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UNITED
STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA
UNITED STATES OF AMERICA, Plaintiff, v.
THE DISTRICT OF COLUMBIA,
Honorable Adrian M. Fenty, Mayor, District of Columbia, in his official capacity only;
DEPARTMENT OF MENTAL HEALTH, Stephen T.. Baron, Director, Department of Mental Health, in his official capacity only;
and SAINT ELIZABETHS HOSPITAL, Patrick J. Canavan, Chief Executive Officer, Saint Elizabeths Hospital, in his official capacity only, Defendants.
Civ. No. 07-
SETTLEMENT AGREEMENT
TABLE OF CONTENTS
I. General Provisions
II. Definitions
III. Compliance Officer
IV. General Introduction
V. Integrated Treatment Planning
VI. Mental Health Assessments
VII. Discharge Planning and Community Integration
VIII. Specific Treatment Services
A. Psychiatric Care
B. Psychological Care
C. Pharmacy Services
D. Nursing and Unit-Based Services
IX. Documentation
X. Restraints, Seclusion, and Emergency Involuntary
Psychotropic Medications
XI. Protection From Harm
XII. Incident Management
XIII. Quality Improvement
XIV. Environmental Conditions
XV. Benchmarks
XVI. Terms and Conditions
A. This Settlement Agreement (the
"Agreement") is entered into between the United States and the
District of Columbia; the District of Columbia Department of Mental
Health; and Saint Elizabeths Hospital (collectively referred to as "the District").
B. The Agreement resolves the
investigation conducted by the United States Department of Justice
("United States") at Saint Elizabeths Hospital ("SEH")
pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. The Agreement
addresses the corrective measures set forth by the United States in
its letter to the District dated May 23, 2006 ("Findings Letter"). This Agreement does not
serve as an admission by the District that corrective measures are
necessary to meet the constitutional and statutory rights of the
residents of SEH.
C. In conformity with CRIPA, this
Agreement represents a voluntary effort by the District to meet the
concerns raised by the United States' investigation. See 42 U.S.C. §
1997b (a) (2) (B) and § 1997g.
D. Nothing in this Agreement shall be
construed as an acknowledgment, an admission, or evidence of liability
of the District under CRIPA, the Constitution, or federal or District
law, and this Agreement may not be used as evidence of liability in this
or any other civil or criminal proceeding.
E. The signatures below of officials
representing the United States and the District signify that these
parties have given their final approval to this Agreement.
F. This Agreement is enforceable only by
the parties or the Court. This Agreement is binding upon the parties, by
and through their officials, agents, employees, and successors. No
person or entity is intended to be a third party beneficiary of the
provisions of this. Agreement for purposes of any civil, criminal, or
administrative action, and, accordingly, no person or entity may assert any claim or
right as a beneficiary or protected class under this Agreement in any
civil, criminal, or administrative action. Similarly, this Agreement
does not authorize, nor shall it be construed to authorize, access to
District documents by persons or entities not a party to this Agreement.
G. Since the United States issued the
May 23, 2006, Findings Letter, the District has made progress in
remedying the problems the United States identified in the Findings
Letter. The parties agree that it is in their mutual interests to avoid
all litigation concerning the care and conditions of patients at SEH.
The parties further agree that resolution of this matter pursuant to
this Agreement is in the best interests of SEH's residents.
H. All parties shall bear their own
costs, including attorneys' fees, in this and any subsequent proceeding.
A. Effective Date
The Effective Date of this Agreement shall be the date
that a corresponding order is entered by the District Judge for the
United States District Court for the District of Columbia. Unless
otherwise specified, each provision of this Decree shall be implemented
within one year of the Effective Date.
B. Saint Elizabeths Hospital
SEH consists of all current buildings and facilities and
any buildings and facilities constructed, renovated, and/or designated.
as part of SEH in the future.
C. Incident
As required under Section XII of this Agreement, SEH will
identify categories and definitions of incidents to be reported and
investigated, and such categories and definitions shall include, but not
be limited to, death, abuse, neglect, and serious injury.
The District shall select, subject to the United States'
approval, a Compliance Officer to promote compliance with, and
implementation of the provisions of this Settlement Agreement. The
District shall pay the salary, costs, and expenses associated with the
Compliance Officer and, if needed, shall provide sufficient funds to
permit the .Compliance Officer to hire staff and consultants to assist
in carrying out the Compliance Officer's duties and responsibilities
under the Agreement.
The Compliance Officer shall, serve as the liaison
between Saint Elizabeths Hospital, the District of Columbia, the
Department of Mental Health, and the United States Department of Justice
regarding compliance with this Settlement Agreement. The Compliance
Officer's exclusive duties are to oversee and promote implementation of
the provisions of the Agreement.
Specifically, the Compliance Officer's duties shall
include, but not be limited to:
1. Monitoring and facilitating the
District's compliance with each of the provisions in this Agreement;
2. Preparing semi-annual reports for the
parties regarding compliance with each of the provisions of the
Agreement;
3. Facilitating the organizing of and
conducting formal meetings between the parties on a regular and periodic
basis, at least quarterly, to update the parties regarding compliance
with the Agreement, including areas of improvement and areas of concern;
and
4. Providing to the parties any relevant
information known, or available to the Compliance Officer, under any
provision of the Agreement upon reasonable request.
The Compliance Officer shall not be prohibited from
conducting ex parte communications with the Department of Justice, Civil
Rights Division, regarding any matter related to this Agreement.
A. Care and treatment provided by SEH
shall fully comply with the requirements of federal law, the United
States Constitution, and consistent with generally accepted professional
standards of care for the care and treatment of institutionalized
persons and shall be designed to:
1. strengthen and support individuals'
rehabilitation and recovery; and
2. enable individuals to grow and
develop in ways benefiting their health and well-being.
B. Care and treatment shall be
accomplished while making efforts to maximize individuals'. safety,
security, and freedom from undue bodily restraint. Staff interactions
with individuals shall be therapeutic and respectful.
