U.S. Department of Justice
Civil Rights Division
Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
August 6, 2007
The Honorable M. Jodi Rell Governor of Connecticut State Capitol 210 Capitol Avenue Hartford, CT 06106
Re: CRIPA Investigation of the Connecticut Valley Hospital, Middletown, Connecticut
Dear Governor Rell:
I am writing to report the findings of the Civil Rights Division’s investigation of conditions and practices at the Connecticut Valley Hospital (CVH) in Middletown, Connecticut. On December 19, 2005, we notified you that we were initiating an investigation of conditions and practices at CVH, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997. CRIPA gives the Department of Justice authority to seek a remedy for a pattern and practice of conduct that violates the constitutional or federal statutory rights of patients with mental illness who are treated in public institutions.
As part of our investigation, on May 30 through June 2, 2006, we conducted an on-site review of care and treatment at CVH with expert consultants in the areas of psychiatry, psychology, and suicide prevention. In conducting our on-site investigation, we interviewed administrators, staff, and patients, and examined the physical living conditions at the facility. Before, during, and after our visit, we reviewed a wide variety of documents, including policies and procedures, patients’ medical records, and other documents relating to the care and treatment of dozens of CVH patients. At the end ofthe tour, consistent with our pledge of transparency and to provide technical assistance regarding our investigatory findings, we provided an exit interview to convey our preliminary findings to counsel and facility and State officials.

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As a threshold matter, we wish to express our appreciation to the staff of CVH and to State officials for their extensive assistance and cooperation during our investigation. We hope to continue to work with CVH and the State of Connecticut in the same cooperative manner in addressing the problems that we found. Further, we wish to particularly thank those individual CVH staff members, both new and longstanding, who make daily efforts to provide appropriate care and treatment and improve the lives of patients at the hospital. Those efforts were noted and appreciated by us and our expert consultants.
Consistent with our statutory obligations under CRIPA, I now write to advise you formally of the findings of our investigation, the facts supporting them, and the minimal remedial steps that are necessary to remedy the deficiencies set forth below. 42 U.S.C. § 1997b(a). Specifically, we have concluded that numerous conditions and practices at CVH violate the constitutional and federal statutory rights of its residents. In particular, we find that CVH fails to provide its patients adequate: 1) protection from harm; 2) psychiatric and psychological care and treatment; and 3) discharge planning and placement in the most integrated setting. See Youngberg v. Romeo, 457 U.S. 307 (1982); Title XIX of the Social Security Act, 42 U.S.C. § 1396; 42 C.F.R. Part 483, Subpart I (Medicaid Program Provisions); Americans with Disabilities Act (ADA), 42 U.S.C. § 12132 et seq.; 28 C.F.R. § 35.130(d); see also Olmstead v. L.C., 527 U.S. 581 (1999).
I. BACKGROUND
The General Hospital for Insane of the State of Connecticut opened in 1868 in Middletown, Connecticut. By 1900, the hospital housed approximately 2,000 patients. In 1953, the State’s new Department of Mental Health took over administration of the hospital. The facility was renamed Connecticut Valley Hospital in 1961. In the mid-1990s, the State closed two other State hospitals, Fairfield Hills Hospital and Norwich Hospital, and consolidated those programs at CVH.
CVH is currently a 549-bed psychiatric hospital located on a pleasant campus of approximately 100 acres. CVH is the largest of five public in-patient treatment facilities operated by the Connecticut Department of Mental Health and Addiction Services (DMHAS). CVH provides in-patient treatment and care for individuals 18 years and older, from throughout the State, with acute psychiatric, geriatric, forensic, and addiction service needs. There are three main divisions at CVH: the Whiting Forensic Division, the General Psychiatry Division, and the

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Addiction Services Division. Approximately half of the CVH patients are in the Whiting Forensic Division, which specializes in services for involuntarily committed individuals involved with the criminal justice system and includes the State’s only maximum-security psychiatric units. There are five main residential complexes at CVH: Whiting Forensic Institute (maximum and moderate security forensic units), Battell Hall (general psychiatry and traumatic brain injury units), Woodward Hall (geriatric units), Dutcher Service (forensic community reentry program), and Merritt Hall (addiction services and general psychiatry units).
II. FINDINGS
Patients of state-operated facilities have a right to live in reasonable safety and to receive adequate health care, along with habilitation to ensure their safety and freedom from unreasonable restraint, prevent regression, and facilitate their ability to exercise their liberty interests. See Youngberg v. Romeo, 457 U.S. 307 (1982); Kurlak v. City of New York, 88 F.3d 63, 75 (2d Cir. 1996) (applying the Youngberg standard to treatment given in a mental health hospital). If a patient is admitted to a psychiatric hospital for care and treatment, the State has a duty to treat the patient. Woe v. Cuomo, 729 F.2d 96, 105 (2d Cir. 1984) (holding that if justification for commitment of psychiatric patients rests, even in part, upon the need for care and treatment, then a State that commits must also treat). In the Second Circuit, for the purposes of a patients’ constitutional liberty interests, no distinction exists between voluntarily and involuntarily committed patients. Society for Good Will to Retarded Children, Inc. v. Cuomo, 737 F.2d 1239, 1243 (2d Cir. 1984) (“We need not decide whether . . . residents are [committed] ‘voluntarily’ or ‘involuntarily’ because in either case they are entitled to safe conditions and freedom from undue restraint.”). Determining whether treatment is adequate focuses on whether institutional conditions substantially depart from generally accepted professional judgment, practices, or standards. Youngberg, 457 U.S. at 353. The State is also obliged to provide services in the most integrated setting appropriate to the individual patient’s needs. Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. § 12132 et seq.; 28 C.F.R. § 35.130(d); see Olmstead v. L.C., 527 U.S. 581 (1999).
As described in greater detail below, we find that certain conditions and services at CVH substantially depart from generally accepted standards, and violate the constitutional and federal statutory rights of patients. In particular, we find that CVH fails to: (1) adequately protect patients from harm and

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undue restraints; (2) provide adequate psychiatric and psychological services; and (3) ensure adequate discharge planning and placement in the most integrated setting appropriate to each patient’s individualized needs.
A. PROTECTION FROM HARM
Patients’ constitutional liberty interests compel states to provide reasonable protection from harm. Youngberg, 457 U.S. at 315-16; Good Will, 737 F.2d at 1243 (patients of mental health institutions have a right to safe conditions). In order to protect patients from harm, hospitals have a duty to adequately supervise patients known to be suicidal. Dinnerstein v. U.S., 486 F.2d 34 (2d Cir. 1973) (veterans hospital held liable for not adequately supervising patient with history of known suicidal tendencies).
In our judgment, CVH fails to provide its patients with a reasonably safe living environment. The facility too often subjects its patients to harm or risk of harm. CVH fails to protect its patients from harm due to inadequate suicide policies and practices; overuse of unnecessary seclusion and restraint; an inadequate risk management system that fails to collect, organize, and track incidents of harm and abuse for the purpose of identifying and preventing potential incidents of harm and abuse; and a lack of an adequate quality assurance system necessary to ensure quality of care across all aspects of care and treatment.
Unfortunately, CVH has a history of failing to protect its patients from harm. In a 15-month period in 2003 and 2004, three patients at CVH committed suicide by hanging. In each case, it appeared that staff were aware of the suicide risk, but failed to take appropriate action. One suicide occurred nine hours after a nurse identified that the patient had thoughts of suicide, but then failed to assess him for suicide risk or take proper precautions. In the wake of these suicides, CVH has promulgated new policies and procedures. In spite of these remedial efforts, however, training and practices at CVH are not yet in line with generally accepted professional standards.
1. Suicide Prevention
Suicidal behavior in mental health facilities represents a major threat to the lives and well being of the patients. Generally accepted professional standards require mental health facilities to protect patients from self harm. By failing to provide adequate suicide prevention training, failing to provide

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adequate suicide risk assessments, failing to address known environmental suicide hazards, failing to properly monitor patients, and failing to adequately review serious suicide attempts, CVH fails to meet this requirement.
a. Inadequate Suicide Prevention Training
Suicide prevention training is not sufficiently addressed in any policy, procedure, or practice at CVH. Three patient suicides occurred at CVH during a 15-month period in 2003-2004. Each of the reviews following these deaths cited the need for suicide prevention training at CVH. Unfortunately, these recommendations have not yet been adequately implemented.
Most new nursing and direct care staff complete a new employee training that devotes approximately 90 minutes to suicide prevention. But, additional or on-going suicide prevention training is not mandatory for CVH employees. CVH recently offered a two-hour “On-going Risk Assessment and Care Considerations for the Suicidal Patient” workshop to all nursing and direct care staff, but there are no plans to establish annual mandatory suicide prevention training for all CVH staff. Rather than establishing a pro-active, permanent training program, the philosophy for offering suicide prevention training at CVH appears to be reactionary and seemingly only tied to patient death.
Even then, required suicide prevention training is not consistently carried out. For instance, following the 2003-2004 suicides, CVH revised its policies to require that all direct care staff, as well as nurses, physicians, and rehabilitation staff, to be certified in first aid and cardiopulmonary resuscitation (CPR). As of May 31, 2006, 100% of physicians and 97% of nursing staff were certified, but only 85% of rehabilitation staff and 73% of direct care staff were certified. The high level of professional staff certification is commendable. However, the certification rate for direct care and rehabilitative staff should be over 90%. Also, although CVH policy requires mock emergency drills to occur on a quarterly basis, as of May 2006, there had not been any mock drills regarding the proper response to a suicide attempt since 2004.
b. Inadequate Suicide Risk Assessments
CVH employs very good screening and assessment tools for the identification of suicide risk. The personnel conducting the assessments, however, lack sufficient training, and the screening process is in need of oversight. The 15-page Admission Nursing

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Assessment is very comprehensive and includes at least 12 separate questions related to suicide risk, which will trigger a Suicide Risk Assessment if any of them result in a positive response. However, when we witnessed an Admission Nursing Assessment of a new patient, the intake nurse merely asked, “have you tried to hurt yourself before?” and noted “no evidence” of suicide risk without addressing any of the other lines of inquiry indicated on the Admission Nursing Assessment. This was an inadequate assessment of suicide risk that did not comport with generally accepted professional standards.
In addition, our review of several patient case files indicated that the Suicide Risk Assessment is not consistently completed as required by CVH policy and procedure. CVH policy requires a Suicide Risk Assessment whenever a patient: (1) expresses thoughts of self-harm, (2) displays suicidal behavior, (3) demonstrates a change in mood or behavior, or, (4) as discussed above, yields a positive response during the suicide risk section of the Admission Nursing Assessment. However, interviews with CVH staff revealed that this policy is not well understood. One patient file we reviewed demonstrated that recently a patient with an extensive history of suicidal behavior did not receive a Suicide Risk Assessment at intake and only subsequently received such an assessment after approximately ten months at CVH when he expressed suicidal ideation. Moreover, two of the patients who committed suicide at CVH in 2003 and 2004 never received a Suicide Risk Assessment at intake, despite having histories of prior suicide attempts.
CVH’s lack of quality assurance procedures regarding suicide prevention makes it difficult for CVH to properly implement its policies and forms dedicated to suicide risk assessment. CVH does not perform an adequate quality assurance (or performance improvement) audit of the Admission Nursing Assessment process to ensure that intake nurses are correctly completing the suicide risk section of the assessment form. Similarly, there is no appropriate process in place to ensure that a Suicide Risk Assessment is completed on residents when appropriate.
c. Environmental Suicide Hazards
The issue of safe housing for suicidal patients is not sufficiently addressed in any CVH policy or procedure. Environmental suicide hazards were noted as contributing factors in each of the reviews following the three CVH patient suicides during 2003-2004. As a result, CVH initiated some corrective action, including replacing shower heads and ceiling tiles in

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bathrooms hospital-wide and installing new ventilation grilles in selective bedroom units.
Despite these initial remedial efforts, during our tour of each patient living area, we found numerous protrusions in bedrooms, bathrooms, and closets that were conducive to suicide attempts by hanging. This is particularly alarming in a psychiatric facility such as CVH with a recent history of suicides. The Whiting Forensic Institute and Dutcher Hall had many environmental suicide hazards, including wire mesh bed frames, large gauge mesh ventilation grates on walls, and unlocked bathroom/showers with non-breakaway grab bars, exposed pipes, interior door knobs, and clothing hooks. In Battell Hall, the shower rooms were locked, but the bathrooms were unlocked and contained many of the protrusions described above. In Merritt Hall, many of the above protrusions were present, as well as non-breakaway clothing rods in clothing bureaus. In addition, bathrooms contained plastic covers on ceiling light fixtures, there were large gauge mesh ceiling ventilation grates in seclusion rooms, and laundry rooms were unlocked with numerous protrusions. In Woodward Hall, clothing hooks were found in shower and bathroom areas.
We recognize that it might not be practical to ensure that all patient rooms at CVH are suicide-resistant, it is certainly reasonable, however, to ensure that all patients placed on special observation status for suicide risk are housed in suicide-resistant rooms and only have access to safe bathroom and shower areas.
d. Inadequate Patient Monitoring
According to CVH policy, all forensic, general psychiatric, and geriatric patients are required to be observed at 15-minute intervals from 7:00 a.m. to 7:00 p.m., and then at 30-minute intervals during the night. However, patients assigned to the Merritt Hall Addictions Services Division are only required to be observed at 60-minute intervals throughout the day and at night. The practice of monitoring the Addictions Services Division patients at 60-minute intervals is grossly inadequate and is not in compliance with generally accepted professional standards for mental health facilities. Although CVH officials attempted to justify this level of observation by suggesting that suicidal patients are screened out of the Addictions Services Division, and that a physician can always increase the observation level of an Addictions Services Division patient following an assessment, such justifications are not persuasive. Many suicidal patients are not identified as suicidal at admission and/or become

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suicidal during later stages of a commitment, thus limiting the impact of admission screening on the identification of suicide risk. The fact that a physician can always increase the observation level of patient following an assessment is certainly not unique to the Addictions Services Division; it is a general CVH policy, and irrelevant to setting minimum observation levels. In addition, individuals who are intoxicated and/or going through alcohol/drug withdrawal are at higher risk for suicide. In fact, one of the recent CVH suicides occurred in the Addictions Services Division.
CVH patients on suicide precautions are observed either at 15-minute intervals; continuous observation (in which nursing staff may observe up to three patients at the same time); or oneon-one observation (in which a staff member is assigned to provide continuous, uninterrupted observation of a single patient). Although these three levels of special observation are consistent with generally accepted professional standards, CVH policies do not contain any criteria outlining what specific suicidal behavior translates into a particular observation level.
Finally, CVH does not keep a daily roster of patients on special observation status for suicide risk. This makes it difficult for the facility and treatment teams to track the progress of suicidal patients and hinders accurate communication regarding patients’ needs. For example, one patient had an extensive history of suicidal behavior and was placed on “continuous observation status” upon admission. Although he remained on this status level for several weeks, daily progress notes written during this period erroneously listed his observation level as “15-minute observation.” In another example, although a patient had been discharged from special observation status, a unit nurse continued to write daily progress notes as if he were still on “15-minute observation,” which indicates that the nurse did not review the physician orders.
e. Inadequate Reviews of Suicide Attempts
Although CVH completes appropriate mortality reviews following deaths as a result of patient suicides, the facility does not require adequate reviews following serious suicide attempts. For example, in July 2005, a patient made a serious suicide attempt by attempting hanging while jumping out of an unsecured window. The rope broke, and the patient sustained a series of fractures. This incident demonstrated a policy

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breakdown at CVH. The only Focused Treatment Plan Review1 following the suicide attempt focused solely on treatment changes that were necessary as a result of the patient’s physical injuries from the suicide attempt. The patient’s team did not address the psychiatric issues involved in the incident and did not modify the plan objectives or interventions relative to suicidal ideation. The team also did not address the environmental hazard presented by the unsecured window.
2. Seclusion and Restraint
The right to be free from undue bodily restraint is the “core of the liberty protected by the Due Process Clause from arbitrary governmental action.” Youngberg, 457 U.S. at 316. Consistent with generally accepted professional practice, seclusion and restraints may only be used when a patient is a danger to himself or to others. See Youngberg, 457 U.S. at 324 (“[The State] may not restrain residents except when and to the extent professional judgment deems this necessary to assure such safety to provide needed training.”); Goodwill, 737 F.2d at 1243 (holding patients of mental health institutions have a right to freedom from undue bodily restraint and excess locking of doors violates patients’ freedom from undue restraint); Thomas S. v. Flaherty, 699 F. Supp. 1178, 1189 (W.D.N.C. 1988), aff’d, 902 F.2d 250 (4th Cir. 1990) (“It is a substantial departure from professional standards to rely routinely on seclusion and restraint rather than systematic behavior techniques such as social reinforcement to control aggressive behavior.”); Williams v. Wasserman, 164 F. Supp. 2d 591, 619-20 (D. Md. 2001) (holding that the State may restrain patients via mechanical restraints, chemical restraints, or seclusion only when professional judgment deems such restraints necessary to ensure resident safety or to provide needed treatment). Seclusion and restraint should only be used as a last resort. Thomas S., 699 F. Supp. at 1189. Similar protections are accorded by federal law. See, e.g., Title XIX of the Social Security Act, 42 U.S.C. § 1395hh, and implementing regulations, 42 C.F.R. Parts 482-483 (Medicaid and Medicare Program Provisions); 42 C.F.R. § 482.13(f)(3) (“The use of a restraint or seclusion must be . . . [s]elected only when less restrictive measures have been found to be ineffective to protect the patient or others from harm; [and] . . . [i]n accordance with the order of a physician . . . .”); 42 C.F.R. § 482.13(f)(1) (“The patient has the right to be free from

1


CVH conducts special treatment team reviews for

patients who have been involved in serious incidents. See

discussion, infra at 15.

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seclusion and restraints, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.”).
CVH’s use of seclusion and restraint substantially departs from generally accepted professional standards and exposes its patients to harm due to inadequate reporting, insufficient behavioral programming, poor staff training, and inadequate policies and procedures. Seclusion and restraint at CVH is applied without adequate professional assessment and/or supervision, often with significant clinical error, for the convenience of staff, and without appropriately documented rationale.
Although CVH has the capacity to produce standardized data reports, i.e., reports delineating restraint usage in terms of hours/1000 patient days, and indeed provides standardized data to the National Association of State Mental Health Program Directors, CVH leadership does not routinely use standardized data in its internal analysis of restrictive measures. Instead, meaningless and non-standardized event and hour data are routinely reported without any indicators for determining how to properly interpret the data. This failure places patients at risk of harm due to inaccurate analysis and response to unacceptable trends in the use the restrictive interventions.
CVH policy addresses the need for reviewing individual patient cases when certain seclusion and restraint thresholds have been reached. However, the clinical case review process is flawed. First, the review system eschews the interdisciplinary team process by involving only the attending psychiatrist and service medical director at the first stage of review, rather than the interdisciplinary team. Second, the policy does not call for review by the senior clinicians in each discipline. Third, the policy advances some cases to the headquarters level without adequate interdisciplinary discussion at the hospital level or consideration by an outside consultant with special expertise in the problem behavior. The current process does not assure that proper clinical review takes place at each stage and therefore presents the risk that complicated or “problematic” cases will be elevated to a higher level of review too easily, which allows staff at both the unit level and the hospital level to deflect responsibility for difficult cases.
When seclusion, restraint, and/or pro re nata (PRN or “as needed”) psychotropic medications are frequently used with a patient, generally accepted professional standards require the treatment team to reassess interventions and, as necessary, modify the patient’s treatment plan. Frequent use of seclusion,

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restraints, and/or PRN medications is an indicator that a patient’s diagnosis is erroneous, that the treatment plan is inappropriate, and/or that staff are using restrictive practices to replace active treatment, as punishment, or for the convenience of staff.
At CVH, seclusion and restraint are repeatedly used to respond to behaviors in lieu of the development of positive behavior support plans or consideration of other targeted behavioral treatment. Although we were told that many of the current psychology staff had advanced training in applied behavior analysis, we found no evidence of such training in the treatment records of patients whose behavior consistently resulted in seclusion or restraint.
CVH records are replete with examples of repeated use of seclusion and restraint for patients whose target behaviors strongly suggest the need for individualized behavioral treatment plans. For example:
a. A patient was involved in over 30 incidents of seclusion or restraint in the first few months of 2006 before CVH obtained a consult from an outside behavioral analyst. In April 2006, the consultant recommended developing a positive behavior support plan, but CVH did not implement a plan despite continuing episodes of seclusion or restraint over the following 30 days. CVH contacted the consultant again, who gave the same recommendation, but at the time of our June 2006 tour, there was no evidence of a positive behavior support plan in the patient’s chart.
b. Another patient experienced over 25 incidents of seclusion or restraint in a six-week period in March and April 2006, including consistent use of PRN psychotropic medication during this period. However, her medical record did not contain any indication that her CVH team considered implementing a behavioral treatment plan.
c. Another patient was involved in three episodes of seclusion or restraint that each lasted for more than 24 hours. On April 9, 2006, a Focused Treatment Plan Review resulted in a recommendation to “implement behavior plan.” However, the patient’s chart did not reflect any documentation relating to the development of such a plan six weeks later.

