On May 13, 2003, the U.S. Department of Justice's Civil Rights Division ("DOJ") sent its "findings letter" to California's governor, advising him of the results of one component of the June and July 2002, DOJ investigation of conditions and practices at the Metropolitan State Hospital ("MSH"), a state facility housing children, adolescents, and adults who suffered from mental illness. The letter set out the DOJ's findings concerning MSH's child and adolescent residents. (Findings regarding the adult patient component of MSH had not been completed.) The investigation occurred under the authority of the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. According to the letter, DOJ and expert consultants visited the facility, reviewed a wide array of documents there, and conducted interviews with personnel and residents. The letter commended MSH staff for providing a high level of cooperation during the investigation, as well as the dedication many showed for patient well-being. Nevertheless, the investigation found "significant and wide-ranging" deficiencies in child and adolescent patient care at MSH.
DOJ concluded that these deficiencies at MSH existed in a dozen topic areas, including (1) psychiatry; (2) nursing services; (3) psychology; (4) pharmaceutical services; (4) general medical care, including deficiencies in vision services, x-ray reviews, and incontinence and headache evaluation; (5) infection control; (7) dental care; (8) dietary services; (9) placement in the most integrated setting; (10) special education; (11) protection from harm; and (12) First Amendment and due process rights to confidentially communicate with investigators. The letter provided details of deficiencies for all twelve of these categories.
The letter listed, at length, minimally-acceptable remedial measures for each of these categories. It invited continued collaboration toward resolving the many deficiencies and alerted the state that, absent improvement, a CRIPA lawsuit would be filed to compel correction of the deficiencies and protection of MSH patients' rights.
The second component of the DOJ investigation at MSH was addressed when, on February 19, 2004, DOJ sent its' "findings letter" to the governor regarding MSH's conditions and care for adult patients. The letter described the investigation process as essentially the same as used in reviewing the younger patients' situations; however, the larger number of adult patients (and of programs housing them) made for lengthier investigative and evaluative processes. The findings, however, were equally gloomy: significant and wide-ranging deficiencies in MSH's provision of care to adult patients. The letter set out categories of deficiency, as follows: (1) substandard integrated treatment planning; (2) inadequate psychiatric, psychological, rehabilitative, and social history assessments; (3) poor to almost-nonexistent discharge planning for placement in the most integrated setting; (4) substantial departures from generally accepted professional standards of care in each of MSH's psychiatric, psychological, nursing and unit-based, pharmaceutical, general medical, infection control, dental, physical and occupational therapy, and dietary treatment services; (5) insufficient documentation of patient care and progress; (6) excessive and unnecessarily restrictive use of seclusion, restraints, and "as-needed" medications; (7) failure to protect patients from harm, stemming from ineffective incident management and quality assurance systems and from multiple environmental hazards; and (8) denial of patients' First Amendment and due process rights to confidentially communicate with investigators.
This second findings letter listed almost twenty pages of minimally-acceptable remedial measures addressing each of these categories. It invited continued collaboration toward resolving the many deficiencies and again alerted the state that, absent improvement, a CRIPA lawsuit would be filed to compel correction of the deficiencies and protection of MSH patients' rights.
Another "findings letter" from the DOJ addressed deficiencies found at the Napa State Hospital ("NSH"), another California mental health facility. Sent on June 27, 2005, the letter began by noting the state's unusual change in attitude, in that state officials had stopped cooperating with DOJ investigators, denying them and their consultants access to NSH and other state mental health facilities DOJ was then investigating (Patton and Atascadero state hospitals). DOJ advised that it drew an adverse conclusion about the facility from the state's non-cooperation and investigated, anyway, considering information from regulatory and standards agencies that had surveyed NSH and information from interviews of NSH staff, advocates, family members of patients, and patients. Not only did DOJ find "significant and wide-ranging" deficiencies in NSH patient care, it concluded these deficiencies were "widespread and systemic." NSH deficiencies had been the subject of a prior CRIPA investigation, which led to a consent decree in 1990, which was dismissed in 1995. "Overwhelming" information established to DOJ that, post-dismissal, significant problems at NSH had recurred. These problems included: (1) failure to protect patients from harm from assaults and suicide (and from staff sales of illegal drugs to patients); (2) inappropriate use of seclusion, restraint and PRN ("pro re nata" or "as-needed") psychotropic medications; and (3) inadequate medical, nursing and psychiatric care. In addition to the recurring problems, DOJ received information evidencing (4) deficient mental health treatment planning, programming, and nutritional management; (5) unsanitary conditions; and (6) failure to place patients in the most integrated setting, as required by law. For each of these categories, the findings letter included several specific examples of malfeasance or misfeasance, often describing instances of neglectful, cruel and heart-breaking conduct by state personnel. Remedial measures listed in the letter could be imposed by a decree obtained in a CRIPA lawsuit against the state, although the letter invited the state to avoid litigation and work cooperatively with DOJ to resolve the identified deficiencies.
The DOJ letters eventually resulted in cooperative resolution of these hospitals' many problems, at least on paper. California's officials and the DOJ reached agreement that became the basis of a consent judgment filed contemporaneously with a CRIPA complaint against the state. Via DOJ Civil Rights Division lawyers, the United States, on May 2, 2006, filed in the U.S. District Court for the Central District of California a CRIPA lawsuit against California and state officials responsible for operation of MSH and NSH. The case sought declaratory and injunctive relief to end the substantial departures from generally accepted professional standards of care at each hospital in the multiple aspects mentioned in the findings letters. At the same time, the parties filed a consent judgment containing an explicit "Enhancement Plan" nearly eighty pages long. The plan set out details of standards for comprehensive improvements in care and conditions at MSH and NSH. The consent judgment named an expert independent monitor, Mohamed El-Sabaawi, M.D., to oversee the process of implementing these standards. His costs, including his use of expert consultants, would be borne by the state. While he would not have the powers of a Special Master, he would have full access to the facilities, patients, and staff, and his periodic reports would go to the court, the parties, and hospital administrators. All terms of the plan were to be implemented within three years, except for the immediate implementation of suicide prevention components of the plan. By its' terms, the consent judgment would self-terminate after five years, with earlier termination possible if earlier compliance occurred. While the consent judgment remained in effect, the court retained jurisdiction to enforce the terms of the order. District Judge George P. Schiavelli accepted the settlement and entered the consent judgment.
On February 27, 2007, the parties filed an amended consent judgment. Its' terms and duration remained the same, but it added, as parties, the state officials operating Patton State Hospital and Atascadero State Hospital, two additional state mental health facilities which had been found deficient by recent DOJ CRIPA investigations. Thus, all four hospitals were subject to the consent judgment's enhancement plan, to the monitor's review and reporting regarding compliance, and to court supervision and enforcement of patients' constitutional and statutory rights. Judge Schiavelli again entered judgment in accordance with the parties' agreement.
On December 12, 2007, petitioner Sokolsky filed a petition for a writ of mandamus to compel the defendants to comply with the amended consent judgment. He argued that the judgment applied to the Coalinga State Hospital, where he was being detained. On August 19, 2008, the court denied the petition, finding that the judgment did not apply to residents of the Coalinga State Hospital. This case appears to be ongoing.
Related matters in this database are cases MH-CA-2 and MH-CA-5 which, respectively, are the DOJ CRIPA investigation results for Atascadero State Hospital and for Patton State Hospital.Kristen Sagar - 10/06/2008