C. Each individual served by SEH shall
be encouraged to participate in identifying his or her treatment goals
and in selecting. appropriate treatment options. Care and treatment
shall be designed to address each individual's psychiatric treatment
needs and to assist each individual in meeting his or her specific
treatment goals, consistent with generally accepted professional
standards of care. SEH shall ensure clinical and administrative
oversight of, education of, and support to, its staff in planning and
providing care and treatment consistent with these standards.
By 36 months from the Effective Date hereof, SEH shall
provide integrated individualized services, and treatments
(collectively-"treatment") for the individuals it serves. SEH
shall establish and implement standards, policies, and protocols and/or
practices to provide that treatment determinations are coordinated
by an interdisciplinary team through treatment planning and embodied
in a single, integrated plan..
A. Interdisciplinary Teams
By 36 months from the Effective Date hereof, each
interdisciplinary team's membership shall be dictated by the particular
needs of the individual in the team's care, and, at a minimum, the
interdisciplinary team for each individual shall:
1. Have as its primary objective the
provision of individualized, integrated treatment and be designed to
discharge or outplace the individual from SEH into the most appropriate,
most integrated setting without additional disability;
2. be led by a treating. psychiatrist or
licensed clinical psychologist who, at a minimum,. shall:
a. assume primary responsibility for the
individual's treatment;
b. require that the patient and, with
the patient's permission, family or supportive community members are
active members of the treatment team;
c. require that each member of the team
participates in assessing the individual on an ongoing basis and in
developing, monitoring, and, as necessary, revising treatments;
d. require that the treatment team
functions in an interdisciplinary fashion
e. verify, in a documented manner, that
psychiatric and behavioral treatments are properly integrated; and
f. require that the scheduling and
coordination of assessments and team meetings, the drafting of
integrated treatment plans, and the scheduling and coordination of
necessary progress reviews occur.
3. provide training on the development
and implementation of interdisciplinary treatment plans, including the
skills needed in the development of clinical formulations, needs, goals,
interventions, discharge criteria, and all other requirements of section
V.B., infra;
4. consist of a stable core of members,
including the resident, the treatment team leader, the treating
psychiatrist, the nurse, and the social worker and, as the core team
determines is clinically appropriate, other team members, who may
include the patient's family, guardian, advocates, clinical
psychologist, pharmacist, and other clinical staff; and,
5. meet every 30 days, during the first
60 days; thereafter every 60 days; and more frequently as clinically
determined by the team leader.
B. Integrated Treatment Plans
By 36 months from the Effective Date hereof, SEH shall
develop and implement policies and/or protocols regarding the
development of treatment plans to provide that:
1. where possible, individuals have
input into their treatment plans;
2. treatment planning provides timely
attention to the needs of each individual, in particular:
a. initial assessments are completed
within 24 hours of admission;
b. initial treatment plans are completed
within 5 days of admission; and
c. treatment plan updates are performed
consistent with treatment plan meetings.
3. individuals are informed of the
purposes and major side effects of medication;
4. each treatment plan specifically
identifies the therapeutic means by which the treatment goals for the
particular individual shall be addressed, monitored, reported, and
documented;
5. the medical director timely reviews
high-risk situations, such as individuals requiring repeated use of
seclusion and restraints;
6. mechanisms are developed and
implemented to ensure that all individuals adjudicated Not Guilty by
Reason of Insanity ("NGRI") receive ongoing, timely, and
adequate assessments by. the treatment team to enable the. courts to
review effectively modifications in the individual's legal status;
7. treatment and medication regimens are modified,. as
appropriate, considering factors such as the individual's response to
treatment, significant developments in the individual's condition, and
the individual's changing needs;
8. an inter-unit transfer procedure is
developed and implemented that specifies the format and content
requirements of transfer assessments, including the mission of all units
in the hospital; and
9. to ensure compliance, a monitoring
instrument is developed to review the quality and. timeliness of all
assessments according to established indicators, including an evaluation
of initial evaluations, progress notes, and transfer and discharge
summaries, and a review by the physician peer review systems to address
the process and content of assessments and reassessments, identify,
individual and group trends, and provide corrective follow-up-action.
This requirement specifically recognizes that peer review is not
required for every patient chart.
C. By 24 months from the Effective Date
hereof, SEH shall establish policies and/or protocols to provide that
treatment planning is based on case formulation for each individual
based upon an integration of the discipline-specific assessments 'of the
individual. Specifically, the case formulation shall:
1. be derived from analyses of the
information gathered including diagnosis and differential diagnosis;
2. include a review of clinical history,
predisposing, precipitating, and perpetuating factors, present status,
and previous treatment history;
3. include a psychopharmacological plan
of care that includes information on purpose of treatment, type of
medication, rationale for its use, target behaviors, possible side
effects, and targeted review dates to reassess the diagnosis and
treatment in those cases where individuals fail to respond to repeated
drug trials;
4. consider biochemical and psychosocial
factors for each category in Section V.C.2., supra;
5. consider such factors as age, gender,
culture, treatment adherence, and medication issues that may affect the outcomes of treatment interventions;
6. enable the treatment team to reach
determinations about each individual's treatment needs; and
7. make preliminary determinations as to
the setting to which the individual should be discharged, and the
changes that will be necessary to achieve discharge whenever possible.
D. By 24 months from the Effective Date
hereof, SEH shall establish policies and/or protocols to provide that
treatment planning is driven by individualized factors. Specifically,
the treatment team shall:
1. develop and prioritize reasonable and
attainable goals/objectives (i.e., relevant to each individual's level
of functioning) that build on the individual's strengths and address the
individual's identified needs;
2. provide that the goals/objectives
address treatment (e.g., for a disease or disorder) and rehabilitation
(e.g., skills/supports/quality of life activities);
3. write the objectives in behavioral
and measurable terms;
4. provide that there are interventions
that relate to each objective, specifying who will do what and within
what time frame, to assist the individual to meet his/her goals as
specified in the objective;
5. design a program of interventions
throughout the individual's day with a minimum of 20 hours of clinically
appropriate treatment/rehabilitation per week; and
6. provide that each treatment plan integrates and
coordinates all selected services,, supports, and treatments provided by
or through SEH for the individual in a manner specifically responsive to the
plan's treatment and rehabilitative goals.
