THE PROTECTION AND ADVOCACY FOR INDIVIDUALS WITH MENTAL 

ILLNESS (PAIMI) PROGRAM ACTIVITIES REPORT FOR

FISCAL YEARS 2019 AND 2020 

6/28/2022 
ii
iii

Table of Contents 

INTRODUCTION .......................................................................................................................... 4

HISTORICAL OVERVIEW .......................................................................................................... 4

FUNDING....................................................................................................................................... 5

PAIMI PROGRAM ACTIVITIES ................................................................................................. 6

A. Demographic Information ................................................................................................... 6

B. Services for Individuals ......................................................................................................... 8

1. Abuse ............................................................................................................................... 8

2. Neglect ........................................................................................................................... 10

3. Rights Violations .......................................................................................................... 13

4. Death Investigations ..................................................................................................... 17

5. Complaints Favorably Resolved for Clients .............................................................. 20

6. Intervention Strategies ................................................................................................. 20

C. Class Action Litigation ........................................................................................................ 23

D. Interventions on Behalf of Groups of PAIMI-eligible Individuals ...................................... 25

E. Public Education, Training, and Awareness Activities ....................................................... 28

F. Accomplishments, Impediments, and Unmet Advocacy Needs ............................................ 29

GOVERNANCE ........................................................................................................................... 33

1. The Governing Authority ................................................................................................... 34

2. The PAIMI Advisory Council ............................................................................................. 34

CONCLUSION ............................................................................................................................. 37

Appendix A – Data Tables for Fiscal Years 2019 and 2020 ........................................................ 38

Appendix B - Acronyms ............................................................................................................... 94
4 

INTRODUCTION

This report summarizes the annual activities for fiscal years (FY) 2019 and 2020 of the 

Protection and Advocacy for Individuals with Mental Illness (PAIMI) grantees, funded and 

administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), 

Center for Mental Health Services (CMHS). Each PAIMI grantee is required to transmit an 

annual report to the Secretary of the Department of Health and Human Services (HHS) that 

describes its program activities, accomplishments, and expenditures during the most recently 

completed FY.1 SAMHSA summarizes the grantee activity information and prepares a report, 

which includes aggregate data for the Secretary.2 

HISTORICAL OVERVIEW

The Developmental Disabilities Assistance and Bill of Rights Act of 1975, commonly known as 

the DD Act, established systems in each state, the District of Columbia, and five territories to 

protect the legal and human rights of individuals with developmental disabilities.3

 These 

entities, the state Protection & Advocacy (P&A) systems, were governor-designated and 

approved by the Administration on Disabilities4 (AoD), within the Administration for 

Community Living (ACL). The DD Act authorized formula grants to each eligible state P&A 

system to support activities on behalf of individuals with intellectual and developmental 

disabilities through the Protection and Advocacy for Developmental Disabilities (PADD) 

Program, administered by ACL/AoD. ACL/AoD, which oversees the first P&A program, is the 

lead federal agency on matters pertaining to designation or re-designation of a P&A system. 

The PAIMI Act of 19865

 extended the DD Act protections to individuals with significant 

(serious) mental illness (adults) and significant (severe) emotional impairments (children/youth) 

at risk for, or in danger of abuse, neglect, and rights violations, while residing in public or private 

residential care and treatment facilities. The same AoD-approved, governor-designated state 

P&A systems that received PADD Program funding were authorized to administer the PAIMI 

Program. 

The PAIMI Act6 mandated state P&A systems to: 

1) Protect and advocate for the rights of residents with significant (serious) mental illness 

(adults) and significant (severe) emotional impairments (children and youth),7

 residing in 

public and private care and treatment facilities who are at risk for, or in danger of abuse, 

neglect, and rights violations by using administrative, legal, systemic or other appropriate 

remedies on their behalf; 

1 42 U.S.C. 10805(a)(7)

2 PAIMI Act at 42 U.S.C. 10824 3 42 U.S.C. 6041

4 Formerly named the Administration on Intellectual and Developmental Disabilities (AIDD) 5 42 U.S.C. 10801 et seq.

6 42 U.S.C. 10801(b)

7 Adults with significant mental illness denotes adults with serious mental illness. Children with significant

emotional impairments denotes children with severe emotional impairments.
5 

2) Investigate reports of abuse, particularly incidents involving serious injuries and deaths, 

related to the inappropriate use of seclusion and restraint; and 

3) Ensure enforcement of the United States Constitution, federal laws and regulations, and 

state statutes. 

In 1986, there were 56 P&A systems located in each state, the District of Columbia, and five 

territories (American Samoa, Guam, the Commonwealth of the Northern Mariana Islands, the 

Commonwealth of Puerto Rico, and the U.S. Virgin Islands). At that time, 45 P&A systems 

operated as private, non-profit organizations (as designated by the respective state governors). 

The remaining 11 P&A systems were state or territory operated (Alabama, American Samoa, 

Connecticut, Indiana, Kentucky, New York, North Carolina, North Dakota, Ohio, the 

Commonwealths of Puerto Rico, and Virginia) and independent of any state agency that 

provided treatment or services, other than advocacy services, to individuals with mental illness.8

However, as of September 30, 2018, there remained five state-operated P&A systems (Alabama, 

American Samoa, Kentucky, North Dakota, and the Commonwealth of Puerto Rico). In 2000, 

the PAIMI Act was amended by the Children’s Health Act (CHA) of 2000.9 The CHA 

established a 57th P&A system for Native Americans, the American Indian Consortium (AIC). 

The AIC is composed of the Navajo Nation and Hopi tribal councils in the Four Corners region 

of the Southwest (Colorado, Utah, Arizona, and New Mexico). 

The CHA10 requires “a public or private general hospital, nursing facility, intermediate care 

facility, or other health care facility, that receives support in any form from any program 

supported in whole or in part with funds appropriated to any Federal department or agency shall 

protect and promote the rights of each resident of the facility, including the right to be free from 

physical or mental abuse, corporal punishment, and any restraints or involuntary seclusions 

imposed for purposes of discipline or convenience.”11 Per CHA, “each facility shall notify the 

appropriate agency, as determined by the Secretary, of each death that occurs at each such 

facility while a patient is restrained or in seclusion, of each death occurring within 24-hours after 

the patient has been removed from restraints and seclusion, or where it is reasonable to assume 

that a patient's death is a result of such seclusion or restraint. A notification under this section 

shall include the name of the resident and shall be provided not later than seven days after the 

date of the death of the individual involved.”12 The CHA clarified that the state P&A systems 

had the authority to investigate incidents of restraint and seclusion in these types of facilities. 

The CHA also allowed state P&A systems to serve PAIMI-eligible individuals who lived in the 

community, including their own homes; however, individuals residing in care and treatment 

facilities must have priority for program services. 

FUNDING

Each P&A system must submit an annual application or update its annual program priorities, 

proposed budget/expenditures, the PAIMI Program assurances, and any other information 

8 42 U.S.C. 10801(b)

9 42 U.S.C. 290 et seq. 10 42 U.S.C. 290ii 11 42 U.S.C. 290ii (a) 12 op. cit. at 42 U.S.C. 290ii - 1 
6 

requested by SAMHSA.13 The annual PAIMI Program awards, subject to availability of 

appropriations, are based on a formula prescribed by the statute.14 The PAIMI formula is based 

equally on the population of each state in which there is an eligible system and on the population 

of each state weighted by its relative per capita income.15 Relative per capita income is the 

quotient of the per capita income of the United States and the per capita income of the state. 

Relative per capita income is not used for American Samoa, Guam, the Commonwealth of the 

Northern Mariana Islands, and the U.S. Virgin Islands. Their quotient shall be considered as 

one.16 The Secretary shall use no more than two percent of the amount appropriated, commonly 

known as the set-aside under the PAIMI Act, to provide technical assistance to eligible 

systems.17

The following table reflects the total annual PAIMI Program grant appropriations, the technical 

assistance set-aside, and the minimum and maximum grant allotments awarded to the states and 

territories in FY 2019 and 2020. Based on the final allocations, California, the largest state P&A 

system, received the maximum state award of $3,064,013 for FY 2019 and $3,043,159 for FY 

2020. The minimum state allotment for P&A system grants were $428,000 for both fiscal years. 

Four of the five territories (American Samoa, Guam, the Commonwealth of the Northern 

Mariana Islands, and the U.S. Virgin Islands) and the American Indian Consortium each received 

$229,300 for both fiscal years. 

FY 2019 FY 2020 

To State P&A Systems $35,335,256 $35,331,864 

Technical Assistance Set-aside $720,708 $721,058 

Total Annual PAIMI Appropriation $36,055,964 $36,052,922 

FY 2019 FY 2020 

Minimum State Award $428,000 $428,000 

Maximum State Award $3,064,013 $3,043,159 

Minimum Territory Award $229,300 $229,300 

 [Source: Appendix - Table 1] 

PAIMI PROGRAM ACTIVITIES 

A. Demographic Information 

1. Age and Sex 

The following tables summarize the number of PAIMI-eligible individuals or clients served in 

each FY by age and sex. 

Age in Years FY 2019 

0-4 4 

13 42 U.S.C. 10821 14 42 U.S.C. 10822 15 42 U.S.C. 10822 (a) (1) (A) (i) and (ii) 16 42 U.S.C. 10822 (a) (1) (B) 17 42 U.S.C. 10825
7 

Age in Years FY 2019 

5-12 602 

13-18 1,342 

19-25 895 

26-64 7,141 

65 and over 843 

Total Served 10,827 

Sex FY 2019 

Male 6,120 

Female 4,660 

Unknown 47 

Total Served 10,827 

[Source: Appendix - Table 2a18

Age in Years FY 2020 

0-2 14 

3-5 23 

6-10 308 

11-22 1,825 

23-64 6,906 

65+ 662 

Unknown 130 

Total Served 9,868 

Sex FY 2020 

Male 5,588 

Female 4,176 

Unknown 104 

Total Served 9,868 

 [Source: Appendix - Table 2b]

2. Ethnicity and Race 

PAIMI clients served by the P&A systems self-identified their ethnicity and race19. The 

following tables provide the ethnicity and racial identities reported by individuals served by the 

P&A systems. The information was self-reported by clients and individuals/clients served 

were permitted to select one or more races. 

18 The reporting format for age in years were changed slightly in FY 2020. 19 The total number of PAIMI eligible individuals reported by the P&A programs for the Age and Sex tables and for the Ethnicity 

and Race tables are not identical. There was no category to indicate an “unknown” value for the data element “race” and no 

“unknown” value for either “sex” or “age”, only the combination of these values. Hence any individual with an unknown “race” 

or an unknown “sex” or “age” would not be counted in the totals for “race”, “age” or “sex”. This lapse will be corrected for 

future data collection. 
8 

Ethnicity FY 2019 FY 2020 

Hispanic/Latino 1,035 973 

Non-Hispanic/Latino 8,891 7,937 

Unknown 884 960 

Race FY 2019 FY 2020 

American Indian/Alaskan Native 207 182 

Asian 180 159 

Black/African American 2,396 2,085 

Multiple Race 501 496 

Native Hawaiian/Other Pacific Islander 135 105 

White/Caucasian 6,564 5,549 

 [Source: Appendix – Table 3] 

3. Living Arrangements

P&A systems served individuals who resided in various settings. Examples of these living 

arrangements included: 

Living Arrangement Type FY 2019 FY 2020 

Independently in the community 2,620 2,750 

Adult community residential home 551 532 

Psychiatric hospitals 2,230 1,891 

Public and private institutional living 948 1,00320

Legal detention/jail 1,499 1,33821

Homeless/shelter 277 238 

 [Source: Appendix - Table 4] 

B. Services for Individuals

Under the PAIMI Act, state P&A systems are mandated to protect and advocate for the rights of 

individuals with mental illness and authorized to investigate complaints of abuse, neglect, and 

rights violations.22 The following table shows the total number of individual PAIMI abuse, 

neglect, and rights violation cases opened, investigated, and closed. 

1. Abuse 

Number and types of individual abuse complaints investigated and closed per FY included: 

Abuse Complaints FY 2019 FY 2020 

Cases Investigated & Closed 2,116 1,092 

Inappropriate/excessive use of restraints and seclusion 277 209 

Inappropriate/excessive medication 151 137 

20 In Table 4, public and private institutional living were reported together in FY 2019, but separately in FY 2020. 21 In Table 4, legal detention/jails were reported together in FY 2019, but separately in FY 2020. 22 42 U.S.C. 10805(a)(1)
9 

Abuse Complaints FY 2019 FY 2020 

Involuntary electroconvulsive therapy 8 5 

Failure to provide mental health treatment 842 * 

Physical assaults resulting in serious injuries 184 180 

Sexual assaults 85 77 

Staff threats/retaliation/assaults 92 99 

 [Source: Appendix - Table 5] 

 * Data not collected in FY 2020. 

Case Examples from FY 2019 

Delaware 

A client with PTSD and bipolar disorder residing in a state psychiatric facility reported to the 

P&A that she had been physically neglected, abused and financially exploited by relatives prior 

to her admission to the facility. The P&A investigated the client's allegations and assisted her in 

making police reports. The P&A also assisted the client by referring the matter to the Attorney 

General's office for prosecution and communicating several times with the state investigators. 

Ultimately, the client’s half-sister was arrested and charged with a number of crimes; the 

prosecution is still pending. The client was also assisted with discharge planning and referral for 

her and her agent under a power of attorney to private counsel for possible representation in a 

civil lawsuit against her sister. 

Maryland 

The P&A investigated sexual abuse allegations made by a resident at a state psychiatric hospital 

receiving treatment for mental illness. The P&A’s investigation revealed the hospital failed to 

comply with sexual abuse screening and investigation procedures required by the Jane Doe 

settlement agreement and state law. Furthermore, the P&A discovered the hospital failed to 

properly notify the P&A of an additional sexual assault involving the resident. After sending 

written demands to the hospital for corrective action on the resident’s behalf, the hospital 

retrained all staff, including hospital leadership, on sexual abuse screening, reporting, and 

investigation procedures. As a result of the advocacy, the resident’s treatment team updated her 

unique risk assessment form to identify any past trauma, risks, safety concerns, and developed a 

personal protection plan for her intended to reduce any identified risk of sexual abuse, including 

treatment options and safety measures (ex: trauma therapy; 1:1 staffing; moving abuser to a 

different unit, etc.) 

New York

The P&A assisted a minor child with reactive attachment disorder. The client was frequently 

punished at school for behaviors directly related to her mental health diagnosis, resulting in 

allegedly abusive restraint practices, and ultimately leading to her removal from the school. The 

P&A worked with the client’s parents, who had a contentious relationship with school officials, 
10 

to secure home tutoring services. The school and parents then looked for a more appropriate 

program for the client that could address her needs. Once a program was identified, the P&A 

assisted with several transition meetings and follow-up actions to ensure the client’s Individual 

Education Plan was up to date. The client’s parents have reported that the client has been 

successfully attending school and discovering new interests. 

Case Examples from FY 2020 

Florida

The P&A was contacted by a client with mental illness who resides at a state mental health 

hospital. The client reported to the P&A that he had been physically abused by a security officer 

at the hospital. Surveillance video footage showed the client in restraints and shackles being 

escorted back onto his unit by security officers. An officer is seen exchanging words with the 

client in the unit’s foyer area, after which the officer threw the client to the floor, then picked up 

the client with one hand by the restraints. This same officer then shoved him into a wall, opened 

a door forcefully with the client behind it, and hit the client with the door. The officers then left 

the foyer and escorted the client back into the dorm, and the surveillance footage ended. 

Following the incident, the client had an abrasion on his head that was visible to the P&A staff 

but did not report lasting injuries or wanting further medical evaluation because of the incident. 

The P&A communicated with resident advocate staff that this investigation revealed substantial 

findings of physical abuse. The security guard that was seen in the video picking the client up by 

the restraints and hitting him with the door was subsequently terminated shortly after the P&A 

informed the hospital of its findings. The client has since been discharged without reporting any 

additional incidents. 

Ohio

The P&A received a report about an 11-year-old child who experienced unnecessary, prolonged 

manual and mechanical restraints at a private psychiatric facility. The P&A reviewed video 

footage, records of the incidents, and spoke with the child’s guardian and determined that 

hospital staff failed to use other de-escalation techniques before implementing the restraints. 

Due to the finding, the P&A reached out to the hospital and advocated for the use of therapeutic 

and trauma-informed interventions to address the child’s behaviors. 

2. Neglect 

Number and types of individual neglect complaints investigated and closed per FY included: 

Neglect Complaints FY 2019 FY 2020 

Cases Investigated & Closed 1,731 2,303 

Discharge planning 730 730 

Personal care and safety 373 337 

Mental health diagnoses 131 97 

Medical diagnostic physical examination 179 104 

 [Source: Appendix - Table 6] 
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Case Examples from FY 2019 

Alabama 

The P&A investigated a serious occurrence from a report submitted to the P&A pursuant to the 

reporting requirements of the Children’s Health Act. The occurrence involved an 18-year-old 

female diagnosed with disruptive mood dysregulation disorder who lived in a psychiatric 

residential treatment facility (PRTF). The P&A found that a staff member failed to maintain 

eyes-on supervision of the female following a conversation between the staff member and the 

female that led to the female being upset. The female went to her room, closed the door, and was 

left unsupervised for one hour and 15 minutes during which time she cut herself repeatedly and 

ingested multiple medications. The PRTF’s policy requires that when residents are upset or have 

a known history of self-harming behaviors, they have to be monitored in intervals no longer than 

15-30 minutes. In response to the P&A’s findings, the facility increased its staff-to-client ratio 

and re-trained staff on proper resident care and the importance of supervision. The staff member 

who failed to monitor the female was given individual coaching and the PRTF’s supervision and 

monitoring policies were updated to prevent similar future incidents. 

Iowa

The P&A was contacted by the mother of a nine-year-old female diagnosed with PTSD, 

oppositional defiant disorder, attention deficit hyperactivity disorder and mood dysregulation 

disorder. The individual’s mother reported to the P&A that she was assaulted by peers while 

receiving residential mental health treatment at a psychiatric facility. The mother also alleged 

neglect in that staff were not present to appropriately intervene and protect the individual, and 

that they did not properly notify her of the resulting injuries. The P&A’s investigation found that 

the individual was assaulted by her peers; however, multiple staff were present and intervened. 

In addition, the P&A found that the facility did not properly report the incident to it as required 

by federal law. The facility was notified of the findings and their reporting requirements under 

law. 

Guam 

The P&A provided services to a 14-year-old female diagnosed with bipolar and PTSD. The P&A learned 

that the youth had been at a mental health agency’s children inpatient unit for quite a while 

instead of being placed in an appropriate setting, as recommended by the psychiatric doctor 

treating her at the agency. Specifically, the doctor recommended for the youth to be transitioned 

to a children’s residential facility that included an educational component. The P&A, together 

with other social service agencies, advocated for the youth in transitioning to a children’s 

residential care and treatment, including access to special education accommodations and 

modifications to her mental health needs based on her psychiatric diagnosis. Today, the youth is 

receiving overall mental health care and treatment and now in academic transition to her district 

school. 
12 

Oklahoma

The P&A was contacted by the mother of an adult son diagnosed with schizophrenia, depression, 

and anxiety. She lived out of state and was very upset about the mental health care, or lack 

thereof, that her son was getting in an urban county jail in Oklahoma. She informed the P&A that 

he had been in the county jail for a week, had not received any mental health medication, and 

was doing very poorly. The P&A learned that the son was taken off of his mental health 

medications when he was arrested, and the sudden withdrawal had caused him numerous issues. 

The client reported he had been put on different medications that were somewhat helpful, but 

that was experiencing withdrawal symptoms from stopping his previous medication. Because of 

the P&A’s intervention, the client was changed to a more appropriate mental health medication, 

resulting in a decrease of all the symptoms he was complaining of when they met with him in the 

jail.

Case Examples from FY 2020 

Hawaii 

The P&A was contacted by a walk-in client with an unsafe discharge issue. He is a 62-year-old 

male with mental illness and traumatic brain injury. The client was in a borrowed wheelchair and 

needed immediate help with his Activities of Daily Living (ADLs), since he is unable to do his 

own hygiene, cooking, bathing, etc. He said he was discharged from a short-stay post-acute care 

facility for rehabilitative care. The P&A contacted his Medicaid health plan and Medicaid Home 

and Community-Based Service (HCBS) Waiver Service Coordinator and conducted a three-way 

phone call. The HCBS Waiver provider offered to provide immediate services and added they 

had been looking for the client and knew that he needed services. After the client's needs were 

resolved, the P&A contacted the Social Services Manager at the post-acute care facility to 

investigate the unsafe discharge. The P&A identified the failed communication between the 

facility and the HCBS service provider and cited the communication issue as resulting in an 

unsafe discharge. The Social Services Manager stated they would develop a corrective action 

plan and re-train its discharge staff on the new policies. 

Illinois

The P&A investigated a complaint at a county jail that was allegedly not adequately assessing 

and treating individuals with mental health needs. Specifically, the jail was not providing needed 

medication or allowing a client to be seen by a medical professional after the client started 

showing symptoms of serious mental illness. The P&A confirmed this complaint after witness 

interviews and review of records. In follow-up to this investigation, the P&A engaged in 

advocacy efforts with the jail to address these concerns with the jail. In response, the jail agreed 

to increase its capacity for providing mental health services by contracting with a local 

community mental health provider. 
13 

Maryland 

The P&A assisted the client, a patient at a state hospital, who received the wrong prosthetic foot 

while under the care of the hospital and was experiencing difficulty performing Activities of 

Daily Living (ADLs) due to the difficulties of trying to get around with two right feet. The P&A 

was alerted to this case by a former PAIMI Council member who is an advocate for the patient. 

The P&A met with the hospital CEO and staff. The P&A expressed concern that the client had 

been without the correct leg for more than eight months and had fallen and had trouble walking. 

The P&A advocated for individual supports for the client and hospital-wide policy changes to 

ensure that patients' Individual Treatment Plan goals include ongoing medical needs and specific 

staff responsible for follow up. As a result of the P&A’s advocacy, the client received the proper 

prosthetic foot and additional needed supports (including physical therapy). Additionally, the 

P&A filed a complaint with the state’s quality assurance agency detailing the hospital's medical 

neglect of this patient. The state is currently investigating the P&A’s concerns. The P&A is 

providing additional assistance to the client by helping him preserve his tort claim. 

Nebraska

The P&A advocated on behalf of a 53-year-old white female with multiple mental illness 

diagnoses, including borderline personality disorder, bipolar disorder, PTSD, and substance use 

disorders who resided in a psychiatric facility. Because of a family history of breast cancer, the 

client had requested a mammogram. The facility delayed her receiving a mammogram for nearly 

two and half years, at which time, the mammogram she received was determined “highly 

suggestive for malignancy,” and biopsy later confirmed her diagnosis of breast cancer, requiring 

a partial mastectomy. Even after the mastectomy, facility staff denied her radiation treatments 

ordered by her doctors. The P&A collaborated with attorneys from a local law firm to take legal 

action against the psychiatric hospital. Under the terms of the settlement agreement, the State 

agreed to pay $385,000 to the client. While they made no admission of liability or wrongdoing, 

they did agree to make a number of changes that will affect all future patients, including: 

collection of information about family medical history and dates of preventative care; the 

provision of preventative care as required by the American Medical Association; steps to 

improve the lines of communication between regional center staff, patients and medical staff; 

and staff training about the Americans with Disabilities Act (ADA) and the Patient’s Bill of 

Rights. 

3. Rights Violations 

Number and types of individual rights complaints investigated and closed per FY included: 

Rights Violations FY 2019 FY 2020 

Cases Investigated & Closed 4,394 4,790 

 Individual treatment plan 278 142 

Guardianship/conservator problems 232 174 

Problems with advanced directives 93 60 

Failure to provide confidentiality 31 42 

 [Source: Appendix - Table 7] 
14 

Case Examples from FY 2019 

District of Columbia

The P&A represented a 71-year-old woman with serious mental illness and deafness who was 

hospitalized at a private psychiatric hospital in DC. The client was denied meaningful access to 

treatment and the community because her hearing aids were broken, and she did not have access 

to a teletypewriter (TTY) to communicate with her support system outside the hospital. The 

P&A advocated for the hospital to repair her hearing aids and to acquire a TTY for her to use on 

the unit. In addition, the P&A advocated for her treatment team to seek less restrictive 

alternatives to guardianship and more consumer-directed planning by providing information 

about a range of housing and treatment options that would preserve her choices about placement 

and treatment. 

Idaho 

The P&A assisted a 44-year-old male diagnosed with schizophrenia who had concerns that 

his residential treatment provider violated the facility’s rules by not reporting to the state 

licensing entity when he had to be transported and treated at an Emergency Room/Hospital, as 

well as that he had an injury of unknown source as indicated by a missing front tooth. In 

addition, the P&A assisted his Durable Power of Attorney for Heath Care (DPOAHC) with filing 

a complaint of neglect against the residential provider since they did not assess his decline and 

make appropriate changes to his service plan even though the attorney had presented concerns 

about his mental health decline. The licensing entity disagreed with the P&A's interpretation that 

the facility violated the rules by not reporting the hospitalization and the injury of unknown 

source and withdrew the P&A’s complaints. The P&A presented concerns with the rule’s

interpretation, but the determination was not changed. The P&A then assisted his DPOAHC with 

filing a complaint with licensing entity that they neglected his needs even though she had 

reported to facility that his mental health was decompensating. The licensing entity did not cite 

the facility as being neglectful but cited a rule violation regarding not accessing client even 

though they were aware that he was decompensating. The P&A identified this interpretation of 

rules as a possible systemic issue and created a project to monitor future survey results. 

Kansas 

The P&A provided services to a 68-year-old with a mental health diagnosis who was admitted 

into a Nursing Facility for Mental Health (NFMH) in 2012. While traveling from the west coast 

to Connecticut, he had a mental health crisis. He is a veteran and was paying for his stay with his 

benefits. He contacted the P&A because he wanted to be discharged, but no one would help him, 

including the guardian which the NFMH had identified for him. An advocate from the P&A 

worked with him to convince the guardian and the NFMH that he could live in the community 
15 

successfully. As a result of the P&A work, he was able to be discharged to the community and is 

now living successfully on his own. 

Michigan 

The P&A received a complaint involving a child who was being discharged from a psychiatric 

hospital without the home and community-based services he needed to successfully return home. 

The Child Protective Services (CPS) had been contacted by the hospital after the parent 

expressed being fearful of taking the child home where there were other minor children. The 

P&A reviewed records, spoke with the community mental health case manager, CPS 

investigators, general counsel for state health and human services department, Attorney General's 

Office, and the hospital. They also provided technical assistance and self-advocacy tips to the 

parent to use while requesting additional services. The client was successfully returned home 

with a substantial increase in services as requested by the parent and did not enter the foster care 

system. 

North Carolina 

The P&A was contacted by a client who had requested her landlord to permit her to have an 

emotional support dog for her anxiety and depression. She provided medical documentation in 

support of her request. The landlord refused the request and notified the client that she would 

have to leave her apartment. The P&A filed a Fair Housing Act (FHA) complaint with the state 

human rights commission on behalf of the client, which initiated an investigation. The 

commission determined that the landlord had violated the FHA and initiated conciliation. The 

client’s primary goal had been to effectuate a policy change and training; however, at the time of 

conciliation, the landlord was no longer in the business of renting and managing properties. As 

an alternative, the P&A negotiated a favorable financial settlement for the client. The P&A 

ensured that training was included in the conciliation agreement in the event the landlord 

resumes renting properties. 

Case Examples from FY 2020 

Kentucky

The P&A was called by a 49-year-old male who is an inmate incarcerated in a state prison to 

report that he was not able to make phone calls or write letters. The client, who has a diagnosis 

of bipolar disorder and PTSD, is residing in a restrictive housing unit of the prison. The prison’s 

policy and procedure manual states that inmates can have one phone call a week and can receive 

an indigent package of several sheets of paper and envelopes each week to write letters, which 

the prison will pay for the postage. The client contacted the P&A to let them know that the unit 

was not allowed to make phone calls. The P&A opened a service request for the client for denial 

of telephone calls and access to writing materials. The P&A contacted the unit administrator to 

discuss these concerns and was informed that there was a shortage of staff and stated this was the 

reason for the denial of telephone calls. In addition, the P&A contacted the prison warden and 
16 

was informed that there was a shortage of staff, but that should not affect the prisoners’ access to 

writing materials and telephone calls. The P&A informed the Warden that this denial of 

telephone calls and writing materials further isolated the men housed in the restrictive housing 

unit. The Warden stated he was not aware of these concerns and would address it with his staff. 

