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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