E. By 24 months from the Effective Date hereof, SEH shall
develop or revise treatment plans, as appropriate, to provide that
planning is outcome-driven and based on the individual's progress, or
lack thereof. The treatment. team shall:
1. revise the objectives, as
appropriate, to. reflect the individual's changing needs;
2. monitor, at least monthly, the goals,
objectives, and interventions identified in the plan for effectiveness
in producing the desired outcomes;
3. review the goals, objectives, and
interventions more frequently than monthly if there are clinically
relevant changes in the individual's functional status or risk factors;
4. provide that the review process
includes an assessment of progress related to discharge; and
5. base progress reviews and revision
recommendations on clinical observations and data collected.
By 18 months from the Effective Date hereof, SEH
shall ensure that each individual shall receive, after
admission to SEH, an assessment of the conditions responsible for the
individual's admission. To the degree possible given the obtainable information,
the individual's treatment team shall be responsible, to the extent possible, for obtaining
information concerning the past and present medical,
nursing, psychiatric, and psychosocial factors bearing on the
individual's condition, and, when necessary, for revising assessments
and. treatment plans in accordance with newly discovered information.
A. Psychiatric Assessments and Diagnoses
1. By 24 months from the Effective date
hereof, SEH shall develop and implement policies and procedures
regarding the timeliness and content of initial psychiatric assessments
and ongoing reassessments, including a plan of care that outlines
specific strategies, with rationales, adjustments of medication
regimens, if appropriate, and initiation of specific treatment
interventions;
2. By 24 months from the Effective Date
hereof, SEH shall develop an admission risk assessment procedure, with
special precautions noted where relevant, that includes available
information on the categories of risk (e.g., suicide, selfinjurious
behavior, violence, elopements, sexually predatory behavior, wandering,
falls, etc.); whether the risk is recent and its degree and relevance to
dangerousness; the reason hospital care is needed; and any mitigating
factors and their relation to current risk;
3. By 12 months from the Effective Date
hereof, SEH shall use the most current Diagnostics and Statistics Manual
.("DSM") for reaching psychiatric diagnoses;
4. By 18 months from the Effective Date
hereof, SEH shall ensure that psychiatric assessments are consistent
with SEH's standard diagnostic protocols;
5. By 12 months from the Effective Date
hereof, SEH shall ensure that, within 24 hours of an individual's
admission to SEH, the individual receives an initial psychiatric
assessment, consistent with SEH's protocols;
6. By 12 months from the Effective. Date
hereof, SEH shall ensure that:
a. clinically supported, and current
assessments and diagnoses are provided for each individual;
b. all physician trainees completing
psychiatric assessments are supervised by the attending psychiatrist. In
all cases, the psychiatrist must review the content of these assessments
and write a note to accompany these assessments;
c. differential diagnoses,
"rule-out" diagnoses, and diagnoses listed as "NOS"
("Not Otherwise Specified") are addressed (with the
recognition that NOS diagnosis may be appropriate in certain cases where
they may not need to be justified after initial diagnosis) ; and
d. each individual's psychiatric assessments, diagnoses,
and medications are clinically justified.
7. By 24 months from the Effective Date hereof, SEH shall
develop protocols to ensure an ongoing and timely reassessment of the psychiatric and
biopsychosocial causes of the individual's continued hospitalization..
B. Psychological Assessments (these
assessments may be completed by psychologists or graduate students
in psychology under the supervision of psychologists.)
1. By 24 months from the Effective Date
hereof, SEH hereof, SEH shall ensure that individuals referred for psychological
assessment receive that assessment. These assessments may
include-diagnostic .neuropsychological assessments, cognitive
assessments, risk assessments and personality/differential diagnosis
assessments, rehabilitation and habilitation interventions, behavioral
assessments (including functional analysis of behavior in all settings),
and personality assessments.
2. By 24 months from the Effective Date
hereof, all psychological assessments, shall:
a. expressly state the purpose(s) for
which they are performed;
b. be based on current, and accurate
data;
c. provide current assessment of risk
for harm factors, if requested;
d. include determinations specifically
addressing the purpose(s) of the assessment; and
e. include a summary of the empirical
basis for all conclusions, where possible.
3. By 24 months from the Effective Date
hereof, previously completed psychological assessments of individuals
currently at SEH shall be reviewed by qualified. clinicians and, if
indicated, referred for additional psychological assessment.
4. By 24 months from the Effective Date
hereof, appropriate psychological assessments shall be provided,
whenever clinically determined by the team.
5. By 24 months from the Effective Date
hereof, when an assessment is completed, SEH shall ensure that treating
mental health clinicians communicate and interpret psychological
assessment results to the treatment teams, along with the implications
of those results for diagnosis and treatment.
C. Rehabilitation Assessments
1. When requested by the treatment team
leader, or otherwise requested by the treatment team, SEH. shall perform
a rehabilitation assessment, consistent with the requirements of this
Settlement Agreement. Any decision not to require a rehabilitation
assessment shall be documented in the individual's record and contain a
brief description of the reason(s) for the decision.
2. By 24 months from the Effective Date
hereof, all rehabilitation assessments shall:
a. be accurate as to the individual's
functional abilities;
b. identify the individual's life skills
prior to, and over the course of, the mental illness or disorder;
c. identify the individual's observed
and, separately, expressed interests, activities, and functional
strengths and weaknesses; and
d. provide specific strategies to engage
the individual in appropriate activities that he or she views
as personally meaningful and productive.
3. By 24 months from the Effective Date
hereof, rehabilitation assessments of all individuals currently residing
at SEH who were admitted there before the Effective Date hereof shall be
reviewed by qualified clinicians and, if indicated, referred for an
updated rehabilitation assessment.
D. Social History Assessments
By 18 months from the Effective Date hereof, SEH shall
ensure that each individual has a social history evaluation that is
consistent with generally accepted professional standards of care. This includes identifying
factual inconsistencies among sources, resolving or attempting to
resolve inconsistencies, explaining the rationale for the resolution
offered, and reliably informing the individual's treatment team about
the individual's relevant social factors.