The P&A later called the client and the client stated he was able to make telephone calls and that 

he had access to writing materials. 

Maryland 

The P&A represented a patient in one of our state hospitals who complained that the hospital was 

violating his rights by subjecting him to 72-hour involuntary medication orders in violation of 

the state statute, which requires the hospital to hold a clinical review panel and afford the patient 

the right to appeal a decision to involuntary medicate him or her. The patient was not a danger to 

himself or others and so could not be involuntarily medicated on an emergency basis. The P&A 

filed a complaint with the state and the hospital was cited with a Statement of Deficiencies and 

required to adopt new policies and conduct training for staff. Two months later, the P&A filed a 

second complaint against another state hospital for the same practice, after the hospital refused to 

voluntarily change its practices to conform with the mandate given to the first hospital. The 

second hospital also received a Statement of Deficiencies and were required to change their 

medication policy and retrain staff. The P&A later learned that the Maryland Behavioral Health 

Administration's Director of Hospitals issued a directive to all state hospitals prohibiting the use 

of 72-hour involuntary medication orders on patients. 

Mississippi

The P&A provided services to a female who resides at a state-operated psychiatric hospital and 

filed a complaint about her mental health services, discharge planning, and the need for specific 

mental health treatment when she is discharged from the hospital. The P&A, after talking with 

the female about her issues, spoke with hospital staff about her treatment plan, discharge plan, 

and the need for the individual to be discharged to a recovery model program, then to a personal 

care home in the community where she would like to live. After the P&A talked with her and the 

hospital staff, she was eventually discharged to a recovery model program that she wanted to go 

to continue her treatment. 

Washington 

The P&A was contacted by a client with history of bipolar disorder and self-injurious behavior 

while incarcerated in Canada and fighting extradition to the United States for criminal 

prosecution. Expecting to eventually be incarcerated in Washington State Department of 

Corrections (DOC) custody for a significant period of time, she initially sought information from 

the P&A about the conditions of confinement in DOC for transgender women. When her 

relocation to Washington State became imminent, the P&A agreed to engage in limited 

representation on her behalf to support the continuation of her medication regimen, genderaffirming housing, and the recognition of her legal name in both the county correctional facility

where she would await sentencing, and upon her transfer to DOC. Upon transfer to the county 

correctional facility, client received a gender-affirming housing placement and a continuation of 
17 

her hormone replacement therapy medication without the advocacy from the P&A. However, her 

legal name was not recognized by the jail, which significantly impacted her mental health and 

well-being, as it led to staff constantly misgendering her and using the incorrect name and 

identifying her as transgender to her peers. In collaboration with her public defender, the P&A 

reached out to the county correctional facility’s attorney to request her booking information and 

identification within the institution be updated to reflect her current and gender-affirming legal 

name. The facility responded that due to a technical issue with the agency's software, her legal 

name could not be updated (she had previously been incarcerated at the institution under her 

former name). The facility also reported that the software would be updated in early 2021. The 

P&A met with the facility on July 31, 2020 and September 9, 2020. As a result, they worked 

with their IT department and other county agencies to update legal names in the jail's software 

system. The P&A was informed that the policy change would occur by the end of September 

2020. 

4. Death Investigations

The PAIMI Act authorized state P&A systems to investigate incidents of abuse, neglect, and 

deaths that occur in public and private care and treatment facilities on behalf of eligible 

individuals.23 Most states had no mandatory reporting statutes, central registries, or other 

statewide systems to capture incidents of restraint, seclusion, serious injuries, or fatalities. 

Despite state data collection limitations, the state P&A systems monitored and investigated the 

use of restraint and seclusion in residential care and treatment facilities, especially incidents 

involving serious injury or death. States with mandatory reporting requirements and central 

registries often send all state death reports to the P&A system, whose staff must review the 

information to determine incidents requiring investigation. Deaths reported by states and CMS, 

and investigated by state P&A systems and other sources were as follows: 

Death Reported by FY 2019 FY 2020 

States 781 949 

Centers for Medicare & Medicaid Services (CMS) 2 3 

Other 104 153 

Deaths Reported Total 887 1,105 

Deaths Investigated, by incident type FY 2019 FY 2020 

Seclusion 4 6 

Restraints 6 7 

Non-Seclusion/Restraint-Related 244 339 

Deaths Investigated Total 254 352 

 [Source: Appendix - Table 8] 

Case Examples from FY 2019 

Delaware

23 at 42 U.S.C. 10802 (1), (3), (4), and (5)
18 

A 29-year-old female diagnosed with bipolar disorder, oppositional defiant disorder and autism 

died unexpectedly of unnatural causes in 2018. Because her death was listed as unnatural and 

unexpected, a detailed review was conducted. Prior to the individual’s death, she was involved 

in an incident at her group home and shortly thereafter began to have difficulty breathing. She 

was transported to the hospital by ambulance and admitted to the intensive care units where she 

remained until her death. The individual died of irreversible brain death. The P&A’s review of 

her death resulted in several findings and recommendations, including retraining of staff on deescalation and restraint techniques, and restraint policy review and revisions. 

Massachusetts

The client’s mother contacted P&A because her daughter had died while at a psychiatric 

hospital. The client had a history of depression, anxiety, obsessive compulsive disorder, bipolar 

disorder, and substance use disorder. She was admitted to a hospital to address trauma from a 

recent rape, as well as her dual diagnosis. She died approximately four days after being admitted, 

and her mother contacted the P&A to investigate After reviewing all available records, the P&A

determined that there was probable cause of neglect by hospital staff. The P&A will be 

continuing to investigate this death into FY 2020. 

New Hampshire

The P&A investigated the death of an inmate with significant mental illness on the Residential 

Treatment Unit (RTU) at a state prison. The P&A's investigation investigated the circumstances 

of an inmate's death in the RTU, as well as general conditions (groups, psychiatric services, 

nursing services) leading up to the inmate's death. The P&A identified multiple areas of concern 

during the investigation. The P&A met with DOC to present their findings including a need for 

increased training for staff and procedures for emergency situations. The DOC accepted and has 

implemented many of the changes that the P&A had recommended.

Wyoming 

The P&A continued its investigation from the previous reporting year of a death of a patient at a 

state hospital who had died by suicide. The patient had a history of suicide attempts in a variety 

of settings. Because of the patient's known suicidal ideation, the hospital had ordered 15-minute

checks, but the checks did not always occur. In addition, the hospital did not increase observation 

of the patient to 1:1, did not provide individual treatment or therapy, and did not move the 

patient to a safer location (patient's room had mechanical door closer that patient was able to 

utilize as part of the suicide). The P&A substantiated both abuse and neglect and reported its 

findings to state and federal agencies. As a direct result of the P&A’s investigation findings, the 

hospital removed the door closers and installed a ligature door security alarm system. 

Case Examples from FY 2020 

Connecticut

The client was a 25-year-old patient at a forensic unit of a hospital who died allegedly by 

choking following a physical restraint by staff. He had a long history of inpatient psychiatric 
19 

treatment and had been admitted under a process identifying him as someone who needed 

heightened security. According to records, client was restrained 13 times while at the hospital, 

and was administered intramuscular injected medication during 12 of those restraints. In 

addition, he was denied access by hospital security to his attorney and his mother, made repeated 

allegations of abuse, and was committed by the probate court, following a finding of “not 

competent,” on the day he died. The P&A found that the hospital violated his rights as to access 

to his attorney and mother, failed to properly manage his food-stuffing behavior, and engaged in 

excessive force in restraining him. 

Florida

The client was a 47-year-old forensic resident of a state hospital who died by suicide. The P&A 

received a report of the client’s death through a report of possible abuse made to the Adult 

Protective Services (APS) abuse hotline. The P&A’s investigation determined that the client died 

by suicide due to negligent supervision of the hospital employee responsible for direct 

observation. The client had been properly categorized as a suicide risk, which required 

behavioral checks every 30 minutes, but the employee tasked with doing these checks did not so 

within the required timeframes. Nearly two hours had elapsed between the last behavioral check 

and when the client was found unresponsive. Although staff took appropriate action at that time 

to attempt to revive the client, their efforts were unsuccessful. During the P&A’s investigation, 

the negligent employee resigned his position, and the facility conducted staff refresher trainings 

on how to conduct behavioral safety checks. The P&A also addressed concerns pertaining to the 

structural integrity of the door pins found in the facility’s resident rooms since the ability of 

residents to remove screws from the doors may have helped facilitate the client’s ability to 

engage in self-harm. The facility therefore conducted maintenance on all door hinges found in 

residential units. Finally, as part of the P&A’s full monitoring of this facility, the experts 

involved provided additional guidance to facility administrators and direct care staff to improve 

resident safety and outcome. 

Missouri

The P&A received a consumer death notification from the state department of mental health for a 

57-year-old Caucasian male diagnosed with major depressive disorder and anxiety disorder. The 

client died by suicide while residing in a private residential care. The client had previously been 

involuntarily committed to a local hospital due to threats to hang himself and had a history of 

suicidal ideation by hanging. According to the records, he was placed in a program for 

individuals who required high supervision (15-minute safety checks); however, staff did not 

conduct 15 minutes safety checks on the client. Instead, checks were conducted every thirty 

minutes to one hour. On the date of death, client was found hanging and having cut himself with 

a razor 45 minutes after the previous check. Letters with recommendations for staff training to 

ensure staff conducts regular safety checks, ensure searches of individuals for contraband upon 

return from shopping trips, and regarding the provision of razors to individuals with suicidal 

ideation were sent to the facility and to the state behavioral health authority. The facility 

implemented the suggested policy changes. 

Washington
20 

The P&A requested records to investigate the death of a patient at a state hospital in February 

2020. The review of the records revealed concerns about the failure of state hospital staff to 

administer naloxone, miscommunication with emergency medical services, and noncompliance 

with policies on authorized leave. The P&A met with the hospital’s Chief Medical Officer and 

Quality Assurance lead to discuss corrective steps that had already been taken in response to the 

incident as well as the results of the state hospital's root cause analysis. The P&A made a second 

records request for the hospital’s morbidity and mortality review and the investigative report of 

the incident from the state’s health department. The additional documentation confirmed the 

P&A’s previous findings that failures to comply with procedure may have contributed to the 

death of the patient. 

5. Complaints Favorably Resolved for Clients 

The case examples in section (1) Abuse, (2) Neglect, and (3) Rights violations provide 

information on the types of favorable outcomes achieved on behalf of individual P&A system 

clients. The following table shows the total number of individual PAIMI complaints 

investigated, closed, and resolved in the client’s favor. 

Complaints Investigated and Closed, by Type FY 2019 FY 2020 

Abuse 2,180 1,092 

Neglect 1,731 2,303 

Rights violations 4,394 4,293 

Total 8,305 7,688 

 [Source: Appendix - Tables 9, 10, & 11] 

6. Intervention Strategies 

The P&A systems are authorized by the PAIMI Act24 to pursue administrative, legal, and other 

remedies, to ensure protection for individuals with mental illness. An individual’s initial 

complaint may involve multiple issues, and P&A systems often use several strategies to resolve 

them. The total strategies used often exceeded the number of complaints investigated and closed 

in a FY, as clients’ initial complaints frequently include multiple issues and various strategies are 

used to resolve them. 

Intervention Strategies, by Type FY 2019 

Short-term assistance 4,984 

Abuse & neglect investigations 1,364 

Technical assistance 943 

Administrative remedies 280 

Negotiation/mediation 903 

Legal remedies 190 

Total Intervention Strategies 8,664 

 [Source: Appendix - Table 12] 

24 at 42 U.S.C. 10805 (a) (1) (C)
21 

Intervention Strategies, by Type FY 2020 

Self-Advocacy Assistance 3,347 

Limited Advocacy 3,141 

Administrative remedies 334 

Litigation 113 

Mediation 140 

Negotiation 724 

Total Intervention Strategies 7,799 

 [Source: Appendix - Table 12] 

Case Examples from FY 2019 

Minnesota

A 20-year woman who was diagnosed with general anxiety disorder, social phobia with panic 

attacks, and major episodic depression enrolled in a local university; she specifically chose the 

university because of its representations to her that they specialized in accommodating students 

with mental illness. During the summer before her first term in the fall, she attempted to set up 

accommodations; however, when she started the fall semester, the accommodations were not in 

place. When she pressed the university about this, it ignored her multiple attempts and 

communications to secure accommodations. She experienced a mental health crisis and required 

hospitalization, which forced to withdraw from the university. The school however, insisted on 

billing the client for $20,000 in tuition and other costs. At this point, she contacted the P&A for 

help. The P&A investigated the concern, reviewed documents, and determined that the case 

would be appropriate for filing a charge of discrimination with the state department of human 

rights. After the charge was filed, the university agreed to withdraw the tuition bill. Further, the 

university also allowed the client to reenroll and ensured that proper accommodations were in 

place. As a result, she was able to begin classes with the necessary supports in place.

New York

The P&A assisted a client diagnosed with PTSD who had requested to have an emotional 

support animal in her Cooperative apartment to accommodate her disability. When she notified 

the Cooperative of her request, the Cooperative provided her with an overly restrictive agreement 

to sign before the Board would grant her the accommodation. The client requested assistance 

from the P&A with resolving the issues with the Cooperative. The client had also filed a 

complaint with the state’s human rights commission. While the Cooperative drastically edited 

the agreement following her complaint, the agreement still would have required her to start the 

reasonable accommodation process all over again if the dog passed away. The P&A contacted 

the Cooperative’s counsel and they agreed to modify the provision so that if the client’s 

emotional support dog passes away, she would only need to provide the Cooperative with a 

photograph of the new dog and proof of vaccination. The client signed the agreement with the 

changes and is now able to keep an emotional support animal in her apartment and remain in her 

home. 

Wisconsin 
22 

The P&A received a phone call from the mother of a jail inmate who had been incarcerated for 

several months on a probation hold. The doctor in charge of his care while he was in jail was not 

a psychiatrist and had cancelled several of the psychiatric medications that the client had been 

taking successfully for years. The mother indicated that she has noticed a marked decline over 

time. The P&A contacted the client for consent to advocate on his behalf on these medication 

issues. After a review of the records, it appeared that the dropping of the two psychotropic 

medications was primarily a cost-saving measure and the jail doctor did not comprehend the 

client's need for them. After advocating with the county's attorneys, the P&A was able to get 

these medications reinstated and after a few weeks there was a noticeable improvement in the 

client's mental health.

Case Examples from FY 2020 

Arizona 

During FY 2020, the P&A successfully used negotiation and mediation to assist a client, a 

person with anxiety disorder who was subjected to discrimination by his employer. The client’s 

supervisor refused to allow him to pass his annual performance review for the stated reason that 

he was not adequately managing his anxiety. The refusal of the supervisor to allow the client to 

pass the performance review resulted in the loss of an annual pay increase for the client. After 

filing a charge of disability-based employment discrimination with the state’s civil rights 

division, the client contacted the P&A for representation during mediation and the negotiation 

process. The P&A represented the client in a mediation, during which the parties were able to 

arrive at a preliminary verbal agreement. Even though the mediation took place near the end of 

FY 2019, most of the substantive negotiations for a satisfactory written settlement agreement 

continued throughout the first quarter of FY 2020. As a result of the P&A's representation of the 

client in these extensive negotiations, the employer agreed to the following remedies: 1) a 4 

percent pay increase retroactive to January 2019; 2) a revision to the client's employment record 

that deletes the comments made by his supervisor and increases his performance review rating to 

pass the review; 3) a revision of the employer's annual performance review criteria if necessary 

after a review of the employer's compliance with the Americans with Disabilities Act; 4) annual 

training on the Americans with Disabilities Act for managers for two years; 5) the Chief of 

Human Resources of the employer meeting with the client’s supervisor to give guidance and 

correction regarding the performance review of the client; 6) and a payment of $5,500 in 

compensatory damages to the client.

California

The P&A filed a discrimination complaint on behalf of a ten-year-old student with autism and 

psychiatric disabilities, alleging that the student was held on the ground in a prone restraint 77 

times over the course of several months. In addition, the complaint described how the student 

experienced lost instructional time and educational opportunities and experienced a hostile 

educational environment due to the excessive use of restraint. This year, a settlement agreement 

with the school was reached. Under the settlement agreement, the school agreed to revise its 

policies and procedures for behavioral interventions of students with disabilities. Some of the 

revisions include developing a new policy requiring staff to meet after each use of restraint to 
23 

consider alternative interventions that could be used prior to the use of restraint; hiring an ADA 

Compliance Coordinator related to behavior interventions; submitting monitoring data for three 

years; training staff on providing individualized supports and interventions. 

Maine

The P&A provided services to a 58-year-old man with mental illness who was being treated in a 

state psychiatric hospital. The man’s U.S. Department of Housing and Urban Development 

(HUD) Section 8 housing voucher was set to expire. The P&A was able to request an 

accommodation from the housing authority using clinical support from the hospital to extend the 

time for his voucher use until he discharged from the hospital. The P&A was able to get the 

client’s voucher extended and therefore help him maintain stable housing upon discharge from 

the hospital. 

Minnesota

A 56-year-old man with depression, anxiety and PTSD requested help from the P&A because of 

a discharge notice from his group home, where he had resided for some time. The P&A 

concluded that the group home had given him 30 days' notice to vacate, rather than the required 

60 days. Additionally, the P&A determined that the notice of demission contained inaccuracies 

about what it said constituted improper behavior. The P&A challenged the demission to before 

an administrative tribunal. The judge issued an order stating that the group home must give him 

the full 60 days to discharge from the group home. Then P&A ensured that the client was 

working with a housing coordinator on finding housing, as he was just approved for a HUD 

Section 8 housing voucher. 

 

C. Class Action Litigation 

To ensure compliance with federal or state laws and regulations and when immediate action is 

needed to protect a group of individuals, state P&A systems may use class litigation.25 This type 

of litigation is a strategy of last resort. This complex strategy often takes years to resolve the 

presenting problem, and requires special staff expertise, resources, and time. These types of 

cases generally involve a range of issues that affect the lives of individuals or groups of 

individuals with mental illness and other disabilities and their families. Class action activities 

reported by the P&A systems on behalf of PAIMI-eligible individuals included: 

Class Action Litigation FY 2019 FY 2020 

Number of Events 94 129 

Total Number of Individuals Impacted 4,099,327 4,228,457 

 [Source: Appendix – Table 13] 

Case Examples from FY 2019 

Iowa

25 42 U.S.C. 10805 (a)(1)(B)
24 

The P&A filed class action litigation on behalf of youth diagnosed with mental illness who were 

incarcerated at a state-operated correctional facility for youth. The lawsuit is seeking adequate 

mental health care, proper informed consent and oversight of psychotropic drugs, elimination of 

solitary confinement for punitive purposes, and elimination of a restraint device called “the 

wrap.” The complaint was filed on November 27, 2017 and the P &A co-counseled with 

Children’s Rights, Inc., and Ropes & Gray. The litigation continued into Fiscal Year 2019 and a 

bench trial was held in June 2019. Post-trial briefing was completed on August 23, 2019. The 

Judge has not rendered a decision to date. 

Maine

The P&A continues to act as Class counsel in the case of Bates v. Glover which involved 

institutional litigation that provides broad based relief on behalf of approximately 3,500 

individuals who are current or former residents of AMHI/Riverview Psychiatric Center and 

12,000 other otherwise qualified individual with mental illness. The case was settled in 1990. 

One of the aspects of the agreement is that individuals in the community are entitled to 

community services under the terms of this settlement agreement. The P&A, the Court Master 

and the state health and human services agency have continued to meet on a monthly basis to 

monitor progress on these issues. In this fiscal year a recommendation was issued by the Court 

Master, fully supported by the P&A, that would require any contracts that the state health and 

human services agency enters into with any mental health service provider contain a provision 

granting individuals with mental illness who are the beneficiaries of any service the rights of 

third-party beneficiaries to the contracts, thus allowing them to individually assert direct claims 

against providers if they are not providing them the mental health services they are entitled to 

under the contracts. The status of that recommendation is likely to be resolved during the next 

fiscal year.

Utah

The P&A filed a class action against the State of Utah for its failure to protect the constitutional 

rights of pre-trial detainees who have been deemed mentally incompetent and are waiting in 

Utah's county jails until a bed at the state hospital's Forensic Facility becomes available. During 

FY19, the settlement agreement was successfully monitored as per class action settlement terms. 

System-wide, the waitlist for competency restoration services delivered by the state hospital has 

been reduced by 80 percent and the avg wait-time has gone from 6 plus months to less than 14 

days. 

Case Examples from FY 2020 

New Hampshire

The P&A has long been subject to class action litigation involving care of prisoners, including 

prisoners with mental illness at the state prison. The case was settled in 2001, but began in 2018, 

when a prisoner filed a petition to enforce conditions in the settlement including access to mental 

health treatment, access to prescription medication and conditions in the prison. In response to 

the petition, the state Department of Corrections (DOC) moved to dismiss the lawsuit, stating 
25 

that the prisoner lacked standing, and that the state had sovereign immunity. The district court 

ruled in favor of the state and the prisoner appealed to the State Supreme Court. The P&A 

submitted an amicus brief with two legal services partners in the case as the decision placed all 

the P&A’s class actions at risk. If the decision held, settlements of class actions or actions 

involving one or more plaintiffs, which is a focus of the P&A's systemic work, would not be 

specifically enforceable if the state failed to perform its obligations under a settlement 

agreement. In addition, the P&A worked with partners to educate the legislature about this 

interpretation of the law, as many believed that the state legislature did not intend this because of

their most recent legislation in this area. The State Supreme Court ruled on behalf of the prisoner 

and the law was changed to ensure class actions could be enforced.

Illinois 

Historically, the P&A has received numerous complaints about the care and treatment of people 

with mental illness in Illinois prisons. Accordingly, the P&A conducted an extensive 

investigation to determine whether these were systemic problems and what the major issues of 

concern were. The investigation revealed that in the Illinois prison system individuals with 

mental illness received substandard care. They were placed for months and even years in social 

and physical isolation and had little opportunity to see mental health professionals beyond 

cursory conversations to renew their prescription medication. Individual therapy was nearly 

nonexistent. The Illinois Department of Corrections (DOC) had few beds located in specialized 

mental health units, and assignment to those units appeared arbitrary. Accordingly, the P&A and 

a coalition of attorneys filed a class action lawsuit, Rasho v. Walker, against the DOC, 

challenging the conditions of confinement experienced by thousands of mentally ill prisoners in 

its custody. In FFY 2016, the parties reached a comprehensive settlement that, if fully 

implemented would significantly improve the conditions and treatments of inmates with mental 

illness. In FFY 2018, the Court Monitor issued a report raising concerns about the State’s 

compliance with the settlement. The P&A and its co-counsel filed a Motion for a Preliminary 

Injunction seeking the Judge to address the State’s deficiencies. In May, the Judge found 

violations of the Settlement Agreement and the Constitution and granted the Preliminary 

Injunction. After the State failed to adequately address the violations, the P&A and its cocounsel filed a Motion for a Permanent Injunction. Following a two-week trial, in FFY 2019, the 

Judge issued a Permanent Injunction. The State has appealed this decision to the 7th Circuit 

Court of appeals. The parties completed the briefing on the appeal and oral argument proceeded 

in FFY 2020. It is expected a decision will be issued in FFY 2021. 

D. Interventions on Behalf of Groups of PAIMI-eligible Individuals

The majority of P&A systems advocated on behalf of groups of PAIMI-eligible individuals. 

These types of activities were not directed toward individuals, but for resolution of a range of 

systemic issues affecting specific groups or larger populations throughout a state. Some systemic 

advocacy activities included legal actions to protect the rights, health, and safety of vulnerable 

facility residents (See C. Class Action). Sometimes, individual complaints resulted in group 

advocacy. Generally, P&A non-case directed advocacy activities focused on implementing 

changes in administrative policy, procedures, or practices in state agencies, residential treatment 

facilities, and other service providers. Activities reported under the Legislative and Regulatory 

Advocacy section are limited to providing technical assistance, education, and awareness about 
26 

current statutes and regulations regarding the rights and protection of individuals with serious 

mental illness (SMI) or serious emotional disturbance (SED) and do not include strictly 

prohibited activities, such as the inappropriate use of federal dollars to influence legislation or 

any actions by federal or state governments described in Section 503 of Title V, in Division H of 

the Consolidated Appropriations Act and specific prohibitions against lobbying in the PAIMI 

regulations.26

Non-Litigation Advocacy FY 2019 FY 2020 

Number of Events 3,121 2,360 

Total Number of Individuals Impacted 16,515,905 50,999,506 

[Source: Appendix – Table 13b] 

Legislative & Regulatory Advocacy FY 2019 FY 2020

Number of Events 347 250 

Total Number of Individuals Impacted 30,589,896 5,418,610 

[Source: Appendix – Table 13]

Case Example from FY 2019 

Alabama 

The P&A participated on a committee convened by the state department of education to address 

the education provided to children and youth with SED residing in residential treatment 

programs, including psychiatric residential treatment facilities, acute hospital settings, juvenile 

correctional and detention facilities, and state hospital placements. On an annualized basis, it is 

estimated that these settings serve approximately 2,000 children. The P&A raised this 

overarching concern regarding the schooling services provided in such facilities: as currently 

constituted under state law and regulation, state-supported educational programs in these 

facilities are not designed to provide educational opportunities that are equal to those provided to 

Alabama students not in these programs. Among other things, the P&A’s work in these facilities 

demonstrate that state policies do not ensure access by students to Alabama’s state-approved 

Courses of Study and grade-level instruction provided by appropriately state-certified teachers. 

There is no requirement that the educational programs provide instructional hours comparable to 

those of community public schools. Youth placed in these programs often do not earn 

transferable class credit because of the structure of the school programs. The state’s department 

of education, which has general supervisory authority over the implementation of the Individuals 

with Disabilities Education Act (IDEA), has no mechanism to ensure the provision of a free 

appropriate public education for eligible students with disabilities in these facilities. The P&A 

has seen gross deficiencies in how the programs implement Child Find. Few facilities engage in 

individualized determinations regarding children’s least restrictive environment. Concurrent with 

a reliance on computerized, online learning programs, there is little direct instruction and direct 

specialized instruction to meet the disability-related needs of the students. Appropriate and 

individualized transition opportunities are lacking, including ensuring access to such services in 

a youth’s least restrictive environment, where it might be community-based opportunities. The 

26 42 CFR Part 51. Subpart A
27 

P&A urged the committee, as it considers any proposals to refashion state policies affecting 

these state-supported educational programs, to judge such proposals against this standard: how 

does the proposal ensure that a child in one of these facilities is offered the same educational 

opportunities as his or her peers attending a community public school in Alabama? At the close 

of the FY, the committee’s work plan was unresolved. The P&A continues to monitor in such 

facilities regarding the education provided to children and youth with SED and is pursuing 

administrative and/or legal remedies absent any movement by the state. 

Louisiana

As a result of a complaint filed by the P&A, in October 2014, the U.S. Department of Justice 

(USDOJ) notified the state that it was initiating an investigation to determine whether the State 

was unnecessarily institutionalizes in nursing facilities individuals with mental illness, in 

violation of Title II of the ADA and the Supreme Court decision of Olmstead v. L. C. DOJ found 

that Louisiana had been using nursing homes to house people with mental health disabilities 

instead of using community-based services. The DOJ found that the state: failed to properly 

follow Pre-Admission Screening and Resident Review (PASRR) assessment procedures 

designed to prevent the unnecessary institutionalization of persons with developmental 

disabilities and mental illness, failed to address the over-incarceration of person with mental 

illness, and failed to ensure that there was an adequate supply of permanent supportive housing. 

As a result of its findings, DOJ filed a complaint and entered into a court enforceable settlement 

agreement which requires the State to “promptly implement remedial measures to protect the 

civil rights of individuals with serious mental illness in, or at serious risk of entering, nursing 

facilities and to remedy the deficiencies discussed above, taking into account the needs and 

preferences of each individual with serious mental illness.” The state is currently developing and 

implementing a plan to bring it in compliance with the Settlement Agreement.

North Dakota 

The state’s department of children and family services distributed proposed rules for residential 

settings for children with mental illness and solicited comments from the public. As part of this 

process, the P&A reviewed the proposed rules and provided written comments regarding four 

areas: use of seclusion & restraint as well as ‘time out’ and the use of mechanical restraints, staff 

knowledge of reporting child abuse and neglect, resident and family engagement, and runaway 

notification of parents/custodians. The State accepted and reviewed the P&A’s comments. As a 

result, changes are being made to the proposed rules. 