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d. Another patient required approximately 800 hours of bed and ambulatory restraints in a six-month period due to assaultive and self-injurious behavior. However, the patient’s treatment plan did not include any positive behavior supports or strategies to replace the selfinjurious behavior that was resulting in such heavy restraint use.
Contrary to generally accepted professional standards, CVH consistently uses seclusion and restraint as an intervention of first resort and fails to consider lesser restrictive alternatives. Although CVH policies require this consideration before using seclusion and restraint, numerous examples illustrate that CVH practice does not comport with its policy.
For example, a patient was agitated and struck out at a nurse, then turned to a mental health attendant and asked, “Are you happy now, motherf-----?” Staff immediately placed him in locked seclusion, although the documentation does not indicate that he continued to present a threat to staff or other patients. Staff checked off “immediacy prevents less restrictive intervention” on the CVH Seclusion/Restraint Form, but did not provide any assessment of the patient’s need for locked seclusion at the time. There is no documentation of methods used by staff to respond to this patient with less restrictive procedures, nor is there any documented supervisory review of this use of seclusion or restraint or the patient’s treatment plan.
In another example, a patient was restless during snack time and ignored staff’s request to sit down. Staff told the patient that if he could not follow directions, he would be asked to utilize a “Voluntary Time Out.” Voluntary Time Out is a practice at CVH that allows the patient to “voluntarily” seclude himself in an unlocked room.2 At that point, the patient became hostile

2


When utilizing Voluntary Time Out, CVH does not require

staff to document this practice as a restrictive practice. In

addition, CVH does not require an assessment of patients placed

in Voluntary Time Out. Both factors are problematic because

records demonstrate that the practice of Voluntary Time Out is

not consistently voluntary and operates more as seclusion. For

example, on April 8, 2006, a patient was sent to Voluntary Time

Out for 15 minutes. When he decided to terminate his seclusion

after five minutes, staff redirected him to the time out room,

which led him to become hostile and combative. As a result,

staff placed the patient in locked seclusion. Voluntary Time Out

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and threatening and, as a result, was placed in four-point restraints to the bed. None of the documentation indicates why it was necessary for the patient to sit down during snack time and why lesser restrictive interventions were not used.
In a gross departure from accepted practice, CVH often uses seclusion and restraint for the convenience of staff and/or as punishment. For example, on April 25, 2006, a patient became agitated when staff reminded him to keep his hand out of his pants in the hallway. The patient stated “I can do whatever I want” and “I’m going to knock your a–- off,” and went back to his room. Staff then escorted the patient to the seclusion room with a “show of force.” There is no documentation as to why seclusion was necessary, as the patient had returned to his room, and the documentation suggests that the seclusion and “show of force” were intended to punish the patient or teach him a lesson for his threatening comments.
CVH has a variety of policies and procedures relevant to the use of seclusion and restraint. Generally accepted professional standards require psychiatric hospitals to have clearly articulated policies and practices for the safe application of restrictive measures, including but not limited to: (1) definitions of each restrictive practice; (2) the role of each clinical discipline in initiating, authorizing, and continuing a restrictive measure; (3) criteria for discontinuation; (4) criteria for initial and ongoing assessments of patients in restraints; (5) staff training in de-escalating behavioral situations to prevent the need for restrictive measures; (6) staff training in safely applying and discontinuing restrictive measures; and (7) systems for tracking and reporting the utilization of all the above measures.
Policies and procedures at CVH meet applicable standards of care with regard to the initiation of seclusion/restraint by a physician or nurse; face-to-face physician assessment; and ongoing assessment. However, with regard to the delineation of release criteria, there are some failures at the policy level. While the CVH policy for release from seclusion and restraint lists several behavioral criteria that “may” be considered as release criteria, the seclusion and restraint documentation delineates release criteria in a pre-printed list of choices. Therefore, instead of a list of clinical prompts for consideration, in practice CVH has created a specific list of
is not voluntary if there is a pre-set time requirement and should therefore be recorded as seclusion.

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acceptable criteria that clinicians must adhere to in every seclusion and restraint situation. This prevents the clinicians from developing truly individualized release criteria relevant to the specific behavioral emergency for which the restrictive intervention is targeted. The CVH policies also state, often in bolded or otherwise highlighted text, that: “Four-point restraints may be gradually reduced to three-point or two-point in preparation for total release from restraint.” This language reflects a practice of graduated release in all circumstances, regardless of the findings of clinical assessment in each case. Requiring a graduated 4-3-2 step release without accounting for the clinical appropriateness of the procedure unnecessarily leads to the use of more restrictive measures than appropriate. In addition, the policies do not specify if the graduated release requires a new physician or nurse assessment and order. Any restrictive measure requires formal pre-assessment and an order, even if the patient is being moved to a lesser restrictive measure than previously. This is because the decision to order any level of restrictive measure must take into consideration whether a restriction is necessary at all. The lack of individualized consideration demonstrated by these policies and practices is contrary to generally accepted professional standards.
Finally, four-point restraint to the bed and posey net restraints3 are no longer considered acceptable restraint use due to their association with potential serious patient injuries. CVH policies acknowledge that these restraint practices are “highly restrictive,” but they are still allowed, in contrast to generally accepted professional standards. These restraint practices should be prohibited at CVH.
3. Risk Management
Generally accepted professional standards require that patients be provided a reasonably safe environment through an effective risk management system, including effective clinical oversight; mechanisms for reporting, investigating, and tracking and trending incidents of harm and injury; and identification and implementation of appropriate corrective and preventative action.

3


A posey net restraint is a nylon mesh sheet that covers

the body while leaving the head, arms, and feet exposed. Padded

cuffs at the upper arms, wrists, and ankles are designed to hold

a patient’s limbs in place while cross-straps attached to the net

are used to further secure the sheet to a bed frame to prevent

patient movement.

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CVH’s risk management system substantially departs from professional standards, exposing its patients to an unreasonable risk of harm.
Serious problems plague the clinical oversight mechanisms developed by CVH for the review of individual cases. In 2005, CVH developed a system of Focused Treatment Plan Reviews that mandates special treatment team reviews for patients who have been involved in serious incidents, such as seclusion and restraint or self-injurious behavior. This is commendable because a focused review of an individual’s treatment plan following a serious event or behavioral change is required by generally accepted professional standards. However, our investigation revealed that CVH’s Focused Treatment Plan Reviews fall significantly short of the standard of care in this area.
For example, one patient’s team held a Focused Treatment Plan Review after she attempted suicide by overdose. Her medical record indicated a long history of depression and self-injurious behavior, with an appropriate prescription for therapy to address her problems. At the Focused Treatment Plan Review after her suicide attempt, her team added two new interventions to her treatment plan: (1) “will no longer have feelings of depression” and (2) “will talk to staff when she feels she wants to harm self.” The addition of an objective of “will no longer have feelings of depression” is not a “focused” response to a suicide attempt by an individual with a long history of depression. The addition of such an intervention suggests that CVH staff either lack clinical experience or do not take the Focused Treatment Plan Review process seriously. The fact that talking to staff regarding thoughts of self harm was not an objective in her plan prior to the suicide attempt, despite the patient’s history of self-injurious behavior, reveals a serious flaw in the initial plan. The need for a focused review arises precisely because the current treatment plan is not effective. The outcome of a true focused review should not merely develop dubious objectives that do not address the patient’s behavior.
A similar example of problems with CVH’s focused reviews involved a patient who assaulted people seven times between March 29, 2005 and December 15, 2005. His treatment plan indicated that he had a long history of conflicts with others and a potential for violence. The only “focused” interventions added to his treatment plan during the nine-month period were 15-minute checks and unit restriction. While such interventions could have been helpful in reducing incidents of assault, the continuation of his assaultive behavior demonstrated that additional analysis and interventions were necessary to understand and address the

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patient’s aggression. The lack of targeted treatment in response to these incidents of aggression resulted in the patient being secluded or restrained 17 times in one year.
Another patient was involved in a series of assaults, which resulted in seclusion or restraint, in a six-month period, but the patient’s team did not hold a Focused Treatment Plan Review or conduct any reassessment of the patient’s plan to address his aggressiveness or the risk of victimization. The team’s failure to act put this patient at risk of harm from restraint use and put his peers at risk due to his assaultive behavior.
Our investigation confirmed that CVH has an appropriate system for responding to, and tracking allegations of, staff abuse or neglect of patients. But, CVH lacks an adequate system for collecting, organizing, and tracking patient injuries or incidents. CVH does not have a proper hospital-wide process for tracking patient injury data. Rather, the system varies from division to division and does not adhere to a standardized format. Data are presented in raw numbers of patient-on-patient assaults without a statistical formula that takes into account fluctuations in the CVH census, such as the number of assaults per 1000 patient days. Without standardization, data trending is virtually meaningless, and genuine fluctuations in the assault rate resulting from special causes cannot be distinguished from expected trends. Consequently, CVH leadership is unable to analyze trends and take appropriate action to understand and rectify unexpected variations in results by unit, shift, or staff. Worse yet, the lack of reliable and thorough data may cause administrators and clinical leaders to erroneously believe that alterations are not necessary.
The need for appropriately trended data is further highlighted by CVH’s reports on patient injury, which show several months in 2005 in which patient injury rates at CVH were significantly higher than national averages.4 Although the existence of CVH’s patient injury reports demonstrate its ability to collect and cull useful data that could be trended to analyze incidents of injury and other performance indicators, CVH does not appropriately utilize this data. CVH’s failure to identify problematic trends in patient incidents and take appropriate and

4


CVH provides data on patient injury to the National

Association of State Mental Health Program Directors, which

reports on national trends and benchmarks in public mental health

facilities. We did not have access to patient data reports for

2006.

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timely action to address such trends and patterns places its patients at ongoing risk of harm due to injury and abuse.
4. Quality Assurance
Professional standards of care dictate that a hospital like CVH develop and maintain an integrated system to monitor and assure quality of care across all aspects of treatment. Such a quality assurance system incorporates adequate systems for data capture, retrieval, and statistical analysis to identify and track trends in patient treatment. Additionally, a performance improvement mentality must be present in every organizational system and process at the hospital level and in each clinical and administrative department. CVH lacks an adequate quality assurance system. At the hospital level, although CVH produces quarterly quality data reports for the hospital’s governing body, CVH does not use appropriate methodology for data reporting and trending. For example, as noted above, data on key indicators are reported in raw numbers rather than as standardized figures that would allow CVH to determine the difference between normal and special cause variation. Without proper data and data analysis, CVH substantially departs from generally acceptable standards in quality management. As a result, CVH is unable to adequately protect its patients from harm.
At the clinical department level, there is much variation in the appropriate use of quality management tools and procedures. Some divisions only monitor timeliness and presence/absence of specific services, while other divisions take a more content oriented approach. The Department of Nursing’s program, for example, includes a mix of content and presence/absence indicators. However, Nursing is only aggregating quality assurance data on a quarterly and annual basis, rather than monthly, and therefore cannot properly analyze temporal variations. While some departments describe appropriate corrective actions for poorly functioning indicators, other divisions lack corrective action plans.
The Department of Psychology does not currently have any effective quality management program, but only quality assurance counts of some key indicators without accompanying data. CVH considers Psychology Department quality monitoring a part of the peer review process, which demonstrates a misunderstanding of the various steps involved in sound quality monitoring. Aggregated department-wide performance data, devoid of clinicianidentifiers, must be trended monthly and analyzed for special cause variation that can then direct the discipline’s management team to targeted performance improvement projects.

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The wide variability in approaches to quality management at the clinical department level underscores that there is no clearly defined quality management or performance improvement philosophy or methodology at CVH. There is too great a reliance on auditing for presence/absence and timeliness rather than a clear focus on content when monitoring core disciplines. Also, data is too often aggregated quarterly or yearly, which does not allow enough transparency to determine where fluctuations might be occurring. Finally, in those areas where the core discipline functions are consistently performing at acceptable levels, there is no indication that discipline leadership has moved beyond quality assurance to investigate opportunities for quality improvement.
B. PSYCHIATRIC AND PSYCHOLOGICAL CARE AND TREATMENT
The State has an obligation to provide adequate treatment programs to its patients in mental health hospitals. Woe, 729 F.2d at 105. In a mental health hospital, a patient must be provided a treatment program resulting from interdisciplinary treatment planning. The plan must lead to clinically appropriate goals specific to the patient’s needs and designed to support the patient’s recovery and ability to sustain the patient outside of the hospital. Inadequate treatment causes harm because it fails to stabilize the patient’s clinical condition, leads to the patient’s further decompensation, and/or unnecessarily prolongs the institutionalization of the patient.
The State is not providing patients at CVH with adequate mental health services in accordance with generally accepted professional standards. Psychiatric practices at CVH are marked by poor treatment planning, inadequate assessments and diagnoses, and inadequate medication practices. Moreover, psychological services at CVH are inadequate and fail to provide patients with adequate initial assessments and treatment programming.
1. Failure to Provide Adequate Therapeutic
 And Rehabilitative Services

Under generally accepted professional standards, appropriate therapeutic and rehabilitative services rest upon an adequate treatment planning process and the comprehensive, integrated, and individualized treatment plans that result from that process. Adequate therapeutic and rehabilitative services must incorporate a logical process of interdisciplinary care, including: (1) the formulation of an accurate diagnosis based on adequate assessments conducted by all relevant clinical disciplines; (2) the utilization of the diagnosis to identify the fundamental

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problems that are caused by the diagnosed illness; (3) the development of specific, measurable, and individualized goals that are designed to ameliorate problems and promote functional independence; (4) the identification of appropriate interventions that will guide staff as they work toward those goals; and (5) ongoing assessments. Treatment plans must be revised, as warranted.
As an initial matter, we recognize that CVH is trying to improve its therapeutic and rehabilitative services. The leadership at the State level has a vision of transitioning inpatient mental health services from a traditional medical forensic model to one of recovery and psychiatric rehabilitation. This vision is commendable, as the recovery and psychiatric rehabilitation model embodies the current generally accepted standards of care for individuals with serious mental illnesses. It is clear that the administrative leadership of CVH, beginning with the Executive Director, is committed to this transition.
In practice, however, CVH’s therapeutic and rehabilitative services substantially depart from generally accepted professional standards. We reviewed numerous patient charts, conducted interviews with professional and administrative staff, and attended treatment team meetings. From initial diagnosis and assessment to developing the skills necessary for recovery and ultimate community reintegration, CVH’s services fail to meet the fundamental requirements for the treatment and rehabilitation needs of its patients.
The results of these deficiencies are grave. Specifically, patients’ actual illnesses are not being properly assessed and diagnosed; patients are not receiving appropriate treatment; patients are exposed to potentially toxic treatments for conditions from which they do not suffer; patients are not receiving appropriate psychiatric rehabilitation; patients are at risk of self-harm and harm from other patients; patients are subject to excessive use of restrictive treatment interventions, increased risk of relapses and repeat hospitalizations; and patients’ options for discharge are seriously limited, resulting in unnecessary prolonged hospitalization, and, with respect to forensic patients, prolonged involvement in the criminal justice system.
a. Inadequate Treatment Planning Process
The treatment planning process should consist of: (1) team membership that includes all needed disciplines and is consistent and enduring; (2) a team leader, typically the attending

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psychiatrist, who coordinates the team meetings; (3) active participation by the patients at their level of functioning; (4) development, review, and modification of the plans in a timely manner to meet the changing status and needs of individuals; (5) a structure that allows the team members to address all patient issues relevant to treatment planning during the meeting time; and (6) team members who are trained in the principles and practice of treatment planning. The treatment planning process should be clearly identified and implemented through adequately detailed policies and procedures.
CVH fails in nearly every aspect of the above-described treatment planning process. First, CVH lacks policies and procedures that set forth the fundamental requirements and expectations of the treatment planning process.
Second, team membership is neither consistent nor enduring. Team meetings lack the consistent participation by an identified core group of relevant disciplines. Teams also fail to include the minimum number of core disciplines required to provide meaningful planning that addresses the full range of a patient’s needs. Most troubling, psychologists fail to attend treatment team meetings, which results in the facility’s failure to provide behavioral interventions for large numbers of individuals who are appropriate candidates for this treatment.
Third, the interdisciplinary teams lack leadership necessary to provide a structure to facilitate a meaningful treatment planning process. The most glaring deficiency due to the lack of leadership is the failure to ensure completion of assessments prior to the treatment planning session. Without completed assessments, the teams spend much of their time conducting assessments rather than treatment planning. In the remaining time, there is no clear sequence of tasks in terms of who presents what type of information, how, and when. As a result, important relevant issues are not addressed during the planning session, and the information presented is scattered, not meaningful for planning purposes, and not utilized properly.
Fourth, the teams do not have an adequate understanding of the parameters for the timing and nature of effective participation by the patient in the treatment planning process. Teams fail to utilize the input of the individual patients and tend to limit the patients’ participation to answering questions oriented toward gathering initial assessment-type information that should have already been gathered. Specifically, the teams fail to obtain the patient’s explanation of the illness; perspective regarding the reason for and focus of

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hospitalization; the patient’s understanding of the objectives, interventions, and discharge criteria for treatment; and the patient’s progress and determination of what strengths could be used in designing relevant interventions.
Fifth, the teams fail to follow up on important comments made by the individual patients regarding their progress in treatment or lack thereof. Such failures deprive the teams of opportunities to modify the plan to better address the individuals’ needs.
Finally, the team members lack adequate training regarding the principles of psychiatric rehabilitation designed to address the full range of the individuals’ needs and not simply ameliorate symptoms of the individuals’ illness. Thus, teams fail to promote the individuals’ ability to function in the community and cope more effectively with the factors leading to hospitalization.
b. Inadequate Psychiatric Assessments and Diagnoses
Adequate and timely assessments of patients provide the information to support the professionals’ understanding of a patient’s case. Adequate assessments lead to accurate diagnoses. An accurate diagnosis is a critical factor in developing a treatment plan, which is the foundation and guiding document for treatment interventions. Adequate assessments further establish the parameters for individualized, targeted, and appropriate interventions that meet the medical and psychological needs of the patient. Adequate assessments of a patient for treatment planning purposes requires input from various disciplines under the active direction and guidance of the treating psychiatrist.
At a minimum, an adequate assessment should consist of a comprehensive review of the individual’s history and current status, establish a definitive or provisional diagnosis and differential diagnosis, as indicated, and outline a plan of care. The assessment should include: (1) a history of the presenting symptoms and the patient’s mental status based on the patient’s level of functioning; (2) the setting(s) within which the symptoms occur; (3) the functional significance of behavior, as indicated; (4) an outline of relevant historical findings in the biological, behavioral and psychosocial areas; (5) risk factors; (6) a review and critical examination of past diagnostic conclusions, the individual’s response to current and past medications, and other past behavioral and psychosocial interventions; and (7) an evaluation of relevant medical and

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neurological pathology and their impact on psychiatric presentation and treatment.
In the majority of cases that we reviewed, CVH psychiatric assessments were inaccurate, incomplete, uninformative, and failed to include sufficient information to: (1) establish an appropriate differential diagnosis and final diagnosis; (2) prescribe treatment and rehabilitation interventions based on proper treatment goals; (3) determine the appropriateness, effectiveness, and safety of medication regimens; and (4) monitor individuals for various risk factors and provide timely interventions to minimize the risk.
Inaccurate and incomplete assessments are resulting in a number of serious deficiencies at CVH. First, the assessments fail to discuss the context within which a patient’s symptoms occur and the functional significance of important behaviors. Consequently, the assessments fail to integrate and recommend behavioral and psychosocial interventions, including appropriate individual psychotherapy. In fact, there is no documentation of individual psychotherapy.
Second, the assessments ignore important conditions that require further diagnostic evaluations, specific interdisciplinary and individualized interventions, and/or tracking, analysis, and management of risk factors. Examples of such conditions include cognitive disorders; seizure disorders and the interface with psychiatric illness and treatment; substance abuse; and various maladaptive behaviors, including treatment refusal.
Third, there is widespread failure to obtain behavioral assessments in order to provide interventions for numerous individuals who are candidates for behavioral treatment and who do not benefit from drug therapy. When behavioral interventions are provided, CVH fails to integrate treatment with pharmacological interventions. Specifically, there is no documentation of an exchange of data between the psychiatrist and the psychologist in order to distinguish learned behaviors from those that are targeted for pharmacological therapies, and to refine diagnosis and/or treatment, as appropriate, based on this exchange.
Fourth, the assessments fail to adequately evaluate, monitor, and minimize important risks, particularly with respect to individuals with a current or past history of Tardive Dyskinesia, an involuntary movement disorder that is a

