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Full text of "Mental health services : 1973 report"

1973 
REPORTS 



C.2L Sfu^e/f 

F\LE 



OF THE 



LEGISLATIVE RESEARCH 
COMMISSION 



TO THE 



GENERAL ASSEMBLY 



OF 



NORTH CAROLINA 



MENTAL HEALTH 







h »] 4 ro-?^ 



JANUARY, 1973 

STATE LEGISLATIVE BUILDING 

RALEIGH, NORTH CAROLINA 27602 





■ V 

Ik, 



1973 REPORTS 
LEGISLATIVE RESEARCH COMMISSION 



MENTAL HEALTH 

1. MENTAL HEALTH SERVICES 

2. THE "GEOGRAPHIC UNIT" CONCEPT 



STATE OF NORTH CAROLINA 
LEGISLATIVE RESEARCH COMMISSION 

STATE LEGISLATIVE BUILDING 
RALEIGH 27611 



Co CHAIRMAN; 

Gordon P. Allen 

President Pro Temi^ore, Senate 
Members: 

Sen. Lamar Gudoer 
Sen. F. ONeil Jonbs 
Sen. Charles H. Larkins, Jr. 
Sen William W. Staton 
Sen. Thomas E. Strickland 




CO-CHAIRMAN: 

Philip P. Gopwin 

Speaker. House of Representativec 

MEMBERS: 

Rep. Julian B. Fenner 

Rep. Ernsst B. Messer 

Rep. William R. Roberson. Jr. 

Rep. Carl J. Stewart. Jr. 

Rep. Willis P. Whichard 



TO THE MEMBERS OF THE 1975 GENERAL ASSEMBLY 

The Legislative Research Cominission herewith reports 
to the 1975 General Assemhly its findings and recoiimienda- 
tions concerning two areas of mental health. The first 
report is made pursuant to Senate Resolution 871 of the 
1971 General Assembly, which directed the Commission to 
"make a complete in-depth study of the Department of 
Mental Health and related programs and to m^ake recommenda- 
tions to the General Assembly," The second report is made 
pursuant to House Joint Resolution 715 of the 1971 General 
Assembly, which directed the Commission to "study the 
'geographical unit' concept within the State mental hospi- 
tals." 

The reports were initiated by committees of the 
Legislative Research Commission; members of the two 
committees are listed in the individual reports. 

Respectfully submitted. 



Representative Philip P. Godwin Senator Gordon P. Allen 
Co-Chairmen, Legislative Research Commission 



1975 REPORT 
LEGISLATIVE RESEARCH COMMISSION 



MENTAL HEALTH SERVICES 



TABLE OF CONTENTS 

Page 

I. Introduction: The Origin and Task of the Committee on Mental 

Health 1 

A. The Origin and Members of the Committee 1 

B. Scope and Limitations of the Committee's Work 1 

C. Sources of Information 2 

II. Current Trends in the Department of Mental Health 4 

III. Findings and Recommendations 7 

A. New Programs 7 

B. Improvement of Present Programs 11 

C. Community and Area Mental Health Programs 16 

D. Drug Abuse 18 

E. Needed Statutory Revision 21 

F. Costs and Funding 23 

APPENDICES 

Appendix A: Authorizing Resolution and Members of Committee 
on Mental Health 

Appendix B: Names of Persons Who Testified At Meetings of 
the Committee on Mental Health 

Appendix C: Policy on Patients' Rights of the North Carolina 

Board of Mental Health 

Appendix D: Opinion of Court and Standards of Treatment of the 
Mentally Retarded: Wyatt v. Stickney 

Appendix E: Opinion of the Court and Standards of Treatment of 
Mental Patients: Wyatt v. Stickney 



Digitized by the Internet Archive 

in 2013 



http://archive.org/details/mentalhealthservOOnort 



REPORT BY THE LEGISLATIVE RESEARCH COMMISSION 
TO THE 1973 GENERAL ASSEMBLY 

MENTAL HEALTH SERVICES 

I. Introduction: The Origin and Task of the Committee on Mental Health 

A. The Origin and Members of the Committee 

The General Assembly's decision to direct the Legislative Research 
Commission to study the entire mental health area in depth was based on 
its observation that the demand for mental health care is increasing and that 
the General Assembly requires up-to-date information about "mental health 
programs, facilities, and needs of the State" (S.R. 871 of 1971). This 
resolution, reproduced in Appendix A of this report, directed the Commission 
to make an in-depth study of the subject and report its findings and recom- 
mendations to the 1973 General Assembly. 

The Committee on Mental Health was created by the Legislative Research 
Commission to perform the study directed by S.R. 871. The Committee, whose 
members' names are listed in Appendix A, consisted of legislators from 
diverse parts of the state, with widely varying interests in and knowledge 
of mental health, who share a strong commitment to make mental health 
service of the highest possible quality available to the citizens of the 
state. 

B . Scope and Limitations of the Committee's Work 

The Committee's work has not included a detailed study of the internal 
management and organization of the North Carolina Department of Mental 
Health. The Committee believes that such a study can best be done by 
a team of recognized experts in the mental health service management 
field, and recommends that funds be provided for this purpose. 



•2- 



The scope of the Committee's work has included general policies in 
mental health service and the needs and problems of the present mental 
health system throughout the state. Its findings and recorranendations chiefly 
concern the Department of Mental Health and associated community mental 
health programs j but also affect the Department of Public Education and 
the various schools of medicine and education in the state. 

The Committee has found a need for comprehensive statutory change. 
The portions of the General Statutes which deal with incompetency, admission 
and commitment to mental hospitals, discharge therefrom, and mental illness 
as a defense to criminal charges are in a state of confusion. The few 
statutory changes recommended by the Committee in Section III(E) of this 
report have been virtually dictated by recent legal developments. Much 
more remains to be done. The Committee recommends that the 1973 General 
Assembly create a Mental Health Code Conmiission with the function of sub- 
mitting proposed statutory revisions to the 1975 General Assembly. The 
scope of the work of the Mental Health Code Commission should include incom- 
petency, admission and commitment to mental hospitals, discharge from mental 
hospitals, mental illness as a defense to criminal charges, and the desir- 
ability of adopting patients' rights legislation of the type recently 
adopted or proposed in the District of Columbia, California, Pennsylvania, 
and other jurisdictions. The funding of the Commission [see Section III(F) 
of this report] should be sufficient to permit the use of a qualified staff, 
including professionals in the fields of law, forensic mental health, 
medicine, psychiatry, and mental health administration. 

C . Sources o f Information 

The members of the Committee visited (in some cases more than once) 
e\/ery one of the state facilities for mental illness, mental retardation. 



-3- 



and alcoholism. These visits were an important source of information, 
and the Committee is appreciative of the time taken by the staff of the 
various institutions to inform the Committee about their work and their 
problems and needs. The Committee's thinking owes much to testimony at 
its meetings^ and in oral and written communications received by its 
members and wishes to thank all the professional and lay persons who have 
contributed to its understanding of the problems of mental health. Other 
sources of information were the publications of the Department of Mental 
Health, the figures prepared by the DMH Statistics Division, and the Report 
of the State Bureau of Investigation on Cherry Hospital. 



'a list of persons who testified and the subject covered by each is given 
in Appendix B. 



-4- 



II. Current Trends 1n the Department of Mental Health . 

The recently adopted statutory policies favoring community and area 
mental health programs are reflected in a rapid increase in client intake 

and costs at the community level, accompanied by a slowdown of intake 

rates at large state institutions. The table on the next page covering 

actual DMH expenditures over the last ten years indicates that while 

the largest single item, mental hospitals, has decreased in relative share 

from 72% to 53%, and mental retardation's share has remained nearly 

constant, the dollars allocated to community mental health programs 

have increased from zero to nine percent of the total. At the present, 

time, admissions to the state facilities are stabilizing or decreasing, 

whereas community program intake is still rapidly increasing. Dr. Eugene 

Hargrove, Commissioner of Mental Health, told the Committee that total admissions 

to the four regional mental hospitals (Broughton, Cherry, Umstead, and Dix) 

was stabilizing at about 15,000 per year, with an average daily census of 

about 6,800. The four state mental retardation centers (Murdoch, Western 

Carolina, 0' Berry, and Caswell), he said, are levelling off at about 400 

total admissions per year, with an average daily census of about 5,000, and 

admissions to the three state alcoholic rehabilitation centers (Black 

Mountain, Butner, and Jones), having reached 2,840 in fiscal 1971, will 

probably experience a reduction to 2,500 in fiscal 1972 and continue to drop 

due to the increasing role of community alcoholism programs. [The average 

daily census at the three state alcoholic facilities is now about 300.] 

In contrast to the situation at state institutions, total intake of community 

programs serving all 100 counties in the state has increased rapidly to 

33,000 in fiscal 1972 and will probably reach 40,000 in fiscal 1973. 



^See G.S. 122-35.1 (1964), G.S. 122-35.2, .3 (Supp. 1971), and G.S. 122-35.19, 
.20 (Supp. 1971). 



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-5- 



The Committee approves of the trend toward community mental health programs. 
Section III(C) of this report contains more detailed findings and recommenda- 
tions on this subject. 

As the shift from large, isolated institutions to community programs 
proceeds, the Committee is concerned about maintaining quality in the state 
institutions which are still the backbone of the mental health system. How 
are North Carolina's institutions rated in comparison with others in the 
United States? In discussions with several officials of the National 
Institute of Mental Health, the Chairman of the Committee was pleased to 
learn that, in terms of the quality of its professional staff , the North 
Carolina Department of Mental Health was rated among the ten best departments 
in the nation. What about the overall quality of mental health care in this 
state compared with that of other states? It is difficult to find specific, 
unambiguous information on the relative effectiveness of various mental health 
systems. Measuring inputs to mental health service— i .e., the amount of 
resources expended-- is the only way the Committee has found to compare 
North Carolina with other states. Three such measurements are shown in 
the table below. In these terms. North Carolina is significantly below 
the national average and does not rank highly among the fifty states and 
the District of Columbia. 

Some acute problems in one of the state institutions were brought to 
light by the State Bureau of Investigation Report on Cherry Hospital. The 
report documented a number of instances of alleged neglect and nonprofessional 
conduct of medical personnel, alleged criminal violations by patients and 
employees, and poor physical conditions. The Department of Mental Health 
has dismissed all personnel who were significantly involved in the alleged 



-6- 



Thre e Measures of Mental Health Service Input in North Carolina 
and the United States as a Whole 



USA Average North Carolina N.C. Rank 

1. Physician hours per week per 
100 resident patients in public 

mental hospitals, 1970 75.0 52.8 38/51 

2. Professional hours per week per 
100 resident patients in public 

mental hospitals, 1970 304 249 34/51 

3. Full-time equivalent personnel 
per 100 resident patients in 

public mental hospitals, 1970 66.9 62.7 35/51 

[SOURCE: "Eleven Indices," Joint Information Service of the American 

Psychiatric Association and the National Association for Mental 
Health, Washington, D.C., 1971, at pp. 15, 17, and 19.] 



misconduct. The Committee finds that the steps taken by the Department are 
a satisfactory response to the situation at Cherry Hospital, but recommends 
that the Department remain continually watchful to avoid recurrence of 
such problems. The Committee believes that one way of avoiding a recurrence 
is to give greater attention, within the Department, to patient care at 
regional hospitals. 

The overall impression of the Committee is that while the citizens of 
the state can rightly respect the quality of public mental health care, 
much improvement is necessary to bring the quality in all institutions and 
programs to a level of which North Carolina can be proud. The remaining 
sections of this report contain specific findings and recommendations as 
to how improvement can be made. 



■7- 



III. Findi ngs and Recommendations 

The detailed findings and recommendations of the Committee on Mental 
Health are presented below in six parts: new programs, improvement of 
present service, community mental health, drug abuse, costs and funding, and 
statutory change. 

A. New Programs 

1. The mentally retarded . The Committee's finding is that there 
is presently much unnecessary and costly institutionalization of the mentally 
retarded, children as well as adults, and that the retarded are being denied 
the full opportunity to a free public education. The Committee recommends 
that the standards applied by the U.S. District Court in Wyatt v. Stickney ' 
for the care and education of the mentally retarded be adopted as a long- 
range goal by North Carolina, not because they are legally binding on this 
state but because of the professional authority on which they are based. 
These standards are reproduced in Appendix D of this report. 

The Committee especially recommends the following policies and actions 
for immediate adoption. 

a. Persons whose mental retardation is "borderline" or "mild" 
[defined as in the Wyatt standards, p. 13] should not be 
institutionalized. 

b. All retarded persons should receive suitable educational 
service, regardless of chronological age or degree of 
retardation. A full educational program should be provided 
to all retarded persons of school age by the Department of 
Public Education, in a regular school facility where possible, 
or in the home or institution. 

c. The Department of Public Education should assume primary 
responsibility for education of the retarded, including 
those in institutions. Curricula appropriate for this 
purpose should be developed cooperatively by the Department 
of Public Education, the state mental retardation centers, 
and community mental health programs. 



F.Supp. , Civil Action No. 3195-N (M.D. Ala. 1972) 



•8- 



d. Community-based care and education of the retarded of 
all ages should be the preferred treatment. Community 
and area mental health programs should be resporisible 
for developing means of care other than state insti- 
tutions--group homes, day care, and the like--to avoid 
institutionalization and its costs, which are higher 
than the costs of community care. 

e. Greater care should be taken by the Department of Mental 
Health to explain fully to parents or guardians of adult 
mentally retarded patients any plan involving their transfer 
to a community facility or to their homes. 

f. The state should provide financial support for "bene- 
factors" in the community who may wish to provide homes 
or supervision for retarded persons, adults as well as 
children. 



2. Emotionally disturbed children .' The Committee finds that 
programs for emotionally disturbed children, inpatient as well as outpatient : 
are grossly inadequate in size and scope. The Department of Mental Health 
has several excellent programs now in operation which, though small, can 
serve as models for future expansion: the Wright School, which undertakes 
education of 72 emotionally disturbed children per year (an average of 
four months each) in a residential setting and at the same time serves 
children in the surrounding community who attend the public schools; the 
Regional Child Mental Health Training Program at Dix Hospital, which trains 
medical and educational professionals and assists the Raleigh Public 
Schools in operation of an affiliated school for emotionally disturbed 

children; the Children's Psychiatric Institute at Umstead Hos- 
pital, with a capacity of 24 heds; and the Children's Unit 
at Cherry Hospital, with a capacity of 50. Also the state 
is fortunate in having the work of the Study Commission on 

"Emotionally disturbed children" as used herein includes 
autistic children. 



-9- 



North Carolina's Emotionally Disturbed Children as a guide for future 
action. The Committee is hopeful that the continuing review of local and 
state programs for children conducted by the Governor's Advocacy Commission 
on Children and Youth^ will also be of great benefit in planning expansion 
of mental health service for children. 

The Committee recommends the following: 

a. The Department of Mental Health should develop a pro- 
jection of the number of emotionally disturbed children 
who will require service over the next ten years, and 
project the number who will not be serviced by present 
programs . 

b. Depending on the amount and type of need projected, the 
Department of Mental Health should plan an expansion of 
inpatient and community-based programs for emotionally 
disturbed children. 

c. Regional hospitals should not only treat children on an 
inpatient basis in greater numbers, but also increase 
their role in training professionals for work in the 
community with emotionally disturbed children. 

d. The goal of expanded programs for emotionally disturbed 
children should be to avoid institutionalization and its 
potential damage to the child by appropriate community- 
based service, or if institutionalization is necessary, 
to make inpatient treatment genuinely therapeutic, with 
the objective of returning the child to the community 
and providing adequate follow-up service. 

e. In planning expansion of programs for children, the Depart- 
ment should take into consideration the recommendations of 
the Governor's Advocacy Commission on Children and Youth. 



3- Geriatric patients . The Committee finds that 30 to 35% of 
the patients at regional hospitals are over 65 years of age and require 
no more than 24-hour custodial care. In the past, there was no other 



'See "Who Speaks for Children?", published by the Study Commission on North 
Carolina's Emotionally Disturbed Children, North Carolina State University 
Print Shop, Raleigh, .1970. 

^Established pursuant to G.S. 110-65 et seq. (Supp. 1971). 



-10- 



way of caring for the aged. Now, however, there are a number of alterna- 
tive possibilities which should be explored fully, including nursing or 
rest home care, boarding homes, group homes for the aged, and living at home 
where adequate counseling and medical service is provided locally to the 
aged person and his or her family. Some of these alternatives may involve 
considerable cost saving in care of the aged, and will free substantial 
amounts of time of mental health professionals and attendants to work with 
patients who are genuinely mentally ill. The role of federal funding such 
as Medicaid needs to be carefully considered, and also the linkage between 
the Department of Mental Health and the Department of Social Services, 
which has developed various programs of community-based service to the 
aged. 

For the few geriatric patients who require more than custodial care, 
more specific inpatient treatment should be provided. The Committee 
finds that, whatever the merits of the geographic unit system, it does not 
seem to work well for geriatric patients. 

Specifically, the Committee recommends the following: 

a. The Department of Mental Health should study the cost 
benefits and desirability of transferring geriatric patients 
who require only custodial care to community-based facilities 
such as nursing or rest homes, boarding homes, group homes 
for the aged, or to their own homes with suitable medical 
service supplied to the aged person living with his family. 

b. In this study, the linkage between the Department of 
Social Services and the Department of Mental Health should 
be considered. Special emphasis should be given to ways 
in which community mental health service can be expanded 
to assist the aged and their families to avoid commixment 
to regional mental hospitals, and to support new community- 
based custodial arrangements such as boarding or group 
homes for the aged. 

c. In the study, the possibilities of federal funding of 

new custodial arrangements should be thoroughly investigated. 



-11- 



d. Geriatric patients who are now in regional mental hospitals 
and require more than custodial care should receive specific 
treatment depending on need. 



B. Improvement of Present Programs 

This subsection is concerned with all present activities of the 
Department of Mental Health, including regional hospitals, mental retarda- 
tion centers, alcoholic rehabilitation centers, children's units, and 
community and area mental health programs. 

1 . The right to treatment of involuntarily hospitalized patients . 
The constitutional right to treatment is not a settled area of the law. 
The Committee has found strong legal arguments for such a right. In the 
view of Senator Sam Ervin, a noted constitutional scholar, there is a 
constitutional "right to medical treatment, and not just custodial care 
or detention.' Because of the compelling constitutional arguments and 
other considerations, some jurisdictions have provided a statutory right 
to treatment. Among them are the District of Columbia, whose Hospitaliza- 
tion of the Mentally 111 Act of 1964 was sponsored in the U.S. Senate by 
Senator Ervin, and California, which adopted the Lanterman-Petris-Short 

Act in 1969. 

'The Committee finds a need for adoption "by North Carolina 

of r;xpl If.it minimum r'.tnndards of mental health treatment. It 

full.y cndor.'ie.'; the Policy on Patients' Rights recently adopted 

by H>oai-d oJ" Monl;al iloalth (repi'oduced in Appendix C of this 

r'nj)or't), bu f; rinds i,iiat more extensive standards are necessary. 
At tne same time, the Committee recognizes that the standards adopted, it too 

strict, will impose an unacceptable burden on the taxpayer. Accordingly, the 



^Hearings on Constitutional Rights of the Mentally 111 before the Sub- 
committee on Constitutional Rights of the Senate Committee on the 
Judiciary, 91st Cong., 1st & 2d Sess. 4 (1969, 1970). 



-12- 



Committee recommends the adoption by the Board of Mental Health and the 
General Assembly of the standards of mental health treatm.ent applied by the 
U.S. District Court for the Middle District of Alabama in the case of Wyatt v 
Stickney , with the exception of those portions of the VJyatt standards 
which require a higher staff- to-patient ratio than presently exists in 
state institutions in North Carolina. [The Standards are reproduced in 
Appendix E of this report.] The Department of Mental Health has worked 
out an estimate of the cost of full implementation of the Wyatt standards 

for state mental hospitals (see table on next page). Clearly, the higher 

2 
staffing ratio is the most expensive item. When that is subtracted, the 

total cost of compliance is about four million dollars. Most of that 

amount (about 2.3 million) is allocated to payment for patients' work, which 

is already required by the Board's own Policy on Patients' Rights. 

The Committee further recommends that implementation of the Wyatt standards 

on staffing ratios be considered a desirable long-term goal for state 

facilities. The staffing standards are too expensive for immediate 

implementation, but will probably be attainable in the future as community 

mental health programs gradually reduce the number of institutionalized 

patients. 

The basis for the Committee's recommendation of partial adoption of 

the Wyatt standards is not a legal one, since these standards, imposed by 

a U.S. District Court in Alabama, are not legally binding on this state. 