Case Examples for FY 2020 

Connecticut

In November 2019, upon completion of a comprehensive and lengthy investigation, the P&A 

substantiated abuse, neglect, and violations of patient rights at two of the largest congregate 

inpatient psychiatric facilities in the state. The P&A issued an extensive Investigation Report 

with a number of specific findings and recommendations, including a recommendation for the 

state’s General Assembly to place one hospital under licensure by the Department of Public 

Health and for the Commissioner of the Department of Health and Addiction Services to enact 
28 

reforms in the areas of concern identified in the report. This report was presented to the state’s 

General Assembly’s task force related to these facilities. The P&A has subsequently completed 

an additional investigation regarding the death of a patient at one of the facilities, which will 

result in the release of an Investigation Report. 

Florida

The P&A engaged in monitoring compliance with a court-ordered settlement agreement that 

addressed the constitutionally deficient treatment of patients in the custody of the Florida 

Department of Corrections who reside on the inpatient mental health units for inmates with 

serious mental illness who require the highest level of care. The agreement requires two rounds 

of monitoring compliance with the settlement agreement to be completed by a neutral monitoring 

authority to occur over a two-year time period. The first year of monitoring has been completed 

and revealed numerous deficiencies in compliance with the original settlement agreement in the 

areas of: (a) staffing; (b) use of restraints; (c) unstructured out-of-cell activities; (d) psychotropic 

medications; and (e) training of the inpatient mental health unit staff. The P&A successfully 

negotiated a corrective action plan that is designed to correct the deficiencies identified during 

the first year of monitoring, the results of which will be monitored during the second year. 

Michigan

Due to limited bed capacity and other factors, defendants found to lack mental competency who 

are to be provided treatment at a facility for forensic psychiatry may end up waiting in jail for 

several months for a transfer to the hospital. The jails, by their own admission, are incapable of 

providing needed mental health treatment. The P&A developed a three-part advocacy strategy to 

address this issue. First, they participated in an Incompetent to Stand Trial (IST) work group of:

sheriffs, prosecutors, community mental health staff and others. This group was able to make 

changes and recommendations, such as not subjecting misdemeanor defendants to the IST 

process. Another change amended the court form used by judges to indicate that treatment could 

be provided not only in a hospital, but also in the community. A second strategy was to represent 

individual clients. The goal of this advocacy was to force the mental health system to make space 

in a hospital or other setting. This led to the third strategy, a complaint to file in federal court, 

however, in the interim, the State agreed to make significant changes. 

E. Public Education, Training, and Awareness Activities

Each state P&A system received requests for information and referral services from its 

constituents via telephone, e-mail, letter, face-to-face, and walk-in visits. The systems also 

provided information by conducting public awareness, education, and training activities. Many 

state PAIMI Programs met with and provided civil rights informational training to consumers, 

stakeholders, and advocacy groups. Other P&A systems conducted mental health law classes for: 

attorneys, graduate students, current and former recipients of mental health services, and mental 

health service professionals. The P&A system provided information to the public by various 

means, including newspapers, radio/television public service announcements, agency 

newsletters, websites, publications, investigative reports, and listservs. Some P&A systems 

within sparsely populated states or with large rural populations used technology to provide 

information through webcams, videoconferences, teleconferences, webinars, Facebook, and 
29 

Skype. The PAIMI Program public education, training, and awareness activities conducted by 

the P&A systems included: 

Educational or Training Activities FY 2019 FY 2020 

Information and Referral Services Requests 20,908 17,020 

a. Number of Public Awareness Activities or Events 2,075 1,396 

b. Number of Educational/Training Activities Undertaken 2,577 1,723 

c. Number (approximate) of Person Trained in b. 110,486 267,308 

 [Source: Appendix, Table 14] 

F. Accomplishments, Impediments, and Unmet Advocacy Needs 

1. Accomplishments 

P&A system intervention improved the quality of life for individuals with mental illness and 

resulted in systemic changes. Examples of these accomplishments included: 

MAJOR ACCOMPLISHMENTS 

Case Examples from FY 2019 

California

Through an investigation, the P&A found that conditions at one of the largest privately operated 

immigration detention facilities in the United States posed serious risks to people with mental 

illness and other disabilities. The findings are contained in a report: “There Is No Safety Here: 

The Dangers for People with Mental Illness and Other Disabilities in Immigration Detention at 

GEO Group’s Adelanto ICE Processing Center.” The report follows an in-depth year-long 

investigation. Among the nearly 2,000 people held at the facility on a given day, approximately 

300 people have mental health treatment needs. The report finds that the facility fails to provide 

adequate treatment to people with serious mental health needs. People who experience a 

psychiatric crisis are often met with pepper spray or extreme isolation in suicide watch cells. 

During the investigation, the P&A discovered that the GEO Group, a private corrections 

contractor that owns and operates the facility, significantly underreports data on the number of 

suicide attempts that occur at the facility. The P&A continues to monitor the facility and intends 

to advocate for policy changes through negotiation and/or litigation in FY 2020. 

Florida

The P&A was contacted by a resident of a supportive housing complex for individuals with 

serious and persistent mental illness, run by Project Return and funded in part by a grant from the 

United States Department of Housing and Urban Development (HUD). Project Return lost HUD 

funding in February 2019 but failed to provide timely notice to residents or to effectively assist 

residents with relocation efforts. The P&A, in an effort to force Project Return into action, 

contacted numerous local entities including the Tampa Hillsborough Homeless Initiative, Central 

Florida Behavioral Health, the Tampa Mayor’s office, officials from Hillsborough County and 

HUD. The P&A applied pressure to these and other groups (through letters, conference calls and 
30 

communication with the local newspaper) in order to persuade them to offer all available 

housing, financial and case management services to residents of Friendship Palms. The P&A’s 

advocacy efforts were effective in that Hillsborough County and various community partners 

mobilized to assist residents of Friendship Palms with relocation assistance, financial assistance,

and case management assistance.

Maryland 

The P&A published two reports that focus on the use of restrictive housing, a practice that is 

particularly harmful for PAIMI eligible persons. The P&A interviewed and reviewed records of 

individuals who have spent extended periods of time in restrictive housing and determined that 

PAIMI-eligible persons experienced increased anxiety, paranoia, hallucinations, and engaged in 

self-harming behaviors in restrictive housing units without adequate access to mental health 

services or programming. The P&A, along with our coalition and community partners, 

successfully advocated for changes to limit the use of restrictive housing for juveniles and 

pregnant women in State correctional facilities. The P&A and our coalition partners distributed 

copies of the P&A’s report to policymakers to educate them about the harm to people with 

mental illness through restrictive housing practices. The policy and legislative changes became 

effective on October 1, 2019 and will protect PAIMI eligible persons for years to come. 

Oklahoma

The P&A has continued to take significant steps to reach the under-served prison population 

during this fiscal year. In FY 2017, the P&A initiated a systemic investigation into the largest 

prison in Oklahoma due to issues it discovered with failure to provide mental health, medical and 

dental care to its inmates. This investigation will continue into FY 2020. Additionally, the P&A 

opened an investigation into a large rural jail which focuses on mental health care of its inmates. 

Over 50 percent of the population of the prison inmates have been diagnosed with a serious 

mental illness. All of the county jail inmates who are a part of our investigation have been 

diagnosed with a serious mental illness. 

Case Examples from FY 2020 

Arkansas 

The P&A received several complaints from staff at a psychiatric residential treatment facility 

(PRTF) regarding the infection control protocols implemented in response to the COVID-19 

pandemic. Staff reported that they were not provided masks and had to bring their own, many 

staff were not wearing masks, residents were not wearing masks, new residents were not being 

quarantined, and while facility-wide testing occurred, staff were not notified of their results or 

the results were inconclusive. The P&A monitors conducted video interviews with residents in 

which they reported that mask-wearing was lax and that if a resident tested positive for COVID19, they were quarantined in their room, essentially in solitary confinement. Upon receiving this 

information, the P&A spoke by telephone with the person responsible for infection control at the 

facility, who agreed to reinforce the facility’s mask policy with staff, ensure masks are provided 

to all staff and residents, and investigate allegations that youth testing positive were being kept in 
31 

their rooms instead of on a dedicated unit that would allow for some movement and interaction. 

Connecticut

In November 2019, upon completion of a comprehensive and lengthy investigation, the P&A 

substantiated abuse, neglect, and violations of patient rights at two of the largest congregate 

inpatient psychiatric facilities in CT. The P&A issued an extensive Investigation Report, which 

included a number of specific findings and recommendations. In January 2020, the P&A 

presented its findings and recommendations to a task force established by the CT General 

Assembly in June 2018 to review and evaluate the operations, conditions, culture, and finances 

of the two facilities. The P&A has subsequently completed an additional investigation regarding 

the death of a patient at one of the facilities, which will result in the release of an Investigation 

Report. The preliminary findings of the Investigation Report were shared with the task force. 

The P&A will continue to monitor the care and treatment of individual patients as part of its 

continuing monitoring of persistent, systemic problems at this facility.

Georgia

The P&A and the Southern Center for Human Rights filed suit against the Fulton County Sheriff 

and other staff at the Union City Jail. The complaint addresses the treatment of women in the 

jail who experience psychiatric disabilities. Currently, the women are housed in deplorable 

conditions. The suit seeks preliminary and permanent injunctive relief to address the conditions 

of confinement as well as the lack of mental health care provided to the incarcerated women. 

The P&A filed a motion for preliminary injunction and a motion for class certification in the 

matter. We had a hearing on the preliminary injunction and prevailed. The Court also granted 

class certification. The County filed an appeal of the District Court decision granting the 

preliminary injunction. This case was argued December 16th. The case is moving forward with 

discovery which will be completed at the end of December. The P&A is also regularly 

monitoring the jail. The County continues to refuse to discuss any terms of settlement. Any trial 

will likely be scheduled in April or May 2021. 

New York

During the prior fiscal year, the P&A filed a lawsuit, M.G. v. Cuomo, in the United States 

District Court for the Southern District on behalf of putative classes of New Yorkers with mental 

illness who have been held in prison past their lawful release dates because of a lack of 

community-based mental health housing and services. The P&A is partnering in this litigation 

with the Legal Aid Society of New York City and the law firm Paul, Weiss, Rifkind, Wharton & 

Garrison. The lawsuit seeks an injunction requiring New York to create an effective plan for 

community integration, which includes developing a sufficient array of community-based mental 

health housing for these individuals. On December 16, 2019, Defendants moved to dismiss the 

case. In an order on September 25, 2020, the Court rejected nearly all of Defendants’ arguments 

and allowed the case to proceed. During litigation, it was also revealed that Defendants have 

released hundreds of people with serious mental illness from prison to homeless shelters, 
32 

halfway houses, and institutional settings simply because there is inadequate capacity in the 

State’s community-based mental health housing and service programs. Despite the unique 

challenges posed by the pandemic, the P&A investigated and documented these inappropriate 

placements. On August 10, 2020, the Plaintiffs’ counsel moved to amend the case to include 

claims on behalf of individuals with serious mental illness who have been released from prison 

but are unnecessarily segregated or placed at serious risks of institutionalization, in violation of 

the Americans with Disabilities Act and the Rehabilitation Act. The Court granted the Plaintiffs 

request for leave to amend the complaint.

2. Impediments & Unmet Needs

Case Examples from FY 2019 

Arizona

One state hospital continued to place restrictions on the P&A’s statutory authority to have 

reasonable unaccompanied access to the hospital’s facilities and patients in FY 2019. The P&A

were not allowed unaccompanied access to patients for purposes of monitoring or abuse and 

neglect investigations. The P&A were also often denied unaccompanied access to areas 

accessible to patients during monitoring and investigative visits. The state hospital also 

continued to deny the P&A access to peer review records that pertain to an investigation into the 

death of a patient.

District of Columbia

The P&A experienced difficulty engaging in our investigatory function at the one hospital when 

P&A with requested documentation. Through several meetings with hospital administration, the 

P&A has improved our access to patient records by solidifying a plan with the hospital 

administration with concrete steps that the P&A will take with the medical records' staff to 

ensure we receive all records that we have requested.

New Hampshire

The P&A had to limit the assistance provided to people with mental illness as the federal funding 

for the PAIMI program is not sufficient to address all the major problems in mental health 

system in New Hampshire.

Vermont

The P&A has a well-established reputation and good working relationship with all facilities 

monitored and is able also to respond to the Children’s Health Act’s expansion into communitybased abuse and neglect concerns, limited in the most part by inadequate funding resources to 

respond to the demand for services and need to monitor facilities and communities spread over 

an often-mountainous rural territory. The lack of clear access to records authority for nontreatment-based entities has been a barrier to obtaining timely and relevant information. 
33 

Case Examples from FY 2020 

Alabama 

The P&A continues to have to remind PRTFs of their serious occurrence report responsibilities 

under the Children's Health Act of 2000. Not all facilities report and, of those that do, not all 

report all reportable incidents. While the P&A’s PAIMI Act access authority has been repeatedly 

reaffirmed in jurisdictions across the U.S., facilities in Alabama continue to challenge the P&A’s 

access to monitor and investigate, hampering the P&A’s ability. 

Kansas 

Although the number of Kansans with mental illness that the P&A provide services to continues 

rise, the amount of PAIMI funds received has remained stagnant. Kansas is home to more than 

120,000 children and adults with mental illness and the lack of increases in PAIMI funds hinders 

our ability to serve those needing assistance. In FFY 2013, the P&A served 92 PAIMI-eligible

clients and received $400,000. In FFY 2020, they served 328 PAIMI eligible clients and received 

$428,000. As demonstrated, the amount of the P&A’s PAIMI funding has not kept up with the 

increase in the client caseload. This is not sustainable. More resources and higher funding levels 

from PAIMI are needed to properly ensure PAIMI eligible Kansans receive the services they 

need.

Mississippi

The COVID-19 pandemic has been the biggest impediments during this past fiscal year. It has

affected the way advocacy was done this past year. From shutting down for a month to getting 

back and having to change the way advocacy work had to be done and continues to be done. 

Virtual meetings, phone calls, emails have been utilized much more than before COVID 19. 

Monitoring "visits" were done by phone with questionnaires and other times through the use of 

computers and phone, virtually. Once in person visits continued the need for Personal Protective 

Equipment (PPE) and wearing of masks has been of utmost concern. It has been difficult, but 

the P&A has moved forward, one day at a time and continues to fight for the rights of those with 

mental illness around the state during this unprecedented time. 

Wyoming 

Lack of placement options in the community for non-PAIMI eligible persons led to 

institutionalization of some individuals at the only state operated. inpatient psychiatric facility. 

This situation led to some PAIMI-eligible persons being unnecessarily jailed or put in other 

settings until a bed came open for their placement at the state facility. 

GOVERNANCE
34 

1. The Governing Authority

The DD Act of 1975,27 which created the state P&A systems, and the PAIMI Act28 mandated 

that private, non-profit entities have a multimember governing authority (the Board) to oversee 

the system.29 Each Board is responsible for the planning, design, implementation, and 

functioning of the system.30 The Board must work jointly with its PAIMI Advisory Council 

(PAC)31 and establish policies and procedures for the selection of its members.32 The DD Act 

included provisions for Board terms of appointment, size, and composition. The DD Act 

required that: 

• Board members be selected according to policies and procedures of the system; 

• The Board include individuals who broadly represent or are knowledgeable about the 

needs of the clients served by the system; 

• The Board must make continuing efforts to ensure that its members represent racial and 

ethnic minorities.33 

• The majority of Board members include individuals with disabilities who are current or 

former recipients of disability services, their family members, guardians, authorized 

representatives and advocates; 

• The system set term limits to ensure rotating membership on the board; and 

• Board vacancies be filled within 60-days.34 

As of September 30, 2019, there were 52 private, non-profit P&A systems. Unlike private, nonprofit P&A systems, state-operated P&A systems may have a governing authority, but they are 

not required to do so. 

The PAIMI Act and Rules also require that the PAC Chair, who must be a current or former 

recipient of mental health services or a family member of such an individual, sit on the 

governing Board of private, non-profit P&A systems.

2. The PAIMI Advisory Council 

Each state P&A system is mandated to establish a PAC35 to advise the system on policies and 

priorities to be carried out in protecting and advocating for the rights of individuals with mental 

27 42 U.S.C. 15043 (a), amended in 2000 28 42 U.S.C. 10805(c) 29 42 U.S.C. 15044 30 42 U.S.C. 10805(c) (2) (A) 31 42 U.S.C. 10805(c) (2) (B) 32 42 U.S.C. 10805(c) (1) (B) 33 respectively at, 42 U.S.C. 10805(a) (6) (C) and 42 CFR 51.22(b) and (c) 34 respectively, at 42 U.S.C. 15044 (a) (1) (A), (B) (i), (ii) and (C) (3) and (4) 35 PAIMI Act at 42 U.S.C. 10805(a) (6) (C)
35 

illness.36 The composition of the PAC is also mandated.37 The PAC Chair must be a current or 

former mental health recipient or a family member of such an individual.38 

Each PAC is required to provide independent advice and recommendations to its state P&A 

system; to work jointly with the governing authority in the development of policies and 

priorities; and submit a section of the system’s annual report.39 Council terms of appointment 

must be staggered and of reasonable duration. The size of the PAC varies by state, but at least 

60 percent of Council members must be current or former recipients of mental health services or 

their family members. The Council must meet at least three times each calendar year, include 

ethnic and racial minorities, and receive information related to its corresponding P&A system’s 

budget, staff, current program policies, priorities, and performance outcomes.40 

The PAC is mandated to provide the governing board with advice and recommendations on the 

annual PAIMI programmatic activities and priorities to be funded in a FY. The PAIMI Act 

requires that the PAC Chair sit on the governing board of private, non-profit state P&A 

systems;41 however, any PAC member may serve on the governing board.42 

By January 1 of each year, each P&A system is required to submit an annual Program 

Performance Report (PPR) to the HHS Secretary.43 The PAC is also required to submit a section 

of that annual PPR, as mandated by the PAIMI Act44 and the PAIMI Rules.45

The Council’s report must: 

• Describe its membership and its PAIMI Program activities;

• Explain its relationship to the P&A governing board of the previous calendar year; 

• Independently assess the P&A system’s PAIMI Program; and 

• Include whether the program accomplished its priorities, goals, and objectives for the 

previous FY. 

In addition to attending meetings, PAC members participated in numerous activities sponsored 

or endorsed by the PAIMI Program (e.g., attending in- and out-of-state trainings, serving on 

P&A governing board committees, engaging in systemic advocacy; and participating in special 

projects). 

TRAINING AND TECHNICAL ASSISTANCE

36 at 42 U.S.C. 10805 (a) (6) (A) 37 PAIMI Act at 42 U.S.C. 10805(a) (6) (B) 38 42 U.S.C. 10805(a) (6) (C) and the PAIMI Rules at 42 CFR at 51.23(b) (2) 39 PAIMI Rules at 42 CFR 51.23 (a) (1) - (3) 40 PAIMI Rules at 42 CFR 51.23(b) (2), (3) and (c) 41 42 U.S.C. 10805 (a) (6) (A), 42 CFR at 51.22 (b) (3) 42 42 CFR at 51.22(d) 43 42 U.S.C. 10805 (a) (7) 44 42 U.S.C. 10824 45 42 CFR 51.8
36 

SAMHSA provides training and technical assistance (T/TA) to the state P&A systems through 

an interagency agreement (IAA) administered by the AoD. AoD, which oversees the PADD 

Program, is the first federal protection and advocacy program, and is the lead on the federal P&A 

system for issues pertaining to designation, re-designation, and regulations. SAMHSA supports 

the IAA with funds specifically set-aside for T/TA, but limited to a maximum of two percent of 

the annual PAIMI Program appropriation. The Rehabilitation Services Administration (RSA), 

within the Office of Special Education and Rehabilitation Services, U.S. Department of 

Education, administers the Protection and Advocacy for the Individual Rights Program, the 

Client Assistance Program, and the Protection and Advocacy for Assistive Technology Program. 

RSA has a separate IAA with AoD. This consolidation of federal P&A program set-aside funds 

maximizes each agency’s limited resources and contributes to a federal partnership among the 

three agencies that fosters cooperation, information sharing, strategic planning, coordination, and 

integration of P&A system activities. 

The Training Advocacy and Support Center (TASC) of the National Disability Rights Network 

was the contractor selected by the AoD to serve the P&A systems. Under the contract, TASC is 

responsible for various T/TA tasks including both general and agency-specific tasks (for 

example, the annual PAC training). TASC activities under FYs 2019 and 2020 contract included 

the following: 

• Investigation protocols for incidents of abuse and neglect cases involving deaths; 

• Seclusion and restraint; 

• Community integration (Supreme Court decision of Olmstead v. L. C.); 

• Medicaid funding; 

• Consumer self-advocacy; 

• Role of PACs; 

• Access to jails, prisons, and juvenile detention facilities; 

• Housing; and 

• Outreach strategies for unserved and underserved populations, including members of 

ethnic and racial minorities and individuals in urban or rural settings, prisons, jails, and

detention centers. 

TASC also assisted P&A systems prepare legal briefs when their PAIMI Act investigative and 

access authority was challenged. 

Under the IAA, TASC prepared three publications: the TASC Update (monthly), LegalEase

(monthly), and the P&A News (quarterly). Each publication was reviewed and edited by the 

federal P&A TA partners (SAMHSA, AoD, and RSA) before AoD approved their distribution to 

the state P&A systems. 

Under the IAA, TASC staff:

• Maintained a website accessible to the public and a webpage accessible only to the 

federal partners and state P&A systems; 

• Developed model guidelines, training manuals, and legal advocacy materials, including 

LegalEase (monthly) and Case Dockets; 
37 

• Analyzed public policy; 

• Established relationships with state P&A system staff;

• Served as liaison to the state P&A system staff;

• Facilitated information exchanges and requests for assistance from the P&A system staff; 

• Subcontracted with national legal organizations, including the Bazelon Center for Mental 

Health Law, the Center for Public Representation, and other legal experts for P&A 

system consultation services; 

• Promoted the use of the Protection and Advocacy Standards, which were developed in 

2009; 

• Identified and disseminated samples of model P&A system policies and procedures; 

• Developed P&A system self-assessment procedures, a project started in 2009; and 

• Planned and conducted training on current disability, legal, and advocacy issues, 

including the Annual Conference, training the P&A executive director, and fiscal 

management training. 

Through the IAA, SAMHSA assists P&As to improve performance (for example, legal advocacy 

services to include individual and systems advocacy), operations, and outcomes; maintain 

statutory compliance; support P&A’s as leaders and catalysts of systems change, capacity 

building, and advocacy at the national, state/territory, and local levels. 

CONCLUSION

This report offers examples of successful implementation of statutorily mandated activities 

related to the PAIMI program. PAIMI grantees worked tirelessly to protect and advocate for the 

rights of individuals with significant (serious) mental illness (adults) and significant (severe) 

emotional impairments (children and youth), residing in public and private care and treatment 

facilities who are at risk for, or in danger of abuse, neglect, and rights violations, by using 

administrative, legal, systemic, or other appropriate remedies on their behalf. PAIMI grantees 

successfully investigated reports of abuse, particularly incidents involving serious injuries and 

deaths related to the inappropriate use of seclusion and restraint, and ensured enforcement of the 

United States Constitution, federal laws and regulations, and state statutes. 

Through the PAIMI program systemic changes were implemented in a variety of settings, which 

ultimately improved treatment, support, and services for those with SMI and SED. The PAIMI 

grantees assisted states/territories make systemic changes, change, or improve practices, and 

implement best practices. Through these and other efforts, the PAIMI program assisted 

individuals and families obtain better treatment, decreased abuse or neglect, protected rights of 

individuals, expanded employment and educational opportunities, and promoted access to 

community living. 
38 

Appendix A – Data Tables for Fiscal Years 2019 and 2020 

Table 1 – State PAIMI Appropriations 

Table 2 – PAIMI Eligible Individuals Served by Age Group and Sex 

Table 3 – PAIMI Eligible Individuals Served by Race and Ethnicity

Table 4 – Living Arrangements of PAIMI Eligible Individuals 

Table 5 – Complaints Involving Alleged Abuse of PAIMI Eligible Individuals

Table 6 – Complaints Involving Alleged Neglect of PAIMI Eligible Individuals 

Table 7 – Complaints Involving Alleged Rights Violations of PAIMI Eligible Individuals 

Table 8 – Death Investigations

Table 9 – Analysis of Alleged Abuse 

Table 10 – Analysis of Alleged Neglect 

Table 11 – Analysis of Alleged Rights Violations 

Table 12 – Intervention Strategies

Table 13 – Non-Case Directed Services

Table 14 – Information and Referral/Public Education/Awareness & Training Activities
39 

