Court Opinion

ID: 9038373
Source: CourtListenerOpinion
Date Created: 2022-11-27 16:16:46.241534+00
Date Added: 2024-06-11T17:11:53.557639
License: Public Domain

MEMORANDUM
RAYMOND J. BRODERICK, District Judge.
Presently before the Court is a motion filed by the plaintiffs Halderman, et al. in November 1987 to hold the Commonwealth of Pennsylvania and County of Philadelphia in contempt of this Court’s Order of April 5, 1985. For the reasons that follow, this Court finds that both defendants are in contempt of the Order.
I. BACKGROUND
The'Pennhurst litigation has been credited widely for creating a general awareness that retarded persons do have rights—the right to minimally adequate habilitation—the right not to be abused and mistreated—the right to care and training that will enable retarded persons to develop their capabilities and the right not to be warehoused behind institutional walls. Thus, this Court was saddened to learn in the hearing on this contempt motion that the Commonwealth and County have apparently deliberately denied such rights to Pennhurst class members in violation of the obligations that they agreed to undertake—obligations specifically mandated by the Court Decree of April 5,1985. Plainly, the Commonwealth and the County have closed their eyes to the studies that have shown that Pennhurst class members who are now living in the community and receiving adequate habilitation are developing their capabilities and becoming self-sufficient to the extent that some are now working in jobs in private industry.
The litigation surrounding this case has spanned no less than two decades. The case has spawned over 500 court orders, approximately forty-three published opinions, including eleven appeals to the Third Circuit, and three arguments before the United States Supreme Court. After eleven years of active litigation, the parties entered into a final settlement agreement (“FSA”), which was approved and entered by the Court as a consent decree and Order of this Court on April 5, 1985 (“Court Decree”). Since that time, as a result of the defendant’s actions, the plaintiffs have been forced to file numerous motions to enforce the Court Decree.
The long history of this litigation is summarized in the Court’s 1992 published opinion, Halderman, et al. v. Pennhurst State School and Hospital, et al., 784 F.Supp. 215 (E.D.Pa.), aff'd, 977 F.2d 568 (3d Cir.1992), which also contains the text of the FSA and the Court Decree. The record will not be repeated here except as required to set a foundation for the motion presently before the Court.
In May of 1974, the plaintiffs brought a class action suit on behalf of residents of the Pennhurst State School and Hospital, a state institution for mentally retarded persons located in Spring City, Pennsylvania. The suit was brought against various officials of the Commonwealth of Pennsylvania including those of the Pennhurst State School and Hospital and the Department of Public Welfare. In 1975, the Pennsylvania Association for Retarded Citizens (ARC-PA), intervened as plaintiffs, adding as defendants the Mental *596Health/Mental Retardation Administrators of Bucks, Chester, Delaware, Montgomery and Philadelphia Counties. Also in 1975, the United States of America intervened as a plaintiff. The class was certified in November 1976, and the definition of the class was amended by the Court in 1985 to include only those residents who resided at Pennhurst on or after May 30, 1974.
In 1977, after a thirty-two day trial, this Court determined that certain constitutional and statutory rights of the Pennhurst class had been and continued to be violated by the defendants. Halderman, et al. v. Pennhurst State School and Hospital, et al., 446 F.Supp. 1295 (E.D.Pa.1977). A lengthy appeal process ensued, a summary of which can be found in this Court’s 1985 Opinion, Halderman, et al. v. Pennhurst State School and Hospital, et al., 610 F.Supp. 1221, 1225-26 (E.D.Pa.1985). Briefly, the defendants appealed to the Third Circuit Court of Appeals and then to the United States Supreme Court. On remand from the Supreme Court, the Third Circuit affirmed on different grounds. On appeal, the Supreme Court heard two oral arguments and remanded once again. It should be emphasized, however, that the Court’s findings of fact made in 1977 have never been challenged by either the Third Circuit or the Supreme Court. Those findings are directly pertinent to the current motion before the Court, and therefore they will be summarized here.
In 1977, this Court concluded that Pennhurst was overcrowded, understaffed and lacking the programs that experts considered necessary for minimally adequate habilitation of the mentally retarded. “Habilitation” is the term of art used to refer to that education, training and care required by retarded individuals to reach their maximum development. The evidence showed that, in many instances, life skills possessed by residents at the time of their admission to Pennhurst had been destroyed over the years of their institutionalization.
In particular, the evidence demonstrated that Pennhurst residents were regularly subjected to a number of dehumanizing practices, including the use of physical restraints and psychotropic drugs to control the residents in place of adequate staffing and behavioral programs. Residents were not kept in safe conditions: Hundreds of residents sustained both major and minor injuries while at Pennhurst; some reports detailed beatings and rapes of the residents by staff members. As a result of physical abuse, many residents suffered loss of teeth, broken bones and other physical deterioration. Moreover, the Court found that Pennhurst was an isolated, segregated facility. Accordingly, few of its retarded residents were capable of protecting or helping their fellow residents or of registering complaints about their own treatment.
The evidence further showed that routine housekeeping services were not provided to the residents on weekends or in the evenings. Consequently, it was common to find urine and feces on ward floors during these periods. Finally, the average age of a Pennhurst resident was thirty-six years, and the average stay at Pennhurst was twenty-one years.
At the time of the Court Decree, there were 435 retarded individuals living at Pennhurst, and 719 had been previously transferred to community living arrangements pursuant to orders of this Court.
At the time of the trial, none of the parties disputed the testimony of mental health professionals that “normalization” (the antithesis of institutionalization) is now universally accepted as the only successful method of habilitating a retarded person. Normalization requires that a retarded person must be cared for, trained and educated in a normal community living environment. The Court Decree incorporated the “normalization” concept, and the settlement was lauded nationally as recognition that the mentally retarded have the right to minimally adequate habilitation in the least restrictive environment.
Pursuant to the Court Decree, the Commonwealth and County defendants agreed to provide community living arrangements to those members of the plaintiff class for whom such placement was called for by the individual planning process, together with such community services as are necessary to provide each person with minimally adequate habilitation, until such time as the retarded *597individual no longer was in need of such living arrangements and/or community services. The Court Decree required the defendants to provide residential and habilitative services to all persons who had been furnished with such services pursuant to prior orders of this Court. The Court Decree also directed the defendants to develop and provide a written habilitation plan, formulated in accordance with professional standards, to each member of the plaintiff class; provide an individualized habilitation program to each member of the plaintiff class; and permit each class member and his family or guardian to be heard in connection with his or her program. The defendants further agreed to provide an annual review of each person’s individualized habilitation program, and to monitor the services and programs provided to the class members in accordance with a detailed, professionally-established monitoring and visitation procedure. The Court Decree further mandated that all persons provided with services under the terms of the agreement shall be afforded:
(1) protection from harm;
(2) safe conditions;
(3) adequate shelter and clothing;
(4) medical, health-related, and dental care;
(5) protection from physical and psychological abuse, neglect, or mistreatment;
(6) protection from unreasonable restraints and the use of seclusion; and
(7) protection from the administration of excessive or unnecessary medication.
The Court Decree also mandated that the definition of the plaintiff class would be amended to provide that persons who were on the waiting list for placement at Pennhurst (and who had not received any habilitative services under any prior orders of this Court), as well as those persons who “may be placed” at Pennhurst, would no longer be considered members of the plaintiff class and that their claims would be dismissed pursuant to Fed.R.Civ.P. 41 without prejudice to their asserting any claims that they may have had in any court of competent jurisdiction.