Taking into account the limitations of court-imposed
confinement and public safety, SEH, in coordination and conjunction with
the District of Columbia Department of Mental Health ("DMH")
shall pursue the appropriate discharge of individuals to the most
integrated, appropriate setting consistent with each person's needs and
to which they can be reasonably accommodated, taking into account the
resources available to the District and the needs of others with mental
disabilities.
A. By 12 months from the Effective Date
hereof, SEH, in conjunction and coordination with DMH, shall identify at
admission and consider in treatment planning the particular factors for
each individual bearing on discharge, including:
1. those factors that likely would
result in successful discharge, including the individual's strengths,
preferences, and personal goals;
2. the individual's symptoms of mental
illness or psychiatric distress;
3. barriers preventing the specific
individual from being discharged to a more integrated environment,
especially difficulties raised in previous unsuccessful placements, to
the extent that they are known; and
4. the skills necessary to live in a
setting in which the individual may be placed.
B. By 12 months from the Effective Date
hereof, SEH shall provide the opportunity, beginning at the time of
admission and continuously throughout the individual's stay, for the individual to be a participant in the
discharge planning process, as appropriate.
C. By 12 months from the Effective Date hereof, SEH shall
ensure that each individual has a discharge plan that is a fundamental
component of the individual's treatment plan and that includes:
1. measurable interventions regarding
his or her particular discharge considerations;
2. the persons responsible for
accomplishing the interventions; and
3. the time frames for completion of the
interventions.
D. By 12 months from the Effective Date
hereof when clinically indicated, SEH and/or DMH shall transition
individuals into the community where feasible in accordance with the
above considerations. In particular, SEH and/or DMH shall ensure that
individuals receive adequate assistance in transitioning prior to
discharge.
E. Discharge planning shall not be
concluded without the referral of an individual to an appropriate set of
supports and services, the conveyance of information necessary for
discharge, the acceptance of the individual for' the services, and the
discharge of the individual.
F. By 12 months from the Effective Date
hereof, SEH and/or DMH shall develop and implement a quality
assurance/improvement system to monitor the discharge process and
aftercare. services, including:
1. developing a system of follow-up with
community placements to determine if discharged individuals are
receiving the care that was prescribed for them at discharge; and
2. hiring sufficient staff to implement
these provisions with respect to discharge planning.
By 24 months from the Effective Date hereof, SEH shall
provide all of the individuals it serves routine and emergency
psychiatric and mental health services.
1. By 24 months from the Effective Date
hereof, SEH shall develop and implement policies and/or protocols
regarding the provision of psychiatric care. In particular, policies
and/or protocols shall address physician practices regarding:
a. documentation of psychiatric
assessments and ongoing reassessments per the requirements of this
Settlement Agreement;
b. documentation of significant
developments in the individual's clinical status and of appropriate
psychiatric follow up;
c. timely and justifiable updates of
diagnosis and treatment, as clinically appropriate;
d. documentation of analyses of risks
and benefits of chosen treatment interventions;
e. assessment of, and attention to,
high-risk behaviors (e.g., assaults, self-harm, falls) including
appropriate and timely monitoring of individuals and interventions to
reduce risks;
f. documentation of, and responses to,
side effects of prescribed medications;
g. documentation of reasons for complex pharmacological
treatment; and
h. timely review of the use of "pro
re nata" or "as-needed" ("PRN") medications and
adjustment of regular treatment, as indicated, based on
such use.
2. By 18 months from the Effective Date
hereof, SEH shall develop and implement. policies and/or protocols to
ensure system-wide monitoring of the safety, effectiveness, and
appropriateness of all psychotropic medication use. In particular,
policies and/or protocols shall address:
a. monitoring of the use of psychotropic
medications to ensure that they are:
i. clinically justified;
ii. prescribed in therapeutic amounts, and dictated by
the needs of the individual;
iii. tailored to each individual's clinical needs and
symptoms;
iv. meeting the objectives of the individual's treatment
plan;
v. evaluated for side effects; and vi.
documented.
b. monitoring mechanisms regarding
medication use throughout the facility,. In this regard, SEH shall:
i. develop, implement and update, as needed, a complete set
of medication guidelines that address the medical benefits, risks, and
laboratory studies needed. for use of classes of medications in the
formulary;
ii. develop and implement a procedure governing the use
of PRN medications that includes requirements for specific
identification of the behaviors that result in PRN administration of medications, a time limit
on PRN uses, documented rationale for the use of more than one
medication on a PRN basis, and physician documentation to ensure timely
critical review of the individual's response to PRN treatments and
reevaluation of regular treatments as a result of- PRN uses;
iii. establish a system for the pharmacist to communicate
drug alerts to the medical staff; and
iv. provide information derived from
Adverse Drug Reactions, Drug Utilization Evaluations, and Medication
Variance Reports to the Pharmacy and Therapeutics, Therapeutics Review,
and Mortality and Morbidity Committees.
3. By 36 months from the Effective Date
hereof, SEH shall provide adequate levels of psychiatric staffing to
ensure coverage by a full-time psychiatrist for not more than 12
individuals on the acute care units and no more than 24 individuals on
the long-term units.
4. SEH shall ensure that individuals in
need are provided with behavioral interventions and plans with proper
integration of psychiatric and behavioral modalities. In this regard,
SEH shall:
a. ensure that psychiatrists review all
proposed behavioral plans to determine that they are compatible with
psychiatric formulations of the case;
b. ensure regular exchanges of data
between the psychiatrist and the psychologist; and
c. integrate psychiatric and behavioral
treatments.
5. By 24 months from the Effective Date
hereof, SEH shall review and ensure the appropriateness of the
medication treatment.
6. By 24 months from the Effective Date
hereof, SEH shall ensure that individuals are screened and evaluated for
substance abuse.
