s) of the training program,identification of the persons responsible for the consistent implementation of the program; and
d. Procedures to be utilized for data collection to evaluate the effectiveness of the training program or any part thereof and to monitor the implementation of the training program and ensure its modification, as necessary;
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6. Provide competency-based training for all staff responsible for implementing the training programs to enable them to implement the programs consistently and collect data which is sufficiently reliable to meet the treatment needs of the residents; thereafter, prior to implementing any program or program change, such training shall be provided to each person implementing the program or program change;
7. Implement systems for verifying that the recorded data are sufficiently reliable to meet the treatment needs of the residents and ensure that qualified professionals review and adequately modify any individual's training program where the individual has exhibited no measurable progress for a reasonable period of time;
8. Require the IDT to meet on at least a quarterly basis, or more frequently if critical issues arise which the IDT determines need to be addressed in more frequent meetings, to review the individual's progress in training programs; provide that the IDT bases its review of the efficacy of the training programs on the data collected as well as the occurrence of incidents and use of restraints, and, if the IDT identifies the need to revise the training program, it shall be revised and implemented within a reasonable time period identified by the IDT, taking into account the severity of the behavior and the harm it poses;
9. Develop and implement programs, including the use of augmentive devices as determined to be indicated based upon an IDT evaluation, for each resident with communication deficits, including deaf or hearing impaired residents, to teach communication skills using methods adequate to meet the resident's needs, including sign language, communications boards and electronic devices; and
10. Within 90 days from the entry of this Settlement Agreement, defendants shall meet all of the requirements in Section A for those residents who in the past year have had emergency restraint (other than a medical restraint utilized pursuant to a written physician's order) or emergency psychotropic medication. Within 120 days from the entry of this Settlement Agreement, defendants shall meet all of the requirements in Section A for those residents who in the past year have had long-term or chronic restraint, and for those residents who are determined to exhibit self-injurious, aggressive, or pica behavior that is reasonably likely to result in significant illness or injury, or to have other seriously maladaptive behavior(s).
B. The parties understand that one of the goals of
providing residents with adequate programming and psychological
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services is to eliminate, to the extent practicable, constraints
on the residents' personal freedom and human potential that may-
be caused by the use of restraints. The defendants shall ensure
that restraints, including emergency chemical restraints,
unplanned physical or mechanical restraints, time out, and any
form of planned restraint, are never used as punishment, in lieu
of training programs, or for the convenience of staff. The
defendants shall, within sixty days from the entry of this
Settlement Agreement:
1. Ensure that each resident who in the past year has been subjected to significant emergency restraint (other than a medical restraint utilized pursuant to written physician's order) , or to any form of long-term or chronic restraint, has been provided with a formal, written, interdisciplinary assessment and analysis as outlined above;
2. Ensure that the use of restraint as part of a training program shall be prohibited except in those situations where there is written confirmation in the individual's record that other, less restrictive techniques have been tried and implemented in a professionally designed training program and data have demonstrated such techniques to be ineffective;
3. Ensure that any use of restraint shall be the least restrictive form of restraint that has proven effective in addressing the individual resident's behavior;
4. For those individuals who continue to be restrained,
a. develop individualized training programs, specifying:
(1) The behavior (s) to be eliminated, the function of the behavior(s) to be eliminated, and the specific behavior(s), clearly and objectively defined, which trigger the use of the restraint;
(2) Behavior (s) to be taught to the individual to replace the behavior that initiates the use of the restraint and other programs to reduce or eliminate the use of such restraint;
(3) The type of restraint authorized, including the maximum duration and other limitations, when employed;
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(4) The professional responsible for the program and the staff authorized to implement it;
(5) The frequency and manner in which behavioral data are to be recorded by direct care staff;
b. specify in the individualized training program the expected duration of a restraint or the date of next review of a restraint; and
5 . Ensure that the individual' s psychologist or other qualified professional shall begin, on the next day that the psychologist or other qualified professional is scheduled to work, the process of reviewing, each use of restraint and ascertain the circumstances under which such restraint was used; on a daily, weekly and/or monthly basis, the individual's psychologist shall review any regular use of restraint on an individual to ensure that restraint will be continued in individual's program only if data that is sufficiently reliable to meet the treatment needs of the individual supports the efficacy of their continued use; the psychologist shall be responsible for ensuring that the individual's behavior program continues to be appropriate and/or is revised to meet the individual's needs in the least restrictive manner.
C. The defendants shall ensure that for each resident with
a psychiatric disorder, there is communication between the
resident's psychologist, attending physician and psychiatrist
that is adequate to support the exercise of professional judgment
in treating the resident. In combining and integrating
behavioral programming and psychotropic medication for a
particular individual, the psychologist, physician and
psychiatrist shall coordinate their efforts to reinforce the
ultimate treatment objective(s).
IV.
The defendants shall, within 12 0 days from the entry of this
Settlement Agreement, maintain an adequate record for each
resident that shall include current information with respect to
his/her care, medical treatment, and training and shall require
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staff to utilize such records in making care, medical treatment and training decisions. Entries made by physicians, nurses and medical consultants in resident records shall: 1) include the time, when pertinent, and the date, and name and title of the professional making the entry; 2) be timely, legible and accurate; and 3) describe the resident's physical condition and course of treatment. Resident records should contain, in a prominent and visible location, a document identifying the resident's primary treatment and training issues in all areas. Physicians must write summaries in resident charts which contain treatment goals, goal progress, and plans for future treatment. V. STAFT?TWG? AND STAFF TRAINING