Finally, the Court Decree provided that this Court was to retain jurisdiction in this matter until July 1,1989, and that as of that date this case should be marked closed, provided, of course, that at that time all defendants were in compliance with the agreement.
In the years since the Court Decree was entered, empirical evidence has vindicated the opinions of the mental health professionals. That is, many of the Pennhurst residents who were transferred to community living arrangements have progressed to the extent that they enjoy a fuller life and in many instances have become self-supporting members of the community. The Court’s opinion that accompanies the 1985 Court Decree discusses numerous studies conducted in the late 1970s and early 1980s that concluded that the retarded residents of Pennhurst have made significant behavioral strides while in the community. Halderman, et al. v. Pennhurst State School and Hospital, et al., 610 F.Supp. 1221, 1232-33 (E.D.Pa.1985). Briefly, the 1981-82 era studies showed that Pennhurst residents who had moved to community living arrangements improved their habilitative skills and that they also had made significant gains in their adaptive behavior scores. These surveys also indicated that Pennhurst residents had exhibited significant gains in life skills as measured by tests generally accepted by the scientific community. In addition, “family attitudes toward community habilitation ‘changed sharply to more positive attitudes’ toward community habilitation after these families had seen the progress made by their own children in community facilities.” Halderman, 610 F.Supp. at 1232. Moreover, these changes of attitude have had a salutary effect on the family life of the retarded. See id.
More recent studies confirm the progress noted by the earlier studies. A 1992 study conducted by Temple University for the Commonwealth of Pennsylvania concluded “Philadelphia County citizens benefitted strongly from deinstitutionalization in [the] behavioral areas [studied]. People are more independent in many life skill areas and they have also sharply reduced challenging behaviors, since leaving Pennhurst____ In the *598area of social presence, ... contact with people who do not have disabilities has doubled since 1989.” Celia Feinstein, et al., Evaluation of the Well-Being of Pennhurst Class Members Living in the Community in 1992; The Results of Temple Monitoring in Philadelphia County, 7, 22 (1992) (Draft Report 92-3 submitted by Temple University to Pennsylvania Office of Mental Retardation). Moreover, the longer a mentally retarded person resides in the community, the more life skills they gain. James A. Lemanowicz, et al., Pennhurst Class Members in CLAs: Philadelphia County # 87-4 6 (1987) (Temple University Study submitted to the Pennsylvania Office of Mental Retardation). These-findings stand in marked contrast to this Court’s findings in 1977 that Pennhurst residents had regressed in skills while in residence at that institution. Halderman, 446 F.Supp. at 1308.
As previously noted, the original defendants included Delaware, Montgomery, Chester, Bucks, and Philadelphia Counties as well as the Commonwealth of Pennsylvania. In 1989, the plaintiffs filed a contempt motion against Delaware and Montgomery Counties and the Commonwealth. At that time, Delaware County had obligations with respect to approximately 191 Pennhurst residents, and Montgomery County was responsible for 200 residents. This Court found that Delaware and Montgomery Counties and the Commonwealth were not in compliance with the Court Decree on August 28, 1989. Halderman, et al. v. Pennhurst State School and Hospital, et al., 1989 WL 100207, 1989 U.S.Dist.LEXIS 10147 (August 28, 1989 E.D.Pa.), aff'd, 901 F.2d 311 (3d Cir.), cert. denied, 498 U.S. 850, 111 S.Ct. 140, 112 L.Ed.2d 107 (1990). In particular, the Court found that sixty-eight Delaware County residents were not receiving the habilitation mandated by the Court Decree. Montgomery County was found in noncompliance with respect to six of its residents. The defendants were ordered to comply fully with the Court Decree by March 1, 1990, which was later extended to July 1, 1990 in the case of Montgomery County and May 10,1990 in the case of Delaware County. Both -Counties implemented community residential programs in compliance with the Court’s Order. Chester County’s obligations under the Court Decree were terminated when all Pennhurst residents were relocated to community living arrangements. Bucks County’s obligations terminated pursuant to the automatic lapse provision of the Court Decree and because the County was not found to be in noncompliance on or before July 1, 1989.
The current motion before the Court was filed in November 1987 by plaintiff ARC-PA ARC’s motion seeks to hold the Philadelphia defendants in contempt of the Court Decree. Among other things, ARC’s motion requests the Court to appoint a team of experts to review the services being provided to the approximately 500 class members living in Philadelphia and to identify obstacles to the effective delivery of services and to make recommendations for improvement in the delivery of services. The Halderman plaintiffs later joined the ARC motion and, on motion of the Philadelphia defendants, the Commonwealth defendants were joined as defendants in the contempt motion.
Shortly after the filing of ARC’s motion, the Philadelphia defendants agreed to appointment of an expert team. The experts submitted a draft report and, after receiving comments from the parties and other interested persons, a final report was filed with the Court in July, 1988. Shortly after the final report was filed, the parties entered into negotiations to settle the dispute. These negotiations, which continued through late 1989, failed, and a settlement agreement never materialized. In May 1990, the parties agreed to the appointment of a Special Master, Dr. Sue Gant, for purposes of reviewing and analyzing the Philadelphia mental retardation program and to determine whether the defendants were in compliance with the Court Decree.
Dr. Gant’s report was filed with the Court in February 1991. The report detailed numerous instances of noncomplianee with the Court Decree by the defendants. The Court set a hearing date on the plaintiffs’ contempt motion for June 13, 1991.
Shortly before the hearing date, the parties agreed to attempt to settle the contempt motion by cooperatively developing a com*599prehensive plan that would restructure the Philadelphia mental health retardation system (“Collaborative Plan”). The goal of the Collaborative Plan was apparently to ensure that all Philadelphia mentally retarded residents, including the Pennhurst class members, would receive the habilitation ordered by the Court Decree. It should be emphasized, however, that while the Court certainly has no objection to all mentally retarded Philadelphia citizens receiving habilitation services mandated for the Pennhurst class members, this Court’s jurisdiction under the Court Decree, is specifically limited to those Philadelphia residents who were Pennhurst residents on or after May 30, 1974. In any event, the parties stipulated to a continuance of the contempt hearing and proceeded to work on the Collaborative Plan.
Pursuant to the stipulation, the parties have attempted over the past two years to develop a mutually agreeable plan to comply with the Court Decree of April 5, 1985. In June 1993, the Court was advised that such a plan had been developed. Accordingly, on June 22, 1993, the Court ordered the County and Commonwealth defendants to file the plan within ten days of the date of this Court’s order. The June 22nd Order also directed all parties to the stipulation to advise the Court on the nature of the order the Court might enter with regard to the plan and to advise the Court on whether they believe the plan should be reviewed by the Special Master. The defendants filed the plan with the Court on July 8, 1993. The plaintiffs responded with a Memorandum on July 7 and 26, 1993 regarding a proposed order pertaining to the Collaborative Plan. The defendants responded with a proposed order on August 25, 1993.
The Court held a hearing on September 7, 1993 regarding the status of settlement of the contempt motion. At the hearing, the parties advised the Court that they were at an impasse regarding settlement. Accordingly, the Court issued an order setting a hearing date of November 16, 1993 (later rescheduled upon request of the defendants to December 1, 1993) on the plaintiffs’ 1987 contempt motion. The Order also directed the Court’s Special Master, Dr. Sue Gant, to testify at the contempt hearing. In the meantime, the Court also requested that Dr. Gant update her February 1991 report. Dr. Gant sent her update to the Court on November 26, 1993 with copies to all parties. The November update concluded that the defendants still were not in compliance with the Court Decree of April 5, 1985.