The basis of the Committee's recommendation is the professional authority 

of the authors of the standards, who include representatives of the 



"■ F. Supp. _, Civil Action No. 3195-N (M.D. Ala. 1972). 

^The Wyatt staffing standard is at pp. 16-17 of Appendix E of this report. 



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-13- 



American Psychological Association, the American Orthopsychiatric Associa- 
tion, and the American Association on Mental Deficiency. 

The Committee wishes especially to recommend to the General Assembly 
and the Board of Mental Health the following selected portions of the 
Wyatt standards on treatment of the mentally ill, noting that their effect 
is somewhat broader than the Board's Policy on Patients' Rights. 

a. Mental patients have a right to be free from physical 
restraint or isolation unless prescribed for good cause 
by a qualified mental health professional; the only 
exception should be emergencies where it is likely that 
the patients could harm themselves or others. 

b. Each mental patient should have an inidvidual treatment 
plan prepared by a qualified mental health professional, 
to be reviewed at intervals of no more than 90 days, which 
should include a timetable, criteria for discharge, and 

a plan for post-hospitalization. 

c. Mental patients (or their guardians) have a right to 
refuse unusual or hazardous treatment procedures, such 
as lobotomy, electroshock, and aversive conditioning. 

d. No medication should be administered without an order 
by a physician. Each prescription should be reviewed 
weekly by a physician. No drug should be prescribed for 
punishment or for the convenience of hospital staff. 

e. The 1973 General Assembly should fund the Department of 
Mental Health's newly introduced unit dose system, which 
was developed and tested at Western Carolina Center. 

Until this system is funded and implemented, the Department 
will not be in full compliance with federal laws concerning 
drug distribution.! 



2. Allocation of resources with the Department of Mental Health . 
The Committee finds that insufficient attention is being paid by the 
Department of Mental Health to care of patients in state institutions. There 
is a need to redirect some of the staff resources in the central office to 
actual problems of patient care in the field. The Committee has discerned 



The Department of Mental Health requested, but did not receive, funds from 
the 1971 General Assembly to implement the unit dose system. 



-14- 



inequalities of treatment quality among the four mental health regions, and 
finds it regrettable that the opportunity for treatment should depend on 
the region in which a patient happens to reside. Finally, the Committee 
finds that private professional resources outside the Department are not 
being used adequately at present. 

The Committee recommends the following: 

a. The percentage of the time of the Department of Mental 
Health professionals spent in actual patient care at 
state institutions should be increased. Professional 
employees of the Department assigned to the central 
office in Raleigh should spend at least half their time 
in the field--either at state institutions or community 
mental health facilities. 

b. Each of the Deputy Commissioners of mental health regions 
should reside, or have an office, in their region. 

c. In order to reduce present differences in quality of treat- 
ment and administration among the state institutions, the 
Department should take steps to ensure that innovations, 
once tried and proven successful at one institution, be 
adopted by the other institutions. 

d. The Department should create incentives for some of the 
state institutions to "catch up" with the progress made 
by others. In particular, medical staff vacancies at 
Cherry and Broughton Hospitals should be filled. The 
Department should consider increasing the existing salary 
differentials favoring these two hospitals. 

e. In order to benefit from skills and techniques developed 
by private professionals and hospitals, the Department 
should make more extensive use of private psychiatrists 
and clinical psychologists, especially in community mental 
health programs. 



3. Staff development within the Department of Mental Health . 
The quality of public mental health service in North Carolina is essentially 
the quality of the people who provide it. Nothing is more important than 



■15- 



their level of skill and dedication. The Committee finds that more attention 
should be given to certain problems of staffing and staff development covered 
by the specific findings and recommendations below. 

a. The Committee finds an insufficient affiliation between 
state programs for the mentally ill and the mentally retarded 
(including community-based programs as well as institutions) 
and the major schools of medicine, psychology, and education 
in the state. It therefore recommends the joint development 
by the Department of Mental Health and the universities and 
other professional schools in the state (public and private) 
of a complete program of residency training. This program 
should be operated on an equal basis at all state facilities, 
not just those near major universities. It should be offered 
not only to students of medicine and clinical psychology, but 
also to graduate students in special education, school psy- 
chology, nursing, and related fields, including those students 
whose career plans include work with the mentally ill or 
mentally retarded in community programs. The Committee be- 
lieves that such a program will benefit the state facilities 
by providing additional manpower and by introducing the 
point of view of students from these various disciplines; 

and further, that it will benefit the students by giving 
them clinical experience and stimulating their interest 
in the field of mental health. 

b. Of all the institutional staff, attendants and cottage 
parents have the most frequent contact with patients and 
are therefore an important element in the therapeutic 
environment. Because advancement opportunity for attendants 
and cottage parents is poor, the Committee recommends the 
establishment of a career ladder for attendants and cottage 
parents, including pay incentives for training and education 
received either on the job or in schools outside the Depart- 
ment. The Department of Mental Health should create a 
position above the level of attendant for persons who obtain 
the Mental Health Associate degree now offered by some 
community colleges. When the career ladder for attendants 
and cottage parents has been established, the Departments of 
Personnel and Mental Health should review the job classifi- 
cation and salary level of attendants and cottage life per- 
sonnel to determine whether upgrading is appropriate. 

c. In the forensic units of state mental hospitals, there is 

a continued loss of trained attendants to the Department of 
Correction because of salary differentials. The base pay 
of an attendant is now about $5000 per year while that of 
a Security Officer I in the state prison system is about 
$6300. The Committee recommends that a separate job classi- 
fication for forensic unit attendant be created at the same 
level as that of prison security officer. The Committee 
feels this is justified because of the higher risks and 
security needs in forensic units. 



-16- 



d. Attendants' time should be spent attending to patients' 
needs, but too much is now spent in housekeeping tasks. 
More building maintenance staff should be hired to free 
attendants for work with patients. 

e. It is the impression of the Committee that some problems 
at the state institutions, such as those uncovered by the 
SBI Report on Cherry Hospital, are due to psychological 
inaptitude of some staff members, professional as well as 
nonprofessional. The Department should require more 
psychological testing and screening of present and pro- 
spective employees of the Department, especially those 
who work directly with patients. Even a small number of 
psychologically unfit staff can create poor conditions for 
treatment. 

f. The Committee recommends a new arrangement for administration 
of all state mental hospitals and mental retardation centers. 
The position of Business Manager of each such institution 
should be replaced with that of Hospital Administrator. The 
position of General Business Manager of the Department of 
Mental Health should be replaced by that of General Hospital 
Administrator. All Hospital Administrators and the General 
Hospital Administrator should be required to be graduates of 
accredited graduate schools of hospital administration. A 
direct line of authority should be created from the General 
Hospital Administrator in Raleigh to the Hospital Administrators 
in each of the mental hospitals and mental retardation centers. 



C. Community and Area Mental Health Programs 

Present statutes express a statewide policy favoring community and 

area mental health programs. G.S. 122-35.1 (1964) provides: 

It shall be the policy of the State Department of Mental 
Health to promote the establishment of mental health clinics 
in those localities which have shown a readiness to contribute 
to the financial support of such clinics, assisted by the 
federal and State grants-in-aid to the extent available. 

G.S. 122-35.19 (Supp. 1971) authorizes the Board of Mental Health to establish 

area mental health programs, and to "develop and test budgeting procedures 

for combining local and State grants-in-aid funds." G.S. 122-35.20 (Supp. 

1971) provides: 



-17- 



Subject to the supervision, direction, and control of the State 
Board of Mental Health, the area mental health board shall be 
responsible for reviewing and evaluating the area needs and 
programs in mental health, mental impairment, mental retardation, 
alcoholism, drug dependence, and related fields, and for developing 
jointly with the State Department of Mental Health an annual plan 
for the effective development, use and control of State and local 
facilities and resources in a comprehensive program of mental 
health services for the residents of the area. 

The Committee finds that these are good and workable policies, and that the 
Board and Department are in fact complying with these statutes and are shifting 
the emphasis in mental health service to community programs [see statistics 
discussed in Section II above]. The eventual result, of which the Committee 
approves, will be a mental health service system in which treatment in large, 
isolated state institutions is exceptional and where most mental health 
service is delivered in the community. During the period of transition from 
institutional programs to community programs, however, caution must be 
exercised. The problems of state institutions must not be neglected. At the same 
time, we must remember that before any patient is transferred from a state 
institution to a local community, appropriate community facilities must be 
prepared. "Community mental health program" is not a magic slogan. To 
be effective, such programs must be planned carefully. Without adequate 
planning, community facilities may be worse than the institutional programs 
they are meant to replace.^ 

Preceding sections of this report have described problems and inade- 
quacies of present public mental health service which will have to be 
remedied at the community level. Examples are the problem of over- 
institutional ization of the retarded [Section 111(A)(1)], the inadequacy 



^See "Where Have All the Patients Gone?", a report prepared by the California 
State Employees' Association, Sacramento (1972). 



-li 



of present programs for emotionally disturbed children [Section 111(A)(2)], 
and the need to transfer many geriatric patients from hospitals to a 
community setting [Section 111(A)(3)]. All of these problems, in a sense, 
are- being "handed back" to the community by the recommendations herein. 
All will therefore have to be solved by, among other things, increasing the 
responsibility of community and area programs. Increased responsibility 
will require increased awareness in local communities of the need for such 
programs, and increased ability to plan, fund, and operate them. 

The Committee's conclusion is that the Department of Mental Health 
should more assiduously stimulate community and area mental health planning, 
and the General Assembly should, in the coming years, offer additional 
incentives to counties for beginning and expanding community programs. 
Specifically, the Committee recommends: 

a. The state should increase its share of community program 
funding from the present level [two- thirds of the first 
$30,000 and one-half the remainder; G.S. 122-35.12 (Supp. 
1971)] to a level of ninety percent over the next ten 
years. 

b. The Department of Mental Health should provide more 
public education at the local level about the need 
for community mental health service, and offer more 
assistance to communities in planning such services 
and in obtaining state and federal funds. 



D. Drug Abuse 

G.S. 122-35.24 (Supp. 1971) authorizes the Department of Mental Health 

. . . to establish as the need arises and as funds permit, in areas 
to be designated by the Commissioner of Mental Health, community- 
based programs for the treatment and prevention of drug abuse 
[emphasis added]. 



-19- 



The Committee fully supports this statutory policy, and also recognizes that 

in all its activity related to drug abuse, the Department of Mental Health 

must be guided by the North Carolina Drug Authority, whose powers include 

the authority to 

. . . [c]oordinate all State efforts related to drug abuse pre- 
vention, education, control, treatment, and rehabilitation to the 
end that the effort to control drug abuse shall be efficiently 
and effectively administered and duplicating and overlapping 
efforts eliminated. [G.S. 143-473(b)(l ) (Supp, 1971)]. 

The Committee finds that the present level of funding of the North Carolina 
Drug Authority ($44,000 for the 1971-72 biennium) is inadequate. The 
Director of the Drug Authority should be a Psychiatrist (M.D.), Ph.D. 
Clinical Psychologist, or the equivalent, and should have nationally 
recognized professional competence in prevention and treatment of drug 
abuse. To obtain a person with such qualifications for this key position, 
a salary of $35,000 to $38,000 will have to be paid, according to knowledge- 
able sources consulted by the Committee. An adequate supporting staff for 
the Drug Authority would require approximately $50,000. Other costs 
including personnel benefits would bring the total necessary for the Drug 
Authority to an estimated $100,000 per year , or $200,000 per biennium. 
The General Assembly must face the fact that this level of funding is 
necessary if the mission of the Drug Authority as provided by the statute 
is to be accomplished. 

The Committee finds that, as in the case of community mental health 
programs, greater funding incentives and greater encouragement and 
assistance by the Department of Mental Health are required to extend and 
improve community drug abuse programs. Further, the Committee finds that 
more attention needs to be paid to drug abuse prevention programs--first , 
by the Department of Mental Health, which has until now been concerned 



-20- 



almost exclusively with treatment , and second, by the Department of Public 
Education. All evidence considered by the Committee indicates that in 
the war against drugs, prevention and education are as effective as treat- 
men-t. Finally, the Committee finds that, although community programs should 
receive the most emphasis, inpatient programs for long-term treatment should 
not be neglected. As community programs expand, and the needs of drug abusers 
become better understood, increased facilities for inpatient drug abuse 
treatment may be required. 

The specific recommendations of the Committee are as follows. 

a. To enable the North Carolina Drug Authority to perform 
fully the function assigned to it by law, the General 
Assembly should fund its staff at the level indicated 
in the findings above, and should establish qualifica- 
tion requirements for the position of Director as 
described in the findings above. 

b. The General Assembly should extend the state's share of 
community drug abuse program funding from the present 
level of fifty percent [Session Laws 1971, ch. 1123, 
sec. 5] to ninety percent over a period of ten years. 

c. The Department of Mental Health should provide more 
assistance to communities in planning community drug 
abuse programs and in obtaining state and federal funds. 

d. The Department of Public Education should initiate 
courses of instruction and other appropriate programs to 
prevent and counteract drug abuse among children of 
school age. These programs should begin at the earliest 
possible age, and should be considered as important as 
any other aspect of health education for the protection 
of children. 

e. The General Assembly should be prepared to fund, and the 
Department of Mental Health to operate, facilities for 
long-term inpatient treatment of drug abusers should 
such facilities be found necessary for persons referred 
from community drug abuse programs. 



-21- 



E. Needed Statutory Revision 

As explained in Section 1(B) of this report, the following recommenda- 
tions for statutory change are limited to a few changes which the General 
Assembly is virtually compelled to make by recent legal developments. One 
additional change, relating to the authority of the superintendents of 
public mental institutions to order autopsies of deceased patients, is 
prompted by a need for additional information about the causes of death 
among mental patients, which will assist in improving diagnosis and treat- 
ment and preventing needless deaths. 

1. G.S. 122-86 (1964), which deals with discharge from a state 
mental hospital of persons acquitted of a crime by reason 
of insanity and then committed, should be rewritten. 

According to the first sentence of this statute, a person acquitted of 
a capital felony by reason of insanity may not be discharged without authori- 
zation from the General Assembly. This provision was declared unconstitu- 
tional by the North Carolina Supreme Court in 1904, but was rewritten with 
a proviso preserving the right of a patient committed after an insanity 
acquittal to petition for habeas corpus . The statute places a qualification 
on the right to petition for habeas corpus in that the application may not 
be granted without a certificate from the superintendent of the hospital. 
This qualification was declared unconstitutional by the North Carolina 
Supreme Court in March 1972, with respect to persons acquitted by reason 
of insanity and then committed [ In re Tew , 280 N.C. 612, 187 S.E.2d 13 
(1972)]. Even after this qualification on the right to habeas corpus is 
excised, doubt is cast on the validity of the requirement of legislative 
authorization of discharge where acquittal was for a capital offense 
and of the governor's authorization where the offense was less than 
capital . I V 



•22- 



As Justice Sharp commented in In re Tew , the reenactment of the 
requirement of legislative authorization after it had been held unconsti- 
tutional did not validate it. Furthermore, a verdict of not guilty 
by. reason of insanity amounts to a full acquittal, and subsequent commit- 
ment is not a punishment. Since a person committed after an insanity 
acquittal is not being punished, it is probably unconstitutional for 
the procedures for his discharge to differ from procedures for the 
discharge of any person committed involuntarily. 

2. G.S. 35-3 (1966), which deals with the appointment 
of guardians for patients in state hospitals, should 
be reconsidered. 

According to G.S. 122-55 (1964), hospitalization of an allegedly mentally 

ill person or alleged inebriate or mental retardate shall have no effect 

on incompetency proceedings. G.S. 35-3 is listed as a specific exception 

to this general proposition. It provides that a patient in a regional 

mental hospital, alcoholic rehabilitation center, or mental retardation 

center may be found incompetent (in order to have a guardian appointed 

for him) on certification of incompetency from the superintendent of 

the facility. There is an inconsistency in saying, on the one hand, that 

hospitalization shall have no effect on competency and, on the other 

hand, that any hospitalized person may be found incompetent by certification. 

Also, G.S. 35-3 may be vulnerable to constitutional attack on several 

grounds, including due process, equal protection, or improper delegation 

of judicial power. 

3. G.S. 122-44 (1964), which requires that all nonindigent 
patients or those responsible for their support pay the 
cost of treatment in Department of Mental Health facilities, 
is now vulnerable to constitutional attack insofar as it 
concerns payment by involuntarily committed patients. The 
General Assembly should be prepared to amend it and to 
provide funds to replace such payment. 



-23- 



This provision may be unconstitutional with respect to involuntarily 

committed patients. In Department of Mental Hygiene v. Kirchner , 50 

Cal.2d 716, 400 P. 2d 321 (1965), the California Supreme Court held 

unconstitutional under both the state and federal equal protection clauses 

the relatives' support provisions of the state's mental health program. 

In Kirchner , the child of a person involuntarily committed to a state 

mental hospital was asked to pay for his parent's care in the hospital. 

The California Supreme Court held that involuntary commitment served 

the purposes of the state, and the cost of financing this public purpose 

could not be arbitrarily charged to a single class of society. Charging 

one particular class of persons amounted to a form of tax discrimination 

with no rational basis. This decision is not binding in North Carolina. 

However, it provides a potential basis for a similar attack on G.S. 122-44, 

at least in cases of involuntary commitment. 

4. G.S. 90-218 (1965), which now permits "post-mortem 

examination" of deceased inmates of public institutions 
in the state "for the care of the sick, the feeble- 
minded or insane," should be amended to permit super- 
intendents of public mental hospitals to authorize com- 
plete autopsies on deceased patients for the purpose of 
accumulating information on usual causes of death of 
mental patients. The amendment should require that the 
next of kin be notified and have the right to refuse 
autopsy within a reasonable period of time. 



F. Costs and Funding 

In the latter portion of this subsection of the report, cost estimates 
are given covering the expansion and improvement of mental health service 
as recommended herein. The Committee requests that the budgetary staffs 



-24- 



of the Department of Mental Health and the Department of Public Education^ 
work with it to develop more accurate cost projections. The preliminary 
figures given below are sufficiently realistic to show the order of 
magnitude of the funding increases which will be required to bring mental 
health service up to the level at which the Committee believes it should 
be. 

In considering ways of funding the recommended expansion and improvement 
of service, the Committee is guided by the following considerations. 

1. The voters of the state should be asked for their support 
of improved mental health service at this time. 

2. The cost of the service improvements recommended by the 
Committee exceeds significantly the current and projected 
budgets of the Departments of Mental Health and Public 
Education. 

3. Funding schemes which will exceed present and projected 
sources of revenue, and thereby require increased taxes, 
should be avoided if possible. 

4. Full use should be made of federal funding programs. 

The Committee sees several acceptable ways of funding its package of mental 
health service improvements, and leaves the choice to the wise judgment of 
the 1973 General Assembly. The funding schemes described below are not 
mutually exclusive and could be used in combination. 

One funding method is simply to provide the necessary funds to the 
Departments of Mental Health and Public Education as a general fund appro- 
priation. If this method of funding is selected, the views of the voters 
on improving mental health service should be obtained and considered. 



The Department of Public Education's role, in these recommendations, will be in 
education of the mentally retarded and in education about drugs and drug abuse. 



-25- 



This should be done by means of an opinion poll conducted by a competent 
private firm or research institute. Another method of funding is unprece- 
dented in this state but has been used by a number of other states: bonds 
could be issued to cover the cost of improved services. Although such 
bonds have never been issued by the General Assembly, there is no constitu- 
tional bar against it. The total amount of such a bond issue, once 
approved by the voters, could be obtained by a series of issues timed to 
coincide with phased planning and implementation of the recommended mental 
health service improvements. A third method is in a sense a combination 
of the first two. The currently planned request for capital improvements 
in the Department of Mental Health's expense budget for the 1973-75 
biennium, which involves a total of approximately $26 million, could be 
removed from the expense budget and satisfied by means of a bond issue. 
The expense of the recommended service improvements could then be 
substituted for all, or some portion of, the removed capital items, in such 
a way that the cost of the improved service could be met over the next 
five to ten years. Eventually, the question of continued funding of the 
higher level of service would again be faced; however, by that time, com- 
munity mental health programs may well have lowered costs of institutional 
programs, including capital improvements, which would release funding 
capacity and allow continuation of service at the higher level. 