A. Defendants shall employ and deploy a sufficient number of professional and non-professional staff to adequately supervise residents and adequately protect them from harm, and to otherwise meet the residents' needs and the terms of this Settlement Agreement. To that end, Defendants shall maintain current direct care staffing ratios.
B. Within 180 days from the entry of this Settlement Agreement, unless otherwise specified herein, the defendants shall ensure that all appropriate staff, including physicians and nurses, who provide services to residents are adequately trained to implement the requirements of this Settlement Agreement and are thereafter provided with competency-based in-service training on a regular basis. The training should at least include the following topic areas: mental retardation; mental illness and
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psychiatric disorders and treatment; psychopharmacology,particular medical and nursing needs of the developmentally disabled,- emergency medical response and procedures; physical and nutritional management; recognition of seizures and seizure management, including recordkeeping for seizures; behavior management techniques; implementation of individualized treatment and training programs,- and use of bodily restraint and time out, including recordkeeping for such procedures. Defendants shall keep a record that such training occurred, and maintain a list of those in attendance as well as clinical areas covered. VI. POMMUNITY SERVICES
A. The defendants shall operate under policies that provide services to individuals with developmental disabilities in the least restrictive, and most integrated and normalized setting consistent with their individual treatment, habilitation and safety needs. To this end, defendants shall:
1. Evaluate all residents to determine their appropriateness for community-based placements and/or programs,residents with outstanding community placement recommendations shall only be re-evaluated for the purpose of determining need for community placement in circumstances where the needs of or facts relevant to the individual change,- such evaluation shall include where possible involved parents, guardians, advocates, the responsible placement agency and appropriate professionals, including professionals who are reflective of the kinds of services and support needed by the resident in the community; the
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resident shall be involved in the planning process to the maximum extent practicable and shall be given the opportunity to express a choice regarding placement; no individual shall be excluded from consideration for community placement based on his or her level of disability;
2. Based on the written evaluations of individuals identified as appropriate for community placement, assist the responsible placement agency to identify the required residences, day programs, including vocational opportunities, specialized services, including medical care and related services, and other supports needed to serve these individuals in the community,-
3. Within a reasonable period of time, assist responsible placement agencies to establish or directly establish such community-based supports consistent with the requirements of Paragraph VI.A.2., first, for children under the age of 18; second, for those individuals identified as appropriate for in need of community placement as of the date of this order; and, third, for those individuals identified pursuant to Paragraph VI.A.I.;
4 . Accept no admissions that are intended to be permanent; only admit or readmit individuals into the Centers temporarily when no other services areavailable whichare adequate to meet the individual's needs;
5. Working with the responsible placement agency, develop andimplement a transition plan for each resident who is
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identified pursuant to Paragraph VI.A.I that reflects the supports identified in Paragraph VI.A.2;
6. Assist responsible placement agencies to place all individuals residing at the Centers who are appropriate for community-based programs, as determined by an adequate assessment of their individual needs, into residential placements or other community-based programs; place no individual residing at one of the Centers into a program which does not meet his or her individual needs; operate a system to adequately monitor community-based programs pursuant to the defendants' Medicaid (MA) Community Waivers Manual, sections 4.04 and 7.05 (attached) to help ensure that they meet residents' needs and protect them from harm;
7. Identify within the Department of Health and Family Services an employee whose responsibility it is to coordinate and otherwise assist in the development and expansion of specialized services needed to provide necessary medical and medically related services in community services throughout Wisconsin;
8. Review all federal financial assistance presently received by defendants in support of services for persons with developmental disabilities and ensure that application has been made for all funding, including waiver programs, available to support community based services of persons with developmental disabilities;
9. Assist in the development and expansion of community-based programs with appropriate county officials, and
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10. Help ensure that individuals residing at the Centers who are appropriate for community-based programs w i l l be returned to the community through the following immediate or near term changes in operational and budget policy:
a. A community services plan will be developed for a l l residents of the Centers as part of each resident's -annual review. All such plans will be completed within 12 months of entry of this Settlement Agreement. The cost of community services for each individual will be developed as part of t h i s community services plan;
b. The Department's SFY 1997-1999 budget request includes an increase in the CIP 1A funding used to fund individuals return to the community effective July 1, 1997;
c. The Department will explore pooling a l l long term care institutional and community funding, providing that funding to an entity (county or alternative managed care organization) , and charging the county or organization the f u l l daily rate for any resident remaining in a Center.
B. The parties agree that the goal of the defendants shall be to serve as many individuals in community-based programs as appropriate to the individuals' needs. VII . FEDERAL STATUTORY COMPLIANCE
A. In t h e o p e r a t i o n and management of the Centers and i n providing services to r e s i d e n t s , %the defendants shall f u l l y comply with a l l a p p l i c a b l e f e d e r a l s t a t u t e s and r e g u l a t i o n s , i n c l u d i n g : the Americans w i t h D i s a b i l i t i e s Act of 1990,
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42 U.S.C. §§ 12101 fit ££3.; Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 £t ££ij.; and all the regulations promulgated pursuant to the statutes cited above. This provision is not intended to impose any additional responsibilities or confer any additional authority upon the parties than otherwise already exists under these statutes and regulations and other federal law. VIII. MONITORING BY JOINT EXPERTS