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potentially irreversible side effect of antipsychotic drug treatments.
Fifth, there is a general failure to evaluate the needs of individuals suffering from various cognitive disorders. With regard to such disorders, CVH fails to conduct timely and appropriate diagnostic evaluation and mental status examinations, resulting in imprecise and vague diagnoses. When the diagnostic evaluation occurs, including neuropsychological testing and neurological consultations, the results are sometimes either ignored by the psychiatrist or not integrated into diagnostic and treatment approaches.
Sixth, there is general failure to assess and manage comorbid medical conditions (e.g., polydipsia) or neurological disorders marked by simultaneous presentations of psychiatric and neurological symptoms.
Finally, CVH fails to meet the assessment needs of individuals adjudicated not guilty by reason of insanity and admitted under the jurisdiction of the Psychiatric Security Review Board (PSRB). Specifically, the PSRB does not ensure complete, timely, and appropriate court submissions by the interdisciplinary teams. As a result, the current system of court submissions fails to provide the PSRB with adequate review and analysis of the patient’s status to ensure that legal decisions and clinical opinions regarding modifications of forensic status are informed by a thorough and individualized risk assessment.
Numerous examples demonstrate the above deficiencies. In one instance, a patient was given a preliminary diagnosis of dementia without any work-up to justify the diagnosis. The preliminary diagnosis was never finalized and when asked, the treating psychiatrist stated that as far as he knew, there was no plan to finalize the diagnosis. Based upon the clinically unjustified diagnosis that was never finalized, the patient was placed on high risk medications that put the patient at risk of cognitive decline. The justification given for the use of a medication that could cause cognitive decline was that the patient came to the psychiatrist on such medication. The psychiatrist merely continued a potentially dangerous and harmful medication without determining the correct diagnosis upon which the medication was based. The risks for the patient include further worsening of the patient’s cognitive state without proper monitoring of the risks and benefits of treatment. In addition to a potentially flawed diagnosis supporting dangerous medication use, the clinicians for this patient could not adequately explain

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the rationale for continued hospitalization for this patient who did not appear to meet the requirements for the restrictive level of care at CVH. The justification given by the clinician for continued hospital stay was that “we do not have a nursing home.” The outcome for this patient is continued and unnecessarily restrictive in-patient treatment.
In another example, the admission psychiatric assessment for a patient failed to include the necessary information to reach a provisional diagnosis and to guide treatment during early hospitalization. The assessment failed to include an adequate history of the present illness (there was no discussion of presenting symptoms and their recent history), and contained a cursory discussion of past psychiatric history. The mental status examination did not adequately address the nature of thought processes and thought content (described such processes as “appropriate for the most part”) or address past hallucinations (stating only that the patient “heard voices in the past”). There was no diagnostic formulation, and the plan of care was vague and meaningless (e.g., “continue patient’s stabilization,” “observe patient for impulsivity”).
The result of such an inadequate initial assessment was that proper treatment objectives could not be formulated that would meet the needs of the patient. As a result, the patient decompensated into maladaptive behaviors that resulted in numerous restrictive interventions, including highly invasive four-point restraints. Further, the annual psychiatric assessments and the psychiatric reassessments failed to even mention the numerous four-point restraints. The reassessments failed to identify target behaviors, summarize interval events, review and evaluate the use of PRN medications, optimize polypharmacy, and refine diagnosis based on treatment response data. These deficiencies also resulted in reactive medication strategies, including the use of high risk medications that posed a danger of addiction in a patient with a history of polysubstance abuse.
CVH’s failures carry risks of actual and potential harm to patients in multiple ways. As diagnoses are without clinical justification, patients’ actual illnesses are not being properly identified and treated; patients are exposed to potentially toxic pharmacological treatments for conditions from which they do not suffer; patients are not provided appropriate psychiatric rehabilitation; patients are subjected to unnecessarily restrictive restraints; and patients’ options for discharge and/or placement in a less restrictive setting are seriously limited, particularly with regard to the forensic population.

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c. Psychological Assessments
Generally accepted professional standards dictate that before a patient’s treatment plan is developed, facility psychologists provide a thorough psychological assessment of the patient to assist the treating psychiatrist in reaching an accurate diagnosis and provide an accurate evaluation of the patient’s psychological needs. Moreover, as needed, generally accepted standards dictate that additional psychological assessments be performed early in the patient’s hospitalization to assist with any psychiatric disorders that may need further study and/or diagnosis.
When CVH does psychological assessments, they consistently meet applicable clinical standards. CVH psychologists have the ability to contribute valuable input to patient care. Unfortunately, CVH policy does not require an initial admission psychological assessment for all patients. Instead, referrals for assessment are usually only generated by external requests (e.g., movement throughout the State forensic system) or at the request of the attending psychiatrist. Without an initial psychological assessment, the interdisciplinary teams do not have the unique data provided by a psychological assessment, including the cognitive functioning level and personality dynamics, that is essential to developing a full clinical picture of each newly admitted patient. As a result, CVH patients are not receiving fully integrated treatment plans.
It is also unfortunate that when psychological assessment results are received, including neuropsychological evaluations, they are only marginally integrated into CVH patients’ overall treatment plans. For example, a psychologist conducted a neuropsychological evaluation of a patient and made clear recommendations on necessary strategies for development of interventions to compensate for the effects of the patient’s cognitive problems. During a treatment plan review several months after the evaluation, the team added “cognitive impairment” to the patient’s problem list, but there was no indication that the patient’s treatment interventions were modified in accordance with the psychologist’s recommendations. Another patient had a neuropsychological assessment, but over seven months later, his team still had not adjusted the patient’s treatment plan to reflect the neuropsychological assessment results. The team also failed to integrate the assessment results into the patient’s annual psychiatric evaluation, even though the patient’s behavior had led to over 25 incidents of seclusion or restraint during the intervening period between the assessment and the annual evaluation. As a result, the patient

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continued to participate in group treatment that was clearly designed for patients with a higher level of cognitive functioning.
These problems are compounded by the division of labor in the psychology department, and a lack of adequate supervision of psychology staff. Psychologists at CVH serve in a variety of roles, including conducting assessments and developing treatment programs targeting specific patient sub-populations. However, all of the psychologists at CVH, including the department chair and division chairs, carry full clinical caseloads of 20-25 patients. It appears that psychology is the only clinical department in which the chair carries a standard caseload, which interferes with both supervision and effective quality monitoring. As the leadership of the department is encumbered by the demands of day-to-day clinical practice, the psychology department is without a supervisory structure to develop and effectively monitor the range of services that the profession is capable of providing to the patient population at CVH. Numerous patient records indicate that psychological services at CVH are fragmented and not well-integrated with overall clinical care. As a result, the unique contributions that clinical psychologists could provide at CVH are under-utilized, which leaves CVH patients at risk of harm from overuse of seclusion and restraint and improper diagnoses.
d. Inadequate Ongoing Assessments
Generally accepted professional standards require that psychiatric assessments continue on an ongoing basis after the initial and/or admissions assessment, involve timely and thorough reevaluations of behaviors targeted for treatment, and evaluate new clinical developments. Such ongoing assessments should be conducted at a frequency that reflects the individual's clinical needs, delineate the nature of behaviors targeted for treatment, and thoroughly document clinically significant changes in the individual’s condition. Furthermore, to ensure continuity of care when individuals are transferred between units, an additional psychiatric assessment should be done by the referring psychiatrist, particularly when new treatment teams take over the responsibility for providing treatment.
Upon review of numerous patient charts and documentation, in addition to interviews with administrative and professional staff, we conclude that CVH fails to provide adequate ongoing psychiatric assessments. Plans, as a result, are not modified in any significant way in response to the changing needs of the patients.

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A number of significant harms arise from CVH’s inadequate ongoing assessments. First, the ongoing assessments generally fail to address the patient’s response to treatment, or lack thereof, which prevents the team from adequately reexamining the patient’s diagnosis and overall treatment plan. Without an adequate evaluation of treatment progress, including an evaluation of critical and current needs relevant to community reintegration, patients suffer from undue prolonged confinement in a restrictive setting such as CVH. Second, without continual reevaluation of treatment goals and progress through ongoing assessments, individuals at CVH are denied services that meet their real and changing needs. Third, CVH’s failure to provide appropriate reassessments and treatment modifications prevents the hospital from providing timely and proper modifications of patients’ medication regimens, particularly in the face of adverse developments in a patient’s condition such as the increased use of restrictive interventions. For those patients subject to seclusion and restraint, the lack of required frequent and ongoing assessments unnecessarily continues such restrictive interventions to the detriment of the patients.
A particularly egregious example demonstrates the above deficiencies. In one case, a patient with severe and extensive behavioral problems, including severe self-destructive behaviors such as cutting his arms and forearms with various objects and overdosing on non-prescribed medications, was given neuropsychological testing. That testing did not support the patient’s original diagnosis of attention deficit disorder. However, the patient’s psychiatric reassessments and treatment plan reviews failed to address the results and recommendations of the neuropsychological testing that suggested a diagnosis of cognitive disorder. In an interview with the clinician, he admitted that “it should have been addressed, it might have helped.”
Ignoring the results of the neuropsychological testing, the patient was continued on stimulants and medications with stimulating effects in the face of the patient experiencing numerous episodes of agitation and serious self-injurious behavior. Furthermore, the patient’s chart clearly indicated that the patient was not responding to any of the medications the team tried. CVH clinicians, however, never addressed the need for, or obtained any behavioral consultation to assist in, the management of his maladaptive behaviors, even though the patient was not benefitting from medications. The treating psychiatrist was unable to tell us if the patient received any meaningful rehabilitation aimed at teaching new skills and/or addressing the underlying impairments that perpetuated the patient’s prolonged

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hospitalization. The CVH clinicians also failed to even track or assess the patient’s numerous episodes of restrictive interventions and to modify treatments to minimize such risk. Finally, the patient was prescribed numerous PRN medications for the generic diagnosis of anxiety/agitation (which the further neuropsychological testing called into question). CVH clinicians were not able to state why or under what circumstances PRN medications would be appropriate, yet PRN medications were continually administered. The use of medications in this manner is one example of a systemic deficiency at CVH –- PRN medication is often used for the convenience of staff and/or as a substitute for appropriate regular treatment.
CVH also fails to conduct and provide adequate inter-unit transfer evaluations. In general, such assessments are usually completely absent from chart documentation. When present, the inter-unit transfer assessments are seriously deficient and fail to ensure continuity of care in a number of ways. First, the transfer assessments fail to discuss the course of treatment and rehabilitation in the unit of origin. Second, the assessments lack a summary of medication trials and patient responses to treatment. Third, they fail to delineate the current status of the patient, especially for those behaviors that are targeted for treatment. Fourth, the assessments fail to review various risk factors for the patient. Fifth, they fail to discuss projected discharge plans and to review, in specific terms, what the patient must achieve to be ready for discharge. Finally, the inter-unit assessments fail to discuss the rationale for and anticipated benefits of the transfer.
One example that demonstrates the deficiencies in CVH’s transfer assessments involves a patient subjected to numerous restraints, including four-point restraints. That patient was transferred to another unit without an inter-unit assessment just several days after the use of restraints. The accepting psychiatrist continued the same medication regime despite the patient’s poor response to those medications and failed to consider a behavioral consultation to assess the functional significance of the patient’s behavior or institute appropriate interventions. Subsequent to his transfer, the patient was again placed in four-point restraints. The patient was then transferred to a third unit, again without any clinical rationale or indication of the anticipated therapeutic benefits of this transfer.
In sum, because CVH fails to conduct adequate ongoing assessments, treatment plans are not modified and updated in a timely manner, particularly in response to high-risk behaviors

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requiring new interventions and/or modified goals. Insufficient ongoing assessments and inter-unit transfer assessments result in numerous harms to the patients, including lack of treatment and appropriate psychiatric rehabilitation, unnecessarily restrictive restraints, continued risk of self-harm, continued inappropriate medication regimens, and unnecessarily prolonged hospitalization.
e. Inadequate Treatment Plans
As stated above, adequate therapeutic and rehabilitative services depend upon appropriate treatment planning process. Treatment planning process rests upon adequate initial and ongoing assessments that lead to comprehensive, integrated and individualized treatment plans. Generally accepted professional standards instruct that adequate treatment plans should: (1) integrate the individual assessments, evaluations, and diagnoses of the patient that are performed by all disciplines involved in the patient’s treatment; (2) identify a patient’s individualized strengths and needs; and (3) identify treatment goals and interventions related to those goals that build on the patient’s needs in order to support the patient’s recovery and ability to sustain him or herself in the most integrated, appropriate setting.
CVH fails to provide adequate treatment plans. After reviewing numerous treatment plans, we found them to be deficient in nearly every aspect listed above. First, the treatment plans are not based on complete and comprehensive interdisciplinary assessments of individuals across all relevant disciplines. The information provided in the treatment plans from the assessments is insufficient to reach adequately reliable and valid diagnoses. As a result, the treatment plans fail to address all relevant psychiatric, behavioral/psychological, medical, nursing, and rehabilitation issues and, in general, fail to delineate the individual's strengths that can be utilized in treatment.
Second, the treatment plans fail to identify the patient’s individualized needs. In too many charts, there is a serious disconnection between the psychiatric progress notes about current symptoms and the identification of needs in the corresponding treatment plans. In one illustrative example, the treating psychiatrist indicated that medication noncompliance was the main factor in the patient having repeated episodes of violence, destruction of property, and self-injurious behavior, resulting in frequent use of restrictive interventions. However, the treatment plan did not address treatment refusal or its contributing factors as a focus for appropriate interventions. Furthermore, the vast majority of the plans that we reviewed fail

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to include evidence of an adequate review and analysis of the information in the assessments, including a proper synthesis of pertinent history and factors that predispose the individual to the illness and its associated impairments, precipitating events, perpetuating elements, important data regarding previous treatment, and an outline of present needs/status. As a result, the plans are, in general, not meaningful or properly individualized, and they lack foundation to address important treatment and rehabilitation needs of the patients or improve their quality of life.
Third, the objectives or goals of the treatment plan are not aligned with the actual needs of the individuals, when those needs are identified. CVH’s treatment plan objectives are often not attainable. The objectives are vague, not individualized, and not stated in measurable, specific, or behavioral terms. They are not written in terms of what the individual must do specifically to achieve recovery and improve functional skills. For example, in one patient’s chart, the psychiatric documentation indicated that the “focus of treatment has been to target [the patient’s] target symptoms and decrease his aggressive behavior.” Such a circular treatment rationale -- to target a person’s target symptoms -- is inappropriately vague and is unable to form the basis of a plan to decrease a patient’s aggressive behavior. In another example, a patient’s annual psychiatric review indicated that the individual’s cognitive status was “gravely impaired.” However, neither the treatment plan nor the psychiatric documentation included interventions suited for someone with a significant cognitive disorder. The treatment plan further failed to specify how the patient’s current group activities were linked to the patient’s needs and to document the patient’s progress in those activities.
Fourth, in almost all of the charts reviewed, the objectives are not updated to reflect the changing status of the individuals. In general, treatment plan goals tend to be static and are rarely modified in response to the progress of the individuals, or lack objectives that are attainable and account for the individual’s level of functioning.
Finally, interventions designated to achieve treatment goals are mostly generic, not tailored to the actual needs of the individuals, and do not lead to any meaningful or measurable outcomes. The following is a summary of deficiencies regarding treatment plan interventions: (1) interventions fail to account for and utilize the patients’ strengths and most of the clinicians lack an understanding of the proper formulation of individuals’ strengths for planning purposes; (2) interventions

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tend to ignore key characteristics of the patient such as motivational and other attributes that can facilitate treatment, rehabilitation, and quality of life; (3) interventions generally fail to utilize those strengths that are correctly identified; (4) interventions are standardized and generally not linked to the goal they are designed to achieve and do not specify the activity, frequency, duration, responsible staff, and the rationale and purpose of the interventions; (5) interventions fail to specify the type and method of measuring the outcome of the interventions, and for some interventions, there is no documentation that the interventions even took place; (6) there is no formalized system to ensure that objectives are identified and matched to the needs of the patients; and (7) the treatment plans do not include any systematic review of the progress of the individual in each specified intervention.
2. Failure to Provide Adequate Psychiatric Services
Under generally accepted professional standards, a mental health hospital has the duty to provide adequate supports and services necessary to implement a patient’s treatment plan, including: (1) providing medication treatments based upon evidence of appropriateness, safety, and efficacy; (2) implementing a monitoring system to ensure appropriate use of medications; and (3) instituting an adequate array of relevant treatment programs to meet the specific needs of its patient population. Lack of adequate supports and services can result in improper implementation of treatment plans and can cause substantial harm to patients, including inadequate and counterproductive treatment, serious physiological and other side effects from inappropriate and unnecessary medications, and excessively long hospitalizations.
CVH’s psychiatric supports and services substantially depart from generally accepted professional standards, exposing patients to harm and a significant risk of harm due to the failure to exercise adequate and appropriate medication management; monitor medication use and side effects; and provide sufficient staffing to ensure consistent coverage by each attending psychiatrist of an appropriate case load.
a. Inappropriate Medication Management
Medication practices that comport with generally accepted professional standards should ensure that: (1) medication use is part of an interdisciplinary plan of care that considers the impact of medication use on individuals’ quality of life; (2) there is appropriate integration of medication treatment with

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behavioral treatment, including evidence that medications are not used in lieu of such treatment; (3) there is a documented rationale for medication use based on clinical and empirical criteria, including diagnosis, presenting symptoms, history of response to previous treatments, and the specific risks and benefits of chosen treatments; (4) attention is given by practitioners to high-risk medication uses, including the PRN administration of medications, Stat use of medications (one-time emergency use of medication), polypharmacy (the contemporaneous use of multiple medications to treat the same condition), the use of sedating and habit forming medications for individuals with substance abuse problems, medications that can induce diabetes and weight gain for individuals at risk, medications that can aggravate cognitive impairments, and medications that can have detrimental effects for individuals suffering from irreversible movements disorders; and (5) a hospital has systematic monitors and review mechanisms to ensure the safety, appropriateness, and efficacy of medication uses throughout the facility, including a drug utilization evaluation or monitoring of practitioner’s adherence to specific and current guidelines in the use of each medication, adverse drug reaction reporting, medication variance reporting to ensure accurate reporting and analysis of variances in drug use at the facility, systematic monitoring of the high risk medication uses to ensure caution in their use and proper attention by practitioners, and regular updates on drug alerts from the pharmacy department to the medical staff.
CVH fails to meet every one of the above standards of professional care and is unable to afford appropriate pharmacological treatment to its patients. CVH fails to ensure that medications are used as an integral part of treatment planning. There is no documented evidence that the interdisciplinary team reviews patients’ psychopharmacological plans in any meaningful way. The treatment plans do not include documentation of the current target symptoms for medication use, the rationale for the selection of these medications, nor the anticipated risks/benefits or parameters for assessment of treatment outcomes. There is no documentation of a review by the team of the possible adverse impact of treatment on the individual’s cognition, communication skills, ability to participate in activities, or other indicators of life quality. For example, one patient developed an irreversible movement disorder. The admission psychiatric assessment and the first annual psychiatric assessment do not include this diagnosis or a mental status examination that addresses motor functions. Nine months later, the individual was described, for the first time, to have overt signs of involuntary movements, and the diagnosis was then documented. At that time, the patient’s team