Table 1 – State PAIMI Appropriations

State/Jurisdiction FY 2019

Final Appropriations

FY 2020

Final Appropriations

Alabama $457,665 $454,402

Alaska $428,000 $428,000

Arizona $638,784 $641,505

Arkansas $428,000 $428,000

California $3,064,413 $3,043,159

Colorado $449,205 $450,031

Connecticut $428,000 $428,000

Delaware $428,000 $428,000

District of Columbia (DC) $428,000 $428,000

Florida $1,776,069 $1,801,228

Georgia $929,003 $931,818

Hawaii $428,000 $428,000

Idaho $428,000 $428,000

Illinois $1,039,636 $1,031,488

Indiana $590,775 $588,634

Iowa $428,000 $428,000

Kansas $428,000 $428,000

Kentucky $428,000 $428,000

Louisiana $428,000 $428,000

Maine $428,000 $428,000

Maryland $463,525 $462,191

Massachusetts (MA) $502,083 $500,268

Michigan $872,164 $869,127

Minnesota $447,375 $448,703

Mississippi $428,000 $428,000

Missouri $543,808 $540,864

Montana $428,000 $428,000

Nebraska $428,000 $428,000

Nevada $428,000 $428,000

New Hampshire $428,000 $428,000

New Jersey $671,867 $670,077

New Mexico $428,000 $428,000

New York $1,503,880 $1,476,892

North Carolina $913,289 $917,038

North Dakota $428,000 $428,000

Ohio $1,016,255 $1,011,130

Oklahoma $428,000 $428,000

Oregon $428,000 $428,000

Pennsylvania (PA) $1,048,742 $1,040,125
40 

State/Jurisdiction FY 2019

Final Appropriations

FY 2020

Final Appropriations

Rhode Island $428,000 $428,000

South Carolina $462,839 $463,238

South Dakota $428,000 $428,000

Tennessee $590,750 $590,472

Texas $2,392,318 $2,437,992

Utah $428,000 $428,000

Vermont $428,000 $428,000

Virginia $676,109 $677,110

Washington (WA) $577,556 $578,507

West Virginia $428,000 $428,000

Wisconsin $493,546 $490,949

Wyoming $428,000 $428,000

American Indian Consortium (AIC) $511,100 $512,416

American Samoa (Am. Samoa) $229,300 $229,300

Guam $229,300 $229,300

Northern Marianas (N. Marianas) $229,300 $229,300

Puerto Rico $229,300 $229,300

Virgin Islands $229,300 $229,300

Total State P&A Systems $35,335,256 $35,331,864

Technical Assistance Set-aside (20%) $720,708 $721,058

Total Annual PAIMI Appropriations $36,055,964 $36,052,922
41 

Table 2 – PAIMI-Eligible Individuals Served by Age Group and Sex – FY2019 

State/ HHS Age Sex

Jurisdiction Region 0-

4 

5-

12

13-

18

19-

25

25-

64

65+ Total Male Female Unknown Total

Alabama 4 0 16 67 23 69 15 190 136 54 0 190

Alaska 10 0 2 3 3 44 0 52 33 19 0 52

American Indian 

Consortium 13 0 2 12 0 2 0 16 10 6 0 16

American Samoa 9 0 0 5 47 29 4 85 55 30 0 85

Arizona 9 0 6 12 29 271 31 349 166 183 0 349

Arkansas 6 0 23 36 6 26 3 94 58 35 1 94

California 9 0 34 72 62 694 75 937 410 520 7 937

Colorado 8 0 1 4 20 72 4 101 70 30 1 101

Connecticut 1 0 1 6 2 23 6 38 24 14 0 38

Delaware 3 0 2 13 22 121 7 165 82 83 0 165

District of Columbia 3 0 0 10 1 79 21 111 68 43 0 111

Florida 4 0 6 10 17 219 23 275 179 96 0 275

Georgia 4 0 3 7 17 99 5 131 81 50 0 131

Guam 9 0 1 5 2 8 0 16 8 8 0 16

Hawaii 9 0 30 31 5 100 12 178 101 77 0 178

Idaho 10 1 4 7 15 74 10 111 68 43 0 111

Illinois 5 1 77 79 39 347 26 569 313 252 4 569

Indiana 5 0 6 10 5 50 5 76 57 19 0 76

Iowa 7 0 10 12 4 10 4 40 22 18 0 40

Kansas 7 1 8 5 19 295 36 364 161 203 0 364

Kentucky 4 0 9 15 5 60 9 98 61 37 0 98

Louisiana 6 0 14 36 56 368 26 500 257 222 21 500

Maine 1 0 49 76 23 91 15 254 162 92 0 254

Maryland 3 0 4 24 14 161 14 217 126 91 0 217

Massachusetts 1 0 1 0 2 26 2 31 20 11 0 31

Michigan 5 0 6 16 13 115 28 178 115 63 0 178

Minnesota 5 0 20 20 17 137 11 205 94 111 0 205

Mississippi 4 0 3 9 1 18 0 31 13 18 0 31

Missouri 7 0 0 2 14 174 23 213 152 61 0 213

Montana 8 0 23 86 14 107 3 233 136 97 0 233

Nebraska 7 0 0 1 2 12 3 18 5 13 0 18

Nevada 9 0 0 0 1 29 2 32 17 15 0 32

New Hampshire 1 0 11 26 14 198 15 264 111 152 1 264

New Jersey 2 0 4 27 44 151 30 256 149 107 0 256

New Mexico 6 0 16 39 4 52 14 125 75 50 0 125

New York 2 0 2 1 12 128 9 152 75 77 0 152

North Carolina 4 0 2 7 18 63 5 95 72 23 0 95

North Dakota 8 0 57 62 21 61 10 211 140 71 0 211

Northern Marianas 9 0 0 2 2 15 0 19 13 6 0 19

Ohio 5 1 29 63 55 644 55 847 452 393 2 847

Oklahoma 6 0 1 1 5 59 10 76 52 24 0 76

Oregon 10 0 0 0 2 20 3 25 17 7 1 25
42 

State/ HHS Age Sex

Jurisdiction Region 0-

4 

5-

12

13-

18

19-

25

25-

64

65+ Total Male Female Unknown Total

Pennsylvania 3 0 21 34 21 158 11 245 119 126 0 245

Puerto Rico 2 0 1 1 3 64 8 77 34 43 0 77

Rhode Island 1 0 9 21 21 164 33 248 133 115 0 248

South Carolina 4 0 5 159 8 17 2 191 101 90 0 191

South Dakota 8 0 5 6 6 18 2 37 19 18 0 37

Tennessee 4 0 4 6 6 44 1 61 33 28 0 61

Texas 6 0 47 131 81 600 42 901 552 349 0 901

Utah 8 0 7 9 21 124 4 165 74 91 0 165

Vermont 1 0 0 12 3 50 6 71 42 29 0 71

Virgin Islands 2 0 0 2 1 11 2 16 7 9 0 16

Virginia 3 0 0 13 8 72 33 126 73 51 2 126

Washington 10 0 4 1 25 381 108 519 385 127 7 519

West Virginia 3 0 5 4 1 37 9 56 42 14 0 56

Wisconsin 5 0 9 24 11 60 4 108 71 37 0 108

Wyoming 8 0 2 0 2 20 4 28 19 9 0 28

Totals 4 602 1,342 895 7,141 843 10,827 6,120 4,660 47 10,827

Percentages .04 5.6 12.4 8.3 66 7.8 100 56.5 43 .43 100 
43 

Table 2 – PAIMI-Eligible Individuals Served by Age Group and Sex – FY2020 

State/ HHS Age Sex

Jurisdiction Region 0-2 3-5 6-

10

11-

22

23-

64

65+ Unknown Total Male Female Unknown Total

Alabama 4 0 1 11 77 64 8 0 161 112 49 0 161

Alaska 10 0 0 2 3 30 1 0 36 22 14 0 36

American 

Indian 

Consortium

13 0 0 1 10 2 0 0 13 12 1 0 13

American 

Samoa 9 0 0 0 4 39 1 0 44 27 17 0 44

Arizona 9 0 0 10 34 328 30 0 402 178 224 0 402

Arkansas 6 0 0 17 37 9 0 0 63 48 15 0 63

California 9 0 0 11 84 632 69 0 796 337 444 15 796

Colorado 8 0 0 0 3 53 5 2 63 48 15 0 63

Connecticut 1 0 0 1 3 24 2 1 31 20 10 1 31

Delaware 3 0 0 1 22 94 8 0 125 67 58 0 125

District of 

Columbia 3 0 0 0 11 65 18 0 94 60 34 0 94

Florida 4 0 0 3 20 218 21 0 262 180 82 0 262

Georgia 4 0 0 2 17 101 11 0 131 71 60 0 131

Guam 9 0 0 0 4 15 0 0 19 11 8 0 19

Hawaii 9 0 0 13 48 99 11 0 171 95 76 0 171

Idaho 10 0 0 1 21 62 4 0 88 45 42 1 88

Illinois 5 0 4 31 126 355 33 0 549 303 239 7 549

Indiana 5 0 0 3 29 41 5 9 87 51 36 0 87

Iowa 7 0 0 4 21 19 1 0 45 25 19 1 45

Kansas 7 0 2 3 31 273 19 0 328 141 187 0 328

Kentucky 4 0 0 7 18 54 8 2 89 52 37 0 89

Louisiana 6 0 0 3 19 39 2 0 63 45 18 0 63

Maine 1 0 1 16 66 103 11 0 197 123 74 0 197

Maryland 3 0 0 4 27 149 14 0 194 108 86 0 194

Massachusetts 1 0 1 0 16 104 8 0 129 57 69 3 129

Michigan 5 0 1 10 28 118 48 1 206 122 84 0 206

Minnesota 5 0 3 15 60 238 12 0 328 150 170 8 328

Mississippi 4 0 0 1 14 32 2 0 49 32 17 0 49

Missouri 7 0 0 0 8 148 19 0 175 123 52 0 175

Montana 8 0 0 1 59 106 6 0 172 115 55 2 172

Nebraska 7 0 0 0 2 12 2 0 16 4 12 0 16

Nevada 9 0 0 0 3 22 2 0 27 15 12 0 27

New 

Hampshire 1 0 0 3 27 179 9 0 218 104 112 2 218

New Jersey 2 0 0 0 11 173 36 5 225 133 91 1 225

New Mexico 6 0 0 7 32 58 10 1 108 65 42 1 108

New York 2 0 1 3 7 128 11 3 153 82 70 1 153

North 

Carolina 4 0 0 3 23 103 17 0 146 104 42 0 146

North Dakota 8 0 2 35 50 58 6 0 151 101 50 0 151

Northern 

Marianas 9 0 0 0 2 11 0 0 13 10 3 0 13

Ohio 5 9 2 33 117 532 52 0 745 430 306 9 745

Oklahoma 6 0 0 0 5 42 3 0 50 36 14 0 50
44 

State/ HHS Age Sex

Jurisdiction Region 0-2 3-5 6-

10

11-

22

23-

64

65+ Unknown Total Male Female Unknown Total

Oregon 10 0 0 0 1 21 4 1 27 17 9 1 27

Pennsylvania 3 0 0 4 32 203 12 0 251 140 111 0 251

Puerto Rico 2 0 0 1 5 67 8 0 81 39 42 0 81

Rhode Island 1 0 3 8 34 126 9 22 202 119 83 0 202

South 

Carolina 4 4 0 6 189 103 12 0 314 174 140 0 314

South Dakota 8 0 0 2 11 31 4 0 48 18 30 0 48

Tennessee 4 0 0 3 8 25 0 0 36 24 12 0 36

Texas 6 1 2 17 220 627 30 0 897 539 358 0 897

Utah 8 0 0 5 30 201 8 0 244 103 140 1 244

Vermont 1 0 0 0 3 43 3 0 49 30 19 0 49

Virgin Islands 2 0 0 0 2 13 2 0 17 10 7 0 17

Virginia 3 0 0 0 28 58 19 0 105 59 4 42 105

Washington 10 0 0 0 16 371 14 83 484 356 120 8 484

West Virginia 3 0 0 1 13 40 7 0 61 45 16 0 61

Wisconsin 5 0 0 6 34 37 1 0 78 43 35 0 78

Wyoming 8 0 0 0 0 8 4 0 12 8 4 0 12

Totals 14 23 308 1,825 6,906 662 130 9,868 5,588 4,176 104 9,868

Percentages 0.14 0.23 3.12 18.49 69.98 6.71 1.32 100.00 56.63 42.32 1.05 100.00 
45 

Table 3 - PAIMI-Eligible Individuals Served by Race and Ethnicity – FY2019 

 Race Ethnicity

State/ 

Jurisdiction 

HHS 

Region American 

Indian / 

Alaska 

Native 

Asian 

Black or 

African 

American 

Multiple 

Races 

Native 

Hawaiian 

/ Other 

Pacific 

Islander 

White Total 

Hispan

ic or 

Latino 

Not 

Hispanic 

or Latino

Unkno

wn Total 

Alabama 4 0 1 92 2 0 95 190 4 186 0 190

Alaska 10 16 0 5 3 0 28 52 4 48 0 52

American 

Indian 

Consortium

13 16 0 0 0 0 0 16 0 16 0 16

American 

Samoa 9 0 2 0 4 79 0 85 0 81 4 85

Arizona 9 5 6 33 8 0 236 288 61 288 0 349

Arkansas 6 0 0 31 3 0 53 87 5 87 2 94

California 9 10 43 138 43 1 606 841 188 650 99 937

Colorado 8 0 0 12 1 0 46 59 21 59 21 101

Connecticut 1 0 0 5 2 0 22 29 7 29 2 38

Delaware 3 0 3 60 2 0 91 156 8 156 1 165

District of 

Columbia 3 2 0 96 2 0 11 111 2 109 0 111

Florida 4 0 3 99 10 0 163 275 20 255 0 275

Georgia 4 2 1 70 7 0 48 128 5 101 0 106

Guam 9 0 2 1 0 12 1 16 0 16 0 16

Hawaii 9 2 34 7 60 16 59 178 10 168 0 178

Idaho 10 2 0 1 2 0 106 111 10 101 0 111

Illinois 5 4 12 185 34 0 306 541 88 449 32 569

Indiana 5 0 0 17 1 0 56 74 1 75 0 76

Iowa 7 1 0 3 1 0 35 40 1 39 0 40

Kansas 7 4 6 31 9 1 300 351 13 351 0 364

Kentucky 4 1 1 15 3 0 78 98 3 95 0 98

Louisiana 6 1 0 239 0 0 213 453 11 464 25 500

Maine 1 7 3 11 13 0 220 254 2 102 150 254

Maryland 3 1 3 133 8 1 61 207 6 201 10 217

Massachuse

tts 1 2 1 5 2 1 19 30 1 30 0 31

Michigan 5 4 0 66 2 0 102 174 4 174 0 178

Minnesota 5 5 6 54 22 0 117 204 8 196 0 204

Mississippi 4 2 0 6 0 0 23 31 0 31 0 31

Missouri 7 1 1 61 0 1 149 213 0 213 0 213

Montana 8 39 2 2 4 2 184 233 7 190 36 233

Nebraska 7 0 0 3 0 0 14 17 1 17 0 18

Nevada 9 0 1 3 2 1 24 31 1 31 0 32

New 

Hampshire 1 3 4 7 4 1 239 258 5 258 1 264

New Jersey 2 1 9 59 9 0 178 256 29 219 8 256

New 

Mexico 6 3 0 2 1 0 75 81 44 81 0 125

New York 2 1 1 50 3 0 81 136 23 120 9 152

North 

Carolina 4 1 0 41 3 0 48 93 2 78 15 95
46 

 Race Ethnicity

State/ 

Jurisdiction 

HHS 

Region American 

Indian / 

Alaska 

Native 

Asian 

Black or 

African 

American 

Multiple 

Races 

Native 

Hawaiian 

/ Other 

Pacific 

Islander 

White Total 

Hispan

ic or 

Latino 

Not 

Hispanic 

or Latino

Unkno

wn Total 

North 

Dakota 8 32 0 7 18 0 154 211 10 201 0 211

Northern 

Marianas 9 1 3 0 2 12 1 19 0 19 0 19

Ohio 5 1 3 184 16 1 442 647 2 647 205 854

Oklahoma 6 4 0 18 2 0 52 76 0 76 0 76

Oregon 10 0 1 3 1 0 21 26 2 14 10 26

Pennsylvani

a 3 1 7 49 6 0 145 208 17 228 0 245

Puerto Rico 2 0 0 0 77 0 0 77 77 0 0 77

Rhode 

Island 1 1 1 16 7 0 191 216 17 216 15 248

South 

Carolina 4 0 0 85 5 2 99 191 4 185 2 191

South 

Dakota 8 6 0 0 1 0 27 34 1 35 1 37

Tennessee 4 0 0 18 4 0 39 61 2 54 5 61

Texas 6 4 9 224 30 1 633 901 238 658 5 901

Utah 8 2 1 6 0 1 138 148 19 149 0 168

Vermont 1 1 0 4 4 0 61 70 0 70 0 70

Virgin 

Islands 2 0 0 11 1 0 2 14 1 14 0 15

Virginia 3 0 1 25 14 0 82 122 4 122 0 126

Washington 10 12 8 74 31 2 246 373 32 261 226 519

West 

Virginia 3 1 0 2 2 0 51 56 0 56 0 56

Wisconsin 5 2 1 27 6 0 72 108 10 98 0 108

Wyoming 8 3 0 0 4 0 21 28 4 24 0 28

Totals 207 180 2,396 501 135 6,564 9,983 1,035 8,891 884 10,810

Percentages 2.07 1.80 24.00 5.02 1.35 65.75 100 9.57 82.25 8.18 100
47 

Table 3 - PAIMI-Eligible Individuals Served by Race and Ethnicity – FY2020 Race Ethnicity 

State/ 

Jurisdiction 

HHS 

Region American 

Indian / 

Alaska 

Native 

Asian 

Black or 

African 

American 

Multiple 

Races 

Native 

Hawaiian 

/ Other 

Pacific 

Islander 

White Total 

Hispanic 

or 

Latino 

Not 

Hispanic 

or 

Latino 

Unknown Total 

Alabama 4 1 2 78 2 0 76 159 2 159 0 161

Alaska 10 9 0 3 2 0 21 35 0 36 1 37

American 

Indian 

Consortium

13 13 0 0 0 0 0 13 0 13 0 13

American 

Samoa 9 0 0 0 0 44 0 44 0 44 0 44

Arizona 9 6 5 31 9 1 275 327 71 331 4 406

Arkansas 6 1 0 21 3 0 31 56 2 61 5 68

California 9 7 38 133 32 2 321 533 175 527 88 790

Colorado 8 1 0 11 0 0 31 43 9 43 11 63

Connecticut 1 0 0 7 1 0 11 19 5 26 7 38

Delaware 3 0 1 40 2 0 71 114 9 112 2 123

District of 

Columbia 3 0 0 84 1 0 5 90 3 91 1 95

Florida 4 0 2 94 13 0 145 254 28 214 8 250

Georgia 4 2 0 70 5 0 43 120 2 119 11 132

Guam 9 0 0 0 0 14 5 19 0 19 0 19

Hawaii 9 3 33 6 62 13 54 171 7 164 0 171

Idaho 10 3 0 1 2 2 80 88 10 78 0 88

Illinois 5 8 11 159 38 2 300 518 79 419 31 529

Indiana 5 0 1 13 5 0 56 75 1 86 12 99

Iowa 7 0 0 5 4 0 35 44 4 41 1 46

Kansas 7 4 7 25 6 1 225 268 12 316 60 388

Kentucky 4 0 0 10 5 0 71 86 3 86 0 89

Louisiana 6 0 2 29 1 0 29 61 2 60 2 64

Maine 1 2 3 11 6 0 119 141 3 97 56 156

Maryland 3 0 1 107 16 1 61 186 6 188 2 196

Massachusetts 1 1 3 24 2 0 92 122 7 122 0 129

Michigan 5 2 1 49 1 0 95 148 6 174 58 238

Minnesota 5 7 0 70 30 7 203 317 7 0 11 18

Mississippi 4 0 0 20 1 0 24 45 1 48 4 53

Missouri 7 0 1 48 0 1 125 175 0 175 0 175

Montana 8 30 0 1 8 1 105 145 5 167 27 199

Nebraska 7 0 0 3 0 0 13 16 0 16 0 16

Nevada 9 0 0 7 3 0 17 27 0 27 0 27

New 

Hampshire 1 3 1 6 3 0 199 212 7 211 0 218

New Jersey 2 1 10 59 3 0 116 189 32 157 36 225

New Mexico 6 3 0 2 1 0 101 107 34 73 1 108

New York 2 2 2 35 10 0 97 146 23 130 7 160

North 

Carolina 4 2 0 65 2 0 66 135 2 144 11 157

North Dakota 8 25 0 11 11 0 104 151 12 139 0 151
48 

Race Ethnicity 

State/ 

Jurisdiction 

HHS 

Region American 

Indian / 

Alaska 

Native 

Asian 

Black or 

African 

American 

Multiple 

Races 

Native 

Hawaiian 

/ Other 

Pacific 

Islander 

White Total 

Hispanic 

or 

Latino 

Not 

Hispanic 

or 

Latino 

Unknown Total 

Northern 

Marianas 9 0 1 0 4 7 1 13 0 13 0 13

Ohio 5 0 3 148 14 0 364 529 7 738 216 961

Oklahoma 6 4 1 14 5 0 26 50 3 47 0 50

Oregon 10 0 1 1 1 1 8 12 3 24 15 42

Pennsylvania 3 2 2 45 8 0 148 205 14 237 46 297

Puerto Rico 2 0 0 0 81 0 0 81 81 0 0 81

Rhode Island 1 1 2 9 4 0 139 155 13 187 34 234

South 

Carolina 4 2 0 135 7 1 163 308 10 298 6 314

South Dakota 8 5 0 2 3 1 33 44 0 43 4 47

Tennessee 4 0 0 13 1 0 21 35 1 35 0 36

Texas 6 7 9 241 26 0 578 861 203 664 36 903

Utah 8 6 2 9 9 1 184 211 19 205 14 238

Vermont 1 1 1 3 0 0 42 47 1 48 1 50

Virgin Islands 2 0 0 16 0 0 1 17 2 15 0 17

Virginia 3 0 1 23 2 0 54 80 5 75 25 105

Washington 10 13 11 68 29 4 254 379 35 257 105 397

West Virginia 3 1 0 5 1 0 54 61 0 61 0 61

Wisconsin 5 3 1 15 10 1 47 77 6 66 1 73

Wyoming 8 1 0 0 1 0 10 12 1 11 0 12

Totals 182 159 2,085 496 105 5,549 8,576 973 7,937 960 9,870

Percentages 2.12 1.85 24.31 5.78 1.22 64.70 100 9.86 80.42 9.73 100
49 

Table 4 - Living Arrangements of PAIMI Eligible Individuals – FY2019 

State/

Jurisdiction

HHS 

Region 

Community Residential Home for Children/ 

Youth up to age 18 Yrs.Community Residential

Home for Adults

Non-Medical Community

-Based Residential Facility 

for Children/ Youth

Foster Care

Nursing Homes, Including 

Skilled Nursing Facilities (SNF)

Intermediate Care Facilities 

(ICF)

Public and Private General Hospital

Public and Private Institutions

Psychiatric Hospitals 

(Public or Private)

Legal/Jail/ Detention

Veterans Administration Hospital

Other Federal Facility

Homeless

Independent (in the community &

PAIMI-eligible)

Parental or Other Family Home

Unknown

Total

Alabama 4 2 12 0 24 3 0 0 58 2 24 0 0 0 8 53 0 202

Alaska 10 0 2 0 0 0 0 0 3 2 2 0 0 14 25 4 0 54

American 

Indian 

Consortium 

13 0 0 0 1 0 0 0 0 0 1 0 0 0 1 13 0 16

American 

Samoa 9 8 5 5 0 0 0 4 0 17 6 0 0 5 15 20 0 91

Arizona 9 3 46 0 1 0 2 6 16 7 3 0 0 28 56 16 165 349

Arkansas 6 0 2 0 0 1 1 1 6 5 20 0 0 3 2 10 43 100

California 9 5 14 0 1 5 0 4 57 71 74 1 0 47 500 155 3 965

Colorado 8 1 2 0 0 1 2 22 20 19 16 0 1 0 16 0 1 113

Connecticut 1 0 0 0 0 7 0 1 1 8 7 0 0 1 8 5 0 44

Delaware 3 0 10 0 0 1 0 0 0 83 6 0 0 5 31 28 1 171

District of 

Columbia 3 0 20 0 0 0 0 1 30 13 4 0 0 17 18 7 1 111

Florida 4 1 12 1 0 5 0 1 137 52 55 1 0 0 5 5 0 321

Georgia 4 0 10 0 0 0 0 4 8 76 1 0 0 2 3 4 0 109

Guam 9 4 0 0 0 0 0 0 0 2 0 0 0 0 0 10 0 16

Hawaii 9 0 21 0 5 1 0 0 0 22 3 0 0 4 53 69 0 178

Idaho 10 0 9 0 0 3 1 0 59 2 3 0 0 3 17 12 2 113

Illinois 5 0 9 2 3 42 2 6 105 53 29 0 0 12 143 161 2 594

Indiana 5 0 2 0 0 0 1 0 0 8 29 0 0 0 14 14 8 93

Iowa 7 0 2 0 0 3 0 0 3 2 2 0 0 0 1 5 22 40

Kansas 7 0 12 0 0 83 0 0 12 21 4 0 0 6 201 25 0 364

Kentucky 4 1 14 0 0 4 1 0 34 6 18 0 0 0 7 16 0 110

Louisiana 6 1 54 2 1 3 1 3 2 180 28 0 0 9 164 49 3 512

Maine 1 14 27 7 3 2 0 18 0 47 22 0 0 5 21 17 71 255

Maryland 3 0 9 0 0 0 0 6 18 99 27 0 0 6 41 10 1 239

Massachusetts 1 0 1 0 0 0 0 0 15 1 1 0 0 1 8 4 0 32

Michigan 5 1 15 0 0 20 0 5 8 41 65 0 0 1 8 14 0 212

Minnesota 5 2 23 0 3 0 2 1 11 17 19 0 0 3 95 50 0 237

Mississippi 4 0 2 0 0 1 0 0 2 12 4 0 0 0 7 6 0 36

Missouri 7 0 19 0 0 41 8 0 67 5 36 0 0 3 30 4 0 247

Montana 8 106 0 0 0 0 0 0 0 39 58 0 0 2 23 5 0 288

Nebraska 7 0 0 0 0 0 0 0 9 7 0 0 0 0 1 1 0 18

Nevada 9 0 1 0 0 1 0 0 2 10 9 0 0 0 9 0 0 40

New 

Hampshire 1 2 5 0 0 2 0 8 6 53 7 0 0 12 132 36 1 270

New Jersey 2 2 3 0 0 2 1 7 13 160 3 0 0 0 36 29 0 257

New Mexico 6 0 17 0 0 3 25 0 45 3 2 0 0 0 0 30 0 125
50 

State/

Jurisdiction

HHS 

Region 

Community Residential Home for Children/ 

Youth up to age 18 Yrs.Community Residential

Home for Adults

Non-Medical Community

-Based Residential Facility 

for Children/ Youth

Foster Care

Nursing Homes, Including 

Skilled Nursing Facilities (SNF)

Intermediate Care Facilities 

(ICF)

Public and Private General Hospital

Public and Private Institutions

Psychiatric Hospitals 

(Public or Private)

Legal/Jail/ Detention

Veterans Administration Hospital

Other Federal Facility

Homeless

Independent (in the community &

PAIMI-eligible)

Parental or Other Family Home

Unknown

Total

New York 2 0 3 0 0 2 0 1 4 3 36 0 0 4 11 1 87 182

North 

Carolina 4 0 1 0 0 1 0 0 31 2 44 0 0 1 6 9 0 106

North Dakota 8 1 8 1 3 3 1 1 26 6 7 0 0 4 28 122 0 213

Northern 

Marianas 9 0 0 0 0 0 0 0 0 1 5 0 0 2 3 8 0 24

Ohio 5 9 82 0 1 24 1 9 8 189 92 2 0 31 290 93 23 913

Oklahoma 6 0 0 0 0 2 0 0 7 6 52 0 0 0 6 3 0 124

Oregon 10 1 3 0 1 0 0 1 0 15 4 0 0 0 0 1 0 27

Pennsylvania 3 2 7 0 0 3 0 2 5 54 15 0 0 5 105 47 0 250

Puerto Rico 2 0 2 0 0 0 0 0 42 11 3 0 0 0 12 7 0 80

Rhode Island 1 1 8 1 0 13 0 3 11 46 28 0 0 4 69 59 5 273

South 

Carolina 4 3 2 0 3 0 0 0 4 10 129 0 0 0 6 32 2 195

South Dakota 8 0 0 2 0 0 0 0 4 18 1 0 0 0 5 7 0 38

Tennessee 4 0 6 2 0 2 0 0 0 14 20 0 0 1 5 11 0 71

Texas 6 10 13 22 52 11 0 8 10 428 146 0 0 12 130 55 4 907

Utah 8 1 2 0 0 2 0 0 9 2 8 0 0 6 118 19 0 169

Vermont 1 2 4 0 0 0 0 1 3 10 23 0 0 3 22 1 3 95

Virgin Islands 2 0 0 0 0 0 0 0 0 0 0 0 0 0 8 7 1 16

Virginia 3 2 10 1 0 4 0 2 11 82 6 0 0 0 4 3 1 130

Washington 10 4 1 0 0 0 0 4 22 132 251 0 0 14 68 6 17 654

West Virginia 3 2 7 0 0 0 1 1 0 23 9 0 0 0 7 6 0 63

Wisconsin 5 0 9 1 0 2 0 0 4 12 32 0 0 1 16 31 0 127

Wyoming 8 1 3 0 0 0 0 0 0 21 0 0 0 0 2 1 0 28

Totals 192 551 47 102 303 50 131 948 2,230 1,499 4 1 277 2,620 1,416 467 11,607 

Percentages 1.65 4.75 0.40 0.88 2.61 0.43 1.13 8.17 19.21 12.91 0.03 0.01 2.39 22.57 12.20 4.02 100.00 
51 

Table 4 - Living Arrangements of PAIMI Eligible Individuals – FY2020 

State/ 

Jurisdiction 

HHS 

Region 

Community Residential Home for Children/ 

Youth up to age 18 Yrs.Community Residential

Home for Adults

Non-Medical Community

-Based Residential Facility 

for Children/ Youth

Foster Care

Nursing Homes, Including 

Skilled Nursing Facilities (SNF)

Intermediate Care Facilities 

(ICF) 

Public and Private General Hospital including 

Emergency Rooms

Public Institutional Living Arrangement

Private Institutional Living Arrangement 

Psychiatric Hospitals 

(Public or Private)

Jails 

State Prison

Federal Detention Center

Federal Prison

Veterans Administration Hospital/Clinic

Other Federal Facility

Homeless 

Independent (in the community &

PAIMI-eligible) 

