IN THE UNITED STATES DISTRICT COURT FOR
THE WESTERN DISTRICT OF WISCONSIN
UNITED STATES OF AMERICA, Plaintiff
v.
THE STATE OF WISCONSIN, et al., Defendants
SETTLEMENT AGREEMENT
I. INTRODUCTION
A. This case was instituted by the United States pursuant
to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997.
B. This Court has jurisdiction over these actions pursuant
to 28 U.S.C. § 1345.
C. Venue is appropriate pursuant to 28 U.S.C. §§ 1391 and
1392.
D. The United States is authorized to institute this civil
action by 42 U.S.C. § 1997a and has met all the prerequisites for
the institution of this civil action prescribed by the statute.
E. The plaintiff is the United States of America.
F. The defendants include: the State of Wisconsin; Joseph
S. Leean, Secretary of the Department of Health & Family
Services; James Hutchison, Superintendent of the Southern
Wisconsin Center for the Developmentally Disabled ("SWC"), in
Union Grove, WI; and Steve Watters, Acting Superintendent of the
Central Wisconsin Center for the Developmentally Disabled
("CWC"), in Madison, WI.
G. The individual defendants who are officers of the
Executive Branch of the State of Wisconsin have authority and
responsibility for the operation of SWC and CWC ("the Centers")
and are sued in their respective official capacities.
H. The parties agree that the care, conditions and training
of the developmentally disabled citizens residing at the Centers
("the residents") implicate rights that are secured and protected
by the laws and Constitution of the United States. The parties
entering into this Settlement Agreement recognize these statutory
and constitutional interests, and for the purpose of avoiding
protracted and adversarial litigation, agree to the provisions
set forth herein.
I. In entering into this Settlement Agreement, defendants
do not admit any violation of law and this Settlement Agreement
may not be used as evidence of a violation of law in any other
civil proceeding. The defendants maintain that the care,
treatment and services provided at the Centers meet or exceed all
applicable legal standards, and far exceed the constitutional
minimums at issue in legal actions of this nature. The United
States maintains that the care, treatment and services provided
at the Centers continue to violate the constitutional and federal
statutory rights of the individuals residing in these
institutions. The defendants contend that they are currently
adhering to some of the policies and practices required by this
Agreement. The fact that a particular policy or practice is
included as a requirement in this Agreement is not to be
construed for any purpose by any person or forum as evidence that
the defendants are or are not currently following that policy or
practice. This Settlement Agreement is enforceable only by the
parties hereto, and only in the manner herein provided.
J. The provisions of this Settlement Agreement are a
lawful, fair and appropriate resolution of this case.
K. In all cases, the defendants agree to provide adequate
care, treatment and services consistent with the requirements of
Youngberg v. Romeo, 457 U.S. 307 (1982). To the extent any
provision of this Agreement relating to the provision of care,
treatment or services requires that any action be taken or thing
be done to a level of quality or in an amount that is not
otherwise specified or quantified in the Agreement, that
provision shall be interpreted consistent with the "professional
judgement" standard enunciated in Youngberg. In particular, all
qualifying terms used in this Agreement, including but not
limited to "medically indicated," "adequate" or "timely" shall be
interpreted to mean that level, quality, amount or timeliness of
care, treatment or services that is consistent with the
"professional judgment" standard enunciated in Youngberg.
However, the "professional judgment" standard enunciated in
Youngberg in no way relieves the defendants of any obligation to
meet specific requirements of federal law, including but not
limited to regulations of the Health Care Financing
Administration governing Intermediate Care Facilities for the
Mentally Retarded.
L. This Settlement Agreement, voluntarily entered into,
shall be filed by the United States with the United States
District Court for the Western District of Wisconsin at the same
time as the summons and complaint in this matter are filed, and
shall be entered by the Court and shall be enforceable as an
order of this Court pursuant to the procedures provided herein.
The parties acknowledge that venue is proper in this Court and
that this Court retains jurisdiction over the Centers to the
extent and pursuant to the procedures provided in this Settlement
Agreement. This Settlement Agreement is legally binding on and
judicially enforceable by the parties pursuant to the procedures
provided herein and it shall be applicable to and binding upon
all of the parties, their officers, agents, employees, assigns,
and successors.
II. MEDICAL CARE
A. Defendants will ensure that the Centers' residents
receive adequate preventive, chronic, routine, acute, and
emergency medical care. To this end, at a minimum, the Centers
will continue to maintain a full time equivalent ("FTE") primary
care physician to resident ratio of at least 1:120 commencing no
later than April 1, 1997. For the purpose of calculating this
ratio, each Center Medical Director shall be considered to work
at that proportion of one FTE that his or her primary care
patient case load bears to the average patient case load of a FTE
primary care physician at the Center. Within 120 days from the
entry of this Settlement Agreement, the Centers' primary care
physicians will:
1. Conduct annual comprehensive evaluations of all
residents who are due for their regular annual evaluations;
2. Determine what specialized medical services are
required for the residents for whom they are responsible and
timely provide or arrange for such services whenever necessary to
evaluate or treat the individual's medical problems;
3. Participate in the development of an integrated
medical plan of care for each resident to address any chronic
medical problems of that individual, as part of the annual
comprehensive medical evaluation of that individual;
4. Adequately review each resident's medical status
and progress in response to his or her medical plan of care as
often as is medically indicated given the resident's particular
medical condition and needs;
5. Review and adequately respond to all
recommendations of outside medical specialists, including regular
consultants, and laboratory findings, if medically indicated,
documenting what action has been taken and the reasons therefor,
including, if action is recommended by a physician specialist
within his or her field of expertise and is not taken, the
reason(s) for not acting upon the recommendations or findings, or
seeking a second opinion;
6. Maintain formal relationships to coordinate care
with medical personnel at acute care hospitals and to review the
care residents receive at these hospitals; implement a protocol
requiring staff at the Centers to obtain from the hospitals a
timely, adequate record of the diagnosis, course of treatment at
the hospitals, and prescribed treatment; perform a re-admission
assessment and write orders specifying the individual's follow-up
care after an individual is returned from the hospital; record
in the individual's medical record any treatment rendered or
recommendations made by hospital staff during the individual's
hospital stay; and
7. Implement peer review at each facility to review a
random sample of not less than 10% of all residents' medical
charts annually, in order to evaluate and make recommendations
regarding the medical care provided these residents.