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appropriately changed his medication. However, the neglect in earlier psychiatric assessments to document an examination of motor functions seems to indicate inattention to possible early signs of movement disorder and failures in providing timely medication adjustments that could have averted or minimized the occurrence of this potentially disabling condition.
CVH also fails to ensure the safety, appropriateness, and efficacy of high risk medication uses. For example, the psychiatrists fail to adequately document the administration of PRN medications, including the circumstances that required the administration of the drugs, the type and doses of drugs administered, or the individual’s response to the drugs. As a result, there is failure to adjust treatment based on the use of PRN and Stat medications. At CVH, PRN medications are prescribed for generic indications, typically “anxiety/agitation,” without specific information on the nature of behaviors that require the drug administration. PRN medications are sometimes ordered without clear documentation of the target symptoms that require these medications. At times, more than one drug is ordered on a PRN basis, without specification of the circumstances that require the administration of each drug. PRN medications are frequently ordered when the individual’s condition, as documented in psychiatric progress notes, no longer requires this intervention. CVH fails to provide timely reassessment of psychiatric diagnosis and treatment strategies following the administration of a Stat medication. Furthermore, CVH fails to provide parameters that ensure the safe and appropriate use of PRN and Stat medications, and the facility does not appear to have a system that tracks PRN medication use to ensure proper utilization.
With regard to the use of benzodiazepines, there is a failure to ensure their appropriate use, particularly for high risk individuals. Benzodiazepines are psychotropic medications that are prescribed for a variety of conditions, but they are particularly used to treat anxiety. However, when used extensively, benzodiazepines can be addicting. Generally accepted professional practice dictates that caution must be used when prescribing them to patients with a current or remote history of substance abuse. At CVH, benzodiazepines are used on a long-term basis without documentation of diagnostic justification. CVH clinicians fail to provide clinical monitoring of their patients for the risks associated with benzodiazepines use, including sedation, addiction, and/or cognitive decline. This failure extends to high risk groups including the elderly, individuals with substance abuse diagnoses, and those with cognitive impairments. Furthermore,

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CVH does not provide systemic monitoring of individual or group practitioner trends and patterns regarding the prescription of benzodiazepines to control for the risks of their prescription.
In one example, early in a patient’s treatment, he was treated with benzodiazepines. The patient had a diagnosis of polysubstance abuse and a cognitive disorder. Furthermore, he experienced several restrictive interventions, including four-point restraints for challenging behaviors. The benzodiazepines may have reinforced the patient’s drug-seeking behavior, may have contributed to his challenging behaviors, and may have worsened his cognitive status, without therapeutic benefits.
In another example, a patient had a polysubstance dependence disorder. The patient’s medication regimen included long-term use of two benzodiazepine agents without documented evidence of real therapeutic benefits. The most recent annual psychiatric review included a statement that the individual “had been requesting [a benzodiazepine] on a regular basis for no apparent reason.” Given the addicting nature of benzodiazepines, it is puzzling as to why the treating practitioner did not recognize the obvious likely reason for this request. Such inattention was reflected in the lack of documentation of a rationale to explain why the doses of benzodiazepines were continued for so long and not reduced and withdrawn in favor of safer and more effective alternatives in a timely manner.
Another class of high risk drugs are anticholinergic medications, which are used to counter the side-effects of other psychotropic drugs, but have their own harmful side effects. CVH fails to ensure proper use and attention to the risks associated with the unjustified use of anticholinergic medications. Such risks include various degrees of memory impairment, including acute states of confusion, inattention, sedation, aggression, paranoid ideation and/or behavior, mood swings, and restlessness. The risks are particularly elevated for elderly patients, but also rise with the level of dose and any pre-existing mental conditions. At CVH, clinicians generally prescribe anticholinergic medications without documentation of the justifying indications. When documentation does occur, it reveals little attention to associated risks, even for high risk individuals. Finally, there is generally no documentation of timely modifications of treatment to ensure proper use of anticholinergic medications and to minimize risks.
CVH also fails to provide a meaningful system for monitoring the appropriate use of polypharmacy. No system exists to

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effectively assess the justification for the use of polypharmacy. Our review of the charts of most individuals receiving polypharmacy revealed a consistent pattern of a failure to employ appropriate strategies that justify this treatment, to document attention to associated risks, including drug-on-drug interactions, and/or to provide timely modification of treatment to achieve appropriate indications and to minimize risks. There is also no evidence of monitoring by the Pharmacy, Nutrition and Therapeutics Committee, the Department of Psychiatry, or the Department of Medicine of individual and group practitioner trends and patterns in the use of polypharmacy. Consequently, no evidence exists of any educational corrective actions to address polypharmacy trends/patterns and to enhance the performance of the medical staff. The current physician peer review system also fails to integrate data regarding polypharmacy.
One example of the above deficiencies in medication management involved the inappropriate use of polypharmacy in the administration of benzodiazepine and anticholinergic drugs. A patient diagnosed with borderline intellectual functioning was repeatedly given a benzodiazepine and an anticholinergic medication on an emergency basis without anyone tracking or assessing such use or monitoring the risks and benefits of such high risk drug use. Excessive use of these two medications can compromise further an individual’s cognitive impairments, and particularly so in a patient with borderline intellectual functioning. Furthermore, there was no evidence that the medication regimen was modified in a timely manner, even after the patient experienced several episodes in restraints and seclusion.
Finally, CVH fails to provide systematic monitoring of practitioner trends and patterns regarding the metabolic and endocrine risks associated with the use of new generation antipsychotic agents. Our interviews revealed that the prescribing psychiatrists are, by and large, unaware of the facility’s standards regarding this monitoring. In one example, a patient had a diagnosis of obesity and diabetes, yet was maintained on antipsychotic polypharmacy for an unnecessary and prolonged period of time without documented justification. The psychiatric documentation did not address the risks and benefits of antipsychotic polypharmacy in view of the individual's diagnosis. The treating psychiatrist was also unable to explain or show evidence of efforts to provide timely and appropriate modification of the patient’s psychiatric regimen to address symptoms that resulted in the use of seclusion/restraints. The treating psychiatrist was unable to speak to the individual’s current treatment plan regarding the provision of any

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rehabilitative interventions. There was no evidence of any integration of pharmacological and behavior interventions in light of the restrictive procedures. Further, there was no evidence that the treatment team provided a focused treatment plan review of incidents requiring the use of restrictive interventions or made any adjustment of treatment to reduce the risk in the future. Thus, in this one example of significant harm, CVH is administering antipsychotic polypharmacy to a patient with a diagnosis of obesity and diabetes without any evaluation or acknowledgment of the risks of the polypharmacy to the diagnosis, coupled with a history of the limited effectiveness of antipsychotic polypharmacy, as demonstrated by incidents of restraint and seclusion, without any effort by the treating psychiatrist and treatment team to provide analysis, review, or revision of the psychiatric treatment and/or integration of the medications with possible behavioral interventions.
b. Inadequate Medication Monitoring
Generally accepted professional standards further require that a systematic monitoring and reviewing mechanism exist to ensure the safety, appropriateness, and efficacy of medication uses throughout the facility. This mechanism should include: (1) a system to monitor the practitioner’s adherence to specific and current guidelines in the use of each medication; (2) an adverse drug reaction reporting system; and (3) a system to report actual and potential variances or errors in the prescription, transcription, procurement/storage, dispensing, and administration of medication.
CVH fails to provide any of the above systematic monitoring to ensure appropriate, safe, and effective medication use in the facility. CVH does not have an adequate system that evaluates medical staff’s adherence to established individualized guidelines, with priority given to high risk and high volume medication uses; ensures systematic review of all medications; and determines the order in which the medications are evaluated, the frequency of evaluation, the indicators to be measured, the data collection form, the sample size, and acceptable thresholds of compliance.
CVH’s medication guidelines are seriously inadequate. Guidelines are dated, limited to a small number of medications, and inaccurate. Current medication guidelines are also incomplete and fail to address significant risks, particularly for anti-psychotics such as cloxapine, risperidone, olanzapine, carbamazepine, oxcarbazepine, and benzodiazepines. Records

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provided by CVH indicate that during the fiscal year 2005-2006, only one medication use review was completed (for aripiprazole). The facility’s choice of aripiprazole, a low risk medication with limited use at the time of the review, seems to illustrate a failure in the priorities utilized in the current system. During fiscal year 2004-2005, the facility conducted a medication use review of 253 charts of individuals receiving new generation antipsychotic medications. This study assessed overall patterns of metabolic parameters, but did not utilize an acceptable methodology to assess practitioner’s adherence to current medication guidelines. Based on this study, the facility concluded that were no differences among the new generation antipsychotic medications in terms of the metabolic complications. However, this result clearly conflicts with current generally accepted standards and relevant clinical findings, which indicate that these medications do vary significantly in their potential to cause metabolic complications in patients.
CVH also fails to provide adequate guidance to its clinical staff regarding the proper completion of the data collection tool regarding adverse drug reactions, and the investigation and analysis of those reactions. Consequently, there is no mechanism to ensure adequate reporting of those reactions. The data we reviewed indicates a serious under-reporting of adverse drug reactions. CVH also fails to aggregate this data and could provide no documentation of any data analysis regarding trends and patterns of adverse reactions.
CVH’s medication variance reporting system is inadequate to identify and assess actual and potential medication use problems or to initiate any meaningful performance improvement activities. For example, the facility does not provide information or have written guidelines and, consequently, fails to ensure that clinical staff is educated regarding the proper methods of reporting medication variances and of providing information that aid the proper investigation and analysis of the variances. Furthermore, the data collection tool itself does not include an adequate outline of factors contributing to the variance (e.g., human, environmental, communication issues, dispensing/storage/administration system variables, or product-related issues). As a result, the current system does not lend itself to adequate analysis regarding contributing factors and/or performance improvement measures that address these factors.

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c. Inadequate Treatment Programming
Generally accepted professional standards require that CVH provide an adequate array of relevant treatment programs to meet the specific needs of its patient population. CVH lacks such an array of adequate treatment programs for its patient population. CVH has limited offerings for all individuals regardless of the different profiles of needs that these individuals have. For example, CVH does not provide cognitive development groups to many of its individuals who are diagnosed with various cognitive disorders and are in need of this service. Instead, CVH patients with known cognitive impairments are participating in group treatments that are clearly designed for individuals with a higher level of cognitive functioning. This failure precludes meaningful participation by these individuals in treatment and rehabilitation programs.
Furthermore, CVH generally fails to provide sufficient and appropriately tailored substance abuse programming for individuals who have a need for this service and who reside in the psychiatric and forensic units. The offerings are limited and do not account for the individual’s preferences and unique needs. This occurs even for individuals who have serious substance use disorders that have precipitated hospitalization and/or legal difficulties.
3. Failure to Provide Adequate Psychological Services
Psychosocial and rehabilitative interventions improve a patient’s ability to engage in more independent life functions, in order to better manage the consequences of psychiatric distress and avoid decompensation in more integrated settings. To be effective, these interventions should address the patient’s needs, should build on the patient’s existing strengths, and should be clearly organized in an integrated individualized treatment plan. Where needed, interventions that are designed to promote and facilitate skills development and that address behavioral issues should be clearly outlined in an adequately developed behavior plan supported by appropriate individual and group therapies. Adequate behavior plans should contain the following minimum information: (1) a description of the challenging behavior; (2) a functional analysis of the challenging behavior and competitive adaptive behavior that is to replace the challenging behavior; and (3) documentation of how reinforcers for the patient were chosen and what input the patient had in the development of those reinforcers along with the system for earning the reinforcers.

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CVH’s behavior plans and treatment programs substantially depart from professional standards of care. In no case did the behavior plans at CVH contain the above-stated minimum requirements. In fact, CVH psychologists rarely even develop behavior plans for their patients, even those with serious needs such as aggression, self-injury, or those who are repeatedly the subject of seclusion and restraints. The State told us that only six patients, out of more than 500, were on individualized behavior management plans. In addition, the psychology department told us that one of the six plans was not, in fact, a formal behavioral management plan. However, during our review, we identified behavior management plans in the medical records of more than six patients, which leads us to further question the organization and supervision of the psychology department.
Nevertheless, it is clear that CVH fails to provide behavioral treatment for the vast majority of its patients who need this service. Many of the individuals at CVH who require behavioral treatment but are not receiving that treatment continue to suffer from a variety of psychiatric symptoms and challenging behaviors, including, but not limited to, aggression to others, self-injurious behavior, property destruction, self care deficits, failure to attend treatment, and medication non-adherence. Most of these individuals are unable to benefit from current pharmacological therapies, and their conditions constitute appropriate targets for behavioral interventions. Very few of these individuals, however, have behavioral plans.
CVH policies regarding behavior treatment plans were incomplete and did not meet currently accepted standards of care. We found confusion on all levels as to what constituted an acceptable behavioral treatment plan. Although the State informed us that many of the current CVH psychologists had received some type of advanced training in applied behaviors analysis, and CVH policies require credentialing in this area, in practice, the CVH psychologists fail to provide patients with adequate behavioral supports, resulting in over-utilization of seclusion and restraint. Furthermore, CVH has no mechanism to ensure that direct care staff have received competency-based training on implementing the specific behavioral interventions for which they are responsible, and that performance improvement measures are in place for monitoring the implementation of such interventions. CVH behavior treatment plans did not contain adequate functional analyses nor positive replacement behaviors. A staff psychologist even reported that the planned use of seclusion and restraint is allowed by CVH as an intervention in a behavior management plan. This is in direct conflict with generally accepted professional standards.

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With regard to the limited number of behavioral plans that are being offered to individuals, the plans do not comport with generally accepted standards of care and fail to meet the treatment and rehabilitation needs of individuals in a number of ways. First, CVH often fails to provide functional assessment and analysis of why and for what purpose the behavior is occurring, which is an essential prerequisite for effective behavioral interventions. Second, behaviors targeted for intervention are generally not well defined, and are not measurable and observable. Third, some challenging behaviors are not even incorporated in the behavioral plans. Fourth, there is little or no direct observations of target behaviors. Fifth, data that are provided from functional assessments are not used to assess trends in challenging behaviors, to determine the cause of behaviors, or to assess the effectiveness of treatments. Sixth, the identification of precursor behaviors leading up to potentially challenging behavior is inadequate, and there is a failure to obtain data regarding precursors from appropriate sources.
Seventh, strategies to reinforce appropriate behavior are generally inadequate. Eighth, behavioral interventions generally do not include identification of skills designed to replace challenging behaviors or means of teaching these skills. When CVH attempts to identify replacement behaviors, the “replacement behaviors” included in the plan are not functionally equivalent the challenging behavior and, consequently, are unlikely to replace the inappropriate behavior. Ninth, the behavioral interventions generally fail to include strategies to enhance the quality of life of the patients and to develop appropriate, socially-acceptable behaviors. Tenth, there is failure to train staff on plan implementation as well as lack of monitoring of the appropriateness and consistency of implementation by the team or across situations, individuals, or environments. Eleventh, there is lack of follow up assessment of the effectiveness of behavioral interventions. Finally, the behavioral interventions are not integrated with either psychopharmacological therapies or the overall treatment plan.
The existing behavior plans are generally rudimentary, not clearly integrated into the patient’s overall treatment plan, and rarely updated. Assessments and evaluations that should shape psychological services frequently are incomplete and/or missing, and unreliable in identifying important elements of the patient’s condition. Consequently, interventions often do not address assessed needs regarding functional skills and challenging behaviors, and those interventions actually addressing such needs typically are poorly conceived, excessively generic, and non-

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therapeutic. For example, one patient in the Whiting Forensic Division maximum security unit had a behavioral treatment plan. However, CVH had failed to analyze why the patient was behaving the way he was. As a result, although his team updated the plan every few days between April 17, 2006 and May 30, 2006, the team could not formulate appropriate interventions because CVH did not know what was causing the behavior. The patient therefore experienced continued episodes of restraint and seclusion during that time period. Another patient had a behavioral treatment plan since February 2006 that specifically called for the planned use of forced seclusion of the patient in response to a specific behavior, which is contrary to generally accepted standards. Furthermore, the patient’s records suggested that, at times, staff improperly executed elements on his hierarchy of punishing stimuli, which led inevitably to planned seclusion.
Our review of CVH’s behavioral treatment plans demonstrated that CVH was not following its existing policies on development and implementation of these plans. For example, the behavior treatment plans for two patients contain the use of only punishing interventions if the patients engage in the targeted negative behaviors, without any attempts at replacement behaviors or positive behavioral supports. Their plans contain no analysis of the reasons behind the patients’ challenging behaviors and no suggestions for redirecting the patients toward alternative or positive behaviors instead of punishing them. Another patient’s behavior treatment plan contained an apparent functional analysis, but then simply narrated specific examples of his behaviors without attention to temporal, environmental, or psychological antecedents. Without this sort of analysis, it is difficult to reveal patterns in the patient’s target behaviors. While he received rewards for “positive behaviors,” the plan did not specify these behaviors in measurable terms and, in many instances, “positive behavior” appeared merely to be the absence of negative behaviors. The plan did not include any attempt to describe to the patient, in understandable terms, various positive behaviors that he could engage in as part of the learning process. Thus, it was not surprising that the patient experienced on-going episodes of seclusion and restraint.
In another example, the psychiatric documentation for a patient made reference to the individual’s proclivity for assaultive behaviors in community placements and during hospitalization, even during periods of symptomatic improvement. Reportedly, these episodes typically occurred when he was asked to do tasks that he did not wish to do, particularly showering. This appears to have been the main reason for continued hospitalization. However, there was no evidence that the

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psychiatrist sought or considered behavioral consultations to provide functional assessment/analysis of the behavior and to design and implement interventions to reduce the risk and to facilitate community integration.
C. DISCHARGE PLANNING AND THE MOST INTEGRATED SETTING
Within the limitations of court-imposed confinement, federal law requires that CVH and the State actively pursue the timely discharge of patients to the most integrated, appropriate setting that is consistent with patients’ needs. Olmstead v. L.C., 527 U.S. 581 (1999). From the time of admission, the factors that likely will foster viable discharge for a particular patient should be identified expressly, through professional assessments, and should drive treatment interventions. Furthermore, a psychiatric hospital should: (1) have a review process that effectively monitors both length of stay data and difficult discharge cases; (2) develop systems to assure timely return to the community; and (3) ensure that readmission statistics are studied to identify and correct potential breakdowns in care and treatment that lead to unnecessary readmission to more restrictive levels of care.
The discharge planning process for CVH patients falls well short of these standards of care. Consequently, patients are subjected to unnecessarily extended hospitalizations and a high likelihood of readmission, all of which result in harm. CVH fails to initiate, maintain, monitor, or adjust adequate discharge criteria. Several patients’ treatment planning documents demonstrate that CVH teams often carry over the “discharge plan” language verbatim from one treatment plan review to another, without assessing new options or any changes that may have effected the patients’ discharge plans. CVH fails to maintain an adequate review process necessary to ensure appropriate lengths of stay. As a result, CVH’s patients are likely being unnecessarily institutionalized and potentially deprived of a reasonable opportunity to live successfully in the most integrated, appropriate setting.
III. MINIMUM REMEDIAL MEASURES
To remedy the deficiencies discussed and to protect the constitutional and federal statutory rights of the patients at CVH, Connecticut should promptly implement the minimum remedial measures set forth below:

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A. Protection From Harm
1. Suicide Prevention
CVH should protect its patients from harm, including selfharm and death from suicide and suicide attempts. At a minimum, CVH should:
a. For patients identified as suicidal, develop and implement a clear and uniform policy for patient assessment and treatment that ensures adequate oversight of the suicide screening process.
b. Ensure a sufficient number of qualified staff to supervise suicidal patients adequately and ensure that physician orders for enhanced supervision be communicated to appropriate staff and implemented.
c. Ensure that staff receive adequate training to serve the needs of patients requiring specialized care for suicidality, including annual suicide prevention training for all staff.
d. Ensure that patients identified as at risk for suicide are housed in safe rooms, free from fixtures and design features that could facilitate a suicide attempt.
e. Ensure that 15-minute (day) and 30-minute (night) checks of all patients are timely performed and appropriately documented.
2. Restraint and Seclusion
CVH should ensure that seclusion and restraints are used in accordance with generally accepted professional standards. Absent exigent circumstances -- i.e., when a patient poses an imminent risk of injury to himself or a third party -- any devise or procedure that restricts, limits or directs a person’s freedom of movement (including, but not limited to, chemical restraints, mechanical restraints, physical/manual restraints, or time out procedures) should be used only after other less restrictive alternatives have been assessed and exhausted. More particularly, CVH should:

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a. Ensure that restraints and seclusion:
i. are used in a reliably documented manner;
ii. will not be used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;
iii. will not be used as part of a behavioral intervention; and
iv. will be terminated once the person is no longer an imminent danger to himself or others.
b. Revise, as appropriate, and implement policies and procedures consistent with generally accepted professional standards that cover the following areas:
i. the range of restrictive alternatives available to staff and a clear definition of each;
ii. the training that all staff receives in the management of the patient crisis cycle and the use of restrictive procedures; and
iii. the assessments to be conducted by staff attending a patient in seclusion and restraint.
c. Ensure that the use of seclusion and restraint only be initiated by appropriately trained staff.
d. Ensure appropriate assessments are completed by a physician or licensed medical professional of any patient placed in seclusion or restraints.
e. Ensure that if physical, non-mechanical restraint is initiated, the patient is assessed within an appropriate period of time of his/her being physically restrained and an

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appropriately trained staff member makes a determination of the need for continued physical, mechanical, and/or chemical restraint, and/or seclusion.
f. Ensure that a physician’s order for seclusion or restraint include:
i. the specific behaviors requiring the procedure;
ii. the maximum duration of the order; and
iii. behavioral criteria for release, which, if met, require the patient’s release even if the maximum duration of the initiating order has not expired.
g. Ensure that immediately following a patient being placed in seclusion or restraint, the patient’s treatment team reviews the incident, and the attending physician documents the review and the reasons for or against any change in the patient’s current pharmacological, behavioral, or psychosocial treatment.
h. Ensure that staff successfully complete competency-based training regarding implementation of such policies and the use of less restrictive interventions.
i. Prohibit the use of four-point restraint to the bed and posey net restraints.
3. Risk Management
CVH should provide its patients with a safe and humane environment and protect them from harm. At a minimum, CVH should:
a. Implement an incident management system that comports with generally accepted professional standards. At a minimum, CVH should:
i. review, revise, as appropriate, and implement comprehensive, consistent

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incident management policies and procedures that provide clear guidance regarding reporting requirements and the categorization of incidents;
ii. require all staff to complete successfully competency-based training in the revised reporting requirements;
iii. review, revise, as appropriate, and implement policies and procedures related to the tracking and trending of incident data and ensure that appropriate corrective actions are identified and implemented in response to problematic trends;
iv. develop and implement thresholds for patient injury/event indicators that will initiate review at both the unit/treatment team level and at the appropriate supervisory level and that will be documented in the patient medical record with explanations given for changing/not changing the patient’s current treatment regimen; and
v. develop and implement policies and procedures on the close monitoring of patients assessed to be at risk that clearly delineate: who is responsible for such assessments; the requisite obligations to consult with other staff and/or arrange for a second opinion; and how each step in the process should be documented in the patient’s medical record.
b. Conduct a thorough review of all units to identify any potential environmental safety hazards, or conditions unsupportive of a therapeutic environment and develop and implement a plan to remedy any identified issues.