II. FINDINGS OF FACT
This Court held hearings over a period of approximately nine days between December 1 and December 23, 1993 in connection with the plaintiffs’ motion for contempt against the defendants. On the basis of the evidence presented at that hearing as well as the Special Master’s Reports, the Court finds that the County and the Commonwealth are not in substantial compliance with the provisions of the Court Decree. Specifically, the Court finds that the Commonwealth and the County are not in compliance in that:
Defendants’ Obligations Under the Court Decree
1. Paragraph A2 of the Court Decree requires the County and Commonwealth defendants to provide community living arrangements (“CLAs”) to plaintiff class members, together with community services as are necessary to provide them with minimally adequate habilitation.
2. Paragraph A4 provides that the defendants shall develop and provide written individualized habilitation plans (“IHPs”), formulated in accordance with professional standards, for all class members and that such IHPs shall be implemented and reviewed annually.
3. Paragraph A5(b) provides that the County shall monitor the programs and services being received by each individual class member in accordance with the member’s IHP. Paragraph A5(e) requires the Commonwealth to monitor the County’s performance under subsection b and to monitor annually 20% of class members’ residential and day programs.
4. Paragraph A5(c) provides that the Commonwealth shall measure annually the progress of each class member and the characteristics of the person’s environment and *600report its findings promptly to the County who shall distribute the findings to case managers and care providers.
5. Paragraph A5(d) provides that each class member shall have a county case manager and that caseloads for county case managers shall not exceed the ratios established by the Title 19 waiver agreement between the County and Commonwealth (twenty-five (25) class members per case manager). Paragraph A5(d) also states that the Commonwealth shall provide at least three days training to newly hired case managers assigned to Pennfmrst class members and continuing annual training to all such case managers.
6. Paragraphs A6(a), (b), and (e) provide that the County and Commonwealth shall take adequate actions and require providers of residential or habilitative services to take adequate actions to provide class members with protection from harm, safe conditions, and prohibit physical and psychological abuse, neglect or mistreatment.
7. Paragraph A6(d) requires that the Commonwealth and County defendants take adequate actions and require care providers to take adequate actions to ensure that class members have medical, health-related and dental care.
8. Paragraph A6(g) requires the Commonwealth and County defendants to take adequate actions and require care providers to take adequate actions to prohibit the administration of excessive or unnecessary medication.
9. Paragraph A7 requires the Commonwealth and County to maintain written rules and procedures requiring prompt review/investigation of any complaints in connection with Paragraph A6 and to adopt the necessary corrective action in response to its reviews and investigations.
Community Living Arrangements
10. The Commonwealth and County have violated the Court Decree in that at least thirty-three (33) and perhaps as many as fifty-five (55) class members still reside in large institutional settings, nursing homes and boarding facilities despite professional recommendations that they be moved to community living arrangements. Some class members were recommended for placement over a decade ago, but the County and Commonwealth have failed to take any action to move them to the community. The Commonwealth notified the County in both 1990 and 1991 that the County was not in compliance with the Court Decree because of its failure to provide class members with CLAs. Even though the Commonwealth is required to comply with the Court Decree, it failed to take any corrective action to enforce the Court Decree.
11. Of the class members still residing in institutions, approximately eighteen (18) class members from Philadelphia County reside at Embreeville Center, a Commonwealth institution that houses about 300 individuals. These class members do not have IHPs or case managers; nor have they been provided with community living arrangements mandated by the Court Decree. The class members residing at Embreeville are being unnecessarily segregated from the community and denied minimally adequate habilitation. All class members residing at Embreeville should be transferred to CLAs. The County and Commonwealth have knowingly and deliberately violated the Court Decree by maintaining Pennhurst class members at Embreeville Center.
12. The Deputy Secretary of the Commonwealth’s Office of Mental Retardation, Nancy Thaler, previously has notified the County of Philadelphia that class members residing at Embreeville Center are at risk for neglect and that the institution should be closed and its residents moved into the community.
13. Approximately eleven (11) class members from Philadelphia County reside at Woodhaven, a 250-bed intermediate care facility. None of these class members has been provided with an IHP, case manager, or community living arrangements as mandated by the Court decree. Woodhaven class members are being unnecessarily segregated from society and denied minimally adequate habilitation. All class members residing at Woodhaven should be transferred to CLAs. The County and Commonwealth have know*601ingly and deliberately violated the Court Decree by maintaining Pennhurst class members at Woodhaven.
14. Approximately five (5) class members live at Allegheny Valley School (“AVS”), also a non-CLA facility. None of these class members has been provided with an IHP, case manager, or community living arrangements. Class members living at AVS are being unnecessarily segregated from the community and denied minimally adequate habilitation. All class members living at AVS should be transferred to CLAs. The Commonwealth and the County have knowingly and deliberately violated the Court Decree by maintaining Pennhurst class members at AVS.
15. Approximately twenty-one (21) other class members are living in other institutional type facilities in violation of Paragraph A2 of the Court Decree. These class members are being unnecessarily segregated from the community and denied minimally adequate habilitation. Class members living at these institutions should be transferred to CLAs. The Commonwealth and the County have knowingly and deliberately violated the Court Decree by maintaining Pennhurst class members in these institutions.
Individual Habilitation Plans
16. The defendants have knowingly and deliberately violated the Court Decree by failing to provide all class members with IHPs. The County and Commonwealth did not provide at least 103 class members with an IHP in 1992; at least eighty-two (82) class members had no IHP in 1993; at least twenty-eight (28) class members living in CLAs had no IHP in both years. None of the class members living in institutional living arrangements have IHPs.
17. Where IHPs have been written for class members, the County and Commonwealth have either 1) failed to implement the IHP, or 2) delayed implementation of the plan, or 3) not provided services consistent with the IHP’s objectives, or 4) developed IHPs that are not in accordance with accepted professional standards of practice as mandated by the Court Decree.
For example, many class members have severe physical disabilities that require adaptive and assistive equipment and/or specialized therapies. Many IHPs call for these particular individualized therapies or services. The County and Commonwealth, however, have failed to provide class members with such services as occupational, physical, speech and behavior therapies, nutrition services, and adaptive equipment such as wheelchairs and eyeglasses.
In addition, a large proportion of IHPs call for class members to be employed in the community rather than in sheltered workshops. In the workshop setting, class members earn a fraction of what is available through community employment and they have very little opportunity to interact with nondisabled persons. Accordingly, these mentally retarded plaintiffs are being unnecessarily segregated from the community. The Commonwealth has a written policy that provides that community integrated employment for the mentally retarded is a priority service. See 55 Pa.Code § 6000.171 et seq. (1991) (“Counties are encouraged to redirect existing resources from traditional adult day services, such as ... sheltered workshops, to community-integrated employment opportunities for persons with mental retardation.”). Yet, neither the Commonwealth nor the County has undertaken to enforce this policy. As a result, many Pennhurst class members sit idle in either institutions or community living arrangements or work in sheltered workshops. Accordingly, these members are being harmed because they are not being given the opportunity to develop life skills and in some cases they are losing skills and/or learning to engage in counterproductive behavior.
18. The defendants have knowingly and deliberately failed to review and update IHPs as required by the Court Decree. Individual Habilitation Plans were not reviewed annually for approximately 76% of the class members in 1990 as required by Paragraph A4 of the Court Decree. In 1991, approximately 67% of the class had IHPs that were out of date; 56% of class members’ IHPs were out of date during 1993. In addition, approximately 45% of class members living in *602CLAs do not have a current IHP. The purpose of IHPs is to memorialize in writing the habilitation goals for each individual class member as determined by qualified professionals and to provide class members with individualized training, goals and programs. In the absence of an IHP, a class member likely will receive generic or pro forma habilitation that is unsuitable to that class member or no habilitation at all. An IHP must be current and implemented to be effective. Thus, an out of date IHP is tantamount to having no IHP.