The Committee wishes to stress the need to exploit fully the 
potential of federal programs. 6.S. 122-35.1 (1964) provides: 

The State Department of Mental Health is hereby designated as 
the State's mental health authority for purposes of adminis- 
tering federal funds allotted to North Carolina under the 
provisions of tne National Mental Health Act and similar 
federal legislation pertaining to mental health activities . . . 
It shall be the policy of the State Department of Mental Health 
to promote the establishment of mental health clinics in those 
localities which have shown a readiness to contribute to the 



-26- 



financial support of such clinics, assisted by the federal and 
State grants-in-aid to the extent available. 

The Committee recommends that the Department of Mental Health work more 

vigorously to assist local communities in obtaining federal funds and to 

take advantage of federal funding possibilities for mental health at the 

state level . 



Estimate of Costs to State . In the table which follows, the 
Committee has attempted to provide rough but realistic cost estimates 
for those of its recommendations which will require significant increases 
in state spending during the 1973-75 biennium. The cost items are listed 
in order of occurrence in this report of the recommendations to which they 
belong. The primary sources of information on which the cost estimates 
are based are the Department of Mental Health, the Charlotte Drug Education 
Center, and the North Carolina Association for Retarded Children. 



-27- 



ESTIMATED COSTS TO STATE OF RECOMMENDATIONS, 1973-75 BIENNIUM 



Location i 
in 
This 
t Report 



Biennial Cost 
1973-75 ' 1973-75 i T973^7F 
NON- I j 

RECURRING RECURRING TOTAL 



1. Study of internal management and 
organization of Department of 
Mental Health. 

2. Mental Health Code Commission: 
cost of staff work to prepare 
proposed statutory revisions for 
1975 General Assembly. 

3. Implementation of the standards 
for inpatient care of the mentally 
retarded imposed by the U.S. Dis- 
trict Court in Wyatt v. Stickney , 
with the exception of the staffing 
ratio standards. NOTE: $1,977,000 
of this amount is for payment of 
working patients. 

4. Full educational program for all 
retarded persons of school age, 
including those now living in the 
community as well as those in 
regional mental retardation centers 

a. Curriculum development. 

b. Operation of 6 hour per day 
educational program for insti- 
tutionalized mentally retarded 
persons age 6-21 in state men- 
tal retardation centers (2600 
children x $1800 per child x 

2 years). 

c. Operation of 6 hour per day 
educational program for mentally 
retarded persons age 6-21 living 
in the community 
institutions and 
by public school 
the educable and 
tally retarded (36,600 children 
x $1250 per child per year x 

2 years). 



p. 1 



p. 2 



p. 7; 

App. D 



p. 7 



or in private 
not now served 
programs for 
trainable men- 



$100,000 



125,000 



500,000 



$ 100,00C 



125, OOC 



$ 3,708,000 



3, 708, OOC 



500,000 



9,360,000 9,360,000 



45,750,0001 45,750,000 



-28- 




Biennial Cost 



1973-75 
NON- 
RECURRING 



1973-73 I 

I 

recurring! 



1973-75 
TOTAL 



Community-based programs for the 
mentally retarded: 

a. Mental Retardation Complexes 

b. Group homes 

c. Day and residential care. [Much 
of this amount is matched 3 to 1 
by federal funds under Title 
IV-A of the Social Security 
Act.] 

d. Institution-community liaison 
for persons transferred to 
community programs from re- 
tional Mental Retardation Cen- 
ters and their families. 

e. Community services in Eastern 
Region operated by Caswell MRC: 
day care, work activity, emer- 
gency care, temporary care to 
relieve families. 

Expansion of inpatient and com- 
munity programs for emotionally 
disturbed children: 

a. Children's programs within 
community mental health centers. 

b. Expansion of present Department 
of Mental Health training pro- 
grams for children's mental 
health. 

Implementation of the inpatient 
mental health treatment standards 
imposed by the U.S. District Court 
in Wyatt v. Stickney , with the ex- 
cepti on of the staffing ratio 
standards. NOTE: $2,288,000 of 
this amount is for payment of 
working patients. 

Unit dose system of medication 
in regional nospitals. 



pp. 8-9 



$2,114,000 
2,175,000 



583,000 



252,000 



$2,114,000 
2,175,000 



583,000 



252,000 



2,492,000 2,492,000 



2,500,000 



1,119,000 



pp. 11-13; 
App. E 



p. 13 



3,750,000 



5,642,000 



2,500,000 



1,119,000 



3,750,000 



5,642,000 



-29- 



10, 



11 



Location 

in 

This 

Report 



Biennial Cost 



1973-75 I 1973-75 | 1973-75 
NON- I 

RECURRING! RECURRING! TOTAL 



Cost of salary differential for 
medical staff positions at Broughton 
and Cherry Hospitals. NOTE: The 
Department of Mental Health current- 
ly offers a differential for start- 
ing salary at these hospitals, which 
does not affect maximum pay . The 
present budget of the Department 
includes funds for merit salary 
increases which would permit a ten 
percent differential in maximum pay. 
Hence the cost of a differential in 
maximum pay would be zero. p. 14 

Expansion of present residency 
training programs to include all 
regional mental hospitals, mental 
retardation centers and complexes, 
children's units, and community men-] 
tal health programs, and to include 
students of psychology, nursing, and 
related fields, as well as students 
of medicine and psychiatry. I p. 15 



Career ladder for attendants and 
cottage parents: 



a. In service training. 

b. Salary incentives for training 
(either in service or in schools 
outside the Department of Mental 
Health). NOTE: This estimate 
is based on an estimated three 
step increase in pay grades. 

12. Additional pay for Forensic Unit 
Attendants to make the total salary 
for the position equal to that of 
Security Officer I in the Depart- 
ment of Correction. 

13. Additional building maintenance and 
housekeeping staff to free more of 
attendants' time for actual work 
with patients. 



p. 15 



2,800,000 



2,800,000 



1,718,000 1,718,000 



5,025,000! 5,025,000 



p. 15 



p. 16 



150,000! 150,000 



1,335,000 



1,335,000 



■30- 



Location 

in 

This 

Report 



Biennial Cost 



1973-75 ! 1973-75 ! 1973-75 
NON- I I 
RECURRING RECURRING TOTAL 



Additional funds required in the 
1973-75 biennium to increase the 
current state share of community 
mental health programs to ninety 
percent over the next ten years. 
NOTE: This estimate is based on the 
assumption that the local share will 
remain constant at about $4,760,000 
per year. It also assumes that the 
actual state-local ratio, which is 
currently about 50-50, will increase 
as follows: 60-40 (1973-75), 70-30 
(1975-77), 80-20 (1977-79), 85-15 
(1979-81), and 90-10 (1981-83). 
Under these assumptions, the addi- 
tional cost in the final biennium 
(1981-83) will be $74,464,768, and 
the average additional cost per 
biennium will be $31,624,766. The 
current biennial state appropria- 
tion for this purpose is about 
$11,215,000. 

Additional funds required to upgrade 
N.C. Drug Authority staff (current 
funding is $44,000 per biennium). 

Additional funds required in the 
1973-75 biennium to increase the 
state share of community drug abuse 
programs to ninety percent over the 
next ten years. NOTE: This esti- 
mate assumes that the local share 
will remain constant at about 
$275,000 per year. It also 
assumes that the actual state- 
local ratio, which is currently 
50-50, will increase as follows: 
60-40 (1973-75), 70-30 (1975-77), 
80-20 (1977-79), 85-15 (1979-81), 
90-10 (1981-83). Under these 
assumptions, the additional cost in 
the final biennium (1981-83) will be 
$4,400,000, and the average addi- 
tional cost per biennium will be 
$1,924,998. The current biennial 
state appropriation for this pur- 
pose is about $550,000. 



pp. 16-18 



pp. 19-20 



$3,065,000 



156,000 



$3,065,000 



156,000 



pp. 19-20 



275,000 



275,000 



•31 



Location 

in 

This 

Report 



Biennial Cost 



1973-75 

NON- 
RECURRING 



1973-7; 



TOTAL 




17. Drug abuse prevention program within 

Department of Public Education. ipp, 



Nonrecurring cost of adding to 
drug education film and tape 
cassette stock of State Library, 
Technical assistance team to 
develop curriculum and train 
teachers, principals, and 
counselors to use curriculum. 



19-20 



18. TOTAL 



$ 25,000 



750,000 



$ 25,000 



APPENDICES 



CORRECTIONS 
TO 
REPORT OF THE LEGISLATIVE RESEARCH COMMISSION CONCERNING MENTAL HEALTH SERVICES (1972) 



Please insert the corrected cost estimates (pp. 27-30) in place of pp. 27-31 
of the original report. The corrected cost figures, totalling $48,052,934 
rather than the original $94,873,000, are based on information received 
subsequent to the preparation of the original report. 



•27- 



ESTIMATED COSTS TO STATE OF RECOMMENDATIONS, 1973-75 BIENNIUM 



Location 
in 

This 
Report 



p. 7; 

App. 



Study of internal management and { 

organization of Department of 

Mental Health. p. 1 

Mental Health Code Commission: | 

cost of staff work to prepare j 

proposed statutory revisions for i 

1975 General Assembly. Ip. 2 

i 

Implementation of the standards | 

for inpatient care of the mentally , 

retarded imposed by the U.S. Dis- I 

trict Court in Wyatt v. Stickney , \ 

with the exception of the staffing | 

ratio standards. NOTE: $1,977,000 ; 

of this amount is for payment of 

working patients. 

Full educational program for all 

retarded persons of school age, ■ 

including those now living in the < 

community as well as those in , 

regional mental retardation centers \ p. 7 



Operation of 6 hour per day 
educational program for insti- 
tutionalized mentally retarded 
persons age 6-21 in state men- 
tal retardation centers (2600 
children x $1800 per child x 
2 years) . 

Extension of present public 
school special education 
programs for mentally retarded 
persons age 6-21 living in 
the community. 



1973-75 
NON- 
RECURRING 



Biennial Cost 
"^ 1973-75 ' 

RECURRING 



$100,000 



00,000 



1973-75 
TOTAL 



$ 100,000 



100,000 



$ 3,708,000 3,708,000 



9,360,000j 9,360,000 



10,415,520: 10,415, 520 



**CORRECTED** 



-28- 





Location 
in 


Biennial Cost 




1973-75 


1973-73 1973-75 




This 


NON- 


1 




Report 


RECURRING 


RECURRING TOTAL 


5. Community-based programs for the 










mentally retarded: 


pp. 7-8 








a. Mental Retardation Complexes 




1 


t$2,n4,000] 


[$2,114,00(3* 


b. Group homes 






C2, 175,00(3 


[2,175,000]* 


c. Day and residential care. [Much 










of this amount is matched 3 to 1 










by federal funds under Title 










IV-A of the Social Security 










Act.] 






[583,00(3 


[583,000]* 


d. Institution-community liaison 










for persons transferred to 










community programs from re- 










tional Mental Retardation Cen- 










ters and their families. 






[252,00(3 


[252,00(3* 


e. Community services in Eastern 










Region operated by Caswell MRC: 










day care, work activity, emer- 










gency care, temporary care to 










relieve families. 






[2,492,00(3 


[2,492,00(3* 


6. Direct 100% State grants for local 










programs for emotionally dis- 










turbed children; 


pp. 8-9 




2,500,000 


2,500,000 


7. Implementation of the inpatient 










mental health treatment standards 










imposed by the U.S. District Court 










in Wyatt v. Stickney, with the ex- 










cej;)tion of the staffing ratio 










standards. NOTE: $2,288,000 of 










this amount is for payment of 


pp. 11-13; 








working patients. 


App. E 




3,750,000 


3,750,000 


8. Unit dose system of medication 










in regional hospitals. 


p. 13 




[5,642,000] 


[5,642,00(3* 



^NOTE; 



The bracketed figures are already in the 1973-75 DMH Change Budget, 
and are placed here to indicate approval by the Commission of the 
amounts and programs. These figures are not included in the total. 



*CORRECTED* 



-29- 



9. Cost of salary differential for 

medical staff positions at Broughton 
and Cherry Hospitals. NOTE: The 
Department of Mental Health current- 
ly offers a differential for start- 
ing s alar y at these hospitals, which 
does not affect maximum pay . The 
present budget of the Department 
includes funds for merit salary 
increases which would permit a ten 
percent differential in maximum pay. 
Hence the cost of a differential in 
maximum pay would be zero. 

10. Legislative Research Commission 
study of expansion of present 
residency training programs to in- 
clude all public (state and local) 
mental healtn and mental retarda- 
tion programs, and to include stu- 
dents of psychology, social work, • 
nursing and related fields., as well 
as students of medicine and 
psychiatry. 

11. Career ladder for attendants and 
cottage parents: 



Location 

in 

This 

Report 



Biennial Cost 



p. 14 



p. 15 



a. In service training. 

b. Salary incentives for training 
(either in service or in schools 
outside the Department of Mental 
Health). NOTE: This estimate 
is based on an estimated three 
step increase in pay grades. 

12. Additional pay for Forensic Unit 
Attendants to make the total salary 
for the position equal to that of 
Security Officer I in the Depart- 
ment of Correction. 

13. Additional building maintenance and 
housekeeping staff to free more of 
attendants' time for actual work 
with patients. 



1973-75 I 
NON- 
RECURRING 



IP. 15 



p. 15 



p. 16 



1973-75 
RECURRING 



1973-75 
TOTAL 



1,718,267! 1,718,267 



5,025,296 5,025,296 



150,000 150,000 



I 1,334,528 



1,334,528 



*CORRECTED* 



-30- 



Location 

in 

This 

Report 



Biennial Cost 



1973-75 1973-75 
NON- 



RECURRING 



RECURRING 



1973-75 
TOTAL 



14. Additional funds required in the 
1973-75 biennum to increase the 
current state share of community 
mental health programs to sixty 
percent, NOTE: This estimate 
is based on the assumption that 
the local share will be about 
$17,012,647 per biennium. The 
figure of $8,606,323 is in 
addition to the present DMH Base 
and Change budget total of 
$17,012,647 for this purpose in 
1973-75. 

15. Additional funds required to upgrade 
N.C. Drug Authority staff (current 
funding is $44,000 per biennum). 

16. Additional funds required in the 
1973-75 biennum to increase the 
state share of community drug abuse 
programs to sixty percent. NOTE: 
This estimate assumes that the 
local share will be about ; 
$1,333,333 per biennum. The 
figure of $950,000 is in addition 

to the present DMH Base and Change 
budget total of $1,050,000. 

17. Drug abuse prevention program within 
Department of Public Education. 

a. Nonrecurring cost of adding to 
drug education film and tape 
cassette stock of State Library. 

b. Technical assistance team to 
develop curriculum and train 
teachers, principals, and 
counselors to use curriculum. 



18. TOTAL 



pp. 16-U 



pp. 19-2C 



$8,606,323 $8,606,323 



pp. 19-20 



pp. 19-20 



156,000 



156,000 



950,000 



950,000 



$ 25,000 



225,000 



$ 154,000 



47,827,934 



$ 25,000 



154,000 



48,052,934 



**CORRECTED** 



APPENDIX A 

AUTHORIZING RESOLUTION 

AND 

MEMBERS OF COMMITTEE ON MENTAL HEALTH 



B 



GENERAL ASSEMBLY OF NORTH CAROLINA 
1971 SESSION 

SENATE RESOLUTION 871 



m '^ 



.#i: 



fi 



***^**'"" Senators Allsbrook, Baugh, Church and Scott. 

Referred to; Rules and Operation of Senate, ____^ 

June 2*» 

^ A RESOLUTION AUTHORIZING ANE EIRECTING THE LEGISLATIVE RESEARCH 

2 COMMISSION TO MAKE A COMPLETE IN-DEPTH STUDY OF THE DEPARTMENT 

3 OF MENTAL HEALTH AND RELATED PROGRAMS AND TO MAKE 
^ RECOMMENDATIONS TO THE GENERAL ASSEMBLY. 

5 Whereas, North Carolina has for many years realized that 

6 it is in the best interest of the State to provide proper care, 

7 treatment and research in order to promote the mental health of 

8 the citizens; and 

9 Whereas, the Department of Mental Health has made 

10 progress in the area of mental health through its various 

11 programs and facilities; and 

12 whereas, the General Assembly does not have available an 

13 up-to-date in-depth study of the mental health programs, 
Ih facilities, and needs of the State; and 

15 Whereas, due to the growing use of drugs, alcohol and 

16 the stress of the times^ there is an increasing demand for mental 

17 health care; and 

18 Whereas, the' State cannot render the kind of mental 

19 health services and provide for the future needs without an in- 

20 depth study of the present seinrices provided on the State, local 

21 and private levels; 



mmi ASSEMBLY OF ^offTH cMolM" ~"^ _ ilLSili 

1 ^^ow therefore, be it resolved by the Senates 

2 Section !• The Legislative Research Commission is 

3 hereby authorized and directed to conduct an in-depth 
k investigation and study of the Department of ^5ental Health and 
$ all related programs to determine whether sufficient facilities* 

6 treatment, care, supervision, guidance, rehabilitation, and 

7 mental health services are being provided for the mentally ill^ 

8 mentally retarded, alcoholics and drug addicts of the state. The 

9 study shall include, but not be limited to, an evaluation ot 

10 facilities, professional and staff personnel, custodial care^ 

11 state, local and other related mental health programs, funding, 

12 and every aspect of the organization and operation of the 

13 Department of Mental Health. 

Hj Sec. 2, The commission is authorized to employ such 

15 experts, consultants, professional and technical personnel, as it 

16 deems necessary to make a complete in-depth study of the 

17 Department of Mental Health and related programs- 

IQ Sec. 3. The Commission shall make its report and 

19 findings and recommendations to the 1973 General Assembly- 

20 Sec. a. This resolution shall become effective upon 

21 ratification, 

22 

23 
2k 
2$ 
26 
27 
28 

Senate Resolution 871 



STATE OF NORTH CAROLINA 
LEGISLATIVE RESEARCH COMMISSION 

STATE LEGISLATIVE BUILDING 
RALEIGH 27611 



CoChairman 
Gordon p. Allpn 

Prfsidpnt Pro Tempore, Senate 

MEMBERS: 

Sfn. Lamar Guoger 

Sfn. F. ONprL JoNPS 

Sf.n. Charles H. Larkins, Jr. 

Stn William W. Staton 

t.eN Thomas E. Strickland 




CO-CHAIRMAN: 

Philip P. Godwin 

Speaker, House of Representatives 
Members; 

Rep. Julian B. Fenner 
Rep. Ernest B. Messer 
Rep. William R. Roberson. Jr. 
Rep. Carl J. Stewart, Jr. 
REP. Willis p. Whichard 



GO^^ITTEE ON MENTAL liEALTH 
C3R 871) 



Senator Charles H. Larkins, Jr., 
Post Office Box 5029 
Kinston, North Carolina 



Chairman 



Senator Julian R. Allsbrook 

.Post Office Drawer ^4 

Reanoke Rapids, North Carolina 



Representative Robie L. Nash 
232 Richmond Road 
Salisbury, North Carolina 



Senator Philip J. Baugh 
BauRh Industries 
Bauf-';h Building 
Chariobte, North Carolina 



Representative J. Ernest Paschal] 
113 East Nash Street 
Wilson, North Carolina 



Repre:;(.:ntative Jule McMichael 
Post Office Box 11^0 
Reidsville, North Carolina 



Senator Marshall A. Rauch 
1121 Scotch Drive 
uastonia. North Carolina 



R(:;presentative James T. Mayfield 
"522 Kendale Court 



i.ar 



F].ab Rock, North C Carolina 



Senator Ralph H. Scott 

Route 1 

Haw River, North Carolina 



Senator Thomas E. Strickland 
112 North William Street 
Goldsboro, North Carolina 



APPENDIX B 

NAMES OF PERSONS WHO TESTIFIED 
AT MEETINGS OF THE COMMITTEE ON MENTAL HEALTH 



LEGISLATIVE RESEARCH COMMISSION 
Committee on Mental Health 

Persons appearing before the Committee — 

Dr. Eugene Hargrove, Commissioner, Dept . of Mental Health — 

(Background information on the Dept. of Mental 
Health and an outline of services provided by 
the Department ) 

Dr. Lennox Baker, Sec, Depart, of Human Resources — 
(His ideas on mental health) 

Mr. Jere Annis, State Pres. of the N.C. Association of 
Retarded Children — 

(Explained the purpose of suit filed against the State 
on behalf of retarded children) 

Mr'. Carey Eendley, Executive Director, N. C. Association of 
Retarded Children — 

(history of his association and current needs in 
the field of mental retardation) 

Rep. Howard Twiggs, member. Board of Directors of the 
N. C. Mental Health Association — 

(Reviewed findings of the study made by his Association 
and explained the Alabama decision in the suit against 
the state regarding its mental health programs) 

Mr. Victor Sydnor, Executive Director of the N. C. Mental 
Mental Health Association — 

(Spoke on the history of the Association and its 
present activities) 

FLr. Joe Byrd, Chm. , State Board of Mental Health— 
(Spoke on the services provided by the Dept. 
of Mental Health) 

Attorney General Robert H. Morgan — 

(Spoke primarily on the SBI investigations at 
Cherry Hospital) 



APPENDIX C 

POLICY ON PATIENTS' RIGHTS 

OF THE 

NORTH CAROLINA DEPARTMENT OF MENTAL HEALTH 




STATE OF NORTH CAROLINA V, ''7/.\V 

DEPARTMENT OF MENTAL HEALTH x^ .^n 

i». o. BOX aess7 "^ -~,'4_, * 

EXICUTIVC OrFICES 
441 N. HARRINOTON aTRIET 
RALEIOH. N. C. 87611 
(UQKNK A. HAROROVK. M.D. BEN W. AIKEN 

CoMMiaaioNKN November 24, 1970 0«nbral Businsss Manasbr 



MEMORANDUM 

TO: Superintendents and Community Program Directors 

FROM: Eugene A. Hargrove, M, D. 
Commissioner 

The North Carolina Board of Mental Health, on November 19, 1970, 
unanimously adopted the attached policy statement. The Department is 
directed to implement the provisions of this policy as rapidly as its 
current resources permit. 