A. Defendants' compliance with the provisions of this Settlement Agreement shall be monitored by a panel of experts, one each in the fields of psychology/habilitation, developmental medicine (with expertise in neurology) , and psychiatry, all of whom have been jointly selected and agreed upon by the parties (hereafter the "Joint Experts"). The Joint Experts are as follows:
Psychology /Habilitat:ion: Dr. William I. Gardner Medicine: Dr. Steven J. Parker Psychiatry-. Dr. Ludwig S. Szymanski B. As part of the Joint Experts' monitoring function, each expert shall evaluate the care, treatment and services provided by defendants to determine whether defendants are complying with those provisions of the Settlement Agreement relating to the expert's area of expertise. This evaluation shall include: (a) on-site inspection of the Centers; (b) interviews with staff, contractors and residents,- (c) detailed review by each expert of no fewer than 30 resident records to be chosen by the Joint
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Expert; and, (d) review of facility documents as determined byeach Joint Expert to be relevant to his/her evaluation under this Settlement Agreement. The parties shall be permitted to have counsel or other representatives present at any inspection conducted at the Centers by the Joint Experts. Matters inquired into during any such inspection, interview or review of records or other documents shall be limited to matters directly addressed in this Settlement Agreement.
C. The first such evaluation by the Joint Experts shall occur between 90-120 days after the filing of this Settlement Agreement with the Court. This initial "base-line" evaluation is intended to inform the parties of the status of conditions at the Centers and the United States agrees that it will not bring an enforcement action based upon the results of this evaluation unless emergency conditions exist at either Center that place residents at risk of serious and imminent harm. Defendants may move pursuant to Paragraph IX.C. that the case be closed and dismissed with prejudice based on the Joint Experts' findings after the first evaluation. Subsequent evaluations shall take place annually thereafter within thirty days of the year anniversary of the filing of this Agreement with the Court. The on-site inspections shall be arranged on dates and at times mutually agreeable to the parties and the Joint Experts.
D. As part of each evaluation, each Joint Expert shall present his/her evaluation, findings and, where appropriate, recommendations in a written report, which shall be provided to
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the parties. In these reports, each Joint Expert shall make specific findings with respect to each provision of the Settlement Agreement for which he/she is responsible. To execute these duties under this Agreement, each Joint Expert shall utilize forms that contain the exact provisions from this Agreement that are relevant to each Expert's area of review. If an expert determines that the defendants are not in compliance with a provision, the expert shall so state and provide the factual bases for the findings, including, whenever possible, identification of all residents involved and all dates and times of all incidents and/or care, treatment or services at issue. If an Expert determines that the defendants are in compliance with a provision, the Expert shall so state and provide a summary specifying the documents and records the Expert reviewed and the interviews the Expert conducted that support the Expert's determination for that particular provision. Each Joint Expert shall provide his/her report within 45 days of the completion of each on-site tour.
E. Prior to and during any monitoring inspection, each Joint Expert shall be permitted to request copies of relevant documents and records he/she determines to be relevant to the expert's review under applicable provisions of this Settlement Agreement. If the request is submitted prior to the inspection, defendants shall provide the documents to the requesting Joint Expert and the United States within 15 days of the request, which shall be in writing. If the request is made during the
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inspection, defendants shall provide copies as scon as practicable. The parties may recommend to each Joint Expert documents they deem relevant to the Joint Expert's review. In addition, defendants shall provide timely notice to the Joint Experts of all resident deaths, and shall forward copies of any completed autopsies and death summaries, as well as all investigations completed on or after the effective date of this Settlement Agreement of alleged neglect or abuse. The United States may request that the Joint Experts forward them copies of any documents obtained from the defendants and the parties may have ex parte contacts with the Joint Experts at any time.
F. In the event that any of the Joint Experts identified in Paragraph VIII.A. above is unable to serve or continue serving as a Joint Expert, or in the event the parties for any reason jointly agree to discontinue the use of any Joint Expert, the parties shall meet or otherwise confer within 15 days of being notified of the incapacity or the decision to discontinue use of the Joint Expert to agree upon an alternate Joint Expert. The parties shall jointly select an alternate expert, except that if the parties are unable to agree within 15 days of their first meeting or conference as to this selection, they shall immediately and jointly petition the Court to make the selection. In this petition, each party will be permitted to propose two alternate Joint Experts in the field of expertise. The procedure described in this paragraph shall apply to the selection of all successor Joint Experts.
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G. Defendants shall bear the reasonable costs of the Joint Experts' monitoring fees and expenses. IX. ENFORCEMENT AND TERMINATION OF DKCPRK
A. This Agreement will terminate (if it has not alreadybeen terminated based on defendants' or the parties' joint motion) after the third annual inspection tour of the Joint Experts (excluding the initial base-line tour), if the Experts determine, based upon the third annual inspection tour, that defendants are in compliance. If all of the experts conclude upon the third annual inspection tour that defendants are in compliance, the burden will be upon the United States to prove that defendants are not in compliance such that the Agreement should not terminate. At all other times, the burden remains with the defendants to prove compliance.
B. The Court shall retain jurisdiction of this action for all purposes under this Settlement Agreement and resolving disputes under this Settlement Agreement pursuant to the procedure set forth herein until this Agreement is terminated.
C. On or after the date on which defendants shall have complied with the provisions of this Settlement Agreement, defendants or the parties jointly may move that the case be closed and dismissed with prejudice on grounds that defendants have complied with the provisions of this Settlement Agreement. Such motion shall attach the most recent findings of each of the Joint Experts. The defendants, the United States or the parties
- 27 -