Moreover, accepted professional standards mandate that IHP goals must be measurable and objective. In contrast, many of the class members’ IHPs are too subjective and generalized to provide these individuals with the minimally adequate habilitation to which they are entitled under the Court Decree.
19. Immediately prior to the contempt hearing, the County made hurried efforts to update class members’ IHPs in order to conceal its noncompliance.
Case Management of Class Members
20. The defendants have knowingly and deliberately failed to provide case managers to all Pennhurst class members in violation of the Court Decree. Approximately 32% of the Philadelphia class members presently do not have case managers; due to staff shortages, as of November 1993, seventy-six to eighty (76-80) Philadelphia class members did not have case managers. As of October 1993, approximately twenty-two (22) other class members residing with various private provider agencies did not have case managers. There have been chronic staff shortages in case management services at the County level. The County has not responded promptly to alleviate these shortages to ensure that all class members are represented by case managers.
21. In an attempt to conceal its noncompliance, the County assigned case managers to all but thirty-eight (38) class members just prior to the hearing in this matter. Many of these placements took place during the contempt hearings.
22. The County does not regularly provide case management visits to those class members who are assigned case managers. Of those class members living in CLAs, thirty-one (31) members have never had a case manager visit them; twenty (20) other members have not been visited by a case manager for the past one to four years; forty-three members (43) have not had a case manager visit them on a monthly basis during the past year.
23. Caseloads for County case managers exceed the maximum requirement of twenty-five class members per case manager, as mandated by the Court Decree.
24. Several case managers who have attempted to identify and report noncompliance with the Court Decree have been criticized for their efforts by supervisory personnel in the County Office of Mental Health/Mental Retardation.
Monitoring of Class Members
25. The defendants have knowingly and deliberately failed to monitor Pennhurst class members in violation of the Court Decree. The Commonwealth and County have several monitoring functions under Paragraph A5 of the Court Decree, but the defendants cannot adequately perform such monitoring, because they are uncertain as to who comprises the class. The Commonwealth lists 619 class members; the County identifies between 443 and 536 depending on the list provided. There are as many as 103 to 176 class members who are currently unaccounted for in the system. It is not possible for the Commonwealth and County to meet their obligations under the Court Decrees unless there is a full accounting of all class members and their whereabouts.
26. The Commonwealth is not monitoring those class members who are not in community living arrangements. Furthermore, the Commonwealth’s annual monitoring report, which is prepared by a subcontractor, compiles data in summary, rather than individualized form. Thus, the report does not provide information on which class members are experiencing problems adapting or otherwise suffering harm in their respective environments. As a result of this generic format, recipients of the Commonwealth’s reports, including the County and/or provider agen*603cies, are unable to respond adequately to correct any deficiencies. Moreover, the County Office of Mental Health/Mental Retardation does not furnish the Commonwealth reports to care providers as required by the Court Decree.
27. The Special Management Unit of the Commonwealth Department of Public Welfare has failed to annually monitor 20% of class members’ day and residential programs, as mandated by the Court Decree.
28. The County does not have in place a policy for responding to the monitoring reports it receives from outside contractors.
29. The County subcontracts its monitoring responsibilities to Community Monitoring Project (“CMP”), a monitoring service. CMP’s contract with the County provides that it shall annually monitor those class members living in community living arrangements—approximately 400 members. Thus, despite a provision in the Court Decree that mandates that the County monitor all class members, there are at least 100, and possibly in excess of 200 class members who are not monitored by CMP under its contract with the County. Moreover, even though CMP’s contract requires it to monitor approximately 400 class members, it has never met its contract requirement in any given year. CMP reports that in 1991, it only monitored 271 class members; in 1992, 305 class members were monitored; as of October 1993, 201 class members had been monitored. County records show that CMP monitored 34 class members in 1990; 179 class members in 1991; 233 class members in 1992; and 155 class members in 1993 through October. Regardless of the discrepancy, there is no question that the County failed to monitor all class members as mandated by the Court Decree.
30. The County and Commonwealth are allowing care providers to investigate incidents of abuse, neglect, death, serious injury and other unusual incidents among class members. Thus, in effect the care providers are investigating themselves. This arrangement violates Paragraph A5(b), which provides that the “County” shall monitor the programs and services being received by each class member. The Court Decree does not authorize the County to delegate this monitoring function to care providers. Permitting care providers to monitor alleged incidents of death, abuse, neglect and other injury is a violation of the Court Decree. It is akin to putting the fox in charge of the hen house.
31. There is insufficient follow up or monitoring by the County and Commonwealth of incidents of abuse, neglect, injury and death of class members. As of October 1993, over ninety (90) incidents of death, abuse, neglect, and other serious injury had not been reports ed to either the County or the Commonwealth as required by the contracts between the care providers and the County and Commonwealth licensing regulations. In several instances, the County received reports of physical injury of class members and failed to obtain updated information on the injuries for more than a year. In particular, the County received a report in 1992 that six class members had been sexually abused by a staff member of a care provider. The event occurred on July 20,1992. No written update was requested by the county employee responsible for supervising the investigations by care providers until October 18, 1993—just one month before the scheduled contempt hearing. The medical reports received by the county in 1992 did not indicate whether or not the abuse reported had, in fact, occurred; the only information contained in the medical report was a cursory notation that the class members who had been sexually abused tested free of venereal disease. The County employee responsible for receiving unusual incident reports never requested information as to whether these class members were abused and as to what type of abuse they suffered. Moreover, the County did not actively investigate the matter; rather, it referred the complaint to the police for investigation and never conducted any follow up investigation. Such inaction is a clear violation of Paragraphs A6 and A7 of the Court Decree, which require prompt investigation of such incidents and corrective action.
There were numerous other instances of abuse, neglect and deaths of class members in which the County and Commonwealth *604failed to obtain adequate medical and incident reports or to follow up in any meaningful way to provide training, ensure that disciplinary measures were taken, or take other corrective action to prevent the problem from recurring.
32. The County does not have a system to ensure that staff members of care providers who abuse or neglect class members at one site are not re-employed at another class member site. Unusual incident reports from provider agencies consistently do not identify employees involved in abuse or neglect; the County does not request this information. The County employee who is responsible for receiving unusual incident reports does not think it is appropriate for the County to keep track of individuals who abuse and/or neglect class members. The County’s and Commonwealth’s inaction puts class members at serious risk of harm and therefore is a clear violation of Paragraphs A6 and A7 of the Court Decree.
Medical and Dental Care
33. Some class members are being inappropriately medicated with psychotropic drugs rather than being treated with a behavioral program. Psychotropic drugs have a sedative effect thereby impairing cognitive abilities and making learning more difficult. According to accepted medical standards of practice, psychotropic medication is inappropriate where the cause of the behavior is learned; that is, where an individual acts out when he or she is attempting to communicate. The appropriate treatment in such cases is to teach the individual an acceptable form of communication. Behavioral plans should be used in place of psychotropic medication wherever possible. Most of the class members currently taking psychotropic medication do not have a current individualized and implemented behavioral plan based on functional assessments as part of their IHP.