All Superintendents and Program Directors of the Department are 
hereby apprized of the action of the Board. Plans for implementation 
of the policy should be submitted to the Regional Commissioner no 
later than January 15, 1971. Periodic reports of progress will be 
expected, beginning at a date to be announced. 



EAHibs 
Attachment 

cc: Regional Commissioners 



Policy on Patients^ Rights 

It is the policy of the State Board of Mental Health that every 
person receiving the services of the Department of Mental Heal .;h be 
accorded, insofar as is within the reasonable capability of the Depart- 
ment and is consistent with therapeutic treatment, such aare, treatment 
and privileges as enhance one's dignity, promote his welfare and protect 
his rights as a free man. 

I. As a means of implementing this policy, the Department of Mental Health 
is hereby authorized to assure that all persons receiving services, 
subject to such limitations as may be reasonably necessary and which 
are entered in his treatment record, shall be allowed to: 

1. wear his own clothes; 

2. keep and use his own personal possessions, 
including toilet articlas; 

3. have access to individual storage space for 
his personal articles; 

4. keep and to spend a reasonable s\im of his 
own money; 

5. receive remuneration for work done of 
value to facility; 

6. receive visitors on any day; 

7. have reasonable access to telephone, both 
to make and receive confidential calls; 

8. mail and receive unopened correspondence 
and access to a reasonable amount of letter 
writing material and postage; 

9. to consult legal counsel. 



-2- 

II. The Department of Mental Health is hereby authorized to formulate 
procedures which assure: 



1. A written therapeutic plan of treatment for 
each inpatient; 

2. A record made of all such treatment and of a 
periodic review of the patient's treatment; 

3. A comprehensive review of the patient's physical 
and mental condition at least annually and a 
finding stated in his ;-ecord as to whether or 
not he should be retained in the facility or 
discharged, and any recommendations for other 
appropriate treatment or disposition; 

4. That physical restraint, including individ- 
ual confinement, of a patient is to be utilized 
only to prevent danger of abuse or injury to 
himself or others, or as a measure of therapeutic 
treatment, and all instances of such physical 
restraint or individual confinement shall be 
recorded in the patiait's treatment record; 

5. That a patient may refuse electroshock therapy 
unless determined by a medical doctor, to be 
incompetent to make that decision and such 
finding be recorded in his treatment record; 

6. That no unauthorized publication or use of a 
patient's treatment records shall be permitted. 

A patient's treatment records are deemed confidential 
and may be disclosed only on the following conditions 
and circumstances or as otherwise provided by law: 

(a) as necessary between professional persons 
and/or agencies in the provision of services 
to the patient; or 

(b) to those whom the patient or his legal 
representative designate; or 

(c) to the extent necessary to make claims on 
behalf of a patient for legal or financial 
aid, insurance, or medical assistance to which 
he may be entitled; or 



-3- 



(d) to those engaged in research, pursuant to 
rules of the facility or the Department^ 
provided that researchers maintain now 
identification and confidentiality; or 

(«) upon the order of a court of competent 
jurisdiction, or 

(f) to the extent necessary to explain to a 
patient or his legal representative the 
reasons for and nature of a denial or 
limitation of his rights. 

7. That upon discharge a patient receives, if needed, 
suitable clothing for and means of transportation 
to his rasidence; 

8. A patient shall not be arbitrarily transferred; 

9. All patients shall upon request be informed of their 
rights under the mental health laws of the state and 
the related policies and procedures of the Department 
and the facility. Printed copies thereof shall be 
furnished and/or posted in appropriate places; 

10. That all employees of the Department are effectively 
informed of the rights of patients and the Department's 
policies and procedures for the care, treatment and 
promotion of patient welfare; 

11. When any right of a patient or any policy or 
procedure of the Department is limited or denied, 
the nature, extent and reason for such limitation 
or denial shall be entered in the patient's records. 
Any continuing denial or limitation shall be reviewed 
every thirty (30) days and shall be recorded in his 
treatment record. 

12. At such time as a person is initially admitted as an 
inpatient, unless he specifically objects^ he shall inform 
the facility of the name and address of not more than two 
adults or corporate entities that he desires be advised of 
his admission, his rights, and the policies and procedures 
of the Department. The name and address of such persons 
shall be recorded in the patient's record, and the person 
notified. The facility shall make diligent effort to secure 
the name and address of the patient's legal representative, 
spouse, child, parent, a relative, attorney or friend. If 
the facility is unable to locate one of the above, that 
fact shall be entered in the patient's record and the 
Commiasioner of Mental Health shall be notified. A patient 
may designate other persons upon a subsequent admission. 



-4- 



13. A patient, or a person designated in 12 above, who 
believes his rights have been or are being violated 
may give written notice to the facility which in turn 
shall promptly investigate the same and make written 
reply of its findings and disposition. A copy of 
both the notice and the reply shall be included in the 
patient's record. If the patient, or designated 
person, disagrees with the findings and/or disposition, 
he may make written request to the Commissioner of 
Mental Health for review. The Commissioner may cause 
such additional investigation as he deems necessary 
and shall make written reply with copy to the facility 
for inclusion in the patient's record. The Commissioner 
may make such recommendations or direct such actions 
as he deems appropriate. The Commissioner from time to 
time shall make report to the State Board of Mental 
Health of complaints received and dispositions made. 



The Commissioner may designate one or more persons to 
receive such requests for review, to make investigations, 
and r«ply on his behalf. 



APPENDIX D 

OPINION OF COURT AND STANDARDS OF TREATMENT 
OF THE MENTALLY RETARDED: Wyatt v. Stkkney 



IN THE UNITED STATES DISTRICT COTOT FOR THE MIDDLS 
DISTRICT OF ALABAMA, NORTiiERM DIVISION 



RICKY WATT, by and throuch 
hla aunt and legal guardian, 
MrB. W, C. Rawlins, Jr.j ET 
AL. , for thomsclvefl Jointly 
and severally and tov all 
others similarly situated, 

Plaintiffs, 

vs. 

DR. ST0NL1VALL iJ. STICKNEY, as 
Commissioner of Mental Health 
and the State of Alabama Mental 
Health Olftccr; JOHN V. HOTTEL, 
as Deputy Commissioner of Mental 
Health of Alabama and as Interim 
Superintendent of Partlow State 
School and Hospital at Tuscaloosa; 
DR. JAMES C. FOLSOM, individually 
and as Deputy Commissioner for 
Hospitals of the Alabama State 
Board of Mental Health; DR. JAIME 
E. CONDOM, individually and as 
Superintendent of Searcy Hospital 
at Mount Vernon, Alabama; CARL 
M. BOLEY, DR. CLAUDE L. BROWN, JR., 
DR. PAUL W. BURLESON, ED T. HYDE, 
DR. J. PAUL JONES, DR. JOHN A. 
MARTIN, FRANK M. MOODY, DR. ROBERT 
PARKER, WILLARD SMITH, DR. EVERET 
STRANDELL, DU. J. CAREER GALBRAITH 
and JACK NOLEN, as Trustees of the 
Mental Health Board of Alabama; 
THE ALABAMA MENTAL HEALTH BOARD, 
a public corporation; GEORGE C, 
WALLACE, as Governor of Alabama; 
and PiiRRY 0. HOOPER, as Judge of 
Probate of MontRomery County, 
Alabama, and all other Judges of 
Probate of Alabama, Jointly and 
severally, who are similarly 
situated; and all of their suc- 
cessors in each office. 

Defendants, 

UNITED STATES OF AMERICA, the 
AMliRICAI^ PSYCHOLOGICAL ASSOCIATION; 
the AMIJRICAN ORTHOPSYCHIATRIC 
ASSOCLVTION; the AMERICAN CIVIL 
LIBERTIES UNION, and the AI-QiRICAN 
ASSOCIATION ON MENTAL DEFICIENCY, 



Amicl Curiae. 



APR13 1S72 

JANC P. GOROuN. CLERK 



BY. 



L If. V3UKWW 



CIVIL ACTION NO. 3195-N 



(Partlow State School and Hospital) 



ORDER AND DECREE 



This litigation originally pertained only to Alabama's mentally ill. 



1/ 



l_/ On March 12, 1971, in a formal opinion and decree, this Court held thac 
patients Involuntarily committed to Bryce Hospital because of Kjevatal Illness were 

(ConCd.) 



but, by nwtion to amend granted August 12, 1971, plaintiffs have expanded 

their class to include residcnte of Pnrtlow State School and Hospital, a 

public institution locnted in Tuscaloosa, Alabama, designed to habilitate 

2/ 
the mentally rctnrdcd. In their amended complaint, plaintiffs have alleged 

that Pnrtlow ie bolnft operated in a constitutionally Impcrmiasiblc fashion 
and that, as a result, Ite residents are denied the right to adequate habili- 
tation. Relying on these allegations, plaintiffs have asked that the Court 
promulgate and order the implementation at Partlow of minimum medical and 
constitutional standards appropriate for the functioning of such an institution* 
Plaintiffs have asked also that the Court appoint a master and a professional 
advisory committee to oversee the implementation of Judicially ordered guide- 
lines and appoint a human rights conmittcc to safeguard the personal rights 
and dignity of the residents. Finally plaintiffs have requested the Court 
to grant various forms of relief intended to ameliorate the financial diffi- 
culties certain to arise in connection with the upgrading of Alabama's public 



y Contd. 

boiii); (loprivrd of the constitutional right, which they unquestionably possess, 
"to receive such individual treatment ao [would] give each of them a realistic 
opportunity to be cured or to Improve his or her mental condition," Wyntt v. 
Sticknpy . 325 F. Supp. 781 (M.D. Ala. 1971). On August 12, 1S71, the Court 
granted plointifin' motion to add to the lawsuit patients confined at Searcy 
Hospital, Mount Vernon, Alabama, another institution which, although designed to 
treat the mentally ill, failed to do so in accordance with constitutional 
standards. The Court, having unavailingly afforded defendants an opportunity to 
promulgate and effectuate minimum standards for adequate treatment of the mentally 
ill, determined on December 10, 1971, that such standards had to be Judicially 
formulated and ordered implemented. Wyatt v, Stickney , 334 F. Supp. 1341 (M.D, 
Ala. 1971). To that end, the Court conducted a hearing on February 3-4, 1972, 
at which the parties and amici submitted proposed standards for constitutionally 
adequate treatment, and presented expert testimony in support of the proposals. 
The aspect of the case relating to the Bryce-Searcy facilities will be considered 
by the Court In a decree separate from the present one. 

2/ As expreriscd by amici in their briefs and substantiated by the evidence in 
this case, mentnl retardation refers generally to subaverage intellectual function- 
ing whicli is ns.sociatod with impairment in adaptive behavior. This definitional 
approach to mental retardation is based upon dual criteria: reduced intellectual 
functioning, and impairment in adaptation to the requirements of pocial living, 
T'lic ividcnce pr(>Bcntod reflects ncicntifi- advances in understanding the develop- 
mental, proce'i'ier. of the mental retardate. The historic view of rr.jntal retardation 
ai; nn jnnnutable defect of intellegencc lias been supplanted by the recognition 
thai, a pornon may bo mentally retarded at one age level and not at another; that 
he m.iy chanj'.e r.tatur. as a result of changes In the level of his intellectual 
fund I on in J', ; or tliat he may move from retarded to nonretardcd as a result ~<" a 
tralninf, pi-o;;rnin which ha.'i increased his level of adaptive behavior t ■> i point 
where his behavior is no longer of concern to society. ^ec United Stater, Presi- 
dent's I'nnel on Mental Retardation, Report of the Task Force on Law, 1963. 
(Judge David L. Bozelon, Chairman.) 



3/ 
mental health InocltutlonSo 

On February 28-29, 1972, the Court conducted a hearing on the iafluea 

formulated by the pleadings in this cqbc. Evidence wae taken on the adequacy 

of conditions currently existing at Partlow as well as on the stendercii re^juisltfi 

for a constitutionally acceptable mlninnun habilitation program. The partl&u 

4/ 
and amlci stipiilated to & broffidl array of these standards and proposed 

additional ones for the Courc'^s evAluiatloeo The case now is submitted upon the 

pleadings, the evidence;, Che sCipuiiatioBS; a^nd the proposed standards and briefs 

of the parties. 

Initially, thl« QouKt ha.B conaldered plainitlffs' position, not actively 

contested by defendaimts, that people imwoluntarily committed through noncriminal 

procedures to institutions for the mentelly retarded have a constitutional right 

to receive such individual habilitatloEi as will give each of them a realistic 

opportunity to lead a more useful and mefflmiiragful life and to return to eocietyo 

That this position is in accord with th-s applicable legal principles ia cleur 

beyond cavil. In an analogous situation imvsilving the mentally ill at Bryce 

Hospital, this Court said: 

"Adequate and effective treatment is constitutionally 
required because „ absent treatment, the hospital is 
transformed 'into a penitentiary where one could be 
held indefinitely for no convicted offense. ' Rap,sdale 
V. Overholser, 281 Fc2d 943, 950 (D.C. Cir. 1960) . The 



3/ More specifically, in a motion filed September 1, 1971 ^ and renewed March 
15, 1972, plaintiffs have asked that they be permitted to join various state 
officials as defendants in this caseo Plaintiffs maintain that these officials, 
including, among others, the members of the State Legislature and the treasurer 
and the comptroller of Alabama, are necessary parties for the attainment of 
complete relief. Among the relief plaintiffs seek in connection with the state 
officials is an injunction against the expenditure of state funds for non- 
essential functions of Che state until enough money is available to provide 
adequately for the financial needs of the Alabama Mental Health Eoardt In 
addition, plaintiffs have asked the Court to order the sale of a portion of 
defendant Mental Health Board's land holdings and other assets and to enjoin 
the Board from the construction of any physical facilities, including any planned 
for regional centers. 

4/ The amicl in this case, iKcluding the United States of America, -the American 
Orthopsychtatric Association, the American Psycholocical Association, the 
American Civil Liberties Union, &nd the American Association on Mental Deficiency, 
have performed invaluable servl'^e for which this Court is indeed apprectr :iv£ , 

5^/ The Court will deal in thtw decree only with residents involuntarily commit K'^a 
to Partlow because no evidence hae botn adduced tending to demonstrate r '<?.'". any 
ronident is voluntarily confined iu that institution. The Court will presume „ 
therefore, that every resident of Lartiow is entitled to constitutionally mln::^. iS 
habilitation, Tlio burden falls squarely upon the institution to prove that e 
particular resident has not bten tw/oluntarily '•jottmitted, and only if defendanti? 
satisfy this difficult burden of prooS will the Court be confronted with whether 
the voluntarily comimitted resld^me has «i right to habllitatlono 



'3= 



n 



purpoao of Involuntary hospitalisation for treatment '"' 

purposcfi is treatment and not mere custodial care or . 
punishment. Tills ia the only Justification, from a 
constitutional standpoint, that allows civil coiranit- 

mcnto Co mental institutions ouch as BrycCo" Wyatt 
'^- Stickney. 325 F, Suppo at 784o 

In the context of the right to appropriate cere for people civilly confined 

to pubXlc mental sinetitutlons, no viable distinction can be made between the 

mentally ill and the mentally retardcdc Because the only constitutional ; 

1 
Justification for civilly cotranltting a mental retardate, therefore, is habili- j 

tatlon, It follo^^s ineluctably that once committed such a person Is possessed ] 

6/ 1 

of an Inviolable constitutional right to habllitatlono 

Having recognized the existence of this rights the Court now must deter- 
mine whether prevailing conditions at Partlow conform to minimum standards con- 
stitutionally required for a merttal retardation institution. The Court's concluslon<, 
compelled by the evidence, is unmistakably clear. Put simply, conditions at 

Partlow axe grossly substandard. Testimony presented by plaintiffs and amlcl has 

7/ 
depicted hazardous and deplorable inadequacies in the institution's operation. 



6i/ It is interesting to note that the Court's decision with regard to the 
right of the mentally retarded to habilitation is supported not only by applicable 
Ic^al authority, but also by a resolution adopted on December 27, 1971, by the 
General Assembly of the United NationSo That resolution, entitled "Declaration 
on the Rights of the Mentally Retarded.", reads in pertinent part: 

"o „ o The mentally retarded person has a right to 
proper medical care and physical therapy and to such 
education, training, rehabilitation and guidance as 
will enable him to develop his ability and maximum 
potential," 

7/ The most comprehensive testimony on the conditions currently prevailing at 
Patnlow was elicited from Dr. Philip Roos, the Executive Director for the 
Nntlorial A88o«:ia«:ion for Retarded Children^ Dro Roos inspected Partlow over a 
twfi-f'ay prrJod nnd testified as to his subjective evaluation of the institution. 
In •■oncluding hie testimony. Dr. Rooa summartEcd as follows: 

', „ . I feel that the institution and its programs as 
now conceived are incapable of providing habilitation of 
the residents. Incarceration, certainly for most of the 
K evident 8, would I feel have adverse consequences; would 
tend to develop behaviors which would interfere with, 
successful commuatty functioning. I would anticipate to find 
stagnation or deterioration in physical, intellectual, and 
social spheres. The conditions at Partlow today are 
gencrnlly dchumanl?:ingj fostering deviancy, generating self- 
fylfllling prophecy of parasitism and helplessness. The 
conditions I would say are hazardous to psychological 
intcfirityj to health, and in some cases even to life- The 
administration, the physical plants, the programs, and 
the Institution's articulation with the community and with 
the consumers reflect destructive models of mental retarda- 
tion. They hark back to decades ogo when the retarded 
were mlepcrceived as being sick, as being threats to 
(Society „ or aa being subhuman organismSo The new concepts 

(Contd.) 



8/ 
Commcndably, defendants havo offered no rebuttal. At the close of the 

testimony, the Court, having been Impressed by the urgency of the situation. 

Issued an interim emergency order "to protect the lives and well-being of the 

residents of Part low." In that order, the Court found that: 

"The evidence . . . has vividly and undieputedly 
portrayed Partlow State School and Hospital as a ware- 
housing institution which, because of its atmosphere of 
psycnolocical and physical deprivation, is wholly incap- 
able of furnishing [habilitntlon] to the mentelly retarded 
and Is conducive only to the deterioration and the 
debilitation of the residents. The evidence has reflected 
further that safety and sanitary conditions at Partlow 
are substandard to the point of endangering the health 
and lives of those residing there, that the wards are 
grossly understaffed, rendering even simple custodicl 
care impossible, and that overcrowding remains a dangerous 
problem often leading to serious accidents, some of 
which have resulted In deaths of residents." Wya 1 1 v. 
Stlckncy . March 2, 1972, (Unreported Interim Emergency 
Order.) 

Based upon these findings, the Court has concluded that plaintiffs 

have been denied their right to habilitation and that, pursuant to plaintiffs' 

request, minimum standards for constitutional care and training must be 

effectuated at Partlow, Consequently, having determined from a careful study 

of the evidence that the standards set out in Appendix A to this decree are 

9/ 
medical and constitutional mlnlmums, this Court will order their implementation. 

In so ordering, the Court emphasizes that these standards are, indeed, minimums 

only peripherally approaching the Ideal to which defendants should aspire. 



2/ Contd. 

in the field of mental retardation are unfortunately 
not reflected in Partlow as we see it today--concepts 
such as normalization, developmental model in orienta- 
tion toward mental retardation, the thrust of consumer 
Involvement, the trend toward community orientation and 
decentralization of services; none of these are clearly 
in evidence in the facility today." 