jointly may move for partial dismissal as to the areas of expertise of one or more of the Joint Experts.
D. Provided that no evaluation has been conducted by the Joint Experts within 90 days prior to the filing of a motion to dismiss, the Joint Experts shall conduct an evaluation within 45 days after the filing of such motion, on the same terms and conditions as followed during their monitoring tours. As before, each Joint Expert shall produce a written report containing his/her findings relating to the provisions of the Settlement Agreement for which he/she has monitoring responsibility within 45 days from the last day of his/her inspection of either Center. In the event that an evaluation was conducted by the Joint Experts within 90 days prior to the filing of the motion, no subsequent evaluation shall be required.
E. In any determination of whether or not defendants are in compliance with this Settlement Agreement, the findings of the Joint Experts shall be admissible with or without testimony of the experts and shall be accorded a presumption of correctness, which may only be rebutted by a clear and convincing showing to the contrary. The parties reserve the right, however, to request a hearing before the Court in order to present evidence to rebut the presumption of correctness accorded the findings of the Joint Experts.
F. In the event the United States disagrees as to defendants' compliance at the time that a motion to terminate is filed, the parties shall jointly move the Court for a hearing on
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the motion to terminate, at which time the United States shall be permitted the opportunity to rebut the presumption of correctness accorded to the findings of the Joint Experts. At such a hearing, the parties shall be entitled to present any evidence, in addition to the testimony and reports of the Joint Experts that was gathered, developed or obtained independent of the monitoring process provided for in this Settlement Agreement, including the testimony, affidavits or reports of experts other than the Joint Experts subject to the Federal Rules of Evidence as to admissibility.
G. The United States may seek enforcement of this Settlement Agreement from the Court, at any time other than as specified in Paragraph VIII.C. above, in the event that it determines that defendants have failed to comply with this Settlement Agreement. If the Court determines that defendants are not in compliance with this Settlement Agreement, the Court will first issue an order directing defendants to comply within a period of time set by the Court and directing the appropriate Joint Experts to re-evaluate the provisions at issue within a period of time set by the Court. If the United States believes that defendants have not complied within the period of time set by the Court for re-evaluation by the Joint Experts, the United States may proceed to bring any enforcement action it deems appropriate. However, if the United States alleges and the Court finds that emergency conditions exist at either Center that place residents at risk of serious and imminent harm, the Court may
- 29 -