34. Psychotropic medication practices at Embreeville and Woodhaven institutions do not comport with accepted standards of medical practice. Ten of seventeen (58%) class members living at the Embreeville facility are being medicated; nine of eleven (81%) class members living at Woodhaven are medicated. The percentage of people medicated at Embreeville and Woodhaven far exceeds the national average of 20% or less for those people living in institutions. Furthermore, medical personnel at these facilities have not performed the appropriate medical and psychological testing necessary to determine whether medication is appropriate. In addition, Woodhaven and Embreeville personnel do not systematically monitor class members for side effects of these medications. Accordingly, learning has become more difficult for many of these class members and/or they have regressed in skills already learned. As a result of this over-sedation, class members are at risk of harm.
35. Care providers are inadequately monitoring anti-seizure medication given to class members; for example, class members are not given regular blood level tests for toxicity.
36. The County does not have any formal policy for systematic review and monitoring of psychotropic and anti-seizure medication prescribed for class members. There is no monitoring by the County or Commonwealth of psychotropic or anti-seizure prescriptions despite a history of overuse of these types of medications in connection with class members. The County’s and Commonwealth’s failure to prohibit excessive medication of class members clearly violates Paragraph A6 of the Court Decree.
37. The County and Commonwealth have failed to take adequate action to ensure that class members have access to adequate dental services. The County Office of Mental Health/Mental Retardation has received numerous reports from care providers that a crisis situation exists with respect to dental care for class members; preventive care is almost nonexistent. Class members wait inordinate periods of time (ie., six months or more) for procedures such as root canals and the filling of cavities.
38. The defendants have failed to take corrective action to ensure that class members have access to adequate medical care. Medical care is largely provided by hospital emergency rooms rather than by primary care physicians. In addition, two large care providers, JEVS and UCPA, have no doctors *605or nurses employed on staff; at JEVS, medical needs are supervised by a medical coordinator who is not a doctor or registered nurse. Many class members’ medical records are either illegible, unintelligible, incomplete or not present at the facility at which the particular class member resides. As a result of incoherent or nonexistent medical records, class members are receiving inadequate and/or no medical or dental services. The County’s and Commonwealth’s failure to provide class members with access to adequate dental and medical services is a violation of Paragraph A6 of the Court Decree.
Funding
39. The County has failed to request adequate funding from the Commonwealth to meet its obligations to the Pennhurst class under the Court Decree. The Commonwealth has failed to allocate funds to the County to comply with the Court Decree, despite the Commonwealth’s knowledge that the County did not have the necessary funding. It is most unfortunate that as the Deputy Secretary Thaler testified, the Commonwealth allocates funding for Pennhurst class members only when threatened with a contempt action such as this.
III. CONCLUSIONS OF LAW
This Court finds on the basis of the foregoing facts, that Philadelphia County and the Commonwealth of Pennsylvania have been proceeding in total disregard of the terms of the Court Decree. Defendants failure to provide community living arrangements for at least thirty-three, and perhaps as many as fifty-five, class members is a violation of Paragraph A2 of the Court Decree. The Court was astonished to learn that despite a court order that is nearly nine years old, the County and Commonwealth have left a large group of class members to languish in institutions where they are subject to abuse, neglect and over-medication. The dangers of institutionalization of the mentally retarded are well known to the defendants; experts testified at trial in this matter over a decade ago that the vast majority of mentally retarded do not receive adequate habilitation in these types of environments and that they actually tend to lose life skills in institutions. It was because of these dangers that community living arrangements became the focal point of the April 1985 Order. By failing so pervasively to meet their obligations under Paragraph A2, the defendants have committed a fundamental and egregious violation of the Court Decree.
In addition to community living arrangements, the Court Decree mandated that the defendants provide written, individualized IHPs to all class members. The importance of these IHPs has been stressed often enough in this case, including in the Findings of Fact portion of this opinion, and will not be repeated here. Suffice it to say that without an IHP, class members have virtually no opportunity to achieve the minimally adequate habilitation to which they are entitled under the Court Decree. The evidence shows that defendants have failed to provide each class member with an IHP in every year since the Court Decree was entered. Moreover, the evidence also shows that even where IHPs are in place, they are either out of date, not implemented or insufficient to meet individual needs. Class members are not receiving such prescribed items as occupational, physical, speech and behavior therapies, nutrition services, and equipment such as wheelchairs and eyeglasses. They do not have access to community employment; rather, they remain in sheltered workshops where they earn a fraction of what they could earn in the community. Moreover, as testified to by several experts, many class members are not being taught life skills that are useful to them in their particular environments. These findings indicate that the defendants are clearly in violation of Paragraph A4 of the Court Decree.
The defendants have also violated Paragraph A5(d) of the Court Decree in that they have not provided class members with case management services as required by this provision. The evidence shows that approximately 32% of the class do not have case managers as of the date of the hearing in this matter. The County has a long history of tolerating staff shortages in case management services such that many class members either have not had a case manager or have *606not received the required monthly visit from a County case manager. As a result of these staff shortages, the County has not been able to adequately supervise the services received by class members from provider agencies; nor has it been able to correct deficiencies in class members’ treatment programs.
Apart from staff shortages in case management services, the County generally appears to be ill-equipped to provide adequate case management services to class members. The County and the Commonwealth rarely share CMP and other Pennhurst monitoring reports with case managers so that problems with class members’ treatment programs can be identified and resolved. Furthermore, those case managers who identify and report noncompliance with the Court Decree are often labeled “whistleblowers” and criticized for their attempts to comply with the Court Decree. On balance, supervisory personnel of both the Commonwealth and the County appear to have been united in their efforts to avoid compliance with the Pennhurst Court Decree.
Both defendants have also failed to comply with the various monitoring obligations imposed by the Court Decree. It appears that the defendants are uncertain as to the present whereabouts of many Philadelphia Pennhurst class members. Despite the fact that both defendants have lost track of large numbers of class members in the last nine years, neither party has made any attempt to locate them and provide them with the services to which they are entitled under the Court Decree. Moreover, while the Commonwealth is monitoring those class members living in CLAs, it is has ignored those individuals who are still in institutions. Furthermore, the Commonwealth’s monitoring is compiled in summary fashion; that is, the monitoring reports fail to identify individual class members who are not receiving habilitation services in compliance with the Court Decree. Rather, the reports track data on class members as a whole. This type of monitoring, while useful in some respects, is not what was intended by the parties when they entered into the consent agreement in 1985. The language of the agreement is clear: “The Commonwealth Defendants shall continue, either by themselves or by qualified contractor, to measure annually by suitable instruments the progress of each class member and the characteristics of the person’s environment.” Court Decree, Para. A5(c). The words “each class member” and “the person’s environment” demonstrate an intent by the parties that the Commonwealth’s monitoring was to be conducted on an individualized basis.
Furthermore, while the Commonwealth distributes copies of its monitoring reports to the County, the County consistently fails to disseminate the reports to County ease managers and provider agencies as required by Paragraph A5(c) of the Court Decree. In addition, the County has failed overall to respond to the Commonwealth’s monitoring reports. With full knowledge of the County’s unresponsiveness, the Commonwealth in turn has failed to take any follow up action to require the County to comply with this provision of the Court Decree. Accordingly, by their inaction, both the Commonwealth and the County are in violation of Paragraph A5(c).
Additionally, in failing to monitor each individual class member, the County is in violation of Paragraph A5(b). The County admitted in hearing testimony that it had failed to meet its obligations under this subsection. The director of CMP testified that CMP’s contract with the County has never included all class members; nor has CMP ever monitored all of those class members who are covered by the contract. Even in 1992, its best year, CMP only monitored 305 class members—roughly half of the class members on the Commonwealth’s class member list. Yet, the County has taken no action to correct CMP’s deficient monitoring.