8/ Indeed, on February 22, 1972, defendants filed with the Court a statement of 
position providing in relevant part that: 

"Assuming that such a federal constitutional obligation 
exists . . ., defendants will not contest the factual' 
accuracy of an ultimate finding . . , that def;3ndant8 
have not met the constitutional obligation to provide 
adequate care at [Partlow], ..." 

At the hearing, defendants adopted the testimony of Dr. Roos in its entirety. 

9/ In addition to the standards detailed in this order, it is appropriate ;;hat 
defendants comply also x^ith the conditions, applicable to mental health institu- 
tions, ncccnsary to qualify Partlow for participation in the various programs, 
such as Medicare and Medicaid, funded by the United States Government. Because 
many of these conditions of participation have not yet been finally drafted and 
publlslicd, however, this Court will not at this time order that specific Govern- 
ment standards be Implemented. 



-■i >- 



It i» lnopcd tlint the revelations of this case wtll furnish Impetus to defendants 
to provide phystcfll facilities and habllltation programs at Partlow eubatanttally 
exceeding medical and constitutional mlnlmums. 

For the present, however, defendants must realize that the prompt 
institution of mlnlmiun standards to ensure the provision of essential care and 
training for Alabama's mental retardates is mandatory and that no default can 
be Justified by a want of operating funds. In this regard, the principles 
applicable to the mentally ill apply with equal force to the m-antally retarded^ 
See Wyatt v. Sllckncy . 325 F. Supp. at 784-85. 

In addition to requesting that minimum standards be implemented, 

plaintiffs have asked that defendants be directed to establish a standing human 

rlchts committee to guarantee that residents arc afforded constitutional and 

humane habilitatlon. The evidence reflects thnt such a committee is needed at 

Partlow, ond this Court will order its initiation. This committee shall have 

review of all research proposals and all habilitatlon programs to ensure that 

the dignity and himian rights of residents are preserved. The consnlttee also 

shall advise and assist residents who allege that their legal rights have been 

infringed or that the Mental Health Board has failed to comply with Judicially 

ordered guidelines. At reasonable times the committee may inspect the records 

of the institution and interview residents and staff. At its discretion the 

committee may consult appropriate, independent specialists who shall be compen- 

10/ 
sated by the defendant Board. The Court will appoint seven members to 

comprise Partlow's human rights committee, the names and addresses of whom are 
set forth in Appendix B to this decree. Those who serve on the committee shall 
be paid on a per diem basis and be reimbursed for travel expenses at the same 
rate as members of the Alabama Board of Mental Health. 

Plaintiffs, as well as amici, also have advocated Che appointment of 
a federal master and a professional advisory committee to oversee the imple- 
mentation of minimum constitutional standards. These parties maintain that 
coiidltlons at Partlow largely are the product of shameful neglect by the state 
offlcinlfl chnrged with rcsponnlbillty for that institution. Consequently, 



10/ T!ic recitation of the licenses of this committee, and similarly, of the 
committees to bo lnau(',urntcd nt the Brycc and Searcy facilities, is not intended 
to be Inclusive. The human rlchts commiLtnp of each mental health institution 
shall be authorized, within the limits of reasonableness, to pursue whatever 
action is necessary to accomplish its function. 

-6- 



plaintiffs nnd amtci insist, these state officials have proveti themselves 
incapable of instituting a constitutional habilitation program, Alt'aouglt this 
Court acknowledges the intolerable conditions at Partlow end recognizee 

defendants' past nonfeasances, it, nevertheless, reserves ruling on tha appoint'' 

11/ 
ment of a master and a professional advisory committee. Federal courts are 

reluctant to assume control of any organization, but especially one operated 
by a state. This Court, always having shared that reluctance, has adhered to 
a policy of allowing state officials one final opportunity to perform the duties 
imposed upon them by law. See e.g . , Sims v. Amos . 336 F, Supp. 924 (M.D. Ala, 
1972); Nixon v. Wallace . C.A, No, 3479-N, M.D. Ala., January 22, 1972. Addi- 
tionally, since the entry of the interim emergency order of March 2, 1972, 
defendants have worked diligently to upgrade conditions at Partlow in conformity 
with court-established deadlines. These factors, combined with defendants' 
expressed intent that the present order will be implemented forthwith and in 
good faith, cause the Court to withhold its decision on the appointments. Never- 
theless, this Court notes, and the evidence deimnstrates convincingly, that the 
operation of Partlow suffers from a virtual absence of administrative and 
managerial organization. Tliis long-enduring organizational deficiency has been 
intensified by the lack of dynamic, permanent leadership. Regrettably, the 
problem has remained unresolved over the span of this litigation and, indeedj 
has been compounded by the appointment of acting and interim superintendents, 
Tlie massive program of reform and reorganization to be launched at Partlow 
requires the guidance of a professionally qualified and experienced administrator. 
Consequently, this Court will order that defendants employ such an individual 
on a permanent basis. Should defendants fail to do so, or otherwise fail to 
comply timely with the provisions of this decree, the Court will be obligated 
to appoint a master. 

The Court also reserves ruling upon plaintiffs' motion that defendant 



11 / The Court 'n drcision to reserve ruling on the appolntmcMit of a mnsCcr 
cnur;or. it to rcr.crvo ruling also on the appointment of a professional ndvifiory 
coiiiinf rtoo to aid the master. Nevertheless, the Court notes tliat the professional 
mental hcnli;h coinn\unity in the United States has responded with enthusiasm to 
the propoaod initiation of such a committee to assist in the upgrading of Alabama's 
mental retardation services. Consequently, this Court strongly rcconimends to 
dofondants tliat they develop a professional advisory committee compriaed of 
amenable professionals from throughout the country who are able to provide the 
expertise tlie evidence reflects is important to the successful implementation 
of this order. 



-7- 



Mental llonlth IJoard be directed to sell or encumber portions of its extensive land 

holtiinK9. Slmllnrly, this Court rcservea ruling on plaintiffs' notion seeking 

an injunction against the expenditure of state funds for nonessential functions 

of the Btntc, nnd on other aspects of plaintiffs' requested relief designed to 

ameliorate the financial problems incident to the effectuation of minimum 

medical and constitutional standards. The Court reserves these rulings despite 

the fact that the primitive conditions, as well as the atmosphere of futility 

and despair which envelops both staff and residents at Partlow, can be attributed 

largely to dire shortages of operating funds. By withholding its decisions, 

the Court continues to observe its long-standing policy of deferring to state 

organizations and officials charged by law with specified responsibilities. 

The responsibility for appropriate funding ultimately must fall, of course, 

upon the State Legislature and, only to a lesser degree, upon the defendant Mental \ 

Health Board. Unfortunately, never, since the founding of Partlow in 1923, has 

12/ 
the Legislature adequately provided for that institution. The result of almost 

fifty years of legislative neglect has been catastrophic; atrocities occur 
daily. Although, in fairness, the present State Legislature can be faulted 
relatively little for the crisis situation at Partlow, only that body can 
rectify the gross omissions of past Legislatures. To shrink from its constitu- 
tional obligation at this critical Juncture would be to sanction the inhumane 
conditions which plague the mentally retarded of Alabama, The gravity and 
immediacy of the situation cannot be overemphasized. At stake is the very 
preservation of human life and dignity. Consequently, a prompt response from 
the State Legislature, as well as from the Mental Health Board and other 
responsible state officials, is imperative. 

In the event, though, that the Legislature fails to satisfy its 



12 / By defendants' admission, Partlow State School and Hospital always has 
been a "step-child" of the state — never having received the public support it so 
desperately required. Not until the short term in office of Governor Lurleen 
Wallace was any emphasis placed upon securing adequate care for Alabama's 
mentally retarded. Bectnning with Mrs. Wallace's tenure in 1966, the budget 
for mental healtli has increased but remains woefully short of the minimum required 
for constitutional care. 

13 / A few of the atrocious incidents cited at the hearing in this case include 
the following: (a) a resident was scalded to death by hydrant water; (b) a 
rrT.ident war. restrained in a strait Jacket for nine years in order to prevent 
h.iiid nnd ftnj;or sucking; (c) a resident was inappropriately confined in seclusion 
for a period of yearn, and (d) a resident died from the insertion by another 
resident of a running water hose into hie rectum. Each of these incidents could 
have been avoided had adequate staff and facilities been available. 



wcll-dofincd constitutional obit gat ion and the Mental Health Board j because 

of lack of funding or any other legally insufficient reason, fails to 

implement fully the standards herein ordered, it will be necessary for the 

Court to take affirmative steps, including appointing a master, to ensure that 

14/ 
proper funding is realized and that adequate habilitation is available for 

the mentally retarded of Alabama, 

Finally, the Court has determined that this case requires the awarding 
of a reasonable attorneys' fee to piaintiffa' counsel. The basts for the 
award and the amount thereof will be considered and treated in a separate order. 
Tlic fee will be charged against the defendantet aa a part of the court coats in 
this case. 

To assist the Court in its determination of how to proceed henceforth, 
defendants will be directed to prepare and file a report within six months 
from the date of this decree detailing the implementation of each standard herein 
ordered. This report shall be comprehensive and shall include a statement of the 
progress made on each standard not yet completely implemented, specifying the 
reasons for incomplete performance. The report shall include also a statement 
of the financing secured since the issuance of this decree and of defendants' 
plans for procuring whatever additional financing might be required. Upon the 
basis of this report and other information available, the Court will evaluate 
defendants' work and, in due course, determine the appropriateness of appointing 
a master and of granting other requested relief. 

Accordingly, it is the ORDER, JUDGMENT and DECREE of this Court: 

1, That defendants be and they are hereby enjoined from failing to 
implement fully and wltli dlspntch each of tho Btnndnrds set forth in Appendix 
A ntl.(iih<'«l 111 rcio mul liicorpor/iLod t\n a part of thin decree; 

2. That a human rights committee for Partlow State School and Hospital 
bo nn<I to hereby dosignntod and appointed. Tlic mcmbcrfl tlicrcof are listrd in 
Appendix li attached hereto and incorporated herein. This committee shall have 
the purposes, functions, and spheres of operation previously set forth in this 



14 / Thf Court realizes that the Legislature is not due back in regular session 
until May, l'J73. Nevertheless, special sessions of the Legislature aro frequent 
occurrences in Alabama, and there has never been a time when such a session was 
more ur;;ently required. If the Legislature does not act promptly to appropriate 
the nocoricary funding for mental health, the Court will be compelled to grant 
plaintiffs' motion to add various state officials and agencies as additional 
parties to this litigation and to utilize other avenues of fund raising. 



-9- 



order, Tlic mcinbcrH of tl>c committee nhnll be paid on a per diem basio and be 
rcimbiiraod for travel expenses at the same rate as members of the Alabama 
Board of Mental Health; 

3. Tliat defendants, within 60 days from this date, employ a pro- 
fessionally qualified and experienced administrator to serve Partlow State 
School and Hospital on a permanent basis; 

U, That defendants, within six months from this date, prepare and 
file with this Court a report reflecting in detail the progress on the imple- 
mentation of this order. This report shall be comprehensive and precise 
and slmll explain the reasons for incomplete performance in the event the 
dofcndnnts have not met a standard in its entirety. The report also shall 
include a financial statement and an up-to-date timetable for full compliance; 

5. That the court costs incurred in this proceeding, including a 
reasonable attorneys' fee for plaintiffs' lawyers be and they are hereby taxed 
against the defendants; 

6. That jurisdiction of this cause be and the same is hereby 
specifically retained. 

It is further ORDERED that a ruling on plaintiffs' motion for further 
relief, including the appointment of a master, filed March 15, 1972, be and 
the same is hereby reserved. 

Done, this the /-^"^ day of April, 1972. 




UNITED S 



-10- 



APPENDIX A 

MINIMUM CONSTITUTIONAL STANDARDS FOR 
ADEQUATE llABILITATION OF TllE MENTALLY RETARDED 

I, Definitions 

-^— — — — — .; 

The terms used herein below are defined ae follows: 

a. "Inacitution" -- Partlow State School and Hospital. 

b. "Residents" -- All persona who are now confined and all persons 
who may in the future be confined at Partlow State School and Hospital. 

c. "Qualified Mental Retardation Professional" 

(1) a psychologist with a doctoral or master's degree from an accredited 
program and with specialized training or one year's experience in 
treating the mentally retarded; 

(2) a phyolclnn llconncd to prnctlcc in the Stntc of Alnhnmn, with 
spccinlizcd training or one year's experience in treating the 
mentally retarded; 

(3) an educator with a master's degree in special education from an 
accredited program; 

(4) a social worker with a master's degree from an accredited program 
and with specialized training or one year's experience in working 
with the mentally retarded; 

(5) a physical, vocational or occupational therapist licensed to 
practice in the State of Alabama who is a graduate of an accredited 
program in physical, vocational or occupational therapy, with 
specialized training or one year's experience in treating the 
mentally retarded; 

(6) a registered nurse with specialized training or one year of experi- 
ence treating the mentally retarded under the supervision of a 
Qualified Mental Retardation Professional. 

d. "Resident Care Worker" -- nn employee of the institution, other than 
a Qualified Mental Retardation Professional, whose duties require 
regular contact with or supervision of residents. 

e. "ll.ibilltation" — the process by which the staff of the institution 
nsniats the resident to acquire and maintain those life skills which 
en/iblo him to copo more effectively with the dcrar.nda of his own person 
and of his environment and to raise the level of his physical, mental, 
and social efficiency. Habllltation includes but is not limited to 



programs of formal, structured education and treatment. 

f. "Education" -- the proceaa of formal training and Instruction to 
facilitate the intellectual and emotional development of residents. 

g. "Treatment" -- the prevention, amelioration and/or cure of a 
rcsldent^a physical disabilities or Illnesses. 

h. "Guardian" -- a general guardian of a resident, unless the general 
guardian la missing, indifferent to the welfare of the resident or 
has an interest adverse to the resident. In such a case, guardian 
shall be defined as an individual appointed by an appropriate court 
on the motion of the superintendent, such guardian not to be in the 
control or in the employ of the Alabama Board of Mental Health, 
i. "Express and Informed Consent" — the uncoerced decision of a resident 
who has comprehension and can signify assent or dissent. 
II. Adequate TInbilltntion of Residents 

1. Residents shall have a right to habllitatlon, Including medical treatment, 
education and care, suited to their needs, regardless of age, degree of 
retardation or handicapping condition. 

2. Each resident has a right to a habllitatlon program which will maximize 
his human abilities and enhance his ability to cope with his environment. 
The institution shall recognize that each resident, regardless of ability 
or status, is entitled to develop and realize his fullest potential. The 
institution shall implement the principle of normalization so that each 
resident may live as normally as possible. 

3. a. No pcrnon ahnll be admitted to the institution unless a prior dctormina- 

1/ 

(lull riliii I I Iwivn lifcii Ill/Ill'- ' I liiil I Kti I iIimhT III ( lin I iin I I t III I Kit in I lio 

leust roBtrictlve habilltntion acLting feasible for that person. 

b. No mentally retarded person shall be admitted to the institution if 
ncrviccs and projjrams in the community can afford adequate hnbllitation 
to ouch pcraon. 

c. Rcsldcnta sliall have a right to the least restrictive conditions 
neccsoary to achieve the purposes of habllitatlon. To this end, the 
institution shall make every attempt to move residents from (1) more 

1/ See Standard 7, Infra . 

-12- 



to less structured living; (2) larger to smaller facilities, (3) larger 
to smaller living units; (A) group to individual residence; (5) segre- 
gated from the community to integrated into the community living; 
(6) dependent to independent living. 

4. No borderline or mildly mentally retarded person shall be a resident of the 
institution. For purposes of this standard, a borderline retarded person 
is defined as an individual who is functioning between one and two standard 
deviations below the mean on a standardized intelligence tf.at such as the 
Stanford Binet Scale and on measures of adaptive behavior such as the 
American Association on Mental Deficiency Adaptive Behavior Scale. A 
mildly retarded person is defined as an individual who is functioning 
between two and three standard deviations below the mean on a Standardized 
intelligence test such as the Stanford Binet Scale and on a measure of 
adaptive behavior such as the American Association on Mental Deficiency 
Adaptive Behavior Scale. 

5. Residents shall have a right to receive suitable educational services 
regardless of chronological age, degree of retardation or accompanying 
disabilities or handicaps. 

a. The institution shall formulate a written statement of educational 
objectives that is consistent with the institution's mission as set 
forth in Standard 2, supra , and the other standards proposed herein. 

b. School-age residents shall be provided a full and suitable educational 
program. Such educational programs shall meet the following minimum 

standards: 

2/ 
Mild~ Moderate Severe/Profound 

(1) Class Size 12 9 6 

(2) Length of school 

year (in months) 9-10 9-10 11-12 

(3) Minimum length of 
school day (in 

hours) 6 6 6 



1_l As is reflected in Standard 4, supra , it is contemplated that no mildly 
retarded persons be residents of the institution. However, until those mildly 
retarded who are presently residents are removed to more suitable locations 
and/or facilities, some provision must be made for their educational program. 



-13- 



.. ^^ .,__.„ .»-~.-<>«.jnifiiiniii^j»^p— j«i^— ■^■■^■i»-»--i ■■■■ i^^^w^jij'j-CTi 



>^ 



6. Residents shall have a right to receive prompt and adequate medical 
treatment for any physical ailments and for the prevention of any Illness 
or disability. Such medical treatment shall meet standards of medical 
practice In the community* 

III. Indlvldunllzed H.-vbilltatlon Plans 

7. Prior to his admission to the Institution, each resident shall have a 
comprehensive social, psychological, educational, and medical diagnosis 
and evaluation by appropriate specialists to determine if admission Is 
appropriate. 

a. Unless such preadmission evaluation has been conducted within three 

months prior to the admission, each resident shall have a new evalu- 
ation at the Institution to determine If admission is appropriate. 

b. When undertaken at the institution, preadmission diagnosis and 
cvnluntton shall bo completed within five days. 

8. Within 14 dnys of his admission to the Institution, each resident shall have 
an cvnliiation by appropriate specialists for programming purposes. 

9. Lach resident shall have an Individualized habllltatlon plan formulated by 
the Institution. This plan shall be developed by appropriate Qualified 
Mental Retardation Professionals and Implemented as soon as possible but 
no later than 14 days after the resident's admission to the Institution. 
An Interim program of habllltatlon, based on the preadmission evaluation 
conducted pursuant to Standard 7, supra , shall commence promptly upon the 
resident's admission. Each individualized habllltatlon plan shall contain: 

a. a statement of the nature of the specific limitations and specific 
needs of the resident; 

b. a description of Intermediate and long-range habllltatlon goals with 
a projected timetable for their attainment; 

c. a statement of, and an explanation for, the plan of habllltatlon for 
achieving these intermediate and long-range goals; 

d. a statement of the least restrictive setting for habllltatlon 
necofifinry to achieve the habllltatlon goals of the resident; 

e. a Hpocl flcatlon of the professionals and other staff members who are 
rcrponolblc for the particular resident's attaining these habllltatlon 
i'.onla; 



•14- 



f. criteria for release to less restrictive settinge for habiiitation, 
including criteria for discharge and a projected date for discharge, 

10. As part of his habilitation plan, each resident shall have an ind^ v . ualized 
post-in.stitutionalization plan. This plan shall be developed by a Qualified 
Mental Retardation Professional who shall begin preparation of such plan 
prior to the resident's admission to the institution and shall complete such 
plan as soon as practicable. The guardian or next of kin of the resident 
and the resident, if able to give informed consent, shall be consulted in 
the development of such plan and shall be informed of the content of such 
plan. 

11. In the interests of continuity of care, one Qualified Mental Retardation 
Professional shall be responsible for supervising the implementation of the 
habilitation plan, integrating the various aspects of the habilitation 
program, and recording the resident's progress as measured by objective 
indicators. This Qualified Mental Retardation Professional shall also be 
responsible for ensuring that the resident is released when appropriate to 
a less restrictive habilitation setting. 

12. The habilitation plan shall be continuously reviewed by the Qualified Mental 
Retardation Professional responsible for supervising the implementation of 
the plan and shall be modified if necessary. In addition, six months after 
admission and at least annually thereafter, each resident shall receive a 
comprehensive psychological, social, educational and medical diagnosis and 
evaluation, and his habilitation plan shall be reviewed by an interdisci- 
plinary team of no loss than two Qualified Mental Retardation Professionals 
and such resident care workers as are directly involved in his habilitation 
and care. 