B. Emergency care - Defendants shall provide all staff
physicians, registered nurses ("RNs"), licensed practical nurses
("LPNs"), supervisors, and direct care employees who regularly
provide services on-grounds at the Center, with annual training
in procedures for seeking assistance in case of emergency; and
shall provide systematic, periodic training in emergency
procedures, including the proper way to administer cardio-pulmonary resuscitation, to a number of staff sufficient to
ensure that these services are always readily available to all
residents. Thereafter, defendants shall evaluate, through the
use of emergency drills held at least annually on each unit and
for each shift, the competence of all participating staff to
perform adequately, document such evaluations and provide such
additional training as the evaluations indicate are necessary to
ensure staff competence in emergency procedures. Defendants will
ensure necessary medication and equipment to be used in case of
emergency are easily accessible to qualified staff in each
residential unit. Within 30 days of each medical emergency, the
Medical Director shall select a quality assurance committee with
a membership that is appropriate to the nature of each emergency
to review the emergency to assess whether the actual response
was timely and adequate, and make and disseminate any
recommendations for improving the emergency response. The
Medical Director shall develop and oversee the implementation of
a protocol or written guidelines for conducting such reviews and
making recommendations. The medical director, a staff physician,
and a nurse at each Center shall be members of that Center's
committee, along with any other individuals deemed appropriate by
the Centers. An "emergency," within the meaning of this section,
includes status epilepticus, respiratory arrest or any other
sudden, life-threatening event or condition.
The CWC Short Term Care Unit, formerly used as an inpatient hospital unit, will no longer be used for these purposes. This
unit may be used for evaluation services for community residents
with developmental disabilities, rehabilitation for CWC residents
returning from surgery or other hospitalization, short-term
services such as continuous oxygen for respiratory ailments or
fluid therapy for mild dehydration for CWC residents when the
attending physician concludes that hospitalization is not
medically necessary, or hospice care for CWC residents with
terminal conditions where such care cannot be provided on the
resident's living unit. Inpatient hospital treatment of CWC
residents shall be provided at a local hospital.
C. Training for medical staff - Upon the entry of this
Settlement Agreement, defendants shall, periodically but not less
than once annually, obtain the services of expert medical
specialists of the Centers' choice who shall train the Center's
primary care physicians and registered nurses in the assessment,
diagnosis, treatment and monitoring of medical problems typically
associated with persons with developmental disabilities. Topics
covered within the first year following the entry of this
Settlement Agreement shall include: (1) neurologic disorders,
including seizures and specifically the prescription of
medication to control seizures; (2) orthopedic and physiatric
conditions; (3) gastroenterologic disorders, and physical and
nutritional management; and, (4) behavioral and psychiatric
disorders, including the psychopharmacologic treatment of such
disorders, and side effects of behavior modifying medication.
Thereafter, topics covered shall be at the discretion of the
medical director. Defendants shall document that such training
occurred, including maintaining a list of those in attendance as
well as clinical areas covered.
In addition, all newly hired medical staff shall attend an
orientation course which covers, at a minimum, the four topic
areas listed above. Again, defendants shall document that such
training occurred. The trainers for this orientation course may
include qualified Center medical staff.
D. Neurology consultations and seizure management -
Defendants will provide adequate neurology care, including
routine, chronic, and emergency seizure management to all
individuals with epilepsy at the Centers. The defendants shall,
within 120 days from the entry of this Settlement Agreement,
implement and ensure the following:
1. A board certified neurologist(s) shall perform a
comprehensive assessment for each resident receiving
anticonvulsant medication as often as is medically indicated
given the medical condition of the resident to determine whether
the medication treatment is justified; defendants shall maintain
the number of hours of neurology care provided by board certified
neurologists at the Centers and request outside neurology
consults as needed;
2. The neurologist(s) at the Centers shall timely
evaluate, diagnose and recommend treatment for residents who are
referred to them by primary care physicians, and examine and
recommend treatment, as often as is medically indicated for
residents receiving anticonvulsant medications;
3. In performing these duties, the neurologist(s)
shall confer with the referring primary care physician and, if
medically indicated, with the assigned psychiatrist, and timely
record notes in the resident's medical records that reflect the
neurological assessment, diagnosis, recommended course of
treatment, and results;
4. For each individual currently receiving
anticonvulsant medication, the neurologist(s), in concert with
the Center's medical professionals, shall evaluate whether the
type of medication is appropriate and effective for the type of
seizure and is consistent with the principles of monotherapy or
rational polypharmacy, representing the fewest number of
medications medically indicated for effective seizure management.