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4. Quality Assurance and Performance Improvement
CVH should develop and implement an adequate quality assurance process in accordance with generally accepted professional standards. At a minimum, CVH should:
a. actively collect data relating to the quality of care across all aspects of treatment;
b. assess these data monthly as standardized figures for trends;
c. initiate inquiries regarding problematic trends and possible deficiencies;
d. identify corrective action;
e. monitor to ensure that appropriate remedies are achieved; and
f. standardize quality management tools and procedures across all clinical departments.
B. Psychiatric and Psychological Care and Treatment
1. Adequate Therapeutic And Rehabilitative Services
CVH should develop and implement an integrated treatment planning process consistent with generally accepted professional standards. More particularly, CVH should:
a. Develop and implement policies and procedures regarding the development of treatment plans consistent with generally accepted professional standards.
b. Review and revise, as appropriate, each patient’s treatment plan to ensure that it is current, individualized, strengths-based, outcome-driven, emanates from an integration of the individual disciplines’ assessments of patients, and that goals and interventions are consistent with clinical assessments.
c. Ensure that treating psychiatrists verify, in a documented manner, that psychiatric and

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behavioral treatments are properly integrated.
d. Require all clinical staff to complete successfully competency-based training on the development and implementation of interdisciplinary treatment plans, including skills needed in the development of clinical formulations, needs, goals, and interventions as well as discharge criteria.
e. Develop and implement programs for individuals suffering from both substance abuse and mental illness problems; and develop and implement a cognitive remediation program for individuals with cognitive impairments.
2. Assessments and Services
a. Psychiatric Assessments and Diagnoses
CVH should ensure that its patients receive accurate, complete, and timely assessments and diagnoses, consistent with generally accepted professional standards, and that these assessments and diagnoses drive treatment interventions. More particularly, CVH should:
i. Develop and implement comprehensive policies and procedures regarding the timeliness and content of initial psychiatric assessments and ongoing reassessments. Ensure that initial assessments include a plan of care that outlines specific strategies, with rationales, including adjustments of medication regimens and initiation of specific treatment interventions.
ii. Ensure that psychiatric reassessments are completed within time-frames that reflect the individual’s needs, including prompt evaluations of all individuals requiring restrictive interventions.
iii. Develop diagnostic practices, guided by current, generally accepted professional

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criteria, for reliably reaching the most accurate psychiatric diagnoses.
iv. Develop a clinical formulation of each patient that integrates relevant elements of the patient’s history, mental status examination, and response to current and past medications and other interventions, and that is used to prepare the patient’s treatment plan.
v. Ensure that the information gathered in the assessments and reassessments is used to justify and update diagnoses, and establish and perform further assessments for a differential diagnosis.
vi. Review and revise, as appropriate, psychiatric assessments of all patients, providing clinically justifiable current diagnoses for each patient, and removing all diagnoses that cannot be clinically justified. Modify treatment and medication regimens, as appropriate, considering factors such as the patient’s response to treatment, significant developments in the patient’s condition, and changing patient needs.
vii. Develop a monitoring instrument to ensure a systematic review of the quality and timeliness of all assessments according to established indicators, including an evaluation of initial evaluations, progress notes and transfer and discharge summaries, and require the physician peer review system to address the process and content of assessments and reassessments, identify individual and group trends, and provide corrective follow-up action.
b. Psychological Assessments
CVH should ensure that its patients receive accurate, complete, and timely psychological assessments, consistent with

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generally accepted professional standards, and that these assessments support adequate behavior and treatment programs. To this end, CVH should ensure that:
i. Upon admission and prior to developing the treatment plan, psychologists provide a psychological assessment of the patient that will be integrated into the patient’s overall treatment plan.
ii. Where applicable, if behavioral intervention is indicated, further assessments be conducted in a manner consistent with generally accepted professional standards of applied behavioral analysis.
c. Psychiatric Services
CVH should provide adequate psychiatric supports and services for the treatment of it patients, including medication management and monitoring of medication side-effects in accordance with generally accepted professional standards. More particularly, CVH should:
i. Develop and implement policies and procedures requiring clinicians to document their analyses of the benefits and risks of chosen treatment interventions.
ii. Ensure that the treatment plans at CVH include a psychopharmacological plan of care that includes information on purpose of treatment, type of medication, rationale for its use, target behaviors, and possible side effects. Reassess the diagnosis in those cases that fail to respond to repeat drug trials.
iii. Ensure that individuals in need are provided with behavioral interventions and plans with proper integration of psychiatric and behavioral modalities. In this regard, CVH should:

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a. Ensure that psychiatrists review all proposed behavioral plans to determine that they are compatible with psychiatric formulations of the case;
b. Ensure regular exchange of data between the psychiatrist and the psychologist and use such exchange to distinguish psychiatric symptoms that require drug treatments from behaviors that require behavioral therapies; and
c. Integrate psychiatric and behavioral treatments in those cases where behaviors and psychiatric symptoms overlap.
iv. Ensure that all psychotropic medications are:
a. prescribed in therapeutic amounts;
b. tailored to each patient’s individual symptoms;
c. monitored for efficacy against clearly-identified target variables and time frames;
d. modified based on clinical rationales; and
e. properly documented.
v. Ensure that the psychiatric progress note documentation includes:
a. the rationale for the choice and continued use of drug treatments;
b. individuals’ histories and previous responses to treatments;
c. careful review and critical assessment of the use of PRN medications and the use of this

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information in timely and appropriate adjustment of regular drug treatment;
d. justification of polypharmacy in accordance with generally accepted professional standards; and
e. attention to the special risks associated with the use of benzodiazepines, anticholinergic agents and conventional and atypical antipsychotic medications with particular attention given to the long-term use of these medications in individuals at risk for substance abuse, cognitive impairments, or movement and metabolic disorders.
vi. Institute an appropriate system for the monitoring of individuals at risk for TD that includes a standardized rating instrument used by properly trained staff in a timely manner. Ensure that the psychiatrists integrate the results of these ratings in their assessments of the risks and benefits of drug treatments.
vii. Institute systematic monitoring mechanisms regarding medication use throughout the facility. In this regard, CVH should:
a. Develop, implement and continually update a complete set of medication guidelines that address the indications, contraindications, screening procedures, dose requirements and expected individual outcomes for all psychiatric medications in the formulary that reflects generally accepted professional standards;
b. Based upon adequate medication guidelines, develop and implement a

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Drug Utilization Evaluation procedure based on adequate data analysis that includes both random and systematic reviews, prioritizes high risk medications, and produces individual and group practitioner trends;
c. Develop and implement a procedure for the identification, reporting and monitoring of adverse drug reactions (ADRs) that includes the definition of an ADR, likely causes, a probability scale, a severity scale, interventions and outcomes and that establishes thresholds to identify serious reactions;
d. Develop and implement an effective Medication Variance Reporting system that captures both potential and actual variances in the prescription, transcription, procurement/ordering, dispensing/storage, administration and documentation of medications, and identifies critical breakdown points and contributing factors; and
e. Develop and implement a procedure governing the use of PRN medications that includes requirements for specific identification of the behaviors that result in PRN administration of medications, a time limit on PRN uses, documented rationale for the use of more than one medication on a PRN basis, and physician documentation to ensure timely critical review of the individual’s response to PRN treatments and reevaluation of regular treatments as a result of PRN uses.

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viii Establish monitors to ensure the appropriate use of high-risk medications, including:
a. long-term benzodiazepine and anticholinergic medications particularly for individuals with substance use problems, cognitive impairments and current or past history of Tardive Dyskinesia, as indicated; and
b. the use of conventional antipsychotics, particularly for individuals with current or past history of Tardive Dyskinesia.
d. Psychological Services
CVH should provide psychological supports and services adequate to treat the functional and behavioral needs of its patients according to generally accepted professional standards, including adequate behavioral plans and individual and group therapy appropriate to the demonstrated needs of the individual. More particularly, CVH should:
i. Ensure psychologists adequately screen patients for appropriateness of individualized behavior plans, particularly patients who are subjected to frequent restrictive measures, patients with a history of aggression and self-harm, treatment refractory patients, and patients on multiple medications.
ii. Ensure that behavior plans contain a description of the challenging behavior, a functional analysis of the challenging behavior and competitive adaptive behavior that is to replace the challenging behavior, a documentation of how reinforcers for the patient were chosen and what input the patient had in their development, and the system for earning reinforcement.

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iii. Ensure that behavioral interventions are the least restrictive alternative and are based on appropriate, positive behavioral supports, not the use of aversive contingencies.
iv. Develop and implement policies to ensure that patients who require treatment for substance abuse, cognitive impairment, and forensic status are appropriately identified, assessed, treated, and monitored in accordance with generally accepted professional standards.
v. Ensure that psychologists treating patients have a demonstrated competence, consistent with generally accepted professional standards, in the use of functional assessments and positive behavioral supports.
vi. Ensure that psychologists integrate their therapies with other treatment modalities, including drug therapy.
vii. Ensure that psychosocial, rehabilitative, and behavioral interventions are monitored appropriately against rational, operationally defined, target variables and revised as appropriate in light of significant developments and the patient’s progress, or the lack thereof.
C. Discharge Planning and Placement in the Most Integrated Setting
Within the limitations of court-imposed confinement and public safety, the State should pursue actively the appropriate discharge of patients and ensure that they are provided services in the most integrated, appropriate setting that is consistent with patients’ needs. More particularly, CVH should:
1. Identify at admission and address in treatment planning the criteria that likely will foster viable discharge for a particular patient, including but not limited to:

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a. the individual patient’s symptoms of mental illness or psychiatric distress; and
b. any other barriers preventing that specific patient in transitioning to a more integrated environment, especially difficulties raised in previously unsuccessful placements.
2. Include in treatment interventions the development of skills necessary to live in the setting in which the patient will be placed, and otherwise prepare the patient for his or her new living environment.
3. Develop and implement a quality assurance or utilization review process to oversee the discharge process, including:
a. developing a genuine utilization review process based on the principles articulated in Part C that discusses discharge planning and placement in the most integrated setting, and assure that data systems supportive of this process are developed and maintained; and
b. having psychiatrists provide an estimate of the length of hospitalization needed to provide patient stabilization at the time that the master treatment plan is developed and review this estimate at each treatment plan update meeting, making modifications when necessary that are documented in the patient’s record and captured in the utilization review process.
IV. CONCLUSION
The collaborative approach that the parties have taken thus far has been productive. We hope to continue working with the State in this fashion to resolve our significant concerns regarding the care and services provided at CVH.
Please note that this findings letter is a public document. It will be posted on the Civil Rights Division’s website. While we will provide a copy of this letter to any individual or entity upon request, as a matter of courtesy, we will not post this

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letter on the Civil Rights Division’s website until 10 calendar days from the date of this letter.
Provided that our cooperative relationship continues, we will forward our expert consultants’ reports under separate cover. These reports are not public documents. Although our expert consultants’ reports are their work - and do not necessarily represent the official conclusions of the Department of Justice - their observations, analyses, and recommendations provide further elaboration of the issues discussed in this letter and offer practical technical assistance in addressing them. We hope that you will give this information careful consideration and that it will assist in facilitating a dialogue swiftly addressing areas requiring attention.
We are obliged by statute to advise you that, in the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General is empowered to initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1). We would prefer, however, to resolve this matter by working cooperatively with you. We have every confidence that we will be able to do so in this case. The lawyers assigned to this matter will be contacting your attorneys to discuss this matter in further detail.
If you have any questions regarding this letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s/ Wan J.Kim Wan J. Kim Assistant Attorney General Civil Rights Division
cc: The Honorable Richard Blumenthal Attorney General State of Connecticut
Thomas A. Kirk, Jr., Ph.D. Commissioner Department of Mental Health and Addiction Services
Luis Perez, L.C.S.W.

- 58 -
Chief Executive Officer Connecticut Valley Hospital
Mr. Kevin J. O’Connor United States Attorney District of Connecticut

 
 UNITED STATES DISTRICT COURT FOR THE
 DISTRICT OF CONNECTICUT


UNITED STATES OF AMERICA,

)


)


Plaintiff,

)


)


v.

) Civ. No. --

)

THE STATE OF CONNECTICUT;

)

THOMAS A. KIRK, Jr., Ph.D.,

)

Commissioner, Department of

)

Mental Health and Addiction

)

Services, in his official capacity only;

)

LUIS PEREZ, L.C.S.W., Chief

)

Executive Director, Connecticut

)

Valley Hospital, in his official

)

capacity only,

)

)


Defendants.

)


)


____________________________________)


COMPLAINT

PLAINTIFF, THE UNITED STATES OF AMERICA (“Plaintiff”), by its

undersigned attorneys, hereby alleges upon information and belief:

1. The Attorney General files this complaint on behalf of the United States of

America pursuant to the Civil Rights of Institutionalized Persons Act of 1980, 42 U.S.C.

§ 1997, to enjoin the named Defendants from depriving persons institutionalized at the

Connecticut Valley Hospital (“CVH”), located in Middletown, Connecticut, of rights,

privileges, or immunities secured or protected by the Constitution and laws of the United

States.

JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under 28 U.S.C. § 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 1997a. 4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein. 5. Venue in the District of Connecticut is proper pursuant to 28 U.S.C. § 1391.
DEFENDANTS 6. Defendant State of Connecticut (“State”) owns and operates CVH, an inpatient facility housing individuals in need of forensic, general psychiatric, and substance abuse services, and as such, has responsibility for the protections, services, and supports provided to CVH residents. 7. Defendant THOMAS A. KIRK, Jr., Ph.D., is the Commissioner of the Connecticut Department of Mental Health and Addiction Services and has authority over CVH and over the care of patients at CVH. Commissioner KIRK is sued in his official capacity. 8. Defendant LUIS PEREZ, L.C.S.W., is the Chief Executive Director of CVH and is responsible for the day-to-day operations of CVH. Director PEREZ is sued in his official capacity.
- 2 -

9. Defendants are legally responsible, in whole or in part, for the operation and conditions of CVH, and for the health and safety of persons institutionalized at CVH.
10. Defendants are governmental authorities or agents thereof with responsibility for the administration of CVH within the meaning of 42 U.S.C. § 1997a.
11. At all relevant times, the Defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law.
FACTUAL ALLEGATIONS 12. CVH is an institution within the meaning of 42 U.S.C. § 1997(1). 13. Individuals are confined to, or reside at, CVH because they have been determined by the courts or Defendants to have mental illness or other disabilities requiring protections, supports, and services. 14. Defendants are obligated to operate CVH in a manner that does not infringe upon the federal rights, as protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, of CVH residents. 15. The protections, supports, and services at CVH substantially depart from generally accepted professional standards of care, thereby exposing the individuals residing there to significant risk of harm, and in some cases, to actual harm. 16. The protections, supports, and services substantially depart from generally accepted professional standards of care in the following specific respects, among others:
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a. the provision of reasonably safe conditions, including protection from harm, so as to ensure the reasonable safety and personal security of the CVH residents;
b. the provision of adequate treatment planning, necessary to protect the CVH residents’ liberty interests, sufficient to ensure their safety and freedom from undue or unreasonable restraint;
c. the provision of adequate psychological and psychiatric services to CVH residents with mental illness;
d. the provision of adequate suicide prevention; e. the provision of adequate discharge planning and community
placement; and f. the provision of adequate therapeutic services. 17. Persons residing at CVH are “qualified individual[s] with a disability” under the ADA, 42 U.S.C. §§ 12101, 12131. 18. The State and the State of Connecticut Department of Mental Health and Addiction Services are “public entities” under Title II of the ADA, 42 U.S.C. § 12131. 19. Defendants have failed to meet the requirements of the ADA by excluding CVH residents, by reason of their disability, from placement in the most integrated setting appropriate to their needs by failing and continuing to fail to ensure that CVH residents are adequately evaluated for placement in the most integrated setting; that those individual residents whom professionals determine should be placed in community
- 4 -

programs are placed in such programs, when appropriate; and that the CVH residents are served in the most integrated setting appropriate to each resident’s individual needs.
VIOLATIONS ALLEGED 20. The United States incorporates by reference the allegations set forth in Paragraphs 1 through 19, as if fully set forth herein. 21. The acts and omissions alleged in Paragraphs 15 and 16 constitute a pattern or practice and infringe upon the CVH residents’ legal rights and substantive liberty interests and constitute resistance to their full enjoyment of their rights, privileges, or immunities secured or protected by the Fourteenth Amendment to the Constitution of the United States and by other federal law, and deprive the CVH residents of such rights, privileges, or immunities. 22. The acts and omissions alleged in Paragraph 19 violate the Americans with Disabilities Act, 42 U.S.C. § 12101 et seq., and the regulations promulgated thereto, 28 C.F.R. Part 35, by failing to administer services, programs, or activities to CVH residents in the most integrated setting appropriate to their needs. 23. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions set forth in Paragraphs 15, 16, and 19 that deprive CVH residents of rights, privileges, or immunities secured or protected by the Constitution and laws of the United States.
- 5 -

PRAYER FOR RELIEF 24. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Honorable Court enter an order permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practices set forth in paragraphs 15, 16, and 19 above, and that this Court require Defendants to take such actions as will ensure lawful conditions are afforded to patients at CVH. The United States further prays that this Court grant such other and further equitable relief as it may deem just and proper.
Respectfully submitted, /s/ Michael B. Mukasey ___________________________ MICHAEL B. MUKASEY Attorney General of the United States
- 6 -

NORA R. DANNEHY United States Attorney District of Connecticut
/s/ John B. Hughes _________________________ JOHN B. HUGHES Federal Bar No. ct05289 Assistant U.S. Attorney District of Connecticut Connecticut Financial Ctr. 157 Church Street 23rd Floor New Haven, CT 06510 (203) 821-3700 Fax: (203) 773- 5376

/s/ Grace Chung Becker ___________________________ GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
/s/ Shanetta Y. Cutlar ___________________________ SHANETTA Y. CUTLAR
 Chief
 Special Litigation Section
 Civil Rights Division

/s/ Judy Preston ___________________________ JUDY C. PRESTON
 Deputy Chief
 Special Litigation Section

/s/ Kerry Krentler Dean ___________________________ KERRY KRENTLER DEAN
 WILLIAM G. MADDOX
 Senior Trial Attorneys
 Civil Rights Division
 Special Litigation Section
 U.S. Department of Justice 950 Pennsylvania Avenue, NW Room 5026 Washington, DC 20530 (202)514-1841 kerry.k.dean@usdoj.gov
- 7 -

 
 SETTLEMENT AGREEMENT


TABLE OF CONTENTS

I. II.
III. IV. V. VI. VII.
VIII. IX. X. XI. XIV.

General Provisions................................................................................................. 1 
 Definitions.............................................................................................................. 
 2 
 Introduction............................................................................................................ 3 
 Integrated Treatment Planning............................................................................... 3 
 Mental Health Assessments................................................................................... 7 
 Discharge Planning and Community Integration.................................................. 10 
 Psychiatric and Psychological Treatment Services……………………………... 
 12 
 Documentation...................................................................................................... 17
 Seclusion and Restraints....................................................................................... 17 
 Protection From Harm.......................................................................................... 19 
 Suicide Prevention................................................................................................ 22 
 Terms and Conditions........................................................................................... 23 


I. GENERAL PROVISIONS 

1. This Settlement Agreement (the “Agreement”) is entered into between the United States and the State of Connecticut; the Connecticut Department of Mental Health and Addiction Services (“DMHAS”); and the Connecticut Valley Hospital (“the State”).
2. The Agreement resolves the investigation conducted by the United States Department of Justice (“United States”) of the Connecticut Valley Hospital (“CVH”) pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. The Agreement addresses the corrective measures set forth by the United States in its letter to the State dated August 6, 2007 (“Findings Letter”). This Agreement does not serve as an admission by the State that corrective measures are necessary to meet the constitutional and statutory rights of the residents of CVH.
3. In conformity with CRIPA, this Agreement represents a voluntary effort by the State to meet the concerns raised by the United States’ investigation. See 42 U.S.C. § 1997b (a) (2) (B) and § 1997g.
4. Pursuant to 42 U.S.C. § 1997b (a) (2) (B) and § 1997g, the United States agrees to support the State’s application for federal funding conditioned upon the State’s proper implementation of the suggested remedial measures.
5. Nothing in this Agreement shall be construed as an acknowledgment, an admission, or evidence of liability of the State under CRIPA, the Constitution or federal or state law, and this Agreement, including any and all provisions within this agreement, may not be used as evidence of liability in this or any other civil or criminal proceeding.
6. The signatures below of officials representing the United States and the State signify that these parties have given their final approval to this Agreement.
7. This Agreement is enforceable only by the parties. This Agreement is binding upon the parties, by and through their officials, agents, employees, and successors. No person or entity is intended to be a third party beneficiary of the provisions of this Agreement for purposes of any civil, criminal, or administrative action, and, accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Agreement in any civil, criminal, or administrative action. Similarly, this Agreement does not authorize, nor shall it be construed to authorize, access to State documents by persons or entities not a party to this Agreement.