13. In addition to habilitation for mental disorders, people confined at mental 

health institutions also are entitled to and shall receive appropriate 

3/ 
treatment for physical illnesses such as tuberculosis. In providing medi- 
cal care, the State Board of Mental Health shall take advantage of whntt^ver 
community-based facilities are appropriate and available and shall coordinate 
the resident's habilitation for mental retardation with his medical treatment. 



2/ A[-,proxLmntely 50 patients at Brycc-Searcy are tubercular &a also are 
approximately four rcsldcntfl at Partlow, 



•15- 



14. Com])IeLc records for each resident shall be maintatned and shall be readily • 
available to Qualified Mental Retardation Professionals and to the resident 
care workers who are directly involved with the particular resident. All 
informntion contained in a resident's records shall be considered privileged 
and confidential. The guardian, next of kin, and any person properly 
authorized in writing by the resident, if such resident is capable of giving 
informed conr.cnt, or by his gunrdian or next of kin, shall be permitted 
access to the rciiidcnt's records. These records shall include: 

a. Identification data, including tlie resident's legal status; 

b. The resident's history, including but not limited to: 

(1) family data, educational background, and employment record; 

(2) prior medical history, both physical and mental, including 
prior Innt tCutional I7./1I Ion; 

c. Tlio resident's grievances if any; 

d. An inventory of the resident's life skills; 

c, A record of each physical examination which describes the results 
of the examination; 

f. A copy of the individual habilitation plan and any modifications 
thereto and an appropriate summary which will guide and assist the 
resident care workers in implementing the resident's program; 

g, Tlie findings made in periodic reviews of the habilitation plan (see 
Standard 12, supra ) . which findings shall include an analysis of 
the successes and failures of the habilitation program and shall 
direct whatever modifications are necessary; 

h. A copy of the post-institutionalization plan and any modifications 

thereto, and a summary of the steps that have been taken to implement 
that plan; 

t. A medication history and status, pursuant to Standard 22, infra ; 

j. A summary of each significant contact by a Qualified Mental Retarda- 
i.ion Professional with the rer.idcnt; 

k, A fiumniary of Lhc resident's response to his program, prepared by a 
Qualified Mental Retardation Professional involved in the resident's 
hnl>tlitnLion and recorded at least monthly. Such response, wherever 
possible, shall be scientifically documented. 



-16- 



1. A monthly summary of the extent and nature of the resident's 
work activities described In the Standard 33(b), infra and the 
effect of such activity upon the resident's progress along the 
habilitation plan; 

m. A signed order by a Qualified Mental Retardation Professional 
for any physical restraints, as provided in Standard 26(a)(1), 
tnf ra ; 

n. A description of any extraordinary incident or accident in the 

institution involving the resident, tc be entered by a staff member 
noting personal knowledge of the incident or accident or other 
source of information, including any reports of investigations of 
resident mistreatment, as required by Standard 28, infra ; 

o. A ffiuinnary of family visits and contacts; 

p. A summary of attendance and leaves from the institution; 

q. A record of any seizures, illnesses, treatments thereof, and 
immunizations , 
IV. Humnno Phyr^tcal and Psychological Environment 

15. Residents shall have a right to dignity, privacy and humane care, 

16. Residents shall lose none of the rights enjoyed by citizens of Alabama and 
of the United States solely by reason of their admission or commitment to 
the InnLltuCton, except ns expressly determined by an appropriate court. 

17. No person shall be presumed mentally incompetent solely by reason of his 
admission or commitment to the institution, 

18. The opportunity for religious worship shall be accorded to each resident 
who donircs such worship. Provisions for religious worship shall be made 
avaLlablo to all residents on a nondiscriminatory basis. No individual 
nhnll be coorcod into engaging in any religious activities. 

19. Kofil.dcntn uh/ill have the same rij'.hts to telephone communication as patients 
at Alabama public hospitals, except to the extent that a Qualified Mental 
Retardation Professional responsible for formulation of a particular 
resident's habilitation plan (see Standard 9, supra ) writes an order 
Irripor.ing special restrictions and explains the reasons for any such 
restrictions. The written order must be renewed semiannually if any restric- 
tions arc to be continued. Residents shall have an unrestricted right to 



•17- 



visitation, except to tlic extent that a Qualified Mental Retardation Pro- 
fc38ionnl rcsponr.ible for formulation of a particular resident's 
hnbilitntion plan (ace Standard 9, puprn ) writes an order imposing special 
restrictions and explains the reasons for any such restrictions. The written 
order must be renewed semiannually if any restrictions are to be continued. 

20. Residents shall be entitled to send and receive scaled mail. Moreover, it 
shall be the duty of the institution to facilitate the exercise of this 
right by furnishing the necessary materials and assistance. 

21. The institution shall provide, under appropriate supervision, suitable 
opportunities for the resident's interaction with members of the opposite 
sex, except where a Qualified Mental Retardation Professional responsible 
for the formulation of a particular resident's habilitation plan writes an 
or«lor to iho contrary and explains the reasons tliorefor. 

22. Modicat Ion ; 

a. No medication shall be administered unless at the written order of a 
physician. 

b. Notation of each individual's medication shall be kept in his medical 

records (Standard 14(i) siipra ). At least weekly the attending physician 
f 

shall review the drug regimen of each resident under his care. All 

prescriptions shall be written with a termination date, which shall not 

exceed 30 days, 

c. Residents shall have a right to be free from unnecessary or excessive 
medication. The resident's records shall state the effects of psycho- 
active medication on the resident, Wlien dosages of such are changed 
or other psychoactive medications are prescribed, a notation shall be 
made in the resident's record concerning the effect of the new medica- 
tion or new dosages and the behavior changes, if any, which occur, 

d. Medication shall not be used as punishment, for the convenience of 
staff, as a substitute for a habilitation program, or in quantities 
that interfere with the resident's habilitation program. 

e. I'harmacy services at the institution shall be directed by a professionally 
competent pharmacist licensed to practice in the State of Alabama, Such 
pharmacist shall be a graduate of a school of pharmacy accredited by the 
American Council on Pharmaceutical Education, Appropriate officials 



•10- 



of the institution, at their option, may hire such a pharmacist or 
pharmacists fulltimc or, in lieu thereof, contract wich ou'csid? 
pharmacists. 

f. Wlicther employed fulltime or on a contract basis, the pharmacist shaiJ. 
perform ciuttes which include but are not limited to the following: 

(1) Receiving the original, or direct copy, of the physician's drug 
treatment order; 

(2) Reviewing the drug regimen, and any changes, for potentially adverse 
reactions, allergies, interactions, contraindications, rationr 3 i ty, 
and laboratory test modifications and advising the physician of 

any recommended changes, with reasons and with an alternate drug 
regimen; 

(3) Maintaining for each resident an Individual record of all medica- 
tions (prescription and nonprescription) dispensed, including 
quantities and frequency of refills; 

(4) Participating, as appropriate, in the continuing interdisciplinary 
evaluation of individual residents for the purposes of initiation, 
monitoring, and follow-up of individualized habilitation programs, 

g. Only appropriately trained staff shall be allowed to administer drugs. 

23. Seclusion, defined as the placement of a resident alone in a locked room, 
shall not be employed. Legitimate "time out" procedures may be utilized 
under close and direct professional supervision as a technique la behavior- 
shaping programs. 

24. Behavior modification programs involving the use of noxious or aversive 
stimuli shall be reviewed and approved by the institution's Human Rights 
Committee and shall be conducted only with the express and informed consent 
of the affected resident, if the resident is able to give such consent, and 
of his guardian or next of kin, after opportunities for consultation with 
independent specialists and with lecal counsel. Such behavior mooification 
pro;;rajiK; shall be conducted only under the supervision of and in the 
pro;;oncc ni: a Qualified Mental Retardation Professional who has had proper 
trainin,'"; in such techniques. 

25. tlcctric shock devices shall be considered a research technique for the 
purpose of those standards. Such devices shall only be used in extraordinary 

-19- 



circumsLanccr, to prevent self-muti Intion leading to repeated and possibly 
permanent physical damage to the resident and only after alternative tcch- 
nicjucG have failed. The use of such devices shall be subject to the 
conditions prescribed in Standard 24, stipra, and Standard 29, infra, and 
shall bo usetl only under the direct and specific order of the superintendent, 

26. Physical restraint shall be employed only when absolutely necessary to pro- 
tect tlie resident from injury to himself or to prevent injury to others. 
Restraint shall not be employed as punishment, for the convenience of staff, 
or nn n (uil)iiLJ.tute for n habilltatlon program, Kcntrnlnt nhall l)o applied 
only if alternative techniques have failed and only if such restraint 
imposes the least possible restriction consistent with its purpose. 

a. Only Qualified Mental Retardation Professionals may authorize the 
use of restraints, 

(1) Orders for restraints by the Qualified Mental Retardation 
Professionals shall be in writing and shall not be in force 
for longer than 12 hours, 

(2) A resident placed in restraint shall be checked at least every 

/ 

' 30 minutes by staff trained in the use of restraints, and a 

record of such checks shall be kept, 

(3) Mechanical restraints shall be designed and used so as not to 
cause physical injury to the resident and so as to cause the 
least possible discomfort, 

(4) Opportunity for motion and exercise shall be provided for a 
period of not less than ten minutes during each two hours in 
which restraint is employed, 

(5) Daily reports shall be made to the superintendent by those 
Qualifiod Mental Retardation Professionals ordering the use 

of rofitralntd, fiiinuiiarlzing all sucli uses of reatraint, the typos 
used, the duration, and the reasons therefor, 
h. Tho institution shall rausc a written statement of this policy to be 
posted in each living unit and circulated to all staff members, 

27. Corporal puninhmcnt r.hall not be permitted. 

20. The Institution shall prohibit mistreatment, neglect or abuse in any form 
of any resident. 

-20- 



a. Alleged violationG shall be reported immediately to the supcrln- 
itMulcnt ami llirrc sliall bo n written record that: 

(V) I'.u'li allo)',od violation hnn hron tlioiwu^hlv iuvont i [•nt «mI nnti 
findings stated j 

(2) ^ The results of eiich investigation are reported td the superin- 
tendent and to the commissioner within 24 hours of the report 
of the incident. Such reports shall also be made to the 
institution's Human Rights Committee rmnthly and to the 
Alabama Board of Mental Health at its next scheduled public 
meeting. 

b. The institution shall cause a written statement of this policy to 

be posted in each cottage and building and circulated to ail staff \ 
members, 

29, Residents shall have a right not to be subjected to experimental research 
without the express and informed consent of the resident j if the resident 
is able to give such consent, and of his guardian or next of kin, after 
opportunities for consultation with independent specialists and with legal 
counsel. Such proposed research shall first have been reviewed and approved by 
the institution's Human Rights Committee before such consent shall be sought. 
Prior to such approval the institution's Human Rights Committee shall 
determine that such research complies with the principles of the Statement 

on the Use of Human Subjects for Research of the American Association on 
Mental Deficiency and with the principles for research involving human 
subjects required by the United States Department of Health, Education 
and Welfare for projects supported by that agency. 

30, Residents shall have a right not to be subjected to any unusual or hazardous 
treatment procedures without the express and informed consent of the resident, 
if the resident is able to give such consent, and of his guardian or next 

of kin, after opportunities for consultation with independent specialists 
and legal counsel. Such proposed procedures shall first have been reviewed 
and approved by the institution's Human Rights Committee before such consent 
shall be .souj;;ht, 

31, Rosidcntn shall have a right to regular physical exercise several times a 
wo.'k. It (ihall ho the duty of tho Institution to provide both indoor and 
oulilooi- 1 (ic I 1 I I ( I'M /mil cqii I |iiii(Mil lor ;iinli oxi-ioliic, 

-21- 



32. Rcsidonts .shall have a ric^it to be outdoors daily in the absence of 
contr.Try modical considerations. 

33. The iollowing rules shall govern resident labor: 

a. IiT-. r it III ion M.-iiiiton.incc 

(1) No tcsidcnt shall be required to perform labor which involves 
the operation and maintenance of the institution or for which the 
institution is under contract with an outside organization. 
Privileges or release from the institution shall not be conditioned 
upon the performance of labor covered by this provision. Residents 
may voluntarily engage in such labor if the labor is compensated 

in accordance with the minimum wage laws of the Fair Labor Standards 
Act, 29 U.S.C. § 206 as amended, 1966. 

(2) No resident shall be involved in the care (feeding, clothing, 
bathing), training, or supervision of other residents unless he: 

(a) has volunteered; 

(b) has been specifically trained in the necessary skills; 

(c) has tlie humane judgment required for such activities; 

(d) is adequately supervised; and 

(q) is reimbursed in accordance with the minimum wage laws of the 
Fair Labor Standards Act, 29 U,S.C. § 206 as amended, 1966, 

b. TrainJ.nr, Tasks nnd Labor 

(1) Residents may be required to perform vocational training tasks 

which do not involve the operation and maintenance of the institu- 
tion, subject to a presumption that an assignment of longer than 
three months to any task is not a training task, provided the 
specific task or any change in task assignment is: 

(a) An intc[;ratcd part of the resident's habilitation plan and 
approved as a liabilitation activity by a Qualified Mental 
Rit.irdation Profcsiiional responsible for supervising the 
re .'I idfnt ' s hnbilitation ; 

(b) Supervised by a staff member to oversee the habilitation 
aspects of the activity, 

(;;) Uesldcats may voluntarily < n/;age in habilitative laoor at nonprograra 
hours lor. which the institution would otherwise have to pay an 



•72- 



employee, provided the specific labor or any change in labor la: 

(a) An integrated part of the resident's habtlltatlon plan 
and approved as a habilitation activity by a Qualified 
Mental Retardation Professional reaponsible for supervising 

s 

the resident's habilitation; 

(b) Supervised by a staff member to oversee the habilitation 
aspects of the activity; and 

(c) Compensated in accordance with the minimum wap.c laws of the 
I'd I !• l.nhoi" ol niiilai'<!n AoL, 29 U.Ii. C, S ?-0G an amomlcd, l').t(>t 

c. IVTNnnnl HiMir.pV.repinf. Residents may be required to perform tasks of a 
personal housekeeping nature such as the making of one's own bed, 

d. Payment to residents pursuant to this paragraph shall not be applied to 
the costs of Institutionalization, 

e. Staffing shall be sufficient so that the institution is not dependent 
upon the use of residents or volunteers for the care, maintenance or 
habilitation of other residents or for Income-producing services. The 
Institution shall formulate a written policy to protect the residents 
from exploitation when they are engaged in productive work. 

34, A nourishing, well-balanced diet shall be provided each resident. 

a. The diet for residents shall provide at a minimum the Recommended Dally 
Dietary Allowance as developed by the National Academy of Sciences. 
Menus shall be satisfying and shall provide the Recommended Daily 
Dietary Allowances, In developing such menus, the institution shall 
utilize the Moderate Cost Food Plan of the United States Department of 
Aijriculturc. Tlie Institution shall not spend less per patient for raw 
food, including the value of donated food, than the most recent per 
perr.on costs of the >bdrrate Cont Food Plan for the Southern Region of 
l\\c United Ctaten, ao Comi)tlcd by the United States DrpnrLinont of 
Agriculture, for appropriate groupings of residents, discounted for any 
savingr, which might result from institutional procurement of such food. 

b. Provisions shall bo made for special therapeutic diets and for substitutes 
at the request of the resident, or his guardian or next of kin, in 
accordance with the roligioun requirements of any resident's faith. 

c. Denial of a nutritionally adequate diet shall not be used as punishment, 

-23- 



d. Ucsi-dcnts, except for the non-mobile, shall eat or be fed in dining 

I'oor.is, 

35. \i.nc\\ resident r.hnll have an ndcquotc allowance of neat, clean, suitably 
fittinn .nnd r.c.iGonnblc clothing. 

a. h.nch rostdotit rIi.tII have his ovai clothing, which is properly and 
inconspicuously marked with his name, and he nhall be kept drcsncd in 
thif. clothing. The institution has an obligation to supply an adequate 
allowance of clothing to any residents who do not have suitable clothing 
of their own. Residents shall have the opportunity to select from 
various types of neat, clean, and seasonable clothing. Such clothing 
shall be considered the resident's throughout his stay in the insti- 
tution. '^ 

b. Clothing both in amount and type shall make it possible for residents to 
go out of doors in inclement weather, to go for trips or visits appro- 
priately dressed, and to make a normal appearance in the community, 

c. Nonnmbulatory residents shall bo dressed daily in their own clothing, 
including shoes, unless contraindicated in written medical orders, 

d. Washable clothing shall be designed for multiply handicapped residents 
being trained in self-help skills, in accordance with individual needs. 

e. Clothing for incontinent residents shall be designed to foster 
CDnifortablc sitting, crawling and/or walking, and toilet training, 

f. A current inventory shall be kept of each resident's personal and 
clothing items, 

g. The Institution shall make provision for the adequate and regular 
Ijumdcring of the residents' clothing. 

36. Lach resident sliall have the right to keep and use his own personal possessions 
except insofar ae such clothes or personal possessions may be determined to 

be dnni'.crous, cither to himself or to others, by a Qualified Mental 
RcLard.'ition Professional. 

37. a. Each resident shall be assisted in learning normal grooming practices 

with individual toilet articles, including soap and toothpaste, that 
ai'c available to each resident, 
b. T<olh sliall be bruc.hed daily with an effective dentifrice. Individual 
l*runlicn shall be properly marlccd, used, and stored. 

-?4- 



c. Ench resident shall have a shower or tuD bath at least dall ', unlesa 
medically contraindlcated. 

d. Residents shall be regularly scheduled for hair cutting and ; /iir.g, 
in an individualized manner, by trained persoi\ncl , 

c. For rosidpnts who require such assistance, cutting of toe nails and 
finccrnails shall be scheduled at regular intervals. 
38. Physi cal Facilities A resident has a right to a humane physical environment 
within the institutional facilities. These facilities shall be designed to 
make a positive contribution to the efficient attainment of the habilitation 
goals of the institution. 

a. Rr -sidcnt Unit All ambulatory residents shall sleep in single rooms or 
in multi-resident rooms of no more than six persons. The number of 
nonambulatory residents in a multi-resident room shall not exceed ten 
persons. There shall be allocated a minimum of 80 square feet of floor 
space par resident in a multi-resident room,, Screens or curtains shall 
be provided to ensure privacy. Single rooms shall have a minimum of 
IjO square feet of floor space. Each resident shall be furnished with 
a comfortable bed with adequate changes of linen, a closet or locker 

fur liln (KT ni>ii 1 1 liol (>ii)> I ii|i.n , (iiiil npiuiijn I n I «> fiiiiillnip pix h na ;i < Im I i- 
find a bcduldt: talile, uiileus contvaiudicated by a Qualified Mental Retarda- 
tion Professional who shall state the reasons for any such restriction. 

b. Ton.otri nnd Lavatories There shall be one toilet and one lavatory for 
each six residents. A lavatory shall be provided with cacli toilet 
facility. The toilets shall be installed in separate stalls for 
ambulatory residents, or in curtained areas for nonambulatory residents, 
to ensure privacy, shall be clean and free of odor, and shall be equipped 
witli appropriate safety devices for the physically handicapped. Soap 
and towels and/or drying mochnnisins ohnll be available in each lavatory. 
Toilet paper shall be available In cacli toilet facility, 

c. .Shni.'crs There shall be one tub or shower for each eight rcr^iilcncs. If 
a central bathing area is provided, each tub or shower shall be divided 
by curtains to ensure privacy. Shov/ers and tubs shall be equipped with 
(iil(>f|uatc safety accessories. 

d. ]):\y lioDin The minimum day romn area shall be 40 aquarc £cct per resident, 

-25- 



Day rooms shall be attractive and adequately furnished with reading 
lamps, tables, chairs, television, radio and other recreational 
facilities. They shall be conveniently located to residents' bcdrooma 
and shall have outside windows. There shall be at least one day room 
area on "each bedroom floor in a multi-story facility. Areas used for 
corridor traffic shall not be counted as day room space; nor shall a 
chapel with fixed pews be counted as a day room area, 

e. Dlnln.", ]'.>ct] Itlcs The minimum dining room area shall be ten square feet 
per resident. The dining room shall be separate from the kitchen and 
tihall be furnished with comfortable chairs and tables with hard, 
washable surfaces. 

f. Linen Srrvicinr^ and Handlinf^ The institution shall provide adequate 
facilities and equipment for the expeditious handling of clean and 
soiled bedding and other linen. There must be frequent changes of 
bedding and other linen, but in any event no less than every seven days, 
to assure sanitation and resident comfort. After soiling by an inconti- 
nent resident, bedding and linen must be immediately changed and removed 
from the living unit. Soiled linen and laundry shall be removed from 
the living unit daily. 

g. llour.okoopin?'. Regular housekeeping and maintenance procedures which 
will ensure that the institution is maintained in a safe, clean, and 
attractive condition shall be developed and implemented, 

h. Nonambulatory Residents There must be special facilities for nonambula- 
tory residents to assure their safety and comfort, including special 
fittings on toilets and wheelchairs. Appropriate provision shall be 
made to permit nonambulatory residents to communicate their needs to 
ntnff, 

I,. i'Jij/jiL'i'J !'.L"iil. 