It is understood between the parties that adherence to these
principles does not necessarily rule out use of some newer anti-convulsants that are intended as add-on medications. The
neurologist shall ensure that residents are not kept on anti-convulsants that serve no therapeutic purpose and are not
maintained on supertherapeutic or subtherapeutic levels of anti-convulsants for prolonged periods without adequate documentation
of the neurologist's professional judgment that such level is
medically indicated;
5. The Centers will employ systems for the recording
of every seizure of each resident including information on: (a)
the date and time of the onset of the seizure; (b) the duration
of the seizure; (c) a description of the seizure; (d) an
indication as to whether or not the individual is conscious or
unconscious, and the duration of any period(s) of
unconsciousness; (e) any medical or other steps taken to control
the seizure; and (f) the individual's response to the
intervention;
6. The Centers will provide training programs to
ensure that all staff, including nursing and direct care staff,
shall be trained in how to recognize a seizure, describe the
seizure and length of time it lasts and record that information
in the resident's record; and
7. Defendants will utilize a quality assurance process
to ensure that all seizures are being appropriately documented
and evaluated.
E. Psychiatric care and treatment - The defendants will
provide adequate routine and emergency psychiatric and mental
health services to residents who need such services.
Psychotropic medication shall not be used as punishment, in lieu
of a training program, for behavior control, in lieu of a
psychiatric or neuropsychiatric diagnosis, or for the convenience
of staff. To these ends, defendants shall within 180 days from
the entry of this Settlement Agreement, unless otherwise noted:
1. Continue to employ and utilize a board certified or
board eligible consulting psychiatrist(s) with experience
treating developmentally disabled individuals at SWC at least 40
hours per week, and at CWC at least 24 hours per week; ensure
that the consulting psychiatrist(s), among other
responsibilities, is involved in the coordination of mental
health services in the facility, and is responsible for ensuring
that residents with mental health concerns receive an initial
comprehensive psychiatric assessment, diagnosis, treatment plan,
quarterly treatment plan update, and psychotropic review at
least quarterly in connection with the regular quarterly
evaluation of care of each resident; ensure that the
psychiatrist(s) formulate and sign a diagnosis or diagnoses,
considering differential diagnoses where appropriate, and
employing DSM-IV criteria and terminology;
2. The psychiatrists shall, upon request of the
inter-disciplinary team ("IDT") or at the psychiatrists' own
request, serve on the IDT of any resident whose individual plan
of service includes the use of behavior modifying medication or
for whom such has been recommended;
3. Ensure that the psychiatrist(s) adequately review
the current medication regimen of each individual to determine
whether the type and dosage of the medication is indicated by the
resident's needs, and recommend any changes in the medication
regimen; ensure that the psychiatrist(s) consults with the
assigned psychologist to determine whether the existing behavior
management program is indicated by the resident's needs and
whether different programs or interventions could be developed to
address the resident's target behaviors and/or symptoms so as to
reduce or eliminate the need for psychotropic medications; ensure
that the psychiatrist(s) consults with the resident's primary
care physician, psychologist, nurse, and other appropriate
members of the resident's IDT, to determine whether the harmful
effects of the resident's mental illness outweigh the possible
harmful side effects of the psychotropic medication and whether
all reasonable alternate treatment strategies are likely to be
less effective or potentially more dangerous than the medication,
and require that the psychiatrist document his or her evaluation
results and conclusions. This review, consultation and
documentation shall be performed in connection with the regular
quarterly review of each resident, or more often if indicated by
the resident's needs;
4. Ensure that the psychiatrist(s) develop and sign as
part of each resident's quarterly review process (or more often
if indicated by the resident's needs) an overall treatment plan
for each resident with a diagnosis of mental illness with a
description of clear, objective and measurable short-term,
intermediate and long range goals and objectives for each
resident including time frames for the achievement of each;
5. Develop and implement a system that requires the
psychiatrist(s), when prescribing a psychotropic medication for
behavior modification, to specify in the medical record the
behavior(s) that initiate(s) the use of the behavior-modifying
medication, and that requires the psychologist and the treatment
team (including the psychiatrist) to specify in the medical
record, where appropriate, the behavior(s) to be taught to the
resident to replace the behavior(s) that initiate(s) the use of
the medication or other programs to be used to reduce or
eliminate the use of the medication; utilize psychotropic
medications for behavioral control purposes only in the context
of a treatment plan for a mental illness or psychiatric disorder
that is based upon data that is sufficiently reliable to meet the
treatment needs of the residents; avoid use of psychotropic
medication unless specific justification exists and is documented
in the individual's medical record; and
6. Ensure that each resident is receiving benefit from
the treatment once it has begun, by adequately monitoring the
treatment, conducting quarterly reviews of each resident's
working diagnosis, ensuring that the psychiatrist participates in
such reviews, ensuring that decisions about the efficacy of
treatment are based on objective data and by documenting the
results of such reviews in the resident's medical chart.
F. Defendants have organized and will continue to convene a
committee ("the Psychotropic Medication Review Committee"), the
purpose of which is ensure that psychotropic medications are used
appropriately in the Centers and the members of which are
appropriate to achieve this purpose.