7. By 24 months from the Effective Date
hereof, SEH shall institute an appropriate system for the monitoring of
individuals at risk for Tardive Dyskinesia ("TD"). SEH shall
ensure that the psychiatrists integrate the results of these ratings in
their assessments of the risks and benefits of drug treatments.
By 18 months from the Effective Date hereof, SEH shall
provide adequate and appropriate psychological supports and services to
individuals who require such services.
1. By 18 months from the Effective Date hereof, SEH shall
provide psychological supports. and services adequate to treat the
functional and behavioral needs of an individual including adequate
behavioral plans and individual and group therapy appropriate to the
demonstrated needs of the individual. More particularly, SEH shall:
a. ensure that psychologists adequately
screen individuals for appropriateness of individualized behavior plans,
particularly individuals who are subjected to frequent restrictive
measures, individuals with a history of aggression and self-harm,
treatment refractory individuals, and individuals on multiple
medications;
b. ensure that behavior plans contain a
description of the maladaptive behavior, a functional analysis of the
maladaptive behavior and competitive adaptive behavior that is to replace the maladaptive
behavior,
documentation of which reinforcers for the individual were chosen and
what input the individual. had in their development, and the system for
earning reinforcement;
c. ensure that behavioral interventions
are the least restrictive alternative and are based on appropriate,
positive behavioral supports, not the use of aversive contingencies;
d. ensure that psychologists adequately
screen individuals for appropriateness of individualized behavior plans,
particularly individuals who are subjected to frequent restrictive
measures, individuals with a history of aggression and self-harm,
treatment refractory individuals, and individuals on multiple
medications;
e. ensure that psychosocial,
rehabilitative, and behavioral interventions are monitored appropriately
and implemented appropriately; and
f, ensure an adequate number of
psychologists for each unit, where needed, with experience in behavior
management, to provide adequate assessments and behavioral treatment
programs.
2. By 18 months from the Effective Date hereof, SEH shall
provide adequate clinical oversight to therapy groups to ensure that
individuals are assigned to groups that are appropriate to their
individual needs.
3. By 18 months from the Effective Date
hereof, SEH shall provide adequate active psychosocial rehabilitation
sufficient to permit discharge from SEH into the most integrated,
appropriate setting available.
4. By 18 months from the Effective Date
hereof, SEH shall ensure that:
a. behavioral interventions are based on
positive reinforcements rather than the use of aversive contingencies,
to the extent possible;
b. programs are developed and
implemented for individuals suffering from both substance abuse and
mental illness problems;
c. where appropriate, a community living
plan is developed and implemented for individuals with cognitive
impairment;
d. programs are. developed and
implemented for individuals with forensic status recognizing the role of
the courts in the type and length of. the commitment and monitoring of
treatment;
e. psychosocial, rehabilitative, and
behavioral interventions are monitored and revised as appropriate in
light of significant developments, and the individual's progress, or the
lack thereof;
f. clinically relevant information remains readily
accessible; and staff who have a role in implementing individual
behavioral programs have received competency-based training on
implementing the specific behavioral programs for which they are
responsible, and quality assurance measures are in place for monitoring
behavioral treatment interventions.
By 36 months from the Effective Date hereof, SEH shall
provide adequate and appropriate pharmacy services consistent with
generally accepted professional standards of care. By 36 months from the
Effective Date hereof, SEH shall develop and implement policies and/or
protocols that require:
1. pharmacists to complete reviews of
each individual's medication regimen regularly, on at least a monthly
basis, and, as appropriate, make recommendations to treatment teams
about possible drug-to-drug interactions, side effects, medication
changes, and needs for laboratory work and testing; and
2. physicians to consider pharmacists'
recommendations and clearly document their responses and actions taken.
SEH shall within 24 months provide nursing services that
shall result in SEH's residents receiving individualized services,
supports, and therapeutic interventions, consistent with their treatment
plans. More particularly, SEH shall:
1. Ensure that, before they work
directly with individuals, all nursing and unit-based staff have
completed successfully competency-based training regarding mental health
diagnoses, related symptoms, psychotropic medications, identification of
side effects of psychotropic medications, monitoring of symptoms and
target variables, and documenting and reporting of the individuals'
status;
2. Ensure that nursing staff monitor,
document, and report accurately and routinely individual's symptoms,
actively participate in the treatment team process and provide feedback
on individual's responses, or lack thereof, to medication and behavioral
interventions;
3. Ensure that nursing staff monitor,
document, and report routine vital signs and other medically necessary
measurements (i.e., hydration, blood pressure, bowel sounds and
movements, pulse, temperature, etc.), including particular attention to
individuals returning from hospital and/or emergency room visits;
4. Ensure that nursing staff document
properly and monitor accurately the administration of medications;
5. Ensure that, prior to assuming their
duties and on a regular basis thereafter, all staff responsible for the
administration of medication have completed .successfully
competency-based training on the completion of the Medication
Administration Records;
6. Ensure that all failures to properly
sign the Medication Administration Record are treated as medication
errors, and that appropriate follow-up occurs to prevent recurrence of
such errors;
7. Ensure that staff responsible for
medication administration regularly ask individuals about side effects
they may be experiencing and document responses;
8. Ensure that staff monitor, document,
and report the status of symptoms and target variables in a manner
enabling treatment teams to assess individuals' status and to modify, as
appropriate, the treatment plan;
9. Ensure that each individual's
treatment plan identifies:
a. the diagnoses, treatments, and
interventions that nursing and other staff are to implement;
b. the related symptoms and target
variables to be monitored by nursing and other unit staff; and
c. the frequency by which staff need to
monitor such symptoms.
10. Establish an effective infection control program to
prevent the spread of infections or communicable diseases. More
specifically, SEH shall:
a. actively collect data with regard to
infections and communicable diseases;
b. assess these data for trends;
c. initiate inquiries regarding
problematic trends;
d. identify necessary corrective action;
e. monitor to ensure that appropriate
remedies are achieved;
f. integrate this information into
SEH's quality assurance review; and
g. ensure sufficient nursing staff to provide nursing
care and services.
11. Ensure that nursing staff implement the infection control
program.