Parental or Other Family Home & PAIMI Eligible

Unknown

Total 

Alabama 4 1 10 0 3 2 0 0 33 40 3 22 0 0 0 0 0 0 6 40 1 161 

Alaska 10 0 1 0 0 0 0 0 0 0 0 0 3 0 0 0 0 8 20 4 0 36 

American 

Indian 

Consortium 

13 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 10 0 13 

American 

Samoa 9 4 9 0 0 0 0 7 0 0 7 3 0 0 0 0 0 5 9 11 0 55 

Arizona 9 3 64 1 1 1 1 6 17 5 15 3 0 0 0 0 0 23 211 51 0 402 

Arkansas 6 0 2 11 0 0 0 6 0 5 0 0 2 0 0 0 0 1 3 33 0 63 

California 9 3 7 0 2 4 0 2 61 13 54 45 13 1 0 0 0 38 440 109 4 796 

Colorado 8 0 7 0 0 2 0 6 1 0 28 12 7 0 1 0 0 1 5 0 3 73 

Connecticut 1 0 2 0 0 0 0 0 2 3 15 1 2 0 0 0 0 1 4 1 0 31 

Delaware 3 0 9 0 0 1 0 0 0 9 41 3 6 0 0 0 0 2 29 25 0 125 

District of 

Columbia 3 0 8 0 0 0 0 0 35 0 10 4 0 0 0 0 0 15 18 4 0 94 

Florida 4 0 9 2 0 6 0 1 11

5 5 62 17 60 0 1 0 0 1 6 6 0 291 

Georgia 4 1 16 0 0 2 0 2 11 7 113 4 0 0 0 0 0 2 7 8 0 173 

Guam 9 0 3 0 0 0 0 0 0 0 2 0 0 0 0 0 0 2 5 7 0 19 

Hawaii 9 0 18 0 5 1 0 0 0 0 26 0 0 1 0 0 0 1 51 68 0 171 

Idaho 10 0 7 0 0 0 1 0 33 20 0 0 2 0 0 0 0 0 12 13 0 88 

Illinois 5 1 16 1 1 50 8 18 39 0 85 18 9 2 0 0 0 8 145 147 1 549 

Indiana 5 0 4 8 10 1 0 1 0 3 28 1 0 0 0 0 0 2 17 12 0 87 

Iowa 7 2 3 1 0 1 0 0 0 1 1 0 1 0 0 0 0 0 15 20 0 45 

Kansas 7 1 7 0 1 62 0 11 4 2 5 0 0 0 0 0 0 5 199 31 0 328 

Kentucky 4 1 7 0 1 2 0 0 16 30 2 3 3 0 0 0 0 0 7 16 1 89 

Louisiana 6 3 1 0 0 1 1 0 1 0 9 7 2 0 0 0 1 1 17 19 0 63 

Maine 1 6 22 9 1 2 0 16 0 0 44 13 1 0 0 0 0 7 34 42 0 197 

Maryland 3 0 6 0 1 0 0 5 0 14 71 7 22 0 0 0 0 6 50 12 0 194 

Massachusetts 1 0 1 0 0 1 0 9 33 35 0 0 1 0 0 1 0 5 31 8 1 126 

Michigan 5 1 12 0 1 9 0 3 4 3 39 3 33 0 0 0 0 0 12 27 59 206 

Minnesota 5 3 53 0 1 0 0 5 12 12 26 3 6 1 5 1 0 12 104 80 4 328 

Mississippi 4 1 0 0 0 1 0 0 0 6 19 5 10 0 0 0 0 0 2 3 2 49 

Missouri ̃ 7 1 20 0 0 48 4 1 41 1 4 2 20 0 0 0 0 3 27 3 0 175 

Montana 8 0 0 0 0 1 0 0 47 37 1 0 61 0 0 0 0 0 23 4 0 174 

Nebraska 7 0 0 0 0 1 0 0 7 5 0 0 0 0 0 0 0 0 1 2 0 16 

Nevada 9 0 3 0 0 0 0 0 0 1 12 0 1 0 0 0 0 3 7 0 0 27 

New 

Hampshire 1 0 0 0 1 4 0 18 0 5 37 2 4 0 0 0 0 5 123 19 0 218 

New Jersey 2 0 12 0 0 6 1 8 0 5 136 5 1 0 0 0 0 1 22 4 24 225 

New Mexico 6 0 9 0 4 1 0 1 29 3 5 1 0 0 0 0 0 1 21 33 0 108 
52 

State/ 

Jurisdiction 

HHS 

Region 

Community Residential Home for Children/ 

Youth up to age 18 Yrs.Community Residential

Home for Adults

Non-Medical Community

-Based Residential Facility 

for Children/ Youth

Foster Care

Nursing Homes, Including 

Skilled Nursing Facilities (SNF)

Intermediate Care Facilities 

(ICF) 

Public and Private General Hospital including 

Emergency Rooms

Public Institutional Living Arrangement

Private Institutional Living Arrangement 

Psychiatric Hospitals 

(Public or Private)

Jails 

State Prison

Federal Detention Center

Federal Prison

Veterans Administration Hospital/Clinic

Other Federal Facility

Homeless 

Independent (in the community &

PAIMI-eligible) 

Parental or Other Family Home & PAIMI Eligible

Unknown

Total 

New York 2 0 5 0 0 5 2 1 1 1 3 13 21 1 1 0 0 7 81 8 3 153 

North 

Carolina 4 1 4 0 0 3 1 2 32 12 9 35 25 0 0 0 0 0 13 11 0 148 

North Dakota 8 1 4 3 0 0 0 4 2 3 22 7 5 0 0 0 0 0 19 80 1 151 

Northern 

Marianas ̃ 9 0 0 0 0 0 0 0 0 0 0 0 6 0 0 0 0 1 2 4 0 13 

Ohio 5 8 99 0 2 21 0 4 6 1 114 16 60 0 2 0 0 32 223 112 45 745 

Oklahoma 6 0 1 0 0 1 0 0 0 1 4 17 20 0 0 0 0 0 5 1 0 50 

Oregon 10 0 4 0 1 2 0 1 1 1 8 5 2 0 0 0 0 1 1 0 0 27 

Pennsylvania 3 0 2 1 0 2 0 1 3 5 75 4 9 0 0 0 0 5 115 29 0 251 

Puerto Rico 2 2 2 0 0 0 0 0 0 42 12 0 3 0 0 0 0 0 14 6 0 81 

Rhode Island 1 1 9 0 0 8 0 2 6 4 39 2 46 0 0 0 0 6 43 39 6 211 

South 

Carolina 4 4 9 0 2 1 0 5 8 4 7 137 10 0 0 0 0 3 74 45 5 314 

South Dakota 8 0 2 2 0 1 1 0 0 0 28 0 0 0 0 0 0 0 18 7 0 59 

Tennessee 4 1 3 0 0 1 0 0 0 0 9 4 3 0 0 0 0 0 6 10 0 37 

Texas 6 11 16 11 77 3 1 17 4 3 391 14

2 3 1 1 0 0 10 161 43 2 897 

Utah 8 0 1 0 0 6 0 0 15 1 5 6 3 0 0 0 0 6 174 27 0 244 

Vermont 1 1 4 0 0 0 0 2 3 1 12 3 11 0 0 0 0 0 12 1 0 50 

Virgin Islands 2 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 7 8 0 17 

Virginia 3 0 3 2 0 2 0 3 0 13 67 3 0 4 0 0 1 0 2 1 4 105 

Washington 10 0 7 0 0 1 0 4 8 3 129 10

1 

12

8 0 0 0 0 6 74 9 14 484 

West Virginia 3 3 2 0 0 4 1 0 0 2 32 0 7 0 0 0 0 1 3 6 0 61 

Wisconsin 5 0 6 2 0 2 0 0 3 2 8 2 3 0 0 0 0 1 17 28 4 78 

Wyoming 8 0 1 0 0 0 0 0 0 0 17 0 0 0 0 0 0 0 2 0 0 20 

Selected 

States/ 

Jurisdictions ̃ 

 67 532 54 116 273 22 17

2 

63

3 

37

0 

1,8

91 

68

1 

63

5 11 11 2 2 238 2,750 1,347 184 9,991 

of Selected 

States/Jurisdic

tions ̃ 

 0.67 5.32 0.54 1.16 2.73 0.22 1.

72 

6.

34 

3.

70 

18.

93 

6.

82 

6.

36 

0.

11 

0.

11 0.02 0.02 2.38 27.52 13.48 1.84 100.00 

All States/ 

Jurisdictions ̃ 67 532 54 116 273 22 172 

63

3 

37

0 

1,8

91 

68

1 

63

5 11 11 2 2 238 2,750 1,347 184 9,991 

 All 

States/Jurisdic

tions ̃ 

 0.67 5.32 0.54 1.16 2.73 0.22 1.

72 

6.

34 

3.

70 

18.

93 

6.

82 

6.

36 

0.

11 

0.

11 0.02 0.02 2.38 27.52 13.48 1.84 100.00 
53 

Table 5 – Complaints Involving Alleged Abuse of PAIMI Eligible Individuals – FY2019 

State/

Jurisdiction

HHS 

Regi

on

Number of Abuse Complaints 

Closed 

Medication

Physical Restraint

Chemical Restraint

Mechanical Restraint

Seclusion

Medication

Electric Convulsive 

Therapy (ECT)

Aversive Behavioral Therapy

Sterilization

Failure to provide appropriate

mental health treatment

Failure to provide

Medical Treatment

Physical Assault

Sexual Assault

Staff Threats

/Retaliation/Assaults

Coercion

Financial Exploitation

Suspicious Death

Other

Alabama 4 17 0 6 1 0 0 0 0 0 0 4 0 3 0 1 0 0 1 1 

Alaska 10 3 0 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 

American 

Indian 

Consortium

13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

American 

Samoa 9 40 2 0 0 0 2 5 0 0 0 3 1 4 8 5 3 7 0 0 

Arizona 9 61 17 2 1 1 1 2 0 1 0 22 5 1 2 3 1 2 0 0 

Arkansas 6 25 0 2 0 1 1 0 0 0 0 10 1 5 1 0 3 1 0 0 

California 9 47 2 1 1 1 0 0 0 0 0 8 1 11 11 2 1 3 5 0 

Colorado 8 36 1 5 2 11 2 1 0 0 0 11 1 0 1 0 0 0 1 0 

Connecticut 1 5 0 0 0 0 1 0 0 0 0 3 0 0 0 0 1 0 0 0 

Delaware 3 6 0 1 2 0 0 0 0 0 0 0 0 1 0 0 0 2 0 0 

District of 

Columbia 3 40 4 2 1 2 1 1 0 0 0 7 2 1 3 1 0 11 4 0 

Florida 4 86 10 3 1 0 1 1 0 0 0 27 19 11 4 6 0 1 2 0 

Georgia 4 36 2 1 1 0 0 10 1 0 0 2 5 0 0 3 0 0 11 0 

Guam 9 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 

Hawaii 9 7 0 1 2 0 1 0 0 0 0 1 0 0 0 1 0 1 0 0 

Idaho 10 28 0 2 0 13 7 0 0 0 0 1 2 0 1 1 0 0 1 0 

Illinois 5 92 17 5 5 1 1 10 2 0 0 17 13 2 3 8 0 8 0 0 

Indiana 5 9 0 1 0 1 0 1 0 0 0 6 0 0 0 0 0 0 0 0 

Iowa 7 26 0 5 0 0 5 0 0 0 0 12 1 3 0 0 0 0 0 0 

Kansas 7 26 0 2 0 0 0 1 0 0 0 14 4 0 0 1 0 3 1 0 

Kentucky 4 9 1 0 0 1 3 0 1 0 0 0 1 0 0 0 0 0 2 0 

Louisiana 6 17 1 0 0 2 0 0 0 0 0 9 1 4 0 0 0 0 0 0 

Maine 1 35 0 2 0 0 0 3 0 0 0 29 1 0 0 0 0 0 0 0 

Maryland 3 68 3 1 6 1 3 3 0 0 0 10 4 13 19 3 0 0 1 1 

Massachusett

s 1 14 0 1 0 0 0 0 0 0 0 8 1 2 0 2 0 0 0 0 

Michigan 5 36 1 3 5 1 4 1 0 0 0 11 1 2 2 1 0 2 0 2 

Minnesota 5 45 5 1 0 0 0 0 0 0 0 15 5 0 0 1 0 3 0 15

Mississippi 4 4 1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 

Missouri 7 86 10 3 0 0 0 2 0 1 1 39 20 1 2 5 2 0 0 0 

Montana 8 45 6 4 0 0 3 0 0 0 0 12 3 8 5 1 0 0 1 2 

Nebraska 7 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 

Nevada 9 9 0 0 0 0 0 0 0 0 0 8 1 0 0 0 0 0 0 0 

New 

Hampshire 1 54 1 2 2 2 2 2 1 0 0 38 2 0 0 0 1 1 0 0 

New Jersey 2 153 22 2 0 0 0 0 0 0 0 11 18 50 3 8 2 1 36 0 

New Mexico 6 21 3 3 0 2 0 0 2 0 0 4 1 3 0 2 0 1 0 0 
54 

State/

Jurisdiction

HHS 

Regi

on

Number of Abuse Complaints 

Closed 

Medication

Physical Restraint

Chemical Restraint

Mechanical Restraint

Seclusion

Medication

Electric Convulsive 

Therapy (ECT)

Aversive Behavioral Therapy

Sterilization

Failure to provide appropriate

mental health treatment

Failure to provide

Medical Treatment

Physical Assault

Sexual Assault

Staff Threats

/Retaliation/Assaults

Coercion

Financial Exploitation

Suspicious Death

Other

New York 2 16 0 2 0 0 0 0 0 0 0 12 1 1 0 0 0 0 0 0 

North 

Carolina 4 2 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 

North Dakota 8 29 0 4 0 0 0 0 0 0 0 5 1 4 2 3 1 9 0 0 

Northern 

Marianas 9 2 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 

Ohio 5 127 5 9 0 1 1 8 0 0 0 41 13 15 2 14 11 3 0 4 

Oklahoma 6 47 0 1 0 0 0 0 0 0 0 19 22 0 2 0 1 2 0 0 

Oregon 10 9 0 0 0 0 0 1 0 0 0 4 0 2 0 0 2 0 0 0 

Pennsylvania 3 46 1 13 0 0 0 1 0 0 0 19 3 4 0 2 0 3 0 0 

Puerto Rico 2 2 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 

Rhode Island 1 8 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 1 0 0 

South 

Carolina 4 124 0 0 0 0 2 0 0 0 0 117 2 1 0 0 0 0 2 0 

South Dakota 8 17 4 0 0 0 3 2 0 0 0 5 2 1 0 0 0 0 0 0 

Tennessee 4 12 1 0 1 0 1 0 0 0 0 3 1 3 1 1 0 0 0 0 

Texas 6 100 5 9 1 1 2 4 0 0 0 47 6 17 1 5 0 1 1 0 

Utah 8 6 1 0 0 0 1 0 0 0 0 4 0 0 0 0 0 0 0 0 

Vermont 1 29 2 4 3 0 5 0 0 0 0 8 0 0 1 1 0 5 0 0 

Virgin 

Islands 2 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Virginia 3 30 4 5 1 1 0 1 1 0 0 3 0 2 2 1 1 0 8 0 

Washington 10 255 15 7 0 1 17 11 0 0 0 164 15 7 3 9 1 5 0 0 

West 

Virginia 3 9 1 1 0 0 0 0 0 0 0 5 1 0 0 0 0 1 0 0 

Wisconsin 5 32 1 0 0 0 0 0 0 0 0 24 4 1 2 0 0 0 0 0 

Wyoming 8 24 2 5 0 1 1 0 0 0 0 6 4 0 4 0 0 0 1 0 

Selected 

States/ 

Jurisdictions

 2,11

6 

15

1 

12

3 37 45 72 71 8 2 1 842 190 184 85 92 31 77 80 25

% of Selected 

States/Jurisdi

ctions

 

100.

00 

% 

7.1

4 

% 

5.8

1 

% 

1.7

5 

% 

2.1

3 

% 

3.4

0 

% 

3.3

6 

% 

0.3

8 %

0.0

9 

% 

0.0

5 

% 

39.

79 

% 

8.9

8 %

8.7

0 

% 

4.0

2 

% 

4.3

5 %

1.4

7 

% 

3.6

4 

% 

3.7

8 

% 

1.1

8 

% 

All States/ 

Jurisdictions 2,116 

15

1 

12

3 37 45 72 71 8 2 1 842 190 184 85 92 31 77 80 25

% All 

States/Jurisdi

ctions

 

100.

00 

% 

7.1

4 

% 

5.8

1 

% 

1.7

5 

% 

2.1

3 

% 

3.4

0 

% 

3.3

6 

% 

0.3

8 %

0.0

9 

% 

0.0

5 

% 

39.

79 

% 

8.9

8 %

8.7

0 

% 

4.0

2 

% 

4.3

5 %

1.4

7 

% 

3.6

4 

% 

3.7

8 

% 

1.1

8 

% 

Source: 2019 PAIMI Progress Report: C. Complaints/Problems of PAIMI Eligible Individuals - Areas of Alleged Abuse

The following state(s)/jurisdiction(s) did not supply data: FM, MH, PW, RL

Legend:

 ̃ Non-Finalized Data, e.g., the application/report has been not approved and/or there are open revision requests for the source data.
55 
56 

Table 5 – Complaints Involving Alleged Abuse of PAIMI Eligible Individuals – FY2020 

 Inappropriat

e 

/Excessive

Involuntary Complaints Concerning

State/

Jurisdiction

HHS 

Regio

n 

Number of Abuse 

Complaints Closed 

Medication

Restraint and Seclusion

Medication

Electric Convulsive 

Therapy (ECT)

Aversive Behavioral 

Therapy

Sterilization

Physical Assault

Sexual Assault

Staff Threats

/Retaliation/Assaults

Coercion

Financial Exploitation

Suspicious Death

Other

Alabama 4 31 3 16 0 0 0 0 8 1 1 0 0 0 2 

Alaska 10 1 1 0 0 0 0 0 0 0 0 0 0 0 0 

American Indian 

Consortium 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

American Samoa 9 19 2 0 2 0 0 0 5 0 2 2 6 0 0 

Arizona 9 30 11 3 0 0 0 0 2 3 2 1 2 4 2 

Arkansas 6 8 0 2 0 0 0 0 3 1 0 0 1 1 0 

California 9 28 0 3 0 0 0 0 5 10 1 0 0 9 0 

Colorado 8 4 0 1 0 0 0 0 0 2 1 0 0 0 0 

Connecticut 1 2 1 0 0 0 0 0 0 0 0 0 0 1 0 

Delaware 3 5 0 0 0 0 0 0 0 0 0 0 2 3 0 

District of 

Columbia 3 19 0 1 0 0 0 0 4 1 1 0 3 9 0 

Florida 4 30 5 3 1 0 0 0 15 1 0 1 0 2 2 

Georgia 4 54 10 6 12 0 0 0 11 3 4 0 2 3 3 

Guam 9 3 0 1 0 0 0 0 0 1 1 0 0 0 0 

Hawaii 9 5 1 1 0 0 0 0 2 0 1 0 0 0 0 

Idaho 10 9 0 4 3 0 0 0 0 1 0 0 0 1 0 

Illinois 5 79 0 13 20 1 1 0 13 12 5 1 13 0 0 

Indiana 5 10 1 5 0 0 0 0 2 1 0 0 0 1 0 

Iowa 7 13 1 6 0 0 0 0 1 0 0 0 2 3 0 

Kansas 7 14 1 1 0 0 0 0 1 2 3 1 5 0 0 

Kentucky 4 8 1 2 0 0 0 0 1 1 3 0 0 0 0 

Louisiana 6 5 0 0 0 0 0 0 4 0 1 0 0 0 0 

Maine 1 13 1 7 4 1 0 0 0 0 0 0 0 0 0 

Maryland 3 39 4 7 6 1 0 0 9 5 0 2 1 4 0 

Massachusetts 1 45 0 0 0 0 0 0 4 0 1 0 6 0 34

Michigan 5 30 1 19 0 1 0 0 1 1 1 0 1 0 5 

Minnesota 5 14 8 1 0 1 0 0 2 0 0 0 2 0 0 

Mississippi 4 3 2 1 0 0 0 0 0 0 0 0 0 0 0 

Missouri ̃ 7 30 4 2 5 0 0 1 5 4 7 0 0 2 0 

Montana 8 20 1 6 0 0 0 0 2 2 4 0 1 2 2 

Nebraska 7 6 0 5 0 0 0 0 0 0 0 1 0 0 0 

Nevada 9 2 0 0 0 0 0 0 0 0 1 0 0 0 1 

New Hampshire 1 23 4 11 3 0 0 0 0 0 2 2 1 0 0 

New Jersey 2 129 14 3 4 0 0 0 23 1 9 9 0 66 0 

New Mexico 6 17 11 0 0 0 0 0 1 0 4 0 0 0 1 

New York 2 9 4 0 0 0 0 0 1 2 0 1 0 0 1 

North Carolina 4 8 1 2 0 0 0 0 4 1 0 0 0 0 0 

North Dakota 8 19 0 6 0 0 0 0 2 1 3 0 7 0 0 

Northern Marianas ̃ 9 3 0 0 0 0 0 0 1 0 2 0 0 0 0 

Ohio 5 49 4 2 0 0 0 0 10 2 6 14 8 0 3 

Oklahoma 6 3 0 0 0 0 0 0 0 2 1 0 0 0 0 
57 

 Inappropriat

e 

/Excessive

Involuntary Complaints Concerning

State/

Jurisdiction

HHS 

Regio

n 

Number of Abuse 

Complaints Closed 

Medication

Restraint and Seclusion

Medication

Electric Convulsive 

Therapy (ECT)

Aversive Behavioral 

Therapy

Sterilization

Physical Assault

Sexual Assault

Staff Threats

/Retaliation/Assaults

Coercion

Financial Exploitation

Suspicious Death

Other

Oregon 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Pennsylvania 3 20 3 3 5 0 0 0 2 1 0 2 4 0 0 

Puerto Rico 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Rhode Island 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 

South Carolina 4 24 1 0 0 0 0 0 3 2 14 0 3 0 1 

South Dakota 8 5 1 1 1 0 0 0 2 0 0 0 0 0 0 

Tennessee 4 5 2 0 0 0 0 0 2 0 0 1 0 0 0 

Texas 6 41 8 12 1 0 0 0 9 1 5 1 0 4 0 

Utah 8 10 7 0 0 0 0 0 1 1 0 1 0 0 0 

Vermont 1 12 3 3 0 0 0 0 0 1 0 0 0 0 5 

Virgin Islands 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Virginia 3 23 5 5 1 0 0 0 3 2 0 4 0 3 0 

Washington 10 88 7 33 11 0 0 0 15 7 11 1 3 0 0 

West Virginia 3 7 0 0 0 0 0 0 0 1 1 0 5 0 0 

Wisconsin 5 6 0 6 0 0 0 0 0 0 0 0 0 0 0 

Wyoming 8 11 3 5 0 0 0 0 1 0 1 0 0 1 0 

Selected States/ 

Jurisdictions ̃ 1,092 137 209 79 5 1 1 180 77 99 45 78 119 62

% of Selected 

States/Jurisdictions

 ̃ 

 100.0

0 %

12.55 

% 

19.14 

% 

7.2

3 %

0.46 

% 

0.0

9 %

0.0

9 %

16.4

8 %

7.0

5 %

9.07 

% 

4.1

2 %

7.1

4 %

10.9

0 %

5.6

8 %

All States/ 

Jurisdictions ̃ 1,092 137 209 79 5 1 1 180 77 99 45 78 119 62

% All 

States/Jurisdictions

 ̃ 

 100.0

0 %

12.55 

% 

19.14 

% 

7.2

3 %

0.46 

% 

0.0

9 %

0.0

9 %

16.4

8 %

7.0

5 %

9.07 

% 

4.1

2 %

7.1

4 %

10.9

0 %

5.6

8 %

Source: 2020 PAIMI Progress Report: C. Complaints/Problems of PAIMI Eligible Individuals - Areas of Alleged Abuse

Legend:

 ̃ Non-Finalized Data, e.g., the application/report has been not approved and/or there are open revision requests for the source data.
58 

Table 6 – Complaints Involving Alleged Neglect of PAIMI Eligible Individuals – FY2019 

Failure to Provide for Appropriate

State/ 

Jurisdiction

HHS Region

Number of Neglect Complaints Closed

Admission to Residential 

Care or Treatment Facility

Transportation to/from Residential 

Care or Treatment Facility

Discharge Planning or Release from 

Residential Care or Treatment Facility

Mental Health Diagnostic or Other 

Evaluation (does not include treatment) 

Medical (non-mental health related) 

diagnostic physical examination

Inadequate Care (e.g., personal 

hygiene, clothing, food, shelter)

Physical Plant or Environmental Safety

Personal Safety Issues (unsecured 

access to facility, resident rooms, 

Other

Alabama 4 45 1 0 19 0 2 0 0 23 0 

Alaska 10 5 3 0 2 0 0 0 0 0 0 

American Indian Consortium 13 1 0 0 0 0 0 1 0 0 0 

American Samoa 9 35 4 4 4 2 4 7 7 3 0 

Arizona 9 46 4 4 15 13 1 9 0 0 0 

Arkansas 6 6 1 0 2 1 0 1 0 1 0 

California 9 43 0 0 31 3 0 7 0 2 0 

Colorado 8 13 1 0 6 2 1 1 1 1 0 

Connecticut 1 8 0 0 7 1 0 0 0 0 0 

Delaware 3 39 0 1 28 0 2 4 2 1 1 

District of Columbia 3 17 0 0 5 1 0 11 0 0 0 

Florida 4 53 2 0 16 3 12 7 4 9 0 

Georgia 4 122 1 0 75 0 2 4 1 3 36 

Guam 9 5 1 0 3 0 1 0 0 0 0 

Hawaii 9 7 0 0 2 2 0 2 1 0 0 

Idaho 10 57 0 0 42 4 4 0 0 7 0 

Illinois 5 130 6 14 78 6 3 13 4 6 0 

Indiana 5 8 0 0 7 0 0 0 1 0 0 

Iowa 7 22 0 0 4 4 0 1 6 7 0 

Kansas 7 14 2 0 2 1 3 4 1 1 0 

Kentucky 4 5 0 0 0 3 2 0 0 0 0 

Louisiana 6 6 2 0 4 0 0 0 0 0 0 

Maine 1 27 1 0 24 0 0 2 0 0 0 

Maryland 3 25 1 0 2 3 7 4 3 5 0 

Massachusetts 1 11 5 0 3 1 0 0 0 0 2 

Michigan 5 53 31 0 4 0 5 1 0 11 1 

Minnesota 5 32 6 2 7 0 0 5 1 0 11 

Mississippi 4 4 0 0 0 0 1 0 0 3 0 

Missouri 7 77 0 0 23 1 30 18 2 3 0 

Montana 8 106 12 0 5 3 4 0 56 25 1 

Nebraska 7 1 1 0 0 0 0 0 0 0 0 

Nevada 9 7 1 0 6 0 0 0 0 0 0 

New Hampshire 1 32 9 0 16 1 3 3 0 0 0 

New Jersey 2 55 3 0 38 0 3 7 2 2 0 

New Mexico 6 25 3 0 8 0 1 6 0 7 0 

New York 2 19 2 1 13 1 0 2 0 0 0 
59 

Failure to Provide for Appropriate

State/ 

Jurisdiction

HHS Region

Number of Neglect Complaints Closed

Admission to Residential 

Care or Treatment Facility

Transportation to/from Residential 

Care or Treatment Facility

Discharge Planning or Release from 

Residential Care or Treatment Facility

Mental Health Diagnostic or Other 

Evaluation (does not include treatment) 

Medical (non-mental health related) 

diagnostic physical examination

Inadequate Care (e.g., personal 

hygiene, clothing, food, shelter)

Physical Plant or Environmental Safety

Personal Safety Issues (unsecured 

access to facility, resident rooms, 

Other

North Carolina 4 3 0 0 1 0 0 2 0 0 0 

North Dakota 8 25 1 0 4 1 5 10 2 2 0 

Northern Marianas 9 1 0 0 0 1 0 0 0 0 0 

Ohio 5 65 3 1 7 10 14 21 3 4 2 

Oklahoma 6 12 0 0 6 2 4 0 0 0 0 

Oregon 10 1 1 0 0 0 0 0 0 0 0 

Pennsylvania 3 31 0 0 16 1 7 3 2 2 0 

Puerto Rico 2 0 0 0 0 0 0 0 0 0 0 

Rhode Island 1 15 1 0 11 0 0 2 0 1 0 

South Carolina 4 11 1 0 9 0 0 0 0 1 0 

South Dakota 8 2 0 0 1 0 0 0 0 1 0 

Tennessee 4 22 1 0 8 8 1 3 0 1 0 

Texas 6 130 3 0 21 30 29 16 0 28 3 

Utah 8 3 0 0 0 0 1 1 1 0 0 

Vermont 1 20 1 1 17 1 0 0 0 0 0 

Virgin Islands 2 1 0 0 1 0 0 0 0 0 0 

Virginia 3 60 1 0 42 0 5 5 3 4 0 

Washington 10 125 4 1 62 19 15 14 4 6 0 

West Virginia 3 26 0 0 21 0 3 2 0 0 0 

Wisconsin 5 6 1 0 1 1 2 1 0 0 0 

Wyoming 8 11 0 0 1 1 2 2 4 1 0 

Totals 1,731 121 29 730 131 179 202 111 171 57 

Percentages 100 6.99 1.68 42.17 7.57 10.34 11.67 6.41 9.88 3.29 
60 

Table 6 – Complaints Involving Alleged Neglect of PAIMI Eligible Individuals – FY2020 

