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Case Name U.S. CRIPA Investigation of Western State Hospital (VA) MH-VA-0003
Docket / Court docket unknown ( No Court )
State/Territory Virginia
Case Type(s) Disability Rights-Pub. Accom.
Mental Health (Facility)
Attorney Organization U.S. Dept. of Justice Civil Rights Division
Case Summary
On June 29, 1998, the Department of Justice Civil Rights Division (DOJ) opened an investigation, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA) of the Western State Hospital, a state mental health facility in Staunton, Virginia. The facility held approximately 370 patients, ... read more >
On June 29, 1998, the Department of Justice Civil Rights Division (DOJ) opened an investigation, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA) of the Western State Hospital, a state mental health facility in Staunton, Virginia. The facility held approximately 370 patients, with one-third of the patients having a dual diagnosis of mental illness and substance abuse.

On July 23, 1999, Pennsylvania’s Attorney General notified the DOJ that Western State was taking steps to remedy concerns about the conditions of Western State and was developing a plan of correction. The Attorney General suggested the DOJ defer its findings letter until the plan of correction was finalized and Pennsylvania’s own expert had toured Western State.

The DOJ declined to wait for the plan of correction and proceeded to issue its findings letter to the Governor of Pennsylvania on October 6, 1999. The DOJ alleged violations of Fourteenth Amendment due process rights, Medicare/Medicaid regulations requiring adequate staffing and discharge planning, and Title II of the American with Disabilities Act (ADA). The DOJ found that the unlawful conditions of Western State included:
  • inadequate mental health treatment;
  • failure to provide necessary medications to patients;
  • inappropriate use of restraints and seclusion;
  • inadequate nursing and medical care;
  • failure to protect patients from injuries, dangerous behaviors and abuse;
  • unsafe and inadequate physical conditions; and
  • inadequate discharge planning and placement into the most integrated setting.
The DOJ reported that many of the unlawful conditions stemmed from a lack of protocols, monitoring of patients, and an insufficient number of adequately trained staff. The report cited multiple examples of patient injuries and death due to the lack of monitoring and failure to receive timely medical care. In addition, the DOJ highlighted how Western State placed patients in restraints in a face-down position and failed to set objective criteria for the release of patients from restraints and seclusion.

In its findings letter, the DOJ recommended Pennsylvania's plan of correction implement minimal remedial measures at Western State. These remedial measures included:
  • reformation of Western State’s mental health treatment, medical care, and emergency care in accordance with generally accepted medical standards;
  • prescription of medications based on clinical need, rather than budgetary constraints;
  • ending the use of six-point chair restraints, use of eight-point bed restraints, and placing patients in restraints in a face-down position;
  • documentation and monitoring the use of seclusion and restraints;
  • development and implementation of nursing protocols to ensure proper supervision;
  • abatement of suicide hazards in bedrooms and bathrooms;
  • development of a system to oversee discharge planning and aftercare services; and
  • increasing staffing, particularly psychiatrists and nurses.
Based on information acquired from the DOJ in a Freedom of Information Act request, a complaint was not filed in response to these allegations. According to an article in Developments in Mental Health Law, a publication by the Institute of Law, Psychiatry, & Public Policy at the University of Virginia, Western State implemented its plan of correction removing the need for a settlement agreement or the filing of a complaint. 31 Dev. Mental Health L., Oct. 2012 at 12, 15 n.12. According to the DOJ’s fiscal year 2003 report, the DOJ closed the investigation on September 5, 2003.

Emily Kempa - 08/04/2019

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Issues and Causes of Action
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Constitutional Clause
Due Process
Hospital/Health Department
Integrated setting
Least restrictive environment
Mental impairment
Assault/abuse by residents/inmates/students
Failure to supervise
Incident/accident reporting & investigations
Neglect by staff
Restraints : physical
Staff (number, training, qualifications, wages)
Suicide prevention
Medical/Mental Health
Medication, administration of
Mental health care, general
Self-injurious behaviors
Suicide prevention
Mental Disability
Plaintiff Type
U.S. Dept of Justice plaintiff
Special Case Type
Type of Facility
Causes of Action 42 U.S.C. § 1983
Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12111 et seq.
Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997 et seq.
Medicaid, 42 U.S.C §1396 (Title XIX of the Social Security Act)
Medicare, 42 U.S.C. 1395-1395lll (Title XVIII of the Social Security Act)
Defendant(s) Western State Hospital
Plaintiff Description Department of Justice Civil Rights Division, to enforce the rights of individuals housed in the Western State Hospital.
Indexed Lawyer Organizations U.S. Dept. of Justice Civil Rights Division
Class action status sought No
Class action status outcome Not sought
Filed Pro Se No
Prevailing Party None Yet / None
Public Int. Lawyer Yes
Nature of Relief None
Source of Relief None yet
Filed 10/06/1999
Case Closing Year 2003
Case Ongoing No
Additional Resources
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  Review of the Use of Monitors in Civil Settlement Agreements and Consent Decrees Involving State and Local Government Entities
U.S. Department of Justice
Date: 9/13/2021
By: Attorney General Merrick Garland and Assoc. AG Vanita Gupta (U.S. Department of Justice)
[ Detail ] [ PDF ] [ External Link ]

  An Analysis of CRIPA Findings Letters Issued to Jails for Constitutional Violations by the Department of Justice
Date: Apr. 15, 2016
By: Jeff Mellow, Bryce E. Peterson & Mijin Kim (John Jay College of Criminal Justice Faculty)
Citation: Am. J. Crim. Just. (April 2016)
[ Detail ] [ External Link ]

Court Docket(s)
No docket sheet currently in the collection
General Documents
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Re: Findings from CRIPA Investigation of Western State Hospital, Staunton, Virginia
MH-VA-0003-0001.pdf | External Link | Detail
Source: U.S. Department of Justice, Civil Rights Division, Special Litigation Section
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Plaintiff's Lawyers Lee, Bill Lann (District of Columbia) show/hide docs

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