By 24 months from the Effective Date hereof, SEH shall
develop and implement policies and/or protocols setting forth clear
standards regarding the content and timeliness of progress notes,
transfer notes, and discharge notes, including, but not limited to, an
expectation that such records include meaningful, accurate assessments
of the individual's progress relating to treatment plans and
treatment goals.
X. RESTRAINTS, SECLUSION, AND EMERGENCY INVOLUNTARY
PSYCHOTROPIC MEDICATIONS
By 12 months from the Effective Date hereof, SEH shall
ensure that restraints, seclusion, and emergency involuntary
psychotropic medications are used consistent with federal law and the
Constitution of the United States.
A. By 12 months from the Effective Date
hereof, SEH shall develop, revise, as appropriate, and implement
policies and/or protocols regarding the use of seclusion, restraints,
and emergency involuntary psychotropic medications that. cover the
following areas:
1. the range of restrictive alternatives
available to staff and a clear definition of each and that the use of
prone restraints, prone containment and/or prone transportation is
expressly prohibited.
2. training in the management of the
individual crisis cycle and the use of restrictive procedures; and
3. the use of side rails on beds, including a plan:
a. to minimize the use of side rails as
restraints in a systematic and gradual way to ensure safety;. and
b. to provide that individualized
treatment .plans address the use of side rails for those who need them,
including identification of the medical symptoms that warrant the use of
side rails and plans to address the underlying causes of the medical symptoms.
B. By 12 months from the Effective Date
hereof, and absent exigent circumstances (i.e., when an individual poses an imminent risk of injury to self or others), SEH
shall ensure that restraints and seclusion:
1. are used after a hierarchy of less
restrictive measures has been considered and documented;
2. are not used in the absence of, or
as. an alternative to, active treatment, as punishment, or for the
convenience of staff;
3. are not used as part of a behavioral
intervention; and
4. are terminated as soon as the
individual is no longer an imminent danger to self or others.
C. By 12 months from the Effective Date
hereof, SEH shall ensure that a physician's order for seclusion or
restraint include:
1. the specific behaviors requiring the
procedure;
2. the maximum duration of the order;
3. behavioral criteria for release
which, if met, require the individual's release even if the, maximum
duration of the initiating order has not expired;
4. ensure that the individual's
physician be promptly consulted regarding the restrictive intervention;
5. ensure that at least every 30
minutes, individuals in seclusion or restraint must be reinformed of the
behavioral criteria for their release from the restrictive intervention;
6. ensure that immediately following an individual being
placed in seclusion or restraint, there is a debriefing of the incident
with the treatment team within one business day;
7. comply with 42 C.F.R. Part 483,
Subpart G, including assessments by a physician or licensed medical
professional of any individual placed in seclusion or restraints; and
8. ensure that any individual placed in
seclusion or restraints is monitored by a staff person who has completed
successfully competency-based training regarding implementation of
seclusion and restraint policies and the use of less restrictive
interventions.
D. By 12 months from the Effective Date
hereof, SEH shall ensure the accuracy of data regarding the use of
restraints, seclusion, or emergency involuntary psychotropic
medications.
E. By 12 months from the Effective Date
hereof, SEH shall develop, revise, as appropriate, and implement
policies and/or protocols to require the review of, within three
business days, individual treatment plans for any individuals placed in
seclusion or restraints more than three times in any four-week period,
and modification of treatment plans, as appropriate.
F. By 12 months from the Effective Date
hereof, SEH shall develop and implement policies and/or protocols
regarding the use of emergency involuntary psychotropic medication for
psychiatric purposes, requiring that:
1. such medications are used on a
time-limited, short-term basis and not as a substitute for adequate
treatment of the underlying cause of the individual's distress;
2. a physician assess the individual
within one hour of the. administration of the emergency involuntary
psychotropic medication; and
3. the individual's core treatment team
conducts -a review (within three business days) whenever three
administrations of emergency involuntary psychotropic medication occur
within a four-week period, determines whether to modify the individual's
treatment plan, and implements the revised plan, as appropriate.
G. By 18 months from the Effective Date
hereof, SEH shall ensure that all staff whose responsibilities include
the implementation or assessment of seclusion, restraints, or emergency
involuntary psychotropic medications successfully complete
competency-based training regarding implementation of all such policies
and the use of less restrictive interventions..
By 36 months from the Effective Date hereof, SEH shall
provide the individuals it serves with ,a safe and humane environment,
ensure that these individuals are protected from harm, and otherwise
adhere to a commitment to not . tolerate abuse or neglect of
individuals, and require that staff investigate and report abuse or
neglect of individuals in accordance with this Settlement Agreement and
with District of Columbia statutes governing abuse and neglect. SEH
shall not tolerate any failure to report abuse or neglect. Furthermore,
before permitting a staff person to work directly with any individuals
served by SEH, the Human Resources office or officials responsible for
hiring shall investigate the criminal history and other relevant
background factors of that staff person, whether full-time or part-time,
temporary or permanent, or a person who volunteers on a regular basis.
Facility staff shall directly supervise volunteers for whom an
investigation has not been completed when they are working directly with
individuals living at the facility.
By 24 months from the Effective Date hereof, SEH shall
develop and implement, across all settings, an integrated incident
management system. For purposes of this section, "incident"
means death, serious injury, potentially lethal. self harm, seclusion
and restraint, abuse, neglect, and elopement.