Failure to Provide for Appropriate

State/ 

Jurisdiction

HHS Region

Number of Neglect Complaints 

Closed

Medical (other than psychiatric) 

treatment

Mental Health Treatment, Including 

Access to Prescribed Medication

Personal care and safety

Discharge Planning or Release from 

Residential Care or Treatment 

Facility

Mental Health Diagnostic or Other 

Evaluation (does not include 

Medical (non-mental health

related) Diagnostic Physical 

Other

Alabama 4 42 0 0 0 12 2 2 26 

Alaska 10 3 0 0 0 1 0 0 2 

American Indian Consortium 13 1 0 0 1 0 0 0 0 

American Samoa 9 8 3 1 1 1 0 2 0 

Arizona 9 60 11 15 6 11 6 2 9 

Arkansas 6 11 0 5 2 3 1 0 0 

California 9 13 0 0 0 6 2 2 3 

Colorado 8 26 2 23 1 0 0 0 0 

Connecticut 1 4 1 1 0 1 1 0 0 

Delaware 3 24 0 6 6 11 0 1 0 

District of Columbia 3 27 4 10 10 1 1 1 0 

Florida 4 114 21 44 22 23 1 2 1 

Georgia 4 79 3 1 13 61 1 0 0 

Guam 9 5 0 2 2 1 0 0 0 

Hawaii 9 23 0 11 3 5 4 0 0 

Idaho 10 63 10 2 10 41 0 0 0 

Illinois 5 193 22 34 13 79 11 4 30 

Indiana 5 11 0 0 9 2 0 0 0 

Iowa 7 9 0 4 3 1 1 0 0 

Kansas 7 11 3 3 1 4 0 0 0 

Kentucky 4 10 2 2 1 4 1 0 0 

Louisiana 6 15 4 3 1 7 0 0 0 

Maine 1 58 2 27 1 26 1 1 0 

Maryland 3 19 2 0 5 10 2 0 0 

Massachusetts 1 42 3 0 7 9 0 0 23 

Michigan 5 24 0 0 11 8 0 5 0 

Minnesota 5 29 7 0 7 14 1 0 0 

Mississippi 4 4 1 1 1 0 0 1 0 

Missouri ̃ 7 100 17 33 13 15 2 20 0 

Montana 8 102 5 27 62 3 2 3 0 

Nebraska 7 2 1 0 1 0 0 0 0 

Nevada 9 8 0 0 3 4 1 0 0 

New Hampshire 1 43 8 20 5 0 0 2 8 

New Jersey 2 68 9 4 5 47 1 1 1 

New Mexico 6 16 3 1 8 2 1 1 0 

New York 2 17 0 7 4 6 0 0 0 

North Carolina 4 3 0 1 2 0 0 0 0 
61 

Failure to Provide for Appropriate

State/ 

Jurisdiction

HHS Region

Number of Neglect Complaints 

Closed

Medical (other than psychiatric) 

treatment

Mental Health Treatment, Including 

Access to Prescribed Medication

Personal care and safety

Discharge Planning or Release from 

Residential Care or Treatment 

Facility

Mental Health Diagnostic or Other 

Evaluation (does not include 

Medical (non-mental health

related) Diagnostic Physical 

Other

North Dakota 8 28 0 6 12 6 0 4 0 

Northern Marianas ̃ 9 3 3 0 0 0 0 0 0 

Ohio 5 117 15 38 11 44 0 7 2 

Oklahoma 6 19 8 3 1 3 3 1 0 

Oregon 10 4 0 3 0 0 0 0 1 

Pennsylvania 3 73 5 17 1 42 0 5 3 

Puerto Rico 2 5 1 1 0 3 0 0 0 

Rhode Island 1 1 0 0 0 1 0 0 0 

South Carolina 4 135 7 112 6 9 1 0 0 

South Dakota 8 13 4 1 1 6 0 1 0 

Tennessee 4 11 0 1 3 4 0 3 0 

Texas 6 226 8 18 29 90 42 16 23 

Utah 8 5 1 0 3 0 1 0 0 

Vermont 1 17 0 0 2 12 0 0 3 

Virgin Islands 2 1 0 0 1 0 0 0 0 

Virginia 3 34 0 0 7 21 0 6 0 

Washington 10 291 24 175 15 56 6 6 9 

West Virginia 3 23 0 0 3 14 0 4 2 

Wisconsin 5 5 1 2 1 0 1 0 0 

Wyoming 8 5 1 2 1 0 0 1 0 

Totals 2,303 222 667 337 730 97 104 146 

Percentages 100 9.64 28.96 14.63 31.70 4.21 4.52 6.34 
62 

Table 7 – Complaints Involving Alleged Rights Violations of PAIMI Eligible Individuals – FY2019 

State/

Jurisdiction

HHS 

Region 

Number of Rights Complaints Closed 

Financial Benefits and Entitlements 

Guardianship

/Conservative Problems

Rights Protection/Legal Assistance

Privacy Rights

Recreational Opportunities

Visitors

Access to Records

Individual Treatment Plan

Written Discharge Plan

Mental Health Services Planning

Confidentiality

Informed Consent

Problem with Advance Directives

Denial of Parental

/Family Rights

Other

Alabama 4 40 3 5 2 0 1 0 0 2 0 6 0 1 0 0 20 

Alaska 10 24 18 0 0 0 0 0 0 0 0 0 0 0 0 0 6 

American 

Indian 

Consortium 

13 6 0 0 0 0 0 0 0 5 0 1 0 0 0 0 0 

American 

Samoa 9 8 0 1 0 2 2 2 0 0 0 0 0 0 0 1 0 

Arizona 9 50 2 2 3 1 0 2 1 10 4 23 0 1 0 1 0 

Arkansas 6 47 0 2 0 0 0 0 0 0 2 0 0 0 0 1 42 

California 9 709 62 8 37 3 1 0 18 7 3 17 4 2 1 3 543 

Colorado 8 49 1 0 7 7 1 0 0 0 9 23 1 0 0 0 0 

Connecticut 1 16 0 2 0 0 1 0 1 0 0 0 1 0 0 0 11 

Delaware 3 40 17 2 4 0 0 0 0 0 4 0 0 1 1 1 10 

District of 

Columbia 3 16 3 1 0 0 3 0 0 0 2 0 0 0 6 0 1 

Florida 4 64 6 4 24 1 6 0 0 0 0 0 0 2 5 2 14 

Georgia 4 2 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 

Guam 9 10 2 4 1 0 0 0 0 0 0 0 0 0 3 0 0 

Hawaii 9 144 1 7 0 0 0 0 0 76 0 10 0 0 48 0 2 

Idaho 10 26 0 0 2 5 4 0 1 1 5 1 0 0 0 0 7 

Illinois 5 287 4 25 0 5 5 6 14 4 1 0 1 2 0 7 213 

Indiana 5 4 0 1 0 0 1 0 0 0 1 1 0 0 0 0 0 

Iowa 7 32 1 2 2 2 0 0 0 0 0 0 0 1 0 0 24 

Kansas 7 249 12 8 4 1 5 0 2 0 0 0 1 6 1 2 207 

Kentucky 4 25 1 1 1 0 5 1 3 2 2 1 0 0 1 1 6 

Louisiana 6 11 3 0 0 0 0 0 0 4 4 0 0 0 0 0 0 

Maine 1 49 6 3 12 3 1 1 5 1 0 9 0 0 2 0 6 

Maryland 3 33 0 2 6 0 0 0 0 0 0 0 0 3 0 0 22 

Massachusetts 1 4 2 0 0 0 0 0 0 0 0 0 0 0 0 0 2 

Michigan 5 43 8 5 2 1 1 1 0 0 16 1 0 0 0 0 8 

Minnesota 5 57 6 22 4 0 11 2 2 4 4 1 0 1 0 0 0 

Mississippi 4 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 

Missouri 7 85 23 15 5 5 6 1 1 11 17 0 0 1 0 0 0 

Montana 8 32 1 1 3 0 0 0 0 3 7 0 0 0 0 1 16 

Nebraska 7 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 

Nevada 9 13 1 1 2 0 0 0 0 1 1 0 0 0 0 0 7 

New 

Hampshire 1 163 19 20 6 3 11 0 3 4 0 0 2 2 1 1 91 

New Jersey 2 64 10 3 6 0 0 0 3 0 1 0 0 0 0 0 41 

New Mexico 6 13 0 0 3 1 0 0 0 0 7 0 0 2 0 0 0 

New York 2 91 3 5 1 0 0 0 1 0 0 0 1 0 2 0 78 
63 

State/

Jurisdiction

HHS 

Region 

Number of Rights Complaints Closed 

Financial Benefits and Entitlements 

Guardianship

/Conservative Problems

Rights Protection/Legal Assistance

Privacy Rights

Recreational Opportunities

Visitors

Access to Records

Individual Treatment Plan

Written Discharge Plan

Mental Health Services Planning

Confidentiality

Informed Consent

Problem with Advance Directives

Denial of Parental

/Family Rights

Other

North 

Carolina 4 21 0 6 6 4 0 0 0 1 4 0 0 0 0 0 0 

North Dakota 8 86 1 1 0 0 0 0 0 70 6 8 0 0 0 0 0 

Northern 

Marianas 9 9 6 0 0 0 0 0 0 0 0 0 1 0 0 0 2 

Ohio 5 651 46 34 149 25 14 1 14 4 66 28 8 10 9 20 223 

Oklahoma 6 10 0 1 4 0 0 0 1 0 1 0 0 1 0 0 2 

Oregon 10 12 0 1 0 0 0 0 0 1 4 4 0 0 1 0 1 

Pennsylvania 3 168 0 3 16 2 4 0 2 5 13 0 3 0 2 4 114 

Puerto Rico 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Rhode Island 1 49 2 5 0 0 2 1 0 0 0 0 1 0 1 1 36 

South 

Carolina 4 17 1 0 0 0 0 0 0 1 0 0 0 0 0 0 15 

South Dakota 8 15 2 0 1 2 1 0 0 0 6 1 0 0 0 0 2 

Tennessee 4 20 0 1 7 2 2 0 0 0 0 0 0 0 0 2 6 

Texas 6 434 11 12 112 44 26 1 13 1 97 45 2 29 2 6 33 

Utah 8 115 3 3 54 0 1 0 0 54 0 0 0 0 0 0 0 

Vermont 1 14 0 0 2 1 1 0 0 2 0 0 0 1 6 1 0 

Virgin Islands 2 3 0 0 2 0 0 0 0 0 0 0 0 0 0 0 1 

Virginia 3 25 1 5 4 1 0 0 1 2 9 1 0 0 1 0 0 

Washington 10 164 24 2 26 10 6 1 6 0 16 19 5 0 0 8 41 

West Virginia 3 14 3 2 4 0 1 0 0 0 0 0 0 0 0 0 4 

Wisconsin 5 51 2 2 2 1 2 0 0 2 11 0 0 0 0 0 29 

Wyoming 8 5 0 0 2 0 0 0 0 0 1 1 0 1 0 0 0 

Totals 4,394 318 232 528 132 125 21 92 278 324 201 31 67 93 63 1,889 

Percentages 100.00 7.24 5.28 12.02 3.00 2.84 0.48 2.09 6.33 7.37 4.57 0.71 1.52 2.12 1.43 42.99 
64 

Table 7 – Complaints Involving Alleged Rights Violations of PAIMI Eligible Individuals – FY2020 Denial of Failure to Provide 

State/ 

Jurisdiction 

HHS 

Region 

Number of Rights Complaints Closed 

Financial Benefits and Entitlements 

Guardianship 

/Conservative Problems

Rights Protection/Legal Assistance

Access to Administrative or Judicial Process

Privacy Rights

Recreational Opportunities

Visitors 

Access to Transportation 

Access to Records

Access to Community Based Rehabilitation Services 

and/or Treatment

Parental 

/Family Rights

Individual Treatment Plan

Written Discharge Plan

Mental Health Services Planning

Confidentiality 

Educational Services in the Least Restricted 

Environment 

Informed Consent

Advanced Directive Issues

Right to Refuse Treatment

Right to Refuse to Take Prescribed Medication

Employment Discrimination

Housing Discrimination

Alabama 4 38 2 1 2 0 1 3 0 0 1 0 0 3 0 1 0 11 0 4 0 0 1 3 

Alaska 10 23 21 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

American 

Indian 

Consortium 

13 12 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 0 0 0 0 0 0 

American 

Samoa 9 34 0 0 3 0 4 2 3 2 4 0 0 2 1 1 1 0 0 0 2 0 0 3 

Arizona 9 119 4 1 6 0 0 3 1 0 9 0 1 28 5 0 3 0 0 0 0 0 0 0 

Arkansas 6 31 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 27 0 0 0 0 0 1 

California 9 654 24 10 12 0 3 2 0 2 8 0 5 6 4 26 5 81 3 0 0 0 109 165 

Colorado 8 27 2 4 2 0 3 3 0 0 0 0 0 0 5 0 1 0 2 0 0 0 0 0 

Connecticut 1 12 0 0 0 0 0 0 0 0 0 0 0 0 2 1 0 3 2 0 0 0 0 1 

Delaware 3 48 15 0 1 0 1 3 0 0 0 0 2 1 0 0 0 9 0 2 0 0 1 8 

District of 

Columbia 3 16 4 0 0 0 0 0 0 0 0 0 0 2 2 0 0 0 0 4 0 0 0 0 

Florida 4 37 2 0 19 0 2 3 0 0 1 0 1 0 0 0 2 3 2 1 0 0 0 0 

Georgia 4 20 0 4 0 0 0 1 0 0 1 1 0 0 3 2 0 0 0 0 0 0 2 1 

Guam 9 12 0 1 0 1 1 0 0 0 1 0 0 0 0 1 0 2 0 2 0 0 1 0 

Hawaii 9 105 5 7 0 0 1 0 0 0 0 0 0 0 0 1 0 60 0 26 0 0 0 2 

Idaho 10 30 1 3 1 0 1 1 0 0 0 0 0 1 2 0 0 7 0 0 2 0 0 1 

Illinois 5 301 0 0 7 1 6 13 5 2 13 4 6 2 5 1 6 59 1 0 1 6 56 10 

Indiana 5 39 0 0 0 1 1 4 0 2 0 0 0 0 2 8 0 5 0 0 0 0 3 3 

Iowa 7 40 0 5 0 0 1 2 2 0 0 2 1 0 0 1 0 14 0 0 0 0 3 5 

Kansas 7 211 14 18 28 2 2 4 1 1 1 32 1 0 0 0 3 13 3 0 0 1 38 48 

Kentucky 4 53 1 1 0 0 2 4 1 0 0 9 0 3 4 2 0 7 0 0 2 3 0 0 

Louisiana 6 27 4 1 0 0 0 0 0 0 0 7 0 0 0 0 0 11 0 0 1 0 2 0 

Maine 1 111 5 3 7 0 2 2 0 1 0 0 0 0 0 15 0 32 0 3 0 0 6 14 

Maryland 3 56 0 1 4 3 3 1 0 0 1 3 0 0 0 0 1 0 0 0 2 1 0 30 

Massachusetts 1 34 4 0 5 0 0 1 0 0 0 2 1 0 0 0 0 1 0 0 0 0 5 11 

Michigan 5 33 0 1 2 0 1 0 0 0 1 0 0 3 2 8 0 0 0 0 0 0 0 0 

Minnesota 5 119 1 8 8 2 2 3 1 5 0 1 0 26 1 4 0 17 0 0 0 1 1 6 

Mississippi 4 3 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 

Missouri ̃ 7 146 19 19 8 0 5 6 0 0 2 0 0 24 17 2 1 0 0 0 0 0 0 0 

Montana 8 36 6 0 1 0 2 2 0 0 1 4 0 1 0 0 1 0 0 0 0 0 5 2 

Nebraska 7 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Nevada 9 15 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 

New 

Hampshire 1 131 11 13 3 0 1 3 2 0 2 0 2 3 1 15 1 1 0 1 0 0 17 36 

New Jersey 2 29 2 0 1 0 1 5 1 0 0 2 0 0 0 3 0 3 0 1 0 0 1 1 
65 

 Denial of Failure to Provide 

State/ 

Jurisdiction 

HHS 

Region 

Number of Rights Complaints Closed 

Financial Benefits and Entitlements 

Guardianship 

/Conservative Problems

Rights Protection/Legal Assistance

Access to Administrative or Judicial Process

Privacy Rights

Recreational Opportunities

Visitors 

Access to Transportation 

Access to Records

Access to Community Based Rehabilitation Services 

and/or Treatment

Parental 

/Family Rights

Individual Treatment Plan

Written Discharge Plan

Mental Health Services Planning

Confidentiality 

Educational Services in the Least Restricted 

Environment 

Informed Consent

Advanced Directive Issues

Right to Refuse Treatment

Right to Refuse to Take Prescribed Medication

Employment Discrimination

Housing Discrimination

New Mexico 6 15 0 1 1 0 0 0 0 0 1 0 0 1 4 0 0 0 2 0 0 0 0 0 

New York 2 72 2 1 3 1 0 1 0 2 2 4 1 0 0 3 1 7 2 1 0 1 11 25 

North 

Carolina 4 25 0 2 1 1 0 1 0 0 0 3 0 1 0 2 0 4 0 0 0 1 1 4 

North Dakota 8 107 2 0 0 0 0 0 0 0 0 10 0 20 0 0 0 33 0 0 0 11 0 0 

Northern 

Marianas ̃ 9 3 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 

Ohio 5 601 32 28 187 0 5 6 4 0 7 0 11 0 0 42 5 91 2 8 0 0 4 105 

Oklahoma 6 5 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 

Oregon 10 9 0 2 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 1 

Pennsylvania 3 180 3 11 14 0 4 4 0 1 2 9 1 0 8 0 0 9 2 1 1 0 38 16 

Puerto Rico 2 45 42 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 

Rhode Island 1 7 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 

South 

Carolina 4 99 6 2 0 0 1 0 0 0 2 0 6 0 0 0 0 15 0 0 0 0 6 20 

South Dakota 8 38 0 2 0 0 0 0 0 0 0 2 0 6 0 3 0 7 1 0 0 0 1 4 

Tennessee 4 14 0 1 2 0 0 0 0 0 0 1 0 0 0 0 0 6 0 0 0 0 1 2 

Texas 6 481 16 10 123 1 29 39 1 0 8 0 5 3 8 82 2 23 21 1 0 0 2 13 

Utah 8 109 3 1 48 0 1 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0 45 7 

Vermont 1 13 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 3 0 0 2 0 

Virgin Islands 2 5 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 0 

Virginia 3 39 1 2 9 0 0 3 0 0 0 0 0 4 6 1 0 0 0 2 0 0 0 0 

Washington 10 247 40 4 75 0 9 11 3 0 10 1 5 0 0 0 7 3 3 0 0 0 10 17 

West Virginia 3 18 2 2 5 0 2 2 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 2 

Wisconsin 5 54 2 0 2 0 0 0 0 0 0 0 0 2 8 0 0 20 0 0 0 0 5 1 

Wyoming 8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 

Totals 4,790 302 174 593 14 100 138 25 19 78 101 52 142 93 225 42 600 48 60 12 25 378 571 

Percentages 100.00 6.30 3.63 12.38 0.29 2.09 2.88 0.52 0.40 1.63 2.11 1.09 2.96 1.94 4.70 0.88 12.53 1.00 1.25 0.25 0.52 7.89 11.92 
66 

Table 8 – Death Investigations – FY2019 

The number of deaths of individuals reported 

to the P&A for investigation

All Death investigations conducted involving PAIMI-eligible individuals 

related

State/ 

Jurisdiction

HHS 

Region Total 

Number of 

Deaths 

Reported

State

The Center 

for 

Medicaid 

& 

Medicare 

Services

Other 

Sources

Total Number 

of Death 

Investigations 

Number of 

deaths 

investigated 

involving 

incidents of 

seclusion (S). 

Number of 

deaths 

investigated 

involving 

incidents of 

restraint (R).

Number of deaths 

investigated NOT 

related to incidents 

of S&R, (e. g., 

suicides.) 

Alabama 4 4 0 0 4 4 0 0 4 

Alaska 10 6 3 0 3 6 0 0 6 

American 

Indian 

Consortium 

13 0 0 0 0 0 0 0 0 

American 

Samoa 9 0 0 0 0 0 0 0 0 

Arizona 9 1 1 0 0 1 0 0 1 

Arkansas 6 0 0 0 0 0 0 0 0 

California 9 13 7 1 5 12 0 1 11 

Colorado 8 0 0 0 0 0 0 0 0 

Connecticut 1 4 2 0 2 4 0 2 2 

Delaware 3 10 10 0 0 10 0 0 10 

District of 

Columbia 3 7 6 0 1 7 0 0 7 

Florida 4 21 11 0 10 21 0 0 21 

Georgia 4 11 0 0 11 11 0 0 11 

Guam 9 0 0 0 0 0 0 0 0 

Hawaii 9 0 0 0 0 0 0 0 0 

Idaho 10 0 0 0 0 0 0 0 0 

Illinois 5 0 0 0 0 1 0 0 1 

Indiana 5 0 0 0 0 0 0 0 0 

Iowa 7 14 13 0 1 14 0 0 14 

Kansas 7 0 0 0 0 0 0 0 0 

Kentucky 4 2 2 0 0 2 0 0 2 

Louisiana 6 3 0 0 3 3 0 1 2 

Maine 1 1 0 0 1 1 0 0 1 

Maryland 3 47 46 0 1 47 0 0 47 

Massachusetts 1 3 0 0 3 3 0 0 3 

Michigan 5 9 7 0 2 9 0 0 9 

Minnesota 5 0 0 0 0 0 0 0 0 

Mississippi 4 0 0 0 0 0 0 0 0 

Missouri 7 554 550 1 3 2 0 0 2 

Montana 8 0 0 0 0 0 0 0 0 

Nebraska 7 0 0 0 0 2 0 0 2 

Nevada 9 0 0 0 0 0 0 0 0 

New 

Hampshire 1 1 0 0 1 1 0 0 1 

New Jersey 2 23 23 0 0 23 1 0 22 

New Mexico 6 0 0 0 0 0 0 0 0 

New York 2 2 0 0 2 2 0 1 1 

North Carolina 4 2 1 0 1 2 0 0 2 

North Dakota 8 2 1 0 1 2 0 0 2 
67 

The number of deaths of individuals reported 

to the P&A for investigation

All Death investigations conducted involving PAIMI-eligible individuals 

related

State/ 

Jurisdiction

HHS 

Region Total 

Number of 

Deaths 

Reported

State

The Center 

for 

Medicaid 

& 

Medicare 

Services

Other 

Sources

Total Number 

of Death 

Investigations 

Number of 

deaths 

investigated 

involving 

incidents of 

seclusion (S). 

Number of 

deaths 

investigated 

involving 

incidents of 

restraint (R).

Number of deaths 

investigated NOT 

related to incidents 

of S&R, (e. g., 

suicides.) 

Northern 

Marianas 9 0 0 0 0 0 0 0 0 

Ohio 5 13 1 0 12 2 1 0 1 

Oklahoma 6 4 0 0 4 2 0 0 2 

Oregon 10 3 0 0 3 3 0 0 3 

Pennsylvania 3 36 36 0 0 0 0 0 0 

Puerto Rico 2 0 0 0 0 0 0 0 0 

Rhode Island 1 0 0 0 0 0 0 0 0 

South Carolina 4 5 0 0 5 5 0 1 4 

South Dakota 8 1 0 0 1 1 0 0 1 

Tennessee 4 0 0 0 0 0 0 0 0 

Texas 6 13 0 0 13 13 0 0 13 

Utah 8 3 0 0 3 1 0 0 1 

Vermont 1 5 1 0 4 5 0 0 5 

Virgin Islands 2 0 0 0 0 0 0 0 0 

Virginia 3 47 47 0 0 15 1 0 14 

Washington 10 2 0 0 2 2 1 0 1 

West Virginia 3 0 0 0 0 0 0 0 0 

Wisconsin 5 14 12 0 2 14 0 0 14 

Wyoming 8 1 1 0 0 1 0 0 1 

Totals 887 781 2 104 254 4 6 244 
68 

Table 8 – Death Investigations – FY2020 

 The number of deaths of individuals 

reported to the P&A for investigation

All Death investigations conducted involving PAIMI-eligible individuals related

State/ 

Jurisdiction

HHS 

Region Total 

Number 

of 

Deaths 

Reported

State

The 

Center 

for 

Medicaid 

& 

Medicare 

Services

Other 

Sources

Total 

Number 

of Death 

Investigations 

Number of 

deaths 

investigated 

involving 

incidents of 

seclusion 

(S). 

Number of 

deaths 

investigated 

involving 

incidents of 

abuse (A)

Number of 

deaths 

investigated 

involving 

incidents of 

restraint 

(R).

Number of 

deaths 

investigated 

NOT 

related to 

incidents of 

S&R, (e. g., 

suicides.) 

Death 

Investigations 

with a finding 

of 

determination

Provision in 

policy added 

or 

prevented as 

a result of a 

death 

investigation

Alabama 4 0 0 0 0 0 0 0 0 0 0 0 

Alaska 10 4 2 0 2 4 1 0 0 3 0 0 

American 

Indian 

Consortium 

13 0 0 0 0 0 0 0 0 0 0 0 

American 

Samoa 9 0 0 0 0 0 0 0 0 0 0 0 

Arizona 9 1 1 0 0 1 0 0 0 1 0 0 

Arkansas 6 1 0 0 1 1 1 0 0 0 0 0 

California 9 19 17 0 2 2 0 0 0 2 0 0 

Colorado 8 2 0 0 2 2 0 0 0 2 0 0 

Connecticut 1 4 3 0 1 4 0 0 2 2 0 0 

Delaware 3 12 0 0 12 12 0 0 0 12 0 0 

District of 

Columbia 3 21 19 0 2 36 0 0 0 21 11 4 

Florida 4 27 13 0 14 27 0 0 0 27 0 0 

Georgia 4 8 8 0 0 17 0 1 0 8 4 4 

Guam 9 0 0 0 0 0 0 0 0 0 0 0 

Hawaii 9 0 0 0 0 0 0 0 0 0 0 0 

Idaho 10 0 0 0 0 0 0 0 0 0 0 0 

Illinois 5 2 0 2 0 2 0 0 2 0 0 0 

Indiana 5 4 3 0 1 4 0 0 0 4 0 0 

Iowa 7 18 15 0 3 24 0 14 0 4 4 2 

Kansas 7 0 0 0 0 0 0 0 0 0 0 0 

Kentucky 4 5 5 0 0 5 0 1 0 4 0 0 

Louisiana 6 7 2 0 5 17 0 17 0 0 0 0 

Maine 1 1 0 0 1 2 0 0 0 1 1 0 

Maryland 3 40 8 0 32 10 0 0 0 6 4 0 

Massachusetts 1 3 0 0 3 3 0 0 0 3 0 0 

Michigan 5 13 5 0 8 18 0 0 0 13 5 0 

Minnesota 5 0 0 0 0 0 0 0 0 0 0 0 

Mississippi 4 0 0 0 0 0 0 0 0 0 0 0 

Missouri ̃ 7 664 664 0 0 5 1 0 0 1 2 1 

Montana 8 1 0 0 1 1 0 0 0 1 0 0 

Nebraska 7 0 0 0 0 0 0 0 0 0 0 0 

Nevada 9 0 0 0 0 0 0 0 0 0 0 0 

New 

Hampshire 1 1 0 0 1 2 0 0 0 1 0 1 

New Jersey 2 63 63 0 0 63 0 0 0 63 0 0 

New Mexico 6 0 0 0 0 0 0 0 0 0 0 0 

New York 2 0 0 0 0 1 0 0 0 1 0 0 

North 

Carolina 4 1 1 0 0 0 0 0 0 0 0 0 

North Dakota 8 0 0 0 0 0 0 0 0 0 0 0 
69 

 The number of deaths of individuals 

reported to the P&A for investigation

All Death investigations conducted involving PAIMI-eligible individuals related

State/ 

Jurisdiction

HHS 

Region Total 

Number 

of 

Deaths 

Reported

State

The 

Center 

for 

Medicaid 

& 

Medicare 

Services

Other 

Sources

Total 

Number 

of Death 

Investigations 

Number of 

deaths 

investigated 

involving 

incidents of 

seclusion 

(S). 

Number of 

deaths 

investigated 

involving 

incidents of 

abuse (A)

Number of 

deaths 

investigated 

involving 

incidents of 

restraint 

(R).

Number of 

deaths 

investigated 

NOT 

related to 

incidents of 

S&R, (e. g., 

suicides.) 