immediately issue any order the Court deems appropriate. As similarly provided above, in any enforcement proceeding, the Joint Experts' findings shall be accorded a presumption of correctness and the parties shall be entitled to present evidence to rebut this presumption, including the testimony, affidavits or reports of experts other than the Joint Experts, subject to the Federal Rules of Evidence as to admissibility.
H. 1. The United States will have reasonable access to the Centers, if it deems it necessary, during tours by the Joint Experts. During tours by the Joint Experts, access by the United States shall include the right to inspect and tour the Centers' buildings and grounds, review facility records, resident charts and other documents, conduct interviews with employees outside the presence of supervisory staff when requested by the employees, and observe activities normally conducted at the Centers. Such access shall continue until this Settlement Agreement is terminated. Matters inquired into during any such tour shall be limited to matters addressed in this Settlement Agreement.
2 . In addition to the access provided under Paragraph H.I., above, the United States may have access to the Centers if and to the extent permitted as discovery pursuant to the Federal Rules of Civil Procedure. Access under this paragraph shall occur no more than once annually, unless the United States establishes to the satisfaction of the Court that conditions at a Center present an imminent and serious threat to the life or
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health of the residents of the Center. In the event that the United States believes that conditions at a Center present an imminent and serious threat to the life or health of the residents, the United States will first confer with the defendants and may request access, and, if the defendants object to the United States' access, the United States shall apply for the Court's permission for access. Either party may seek relief from the Court in the event that the party believes that access is either too burdensome or too restrictive.
I. The parties reserve the right to withdraw consent to this Settlement Agreement in the event that this Agreement is not approved by the Court in its entirety.
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CONSENTED TO BY THE UNDERSIGNED:

FOR THE DEFENDANTS:

FOR THE PLAINTIFFS:

M±z
THOMAS ALT Administrator Division of Care &
Treatment Facilities Wisconsin Department of
Health & Family Services

ISABELLE KAT2 Acting Assistant Attorney General Civil Rights Division

PEGGY United States Attorney Western D i s t r i c t of Wisconsin

RICHARD A. VICTOR Assistant Attorney General Wisconsin Department
of Justice

THOMAS P. SCHNEIDER United States Attorney Eastern District of Wisconsin

STEVEN H. ROSENBAUM Chief Special Litigation Section Civil Rights Division
ROBINSUE FROHBOESE Deputy Chief Special Litigation Section
ftaj^fr CjL
RPBERTCT BOWMAN RICHARD J . FARANO
Senior Trial Attorneys Special Litigation Section Civil Rights Division U.S. Department of Justice P.O. Box 66400 Washington, D.C. 20035-6400
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WHEREFORE, the parties to this action having agreed to the provisions in the Settlement Agreement set forth above, and the Court being advised in the premises, this Settlement Agreement is hereby entered as the ORDER and JUDGMENT of this Court.

IT IS SO ORDERED, t h i s d * <3ay of
a t MaJLtttn, Wisconsin.

1997,

Judgment is hereby entered this

UNITED STATES DISTRICT JUDGE
day of A p r i l , 1997. JOSEPH W. SKUPNIEWITZ Clerk of Court

Clerk

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ATTACHMENT
MA Waivers Manual Rcccrtification and Monitoring Reviews

Chapter IV Page 30

4.04 State CTP TA Review Process
A. Inirial Follow-along
Thirty to forty-five days after the placement date of the person, CTPIA follow-along staff and a staff person from the appropriate Center (for relocated persons) will visit each participant. (See Appendix L for CIP IA follow-along staff.) During site visit, these staff will meet with participants and observe the services they receive. Interviews will be conducted with the person, the parents and/or die guardians, the case manager and service providers. The focus of the visit is to review how the services that were planned and agreed upon in the Individual Service Plan are being implemented and how well ±ese services meet the participant's needs. This visit constitutes an excellent opportunity to update the goals and objectives that were originally written for me participant. The CIP IA and Center staff will also attempt to assist the local service providers if they are experiencing problems in the development of home and community based services for the participant. After the visit, the CIP IA staff will provide a wrinen report to the participant and/or guardian and the case manager
B. Annual Review
At one year after placement and every year thereafter, CIP IA staff in conjunction with the case manager will conduct a comprehensive review of the CIP IA participant's situation. As with the initial follow-along visit, the intent of mis review is to ensure a high quality of supports and services to the participant and to assist in making adjustments to the Individual Service Plan. The CIP IA staff will observe the services designed for the person including the home and educational, vocational or other day time program. As with the initial review, the person, their family, guardian, advocate and friends are a vital part of this review. CIP IA staff will provide a wrinen report of the review to me case manager who then can share it with the appropriate individuals. As part of this review CIP IA staff are available to provide assistance in developing new services for the individual. CIP IA staff are a resource to the county and are available for consultation and technical assistance as a pan of the formal review processes as well as throughout the year.

7.05 Assuring Health and Safety of Waiver Participants
Wisconsin's approved Home and Community Based Waiver Program requires that program participant's health, safety and welfare be adequately addressed as a condition of that individuals initial and continued panicipatioa in the MA Waiver program. These policies are intended to ensure that each "CIP I administering agency" has an adeauate system to ensure waiver participants are adequately protected from physical, verbal and sexual abuse, maltreatment, neglect, financial exploitation and other violations of cheir rights under law.
a. Application: The policies and requirements in this section apply to each "CI? I administering agency." "CIP 1 administering agency" or "agency" means che agency with primary responsibility for the oversight of MA Waiver participants participating in CIP IA or CIP IB. Tnese agencies include County Departments of Community Programs or Human Services, those Department's of Aging or Social Services assigned responsibility by their county boards and, for individuals placed under the direct supervision of the department, che department.
I

b. SYSTEM: Each CIP I Administering agency shall have an established system in place designed ;o protect the health, safer/ and welfare of Waiver participants and respond CO situations where any of these are placed ac risk of harm. Agencies
_have broad discretion in determining the best design of their system so long is systems are capable of "effectively responding" co situations where the health, safer/ or welfare of "waiver participants may be compromised or at risk because of physical o: sexual abuse, maltreatment, neglect, financial exploitation or other violations of a person's rights under law. In this section, "effectively responding" means that the system is capable of achieving outcomes which remove individuals from situations where they are at risk and which prevent the reoccurrence of threats to individual health, safety and welfare or violations of :he participants client or civil rights.
Systems shall include clearly defined statement evidencing the agencies intent to promote and protect individual health, safer/ and welfare, include written Drocedures and orotocols with, denned time lines for responding to and investigating all allegations or reports of abuse/neglect or situations where an individual's safer/ may be compromised and, where risks or threats to safer/ are found, identify a variety of response options including emergency response options for any situation which ensure that individual's safer/ and welfare are adequately protected. The system snail also include policies addressing reporting of these situations to persons or agencies with an interest in the situation. All systems shall describe and involve appropriate community law enforcement resources.
c. INVESTTGATTON: For any situation where there is evidence or suspicion of any type abuse/ neglect/ exploitation, or violation of an individual's client rights, an immediate investigation by the agency or an entiry authorized by the agency must be conducted. The agency shall identify required time lines for such investigations ail of which shall be set locally. If the Waiver participant resides in a licensed home, the agency responsible for licensing must be notified of the alleged abuse.' neglect/ exploitation or violation of rights in a timely enough fashion to permit that agency co respond to the situation.
d. RESPONSE OPTIONS' Tne health, safer/ and welfare of Waiver participants is the highest priority. If there is ANY evidence of immediate harm to the health, safer/ or welfare of the Waiver participant, the agency must take all reasonable steps necessary to assure the health, safety and well-being of the Waiver participant. Agencies, working with providers, may suspend ihe individual sza.ff person(s) allegedly involved pending their investigation or remove the Waiver