G. Medication - Within 180 days from the entry of this
Settlement Agreement, defendants shall take all reasonable
measures to ensure that prescription medications are adequately
prescribed for and administered to residents, including that such
medications not be used as punishment, in lieu of a habilitation
program, or for the convenience of staff. The defendants will:
1. Administer prescription medication only upon order
of a physician and behavior modifying medication only upon order
of a physician after consultation with a psychiatrist, except in
the case of any psychiatric emergency in which the resident's
behavior escalates to the point where the resident or others are
put at risk, in which case consultation must be had with the
Center's psychiatrist no later than the psychiatrist's next
regularly scheduled work day, but in no event more than 72 hours
after the order;
2. Establish procedures to review the drug regimen of
each resident every 30 days, except in cases where the
prescribing physician has adequately justified in the resident's
medical record that less frequent review is adequate, require
that no prescription is valid for more than 90 days;
3. Utilize an adequate system for detecting, reporting
and responding to any medication side effects, and medication
errors; and
4. Develop and implement a quality assurance procedure
whereby every six months a pharmacist performs a comprehensive
review of anticonvulsant and psychotropic medications used for
each resident; a copy of the review will be included in each
resident's medical record and shall include at least the
following information: the current and prior prescriptions,
dosage and dates of prescription changes; any recent and prior
lab results testing therapeutic blood levels for each medication;
for residents on anticonvulsant(s), each resident's seizure
history, and for residents on psychotropic(s), the current --
and, if different, prior -- psychiatric diagnosis or diagnoses
justifying use of the psychotropic(s); any relevant
recommendations or plans by medical personnel or consultants
contained in the record relating to prescription of the
medication(s); observations of side-effects contained in the
record; and relevant observations or recommendations of the
reviewer, if any. To the extent the required information
consists of historical information for each resident, such
information shall be recorded for that period of time for which
it would be useful for purposes of medical diagnosis and
treatment of the particular resident.
III. PSYCHOLOGICAL SERVICES, TRAINING PROGRAMS AND RESTRAINTS
A. The defendants will provide at the Centers
individualized habilitative services and training programs, which
are developed by qualified professionals, to facilitate the
growth, development, and independence of every resident, and to
reduce or eliminate risks to personal safety, provide protection
from harm, reduce or eliminate undue use of restraint, and
prevent regression. To this end, defendants shall, within 12
months from the entry of this Settlement Agreement, unless
otherwise provided herein:
1. Employ sufficient FTE psychologists to meet the
needs of the residents, and to that end maintain a ratio at each
Center of at least one FTE psychologist to 25 residents requiring
behavior management programs (provided that nothing in this
paragraph may be construed to prohibit psychologists from
treating additional residents not requiring behavior management
programs);
2. Consult with a nationally recognized consultant in
psychological services for persons with severe developmental
disabilities to develop and help implement behavior data
collection systems that maximize reliability of data collection
in a clinical setting and that measure relevant information about
challenging and other behavior(s) and the conditions under which
they occur, including, where appropriate, the frequency,
intensity, severity, and duration of the behavior(s);
3. Conduct an adequate inter-disciplinary assessment
of each resident to determine the individual's need for training;
to that end, a psychologist shall:
a. Conduct an adequate descriptive analysis of
the individual's challenging behavior(s) using rating scale
instruments that are in general use in the professional field;
such descriptive analysis shall be written, adequately documented
and data-based;
b. Develop an hypothesis regarding the cause of
the challenging behavior(s) that is individualized for the
particular client; such an hypothesis shall be written,
adequately documented and data-based;
c. Conduct a functional analysis, or functional
assessment provided a professional shall adequately document why
a functional analysis is unnecessary, in the individual's natural
settings so as to best tailor an adequate intervention for each
of the individual's challenging behavior(s); such an analysis
shall be written, adequately documented and data-based; and
d. Document the rationale and reasons for the
development and implementation of a particular training program;
4. Have a qualified professional develop a
professionally based, individualized training program for each
resident based on the findings of the individual's assessment,
ensure that the training program is implemented over time and
revised when necessary, and provide each resident with an
adequate number of hours of training to enable the resident to
develop behavior(s) designed to reduce risks to personal safety,
afford protection from harm, provide freedom from restraints that
are not necessary to protect the resident or others from harm,
prevent regression or deterioration of skills, facilitate growth,
development and independence, and teach functional, adaptive
skills; ensure that adequate programs are maintained and
generalized across settings, that training programs that seek to
teach skills are taught in functional settings and under
conditions that skills are to be used, and that behavior
reduction programs and skills training programs are integrated
and written in conjunction with one another;
5. Develop and implement training programs that contain
the following:
a. Training objectives developed by an
appropriately constituted IDT and based upon assessments and
evaluations required above; for those individuals identified as
exhibiting maladaptive behavior(s), a behavior management
component which identifies the specific behavior(s) to increase
and decrease, procedures for staff to follow to decrease the
occurrence of the problem behavior(s), the alternative
behavior(s) that will be taught, and environmental changes to
promote the development of positive, adaptive behavior(s);
b. Instructional methods to be utilized by those
with responsibility for implementing the program; such methods
shall emphasize positive approaches and behavioral interventions
which promote functional skill development and socially accepted
behaviors in the individual;
c. An adequate training schedule to be followed
to reach the identified objective(s) of the training program;
identification of the persons responsible for the consistent
implementation of the program; and
d. Procedures to be utilized for data collection
to evaluate the effectiveness of the training program or any part
thereof and to monitor the implementation of the training program
and ensure its modification, as necessary;
6. Provide competency-based training for all staff
responsible for implementing the training programs to enable them
to implement the programs consistently and collect data which is
sufficiently reliable to meet the treatment needs of the
residents; thereafter, prior to implementing any program or
program change, such training shall be provided to each person
implementing the program or program change;
7. Implement systems for verifying that the recorded
data are sufficiently reliable to meet the treatment needs of the
residents and ensure that qualified professionals review and
adequately modify any individual's training program where the
individual has exhibited no measurable progress for a reasonable
period of time;
8. Require the IDT to meet on at least a quarterly
basis, or more frequently if critical issues arise which the IDT
determines need to be addressed in more frequent meetings, to
review the individual's progress in training programs; provide
that the IDT bases its review of the efficacy of the training
programs on the data collected as well as the occurrence of
incidents and use of restraints, and, if the IDT identifies the
need to revise the training program, it shall be revised and
implemented within a reasonable time period identified by the
IDT, taking into account the severity of the behavior and the
harm it poses;
9. Develop and implement programs, including the use
of augmentive devices as determined to be indicated based upon an
IDT evaluation, for each resident with communication deficits,
including deaf or hearing impaired residents, to teach
communication skills using methods adequate to meet the
resident's needs, including sign language, communications boards
and electronic devices; and
10. Within 90 days from the entry of this Settlement
Agreement, defendants shall meet all of the requirements in
Section A for those residents who in the past year have had
emergency restraint (other than a medical restraint utilized
pursuant to a written physician's order) or emergency
psychotropic medication. Within 120 days from the entry of this
Settlement Agreement, defendants shall meet all of the
requirements in Section A for those residents who in the past
year have had long-term or chronic restraint, and for those
residents who are determined to exhibit self-injurious,
aggressive, or pica behavior that is reasonably likely to result
in significant illness or injury, or to have other seriously
maladaptive behavior(s).