A. By 24 months from the Effective Date
hereof, SEH shall develop, revise, as appropriate, and implement
comprehensive, consistent incident management policies, procedures and
practices. Such policies and/or protocols, procedures, and practices
shall require:
1. identification of the categories and
definitions of incidents to be reported and investigated, including
seclusion and restraint and elopements;
2. immediate reporting by staff to
supervisory personnel and SEH's chief executive officer (or that
official's designee) of serious incidents; and the prompt reporting by
staff of all other unusual incidents, using standardized reporting
across all settings;
3. mechanisms to ensure that, when
serious credible allegations of abuse, neglect, and/or serious injury
occur, staff take immediate and appropriate action to protect the
individuals involved, including removing alleged perpetrators. from
direct contact with individuals pending the investigation's outcome;
4. adequate training for all staff on
recognizing and reporting incidents;
5. notification of all staff when
commencing employment and adequate training thereafter of their
obligation to report incidents to SEH and District officials;
6. posting in each unit a brief and
easily_ understood statement of how to report incidents;
7. procedures for referring incidents,
as appropriate, to law enforcement; and
8. mechanisms to ensure that any staff
person, resident, family member, or visitor who, in good faith, reports
an allegation of abuse or neglect is not subject to retaliatory action
by SEH and/or the District, including but not limited to
reprimands, discipline,' harassment, threats, or censure, except for
appropriate counseling, reprimands, or discipline because of an
employee's failure to report an. incident in an appropriate or timely
manner.
B. By 24 months from the Effective Date
hereof, SEH shall develop, revise, as appropriate, and implement
policies and/or protocols addressing the investigation of serious
incidents, including elopements, suicides and suicide attempts, and
abuse and neglect. Such policies and procedures shall:
1. require that such investigations be
comprehensive, include consideration of staff's adherence to
programmatic requirements, and be performed by independent
investigators;
2. require all staff involved in
conducting investigations to complete successfully competency-based
training on technical and programmatic investigation methodologies and
documentation requirements necessary in mental health service settings;
3. include a mechanism which will
monitor the performance of staff charged with investigative
responsibilities and provide technical assistance and training whenever
necessary to ensure the thorough, competent, and timely completion of
investigations of serious incidents; and
4. include a reliable system to identify
the need for, and monitor the implementation of, appropriate corrective
and preventative actions addressing problems identified as s result of
investigations.
C. By 24 months from the Effective Date hereof, whenever
remedial or programmatic action is necessary to correct a reported
incident or prevent re-occurrence, SEH shall implement such action
promptly and track and document such actions and the corresponding
outcomes.
D. By 24 months from the Effective Date
hereof, records of the results of every investigation of abuse, neglect,
and serious injury shall be maintained in a manner that permits
investigators and other appropriate personnel to easily access every
investigation involving a particular staff member or resident.
E. By 24 months. from the Effective Date
hereof, SEH shall have a system to allow the tracking and trending of
incidents and results of actions taken. Such a system shall:
1. Track trends by at least the following categories:
a. type of incident;
b. staff involved and staff present;
c. individuals involved and witnesses
identified;
d. location of incident;
e. date and time of incident;
f. cause(s) of incident; and
g. actions taken.
2. Develop and implement thresholds for
injury/event indicators, including seclusion and restraint, that will
initiate review at both the unit/treatment team level and at the
appropriate supervisory level, and that will be documented in the
individual's medical record with explanations given for changing/not
changing the individual's current treatment regimen.
3. Develop and implement policies and
procedures on the close monitoring of individuals assessed to be at
risk, including those at risk of suicide, that clearly delineate: who is responsible for such
assessments, monitoring, and follow-up; the requisite obligations to
consult with other staff and/or arrange for a second opinion; and how
each step in the process should be documented in the individual's
medical record.
By 36 months from the Effective Date hereof, SEH shall
develop, revise, as appropriate, and implement quality improvement
mechanisms that provide for effective monitoring, reporting, and
corrective action, where indicated, to include compliance with this
Settlement Agreement.
A. Track data, with sufficient
particularity for actionable indicators and targets identified in this
Agreement, to identify trends and outcomes being achieved.
B. Analyze data regularly and, whenever
appropriate, require the development and implementation of corrective
action plans to address problems identified through the quality
improvement process. Such plans shall identify:
1. the action steps recommended to
remedy and/or prevent the reoccurrence of problems;
2. the anticipated outcome of each step;
and
3. the person(s) responsible and the
time frame anticipated for each action step.
C. Provide that corrective action plans are implemented
and achieve the outcomes identified in the Agreement by:
1. disseminating corrective action plans
to all persons responsible for their implementation;
2. monitoring and documenting the
outcomes achieved; and
3. modifying corrective action plans, as
necessary.
D. Utilize, on an ongoing basis,
appropriate performance improvement mechanisms to achieve SEH's
quality/performance goals, including identified outcomes.
By 36 months of the Effective Date hereof, SEH shall
develop and implement a system to regularly review all units and areas
of the hospital to which residents have access to identify any potential
environmental safety hazards and to develop and implement a plan to
remedy any identified issues, including the following:
A. By 36 months from the Effective Date
hereof, SEH shall attempt to identify potential suicide hazards (e.g.,
seclusion rooms and bathrooms) and expediently correct them.
B. By 36 months from the Effective Date
hereof, SEH shall develop and implement policies and procedures
consistent with generally accepted professional standards of care to
provide for appropriate screening for contraband.
C. By 24 months from the Effective Date
hereof, SEH shall provide sufficient professional and direct care staff
to adequately supervise individuals, particularly on the outdoor smoking
porches, prevent elopements, and otherwise provide individuals with a
safe environment and adequately protect them from harm.
D. By 36 months from the Effective Date
hereof, SEH shall ensure that the elevators are fully repaired. If
possible, non-ambulatory individuals should be housed in first floor
levels of living units. All elevators shall be inspected by the
relevant local authorities.
E. By 12 months from the Effective Date
hereof, SEH shall review and update the hospital fire safety and evacuation plan for all buildings and ensure that the
plan is approved by the local fire authority.
F. By 36 months from the Effective Date
hereof, SEH shall develop and implement procedures to timely identify,
remove and/or repair environmentally hazardous and unsanitary conditions
in all living. units and kitchen areas.
By December 31, 2007, the District agrees to make substantial improvement in the following four (4) areas
of this Settlement Agreement listed below. Every four months beginning
with the Effective Date of this Agreement, the District shall submit to
the United States a Corrective Action Plan ("CAP") to achieve
substantial improvement. The CAP shall list the particular provision of
the Agreement being addressed, the action steps to be taken to
adequately comply with the provision, the timeline to achieve the action
steps, the person(s) responsible for implementing the action steps, the
status of the action steps along with quality assurance mechanisms to
evaluate and monitor such status, and the documents that demonstrate
progress and/or compliance with the particular provision. If the
District fails to comply with the below benchmarks, the United States
may assert all its remedies available under law.