participants) from the setting uncil the allegations are satisfactorily resolved. Agencies should have established procedures for terminating providers for continued nohcompliance with safer/ requirements. It is recommended that language permitting termination be incorporated into provider agreements and contracts with providers. Included in procedures for terminating providers must be provision for assisting consumers to change providers. This option should be available to Waiver participants and/or their guardians if, as a result of incident, the consumer or guardian wish :o change providers in response :o mistreatment. Change of providers is a participant right under MA freedom of choice requirements.
e. REPORTING: Scan from provider agencies serving the waiver participant shall inform the agency of ail reports of alleged abuse/aegiect/expicitation involving MA Waiver participants as soon as practical. The agency shall in turn inform the waiver participant's guardian of any report of alleged abuse' neglect/' exploitation and the results of any investigation made by the agency of such reports. If the abuse/ neglect/ exploitation involves a crime (such as rare, assault or theft) the agency law enforcement must be notified. If the agency is a County agency, chat agency snail also report ail instances of alleged physical and sexual abuse, maltreatment, neglect and financial exploitation to their assigned Community Integration Specialist as soon as practical after any allegation of such, mistreatment has been received. County agencies shall also report or: their planned response to ihe report County staff shall offer an assessment of the health, safety and welfare of the waiver participant who is the subject of the report.
f. PR.QVTDER. REQUIREMENTS: Providers of services funded by CI? iA/3 may not employ, contract with, or accept volunteer services from individuals who have beea convicted of child abuse, neglect, or maltreatment; a violation of ihe Vulnerable Adult Law (S940.2S5 and S940.295 Wi Stats.); or a felony involving physical harm to a CIP-1 participant or other health or human service program participant Agencies shall ensure that applicants for employment by the provide: or persons currently employed by the provider do not have histories indicating violations of these laws.
Individuals or entities delivering Waiver services to participants may not being named as beneficiaries of life insurance policies purchased by or on behalf of program participants.
Agencies shall ensure that ail program participants or their guardians are permitted to designate the individual or agency of their choosing to ac: as

representative payee administering benefits such as Social Security, Supplemental Securicy Income or other federal, state or private pension or related benefits.

 
 Case: 3:97-cv-231 As of: 09/25/2016 12:17 PM CDT 1 of 3
U.S. District Court Western District of Wisconsin (Madison) CIVIL DOCKET FOR CASE #: 3:97−cv−00231−bbc

CLOSED

UNITED STATES OF AMERICA v. THE STATE OF WISCONSIN Assigned to: District Judge Barbara B. Crabb Referred to: Magistrate Judge Stephen L. Crocker Demand: $0 Cause: No cause code entered
Plaintiff

Date Filed: 04/04/1997 Date Terminated: 04/10/1997 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Mark A. Cameli 1000 North Water Street, Suite 2100 P.O. Box 2965 Milwaukee, WI 53201−2965 414−298−8155 Email: mcameli@reinhartlaw.com ATTORNEY TO BE NOTICED

V. Defendant The State Of Wisconsin
Defendant Tommy G. Thompson
Defendant Joseph S. Leean
Defendant James Hutchison
Defendant Steve Watters

represented by Eillen W. Pray ASSISTANT ATTORNEY GENERAL MADISON, WI 53707 (608) 267−2798 ATTORNEY TO BE NOTICED
represented by Lee Pray ASSISANT ATTORNEY GENERAL P.O. BOX 7857
MADISON, WI 53707
ATTORNEY TO BE NOTICED
represented by Lee Pray ASSISANT ATTORNEY GENERAL MADISON, WI 53707
ATTORNEY TO BE NOTICED
represented by Lee Pray (See above for address) ATTORNEY TO BE NOTICED
represented by Lee Pray (See above for address) ATTORNEY TO BE NOTICED

Date Filed # Docket Text

Case: 3:97-cv-231 As of: 09/25/2016 12:17 PM CDT 2 of 3

04/04/1997 04/04/1997 04/04/1997 04/04/1997 04/04/1997 04/10/1997
04/21/1997 08/18/1997
02/18/1998 02/18/1998 02/18/1998 02/19/1998
02/20/1998 02/24/1998 02/24/1998 03/09/1998 03/09/1998 03/09/1998 03/09/1998 03/09/1998 03/09/1998 03/09/1998 03/09/1998 03/16/1998 03/23/1998 04/13/1998