B. The parties understand that one of the goals of
providing residents with adequate programming and psychological
services is to eliminate, to the extent practicable, constraints
on the residents' personal freedom and human potential that may
be caused by the use of restraints. The defendants shall ensure
that restraints, including emergency chemical restraints,
unplanned physical or mechanical restraints, time out, and any
form of planned restraint, are never used as punishment, in lieu
of training programs, or for the convenience of staff. The
defendants shall, within sixty days from the entry of this
Settlement Agreement:
1. Ensure that each resident who in the past year has
been subjected to significant emergency restraint (other than a
medical restraint utilized pursuant to written physician's
order), or to any form of long-term or chronic restraint, has
been provided with a formal, written, interdisciplinary
assessment and analysis as outlined above;
2. Ensure that the use of restraint as part of a
training program shall be prohibited except in those situations
where there is written confirmation in the individual's record
that other, less restrictive techniques have been tried and
implemented in a professionally designed training program and
data have demonstrated such techniques to be ineffective;
3. Ensure that any use of restraint shall be the least
restrictive form of restraint that has proven effective in
addressing the individual resident's behavior;
4. For those individuals who continue to be
restrained,
a. develop individualized training programs,
specifying:
(1) The behavior(s) to be eliminated, the
function of the behavior(s) to be eliminated, and the specific
behavior(s), clearly and objectively defined, which trigger the
use of the restraint;
(2) Behavior(s) to be taught to the
individual to replace the behavior that initiates the use of the
restraint and other programs to reduce or eliminate the use of
such restraint;
(3) The type of restraint authorized,
including the maximum duration and other limitations, when
employed;
(4) The professional responsible for the
program and the staff authorized to implement it;
(5) The frequency and manner in which
behavioral data are to be recorded by direct care staff;
b. specify in the individualized training program
the expected duration of a restraint or the date of next review
of a restraint; and
5. Ensure that the individual's psychologist or other
qualified professional shall begin, on the next day that the
psychologist or other qualified professional is scheduled to
work, the process of reviewing, each use of restraint and
ascertain the circumstances under which such restraint was used;
on a daily, weekly and/or monthly basis, the individual's
psychologist shall review any regular use of restraint on an
individual to ensure that restraint will be continued in
individual's program only if data that is sufficiently reliable
to meet the treatment needs of the individual supports the
efficacy of their continued use; the psychologist shall be
responsible for ensuring that the individual's behavior program
continues to be appropriate and/or is revised to meet the
individual's needs in the least restrictive manner.
C. The defendants shall ensure that for each resident with
a psychiatric disorder, there is communication between the
resident's psychologist, attending physician and psychiatrist
that is adequate to support the exercise of professional judgment
in treating the resident. In combining and integrating
behavioral programming and psychotropic medication for a
particular individual, the psychologist, physician and
psychiatrist shall coordinate their efforts to reinforce the
ultimate treatment objective(s).
IV. RECORDKEEPING
The defendants shall, within 120 days from the entry of this
Settlement Agreement, maintain an adequate record for each
resident that shall include current information with respect to
his/her care, medical treatment, and training and shall require
staff to utilize such records in making care, medical treatment
and training decisions. Entries made by physicians, nurses and
medical consultants in resident records shall: 1) include the
time, when pertinent, and the date, and name and title of the
professional making the entry; 2) be timely, legible and
accurate; and 3) describe the resident's physical condition and
course of treatment. Resident records should contain, in a
prominent and visible location, a document identifying the
resident's primary treatment and training issues in all areas.
Physicians must write summaries in resident charts which contain
treatment goals, goal progress, and plans for future treatment.
V. STAFFING AND STAFF TRAINING
A. Defendants shall employ and deploy a sufficient number
of professional and non-professional staff to adequately
supervise residents and adequately protect them from harm, and to
otherwise meet the residents' needs and the terms of this
Settlement Agreement. To that end, Defendants shall maintain
current direct care staffing ratios.