Paragraph A5(b) also requires that the County “follow up and ... require corrective action and the implementation of [CMP’s] recommendations.” Court Decree, Para. A5(b). Yet, case managers testified that they often do not see CMP’s monitoring reports; accordingly, they do have the information necessary to correct problems. The Commonwealth is responsible for monitoring the County’s compliance with Paragraph A5(b) according to Paragraph A5(e) of the *607Court Decree. Despite full knowledge that the County has not complied with Paragraph A5(b), the Commonwealth has never undertaken to ensure that the County complies with this subsection of the Court Decree. Accordingly, both the Commonwealth and County are in violation of their monitoring functions under the Court Decree.
Closely related to the monitoring functions, are those obligations imposed upon the County and Commonwealth in Paragraphs A6 and A7 of the Court Decree. Paragraph A6 of the Court Decree requires that the County and Commonwealth “take adequate actions and shall require providers of residential or habilitative services to take adequate actions to provide individuals ... with____ [protection from harm ... [s]afe conditions ... [and protection from] physical and psychological abuse, neglect or mistreats ment.” Court Decree, Para. A6. Paragraph A7 requires that the Commonwealth and County shall “maintain written rules pertaining to implementation of the provisions of Paragraph A6 ..., including procedures requiring prompt review/investigation of any complaints pertaining thereto, and adoption of necessary corrective actions in response to such reviews/investigations.” Court Decree, Para. A7. In violation of these provisions, the County and Commonwealth do not actively investigate most incidents of abuse, neglect, death or injury of class members. In 1993, over ninety (90) such incidents of abuse had not been reported to the defendants by providers as required by County and Commonwealth policies and regulations. Moreover, when the County does receive incident reports, it does not respond in a prompt fashion. As evidenced by the incident report in which six class members were allegedly sexually assaulted in July 1992, there was no follow up until shortly before the contempt hearing.
Equally disturbing is the fact that provider agencies are allowed to investigate themselves, and the fact that their reports are accepted by the County at face value with little or no follow up or independent investigation by the County. The County employee responsible for receiving unusual incident reports admitted in her hearing testimony that these practices do pose conflicts of interest and a potential risk of harm to class members. As a result, the Court concludes that the defendants have put class members at serious risk of harm in violation of the Court Decree.
Class members are also put at risk by the County’s practice of permitting care providers to employ individuals who have been found to have abused or neglected class members. Provider agencies rarely, if ever, identify to the County those employees who have been found to have abused or neglected class members. The County does not request this information from the agencies, apparently because it is under the impression that it should not be concerned with a list of such provider employees. Thus, individuals who abuse class members can be retained by provider agencies or rehired by other care providers without the knowledge of the County. As a result, class members are frequently abused and neglected. Accordingly, the Court finds that the Commonwealth and County have blatantly disregarded their obligations under Paragraphs A6 and A7 of the Court Decree.
Paragraphs A6 and A7 also impose upon the County and Commonwealth the obligation to ensure that class members have adequate access to medical and dental care and that they not be excessively or unnecessarily medicated. The evidence shows that many class members are being inappropriately medicated with psychotropic and/or anti-seizure drugs. The earliest published opinions in this case cited abuse of class members through the use of such medication in place of behavioral therapies. In spite of their longstanding knowledge of this danger, the County and Commonwealth have failed to monitor class members for over-medication and to correct such abuse. As a result, class members have been harmed in that they have lost life skills and adopted counterproductive behavior.
In addition, the County and Commonwealth have failed to provide class members with access to adequate medical and dental care. The evidence shows that a crisis exists with respect to dental care; some members have waited months or years for appoint*608ments for serious dental problems. Moreover, hospital emergency rooms are used in place of a primary care physician in many cases. Finally, class members’ medical records are either nonexistent or so completely unintelligible that physicians are unable to properly treat class members. As a result, class members are not receiving the medical and dental care promised to them in Paragraph A6 of the Court Decree. Consequently, these are additional violations by the County and Commonwealth of Paragraphs A6 and A7 of the Court Decree.
The foregoing findings and conclusions of law indicate that the Commonwealth and County have violated nearly every substantive provision of the Court Decree. “Courts have the inherent power to enforce compliance with their lawful orders through civil contempt.” Spallone v. United States, 493 U.S. 265, 276, 110 S.Ct. 625, 632, 107 L.Ed.2d 644 (1990) (quoting Shillitani v. United States, 384 U.S. 364, 370, 86 S.Ct. 1531, 1535, 16 L.Ed.2d 622 (1966)); see generally Halderman, et al. v. Pennhurst State Sch. & Hosp. et al., 901 F.2d 311, 317 (3d Cir.) (court has jurisdiction to use contempt sanctions to enforce agreement incorporated into court order), cert. denied, 498 U.S. 850, 111 S.Ct. 140, 112 L.Ed.2d 107 (1990). The purpose of the contempt sanction is to either coerce a defendant into complying with a court order or to compensate injured parties. Sheet Metal Workers v. EEOC, 478 U.S. 421, 443-44, 106 S.Ct. 3019, 3033, 92 L.Ed.2d 344 (1986); Elkin v. Fauver, 969 F.2d 48, 52 n. 2 (3d Cir.1992); Roe, et al. v. Operation Rescue, et al., 919 F.2d 857, 868 (3d Cir.1990) (citing Gregory v. Depte, 896 F.2d 31, 34 (3d Cir.1990)); see also Hicks v. Feiock, 485 U.S. 624, 632-33, 108 S.Ct. 1423, 1430, 99 L.Ed.2d 721 (1988) (contempt sanctions primarily remedial). “A person is liable for civil contempt if he violates a court order with actual notice that the order has been issued.” Quinter v. Volkswagen of America, 676 F.2d 969, 973 (3d Cir.1982) (citations omitted). Contempt must be shown by “clear and convincing” proof. Id. at 974.
Generally, good faith is not a defense to civil contempt. Roe, 919 F.2d at 870; (citing United States v. Romano, 849 F.2d 812, 816 n. 7 (3d Cir.1988); United States v. Malinowski, 472 F.2d 850, 856-57 (3d Cir.), cert. denied, 411 U.S. 970, 93 S.Ct. 2164, 36 L.Ed.2d 693 (1973)); Halderman, et al. v. Pennhurst State Sch. & Hosp. et al., 533 F.Supp. 631, 636 (E.D.Pa.1981), aff'd, 673 F.2d 628 (3d Cir.1982). As the United States Supreme Court stated in McComb v. Jacksonville Paper Co., 336 U.S. 187, 190-91, 69 S.Ct. 497, 499, 93 L.Ed. 599 (1949):
The absence of wilfulness does not relieve [a party] from civil contempt. Civil as distinguished from criminal contempt is a sanction to enforce compliance with an order of the court or to compensate for losses or damages sustained by reason of noncompliance____ Since the purpose is remedial, it matters not with what intent the defendant did the prohibited act. The decree was not fashioned so as to grant or withhold its benefits dependent on the state of mind of respondents. It laid on them a duty to obey specified provisions____ An act does not cease to be a violation of ... a decree merely because it may have been done innocently.
See also Thompson v. Johnson, 410 F.Supp. 633, 640 (E.D.Pa.1976) (fact that prohibited acts committed inadvertently or in good faith does not preclude finding of civil contempt), aff'd, 556 F.2d 568 (3d Cir.1977).