8. This Agreement shall constitute the entire integrated Agreement of the parties. No prior contemporaneous communications, oral or written, or prior drafts shall be relevant or admissible for purposes of determining the meaning of any provisions herein in any litigation or any other proceeding, except for the Findings Letter and the Commissioner’s response to the DOJ Findings Letter. Any amendment to this Agreement shall be in writing, signed by both parties, as provided under provision 92.
9. Since the United States issued the August 2, 2007 Findings Letter, the State has made progress in addressing the issues the United States identified in the Findings Letter. As such, the parties agree that it is in their mutual interests to avoid contested litigation. The parties further agree that resolution of this matter pursuant to this Agreement is in the best interests of CVH residents. Therefore, pursuant to Fed. R. Civ. P. 41(a)(2), the parties hereby agree to file, in the United States District Court for the District of Connecticut, this Agreement, together with a notice Complaint and a joint motion to conditionally dismiss the Complaint. The parties further agree that this case will remain on the Court’s inactive docket with the Court retaining jurisdiction only to resolve disputes between the parties, if any, until this Agreement terminates. Despite the Court's retention of jurisdiction, the United States agrees that it will not file for a finding of contempt against the State in the event of a dispute regarding compliance.
10. All parties shall bear their own costs, including attorneys’ fees, in this and any subsequent proceeding.
II. DEFINITIONS
11. “Effective Date” shall mean the date that it is filed with the United States District Court for the District of Connecticut (“Court”). Unless otherwise specified, each provision of this Agreement shall be implemented by 24 months from the Effective Date hereof.
12. “Consistent With Generally Accepted Professional Standards of Care” shall mean a decision by a qualified professional that is not such a substantial departure from contemporary, accepted professional judgment, practice, or standards as to demonstrate that the person responsible did not base the decision on such accepted professional judgment. “Consistent With Generally Accepted Professional Standards of Care” may also be guided by the scope of practice as defined by state statutes for professional disciplines.
13. “Incident” shall mean defined categories and definitions of incidents to be reported and investigated, and such categories and definitions shall include, but not be limited to, death, abuse, neglect, and serious injury. As required by
2


provisions 65-67 of this Agreement, CVH will identify such categories of reportable incidents.
III. INTRODUCTION
14. Care and treatment provided by CVH shall be based on professional standards of practice and shall seek to:
A. ameliorate symptoms such that a less restrictive locus of treatment may safely be employed;
B. strengthen and support individuals’ rehabilitation and recovery; and
C. enable individuals to grow and develop in ways benefiting their health and well-being.
15. Care and treatment shall be accomplished while maximizing individuals’ safety, security, and freedom from undue bodily restraint. Relationships between CVH staff and individuals whom they serve shall be therapeutic and respectful.
16. Each individual served by CVH shall be encouraged to participate in identifying his or her treatment goals and in selecting appropriate treatment options. Care and treatment shall be designed to address each individual’s psychiatric and/or substance use disorder needs and to assist individuals in meeting their specific treatment goals, consistent with generally accepted professional standards of care. CVH shall ensure clinical and administrative oversight of, education of, and support to, its staff in planning and providing care and treatment consistent with these standards.
IV. INTEGRATED TREATMENT PLANNING
17. By 18 months from the Effective Date hereof, CVH shall provide safe integrated, individualized services, supports, and treatments (collectively “treatment”) for the individuals it serves, consistent with generally accepted professional standards of care. In addition to implementing the discipline-specific treatment planning provisions set forth below, CVH shall establish and implement standards, policies, and procedures and/or practices to provide that treatment determinations are consistently coordinated by an interdisciplinary team through integrated treatment planning and embodied in a single, integrated plan.
3


Interdisciplinary Teams
18. By 18 months from the Effective Date hereof, each interdisciplinary team’s membership shall be informed by the particular needs, strengths, and preferences of the individual in the team’s care, and, at a minimum, the interdisciplinary team for each individual shall:
A. have as its primary objective the provision of individualized, integrated treatment that optimizes the patient’s opportunity for recovery and ability to sustain himself/herself in the most appropriate, least restrictive setting, and supports the patient’s interests of self determination and independence;
B. be led by a treating psychiatrist who, at a minimum, shall:
1.) assume primary responsibility for the individual’s treatment;
2.) require that each member of the team participates appropriately in assessing the individual on an ongoing basis and in developing, monitoring, and, as necessary, revising treatments;
3.) require that the treatment team functions in an interdisciplinary fashion; and
4.) require that the scheduling and coordination of assessments and team meetings, the drafting of integrated treatment plans, and the scheduling and coordination of necessary progress reviews occur in a timely fashion;
C. have its composition informed by the individual’s particular needs, strengths, and preferences, but shall consist of a stable core of members, including the individual, the treating psychiatrist, psychologist (except where clearly not relevant, as in the situation of detoxification), rehabilitation therapist, nurse, the social worker, and unit staff who know the individual best. As appropriate, the individual’s family, guardian, advocates, attorneys, the pharmacist and other clinical staff shall be invited to participate in treatment planning meetings.
D. complete training on the development and implementation of interdisciplinary treatment plans to the point that integrated treatment plans meet the requirements of provisions 19-22, infra.
4


Integrated Treatment Plans
19. By 12 months from the Effective Date hereof, CVH shall develop and implement policies and/or procedures regarding the development of treatment plans consistent with generally accepted professional standards of care, to provide that:
A. individuals have substantive, identifiable input into their treatment plans;
B. treatment planning provides timely attention to the needs of each individual, in particular:
1.) initial treatment plans are completed within 24 hours of admission;
2.) master treatment plans are completed within seven days of admission; and
3.) treatment team will meet to perform treatment plan reviews every 14 days during the first 60 days of hospitalization and every 30 days thereafter;
C. individuals are informed of the purposes and side effects of medication;
D. each treatment plan specifically identifies the therapeutic means by which the treatment goals for the particular individual shall be addressed and monitored, consistent with generally accepted professional standards of care;
E. treatment and medication regimens are modified, as appropriate, considering factors such as the individual’s response to treatment, significant developments in the individual’s condition, and the individual’s changing needs;
F. an assessment of progress related to discharge is included in the review process; and
G. progress reviews and revision recommendations are based on data collected as specified in the treatment plan.
20. By 18 months from the Effective Date hereof, CVH shall use these policies and/or procedures to provide that treatment planning is based on a comprehensive case formulation for each individual that emanates from an integration of the discipline-specific assessments of the individual consistent with
5


generally accepted professional standards of care. Specifically, the case formulation 
 shall:

A. be derived from analyses of the information gathered from discipline-specific assessments, including diagnosis and differential diagnosis;
B. include a review of pertinent history, predisposing, precipitating, and perpetuating factors, present status, and previous treatment history;
C. consider biochemical and psychosocial factors for each category in provision 20.B, supra;
D. consider such factors as age, gender, culture, treatment adherence, and medication issues that may affect the outcomes of treatment interventions;
E. enable the treatment team to reach sound determinations about each individual’s treatment and habilitation needs; and
F. make preliminary determinations as to the least restrictive setting to which the individual should be discharged, and the changes that will be necessary to achieve discharge.
21. By 18 months from the Effective Date hereof, CVH shall use these policies and/or procedures to provide that treatment planning is driven by individualized needs, is strengths-based (i.e., builds on an individual’s current strengths), and that it provides an opportunity to improve each individual’s health and well being, consistent with generally accepted professional standards of care. Specifically, the treatment team shall:
A. develop and prioritize reasonable and attainable goals/objectives (i.e., relevant to each individual’s level of functioning) that build on the individual’s strengths and address the individual’s identified needs and, if any identified needs are not to be addressed, provide a rationale for not addressing the need;
B. provide that the goals/objectives address treatment (e.g., for a disease or disorder) and rehabilitation (e.g., skills/supports/quality of life activities);
C. write the objectives in behavioral and measurable terms;
6


D. provide that there are interventions that relate to each objective, specifying who will do what and within what time frame, to assist the individual to meet his/her goals as specified in the objective;
E. design a program of interventions that seeks to maximize participation in active treatment and rehabilitation throughout the individual’s day that are under the direction of a physician, and which are specific to the patient’s strengths, disabilities, and problems identified in the treatment plan; and
F. provide that each treatment plan integrates and coordinates all selected services, supports, and treatments provided by or through CVH for the individual in a manner specifically responsive to the plan’s treatment and rehabilitative goals.
22. By 18 months from the Effective Date hereof, CVH shall revise existing treatment plans, as appropriate, in accordance with the policies outlined in provision 19, supra, to provide that planning is outcome-driven and based on the individual’s progress, or lack thereof, as determined by the scheduled monitoring of identified treatment objectives, consistent with generally accepted professional standards of care.
V. MENTAL HEALTH ASSESSMENTS
23. By 12 months from the Effective Date hereof, CVH shall ensure that, consistent with generally accepted professional standards of care, each individual shall receive, promptly after admission to CVH, an assessment of the conditions responsible for the individual’s admission, and provide that it is accurate and complete to the degree possible given the available information at the time of admission. To the degree possible given the available information, the individual’s interdisciplinary team shall be responsible for investigating the past and present medical, nursing, psychiatric, substance abuse and psychosocial factors bearing on the patient’s condition, and, when necessary, for revising assessments and treatment plans in accordance with new information that comes to light. Thereafter, each individual shall receive a reassessment whenever there has been a significant change in the individual’s status, a lack of expected improvement resulting from treatment clinically indicated, or twelve months since the previous reassessment.
Psychiatric Assessments and Diagnoses
24. By 12 months from the Effective Date hereof, CVH shall use the diagnostic protocols in the most current Diagnostics and Statistics Manual (“DSM”) for reaching the most accurate psychiatric diagnoses.
7


25. By 12 months from the Effective Date hereof, CVH shall ensure that all clinicians responsible for performing or reviewing psychiatric assessments are verifiably competent in performing psychiatric assessments consistent with CVH’s standard diagnostic protocols.
26. By 12 months from the Effective Date hereof, CVH shall ensure that, within 24 hours of an individual’s admission to CVH, the individual receives an initial psychiatric assessment, consistent with CVH’s procedures.
27. By 18 months from the Effective Date hereof, CVH shall ensure that:
A. clinically justifiable, current assessments and diagnoses are provided for each individual;
B. the documented justification of the diagnoses are in accord with the criteria contained in the most current DSM;
C. differential diagnoses, “rule-out” diagnoses, and diagnoses listed as “NOS” (“Not Otherwise Specified”) are timely addressed, through clinically appropriate assessments, and resolved in a clinically justifiable manner; and
D. each individual’s psychiatric assessments, diagnoses, and medications are clinically justified consistent with generally accepted professional standards of care.
28. By 12 months from the Effective Date hereof, CVH shall develop policies and procedures consistent with generally accepted professional standards of care to ensure an ongoing and timely reassessment of the psychiatric causes of the individual’s continued hospitalization.
Psychological Assessments
29. By 18 months from the Effective Date hereof, CVH shall develop policies and procedures to ensure that patients referred by the treatment team for psychological assessment receive assessments, consistent with generally accepted professional standards of care, in a timely manner. These assessments may include diagnostic neuropsychological assessments, rehabilitative assessments, cognitive assessments, and I.Q./achievement assessments to guide psychoeducational (e.g., instruction regarding the illness or disorder, and the purpose or objectives of treatments for the same, including medications), rehabilitation and habilitation interventions, behavioral
8


assessments (including functional analysis of behavior in all settings), and personality assessments.
30. By 18 months from the Effective Date hereof, all psychological assessments, consistent with generally accepted professional standards of care, shall:
A. expressly state the purpose(s) for which they are performed;
B. be based on current, accurate, and complete data;
C. include an accurate, complete, and up-to-date summary focused on the referral question of the individual’s relevant, clinical, and functional history and response to previous treatment;
D. where relevant to the consultation, include sufficient elements of behavioral assessments to determine whether behavioral supports or interventions are warranted or whether a comprehensive applied behavioral analysis and plan are required;
E. identify the individual’s observed and, separately, expressed interests, activities, life skills, and functional strengths and weaknesses;
F. where relevant to the referral question, identify the individual’s social history, including factual inconsistencies among sources, resolving or attempting to resolve inconsistencies, explaining the rationale for the resolution offered, and reliably informing the individual’s treatment team about the individual’s relevant social factors;
G. where relevant to the assessment provide specific strategies to engage the individual in appropriate activities that he or she views as personally meaningful and productive;
H. include determinations specifically addressing the purpose(s) of the assessment;
I. include a summary of the empirical basis for all conclusions, where possible; and
J. identify any unresolved issues encompassed by the assessment and, where appropriate, specify further observations, records, or re-evaluations that should be undertaken in endeavoring to resolve such issues.
31. By 18 months from the Effective Date hereof, previously completed psychological assessments of individuals currently at CVH shall be reviewed by qualified
9


clinicians and, as indicated, additional psychological assessments will be completed.
32. By 18 months from the Effective Date hereof, appropriate psychological assessments shall be provided in a timely manner, whenever clinically indicated, consistent with generally accepted professional standards of care, including whenever there has been a significant change in condition, a lack of expected improvement resulting from treatment, an individual’s behavior poses a significant barrier to treatment or therapeutic programming, clinical information is otherwise insufficient, and to address unresolved clinical or diagnostic questions, including “rule-out” and deferred diagnoses.
33. If behavioral interventions are indicated, a functional behavioral assessment shall be performed, consistent with generally accepted professional standards of applied behavioral analysis, by a professional having demonstrated competency in applied behavioral analysis.
34. By 18 months from the Effective Date hereof, when an assessment is completed, CVH shall ensure that treating psychologists communicate and interpret psychological assessment results to the treatment teams, along with the implications of those results for diagnosis and treatment.
35. By 18 months from the Effective Date hereof, CVH shall ensure that all clinicians responsible for performing or reviewing pyschological assessments are verifiably competent in performing the assessments for which they are responsible.
VI. DISCHARGE PLANNING AND COMMUNITY INTEGRATION
36. Taking into account the limitations of court-imposed confinement, the State shall actively pursue the appropriate discharge of individuals under the State’s care at CVH and the provision of services in the most integrated, appropriate setting that is consistent with each person’s needs and to which they can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.
37. By 12 months from the Effective Date hereof, CVH shall identify at admission and address in treatment planning the particular considerations for each individual bearing on discharge, including:
A. those factors that likely would foster successful discharge, including the individual’s strengths, preferences, and personal goals;
B. the individual’s symptoms of mental illness or psychiatric distress;
10


C. barriers preventing the specific individual from being discharged to a more integrated environment, especially difficulties raised in previously unsuccessful placements, to the extent that they are known; and
D. the skills necessary to live in a setting in which the individual may be placed.
38. By six months from the Effective Date hereof, CVH shall provide the opportunity, beginning at the time of admission and continuously throughout the individual’s stay, for the individual to be an active participant in the discharge planning process, as appropriate.
39. By 12 months from the Effective Date hereof, CVH shall ensure that, consistent with generally accepted professional standards of care, each individual has a professionally developed discharge plan that is a fundamental component of the individual’s treatment plan that addresses his or her particular discharge considerations, and that includes:
A. measurable interventions regarding his or her particular discharge considerations;
B. the persons responsible for accomplishing the interventions; and
C. the time frames for completion of the interventions.
40. By 24 months from the Effective Date hereof, CVH shall transition individuals to the community consistent with generally accepted professional standards of care. In particular, CVH shall ensure that:
A. individuals who have met discharge criteria are discharged as expeditiously as reasonably possible taking into account the resources available to the State and the needs of others with mental disabilities; and
B. individuals receive adequate assistance in transitioning to the new setting.
41. Prior to discharge, the State shall ensure that the supports and services that discharge planning indicates are necessary are in place.
42. By 12 months from the Effective Date hereof, the State shall develop and implement a quality assurance/improvement system to oversee the discharge process.
VII. PSYCHIATRIC AND PSYCHOLOGICAL TREATMENT SERVICES
Psychiatric Care
11


43. By 12 months from the Effective Date hereof, CVH shall provide all of the individuals it serves with adequate and appropriate routine and emergency psychiatric and mental health services consistent with generally accepted professional standards of care.
44. By 18 months from the Effective Date hereof, CVH shall develop and implement policies and/or procedures regarding the provision of psychiatric care consistent with generally accepted professional standards of care. In particular, policies and/or procedures shall address physician practices regarding:
A. documentation of psychiatric assessments and ongoing reassessments as per provision 27, supra;
B. documentation of significant developments in the individual’s clinical status and of appropriate psychiatric follow up;
C. timely and justifiable updates of diagnosis and treatment, as clinically appropriate;
D. documentation of analyses of risks and benefits of chosen treatment interventions;
E. assessment of, and attention to, high-risk behaviors (e.g., assaults, self-harm, falls) including appropriate and timely monitoring of individuals and interventions to reduce risks;
F. documentation of, and responses to, side effects of prescribed medications, with particular attention to special risks associated with the use of benzodiazepines, anticholinergic medications, polypharmacy (use of multiple drugs to address the same condition), and conventional and atypical antipsychotic medications;
G. timely review of the use of “pro re nata” or “as-needed” (“PRN”) medications and adjustment of regular treatment, as indicated, based on such use; and
H. verification, in a clinically justifiable manner, that psychiatric and behavioral treatments are properly integrated.
12