B. Within 180 days from the entry of this Settlement
Agreement, unless otherwise specified herein, the defendants
shall ensure that all appropriate staff, including physicians and
nurses, who provide services to residents are adequately trained
to implement the requirements of this Settlement Agreement and
are thereafter provided with competency-based in-service training
on a regular basis. The training should at least include the
following topic areas: mental retardation; mental illness and
psychiatric disorders and treatment; psychopharmacology;
particular medical and nursing needs of the developmentally
disabled; emergency medical response and procedures; physical and
nutritional management; recognition of seizures and seizure
management, including recordkeeping for seizures; behavior
management techniques; implementation of individualized treatment
and training programs; and use of bodily restraint and time out,
including recordkeeping for such procedures. Defendants shall
keep a record that such training occurred, and maintain a list of
those in attendance as well as clinical areas covered.
VI. COMMUNITY SERVICES
A. The defendants shall operate under policies that provide
services to individuals with developmental disabilities in the
least restrictive, and most integrated and normalized setting
consistent with their individual treatment, habilitation and
safety needs. To this end, defendants shall:
1. Evaluate all residents to determine their
appropriateness for community-based placements and/or programs;
residents with outstanding community placement recommendations
shall only be re-evaluated for the purpose of determining need
for community placement in circumstances where the needs of or
facts relevant to the individual change; such evaluation shall
include where possible involved parents, guardians, advocates,
the responsible placement agency and appropriate professionals,
including professionals who are reflective of the kinds of
services and support needed by the resident in the community; the
resident shall be involved in the planning process to the maximum
extent practicable and shall be given the opportunity to express
a choice regarding placement; no individual shall be excluded
from consideration for community placement based on his or her
level of disability;
2. Based on the written evaluations of individuals
identified as appropriate for community placement, assist the
responsible placement agency to identify the required residences,
day programs, including vocational opportunities, specialized
services, including medical care and related services, and other
supports needed to serve these individuals in the community;
3. Within a reasonable period of time, assist
responsible placement agencies to establish or directly establish
such community-based supports consistent with the requirements of
Paragraph VI.A.2., first, for children under the age of 18;
second, for those individuals identified as appropriate for in
need of community placement as of the date of this order; and,
third, for those individuals identified pursuant to Paragraph
VI.A.1.;
4. Accept no admissions that are intended to be
permanent; only admit or readmit individuals into the Centers
temporarily when no other services are available which are
adequate to meet the individual's needs;
5. Working with the responsible placement agency,
develop and implement a transition plan for each resident who is
identified pursuant to Paragraph VI.A.1 that reflects the
supports identified in Paragraph VI.A.2;
6. Assist responsible placement agencies to place all
individuals residing at the Centers who are appropriate for
community-based programs, as determined by an adequate assessment
of their individual needs, into residential placements or other
community-based programs; place no individual residing at one of
the Centers into a program which does not meet his or her
individual needs; operate a system to adequately monitor
community-based programs pursuant to the defendants' Medicaid
(MA) Community Waivers Manual, sections 4.04 and 7.05 (attached)
to help ensure that they meet residents' needs and protect them
from harm;
7. Identify within the Department of Health and Family
Services an employee whose responsibility it is to coordinate and
otherwise assist in the development and expansion of specialized
services needed to provide necessary medical and medically
related services in community services throughout Wisconsin;
8. Review all federal financial assistance presently
received by defendants in support of services for persons with
developmental disabilities and ensure that application has been
made for all funding, including waiver programs, available to
support community based services of persons with developmental
disabilities;
9. Assist in the development and expansion of
community-based programs with appropriate county officials, and
10. Help ensure that individuals residing at the
Centers who are appropriate for community-based programs will be
returned to the community through the following immediate or near
term changes in operational and budget policy:
a. A community services plan will be developed
for all residents of the Centers as part of each resident's
annual review. All such plans will be completed within 12 months
of entry of this Settlement Agreement. The cost of community
services for each individual will be developed as part of this
community services plan;
b. The Department's SFY 1997-1999 budget request
includes an increase in the CIP 1A funding used to fund
individuals return to the community effective July 1, 1997;
c. The Department will explore pooling all long
term care institutional and community funding, providing that
funding to an entity (county or alternative managed care
organization), and charging the county or organization the full
daily rate for any resident remaining in a Center.
B. The parties agree that the goal of the defendants shall
be to serve as many individuals in community-based programs as
appropriate to the individuals' needs.
VII. FEDERAL STATUTORY COMPLIANCE
A. In the operation and management of the Centers and in
providing services to residents, the defendants shall fully
comply with all applicable federal statutes and regulations,
including: the Americans with Disabilities Act of 1990,
42 U.S.C. §§ 12101 et seq.; Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq.; and all the regulations promulgated
pursuant to the statutes cited above. This provision is not intended to impose any additional responsibilities or confer any additional authority upon the parties than otherwise already exists under these statutes and regulations and other federal law.