A. Integrated Treatment Planning and its
provisions under Section V of the Agreement.
B. Mental Health Assessments and its
provisions under Section VI of the Agreement.
C. Incident Management System and its
provisions under Section XII of the Agreement.
D. Restraints, Seclusion, and Emergency Involuntary
Psychotropic Medications and its provisions under Section X. of the
Agreement.
A. The District represents that it will
periodically refine and revise the policies and/or protocols outlined in
this Agreement to ensure compliance with the intent of this Agreement.
The District shall notify the United States regarding any substantive
revisions to a policy and or protocol outlined under this Agreement.
Upon request by the United States, the District shall provide the United
States with copies and an opportunity to provide substantive comment
upon any policies and/or protocols revised pursuant to this Agreement.
If it wishes to provide substantive comments, the United States will
provide .such comments or request for additional time within 45 days of
receipt of the revisions.
B. The District represents that it has
educated, or will educate, all employees at SEH with respect to the
policies and/or protocols outlined in this Agreement.
C. The District shall maintain records
to document its compliance with all terms and conditions of this
Agreement. The District shall also maintain any and all records required
by, or developed pursuant to, this Agreement..
D. Until this matter is dismissed,
the-United States shall have unrestricted access to, and shall, upon
request, receive copies of any documents, records, and information
relating to the implementation of this Agreement. SEH shall provide any
requested documents, records, and information to the United States as
soon as possible, but no later than within 30 business days of the
request. The United States shall have reasonable access to all of SEH's
buildings and facilities, including any newly constructed, renovated
and/or designated buildings and facilities; staff and residents,
including private interviews with staff, and, where clinically
appropriate, private interviews with residents; and resident records,
documentation, and information relating to the issues addressed in this Agreement. SEH shall make all employees available so
that they may choose to cooperate fully.with the United States. The United States agrees to
provide SEH with reasonable notice of any visit or inspection, although
the United States and SEH agree that no notice shall be required in an
emergency situation where the life, immediate health, or immediate
safety of individual(s) is at issue. Nothing in this Agreement shall
abridge the whistleblower rights of District employees or contractors
under law.
E. The District shall notify the DOJ
immediately upon the death of any SEH's patient (excluding those
patients on conditional release) and/or any situation resulting in such
patient being placed in imminent and/or immediate jeopardy that has
caused or may cause severe injury to such SEH patient. The District
shall forward to DOJ copies of any completed incident reports related to
deaths, autopsies and/or death summaries of residents as well as all
final reports of investigations of those incidents described in this
subsection.
F. If SEH closes and individuals are
moved to another facility or facilities, the United States reserves the
right to evaluate the appropriateness of such placements. If the
District contracts for any of the services to. be delivered at SEH which
are covered under this Agreement, the Agreement shall be fully
applicable to, and binding upon, any contracted services.
G. If the United States maintains that
the District has failed to carry out any requirement of this Agreement,
the United States shall notify the District of any instance(s) in which
it maintains that the District has failed to carry out the requirements
of this Agreement:
H. With the exception of conditions or
practices that pose an immediate and serious threat to the life, health,
or safety of a resident(s) at SEH, the District shall take substantial
steps to correct the claim of non-compliance within 90 days of any notice of
non-compliance. During this period, the United States and the District shall coordinate and discuss
areas of disagreement and attempt to resolve outstanding differences. If
the United States and the District fail to reach an agreement, the
United States is not limited in any fashion in pursuing its law
enforcement obligations with 30 days notice, including any adverse
litigation against the District and/or. seeking appropriate enforcement
of any provision of this Agreement.
I. The District shall submit to the
United States a status report every 6 months that discusses the current
status of each provision of the Settlement Agreement along with a
projection of the completion date for each provision and. steps needed
to be taken achieve such completion date.
J. If, at any time, any party to this
Agreement desires to modify it for any reason, that party will notify
the other party in writing of the proposed modification and the reasons
therefor. No modification will occur unless there is a written agreement
between the United States and the District. The mutually agreed upon
modification must be approved by the Court.
K. The Court will have continuing
jurisdiction over enforcement of this Agreement for a period of five
years from the effective date hereof. If the District is able to reach
sustained compliance with certain Sections of the Agreement for a period
of two years, the United States will no longer monitor or require
evaluation of such Sections. If the parties agree that the District is
in sustained compliance with each of the provisions of this Agreement
earlier than five years from the Effective Date of the Agreement, and
has maintained sustained compliance for at least one year, then the
parties may file a joint motion to dismiss with the Court. Noncompliance with mere technicalities, or temporary failure to
comply during a period of otherwise sustained compliance, shall not
constitute failure to maintain sustained compliance. At the same time, temporary compliance during a period
of otherwise sustained noncompliance, shall not
constitute sustained compliance.
SO ORDERED this ___ day of ______,
2007.
United States District Court
AGREED TO BY THE UNDERSIGNED:
Dated this 10th day of May, 2007.
FOR THE UNITED STATES:
WAN J. KIM
Assistant Attorney General, Civil Rights Division
SHANETTA Y. CUTLAR
Chief, Special Litigation Section
JUDY PRESTON
Deputy Chief, Special Litigation Section
JE ON JUN
WILLIAM MADDOX
Senior Trial Attorneys, U.S. Department of Justice Civil
Rights Division, Special Litigation Section
950 Pennsylvania Ave, NW
Washington, DC 20530
(202) 514-6251 (202) 514-6903 (fax)
FOR THE DISTRICT:
LINDA SINGER
Attorney General For the District of Columbia
GEORGE C. VALENTINE
Deputy Attorney General, Civil
Litigation Division
ELLEN A. EFROS [250746]
Chief, Equity I Section, Office of the Attorney General
441 4th Street, N.W. 6th
Floor
Washington, D.C. 20001
(202) 442-9886
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