45. By 18 months from the Effective Date hereof, CVH shall develop and implement policies and/or guidelines to ensure system-wide monitoring of the safety, effectiveness, and appropriateness of all psychotropic medication use, consistent with generally accepted professional standards of care. In particular, policies and/or guidelines shall address:
A. monitoring of the use of psychotropic medications to ensure that they are:
1.) specifically matched to current, clinically justified diagnoses;
2.) prescribed in therapeutic amounts, as dictated by the needs of the individual patient;
3.) tailored to each individual's clinical needs;
4.) monitored for effectiveness against the objectives of the individual’s treatment plan;
5.) monitored appropriately for side effects; and
6.) properly documented;
B. monitoring of the use of PRN medications to ensure that these medications are clinically justified and administered on a time-limited basis, and not used as a substitute for adequate treatment of the underlying cause of the individual’s condition;
C. monitoring of the use of benzodiazepines, anticholinergics, and polypharmacy to ensure clinical justification and attention to associated risks;
D. appropriate use of psychotropic medications with attention to side effects;
E. timely identification, reporting, data analyses, and follow up remedial action regarding adverse drug reactions reporting (“ADR”);
F. drug utilization evaluation (“DUE”) in accord with established, up-to-date medication guidelines;
G. documentation, reporting, data analyses, and follow up remedial action regarding actual and potential medication variances (“MVR”);
13


H. tracking of individual and group practitioner trends, including data derived from monitoring of the use of PRNs, benzodiazepines, anticholinergics, and polypharmacy, and of ADRs, DUE, and MVR;
I. feedback to the practitioner and educational/corrective actions in response to identified trends, when indicated; and
J. use of information derived from ADRs, DUE, MVR, and providing such information to the Pharmacy & Therapeutics, Therapeutics Review, and Mortality and Morbidity Committees.
46. By 18 months from the Effective Date hereof, CVH shall ensure that all physicians and clinicians are performing in a manner consistent with generally accepted professional standards of care, to include appropriate medication management, treatment team functioning, and the integration of behavioral and pharmacological treatments.
47. By 18 months from the Effective Date hereof, CVH shall review and ensure the appropriateness of the medication treatment, consistent with generally accepted professional standards of care, for:
A. all individuals prescribed continuous anticholinergic treatment for more than six months;
B. all individuals with cognitive impairments who are prescribed continuous anticholinergic treatment regardless of duration of treatment;
C. all individuals prescribed benzodiazepines as a scheduled modality for more than six months;
D. all individuals prescribed benzodiazepines with diagnoses of substance abuse or cognitive impairments, regardless of duration of treatment except for individuals undergoing detoxification; and
E. all individuals with a diagnosis or evidencing symptoms of tardive dyskinesia.
48. By 18 months from the Effective Date hereof, CVH shall ensure that individuals are screened and evaluated for substance abuse. For those individuals identified with a substance abuse disorder, CVH shall provide them with appropriate inpatient services consistent with their need for treatment.
49. By 18 months from the Effective Date hereof, CVH shall develop and implement a cognitive remediation program for individuals with cognitive impairment, when clinically indicated.
14


Psychological Care
50. By 18 months from the Effective Date hereof, CVH shall provide adequate and appropriate psychological supports and services, consistent with generally accepted professional standards of care, to individuals who require such services. CVH shall integrate psychiatric and behavioral treatments in those cases where behaviors and psychiatric symptoms overlap.
51. By 18 months from the Effective Date hereof, CVH shall ensure, consistent with generally accepted professional standards of care, that all psychologists have a demonstrated competence in the following areas:
A. behavioral treatment;
B. group therapy;
C. psychological testing; and
D. individual therapy.
52. By 18 months from the Effective Date hereof, CVH shall provide adequate clinical oversight to therapy groups to ensure that individuals are assigned to groups that are appropriate to their individual needs, that groups are provided consistently and with appropriate frequency, and that issues particularly relevant for this population, including the use of psychotropic medications and substance abuse, are appropriately addressed consistent with generally accepted professional standards of care.
53. By 18 months from the Effective Date hereof, CVH shall provide adequate active psychosocial rehabilitation, consistent with generally accepted professional standards of care, that:
A. is based on individualized assessment of patients’ needs and is directed toward increasing patient ability to engage in more independent life functions;
B. addresses those needs in a manner building on the individual’s strengths, preferences, and interests;
C. focuses on the individual’s vulnerabilities to mental illness, substance abuse, and readmission due to relapse, where appropriate;
15


D. is provided in a manner consistent with each individual’s cognitive strengths and limitations;
E. is provided as prescribed on each individual’s comprehensive treatment plan;
F. routinely takes place as scheduled;
G. includes, in the evenings and weekends, additional activities that enhance the individual’s quality of life;
H. designates a role for the staff on the living units; and
I. is documented in the individual’s treatment plan.
54. By 18 months from the Effective Date hereof, CVH shall ensure that:
A. behavioral interventions are based on positive reinforcements rather than the use of aversive contingencies, to the extent possible;
B. programs are consistent for each patient within each setting at CVH;
C. triggers for instituting individualized behavior treatment support plans will be specific as to the individual and utilized for those individuals experiencing triggers including recurrent use of seclusion, restraint, and emergency involuntary medication;
D. psychotherapy, is goal-directed, individualized, and informed by a knowledge of the individual’s psychiatric, substance abuse, medical, and psychosocial history and previous response to psychotherapy;
E. psychosocial, rehabilitative, and behavioral interventions are monitored and revised as appropriate in light of significant developments, and the individual’s progress, or the lack thereof;
F. clinically relevant information remains readily accessible; and
G. all staff who have a role in implementing individual behavioral programs have received competency-based training on implementing the specific behavioral programs for which they are responsible, and quality assurance measures are in place for monitoring behavioral treatment interventions.
16


Pharmacy Services
55. By 18 months from the Effective Date hereof, CVH shall provide adequate and appropriate pharmacy services consistent with generally accepted professional standards of care. By 18 months from the Effective Date hereof, CVH shall develop and implement policies and/or procedures that require:
A. pharmacists to complete reviews of each individual’s medication regimen regularly, on at least a monthly basis, and, as appropriate, make recommendations to treatment teams about possible drug-to-drug interactions, side effects, medication changes, and needs for laboratory work and testing; and
B. physicians to consider pharmacists’ recommendations, clearly document their responses and actions taken and, for any recommendations not followed, provide an adequate clinical justification.
VIII. DOCUMENTATION
56. By 24 months from the Effective Date hereof, CVH shall ensure that an individual’s records accurately reflect the individual’s progress as to all treatment identified in the individual’s treatment plan, consistent with generally accepted professional standards of care. By 24 months from the Effective Date hereof, CVH shall develop and implement policies and/or procedures setting forth clear standards regarding the content and timeliness of progress notes, transfer notes, and discharge notes, including, but not limited to, an expectation that such records include meaningful, accurate assessments of the individual’s progress relating to treatment plans and treatment goals.
IX. SECLUSION AND RESTRAINTS
57. By 12 months from the Effective Date hereof, CVH shall ensure that restraints and seclusion are used consistent with generally accepted professional standards of care.
58. By six months from the Effective Date hereof, CVH shall revise, as appropriate, and implement policies and/or procedures regarding the use of seclusion and restraints, consistent with generally accepted professional standards of care and list the types of restraint that are acceptable for use. In particular, the CVH policies and/or procedures shall promote acceptable standards of practice which seek to prevent or minimize the use of restraints, to the degree possible, including the use of four-point restraint to the bed, and the use of posey net restraints. Current policies and/or procedures expressly prohibit the use of mechanical restraints in a prone position.
17


59. By 12 months from the Effective Date hereof, and absent exigent circumstances CVH shall ensure that restraints and seclusion are restricted to use only in emergency situations (i.e., when a patient poses an imminent risk of injury to himself and/or others), CVH shall ensure that restraints and seclusion:
A. are used in a reliably documented manner and after a hierarchy of less restrictive measures has been considered in a clinically justifiable manner or exhausted;
B. are not used in the absence of, or as an alternative to, active treatment, as punishment, or for the convenience of staff;
C. are not used as part of a behavioral intervention; and
D. are terminated as soon as the individual is no longer an imminent danger to himself/herself or others, unless otherwise clinically indicated.
60. By six months from the Effective Date hereof, CVH shall comply with 42 C.F.R. § 483.360 (f), requiring assessments by a physician or licensed medical professional of any individual placed in seclusion or restraints. CVH shall also ensure that any individual placed in seclusion or restraints is continuously monitored by a staff person who has successfully completed competency-based training on the monitoring of seclusion and restraints.
61. By 12 months from the Effective Date hereof, CVH shall ensure the accuracy of data regarding the use of restraints or seclusion.
62. By 12 months from the Effective Date hereof, CVH shall revise, as appropriate, and implement policies and/or procedures to require the review within three business days of individuals’ treatment plans for any individuals placed in seclusion or restraints more than three times in any four-week period, and modification of treatment plans, as appropriate.
63. By 12 months from the Effective Date hereof, CVH shall ensure that all staff whose responsibilities include the implementation or assessment of seclusion, restraints, or emergency involuntary psychotropic medications successfully complete competency-based training regarding implementation of all such policies and the use of less restrictive interventions.
18


X.

PROTECTION FROM HARM 


64. By six months from the Effective Date hereof, CVH shall provide the individuals it serves with a safe and humane environment and seek to minimize the risk of harm.

Incident Management

65. By 12 months from the Effective Date hereof, CVH shall review, revise, as appropriate, and implement incident management policies, procedures and practices that are consistent with generally accepted professional standards of care. Such policies, procedures and practices shall require:

A. a commitment that CVH shall not tolerate abuse or neglect of individuals and that staff are required to report abuse or neglect of individuals;

B. identification of the categories and definitions of incidents to be reported, and investigated; immediate reporting by staff to supervisory personnel who reports to CVH’s Chief Executive Officer (or that official’s designee) of serious incidents, including but not limited to, death, abuse, neglect, and serious injury, and the prompt reporting by staff of all other incidents, using standardized reporting across all settings;

C. mechanisms to ensure that, when serious incidents such as allegations of abuse, neglect, and/or serious injury occur, staff take immediate and appropriate action to protect the individuals involved, including removing alleged staff perpetrators from direct contact with individuals pending the investigation’s outcome; when clinically indicated, alleged patient perpetrators may also be relocated to another unit;

D. adequate competency-based training for all staff on recognizing and reporting potential signs and symptoms of abuse or neglect, including the precursors that may lead to abuse, as well as training on the reporting requirements required under this Agreement;

E. notification of all staff when commencing employment and adequate training thereafter of their obligation to report abuse or neglect to CVH and State officials as required by law. Additionally, continue to require that all CVH employees, upon employment sign receipt of the DMHAS Work Rules, which state that, “physical violence, verbal abuse, inappropriate or indecent conduct and behavior that endangers the safety and welfare of persons or property is prohibited,” and that all “employees shall immediately report alleged violations of existing work rules, policies, procedures or regulations to a supervisor”;

19


F. mechanisms to educate and support individuals, relatives, and personal or health representatives to identify and report incidents, including allegations of abuse or neglect;
G. posting in each living unit and day program site a brief and easily understood statement of individuals’ rights, including information about how to exercise such rights and how to report violations of such rights;
H. procedures for referring, as appropriate, allegations of abuse or neglect to law enforcement; and
I. mechanisms to ensure that any staff person, individual, family member or visitor who in good faith reports an allegation of abuse or neglect is not subject to retaliatory action by the State, including but not limited to reprimands, discipline, harassment, threats or censure, except for appropriate counseling, reprimands or discipline because of an employee’s failure to report an incident in an appropriate or timely manner.
66. By 12 months from the Effective Date hereof, CVH shall review, revise, as appropriate, and implement policies and procedures to ensure the timely and thorough performance of investigations, consistent with generally accepted professional standards of care. Such policies and procedures shall ensure the review of all deaths, as well as allegations of abuse, neglect, suicide attempts, and serious injury.
67. By 12 months from the Effective Date hereof, CVH shall have a system to allow the tracking and trending of all deaths, as well as allegations or indications of abuse and neglect, suicide attempts, and serious injury and review results. Trends shall be tracked by at least the following categories:
A. type of incident;
B. staff involved;
C. other individuals involved;
D. location of incident;
E. date and time of incident;
F. cause(s) of incident; and
G. outcome of review.
Quality Improvement
20


68. By 24 months from the Effective Date hereof, CVH shall develop, revise as appropriate, and implement quality improvement mechanisms that enable it to comply fully support this Agreement, to detect timely and adequately problems with the provision of treatment, services and supports, and to ensure that appropriate corrective steps are implemented. The quality improvement mechanisms shall be otherwise consistent with generally accepted professional standards of care and shall:
A. Track data with sufficient particularity to identify trends by programs, units, work shifts, individual staff and/or patients in regard to protection from harm, provision of care and services, and outcomes being achieved.
B. Analyze data regularly and, whenever appropriate, require the development and implementation of corrective action plans to address problems identified through the quality improvement process. Such plans shall identify:
1.) the action steps that need to be taken to remedy and/or prevent the reoccurrence of problems;
2.) the anticipated outcome of each action step; and
3.) the person(s) responsible, and the time frame in which each action step must occur.
C. Disseminate corrective action plans to all entities responsible for their implementation, and:
1. monitor and document corrective action plans to ensure that they are implemented fully and in a timely manner, and that they have the desired outcome of remedying or reducing the problems originally identified; and
2. modify corrective action plans, as necessary, to ensure their effectiveness.
D. Utilize, on an ongoing basis, appropriate performance improvement mechanisms to assess and address the facility’s progress with its identified service goals.
21


Environmental Conditions
69. By 12 months from the Effective Date hereof, CVH shall continue to implement its system to regularly review all units and areas of the hospital to which individuals being served have access to, in order to identify any potential environmental safety hazards and to develop and implement a plan to remedy any identified issues, consistent with generally accepted professional standards of care. Potential suicide hazards shall be identified and prioritized for corrective action. Interim safety measures shall be instituted until corrective measures are taken. Furthermore, CVH shall review and revise as indicated, policies and procedures consistent with generally accepted professional standards of care to ensure appropriate screening for non-permissible items.
XI. SUICIDE PREVENTION
70. The State shall take reasonable measures to assure that all aspects of its suicide prevention policy are implemented. “Suicide Precautions” means any level of watch, observation or measures to prevent self-harm.
71. Timely suicide risk assessments, using reliable assessment instruments, shall be conducted at CVH:
A. for all patients exhibiting behavior that may indicate suicidal ideation and who are not already on suicide precautions, and
B. when determining whether to place a patient on suicide precautions or change the level of suicide precautions. Suicide risks assessment shall be conducted by a licensed mental health professional. Patients shall not be removed from suicide precautions by anyone other than a licensed mental health professional.
72. Patients who demonstrate suicidal ideation or attempt self-harm shall receive timely and appropriate mental health care by qualified mental health professionals. This care shall include helping patients develop skills to reduce their suicidal ideations or behaviors, and providing patients removed from suicide precautions with adequate follow-up treatment.
73. The State shall assess newly-arrived patients, and other patients at heightened risk of self-harm for the need for an increased level of supervision to maintain their safety.
74. The State shall continue to take reasonable measures to assure that all housing for patients at heightened risk of self-harm, including restraint rooms, seclusion rooms, and housing for patients on suicide precautions, is free of
22


identifiable hazards that would allow patients to hang themselves or commit other acts of self-harm.
75. CVH patients on suicide precautions shall not be restricted in their access to programs and services more than safety and security needs dictate.
76. The following information shall be thoroughly and correctly documented, and provided to all staff at CVH who need to know such information:
A. the times patients are placed on and removed from precautions;
B. the levels of precautions on which patients are maintained;
C. the housing location of patients on precautions;
D. the conditions of the precautions; and
E. the times and circumstances of all observations by staff monitoring the patients.
77. CVH staff shall continue to have immediate access to appropriate equipment to intervene in the event of an attempted suicide by hanging.
78. Appropriate staff shall continue to review all completed suicides and serious suicide attempts for policy and training implications.
79. All CVH staff shall attend annual training on suicide prevention.
XII. TERMS AND CONDITIONS
80. The State represents that it will periodically refine and revise the policies and/or procedures outlined in this Agreement to ensure compliance with the letter and intent of this Agreement. Upon request, the Designated Consultant shall be provided with copies and an opportunity to provide substantive comment upon any policies and/or protocols revised pursuant to this Agreement. The Designated Consultant shall provide comments on revisions to policies and procedures to the State no later than within 30 business days following receipt of the draft policies or procedures.
81. The State represents that it has educated, or will educate, all employees at CVH with respect to the policies and/or procedures outlined in this Agreement.
82. The State shall maintain records to document its compliance with all terms and conditions of this Agreement. The State shall also maintain any and all records required by, or developed pursuant to, this Agreement.
23


83. Until this Agreement terminates, the United States shall have unrestricted access to, and shall, upon request, receive copies of any documents, patient records, and information relating to the implementation of this Agreement, except where covered by attorney work product protections, or attorney-client privilege. The United States’ personnel and consultants shall be deemed “qualified personnel” for the purpose of conducting program evaluations or audits of CVH pursuant to 42 U.S.C. § 290dd-2 (b) (2) (B) and 42 C.F.R. § 2.53 (a) (2). CVH shall provide any requested non-privileged documents, records, and information to the United States as soon as possible, but no later than within 30 business days of the request.
84. The United States shall have reasonable access to all of CVH’s buildings and facilities; staff and residents, including private interviews with staff with the consent of staff and permission of the State, and where clinically appropriate, and with the consent of the residents, private interviews with residents; and resident records, documentation, and information relating to the issues addressed in this Agreement, except where covered by attorney work product protections, or attorney-client privilege. CVH shall make all employees available so that they may choose to cooperate fully with the United States. The United States agrees to provide CVH with reasonable notice of any visit or inspection, although the United States and CVH agree that no notice shall be required in an emergency situation where the life, immediate health, or immediate safety of resident(s) is at issue. Nothing in this Agreement shall abridge the whistleblower rights of State employees or contractors under law.
85. The parties agree to the appointment of Nirbhay N. Singh, Ph.D.to review the State’s implementation of this Agreement (the “Designated Consultant”). The Designated Consultant shall have full authority to independently assess, review, and report semi-annually on the State’s implementation of and compliance with the provisions of this Agreement. The Designated Consultant may provide the State with technical assistance upon request. All reasonable costs and expenses of the Designated Consultant, as set forth in the Proposed 12-month Budget for CVH Preliminary Draft Proposal attached hereto as Exhibit A, shall be borne by the State.
86. The overall duties of the Designated Consultant shall be to observe, review, report findings, and make recommendations to the parties with regard to the implementation of the Agreement. The Designated Consultant shall regularly review the services provided to the residents at CVH to determine the State’s implementation of, and compliance with, this Agreement. The Designated Consultant shall give the State reasonable notice prior to all visits. The State shall develop a project management plan that will be used to guide the work to be performed by the Designated Consultant and will facilitate the State’s selfassessment of its progress in achieving substantial compliance with the provisions of this Agreement in a timely manner.
24


87. Every six months, the Designated Consultant shall provide the State and the United States with a written report regarding the State’s implementation efforts and its compliance with the terms of this Agreement. The State will take timely action to remedy any deficiencies cited in the report.
88. If CVH closes and residents are moved to another facility or facilities, the United States reserves the right to evaluate the appropriateness of such placement. If the State contracts for any of the services to be delivered at CVH which are covered under this Agreement, the Agreement shall be fully applicable to, and binding upon, any contracted services.
89. If the United States maintains that the State has failed to carry out any requirement of this Agreement, the United States shall notify the State of any instance(s) in which it maintains that the State has failed to carry out the requirements of this Agreement.
90. With the exception of conditions or practices that pose an immediate and serious threat to the life, health, or safety of CVH patient(s), the State shall take substantial steps within 90 days of notice of non-compliance. The State shall correct non-compliance with any requirement of this Agreement within a reasonable time. During this period, the United States and the State shall coordinate and discuss areas of disagreement and attempt to resolve outstanding differences. If the United States and the State fail to reach an agreement, the United States is not limited in any fashion in pursuing its law enforcement obligations without further notice, including any adverse litigation against the State and/or seeking appropriate enforcement of any provision of this Agreement.
91. The State shall notify the United States immediately upon the unanticipated death of any resident and shall forward to the United States copies of any completed incident reports related to unanticipated death, autopsies and/or death summaries of residents, as well as all final reports of investigations that involve residents’ deaths.
92. If, at any time, any party to this Agreement desires to modify it for any reason, that party will notify the other party in writing of the proposed modification and the reasons therefore. No modification will occur unless there is written agreement by the United States and the State.
93. This Agreement will terminate four years after its Effective Date. If the parties agree that the State is in substantial compliance with each of the provisions earlier than the termination date specified above, and has maintained substantial compliance for at least one year, then the Agreement may terminate at an earlier date. The burden will be on the State and CVH officials to demonstrate such substantial compliance.
25


Dated this ____20th___ day of ___January____, 2009.
AGREED TO BY THE UNDERSIGNED:
FOR THE UNITED STATES:
/s/ Grace Chung Becker ________________________ GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
/s/ Shanetta Y. Cutlar ________________________ SHANETTA Y. CUTLAR Chief Special Litigation Section
/s/ Judy Preston ________________________ JUDY PRESTON Deputy Chief Special Litigation Section
/s/ Kerry Krentler Dean ________________________ KERRY KRENTLER DEAN WILLIAM G. MADDOX Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave, NW Washington, DC 20530 (202) 514-1841 (202) 514-0212 (fax) FOR THE STATE:
26

/s/ Thomas A. Kirk, Jr. ________________________ Thomas A. Kirk, Jr., Ph.D. Commissioner Connecticut Department of Mental Health and Addiction Services 410 Capitol Avenue P.O. Box 341431 Hartford, CT 06134
/s/ Thomas J. Ring ________________________ THOMAS J. RING, A.A.G. Assistant Attorney General Federal Bar No. ct08293 55 Elm St. P.O. Box 120 Hartford, CT 06141-0120 Tel. (860) 808-5210 Fax: (860) 808-538
27


 
 UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

UNITED STATES OF AMEIUCA Plaintiff

CIVIL ACTION NO. 3:09-CV-85 (AWT)

v.
STATE OF CONNECTICUT, ET AL. Defendants.