VIII. MONITORING BY JOINT EXPERTS
A. Defendants' compliance with the provisions of this
Settlement Agreement shall be monitored by a panel of experts,
one each in the fields of psychology/habilitation, developmental
medicine (with expertise in neurology), and psychiatry, all of
whom have been jointly selected and agreed upon by the parties
(hereafter the "Joint Experts"). The Joint Experts are as
follows:
Psychology/Habilitation: Dr. William I. Gardner
Medicine: Dr. Steven J. Parker
Psychiatry: Dr. Ludwig S. Szymanski
B. As part of the Joint Experts' monitoring function, each
expert shall evaluate the care, treatment and services provided
by defendants to determine whether defendants are complying with
those provisions of the Settlement Agreement relating to the
expert's area of expertise. This evaluation shall include:
(a) on-site inspection of the Centers; (b) interviews with staff,
contractors and residents; (c) detailed review by each expert of
no fewer than 30 resident records to be chosen by the Joint
Expert; and, (d) review of facility documents as determined by
each Joint Expert to be relevant to his/her evaluation under this
Settlement Agreement. The parties shall be permitted to have
counsel or other representatives present at any inspection
conducted at the Centers by the Joint Experts. Matters inquired
into during any such inspection, interview or review of records
or other documents shall be limited to matters directly addressed
in this Settlement Agreement.
C. The first such evaluation by the Joint Experts shall
occur between 90-120 days after the filing of this Settlement
Agreement with the Court. This initial "base-line" evaluation is
intended to inform the parties of the status of conditions at the
Centers and the United States agrees that it will not bring an
enforcement action based upon the results of this evaluation
unless emergency conditions exist at either Center that place
residents at risk of serious and imminent harm. Defendants may
move pursuant to Paragraph IX.C. that the case be closed and
dismissed with prejudice based on the Joint Experts' findings
after the first evaluation. Subsequent evaluations shall take
place annually thereafter within thirty days of the year
anniversary of the filing of this Agreement with the Court. The
on-site inspections shall be arranged on dates and at times
mutually agreeable to the parties and the Joint Experts.
D. As part of each evaluation, each Joint Expert shall
present his/her evaluation, findings and, where appropriate,
recommendations in a written report, which shall be provided to
the parties. In these reports, each Joint Expert shall make
specific findings with respect to each provision of the
Settlement Agreement for which he/she is responsible. To execute
these duties under this Agreement, each Joint Expert shall
utilize forms that contain the exact provisions from this
Agreement that are relevant to each Expert's area of review. If
an expert determines that the defendants are not in compliance
with a provision, the expert shall so state and provide the
factual bases for the findings, including, whenever possible,
identification of all residents involved and all dates and times
of all incidents and/or care, treatment or services at issue. If
an Expert determines that the defendants are in compliance with a
provision, the Expert shall so state and provide a summary
specifying the documents and records the Expert reviewed and the
interviews the Expert conducted that support the Expert's
determination for that particular provision. Each Joint Expert
shall provide his/her report within 45 days of the completion of
each on-site tour.
E. Prior to and during any monitoring inspection, each
Joint Expert shall be permitted to request copies of relevant
documents and records he/she determines to be relevant to the
expert's review under applicable provisions of this Settlement
Agreement. If the request is submitted prior to the inspection,
defendants shall provide the documents to the requesting Joint
Expert and the United States within 15 days of the request, which
shall be in writing. If the request is made during the
inspection, defendants shall provide copies as soon as
practicable. The parties may recommend to each Joint Expert
documents they deem relevant to the Joint Expert's review. In
addition, defendants shall provide timely notice to the Joint
Experts of all resident deaths, and shall forward copies of any
completed autopsies and death summaries, as well as all
investigations completed on or after the effective date of this
Settlement Agreement of alleged neglect or abuse. The United
States may request that the Joint Experts forward them copies of
any documents obtained from the defendants and the parties may
have ex parte contacts with the Joint Experts at any time.
F. In the event that any of the Joint Experts identified in
Paragraph VIII.A. above is unable to serve or continue serving as
a Joint Expert, or in the event the parties for any reason
jointly agree to discontinue the use of any Joint Expert, the
parties shall meet or otherwise confer within 15 days of being
notified of the incapacity or the decision to discontinue use of
the Joint Expert to agree upon an alternate Joint Expert. The
parties shall jointly select an alternate expert, except that if
the parties are unable to agree within 15 days of their first
meeting or conference as to this selection, they shall
immediately and jointly petition the Court to make the selection.
In this petition, each party will be permitted to propose two
alternate Joint Experts in the field of expertise. The procedure
described in this paragraph shall apply to the selection of all
successor Joint Experts.
G. Defendants shall bear the reasonable costs of the Joint
Experts' monitoring fees and expenses.
IX. ENFORCEMENT AND TERMINATION OF DECREE
A. This Agreement will terminate (if it has not already
been terminated based on defendants' or the parties' joint
motion) after the third annual inspection tour of the Joint
Experts (excluding the initial base-line tour), if the Experts
determine, based upon the third annual inspection tour, that
defendants are in compliance. If all of the experts conclude
upon the third annual inspection tour that defendants are in
compliance, the burden will be upon the United States to prove
that defendants are not in compliance such that the Agreement
should not terminate. At all other times, the burden remains
with the defendants to prove compliance.
B. The Court shall retain jurisdiction of this action for
all purposes under this Settlement Agreement and resolving
disputes under this Settlement Agreement pursuant to the
procedure set forth herein until this Agreement is terminated.
C. On or after the date on which defendants shall have
complied with the provisions of this Settlement Agreement,
defendants or the parties jointly may move that the case be
closed and dismissed with prejudice on grounds that defendants
have complied with the provisions of this Settlement Agreement.
Such motion shall attach the most recent findings of each of the
Joint Experts. The defendants, the United States or the parties
jointly may move for partial dismissal as to the areas of
expertise of one or more of the Joint Experts.