Death 

Investigations 

with a finding 

of 

determination

Provision in 

policy added 

or 

prevented as 

a result of a 

death 

investigation

Northern 

Marianas ̃ 9 1 0 0 1 1 0 0 0 1 0 0 

Ohio 5 10 0 0 10 11 0 0 0 10 0 1 

Oklahoma 6 1 0 0 1 1 0 0 0 0 1 0 

Oregon 10 11 0 0 11 11 0 0 0 11 0 0 

Pennsylvania 3 55 55 0 0 0 0 0 0 0 0 0 

Puerto Rico 2 0 0 0 0 0 0 0 0 0 0 0 

Rhode Island 1 0 0 0 0 0 0 0 0 0 0 0 

South 

Carolina 4 2 1 0 1 10 0 1 2 2 3 2 

South Dakota 8 2 0 0 2 5 0 0 0 2 2 1 

Tennessee 4 0 0 0 0 0 0 0 0 0 0 0 

Texas 6 18 0 0 18 18 0 0 0 18 0 0 

Utah 8 9 0 0 9 4 2 0 0 2 0 0 

Vermont 1 2 1 0 1 2 0 0 0 2 0 0 

Virgin Islands 2 0 0 0 0 0 0 0 0 0 0 0 

Virginia 3 58 58 0 0 8 0 0 0 5 3 0 

Washington 10 3 1 0 2 7 0 0 0 2 4 1 

West Virginia 3 2 0 0 2 2 0 0 0 2 0 0 

Wisconsin 5 8 3 1 4 8 1 0 1 4 2 0 

Wyoming 8 1 1 0 0 1 0 0 0 1 0 0 

Totals 1,105 949 3 153 352 6 34 7 242 46 17 
70 

Table 9 – Analysis of Alleged Abuse – FY2019 

State/

Jurisdiction

HHS

Region

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's 

favor

Not resolved 

in the client's 

favor

Percentage 

Favorably 

Resolved*

Alabama 4 23 1 4 13 5 72.22

Alaska 10 3 1 0 0 2 0.00

American Indian 

Consortium 13 0 0 0 0 0 0.00

American Samoa 9 50 9 1 37 3 92.50

Arizona 9 61 3 2 51 5 91.07

Arkansas 6 25 10 6 8 1 88.89

California 9 47 8 9 29 1 96.67

Colorado 8 36 2 4 28 2 93.33

Connecticut 1 5 0 1 4 0 100.00

Delaware 3 6 2 0 4 0 100.00

District of 

Columbia 3 40 7 12 21 0 100.00

Florida 4 86 18 9 59 0 100.00

Georgia 4 44 7 1 36 0 100.00

Guam 9 1 0 0 1 0 100.00

Hawaii 9 7 1 3 3 0 100.00

Idaho 10 29 0 3 26 0 100.00

Illinois 5 92 7 14 31 40 43.66

Indiana 5 10 1 2 7 0 100.00

Iowa 7 26 9 1 16 0 100.00

Kansas 7 28 12 4 11 1 91.67

Kentucky 4 9 0 1 8 0 100.00

Louisiana 6 21 5 0 16 0 100.00

Maine 1 35 3 3 29 0 100.00

Maryland 3 69 1 5 62 1 98.41

Massachusetts 1 14 1 2 11 0 100.00

Michigan 5 36 4 0 27 5 84.38

Minnesota 5 46 4 19 23 0 100.00

Mississippi 4 4 3 0 1 0 100.00

Missouri 7 86 2 0 84 0 100.00

Montana 8 45 0 4 40 1 97.56

Nebraska 7 2 0 0 2 0 100.00

Nevada 9 9 1 1 7 0 100.00

New Hampshire 1 54 2 3 49 0 100.00

New Jersey 2 153 24 28 93 8 92.08

New Mexico 6 24 10 3 9 2 81.82

New York 2 16 0 0 16 0 100.00

North Carolina 4 3 0 0 3 0 100.00

North Dakota 8 29 2 2 24 1 96.00

Northern 

Marianas 9 2 1 0 1 0 100.00

Ohio 5 128 2 6 120 0 100.00

Oklahoma 6 47 8 6 26 7 78.79

Oregon 10 9 0 4 4 1 80.00

Pennsylvania 3 46 1 5 30 10 75.00
71 

State/

Jurisdiction

HHS

Region

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's 

favor

Not resolved 

in the client's 

favor

Percentage 

Favorably 

Resolved*

Puerto Rico 2 2 0 0 2 0 100.00

Rhode Island 1 9 2 3 4 0 100.00

South Carolina 4 125 2 2 120 1 99.17

South Dakota 8 17 4 2 9 2 81.82

Tennessee 4 12 9 1 2 0 100.00

Texas 6 100 16 24 35 25 58.33

Utah 8 6 3 0 3 0 100.00

Vermont 1 35 5 7 17 6 73.91

Virgin Islands 2 1 0 0 1 0 100.00

Virginia 3 30 9 3 18 0 100.00

Washington 10 271 0 0 271 0 100.00

West Virginia 3 10 0 1 9 0 100.00

Wisconsin 5 32 4 4 18 6 75.00

Wyoming 8 24 5 0 19 0 100.00

Totals 2,180 231 215 1,598 136 92.16
72 

Table 9 – Analysis of Alleged Abuse – FY2020 

State/

Jurisdictio

n 

HHS

Regi

on 

Total 

Complai

nts 

Closed

Complai

nts 

withdra

wn, 

no merit

Complai

nts 

withdra

wn by 

Client

Resolv

ed in 

client's 

favor 

Not 

resolv

ed in 

the 

client'

s 

favor 

Other 

Representat

ion Found

Service

s not 

needed 

due to 

client 

death 

or 

relocati

on 

Lost 

Conta

ct

Outco

mes 

Unkno

wn

Lack of 

Resour

ces 

Percent

age 

Favorab

ly 

Resolve

d*

Alabama 4 31 2 3 11 14 0 1 0 0 0 44.00 

Alaska 10 1 0 1 0 0 0 0 0 0 0 0.00 

American 

Indian 

Consortiu

m 

13 0 0 0 0 0 0 0 0 0 0 0.00 

American 

Samoa 9 19 3 2 9 3 0 1 0 0 1 75.00 

Arizona 9 30 0 2 27 0 1 0 0 0 0 100.00 

Arkansas 6 8 1 1 4 2 0 0 0 0 0 66.67 

California 9 28 3 7 18 0 0 0 0 0 0 100.00 

Colorado 8 4 0 0 4 0 0 0 0 0 0 100.00 

Connecticu

t 1 2 0 0 2 0 0 0 0 0 0 100.00 

Delaware 3 5 3 0 2 0 0 0 0 0 0 100.00 

District of 

Columbia 3 19 4 8 7 0 0 0 0 0 0 100.00 

Florida 4 30 11 9 10 0 0 0 0 0 0 100.00 

Georgia 4 54 22 3 29 0 0 0 0 0 0 100.00 

Guam 9 3 2 0 1 0 0 0 0 0 0 100.00 

Hawaii 9 5 2 1 2 0 0 0 0 0 0 100.00 

Idaho 10 9 0 4 2 0 2 1 0 0 0 100.00 

Illinois 5 79 9 4 9 4 0 1 6 45 1 69.23 

Indiana 5 10 4 1 3 1 0 1 0 0 0 75.00 

Iowa 7 13 2 0 10 0 0 0 1 0 0 100.00 

Kansas 7 14 5 2 3 0 0 0 0 0 4 100.00 

Kentucky 4 8 0 0 7 0 1 0 0 0 0 100.00 

Louisiana 6 5 0 1 3 0 1 0 0 0 0 100.00 

Maine 1 13 2 1 10 0 0 0 0 0 0 100.00 

Maryland 3 39 4 5 26 3 0 0 0 0 1 89.66 

Massachus

etts 1 45 1 8 33 0 0 0 3 0 0 100.00 

Michigan 5 30 3 4 20 2 0 1 0 0 0 90.91 

Minnesota 5 14 4 0 8 1 0 0 0 1 0 88.89 

Mississippi 4 3 0 0 2 0 0 1 0 0 0 100.00 

Missouri ̃ 7 30 0 0 30 0 0 0 0 0 0 100.00 

Montana 8 20 4 0 10 6 0 0 0 0 0 62.50 

Nebraska 7 6 1 0 1 0 0 4 0 0 0 100.00 

Nevada 9 2 0 0 2 0 0 0 0 0 0 100.00 

New 

Hampshire 1 23 1 0 21 0 0 0 1 0 0 100.00 

New 

Jersey 2 129 5 11 96 2 3 3 7 1 1 97.96 

New 

Mexico 6 17 0 0 14 0 0 2 1 0 0 100.00 

New York 2 9 1 0 6 0 0 0 0 0 2 100.00 

North 

Carolina 4 8 2 0 6 0 0 0 0 0 0 100.00 

North 

Dakota 8 19 0 0 18 0 0 0 1 0 0 100.00 
73 

State/

Jurisdictio

n 

HHS

Regi

on 

Total 

Complai

nts 

Closed

Complai

nts 

withdra

wn, 

no merit

Complai

nts 

withdra

wn by 

Client

Resolv

ed in 

client's 

favor 

Not 

resolv

ed in 

the 

client'

s 

favor 

Other 

Representat

ion Found

Service

s not 

needed 

due to 

client 

death 

or 

relocati

on 

Lost 

Conta

ct

Outco

mes 

Unkno

wn

Lack of 

Resour

ces 

Percent

age 

Favorab

ly 

Resolve

d*

Northern 

Marianas ̃ 9 3 1 0 2 0 0 0 0 0 0 100.00 

Ohio 5 49 0 5 42 2 0 0 0 0 0 95.45 

Oklahoma 6 3 1 0 1 1 0 0 0 0 0 50.00 

Oregon 10 0 0 0 0 0 0 0 0 0 0 0.00 

Pennsylvan

ia 3 20 0 2 18 0 0 0 0 0 0 100.00 

Puerto 

Rico 2 0 0 0 0 0 0 0 0 0 0 0.00 

Rhode 

Island 1 1 0 0 0 0 1 0 0 0 0 0.00 

South 

Carolina 4 24 0 0 23 1 0 0 0 0 0 95.83 

South 

Dakota 8 5 0 1 3 0 0 1 0 0 0 100.00 

Tennessee 4 5 1 1 3 0 0 0 0 0 0 100.00 

Texas 6 41 11 7 15 5 0 0 1 2 0 75.00 

Utah 8 10 0 2 7 0 1 0 0 0 0 100.00 

Vermont 1 12 2 0 9 1 0 0 0 0 0 90.00 

Virgin 

Islands 2 0 0 0 0 0 0 0 0 0 0 0.00 

Virginia 3 23 9 1 12 1 0 0 0 0 0 92.31 

Washingto

n 10 88 3 1 84 0 0 0 0 0 0 100.00 

West 

Virginia 3 7 0 1 6 0 0 0 0 0 0 100.00 

Wisconsin 5 6 1 0 5 0 0 0 0 0 0 100.00 

Wyoming 8 11 1 0 10 0 0 0 0 0 0 100.00 

Totals 1,092 131 99 706 49 10 17 21 49 10 93.51 
74 

Table 10 – Analysis of Alleged Neglect – FY2019 

State/

Jurisdiction

HHS

Region

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn 

by Client

Resolved 

in client's 

favor

Not 

resolved 

in the 

client's 

favor

Successful 

outcomes 

from P&A 

involvement

Percentage 

Favorably 

Resolved*

Alabama 4 45 7 2 27 9 0 75.00

Alaska 10 5 1 0 1 1 2 25.00

American 

Indian 

Consortium

13 1 0 0 1 0 0 100.00

American 

Samoa 9 35 1 0 31 3 0 91.18

Arizona 9 46 0 3 38 4 1 88.37

Arkansas 6 6 0 0 4 2 0 66.67

California 9 43 4 8 29 2 0 93.55

Colorado 8 13 3 3 6 1 0 85.71

Connecticut 1 8 0 0 7 0 1 87.50

Delaware 3 39 1 0 35 0 3 92.11

District of 

Columbia 3 17 1 8 7 1 0 87.50

Florida 4 53 13 6 33 1 0 97.06

Georgia 4 122 7 14 98 3 0 97.03

Guam 9 5 0 0 5 0 0 100.00

Hawaii 9 7 4 0 3 0 0 100.00

Idaho 10 57 1 1 54 1 0 98.18

Illinois 5 130 5 11 65 49 0 57.02

Indiana 5 8 0 1 0 7 0 0.00

Iowa 7 22 6 0 10 0 6 62.50

Kansas 7 14 4 2 8 0 0 100.00

Kentucky 4 5 0 0 2 3 0 40.00

Louisiana 6 6 1 0 5 0 0 100.00

Maine 1 27 1 0 25 1 0 96.15

Maryland 3 25 7 11 1 1 5 14.29

Massachusetts 1 11 0 2 9 0 0 100.00

Michigan 5 53 3 0 41 9 0 82.00

Minnesota 5 32 3 15 13 1 0 92.86

Mississippi 4 4 0 0 4 0 0 100.00

Missouri 7 77 3 0 74 0 0 100.00

Montana 8 106 2 1 87 4 12 84.47

Nebraska 7 1 0 0 1 0 0 100.00

Nevada 9 7 0 2 4 1 0 80.00

New 

Hampshire 1 32 5 4 19 1 3 82.61

New Jersey 2 55 7 4 37 1 6 84.09

New Mexico 6 25 11 2 2 6 4 16.67

New York 2 19 7 1 11 0 0 100.00

North Carolina 4 3 0 1 2 0 0 100.00

North Dakota 8 25 0 1 23 1 0 95.83

Northern 

Marianas 9 1 0 0 1 0 0 100.00

Ohio 5 65 0 0 17 1 47 26.15

Oklahoma 6 12 0 0 8 4 0 66.67
75 

State/

Jurisdiction

HHS

Region

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn 

by Client

Resolved 

in client's 

favor

Not 

resolved 

in the 

client's 

favor

Successful 

outcomes 

from P&A 

involvement

Percentage 

Favorably 

Resolved*

Oregon 10 1 0 0 0 0 1 0.00

Pennsylvania 3 31 0 2 21 8 0 72.41

Puerto Rico 2 0 0 0 0 0 0 0.00

Rhode Island 1 15 0 2 9 3 1 69.23

South Carolina 4 11 1 2 7 1 0 87.50

South Dakota 8 2 0 0 2 0 0 100.00

Tennessee 4 22 12 7 3 0 0 100.00

Texas 6 130 25 39 44 21 1 66.67

Utah 8 3 1 0 2 0 0 100.00

Vermont 1 20 7 1 12 0 0 100.00

Virgin Islands 2 1 0 0 1 0 0 100.00

Virginia 3 60 7 9 29 1 14 65.91

Washington 10 125 0 0 125 0 0 100.00

West Virginia 3 26 0 4 21 0 1 95.45

Wisconsin 5 6 0 0 4 2 0 66.67

Wyoming 8 11 1 0 10 0 0 100.00

Totals 1,731 162 169 1,138 154 108 81.29
76 

Table 10 – Analysis of Alleged Neglect – FY2020 

State/

Jurisdiction

HHS

Region 

Total Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's favor

Not resolved in 

the client's favor

Successful 

outcomes from 

P&A 

involvement 

Other 

Representation 

Found

Services not 

needed due to 

client death or 

Lost Contact 

Outcome 

Unknown

Lack of 

Resources

Percentage 

Favorably 

Resolved* 

Alabama 4 42 2 1 23 12 0 1 3 0 0 0 65.71 

Alaska 10 3 0 0 1 0 0 0 0 0 0 2 100.00 

American 

Indian 

Consortium 

13 1 0 0 0 0 1 0 0 0 0 0 0.00 

American 

Samoa 9 8 1 1 5 0 1 0 0 0 0 0 83.33 

Arizona 9 60 1 6 50 1 0 2 0 0 0 0 98.04 

Arkansas 6 11 1 1 8 1 0 0 0 0 0 0 88.89 

California 9 13 3 0 10 0 0 0 0 0 0 0 100.00 

Colorado 8 26 0 3 14 1 6 2 0 0 0 0 66.67 

Connecticut 1 4 1 0 3 0 0 0 0 0 0 0 100.00 

Delaware 3 24 0 0 13 0 11 0 0 0 0 0 54.17 

District of 

Columbia 3 27 2 4 19 2 0 0 0 0 0 0 90.48 

Florida 4 114 23 17 71 3 0 0 0 0 0 0 95.95 

Georgia 4 79 10 0 66 0 2 0 1 0 0 0 97.06 

Guam 9 5 1 0 3 1 0 0 0 0 0 0 75.00 

Hawaii 9 23 12 3 8 0 0 0 0 0 0 0 100.00 

Idaho 10 63 0 6 53 4 0 0 0 0 0 0 92.98 

Illinois 5 193 18 5 17 8 14 2 2 1 125 1 43.59 

Indiana 5 11 1 1 7 0 1 0 1 0 0 0 87.50 

Iowa 7 9 0 0 7 0 1 0 0 1 0 0 87.50 

Kansas 7 11 3 2 4 0 0 0 0 0 0 2 100.00 

Kentucky 4 10 0 0 5 2 3 0 0 0 0 0 50.00 

Louisiana 6 15 1 2 5 0 0 1 0 1 0 5 100.00 

Maine 1 58 0 4 51 3 0 0 0 0 0 0 94.44 

Maryland 3 19 0 4 14 0 0 0 0 0 0 1 100.00 

Massachuse

tts 1 42 3 3 24 8 0 0 0 4 0 0 75.00 

Michigan 5 24 5 2 15 2 0 0 0 0 0 0 88.24 

Minnesota 5 29 2 0 24 2 0 0 0 1 0 0 92.31 

Mississippi 4 4 0 0 3 0 0 0 1 0 0 0 100.00 

Missouri ̃ 7 100 0 0 100 0 0 0 0 0 0 0 100.00 

Montana 8 102 56 0 37 8 0 0 0 1 0 0 82.22 

Nebraska 7 2 0 0 2 0 0 0 0 0 0 0 100.00 

Nevada 9 8 1 1 5 0 0 0 0 1 0 0 100.00 

New 

Hampshire 1 43 4 2 32 0 0 0 0 1 0 4 100.00 

New Jersey 2 68 6 14 34 4 0 2 2 6 0 0 89.47 

New 

Mexico 6 16 0 0 16 0 0 0 0 0 0 0 100.00 

New York 2 17 0 4 10 0 0 0 0 1 0 2 100.00 

North 

Carolina 4 3 2 0 1 0 0 0 0 0 0 0 100.00 

North 

Dakota 8 28 0 2 26 0 0 0 0 0 0 0 100.00 

Northern 

Marianas ̃ 9 3 0 0 0 0 0 0 3 0 0 0 0.00 

Ohio 5 117 2 4 110 1 0 0 0 0 0 0 99.10 
77 

State/

Jurisdiction

HHS

Region 

Total Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's favor

Not resolved in 

the client's favor

Successful 

outcomes from 

P&A 

involvement 

Other 

Representation 

Found

Services not 

needed due to 

client death or 

Lost Contact 

Outcome 

Unknown

Lack of 

Resources

Percentage 

Favorably 

Resolved* 

Oklahoma 6 19 2 2 8 3 0 0 4 0 0 0 72.73 

Oregon 10 4 0 0 0 1 2 0 0 1 0 0 0.00 

Pennsylvan

ia 3 73 3 3 63 1 0 0 0 0 0 3 98.44 

Puerto Rico 2 5 0 0 5 0 0 0 0 0 0 0 100.00 

Rhode 

Island 1 1 0 0 0 0 0 1 0 0 0 0 0.00 

South 

Carolina 4 135 0 0 129 4 0 1 0 1 0 0 96.99 

South 

Dakota 8 13 0 0 12 1 0 0 0 0 0 0 92.31 

Tennessee 4 11 0 3 2 2 3 0 0 1 0 0 28.57 

Texas 6 226 37 50 102 20 1 2 4 8 2 0 82.93 

Utah 8 5 0 0 5 0 0 0 0 0 0 0 100.00 

Vermont 1 17 1 0 16 0 0 0 0 0 0 0 100.00 

Virgin 

Islands 2 1 0 0 1 0 0 0 0 0 0 0 100.00 

Virginia 3 34 7 2 17 2 6 0 0 0 0 0 68.00 

Washington 10 291 0 0 291 0 0 0 0 0 0 0 100.00 

West 

Virginia 3 23 2 1 19 1 0 0 0 0 0 0 95.00 

Wisconsin 5 5 0 0 5 0 0 0 0 0 0 0 100.00 

Wyoming 8 5 0 0 5 0 0 0 0 0 0 0 100.00 

Totals 2,303 213 153 1,576 98 52 14 21 29 127 20 91.31 
78 

Table 11 – Analysis of Alleged Rights Violations – FY2019 

State/

Jurisdiction

HHS

Region 

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's favor

Not resolved in 

the client's favor

Percentage 

Favorably 

Resolved* 

Alabama 4 40 3 6 24 7 77.42 

Alaska 10 24 1 2 9 12 42.86 

American Indian 

Consortium 13 6 0 0 6 0 100.00 

American Samoa 9 8 1 0 7 0 100.00 

Arizona 9 50 0 4 43 3 93.48 

Arkansas 6 47 1 9 33 4 89.19 

California 9 709 7 18 677 7 98.98 

Colorado 8 49 11 7 26 5 83.87 

Connecticut 1 16 2 1 12 1 92.31 

Delaware 3 40 0 5 35 0 100.00 

District of 

Columbia 3 16 0 7 9 0 100.00 

Florida 4 64 8 13 42 1 97.67 

Georgia 4 2 1 0 1 0 100.00 

Guam 9 10 0 1 9 0 100.00 

Hawaii 9 144 6 23 115 0 100.00 

Idaho 10 26 0 2 19 5 79.17 

Illinois 5 287 9 14 146 118 55.30 

Indiana 5 4 0 0 4 0 100.00 

Iowa 7 32 5 5 22 0 100.00 

Kansas 7 249 106 50 86 7 92.47 

Kentucky 4 25 0 5 20 0 100.00 

Louisiana 6 11 1 0 10 0 100.00 

Maine 1 49 0 5 40 4 90.91 

Maryland 3 33 0 0 33 0 100.00 

Massachusetts 1 4 0 1 3 0 100.00 

Michigan 5 43 1 0 42 0 100.00 

Minnesota 5 57 14 13 27 3 90.00 

Mississippi 4 3 1 0 2 0 100.00 

Missouri 7 85 1 5 77 2 97.47 

Montana 8 32 0 3 27 2 93.10 

Nebraska 7 2 0 0 2 0 100.00 

Nevada 9 13 2 3 8 0 100.00 

New Hampshire 1 163 0 0 163 0 100.00 

New Jersey 2 64 14 15 32 3 91.43 

New Mexico 6 13 8 0 5 0 100.00 

New York 2 91 0 0 91 0 100.00 

North Carolina 4 21 0 3 18 0 100.00 

North Dakota 8 86 0 1 85 0 100.00 

Northern Marianas 9 9 1 2 6 0 100.00 

Ohio 5 651 8 12 623 8 98.73 

Oklahoma 6 10 2 1 7 0 100.00 

Oregon 10 12 4 0 7 1 87.50 

Pennsylvania 3 168 4 9 111 44 71.61 
79 

State/

Jurisdiction

HHS

Region 

Total 

Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's favor

Not resolved in 

the client's favor

Percentage 

Favorably 

Resolved* 

Puerto Rico 2 0 0 0 0 0 0.00 

Rhode Island 1 49 1 10 26 12 68.42 

South Carolina 4 17 0 2 14 1 93.33 

South Dakota 8 15 3 1 10 1 90.91 

Tennessee 4 20 3 5 12 0 100.00 

Texas 6 434 61 112 192 69 73.56 

Utah 8 115 5 13 97 0 100.00 

Vermont 1 14 2 1 8 3 72.73 

Virgin Islands 2 3 1 0 1 1 50.00 

Virginia 3 25 2 3 18 2 90.00 

Washington 10 164 0 0 164 0 100.00 

West Virginia 3 14 2 2 10 0 100.00 

Wisconsin 5 51 4 5 38 4 90.48 

Wyoming 8 5 0 0 5 0 100.00 

Totals 4,394 306 399 3,359 330 91.05 
80 

Table 11 – Analysis of Alleged Rights Violations – FY2020 State/ Jurisdiction HHS Region Total Complaints Closed Complaints withdrawn, no merit Complaints withdrawn by Client Resolved in client's favor Not resolved in the client's favor Other Representation F d Services not needed due to li t d th Lost Contact