. SEPTEMBER 10,2013

NOTICE OF SUBSTANTIAL COMPLIANCE WITH CERTAIN TERMS OF THE SETTLEMENT AGREEMENT AND EXTENSION OF TERMINATION
The United States and the State of Connecticut, the Commissioner of the Connecticut Depmiment ofMental Health and Addiction Services, and the Chief Executive Director of the Connecticut Valley Hospital, entered into a Settlement Agreement that was filed with a Complaint and Joint Motion to Dismiss pursuant to Fed. R. eiv. P. 41(a)(2), in the above captioned matter ("Settlement Agreement").
On July 8, 2009, the above captioned matter was conditionally dismissed pursuant to Fed. R. eiv. P. 41(a) (2), by order of the Honorable Alvin W. Thompson, United States District Judge for the District of Connecticut.
The Parties are notifying the Court that Defendants have substantially complied with Section III, Section IV; Section V; Paragraphs 37, 38, 39, 41, and 42 of Section VI; Section VII; Section VIII; Section IX; Section X; and Section XI. Such listed Sections and Paragraphs are immediately terminated and no longer subject to compliance by Defendants.
The Parties further notify the Court that Paragraphs 36 and 40 of Section VI shall . remain subject to compliance under the terms of the Settlement Agl·eement. The State, . while agreeing to the continued application ofthe Settlement Agreement· limited to said Paragraphs, takes the position that this Notice does not constitute an admission that the State has failed to achieve substantial compliance with Paragraphs 36 and 40 of Section VI of the Settlement Agreement. The Parties have extended the termination date of the Settlement Agreement contained in Section XII, Paragraph 93, as follows:
93. This Agreement will terminate on September 10,2015. If the Designated Consultant determines !llat the State has not achieved substantial compliance with the remaining provisions of this Agreement, upon mutual agreement of the parties, in writing, this Agreement may be fbrther extended for an additional (60) days to allow the parties to enter into negotiations related to a further extension of this Amended Agreement, ifnccessal'Y. Tfthe parties agree that the State is in .

sUbstantial cOll1plipn~e with !Boh of the provisions cQrlier ,hall the tCOl'llnllion data specIfied llbol'e, then the AgrCOl1lsn!mRY terminate at all earlier date, Tile bllrd~n will bo on Ihe Stnte one! CVH (0 demonstrate suoh substantial cOlll,l1l3TlCe,
Dated this IOlh dn)' ofSeptember, 201~,
POR THE UNITED STATES:
IONATHAN M, SMITH 
 ChIef 
 SpecIal Litlgulloll Seotion 

SHELLBY R. JACKSON 
 Deputy Chief 
 StlCClal Litigation SectioJ\ 

WkILLL lAM~Q,M6A,D'D«Qd.X.£~~/AI­~

DC Bar No. 42 ! 564 
 Trill! Attorneys 
 U,S. Depal1mellt ofJustice 
 Civil Rights Division 

Speoial Litigation Section 

950 Ponnsylvanla Ave" N,W. 
 WlIshingjon D,C, 20530 
 (202) 514.625 I (202) 514-0~12 (fax)
FOR TI'!ESTA'r(\;
I~~-<J,'~
"Paul DILe~ 

Deputy Commissioner 
 Conneotlcut Oepnrtlllent ofMenIal Health and A.ddlctioll Servioes 
 410 Capitol Avenue 
 P.O. Box 341431 

Haltlbl'd, cr OG 134 


 
 Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 1 of 6
CLOSED,EFILE
U.S. District Court United States District Court for the District of Connecticut (New Haven)
CIVIL DOCKET FOR CASE #: 3:09−cv−00085−AWT

USA v. Connecticut et al Assigned to: Judge Alvin W. Thompson Cause: No cause code entered
Plaintiff USA

Date Filed: 01/20/2009 Date Terminated: 07/08/2009 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff
represented by John B. Hughes U.S. Attorney's Office−NH 157 Church St., 25th Floor New Haven, CT 06510 203−821−3802 Fax: 203−773−5373 Email: john.hughes@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kerry Krentler Dean U.S. Department of Justice−Penn Ave−DC Civil Rights Division, Special Litigation Section 950 Pennsylvania Avenue, N.W. Washington, DC 20530 202−514−1841 Fax: 202−514−0212 Email: kerry.k.dean@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Nora R. Dannehy U.S. Attorney's Office−HFD 450 Main St. Room 328 Hartford, CT 06103 860−947−1101 Fax: 860−240−3291 TERMINATED: 12/27/2010 LEAD ATTORNEY ATTORNEY TO BE NOTICED
William Granville Maddox U.S. Dept. of Justice − PHB−5018 950 Pennsylvania Ave., N.W. Washington, DC 20530 202−514−6251 Fax: 202−514−0212 Email: william.maddox@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

V. Defendant State of Connecticut

represented by Henry A. Salton Attorney General's Office Health & Human Services 55 Elm St., Po Box 120 Hartford, CT 06101

Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 2 of 6

860−808−5318 Email: Henry.Salton@ct.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Jacqueline S. Hoell Office of the Attorney General − Elm Htfd 55 Elm Street P.O. Box 120 Hartford, CT 06141−0120 860−808−5210 Fax: 860−808−5385 Email: Jacqueline.Hoell@ct.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Thomas J. Ring Attorney General's Office 55 Elm St., Po Box 120 Hartford, CT 06101 860−808−5318 Email: thomas.ring@po.state.ct.us TERMINATED: 11/06/2009 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant
Dept of Mental Health & Addiction Svc Thomas A. Kirk, Jr.,Ph.D.,Comm, /O

represented by Henry A. Salton (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Jacqueline S. Hoell (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Thomas J. Ring (See above for address) TERMINATED: 11/06/2009 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant
Luis Perez LCSW, Chief Executive Dir, CT Valley Hosp, /O

represented by Henry A. Salton (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Jacqueline S. Hoell (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Thomas J. Ring (See above for address) TERMINATED: 11/06/2009 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant Pedro Cartagena

Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 3 of 6

Movant Ruben Perez
Movant Connecticut Legal Rights Project, Inc
Movant Patricia Dugas
Movant Gertrude Duncan
Movant Pedro Cartagena

represented by Kirk W. Lowry Connecticut Legal Rights Project, Inc.−Mdltn Silver St., PO Box 351 Middletown, CT 06457 860−262−5017 Fax: 860−262−5035 Email: klowry@clrp.org LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Kirk W. Lowry (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Kirk W. Lowry (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Kirk W. Lowry (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
represented by Kirk W. Lowry (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed 01/20/2009 01/20/2009
01/20/2009
01/20/2009 01/26/2009 01/26/2009

# Docket Text
1 COMPLAINT against State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez, filed by USA.(Spielberg, N.) (Entered: 01/22/2009)
2 Order on Pretrial Deadlines: Motions to Dismiss due on 4/20/2009. Amended Pleadings due by 3/21/2009 Discovery due by 7/22/2009 Dispositive Motions due by 8/21/2009. Signed by Clerk on 1/20/2009. (Spielberg, N.) (Entered: 01/22/2009)
3 ELECTRONIC FILING ORDER − PLEASE ENSURE COMPLIANCE WITH COURTESY COPY REQUIREMENTS IN THIS ORDER. Signed by Judge Alvin W. Thompson on 1/20/09. (Spielberg, N.) (Entered: 01/22/2009)
4 MOTION for Entry of Settlement Agreement by USA. (Attachments: # 1 Text of Proposed Order)(Spielberg, N.) (Entered: 01/22/2009)
5 MOTION to Intervene by Ruben Perez, Connecticut Legal Rights Project, Inc.Responses due by 2/16/2009 (Lowry, Kirk) (Entered: 01/26/2009)
6 ENTERED IN ERROR: MOTION to Intervene Memorandum in Support by Ruben Perez, Connecticut Legal Rights Project, Inc.Responses due by 2/16/2009 (Attachments: # 1 Exhibit A Doe v. Hogan Consent Decree, # 2 Exhibit B Letter to USDOJ and CT AG, # 3 Exhibit C USDOJ Response Letter)(Lowry, Kirk) Modified on 1/27/2009 (Bauer, J.). (Entered: 01/26/2009)

Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 4 of 6

01/26/2009 01/27/2009 01/28/2009 01/30/2009 02/02/2009
02/11/2009
02/13/2009 02/13/2009 02/17/2009 02/19/2009 02/19/2009
03/02/2009 04/20/2009 04/21/2009
04/21/2009 04/21/2009

7 Memorandum in Support re 5 MOTION to Intervene filed by Ruben Perez, Connecticut Legal Rights Project, Inc. [correction to entry 6](Bauer, J.) (Entered: 01/27/2009)
8 NOTICE of Appearance by Kirk W. Lowry on behalf of Ruben Perez, Connecticut Legal Rights Project, Inc (Lowry, Kirk) (Entered: 01/27/2009)
9 NOTICE of Appearance by Jacqueline S. Hoell on behalf of State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez (Hoell, Jacqueline) (Entered: 01/28/2009)
10 NOTICE of Appearance by Thomas J. Ring on behalf of State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez (Ring, Thomas) (Entered: 01/30/2009)
11 Minute Entry for proceedings held before Judge Alvin W. Thompson: Telephonic Status Conference held on 2/2/2009. In addition to counsel for the parties, the Movants Ruben Perez, Dan van Tassel, and their Attorney Kirk Lowry, were also on this conference call. The parties will file oppositions to the motion to intervene. Oral argument on that motion is scheduled for 2/18/09 at 3:30pm. 15 minutes (Court Reporter Thompson) (Smith, S.) (Entered: 02/03/2009)
NOTICE OF E−FILED CALENDAR: THIS IS THE ONLY NOTICE COUNSEL WILL RECEIVE. Hearing on Motion to Intervene 5 set for 2/18/2009 at 03:30 PM in the South Courtroom, 450 Main Street, Hartford, CT before Judge Alvin W. Thompson. All persons entering the courthouse must present photo identification. (Smith, S.) (Entered: 02/11/2009)
12 OBJECTION re 5 MOTION to Intervene filed by State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez. (Attachments: # 1 Memorandum in Support of Objection to Motion to Intervene)(Ring, Thomas) (Entered: 02/13/2009)
13 RESPONSE re 5 MOTION to Intervene filed by USA. (Dean, Kerry) Motion Link Modified on 2/17/2009 (Bauer, J.). (Entered: 02/13/2009)
14 Joint MOTION to Continue Hearing on Motion to Intervene by Ruben Perez, Connecticut Legal Rights Project, Inc. (Lowry, Kirk) (Entered: 02/17/2009)
15 ORDER: The Joint Motion for Continuance 14 of the motion hearing is hereby GRANTED to May 21, 2009 at 3:00pm. It is so ordered. Signed by Judge Alvin W. Thompson on 2/18/09. (Smith, S.) (Entered: 02/19/2009)
NOTICE OF E−FILED CALENDAR: THIS IS THE ONLY NOTICE COUNSEL WILL RECEIVE.ALL PERSONS ENTERING THE COURTHOUSE MUST PRESENT PHOTO IDENTIFICATION. Hearing on Motion to Intervene set for 5/21/2009 at 03:00 PM in the South Courtroom, 450 Main Street, Hartford, CT before Judge Alvin W. Thompson. (Smith, S.) (Entered: 02/19/2009)
16 REPLY to Response to 5 MOTION to Intervene filed by Ruben Perez, Connecticut Legal Rights Project, Inc. (Attachments: # 1 Exhibit A USDOJ Findings Letter)(Lowry, Kirk) (Entered: 03/02/2009)
17 Amended Memorandum in Support re 5 MOTION to Intervene filed by Ruben Perez, Connecticut Legal Rights Project, Inc. (Attachments: # 1 Exhibit A Doe v. Hogan Consent Decree, # 2 Affidavit B Nancy Ray Affidavit, # 3 Exhibit C Ray CV, # 4 Exhibit D MH Community Letters)(Lowry, Kirk) (Entered: 04/20/2009)
18 Amended Memorandum in Support re 5 MOTION to Intervene filed by Ruben Perez, Connecticut Legal Rights Project, Inc. (Attachments: # 1 Exhibit A Doe v Hogan Consent Decree, # 2 Affidavit Exh. B Ray Affidavit, # 3 Exhibit C Ray CV, # 4 Exhibit D MH State−wide Organizations Letters, # 5 Exhibit E CLRP Letter to USDOJ and CTAG, # 6 Exhibit F USDOJ Response to CLRP)(Lowry, Kirk) (Entered: 04/21/2009)
19 MOTION to Intervene by Patricia Dugas, Gertrude Duncan, Pedro Cartagena, Connecticut Legal Rights Project, Inc.Responses due by 5/12/2009 (Lowry, Kirk) (Entered: 04/21/2009)
20 Memorandum in Support re 19 MOTION to Intervene filed by Connecticut Legal Rights Project, Inc, Patricia Dugas, Gertrude Duncan, Pedro Cartagena. (Attachments:

Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 5 of 6

05/11/2009 05/20/2009 05/27/2009 05/27/2009
06/17/2009
06/30/2009 07/02/2009 07/02/2009
07/08/2009 07/08/2009 11/02/2009 11/06/2009 07/01/2013 07/02/2013

# 1 Exhibit A Doe v Hogan Consent Decree, # 2 Affidavit Exh B Ray Affidavit, # 3 Exhibit C Ray CV, # 4 Exhibit D MH State−wide Orgs Letters, # 5 Exhibit E CLRP Letter to USDOJ and CTAG, # 6 Exhibit F DOJ Letter to CLRP)(Lowry, Kirk) (Entered: 04/21/2009)
21 REPLY to Response to 19 MOTION to Intervene filed by USA. (Attachments: # 1 Exhibit Original Response to Motion)(Dean, Kerry) (Entered: 05/11/2009)
22 Joint MOTION to Continue Hearing on Motion to Intervene by Ruben Perez, Connecticut Legal Rights Project, Inc, Patricia Dugas, Gertrude Duncan, Pedro Cartagena. (Lowry, Kirk) (Entered: 05/20/2009)
23 ORDER: The Joint Motion for Continuance 22 is hereby GRANTED. The hearing will be continued to June 22, 2009 at 2:00pm. It is so ordered. Signed by Judge Alvin W. Thompson on 5/26/09. (Smith, S.) (Entered: 05/27/2009)
NOTICE OF E−FILED CALENDAR: THIS IS THE ONLY NOTICE COUNSEL WILL RECEIVE. ALL PERSONS ENTERING THE COURTHOUSE MUST PRESENT PHOTO IDENTIFICATION. Hearing on motion to intervene set for 6/22/2009 at 02:00 PM in the South Courtroom, 450 Main Street, Hartford, CT before Judge Alvin W. Thompson. (Smith, S.) (Entered: 05/27/2009)
NOTICE OF E−FILED CALENDAR: THIS IS THE ONLY NOTICE COUNSEL WILL RECEIVE. ALL PERSONS ENTERING THE COURTHOUSE MUST PRESENT PHOTO IDENTIFICATION. Hearing on Motion to Intervene has been MOVED to 7/17/2009 at 11:30 AM in the South Courtroom, 450 Main Street, Hartford, CT before Judge Alvin W. Thompson. (Smith, S.) (Entered: 06/17/2009)
24 NOTICE of Settlement and Withdrawal of Motions to Intervene by Ruben Perez, Connecticut Legal Rights Project, Inc, Patricia Dugas, Gertrude Duncan, Pedro Cartagena (Lowry, Kirk) (Entered: 06/30/2009)
25 Joint MOTION to Amend/Correct 4 MOTION for Settlement by State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez.AND USA Responses due by 7/23/2009 (Hoell, Jacqueline) FILERS Modified on 7/6/2009 (Bauer, J.). (Entered: 07/02/2009)
26 ORDER: The Notice of Settlement and Withdrawal of Motions to Intervene 24 filed by Gertrude Duncan, Ruben Perez, Patricia Dugas, Pedro Cartagena, and Connecticut Legal Rights Project, Inc is hereby APPROVED. The docket sheet shall reflect that the Motion of Ruben Perez and Connecticut Legal Rights Project to Intervene 5 and the Motion to Intervene 19 have been withdrawn. It is so ordered. Signed by Judge Alvin W. Thompson on 7/2/2009. (Jones, S.) (Entered: 07/02/2009)
27 ORDER: The Joint Motion to Amend Settlement Agreement 25 is hereby GRANTED. It is so ordered. Signed by Judge Alvin W. Thompson on 7/8/2009. (Jones, S.) (Entered: 07/08/2009)
28 ORDER granting the Joint Motion for Entry of Settlement Agreement 4 and dismissing the case. Signed by Judge Alvin W. Thompson on 7/8/2009. (Jones, S.) (Entered: 07/08/2009)
29 MOTION for AAG Thomas J. Ring to Withdraw as Attorney by State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez. (Hoell, Jacqueline) (Entered: 11/02/2009)
30 ORDER: Thomas Ring's Motion to Withdraw as Attorney 29 is hereby GRANTED. Attorney Thomas J. Ring terminated. Signed by Judge Alvin W. Thompson on 10/5/09.(Smith, S.) (Entered: 11/06/2009)
31 Joint NOTICE by State of Connecticut, Dept of Mental Health & Addiction Svc, USA (Hoell, Jacqueline) Modified on 7/2/2013 to include additional filer (Ferguson, L.). (Entered: 07/01/2013)
Docket Entry Correction re 31 Joint Notice: modified to include additional filer (USA). (Ferguson, L.) (Entered: 07/02/2013)

Case: 3:09-cv-85 As of: 03/31/2017 01:56 PM EDT 6 of 6

07/03/2013 09/10/2013
09/10/2013 09/25/2013
05/18/2015 05/22/2015

32 NOTICE of Appearance by William Granville Maddox on behalf of USA (Maddox, William) (Entered: 07/03/2013)
33 NOTICE of Appearance by Henry A. Salton on behalf of State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez official capacity only (Salton, Henry) (Entered: 09/10/2013)
34 Joint NOTICE by State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez, USA (Hoell, Jacqueline) (Entered: 09/10/2013)
35 ORDER: Notice of Substantial Compliance with Certain Terms of the Settlement Agreement and Extension of Termination 34 is hereby APPROVED. It is so ordered. Signed by Judge Alvin W. Thompson on 9/24/13. (Smith, S.) (Entered: 09/25/2013)
36 NOTICE by State of Connecticut, Dept of Mental Health & Addiction Svc, Luis Perez of Substantial Compliance and Termination (Hoell, Jacqueline) (Entered: 05/18/2015)
37 ORDER: The Notice of Substantial Compliance and Motion to Terminate the Settlement Agreement (Doc. No. 36 ) is hereby APPROVED. The Settlement Agreement is terminated with prejudice and the court's continuing jurisdiction to enforce the Settlement Agreement has ended. It is so ordered. Signed by Judge Alvin W. Thompson on 05/22/2015. (Koehler, S) (Entered: 05/22/2015)