D. Provided that no evaluation has been conducted by the
Joint Experts within 90 days prior to the filing of a motion to
dismiss, the Joint Experts shall conduct an evaluation within 45
days after the filing of such motion, on the same terms and
conditions as followed during their monitoring tours. As before,
each Joint Expert shall produce a written report containing
his/her findings relating to the provisions of the Settlement
Agreement for which he/she has monitoring responsibility within
45 days from the last day of his/her inspection of either Center.
In the event that an evaluation was conducted by the Joint
Experts within 90 days prior to the filing of the motion, no
subsequent evaluation shall be required.
E. In any determination of whether or not defendants are in
compliance with this Settlement Agreement, the findings of the
Joint Experts shall be admissible with or without testimony of
the experts and shall be accorded a presumption of correctness,
which may only be rebutted by a clear and convincing showing to
the contrary. The parties reserve the right, however, to request
a hearing before the Court in order to present evidence to rebut
the presumption of correctness accorded the findings of the Joint
Experts.
F. In the event the United States disagrees as to
defendants' compliance at the time that a motion to terminate is
filed, the parties shall jointly move the Court for a hearing on
the motion to terminate, at which time the United States shall be
permitted the opportunity to rebut the presumption of correctness
accorded to the findings of the Joint Experts. At such a
hearing, the parties shall be entitled to present any evidence,
in addition to the testimony and reports of the Joint Experts
that was gathered, developed or obtained independent of the
monitoring process provided for in this Settlement Agreement,
including the testimony, affidavits or reports of experts other
than the Joint Experts subject to the Federal Rules of Evidence
as to admissibility.
G. The United States may seek enforcement of this
Settlement Agreement from the Court, at any time other than as
specified in Paragraph VIII.C. above, in the event that it
determines that defendants have failed to comply with this
Settlement Agreement. If the Court determines that defendants
are not in compliance with this Settlement Agreement, the Court
will first issue an order directing defendants to comply within a
period of time set by the Court and directing the appropriate
Joint Experts to re-evaluate the provisions at issue within a
period of time set by the Court. If the United States believes
that defendants have not complied within the period of time set
by the Court for re-evaluation by the Joint Experts, the United
States may proceed to bring any enforcement action it deems
appropriate. However, if the United States alleges and the Court
finds that emergency conditions exist at either Center that place
residents at risk of serious and imminent harm, the Court may
immediately issue any order the Court deems appropriate. As
similarly provided above, in any enforcement proceeding, the
Joint Experts' findings shall be accorded a presumption of
correctness and the parties shall be entitled to present evidence
to rebut this presumption, including the testimony, affidavits or
reports of experts other than the Joint Experts, subject to the
Federal Rules of Evidence as to admissibility.
H. 1. The United States will have reasonable access to the
Centers, if it deems it necessary, during tours by the Joint
Experts. During tours by the Joint Experts, access by the United
States shall include the right to inspect and tour the Centers'
buildings and grounds, review facility records, resident charts
and other documents, conduct interviews with employees outside
the presence of supervisory staff when requested by the
employees, and observe activities normally conducted at the
Centers. Such access shall continue until this Settlement
Agreement is terminated. Matters inquired into during any such
tour shall be limited to matters addressed in this Settlement
Agreement.
2. In addition to the access provided under Paragraph
H.1., above, the United States may have access to the Centers if
and to the extent permitted as discovery pursuant to the Federal
Rules of Civil Procedure. Access under this paragraph shall
occur no more than once annually, unless the United States
establishes to the satisfaction of the Court that conditions at a
Center present an imminent and serious threat to the life or
health of the residents of the Center. In the event that the
United States believes that conditions at a Center present an
imminent and serious threat to the life or health of the
residents, the United States will first confer with the
defendants and may request access, and, if the defendants object
to the United States' access, the United States shall apply for
the Court's permission for access. Either party may seek relief
from the Court in the event that the party believes that access
is either too burdensome or too restrictive.
I. The parties reserve the right to withdraw consent to
this Settlement Agreement in the event that this Agreement is not
approved by the Court in its entirety.
CONSENTED TO BY THE UNDERSIGNED:
FOR THE PLAINTIFFS:
ISABELLE KATZ PINZLER, Acting Assistant Attorney General, Civil Rights Division
PEGGY A. LAUTENSCHLAGER, United States Attorney, Western District of Wisconsin
THOMAS P. SCHNEIDER, United States Attorney, Eastern District of Wisconsin
STEVEN H. ROSENBAUM, Chief, Special Litigation Section, Civil Rights Division
ROBINSUE FROHBOESE, Deputy Chief, Special Litigation Section
ROBERT C. BOWMAN
RICHARD J. FARANO
Senior Trial Attorneys
Special Litigation Section
Civil Rights Division
U.S. Department of Justice
P.O. Box 66400
Washington, D.C. 20035-6400
FOR THE DEFENDANTS:
THOMAS ALT, Administrator, Division of Care & Treatment Facilities, Wisconsin Department of Health & Family Services
RICHARD A. VICTOR, Assistant Attorney General, Wisconsin Department of Justice
WHEREFORE, the parties to this action having agreed to the provisions in the Settlement Agreement set forth above, and the
Court being advised in the premises, this Settlement Agreement is
hereby entered as the ORDER and JUDGMENT of this Court.
IT IS SO ORDERED, this _____ day of _______________, 1997,
at _______, Wisconsin.
____________________________
UNITED STATES DISTRICT JUDGE
Updated July 25, 2008