(1) Pursuant to an CGtablichcd routine maintenance and repair program, 
the physical plant shall bo kept in a continuous state of good 
repair and operation so as to ensure the health, comfort, safety 
and wcll-bcin;; of the residents and so as not to impede in any 
manner the liabilitation programs of the residents. 



■ 26- 



(2) Ailcqitnto hontinf}, air coiut it tonini', and vcntllnLion syr.tcmM and 
cqulpinci'it nhnll be n£lor<lrtl to mniatnin tcnipcrn tviros and nlr 
rli.ui)'rri whii'li ;u<- riM|\i I ii-il liir I In' ((iinl o il of rrn I iW-ii I n n{ nil 
tliiioH. Vcntil'itlon nysLcmn shall be ndeqiinLc Lo remove lU e/iiii and 
offensive odors or to mar.k such odors. The temperature tn the 
institution shall not exceed 83°F nor fall below 68 F. 

(3) Thermostatically controlled hot water shall be provided in adequate 
quantities and maintained at the required temperature for resident 
use (110°F at the fixture) and for mechanical dishwashing and 
laundry use (180°F at the equipment). Thermostatically controlled 
hot water valves shall be equipped with a double valve system that 
provides both auditory and visual signals of valve failures. 

(4) Adequate refuse facilities shall be provided so that solid waste, 
rubbish and other refuse will be collected and disposed of in a 
manner which will prohibit transmission of disease and not create 
a nuisance or fire hazard or provide a breeding place for rodents 
and insects. 

(5) The physical facilities must meet all fire and safety standards 
cfltablishcd by the state and locality. In addition, the institution 
shall meet such provisions of the Life Safety Code of the National 
Fire Protection Association (21st edition, 1967) as are applicable 
to it. 

V. Qunlifled Staff in Numbers Sufficient to Provide Adequate Habilitation 

39. K.ich Qualified Mental Retardation Professional and each physician shall meet 
all licensing and certification requirements promulgated by the State of 
Alabama for persons engaged in private practice of the same profession else- 
where in Alabama. Other staff members shall meet the same licensing and 
certification requirements as persons who engage in private practice of their 
specialty elsewhere in Alabama. 

a. All resident care work(!rs who have not had prior clinical experience in 

a mental retardation institution shall have suitable orientation training. 

b. Staff members on all levels shall have suitable, regularly scheduled 
in-service training. 

40. j;.ich rc'-.tdcnt c.ire worker shall be undor the direct professional supervision 
of a (,>Li.i] I ( ir'<l Mental Retardation Professional. 



•27- 



Al. Staff in}'. H.nelor. 

a. Qualified ctnff in numbers sufficient to administer adequate habili- 
tation shall be provided. Such staffing shall include but not be limited 
to the followinc fulltime professional and special services. Qualified 
Mental Retardation Professionals trained in particular disciplines may 

in appropriate situations perform r^ervices or functions traditionally 
performed by members of other disciplines. Substantial changes in staff 
deployment may be made with the prior approval of this Court upon a 
clear and convincing demonstration that the proposed deviation from this 
Htaffin,", r.tructurc would enhance the habilitation of the residents. 
Profo.'ir.ional (staff shall possess the qualifications of Qualified Mental 
Retardation Professionals as defined herein unless expressly stated 
otherwise. 

b. Unit 

(1) Pcychologists 

(2) Social Workers 

(3) Special educators (shall 
include an equal number 
of master's degree and 
bacliclor's degree holders- 
In special education) 

(4) Vocational Therapists 1:60 1:60 

(5) Recreational Therapists 1:60 1:60 1:60 
(shall be master's degree 
graduates from an accredi- 
ted program) 

(6) Occupational Therapists 

(7) Registered Nurses 1:60 

(8) Resident Care VVorkers 1:2.5 

Tlie following professional staff shall be fulltime employees of the 
institution who shall not be assig.ned to a single unit but who 
shall be available to meet the needs of any resident of the 



4/ 

Mild 

60 


Moderate 
60 


Severe/Profound 
60 


1:60 


1:60 


1:60 


1:60 


1:60 


1:60 


1:15 


1:10 


1:30 



— 


1:60 


1:60 


1:12 


1:1.25 


1:1 



h_l Sec n. 2, suprn . 



•28- 



institution: 

I'hysicians 1:200 

Physical Therapists 1:100 

Speech & llonring Therapists 1:100 

Dentists" 1:200 

Social V/orkcrs (shall be principally involved 1:80 
in the placement of residents in the community 
and shall include bachelor's degree graduates 
from an accredited program in social work) 

6/ 
Chaplains 1:200 

c. Qualified medical specialists of recognized professional ability shall 

be available for specialized care and consultation. Such specialist 

ncrvicet; shall include a psychiatrist on a one-day per week basis, a 

phyr; l.nl risi on n tw(i-<lny per week hnfiln, and any other medical or 

heal Lli-ri'laLed ni)ccinlily available in the comn\unlty. 

VI, Ml srcl Taneoiir. 

42. Tlie guardian or next of kin of each resident shall promptly, upon resident's 
admisaion, receive a written copy of all the above standards for adequate 
hnbil Itation. Each resident, if the resident is able to comprehend, shall 
promptly upon his admission be orally informed in clear language of the above 
standards and, where appropriate, be provided with a written copy. 

43. The superintendent shall report in writing to the next of kin or guardian of 
the resident at least every six months on the resident's educational, vocational 
and living skills progress and medical condition. Such report shall also state any 
appropriate habilitation program which has not been afforded to the resident 
because of inadequate habilitation resources. 

44. a. No resident shall be subjected to a behavior modification program designed 

to cUminntc n particular pattern of behavior without prior ccrfl f I c.n t ion 
l>y II ))hy;i 1 «.■ I .111 Lhnl. li<; liaii cxiiiii I ncil the VfiililfuL ill r»'^J,iiril to heh.'ivivU- Co 
hv u;:t inj^uislied iind finds that such behavior is not caused by a physical 
condition wliich could be corrected by appropriate medical procedures. 



_5/ i)(' fcirii.-ml :■ iii.iy, in IJ.cu of omploying f'ulltimc dentists , contract outside the 
Inntltiil ioi) for d.-iii .il c.iri'. In thin event the dental services provided th<^ residents 
must iiiclnde (,)) compi ote il.-iit.d cxniuin/it: ions and appropriate corrective dental work 
for (-ach re;.i,;e;iC each six inontlis and (b) a dentist on call 24 hours per day for 
enicr)',rncy woric. 

f}/ 1J(;I entlnai ;; ui.iy, in lieu of emplnylnj', fulltime chaplains, recruit, upon the ratio 
nliown /ibovc, inter faith volunti-er chaplains. 

-29- 



b. No resilient shall be subjected to n behavior modi f icntion program which 
attenipto to cxtiiii'.niiih socinlly .ippropria tc bcimvior or to develop new 
bolmvior pattcrna when such behavior modifications serve only institu- 
tionnl convenience. 
45. No rc;.ident shall have any of his organs removed for the purpose of 

transplantation without compliance with the procedures set forth in Standard 
30, njjjnvi, and after a court hearing on such transplantation in which the 
resident is represented by a guardian ad litem . This standard shall apply 
to any other surgical procedure which is undertaken for reasons other than 
therapeutic benefit to the resident. 
A6. Within 90 days of the date of this order, each resident of the institution 
shall be evaluated as to his mental, emotional, social, and physical 
condition. Such evaluation or reevaluation shall be conducted by an inter- 
disciplinary team of Qualified Mental Retardation Professionals who shall use 
professionally recognized tests and examination procedures. Each resident's 
;;uardian, next of kin or legal representative shall be contacted and his 
readiness to make provisions for the resident's cnre in the community shall 
!)<■• nricf'rlnlnrd. F.acli resident shall be returned to liis family, if adequately 

IkiIi I I I I III t'.l , III (iniii )'.immI I.I Ihc' leant I'lrll r I <' I I Vo h/il> I M I ill I t>it ihiIIIuk. 

A7. iJ.iih resilient di3char;;cd to tlic connnunity shall have a program of transitional 
liabill tation assistance. 

48. The inntitution shall continue to suspend any new admissions of 
rciiidonts until all of the above standards of adequate habilltation have 
been met. 

49. No person shall be admitted to any publicly supported residential institution 
cariu;'; for mentally retarded persons unless such institution meets the above 
stnndarvls . 



-30- 



APPKNDTX n 



PARTLOW HUMAN RIGHTS CaiMITTEE 



1. Ms. Harriet S. Tillman - Chairman - 3544 Brookwood Road, Birmingham, Alabama 



2. Dr. J. W. Benton 

3. Mr. Paul R. Davis 

4. Reverend Robert Kcever 

5. Ms. Nancy Poole 

6. Mr. liugcne Ward 

7. Ms. Eotcllc Witherspoon 



- 3008 Brook Hollow Lane, Birmingham, Alabama 

- Tuscaloosa News, Tuscaloosa, Alabama 35401 

- University Presbyterian Church, Tuscaloosa, 

Alabama 35401 

- 1836 Dorchester, Birmingham, Alabama 

- c/o Partlow State School and Hospital, 

Tuscaloosa, Alabama 35401 

- Alberta, Alabama 36720 



o 



FILED 



IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE 

DISTRICT OF ALABAMA, NORTHERN DIVISION APR 2] 1972 



RICKY WYATT, by nnd throiich 
lilr. a\int and legal guardian, 
Mre. W. C. RnwlinB, Jr., ET AL. 

Plaintiffs, 

vs. 

DR. STONOTALL B. STICKNEY, 
etc. , EX AL. , 

Defendants, 

UNITED STATES OF AMERICA, ET AL. , 

Amlci Curiae. 



JANE P. GORDON, CLERK 

BY A.-^i__ 

DEPUTY CURK 



CIVIL ACTION NO. 3195-N 



ORDER 



It is ORDKRED that the orders entered herein April 13, 1972, for 
Hrycc nnd Scnrcy Hospitals and for Partlow State School and Hospital be and 
onch ta hereby amended as follows: 

1. Standard 8 for Bryce and Searcy Hospitals be and the same is 

hereby stricken and the following is substituted therefor: 

Patients shall have a right not to be subjected 
to experimental research without the express and 
informed consent of the patient, if the patient is 
able to give such consent, and of his guardian or 
next of kin, after opportunities for consultation 
with independent specialists and with legal counsel. 
Such proposed research shall first have been re- 
viewed nnd approved by the institution's Human 
Rir.litB Committee before such consent shall be sought. 
Prior to such approval the Committee shall determine 
that siich research complies with the principles for 
rencarclj involving liuman subjects published by the 
American Psychiatric and Psychological Associations 
and with those required by the United States Depart- 
ment of Health, Education and Welfare for projects sup- 
ported by that agency. 

2. Standard 20 for Drycc and Searcy Hospitals be and the same is 

hereby stricken and the following is substituted therefor: 

Patients, except for the non-mobile, shall eat or 
bo fed in dining rooms. The diet for patients will 
provide at a minimum the Recommended Daily Dietary 
Allowances as developed by the National Academy of 
Sciences, Menus shall be satisfying and nutritionally 
adequate to provide the Recommended Daily Dietary 
Allowances. In developing such menus, the hospital 
will utilize the htoderato Cost Food Plan of the Depart- 
ment of Agriculture. The hospital will not spend less 



per patient for raw food, Including the value of donated 
food, than the most recent per person costs of the 
Moderate Cost Food Plan for tlie Southern Region of the 
United States, as compiled by the United States Depart- 
ment of Anrlculture, for npproprinte groupings of patients, 
discounted for any savings which might result from 
institutional procurement of such food. Provisions shall 
bo made for special therapeutic diets and for substitutes 
at the request of the patient, or his guardian or next of 
kin, in accordance with the religious rcqulremcats of any 
patient's faith. Denial of a nutritionally adequate diet 
shall not be used as punishment. 

It is further ORDliRliD that all references to the Fair Labor Standards 
Act in the standards promulgated by this Court for Bryce and Searcy Hospitals 
and for Partlow State School and Hospital be changed to read as follows: "Fair 
Labor Standards Act, 29 U.S.C. § 206 et. seq. as amended, 1966." 

Done, this the ^^/-^ day of jlS^H^-^ . 1972. 




^- V 



IN 'HIE UNITED STATES DISTKICT COURT FOR THE MIUDLE 

DISTRICT OF A/.AJJAMA, NORTlll.lvW DIVISION I I L E! D 



RICKY WYATT, by and through 
Ul.-; aunt nnJ lc(;.il guardian 
MRS. W. C. RAVn.INS, JR. , 
ET AL. , 

Plaintiffs, 

vs. 

DR. STONEWALL B. STICJCNEY , 
iiF? Commlasloncr of Mental 
Health and the State of 
Alabama Mental Health Officer, 
ET AL. , 

Defendants, 

UNITED STATES OF AMERICA, 
ET AL. , 

Amlcl Curiae. 



AUG 7 1972 

iANE P. GORDON, QEKK 
BY 

DlPUiy ClEKK 



CIVIL ACTION NO. 3195-N 



ORDER 

Upon consideration of the defendants' motion for an order of 
modification filed July J9, 1972, the- motion of the defendants seeking 
di.Hmi.ssal of tlicir motion for an order of modification filed August 4, 1972, 
and the plaintiffs' and the defendants' joint motion for an order of modifica- 
tion filed August 4, 1972, it is ORDERED that the order of this Court made 
and entered herein April 13, 1972, relating to the Partlow State School and 
Hospital, be and the same is hereby amended and modified as follows: 

(1) By substituting for Stanciard 46, as set out in Appendix A 

to this Court's April 13, 1972, order, tnc following: 

« 

46. On or before February 7, 1973, each residen;: of 
i;hc institution shall oe evaluated as to hit, 
r.^utal, emotion 1, social, and physical condition. 
Such evaluation or rccvaluation shall bo conductea 
by an intcrdisciplin..ry team of Qualified Moutal 
:ctardation Proiossionals who shall use profoss- 
jon.illy roco;;iiizcd L'':;ts and examination prv^CiiJurfe . 
r icli reside..; 's i^uaiwjnn, next of kin of" li-:;-'c*J 
ruprosontativc .iliali bo contacted anu h'S 5fe.idj.nets 
to make provis:.-ons for tlic resident's carfi. ift uhe 
commtinlty shail be .ascortained . Eacli res»<^6ftt 
shall be rccurnod l<- i.i.s family, ii adcqUAtC-ly 
li.ib ilitatod, olr assigned to the le.ast rostritivo 
h.ibllitation ..:>.'i_ting The defendants ...lall fix.ily 
Implem.^nt, in ,:onjuiu,tion with this Standarfl^ the ^ 

provision of Standards 9-13 relating to th 



Indivitlu.i] L::cci hnblL.tiLion p].na. If by 
October 30, 1972, two-tlilrd.) (2/3) of such 
cvaluation.s .ind plaiiB have not bocn complcLcd, 
ndditlonal staff or contract personnel shall be 
liired in order co insure that on or before 
February 7, 1973, all such cvaluatioi>; and plana 
will be compJctcu. 



(2) By adding to Standard 49, as set out in Appendix A to this 

Court's order of April 13, 1972, the following: 

49. The above standards heretofore enumerated applicable 
to Partlow as a residential facility may be modified 
and adjusted wlicn professionally and scientifically 
appropriate upon the placement of residents in less 
restrictive conununitv based alternatives consistent 
with the approved principles of Normalization as 
expressed in the professional literature. 



Done, this the 7th day or August, 1972. 



UNITED STATES DISTRICT JUDGE 



APPENDIX E 

OPINION OF THE COURT AND STANDARDS OF 
TREATMENT OF MENTAL PATIENTS: Wyatt v. Stickney 



IN THE UNITED STATES DISTRICT COURT FOR THE SffiDBLE 
DISTRICT OF ALABAMA, NOaTHBRM DIVISION 



RICKY WYATT, by and through 
his avint and legal guardian, 
Mrg. W, C. Rawlins, Jr., ET 
AL., for themselves Jointly 
and severally and for all 
others similarly situated, 



Plaintiffs, 



vs. 



DR. STONEWALL B. STICKNEY, as 
Comminsioner of Mental Health 
nnd the State of Alabama Mental 
Health Officer; JOHN V. HOTTEL, 
an Deputy Commissioner of Mental 
Health of Alabama and as Interim 
Superintendent of Partlow State 
School and Hospital at Tuscaloosa; 
DR. JAMES C. FOLSOM, individually 
and as Deputy Commissioner for 
Hospitals of the Alabama State 
Board of Mental Health; DR. JAIME 
E. CONDOM, individually and as 
Superintendent of Searcy Hospital 
af Mount Vernon, Alabama; CARL 
M. BOLEY, DR. CLAUDE L. BROWN, JR., 
DR. PAm, W. BURLESON, ED T. HYDE, 
DR. J. PAI;L JONES, DR. JOHN A. 
MARTIN, FRANK M. MOODY, DR. ROBERT 
PARKl'R, WILLARD SMITH, DR. EVERET 
STRANDKLL, DR. J. GARBER GALBRAITH 
and JACK NOLEN, as Trustees of the 
Mental Health Board of Alabama; 
THE ALABAMA MENTAL HEALTH BOARD, 
a public corporation; GEORGE C. 
WALLACE, as Governor of Alabama; 
and PliRRY 0. HOOPER, as Judge of 
Probate of Montgomery County, 
Alabama, and all other Judges of 
Probate of Alabama, Jointly and 
severally, who are similarly 
situated; and all of their suc- 
cessors in each office. 

Defendants, 

UNITED STATES OF AMERICA, the 
AMERICAN PSYCHOLOGICAL ASSOCIATION} 
the AMERICAN ORTHOPSYCHIATRIC 
ASSOCIATION; the AMERICAN CIVIL 
LIBKRTIES UNION, and the AMERICAN 
ASSOCIATION ON MENTAL DEFICIENCY, 

Amlci Curiae. 



^ ^P^^^R^^' CLERK 




PIJTY >"' f- 



CIVIL ACTION NO. 3195- 



(Bryce Hospital and Searcy Ikuspital) 



ORDER AND DECREE 



This class action originally was filed on October 23, 1970, in behalf 
of patients involuntarily confined for mental treatment purposes at Bryce Hospital, 
Tuscaloosa, Alabama. On March 12, 1971, in a formal opinion and decrae, this 



Cc<v, r AC .a that theoe Invoiuntariiy committed piitients "unquestionaoly have a 
constitutional right to receive euch individual treatment as will give each o£ 
them a realistic opportunity to be cured or to Improve his or her mental 
condition," The Court further held that patients at Bryce were being denied 
their right to treatment and that defendants, per their request, would be 
allowed six months in which to raise the level of care at Bryce to the con- 
stitutionally required minimum. Wyatt v. Stlckney . 325 F,3upp. 781 (M.D. Ala, 
1971). In this decree, the Court ordered defendants to file reports defining 
the: mission and functions of Bryce Hospital, specifying the objective and 
subjective standards required to furnish adequate care tc th.e treatable mentally 
ill and detailing the hospital's progress toward the implementation of minimum 
constitutional standards. Subsequent to this order, plaintiffs, by motion to 

amend granted August 12, 1971, enlarged their clasa to include patients involun- 

1/ 
tarily confined for mental treatment at Searcy Hospital and at Fartlow State 

2/ 
School and Hospital for the mentally retarded. 

On September 23, 1971, defendants filed their final report, from 
which this Court concluded on December 10, 1971, that defendants had failed to 
promulgate and implement a treatment program satisfying minimum medical and 
ronstltutlonal requisites. Generally, the Court found that defendants' treat- 
ment program was deficient in three fundamental areas. It failed to provide: 
(1) a humane psychological and physical environment, (2) qualified staff in 
numbers sufficient to administer adequate treatment and (3) individualized 
treatment plans. More specifically, the Court found that many conditions, such 
HA nontherapeutic, uncompensated work assignments, and the absence of any 



1/ Scnrcy Hospital, located In Mount Vernon, Alabama, is also a State institution 
designed to treat the mentally ill. On September 2, I97I5 defendants answered 
plaintiffs' amended complaint, as it related to Searcy, with the following languags! 