In contrast to good faith, substantial compliance is a defense to civil contempt. Merchant & Evans, Inc. v. Roosevelt Bldg. Prods. Co., No. 90-7973, 1991 WL 261654 at *1, 1991 U.S.Dist.LEXIS 17755, at *2 (E.D.Pa. Dec. 6,1991) (citing General Signal Corp. v. Donallco, Inc., 787 F.2d 1376, 1379 (9th Cir.1986)); see also Washington Metro. Transit Auth. v. Amalgamated Transit Union, 531 F.2d 617, 621 (D.C.Cir.1976). In order to show substantial compliance, a defendant must demonstrate “reasonable diligence and energy in attempting to accomplish what was ordered.” Merchant & Evans, 1991 WL 26165 at *1, 1991 U.S.Dist. 17755, at *2.
Neither defendant in this case can meet the standard of substantial compliance. The defendants violations of the Court Decree are both pervasive and profound. Neither party has demonstrated diligence and *609energy in fulfilling the Court Decree. Instead, the evidence shows that the defendants have engaged in sustained and deliberate avoidance of their obligations under the Court Decree. Moreover, the evidence also shows that the County attempted to cover up its noncompliance through a flurry of activity in October, November and December 1993 just prior to and during the hearings in this matter. During this time period, the County moved with unprecedented alacrity to write, update and revise numerous IHPs, and assign case managers to previously unrepresented class members. In addition, the County employee responsible for receiving reports of unusual incidents updated files in which no action or follow up had been taken for over a year. All of these actions were designed to conceal or minimize massive noncompliance by both defendants. Moreover, the Deputy Secretary of the Commonwealth’s Department of Mental Health and Retardation admitted in open court that the Commonwealth allocates money to comply with the Court Decree only when threatened with a contempt action. For these reasons, the Commonwealth’s and County’s arguments regarding substantial compliance are insincere, self-serving and utterly without merit.
The defendants have argued that this Court should find that they are in substantial compliance because they have met their obligations under the Court Decree with respect to most class members. First, this Court rejects defendants’ premise that they have met their court ordered obligations as to most class members. The evidence clearly indicates that the defendants have violated nearly every provision of the Court Decree and that many of these violations have affects ed the well being of nearly every class member. More importantly, it is no defense to a class action involving the individual rights and needs of mentally retarded people that the defendants have complied with the Court Decree as to some class members. As the Court stated in previous opinions, where the obligations imposed by a court order run to class members as individuals, compliance is measured with respect to each individual class member and not the class as a whole. Halderman v. Pennhurst State Hospital & School, No. 74-1345, 1989 WL 100207, *2-3, 1989 U.S.Dist. LEXIS 10147, *7 (E.D.Pa. Aug. 28, 1989), aff'd, 901 F.2d 311, 324 (3d Cir.1990) (contempt action against Commonwealth and suburban Counties of Montgomery and Delaware). The defendants undertook in the Court Decree to fulfill certain obligations with respect to the class members. These are mandated legal obligations that run from both defendants to each individual class member. The defendants cannot obviate their obligations to each individual class member by meeting their obligations to some class members.
This Court also rejects the Commonwealth’s argument that it is somehow helpless to enforce the County’s obligations under the Court Decree. The Commonwealth has advised the County on numerous occasions of problems with care providers as well as other types of noncompliance. With the full knowledge of the Commonwealth, however, the County repeatedly has failed to correct its noncompliance. Thus, the evidence in this case requires this Court to conclude that the Commonwealth and the County have joined hands in their determination to ignore the legal obligations imposed upon them by the Court Decree.
The plaintiffs have requested the Court to order the defendants to pay a compensatory fine of $5,000,000 to be allocated to a compensation fund for distribution to class members in addition to other equitable relief and coercive fines. The Court agrees with the plaintiffs that it certainly has the power to award compensation to plaintiffs for defendants’ contempt. Sheet Metal Workers, 478 U.S. at 443-44, 106 S.Ct. at 3033. Clearly, those members of the Pennhurst class who have been secreted in institutions since the Court Decree have not only suffered indignities but damage to their habilitation. This Court would be presented with an insurmountable challenge, however, in ascertaining the amount of compensation to which each member of the class would be entitled as a result of the County’s and Commonwealth’s intentional withholding of habilitation. Any such award of monetary damages might well require the Court to engage in *610speculation. Furthermore, this Court is convinced that Pennhurst class members would be best compensated through a court order that requires the County and Commonwealth to use their resources to make certain the each class member receives the habilitation and services mandated by the Court Decree. Accordingly, the Court will provide appropriate equitable relief as outlined in a separate Order, including a provision for contingent coercive fines against both defendants.
IV. CONCLUSION
It has been approximately seventeen years since this Court determined that the members of the Pennhurst class had the right to a community living arrangement and to receive minimally adequate habilitation. This Court concluded at that time that the mentally retarded plaintiffs had the right to receive a level of care and training that would enable them to develop their individual potential. The 1977 Pennhurst decision was in fact one of the first cases to recognize that the mentally retarded had such rights. When this decision was rendered in 1977, it brought an end to an era of seclusion, segregation and sedation for the residents of Pennhurst. The 1985 Court Decree offered these mentally retarded citizens the prospects of full access to community living and community services—and with those prospects, the promise of a better, more productive and self-sufficient life. That promise has been realized by many of the plaintiff class members over the past seventeen years. During the hearings in this matter, several mentally retarded plaintiffs testified that the services provided to them under the Court Decree have enabled them to enjoy a fuller life and to achieve some measure of independence. Moreover, a multitude of studies done by mental retardation experts throughout the 1970s and 1980s have documented the extraordinary progress made by Pennhurst plaintiffs once they were removed from Pennhurst and received habilitation services in community living arrangements.
It is particularly disappointing therefore that the County and Commonwealth have shown' such utter disregard for the Court Decree. The evidence is overwhelming that both defendants have violated nearly every substantive portion of the order. They have failed to provide community living arrangements to at least thirty-three members of the class; those members remain institutionalized to this day. They have failed to provide many members of the class with an individualized IHP. Other members of the class have IHPs that are either out of date, not implemented, inappropriate and/or inadequate. The defendants have also failed to provide the case management services mandated by the Court Decree. Moreover, the County and Commonwealth have virtually abdicated any meaningful supervision over contract care providers. As a result of their disregard and contempt of the Court Decree, class members have suffered substantial harm. They have lost life skills and have been denied the right to develop their capabilities. The defendants have not been merely complacent; they have proceeded in blatant disregard of the Court Decree.
The defendants’ actions demonstrate a clear need for judicial oversight. During the last two decades, the members of the Pennhurst class have fought long and hard in this Court to obtain their right to minimally adequate habilitation. This Opinion together with the accompanying Order are intended to make certain that the members of the Pennhurst class receive habilitation in community living arrangements as mandated by the 1985 Court Decree.
ORDER
AND NOW, this 28th day of March, 1994, in consideration of the reasons set forth in the Court’s Memorandum of March 28, 1994 and this Court having found that the County of Philadelphia (“County”) and Commonwealth of Pennsylvania (“Commonwealth”) defendants are in contempt of this Court’s Order of April 5, 1985 (“Court Decree”);
IT IS ORDERED:
1. Within sixty (60) days of the date of this Order, the plaintiffs, plaintiff-intervenor and defendants shall agree upon any additions or deletions to the list of Philadelphia plaintiff class members contained in Exhibit A to this Order. The parties shall submit the final list of Philadelphia class members *611(“Philadelphia Class Members”) to the Special Master for the Special Master’s review and approval. If the parties are unable to resolve disputes concerning the identity of Philadelphia Class Members within the sixty-day time frame, the parties shall so notify the Special Master. The Special Master shall resolve any disputes regarding the composition of Philadelphia class members and develop a final list of Philadelphia class members in the event that the parties are unable to agree on such a list.