Jams Import Utility Entry (Entered: 04/04/1997)
NORTC (Entered: 04/07/1997)
1 JS−44 (Entered: 04/07/1997)
2 COMPLAINT (Entered: 04/07/1997)
3 MOTION (JOINT) TO APPROVE THE SETTLEMENT AGREEMENT. (Entered: 04/07/1997)
4 ORDER GRANTING PARTIES' MO TO APPROVE THE SETTLEMENT AGMT (INCLUDES SETTLEMENT AGREEMENT & JUDGMENT). (BC/JWS) cc mld (Entered: 04/10/1997)
5 WAIVER OF SERVICE OF SUMMONS & FILING OF RESPONSIVE PLEADING BY DEFTS. (Entered: 04/22/1997)
6 STIPULATION AND ORDER −SCHEDULE FOR JOINT EXPERTS' BASE−LINE EVAL. OF SO. & CENTRAL WI DEVELOP. CENTERS.(BC)CCMLD(8/15/97) (Entered: 08/18/1997)
7 MOTION TO ENFORCE TERMS OF THE SETTLEMENT AGREEMENT,BY U.S. (Entered: 02/18/1998)
8 BRIEF IN SUPPORT BY U.S. OF MO TO ENFORCE TERMS OF SETTLEMENT AGREEMENT. (Entered: 02/18/1998)
9 AFFIDAVIT OF −DECLARATION OF WILLIAM I. GARDNER, PH.D. (Entered: 02/18/1998)
10 ORDER SETTING BRFG ON PLTF'S MO TO ENFORCE TERMS OF SETTLEMNT AGREEMENT (OBJS BY 2/27/98; REPLY BY 3/6/98). (BC) (Entered: 02/19/1998)
11 NOTICE OF APPEARANCE BY AAGs BARNETT AND PRAY FOR DEFTS. (Entered: 02/20/1998)
12 PLTF'S NOTICE OF NO OPPO. TO DEFTS' REQUEST FOR EXT OF TIME (Entered: 02/24/1998)
13 ORDER ALLOWING BRIEFING SCHEDULE ON PLTF'S MO. TO ENFORCE THE TERMS OF A SETTLEMENT AGREEMENT (BBC) (Entered: 02/24/1998)
14 OBJECTIONS OF DEFTS TO MO. OF U.S. TO ENFORCE CONSENT DECREE (Entered: 03/09/1998)
15 BRIEF IN OPPOSITION TO MOTION OF U.S. TO ENFORCE CONSENT DECREE, BY DEFTS. (Entered: 03/09/1998)
16 AFFIDAVIT OF NEIL GEBHART (Entered: 03/09/1998)
17 AFFIDAVIT OF DANIEL STIER (Entered: 03/09/1998)
18 AFFIDAVIT OF THOMAS ALT (Entered: 03/09/1998)
19 AFFIDAVIT OF JANET DEVORE (Entered: 03/09/1998)
20 AFFIDAVIT OF MARY GREEN (Entered: 03/09/1998)
21 AFFIDAVIT OF SARAH SPELLMEYER (Entered: 03/09/1998)
22 BRIEF IN REPLY BY U.S. IN SUPP OF MO TO ENFORCE CONSENT DECREE. (Entered: 03/17/1998)
23 LETTER RE:MEMORANDUM RELEVANT TO DEFT'S OBJS.TO MO TO ENFORCE CONSENT DECREE, BY DEFT. (Entered: 03/23/1998)
24 ORDER −OPINION & ORDER GRANTING PLTF'S MOTION TO ENFORCE THE TERMS OF THE SETTLEMENT AGREEMENT. (BC) (Entered: 04/14/1998)

Case: 3:97-cv-231 As of: 09/25/2016 12:17 PM CDT 3 of 3

11/24/1998
02/09/2006 02/09/2006 02/13/2006

25 STIPULATION AND ORDER BY PARTIES RE: SCHEDULE FOR JOINT EXPERTS' 1ST ANNUAL EVAL. PURS. TO SETTLEMENT AGREEMENT.(BC) (Entered: 11/24/1998)
26 MOTION (JOINT) TO DISMISS. (Entered: 02/09/2006)
27 BRIEF IN SUPPORT OF PARTIES JOINT MOTION TO DISMISS. (Entered: 02/09/2006)
28 ORDER GRANTING JOINT MOTION TO DISMISS; SETTLEMENT AGREEMENT TERMINATED; CASE DISMISSED WITH PREJUDICE. (Entered: 02/13/2006)