Outcome 

Unknown

Lack of 

Resources

Percentage 

Favorably 

Resolved* 

Alabama 4 34 3 5 23 3 0 0 0 0 0 88.46 

Alaska 10 23 3 3 11 5 0 0 1 0 0 68.75 

American Indian Consortium 13 12 0 2 7 0 0 0 0 2 1 100.00 

American Samoa 9 28 2 2 12 9 0 0 0 0 3 57.14 

Arizona 9 86 1 10 35 40 0 0 0 0 0 46.67 

Arkansas 6 30 0 5 19 3 0 0 3 0 0 86.36 

California 9 618 5 20 583 10 0 0 0 0 0 98.31 

Colorado 8 22 2 3 13 2 0 2 0 0 0 86.67 

Connecticut 1 9 2 1 5 1 0 0 0 0 0 83.33 

Delaware 3 47 0 3 41 0 3 0 0 0 0 100.00 

District of Columbia 3 12 1 4 7 0 0 0 0 0 0 100.00 

Florida 4 37 8 4 24 1 0 0 0 0 0 96.00 

Georgia 4 15 0 0 10 2 1 0 2 0 0 83.33 

Guam 9 11 2 1 7 0 0 1 0 0 0 100.00 

Hawaii 9 104 5 16 83 0 0 0 0 0 0 100.00 

Idaho 10 25 0 1 24 0 0 0 0 0 0 100.00 

Illinois 5 286 13 7 73 10 2 0 3 174 4 87.95 

Indiana 5 29 5 7 13 0 0 2 1 0 1 100.00 

Iowa 7 39 4 2 24 2 1 0 6 0 0 92.31 

Kansas 7 210 21 26 128 6 0 0 0 0 29 95.52 

Kentucky 4 39 0 8 20 9 0 0 2 0 0 68.97 

Louisiana 6 26 4 3 11 0 2 0 1 0 5 100.00 

Maine 1 96 3 20 71 2 0 0 0 0 0 97.26 

Maryland 3 53 2 9 37 2 0 0 0 0 3 94.87 

Massachusetts 1 34 0 4 30 0 0 0 0 0 0 100.00 

Michigan 5 20 1 3 14 0 1 1 0 0 0 100.00 

Minnesota 5 87 5 0 73 7 0 0 2 0 0 91.25 

Mississippi 4 3 0 0 3 0 0 0 0 0 0 100.00 

Missouri ̃ 7 103 0 4 94 5 0 0 0 0 0 94.95 

Montana 8 35 3 0 28 4 0 0 0 0 0 87.50 

Nebraska 7 2 0 0 1 0 1 0 0 0 0 100.00 

Nevada 9 14 2 0 11 0 0 0 1 0 0 100.00 

New Hampshire 1 112 12 0 98 0 0 0 1 0 1 100.00 

New Jersey 2 26 1 1 20 4 0 0 0 0 0 83.33 

New Mexico 6 10 0 1 9 0 0 0 0 0 0 100.00 

New York 2 68 6 3 59 0 0 0 0 0 0 100.00 

North Carolina 4 21 1 0 17 0 0 1 2 0 0 100.00 

North Dakota 8 76 0 2 71 0 0 1 2 0 0 100.00 

Northern Marianas ̃ 9 3 0 0 2 1 0 0 0 0 0 66.67 

Ohio 5 559 2 14 533 10 0 0 0 0 0 98.16 

Oklahoma 6 5 1 0 2 2 0 0 0 0 0 50.00 

Oregon 10 8 1 1 4 2 0 0 0 0 0 66.67 
81 

State/

Jurisdiction

HHS

Region 

Total Complaints 

Closed

Complaints 

withdrawn, 

no merit

Complaints 

withdrawn by 

Client

Resolved in 

client's favor

Not resolved in 

the client's favor

Other 

Representation 

F d

Services not 

needed due to 

li t d th 

Lost Contact

Outcome 

Unknown

Lack of 

Resources

Percentage 

Favorably 

Resolved* 

Pennsylvania 3 171 12 4 152 2 0 0 0 0 1 98.70 

Puerto Rico 2 45 42 0 3 0 0 0 0 0 0 100.00 

Rhode Island 1 7 1 3 2 0 0 0 0 1 0 100.00 

South Carolina 4 99 0 4 91 2 0 0 2 0 0 97.85 

South Dakota 8 29 1 5 17 1 0 4 1 0 0 94.44 

Tennessee 4 14 0 2 9 0 1 0 0 0 2 100.00 

Texas 6 388 46 87 165 35 2 4 13 28 8 82.50 

Utah 8 109 0 9 92 0 8 0 0 0 0 100.00 

Vermont 1 13 3 0 10 0 0 0 0 0 0 100.00 

Virgin Islands 2 4 0 0 4 0 0 0 0 0 0 100.00 

Virginia 3 28 6 2 17 2 0 1 0 0 0 89.47 

Washington 10 247 1 0 246 0 0 0 0 0 0 100.00 

West Virginia 3 18 1 1 15 1 0 0 0 0 0 93.75 

Wisconsin 5 44 1 3 40 0 0 0 0 0 0 100.00 

Wyoming 8 0 0 0 0 0 0 0 0 0 0 0.00 

Totals 4,293 235 315 3,213 185 22 17 43 205 58 94.56 
82 

Table 12 – Intervention Strategies – FY2019 

State/ 

Jurisdiction

HHS 

Region 

Total 

Intervention 

Strategies 

Short Term 

Assistance

Abuse & 

Neglect 

Investigations 

Technical 

Assistance

Administrative 

Remedies

Negotiation/ 

Mediation 

Legal 

Remedies

Alabama 4 108 50 37 0 0 8 13 

Alaska 10 33 26 5 0 1 1 0 

American Indian 

Consortium 13 7 0 0 3 2 0 2 

American Samoa 9 85 8 45 11 1 18 2 

Arizona 9 156 138 2 11 2 3 0 

Arkansas 6 78 35 23 8 5 0 7 

California 9 799 799 0 0 0 0 0 

Colorado 8 98 23 2 51 20 2 0 

Connecticut 1 27 11 0 5 1 3 7 

Delaware 3 86 39 17 2 15 13 0 

District of 

Columbia 3 73 28 14 10 2 17 2 

Florida 4 203 167 6 15 1 11 3 

Georgia 4 168 22 54 1 1 90 0 

Guam 9 16 5 6 0 1 0 4 

Hawaii 9 158 118 14 4 2 20 0 

Idaho 10 117 29 38 41 4 4 1 

Illinois 5 538 370 7 121 7 24 9 

Indiana 5 48 12 10 2 10 13 1 

Iowa 7 33 13 5 2 0 12 1 

Kansas 7 292 33 4 210 4 6 35 

Kentucky 4 62 8 14 24 3 13 0 

Louisiana 6 37 18 7 0 0 8 4 

Maine 1 192 78 2 36 9 64 3 

Maryland 3 173 16 95 55 0 4 3 

Massachusetts 1 29 18 5 0 0 6 0 

Michigan 5 132 18 82 6 2 16 8 

Minnesota 5 135 73 0 6 8 48 0 

Mississippi 4 23 1 6 0 12 3 1 

Missouri 7 247 20 50 47 9 109 12 

Montana 8 183 73 91 8 8 1 2 

Nebraska 7 4 0 4 0 0 0 0 

Nevada 9 29 21 0 7 1 0 0 

New Hampshire 1 248 238 8 0 0 2 0 

New Jersey 2 272 105 124 18 3 19 3 

New Mexico 6 121 87 10 5 5 13 1 

New York 2 126 68 1 35 4 14 4 

North Carolina 4 27 22 0 0 1 4 0 

North Dakota 8 140 71 52 0 1 15 1 

Northern 

Marianas 9 12 2 4 0 6 0 0 

Ohio 5 844 770 16 38 0 19 1 

Oklahoma 6 69 11 49 0 0 8 1 

Oregon 10 22 9 12 0 0 0 1 

Pennsylvania 3 245 173 11 52 1 3 5 
83 

State/ 

Jurisdiction

HHS 

Region 

Total 

Intervention 

Strategies 

Short Term 

Assistance

Abuse & 

Neglect 

Investigations 

Technical 

Assistance

Administrative 

Remedies

Negotiation/ 

Mediation 

Legal 

Remedies

Puerto Rico 2 2 0 1 0 0 1 0 

Rhode Island 1 73 18 21 21 5 4 4 

South Carolina 4 153 10 2 3 1 130 7 

South Dakota 8 34 13 3 6 1 9 2 

Tennessee 4 60 10 41 1 1 7 0 

Texas 6 664 174 277 19 108 58 28 

Utah 8 123 86 0 23 0 10 4 

Vermont 1 69 45 15 2 5 0 2 

Virgin Islands 2 12 10 2 0 0 0 0 

Virginia 3 114 56 35 2 3 14 4 

Washington 10 693 686 1 6 0 0 0 

West Virginia 3 44 19 0 10 0 14 1 

Wisconsin 5 88 28 9 16 4 30 1 

Wyoming 8 40 3 25 0 0 12 0 

Totals 8,664 4,984 1,364 943 280 903 190 

Percentages 100.00 57.53 15.74 10.88 3.23 10.42 2.19 
84 

Table 12 – Intervention Strategies – FY2020 

State/ Jurisdiction HHS 

Region 

Total Intervention 

Strategies 

Self-Advocacy 

Assistance

Limited 

Advocacy 

Administrative 

Remedies Litigation Medication Negotiation 

Alabama 4 60 38 0 2 7 1 12 

Alaska 10 27 24 2 0 0 1 0 

American Indian 

Consortium 13 13 2 0 6 3 0 2 

American Samoa 9 55 5 12 5 0 15 18 

Arizona 9 176 151 15 8 0 0 2 

Arkansas 6 49 2 39 7 1 0 0 

California 9 673 673 0 0 0 0 0 

Colorado 8 52 0 49 0 1 0 2 

Connecticut 1 15 1 10 2 1 0 1 

Delaware 3 76 23 28 16 0 0 9 

District of 

Columbia 3 58 1 33 3 3 0 18 

Florida 4 109 104 0 3 1 0 1 

Georgia 4 208 100 46 17 0 3 42 

Guam 9 19 6 6 6 1 0 0 

Hawaii 9 132 11 70 7 1 43 0 

Idaho 10 97 26 66 0 1 3 1 

Illinois 5 643 425 172 12 1 5 28 

Indiana 5 50 11 31 2 1 0 5 

Iowa 7 48 6 13 5 3 0 21 

Kansas 7 235 207 16 5 7 0 0 

Kentucky 4 57 8 27 0 0 3 19 

Louisiana 6 46 24 11 4 1 0 6 

Maine 1 167 11 67 8 4 11 66 

Maryland 3 152 25 112 4 4 0 7 

Massachusetts 1 121 113 0 0 0 1 7 

Michigan 5 81 1 43 29 8 0 0 

Minnesota 5 130 5 85 7 12 0 21 

Mississippi 4 41 4 8 29 0 0 0 

Missouri ̃ 7 202 13 55 14 4 0 116 

Montana 8 157 6 147 1 1 2 0 

Nebraska 7 10 1 8 0 1 0 0 

Nevada 9 24 0 23 0 0 1 0 

New Hampshire 1 178 0 174 1 0 0 3 

New Jersey 2 223 52 138 0 3 1 29 

New Mexico 6 43 1 18 2 5 2 15 

New York 2 94 20 50 3 1 0 20 

North Carolina 4 32 26 0 0 1 0 5 

North Dakota 8 123 49 47 1 0 2 24 

Northern Marianas ̃ 9 9 0 1 5 0 2 1 

Ohio 5 729 0 701 0 0 6 22 

Oklahoma 6 27 4 3 1 1 0 18 

Oregon 10 12 7 2 0 0 0 3 
85 

State/ Jurisdiction HHS 

Region 

Total Intervention 

Strategies 

Self-Advocacy 

Assistance

Limited 

Advocacy 

Administrative 

Remedies Litigation Medication Negotiation 

Pennsylvania 3 264 238 23 0 2 0 1 

Puerto Rico 2 50 0 42 0 0 7 1 

Rhode Island 1 9 8 1 0 0 0 0 

South Carolina 4 258 132 7 2 2 0 115 

South Dakota 8 47 17 23 1 1 0 5 

Tennessee 4 17 5 2 1 0 0 9 

Texas 6 655 19 485 101 23 7 20 

Utah 8 106 89 11 5 0 1 0 

Vermont 1 42 23 16 1 1 0 1 

Virgin Islands 2 5 1 2 0 2 0 0 

Virginia 3 146 4 129 5 2 0 6 

Washington 10 626 593 25 0 0 8 0 

West Virginia 3 49 24 18 1 2 0 4 

Wisconsin 5 55 6 16 2 0 15 16 

Wyoming 8 17 2 13 0 0 0 2 

Totals 7,799 3,347 3,141 334 113 140 724 

Percentages 100.00 42.92 40.27 4.28 1.45 1.80 9.28 
86 

Table 13 – Non-Case Directed Services – FY2019 

 Non-Litigation Advocacy Class Litigation Legislative & Regulatory Advocacy

State/ 

Jurisdiction

HHS Region

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Alabama 4 3,549,030 16 1 34 99,625 1 0 2 296,262 10 0 5 

Alaska 10 5,343 5 27 6 1,500 0 0 1 537 0 0 2 

American Indian Consortium 13 2,188 3 0 22 0 0 0 1 25,000 0 1 0 

American Samoa 9 1,400 88 2 2 200 0 0 0 100 5 0 0 

Arizona 9 43,864 0 0 10 260 0 0 1 0 0 0 0 

Arkansas 6 4,190 1 0 12 0 0 0 0 49,800 2 0 2 

California 9 1,298,483 14 0 58 59,888 0 1 11 0 0 0 0 

Colorado 8 4,505 1 0 6 0 0 0 0 0 0 0 0 

Connecticut 1 718,710 3 0 15 7,900 0 0 2 390,000 0 0 1 

Delaware 3 2,190 20 3 11 0 0 0 0 0 0 0 0 

District of Columbia 3 26,150 9 0 6 3,162 0 0 1 20,000 1 0 3 

Florida 4 1,056,658 28 5 57 43,500 1 0 8 9,292,282 2 0 19 

Georgia 4 1,637,848 64 50 55 1,790,589 0 0 3 1,790,589 0 0 2 

Guam 9 1,110 0 0 3 1,200 0 0 1 0 0 0 0 

Hawaii 9 15 0 0 1 1,900 0 0 2 500 0 0 1 

Idaho 10 104,058 16 0 0 0 0 0 0 272,650 16 14 3 

Illinois 5 2,343 10 21 11 147,740 1 0 3 0 0 0 0 

Indiana 5 9,123 0 0 2 0 0 0 0 0 0 0 0 

Iowa 7 1,389,554 44 0 12 1,000 0 0 1 0 0 0 0 

Kansas 7 1,530 0 0 13 0 0 0 0 0 0 0 0 

Kentucky 4 192,253 34 23 1 0 0 0 0 3,000 3 3 2 

Louisiana 6 983,270 1 0 9 1,311,500 0 0 4 1,000 1 0 0 

Maine 1 33,300 22 14 21 12,000 0 1 1 0 0 0 0 

Maryland 3 70,350 875 0 33 0 0 0 0 0 0 0 0 

Massachusetts 1 41,530 24 1 12 0 0 0 0 0 0 0 0 

Michigan 5 234,330 16 14 1 65,000 0 0 1 344,911 9 0 1 

Minnesota 5 4,772 48 0 3 200 0 0 1 100,000 0 0 1 

Mississippi 4 12,238 62 0 17 0 0 0 0 0 0 0 0 

Missouri 7 5,301 5 0 4 0 0 0 0 0 0 0 0 

Montana 8 4,500 6 0 9 0 0 0 0 30,000 0 0 3 

Nebraska 7 6,281 31 0 4 0 0 0 0 642,170 12 13 7 

Nevada 9 753 8 0 4 0 0 0 0 1,600 0 0 1 

New Hampshire 1 819,363 6 1 43 50,000 0 0 2 100 1 0 1 

New Jersey 2 5,692 1 0 7 9,000 2 0 0 0 0 0 0 

New Mexico 6 151,002 2 0 2 4,737 0 0 1 8,104 0 0 1 

New York 2 247,619 29 1 31 17,602 2 0 10 38,020 3 1 1 

North Carolina 4 242,182 1 0 8 1,000 1 0 0 26,700 0 0 2 

North Dakota 8 85 0 0 2 0 0 0 0 7,548 2 0 0 

Northern Marianas 9 40 1 0 1 0 0 0 0 0 0 0 0 

Ohio 5 1,768,200 54 0 46 250,141 3 0 1 13,954,933 13 0 47 

Oklahoma 6 4,891 29 0 4 0 0 0 0 840,302 4 0 0 
87 

 Non-Litigation Advocacy Class Litigation Legislative & Regulatory Advocacy

State/ 

Jurisdiction

HHS Region

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Oregon 10 18,026 19 0 27 7,800 0 0 1 238,071 3 0 15 

Pennsylvania 3 3,742 21 0 9 19,700 0 0 2 560,949 2 1 19 

Puerto Rico 2 1,399 9 0 30 0 0 0 0 0 0 0 0 

Rhode Island 1 5,660 0 0 4 0 0 0 0 20,000 1 0 0 

South Carolina 4 172,197 1 0 5 3,400 1 0 0 1,000 0 0 2 

South Dakota 8 493 6 3 8 0 0 0 0 0 0 0 0 

Tennessee 4 275,576 25 0 22 0 0 0 0 338,500 0 0 1 

Texas 6 259,200 0 0 0 1,200 0 0 0 238,000 0 0 0 

Utah 8 5,330 1 0 5 16,500 2 0 0 118,815 2 0 5 

Vermont 1 25,295 55 0 57 0 0 0 0 137,642 17 0 14 

Virgin Islands 2 6,824 11 0 15 0 0 0 1 0 0 0 0 

Virginia 3 547,298 46 0 2 0 0 0 0 176,569 5 0 0 

Washington 10 293,435 26 0 36 72,083 3 0 8 416,367 17 0 5 

West Virginia 3 134,770 239 0 16 99,000 0 0 5 131,000 1 0 6 

Wisconsin 5 76,924 12 0 20 0 0 0 0 76,875 6 0 4 

Wyoming 8 3,492 41 0 12 0 0 0 0 0 0 0 0 

Totals 16,515,905 2,089 166 866 4,099,327 17 2 75 30,589,896 138 33 176 
88 

Table 13 – Non-Case Directed Services – FY2020 

 Non-Litigation Advocacy Systemic Litigation Educating Policy Makers

State/ 

Jurisdiction

HHS Region

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Alabama 4 3,273,756 11 0 32 158,828 1 1 5 476,748 5 2 6 

Alaska 10 485,376 0 7 14 8,724 0 1 2 20,123 0 0 3 

American Indian Consortium 13 36,949 1 1 11 320 0 0 2 2,188 0 0 3 

American Samoa 9 860 51 19 8 50 0 0 0 55,000 3 1 1 

Arizona 9 64,050 0 0 41 260 0 0 2 0 0 0 0 

Arkansas 6 1,642 6 0 8 350 0 0 2 5,000 1 0 0 

California 9 1,919,149 3 0 41 0 0 0 0 0 0 0 0 

Colorado 8 4,842 2 0 9 0 0 0 0 0 0 0 0 

Connecticut 1 3,809 13 1 9 404 0 0 2 391,862 0 0 1 

Delaware 3 2,252 43 0 10 0 0 0 0 0 0 0 0 

District of Columbia 3 26,510 5 0 8 3,088 0 0 2 22,000 3 0 4 

Florida 4 7,112,188 14 4 55 2,506,055 1 0 7 356,277 1 0 3 

Georgia 4 27,579,407 207 0 39 4,800 0 0 3 1,116,300 5 0 2 

Guam 9 3,004 4 0 3 1,800 1 0 0 0 0 0 0 

Hawaii 9 15 0 0 1 1,900 1 0 1 500 0 0 1 

Idaho 10 30,058 18 1 0 0 0 0 0 272,650 9 2 1 

Illinois 5 243,293 3 1 22 96,080 0 0 5 10,000 1 0 0 

Indiana 5 1,900 0 0 2 2,500 0 0 1 0 0 0 0 

Iowa 7 1,441,036 50 0 14 1,000 0 0 1 0 0 0 0 

Kansas 7 650 0 0 13 0 0 0 0 0 0 0 0 

Kentucky 4 19,400 5 0 2 150,000 2 0 2 20,000 1 0 0 

Louisiana 6 661,605 0 0 16 5,000 1 1 3 25,000 0 0 1 

Maine 1 32,500 22 13 21 12,000 0 1 1 10,000 2 2 2 

Maryland 3 72,950 28 2 6 1,000 0 0 1 0 0 0 0 

Massachusetts 1 93,760 15 2 25 0 0 0 0 0 0 0 0 

Michigan 5 8,829 32 5 20 60,579 0 0 4 696,695 14 1 3 

Minnesota 5 256,283 44 0 1 200 0 0 1 1,000 1 0 0 

Mississippi 4 35,582 49 1 32 0 0 0 0 2,350 3 0 0 

Missouri ̃ 7 6,515 13 0 5 0 0 0 0 0 0 0 0 

Montana 8 35,303 9 1 42 0 0 0 0 0 0 0 0 

Nebraska 7 8,819 4 0 12 85 1 0 0 8,315 4 1 4 

Nevada 9 790 1 0 3 0 0 0 0 200 1 0 0 

New Hampshire 1 744,952 7 3 47 50,100 1 0 2 100 0 0 1 

New Jersey 2 1,127,642 23 0 12 48,215 3 0 0 195,237 1 0 1 

New Mexico 6 152,650 2 0 3 2,300 1 0 0 0 0 0 0 

New York 2 165,453 28 0 20 12,104 0 0 1

2 69,000 4 0 0 

North Carolina 4 244,100 0 0 9 500 1 0 0 7,000 1 0 1 

North Dakota 8 63 3 0 0 0 0 0 0 4,178 3 0 0 

Northern Marianas ̃ 9 9 0 0 9 0 0 0 0 0 0 0 0 

Ohio 5 156,857 47 1 44 251,000 3 0 1 60,301 12 0 35 

Oklahoma 6 140,410 34 0 12 27 1 0 0 66,909 5 0 2 
89 

 Non-Litigation Advocacy Systemic Litigation Educating Policy Makers

State/ 

Jurisdiction

HHS Region

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Total number 

of Individuals 

Impacted

Concluded 

Successfully

Concluded 

Unsuccessfully

Ongoing

Oregon 10 324,040 7 0 35 67,412 2 0 4 53,262 1 0 9 

Pennsylvania 3 1,668 11 0 0 23,729 3 0 3 576,090 4 0 3 

Puerto Rico 2 1,346 3 0 33 0 0 0 0 0 0 0 0 

Rhode Island 1 8,518 4 0 5 541 0 0 2 0 1 0 0 

South Carolina 4 872,200 1 0 5 403,400 2 0 3 1,000 0 0 2 

South Dakota 8 427 12 0 4 0 0 0 0 47,038 7 0 0 

Tennessee 4 1,785,180 53 0 11 0 0 0 0 118,997 1 0 1 

Texas 6 173,550 42 11 5 17,732 0 0 3 0 0 0 0 

Utah 8 25,730 64 0 9 1,000 1 0 1 85,300 4 0 0 

Vermont 1 40,141 15 0 44 0 0 0 0 16,315 5 0 5 

Virgin Islands 2 7,584 12 0 28 5,444 1 0 1 5,444 0 0 1 

Virginia 3 126,793 29 0 3 0 0 0 0 36,560 2 0 0 

Washington 10 311,605 27 0 76 198,730 6 0 8 376,338 14 0 9 

West Virginia 3 133,562 234 0 17 131,000 0 0 4 131,000 0 0 8 

Wisconsin 5 989,748 3 1 2 0 0 0 0 76,333 6 0 3 

Wyoming 8 2,196 8 1 5 200 0 0 1 0 0 0 0 

Totals 50,999,506 1,322 75 96

3 4,228,457 33 4 92 5,418,610 125 9 116 
90 

Table 14 – Information/Referral/Public Education/Awareness & Training Activities – FY2019 

State/ 

Jurisdiction

HHS 

Region Number of PAIMI Program 

Information & Referral 

Services

A.

Number of public 

awareness activities or 

events

B.

Number of 

education/training activities 

undertaken

C.

Number (approximate) 

of persons trained in B. 

Alabama 4 361 3 37 2,578 

Alaska 10 567 9 4 135 

American Indian 

Consortium 13 1 1 3 258 

American Samoa 9 403 16 8 722 

Arizona 9 112 12 8 148 

Arkansas 6 184 16 8 2,533 

California 9 22 45 737 8,778 

Colorado 8 184 32 14 224 

Connecticut 1 366 21 7 400 

Delaware 3 85 11 20 399 

District of 

Columbia 3 255 61 65 950 

Florida 4 1,158 60 16 1,230 

Georgia 4 503 25 31 1,572 

Guam 9 26 22 19 916 

Hawaii 9 219 279 340 4,925 

Idaho 10 339 44 36 1,245 

Illinois 5 501 41 83 2,625 

Indiana 5 655 9 48 2,102 

Iowa 7 260 18 17 512 

Kansas 7 22 234 57 3,250 

Kentucky 4 563 5 33 657 

Louisiana 6 477 21 49 744 

Maine 1 661 237 196 4,107 

Maryland 3 169 4 8 299 

Massachusetts 1 313 16 6 300 

Michigan 5 1,692 8 0 214 

Minnesota 5 301 26 24 793 

Mississippi 4 152 17 21 3,348 

Missouri 7 590 15 10 261 

Montana 8 290 4 6 526 

Nebraska 7 208 65 41 1,465 

Nevada 9 452 1 10 3,588 

New Hampshire 1 69 6 9 242 

New Jersey 2 343 44 56 1,777 

New Mexico 6 496 18 64 630 

New York 2 964 16 8 856 

North Carolina 4 127 16 8 218 

North Dakota 8 317 12 14 292 

Northern Marianas 9 12 20 6 424 

Ohio 5 82 36 49 9,360 

Oklahoma 6 124 25 5 204 
91 

State/ 

Jurisdiction

HHS 

Region Number of PAIMI Program 

Information & Referral 

Services

A.

Number of public 

awareness activities or 

events

B.

Number of 

education/training activities 

undertaken

C.

Number (approximate) 

of persons trained in B. 

Oregon 10 277 13 5 180 

Pennsylvania 3 605 21 7 299 

Puerto Rico 2 185 30 37 701 

Rhode Island 1 119 7 6 453 

South Carolina 4 560 8 33 830 

South Dakota 8 285 150 14 737 

Tennessee 4 498 110 25 829 

Texas 6 948 15 115 4,949 

Utah 8 515 13 6 212 

Vermont 1 722 3 23 194 

Virgin Islands 2 11 7 4 79 

Virginia 3 351 14 11 19,323 

Washington 10 247 13 52 12,443 

West Virginia 3 191 66 19 751 

Wisconsin 5 589 15 13 1,979 

Wyoming 8 180 19 26 720 

Totals 20,908 2,075 2,577 110,486 
92 

Table 14 – Information/Referral/Public Education/Awareness & Training Activities – FY2020 

State/ 

Jurisdiction

HHS 

Region Number of PAIMI Program 

Information & Referral 

Services

A.

Number of public 

awareness activities or 

events

B.

Number of 

education/training activities 

undertaken

C.

Number (approximate) 

of persons trained in B. 

Alabama 4 407 0 22 10,419 

Alaska 10 336 8 6 257 

American Indian 

Consortium 13 0 33 12 2,188 

American Samoa 9 323 12 6 630 

Arizona 9 164 5 15 363 

Arkansas 6 83 2 2 75 

California 9 10 10 383 5,412 

Colorado 8 116 10 0 0 

Connecticut 1 259 6 2 70 

Delaware 3 76 4 12 422 

District of 

Columbia 3 145 63 57 846 

Florida 4 1,127 32 10 884 

Georgia 4 349 41 49 4,365 

Guam 9 25 15 11 125,932 

Hawaii 9 250 214 48 659 

Idaho 10 345 11 17 504 

Illinois 5 717 28 98 3,858 

Indiana 5 579 2 2 55 

Iowa 7 142 14 21 1,119 

Kansas 7 9 3 141 3,720 

Kentucky 4 575 1 8 322 

Louisiana 6 225 1 1 10 

Maine 1 394 252 163 8,309 

Maryland 3 140 2 22 463 

Massachusetts 1 212 10 4 300 

Michigan 5 1,515 11 0 0 

Minnesota 5 127 15 27 1,450 

Mississippi 4 62 18 67 3,000 

Missouri ̃ 7 575 9 6 285 

Montana 8 301 0 7 8,930 

Nebraska 7 205 43 22 1,215 

Nevada 9 345 12 5 98 

New Hampshire 1 77 6 23 1,127 

New Jersey 2 39 22 25 1,915 

New Mexico 6 509 8 58 465 

New York 2 762 12 4 125 

North Carolina 4 43 0 9 258 

North Dakota 8 290 65 10 242 

Northern 

Marianas ̃ 9 10 6 15 10 

Ohio 5 27 12 28 1,363 

Oklahoma 6 162 15 17 446 
93 

State/ 

Jurisdiction

HHS 

Region Number of PAIMI Program 

Information & Referral 

Services

A.

Number of public 

awareness activities or 

events

B.

Number of 

education/training activities 

undertaken

C.

Number (approximate) 

of persons trained in B. 

Oregon 10 247 7 7 396 

Pennsylvania 3 438 11 7 276 

Puerto Rico 2 102 30 7 169 

Rhode Island 1 174 2 5 170 

South Carolina 4 410 1 23 489 

South Dakota 8 170 204 10 378 

Tennessee 4 238 22 64 53,447 

Texas 6 909 12 98 15,261 

Utah 8 615 7 1 40 

Vermont 1 512 4 13 487 

Virgin Islands 2 9 11 2 22 

Virginia 3 266 12 9 2,450 

Washington 10 27 0 14 415 

West Virginia 3 227 20 7 220 

Wisconsin 5 468 2 11 722 

Wyoming 8 151 18 10 255 

Totals 17,020 1,396 1,723 267,308 
94 

Appendix B – Acronyms (Still under review and revisions) 

ACT Assertive Community Treatment

ADA Americans with Disabilities Act

ACL Administration for Community Living

ACT Assertive Community Treatment

ADA Americans with Disabilities Act

ADLs Activities of Daily Living

ADX Administrative Maximum Facility

AIC American Indian Consortium 

AIDD Administration on Intellectual and Developmental Disabilities

AoD Administration on Disabilities

APS Adult Protective Services

ASL American Sign Language 

BHA Behavioral Health Authority 

BOP Bureau of Prisons 

CHA Children’s Health Act 

CMHS Center for Mental Health Services

CMS Centers for Medicare & Medicaid Services

CPS Child Protective Services 

CSA Core Service Agency

DD Act Developmental Disabilities Assistance and Bill of Rights Act 

DBH Department of Behavioral Health 

DMAT Decision-Making Assessment Tool 

DMH Department of Mental Health 

DOC Department of Corrections

DPH Department of Public Health

DPOAHC Durable Power of Attorney for Health Care

ECT Electroconvulsive Therapy 

FHA Fair Housing Act 

FY Fiscal Year

HCBS Home and Community-Based Services

HHS Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act 

HUD U.S. Department of Housing and Urban Development 

IAA Interagency agreement

IST Incompetent to Stand Trial 

NFMH Nursing Facility for Mental Health 

OCD Obsessive Compulsive Disorder 

OCR Office of Civil Rights

OIG Office of Inspector General 

P&A Protection and Advocacy systems 

PAC PAIMI Advisory Council 

PADD Protection and Advocacy for Developmental Disabilities Program 

PAIMI Protection and Advocacy for Individuals with Mental Illness 

PASRR Pre-Admission Screening and Resident Review 

POA Power of Attorney 
95 

PPE Personal Protective Equipment 

PPR Program Performance Report

PRTF Psychiatric Residential Treatment Facility

PTSD Post-Traumatic Stress Disorder

RSA Rehabilitation Services Administration

RCA Root Cause Analysis 

RN Registered Nurse

RTC Residential Treatment Center

RTU Residential Treatment Unit

SAMHSA Substance Abuse and Mental Health Services Administration

SCM Safe Crisis Management 

SED Serious Emotional Disturbance 

SMI Serious Mental Illness

TASC Training Advocacy and Support Center 

T/TA Training and technical assistance

TTY Teletypewriter

USDOJ United States Department of Justice

VR Vocational Rehabilitation