2. Within twelve (12) months of the date of this Order, the County and Commonwealth shall provide community living arrangements to all Philadelphia Class Members. In the event that the County and Commonwealth fail to provide community living arrangements to all Philadelphia Class Members within twelve (12) months of the date of this Order, the County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each class member who has not received community living arrangements.
3. Within sixty (60) days of the date of this Order, every Philadelphia class member shall be assigned a county case manager in accordance with Paragraph A5(d) of the Court Decree. The County shall provide the Commonwealth and Special Master with revised case manager lists within thirty (30) days of a change in case manager assignment. In the event that the Philadelphia class members have not been provided with case managers within sixty (60) days of this Order, the County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each class member who has not been provided with a case manager.
4. The County shall bring its case management levels into compliance with Paragraph A5(d) of the Court Decree within thirty (30) days of the date of this Order. The County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each day that the County’s case manager levels are not in compliance with Paragraph A5(d) of the Court Decree and this paragraph of the Court’s Order.
5. The County shall require each of its case managers who has not received the three (3) day training required by Paragraph A(5)(d) of the Court Decree to complete such training within sixty (60) days of the date of this Order. Any new case manager shall complete such training promptly upon assuming responsibilities for Philadelphia class members. The County shall provide the Commonwealth with thirty (30) days advance notice of all training requests; the Commonwealth shall provide all training requested by the County in connection with Paragraph A(5)(d) of the Court Decree. The County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each day that a county case manager assigned to Philadelphia Class Members has not received training pursuant to the terms of Paragraph A5(d) of the Court Decree and this paragraph of the Court’s Order.
6. The County shall require all County case managers responsible for Philadelphia class members who have not received at least one (1) day of continuing annual training in 1993, as required by Paragraph A5(d), to complete such training within ninety (90) days of the date of this Order. The County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each day that county case managers have not received training pursuant to the terms of Paragraph A5(d) of the Court Decree and this paragraph of the Court’s Order.
7. The County shall provide every Philadelphia class member with a current individual habilitation plan (“IHP”) within one-hundred twenty (120) days from the date of this Order. Such IHP shall be developed in accordance with Paragraph A4 of the Court Decree. All services and therapies prescribed by each individual IHP shall be implemented within sixty (60) days of the completion of each IHP. The County and Commonwealth each shall be subject to a fine of not less than $5,000 per day for each class member who has not received an IHP or the services and therapies prescribed by the IHP in accordance with the terms of Paragraph A4 of the Court Decree and this paragraph of the Court’s Order.
8. Within thirty (30) days of this Order, the County shall require that any treating *612physician who prescribes psychotropic and/or anti-seizure medication to a Philadelphia class member shall certify at least every ninety (90) days that the continued use of such medication is not excessive or unnecessary according to accepted standards of medical practice and that the prescription otherwise is in accordance with accepted standards of medical practice. Within ninety (90) days of the date of this Order, the County shall retain an independent physician, qualified in the use of psychotropic and anti-seizure medication, to review and evaluate the medical records of each Philadelphia class member for whom psychotropic and/or anti-seizure medication is prescribed. Prior to retaining the independent physician, the County shall submit the name of the independent physician to the Special Master for review and approval. Not later than one-hundred eighty (180) days from the date of this Order, the independent physician shall make an initial determination as to whether the administration of psychotropic and/or anti-seizure medication to Philadelphia Class Members is excessive or unnecessary according to accepted standards of medical practice. The independent physician shall certify in writing 1) the reasons for the medication, and 2) that each prescription is in accordance with accepted standards of medical practice. After this initial evaluation, the independent physician shall monitor treating physicians’ prescriptions of psychotropic and anti-seizure medication for Philadelphia Class Members on a semi-annual basis. The independent physician shall certify in writing 1) the reasons for psychotropic and/or anti-seizure medication, and 2) that each prescription is in accordance with accepted standards of medical practice. A copy of the certifications described in this paragraph of the Court’s Order shall be maintained in the affected class member’s medical records file and shall be reviewed as part of the annual monitoring process described in the Court Decree and this Order. The County shall be subject to a fine of not less than $5,000 per day for each class member who is administered psychotropic and/or anti-seizure medication in violation of the terms of Paragraph A6(g) of the Court Decree and this paragraph of the Court’s Order.
9. Within sixty (60) days of the date of this Order, the County shall take such steps as are necessary to ensure that every Philadelphia class member will receive annual on-site monitoring as required by Paragraph A5(b) of the Court Decree. The County shall be subject to a fine of not less than $5,000 per day for each Philadelphia class member who has not received annual monitoring within one year of the date of this Order in compliance with Paragraph A5(b) of the Court Decree and this paragraph of the Court’s Order.
10. Within sixty (60) days of the date of this Order, the Commonwealth shall take such steps as are necessary to ensure that Philadelphia class members are monitored by the Commonwealth as required by Paragraphs A5(a), (c) and (e) of the Court Decree. The Commonwealth shall be subject to a fine of not less than $5,000 per day for each Philadelphia class member who has not received within one year of the date of this Order on-site monitoring pursuant to Paragraphs A5(a), (c) and (e) of the Court Decree and this paragraph of the Court’s Order.
11. Within ninety (90) days of the date of this Order, the County shall submit to the Commonwealth and the Special Master, for the Special Master’s review and approval, a plan under which the County shall assume the responsibility for investigation and resolution of all reported incidents involving abuse, neglect, injury and death of class members. The County shall implement the plan as approved by the Special Master within thirty (30) days of such approval. The County shall be subject to a fine of not less than $5,000 per day for each instance in which the County fails to promptly investigate and resolve reported cases of abuse, neglect, injury or death of Philadelphia class members in compliance with Paragraph A6 of the Court Decree and this paragraph of the Court’s Order.
12. Within ninety (90) days from the date of this Order, the County shall develop, and submit to the Special Master for review and approval, a plan to ensure that Philadelphia class members have access to adequate dental and medical services as mandated by *613Paragraph A6(d) of the Court Decree. The County shall implement the plan as approved by the Special Master within thirty (30) days of such approval. The County shall be subject to a fine of not less than $5,000 per day for each day that it is not in compliance with Paragraph A6(d) of the Court Decree and this paragraph of the Court’s Order.
13. Within one-hundred twenty (120) days of the date of this Order, the County shall require a physician, other than a class member’s treating physician, to review each class member’s medical records for the purpose of making certain that such records are legible, intelligible, complete and present at the facility at which each class member resides. The County shall be subject to a fine of not less than $5,000 per day for each class member whose medical records are not in compliance with this paragraph of the Court’s Order.
14. Within sixty (60) days of the date of this Order, the County shall commence submitting monthly status reports to the Commonwealth detailing the County’s compliance with all terms of the Court Decree and this Order. In addition, within sixty (60) days of the date of this Order, the Commonwealth and County each shall commence submitting monthly reports to the Special Master, in a form acceptable to the Special Master, detailing their compliance with the terms of the Court Decree and this Order.
15. The Court shall hold a hearing on Monday, April 4, 1994 at 10:00 a.m. in Courtroom 10B, United States Courthouse, 601 Market Street, Philadelphia, PA, for the purpose of hearing from all parties concerning the appointment of the Special Master.
16. The Court will retain jurisdiction of this matter for purposes of enforcing the Court Decree and this Order.
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