"DcCcndnnts fflRrce to be bound by the objective and 
nubjcctlvo stand/irds ultimately ordered by this Honor- 
able Court in this cause at both Bryce and Searcy." 

This answer obviated the necessity for this Court's holding a formal hearing on 
Lho conditions currently existing at Searcy. Nevertheless, the evidence in the 
record relative to Searcy reflects that the conditions at that institution are 
no bettor than those at Bryce. 

2/ The aspect of the case relating to Partlow State School and Hospital for the 
mentally retarded will be considered by the Court in a decree separate from the 
present one. 



-2- 



;tcmiii.ince o£ prtvncy, conetltutcd dchumnniztng factors contr ibvicinp, to i nc 
drgrncratLon of the patients' Belf-esteem. The physical facilities at Drycc 
were overcrowded and plagued by fire and other emergency hazards. The Ccrvt 
found also that most ataff members were poorly trained and that staffing ratios 
were so inadequate as to render the administration of effective treatment 
impossible. The Court concluded, therefore, that whatever trsetment was 
provided at Dryce was grossly deficient and failed to satisfy minimum medical 

and constitutional standards. Based upon this conclusion, the Court ordered 

3/ 
that a formal hearing be held at which the parties and amici would have the 

opportunity to submit proposed standards for coR?3tltutionaily adequate treat- 
ment and to present expert testimony in support of their proposals. 

Pursuant to this order, a hearing was held at which the foremost 
authorities on mental health In the United States appeared and testified as 
to the minimum medical and constitutional requisites for public institutions, 
such as Bryce and Searcy, designed to treat the mentally ill. At this hearing, 

the parties and amici submitted their proposed standards, and now have filed 

it/ 
briefs in support of them. Moreover, the parties and amici have stipulated 



2/ Tho amici in this case, including the United States of America, the 
American Orthopsychiatric Association, the American Psychological Association, 
the American Civil Liberties Union, and the American Association on Mental 
Deficiency, have performed exemplary service for which this Court is indeed 
grateful. 

4/ On March 15, 1972, after the hearing In this case, plaintiffs filed a motion 
for further relief. This motion served, among other things, to renew an earlier 
motion, filed by plaintiffs on September 1, 1971, and subsequently denied by the 
Court, to add additional parties. That earlier motion asked that the Court add: 

"AgncB Baggett, as Treasurer of the State of Alabama; 
Roy W, Sanders, as Comptroller of the State of Alabama; 
Ruben King, as Coramissioner of the Alabama Department of 
Pensions and Security, George C. Wallace as Chairman 
of the Alabama State Board of Pensions and Security, and 
James J. Bailey as a member of the Alabama State Board of 
Pensions and Security and as representative of all other 
members of the Alabama State Board of Pensions and Security; 
J. Stanley Frazer, as Director of the Alabama State 
Personnel Board and Ralph W. Adams, as a member of the 
Alabama State Personnel Board and as representative of 
all other members of the Alabama State Personnel Board." 

The motion of September 1, 1971, also sought an injunction against the treasurer 
and thp comptroller of the State paying out State funds for "non-essential 
functions" of the State until enough funds were available to provide adequately 
for the financial needs of the Alabama State Mental Health Board. 

In their motion of March 15, 1972, plaintiffs asked that, in addition to 
the above-named State officials and agencies, the Court add as parties to this 
litigation Dr. LeRoy Brown, State Superintendent of Education end Lt. Ck>vernor 
Jero Bcasley, State Senator Pierre Pelham and State Representative Sage Lyons, 
as rcprcaentativet of the Alabanui Legislature. The motion of March 15, 1972, 

(Contd.) 
-3- 



iJM- :fWMB»|pW7»TTTfl|irV>fJP.l'l» '"'flU^JiJSJULJB 



to n .jtoad Bpeclriim of conditions they feci ore mnndatory for ft constitutionnily 

Kccopfnble mlnlimim treatment program. This Court, having considered the evidence 

In the case, as well an the briefs, proposed ntandards and fltlpulationfl of the 

parties, has concluded that the standards set out in Appendix A to this decree 

are medical and constitutional mlnlmuina. Consequently, the Court will order 

5/ 
their implementation. In so ordering, however, the Court emphasizes that 

these standards are. Indeed, both medical and constitutional mlnlmums and should 
be viewed as such. The Court urges that once this order is effectuated, 
defendants not become complacent and sclf-satlsf led. Rather, they should 
dedicate themselves to providing physical conditions and treatment programs 
at Alabama's mental Institutions that substantially exceed medical and constitu- 
tional mlnlmums. 

In addition to asking that their proposed standards be effectuated, 
plaintiffs and amlcl have requested other relief designed to guarantee the 
provision of constitutional and humane treatment. Pursuant to one such request 
for relief, this Court has determined that it is appropriate to order the 
Initiation of human rights committees to function as standing conmittees of 
the Bryce and Searcy facilities. The Court will appoint the members of these 
conmltteea who shall have review of all research proposals and all rehabilita- 
tion programs, to ensure that the dignity and the human rights of patients are 
preserved. The conmittees also shall advise and assist patients who allege 
that their legal rights have been infringed or that the Mental Health Board 
has failed to comply with judicially ordered guidelines. At its discretion, the 
committees may consult appropriate, independent specialists who shall be 
compensated by the defendant Board. Seven members shall comprise the human 
rights committee for each institution, the names and addresses of whom are 



hi Contd. 

nloo requested the Court to appoint a master, to appoint a himian rights committee 

and (\ profennional advisory committee, to order the sale of defendant Mental Health 

Board's land holdings and other assets to raise funds for the operation of Alabama's 

monLfll health institutions, to enjoin the construction of any physical facilities 

by the Mrntal Health Board and to enjoin the commitment of any more patients to 

Bryce and Searcy until such time as adequate treatment is supplied In those hospitals, 

^/ In nddlcion to the standards detailed In this order, It Is appropriate that 
defondnntB comply also with the conditions, applicable to mental health institu- 
tlonB, necconary to qualify Alabamn's facilities for participation In the various 
pro();rnmn, nuch as Medicare and Medicaid, funded by the United States Government. 
Because many of these conditions of participation have not yet been finally 
drafted and published, however, this Court will not at this time order that specific 
Government standards be implemented. 



r.ot forth in Appendix B to thte decree, ThoBC vho seT-ve on the corrsnlttcea 

shall bo paid on a per diem basis and be relmbursec for travel expenses et the 

same rate as membero of the Alabama Board of Mental Health. 

This Court will reserve ruling upon other forms of relief advocated 

by plaintiffs and amlcl, including their prayer for the appointment of a 

master and a professional advisory committee to oversee the implementation of 

6/ 
the court-ordered minimum constitutional standards. Federal courts are 

reluctant to assume control of any organization, but especially one operated 
by a state. This reluctance, combined with defendants' expressed Intent that 
this order will be Implcmontcd forthwith and In good faith, causes the Court 
to withhold its decision on these appointments. Nevertheless, defendants, 
as well as the other parties and amici in this case, are placed on notice that 
unless defendants do comply satisfactorily with this order, the Court will 
be obligated to appoint a master. 

Because the availability of financing may bear upon the Implementa- 
tion of this order, the Court is constrained to emphasize at this juncture that 
a failure by defendants to comply with this decree cannot be Justified by a 
lack of operating funds. As previously established by this Court: 

"There can be no legal (or moral) Justification 
for the State of Alabama's falling to afford treat- 
mcnt--and adequate treatment from a medical 
8tnndprilnt--to the several thousand patients who 
have been civilly committed to Bryce's for treatment 
purposes. To deprive any citizen of his or her 
liberty upon the altruistic theory that the confine- 
ment is for humane therapeutic reasons and then fail 
to provide adequate treatment violates the very 
fundamentals of due process." Wyatt v. Stlckncy , 
325 F.Supp. at 785. 

From the above, it follows consistently, of course, that the unavailability 

of neither funds, nor staff and facllltlee, will Justify a default by defendants 

in the provision of suitable treatment for the mentally 111. 

Despite the possibility that defendants will encounter financial 

difficulties in the implementation of this order^ this Court has decided to 



6/ Tlio Court's decision to reserve its ruling on the appointment of a master 
ncccsfsttatcs the reservation also of the Court's appointing a professional 
advisory committee to aid the master. Nevertheless, the Court notes that the 
profenalonal mental health community in the United States has responded with 
enthusiasm to the proponed Initiation of such a committee to assist in the 
upgrading of Alabama's mental health facilities. Consequently, this Court 
strongly recommends to defendants that they develop a professional advisory 
committee comprised of amenable professionals from throughout the country who 
are able to provide the expertise the evidence reflects la important to the 
successful implementation of thlt order. 



TP3crve ruling aiao upon plaintiffs' motion Chat defendant Mental Health 

Board be directed to sell or encumber portions of its land holdings in order 

7/ 
to raise funds. Similarly, this Court will reserve ruling on plaintiffs' 

motion seeking an injunction against the treasurer and the comptroller of the 

State authorizing expenditures for nonessential State functions, and on other 

aspects of pluinttffa' requested relief designed to ameliorate the financial 

problems Incident to the implementation of this order. The Court stresses, 

however, the extreme Importance and the grave immediacy of the need for proper 

funding of the State's public mental health facllitiea. The responsibility 

for appropriate funding ultimately must fall, of course, upon the State 

Legislature and, to a lesser degree, upon the defendant Mental Health Board 

of Alabama. For the present time, the Court will defer to those bodies in 

hopes that they will proceed with the realization and understanding that what 

is involved in this case is not representative of ordinary governmental functions 

such as paving roads and maintaining buildings. Rather, what is so inextricably 

intertwined with how th« Legislature and Mental Health Board respond to th* 

revelations of this litigation is the very preservation of human life and 

dignity. Not only are the lives of the patients currently confined at Bryce 

and Searcy at stake, but also at issue are the well-being and security of 

every citizen of Alabama. As Is true in the case of any disease, no one is 

Immune from the peril of mental illness. The problem, therefore, cannot be 

overemphasized and a prompt response from the Legislature, the Mental Health 

Board and other responsible State officials, is imperative. 

In the event, though, that the Legislature falls to satisfy its 

well-defined constitutional obligation, and the Mental Health Board, because 

of lack of funding or any other legally insufficient reason, falls to implement 

fully the standards herein ordered, it will be necessary for the Court to take 

affirmative steps. Including appointing a master, to ensure that proper funding 

Is realized and tnat adequate treatment is available for the mentally 111 



T_l Sec n. 4, supra. The evidence presented in this case reflects that the 
land holdings nnd other assets of the defendant Board are extensive. 

8/ The Court undoratands nnd appreciates that the Legislature is not due back 
in rcf'.ular session until May, 1973. Nevertheless, special sessions of the 
LcRlslnture are frequent occurrences in Alabama, and there has never been a time 
when such a session was more urgently required. If the Legislature does not act 
promptly to appropriate the necessary funding for mental health, the Court will 
be compelled to grant plaintiffs' motion to add various State officials and 
anencles as additional parties to this litigation, and to utlllEe other avenues 
of fund raising. 



of Alabama. 

This Court now muet consider that aspect of plaintiffs * motion of 
Mnrcli 15, 1972, seeking an Injunction against further commltmcnta to nryce and 
Scnrcy until such time as adequate treatment la supplied In those ho^pltalo. 
Indisputably, the evidence In this case reflects that no treatment program at 
the Bryce-Searcy facilities approaches constitutional standards. Nevertheless, 
because of the alternatives to commitment commonly utilized In Alabama, aa well 
as in other states, the Court Is fearful that granting plaintiffs' request at 
the present time would serve only to punish and further deprive Alabama's 
mentally ill. 

Finally, the Court has determined that this case requires the award- 
ing of a reasonable attorneys' fee to plaintiffs' counsel. The basis for the award 
and the amount thereof will be considered and treated in a separate order. The 
fee will bo charged against the defendants aa a part of the court costs in this 
case. 

To assist the Court in its determination of how to proceed henceforth, 
defendants will be directed to prepare and file a report within six months from 
the date of this decree detailing the implementation of each standard herein 
ordered. This report shall be comprehensive and shall Include a statement of 
the progress made on each standard not yet completely implemented, specifying 
the reasons for Incomplete performance. The report shall include also a state- 
ment of the financing secured since the Issuance of this decree and of 
defendants' plans for procuring whatever additional financing might be required. 
Upon the basis of this report and other available Information, the Court will 
evaluate defendants' work and, in due course, determine the appropriateness of 
appointing a master and of granting other requested relief. 

Accordingly, it is the ORDER, JUDGMENT and DECREE of this Court: 

1. That defendants be and they are hereby enjoined from falling to 
Implement fully and with dispatch each of the standards set forth in Appendix A 
attached hereto and Incorporated as a part of this decree; 

2. That human rights committees be and are hereby designated and 
appointed. The members thereof arc listed in Appendix B attached hereto and 
incorporated herein. These comnitteeo shall have the purposes, functions, and 
spheres of operation previously sat forth In this order. The members of the 



cofrmitCeeB shall be paid on fi per diem baala and be reimbursed for travel 
expenses at the same rate as members of the Alabama Board of Mental Health; 

3. That defendants, within six months from this date, prepare 
and file with this Court a report reflecting In detail the progress on the 
Implementation of this order. This report shall be comprehensive and precise, 
and shall explain the reasons for incomplete performance In the event the 
defendants have not met a standard In Its entirety. The report also shall Include 
a financial statement and an up-to-date timetable for full compliance. 

4. That the court costs Incurred in this proceeding, including a 
reasonable attorneys' fee for plaintiffs' lawyers, be and they are hereby taxed 
against the defendants; 

5. That Jurisdiction of this cause be and the sane is hereby 
specifically retained. 

It is further ORDERED that ruling on plaintiffs' motion for further 
relief, including the appointment of a master, filed March 15, 1972, be and the 
same is hereby reserved. 



Done, this the /^ d ay of April, 1972. 




UNITED STATEyTJT STRICT JUDG: 



APPENDIX A 



MINIMUM CONSTITUTIONAL STANDARDS ¥m. 
ADEQUATE TREATMENT OF THE MENTALLY ILL 



I. Definitions ; 

a. "Hospital" — Bryce and Searcy Hospitals. 

b. "Patients" -- all persons who are now confined and all persona who 
may in the future be confined at Bryce and Searcy Hospitals pursuant to an 
Involuntary civil commitment procedure. 

c. "Qualified Mental Health Professional" — 

(1) a psychiatrist with three years of residency training in psychiatry; 

(2) a psychologist with a doctoral degree from an accredited program; 

(3) a social worker with a master's degree from an accredited program 
and two years of clinical experience under the supervision of a 
Qualified Mental Health Professional; 

(4) a registered nurse with a graduate degree in psychiatric nursing 
and two years of clinical experience under the supervision of a 
Qualified Mental Health Professional. 

d. "Non-Professional Staff Member" -- an employee of the hospital, other 
than a Qualified Mental Health Professional, whose dutlei require contact with 
or supervision of patients. 

II. Humane Psychological and Physical Environment 

1. Patients have a right to privacy and dignity. 

2. Patients have a right to the least restrictive conditions necessary to 
achieve the purposes of commitment. 

3. No person shall be deemed Incompetent to manage his affairs, to contract, 
to hold professional or occupational or vehicle operator's ilcenoes, Co marry 
and obtain a divorce, to register and vote, or to make a will solely by reason 

of his admission or commitment to the hospital. 

4. Patients shall have the same rights to visitation and telephone contmunl- 
cations as patients at other public hospitals, except to the extent that the 
Qualified Mental Health Professional responsible for formulation of « particular 
patient's treatment plan writes an order impoeing special restrictions. The 



-9- 



written order must be renewed after each periodic review of the treatment 
plan If any rretrictlonfl are to be continued. Patients ahall have an unreatrlcted 
right to visitation with attorneys and with private physicians and other health 
professional 8 . 

5. Patients ahall have an unrestricted right to send sealed mall. Patients 
shall have an unrestricted right to receive sealed mail from their attorneys, 
private physicians, and other mental health professionals, from courts, and 
government officiala. Patients shall have a right to receive sealed mall from 
others, rxcept to the extent that the Qualified Mental Health Professional 
responsible for formulation of a particular patient's treatment plan wrltea an 
order imposing special restrictions on receipt of sealed mail. The written 
order must be renewed after each periodic review of the treatment plan if any 
restrictions are to be continued. 

6. Patients have a right to be free from unnecessary or excessive medication. 
No modirnrlon shall be administered unless at the written order of a physician. 
The niiperlntendent of the hospital and the attending physician shall be 
responsible for all medication given or administered to a patient. The use of 
^ncdlcatlon shall not exceed standards of use that are advocated by the United 
States Food and Drug Administration. Notation of each individual's medication 
shall be kept in his medical records. At least weekly the attending physician 
shall review the drug regimen of each patient under his care. All prescriptions 
shall be written with a termination date, which shall not exceed 30 days. Medi- 
cation shall not be used as punishment, for the convenience of staff, as a 
substitute for program, or in quantities that interfere with the patient's 
treatment program. 

7. Patients have a right to be free from physical restraint and isolation. 
Except for emergency situations, in which it is likely that patients could harm 
thomselvcs or others and in which less restrictive means of restraint are not 
fcnslblc, patients may be physically restrained or placed in isolation only on 
a Qiinllfied Mental Health Professional's written order which explains the 
rotlonnlc for such action. The written order may be entered only after the 
Qualified Mental Health Professional has personally seen the patient concerned 
and evaluated whatever episode or eltuatlon is said to call for restraint or 



•10- 



Isolotlon, Emergency use of restralnto or Isolation shall be for no more than 
one hour, by which time a Qualified Mental Health Professional shall >- --■re bten 
consulted and shall have entered an appropriate order in writing. Such written 
order shall be effective for no more than 24 hours and must be renewed if 
restraint and isolation are to be continued. While in restraint or isolation 
the patient must be seen by qualified ward personnel who will chart the patient's 
physical condition (If it is compromised) and psychiatric condition every hour. 
The patient must have bathroom privileges every hour and must be bathed every 
12 hours. 

8. Patients shall have a right not to be subjected to experimental research 
without the express and informed consent of the patient, if the patient Is able 
to give such consent, and of his guardian or next of kin, after opportunities 
for consultation with independent specialists and with legal counsel. Such 
proposed research shall first have been reviewed and approved by the institution's 
Human Rights Coimlttee before such consent shall be sought. Prior to such 
approval the Committee shall determine that such research complies with the 
principles of the Statement on the Use of Human Subjects for Research of the 
American Association on Mental Deficiency and with the principles for research 
involving human subjects required by the United States Department of Health, 
Education and Welfare for projects supported by that agency. 

9. Patients have a right not to be subjected to treatment procedures such 
as lobotomy, electro-convulsive treatment, ailversive reinforcement conditioning 
or other unusual or hasardous treatment procedures without their express and 
Informed consent after consultation with counsel or Interested party of the 
patient's choice. 

10. Patients have a right to receive prompt and adequate medical treatment 
for any physical ailments. 

11. Patients have a right to wear their own clothes and to keep end use 
their own personal possessions except Insofar as such clothes or personal 
possessions may be determined by a Qualified Mental Health Professional to be 
dangerous or otherwise inappropriate to the treatment regimen. 

12. The hospital has an obligation to supply an adequate allowance of 
clothing to any patients who do not have suitable clothing of their own. Patients 
shall have the opportunity to select from various typea of neat, clean, and 



•11- 



/ » 



■easonable clothing. Such clothing shall be considered the patient's through- 
out his stay In the hospital. 

13. The hospital shall make provision for the laundering of patient clothing. 

14. Patients have a right to regular physical exercise several times a 
week. Moreover, it shall be the duty of the hospital to provide facilities and 
equipment for such exercise, 

15. Patients have a right to be outdoors at regular and frequent intervals, 
in the absence of medical considerations. 

16. The right to religious worship shall be accorded to each patient who 
desires such opportunities. Provisions for such worship shall be made available 
to all patients on a nondiscriminatory basis. No Individual shall be coerced 
into engaging in any religious activities. 

17. The institution shall provide, with adequate supervision, suitable 
opportunities for the patient's Interaction with members of the opposite sex. 

16. The following rules shall govern patient labor: 

A. Hospital Maintenance No patient shall be required to perform labor 
which Involves the operation and maintenance of the hospital or for which the 
hospital is under contract with an outside organization. Privileges or release 
from the hospital shall not be conditioned upon the performance of labor covered 
by this provision. Patients may voluntarily engage in such labor if the labor is 
compensated in accordance with the minimum wage laws of the Fair Labor Standards 
Act, 29 U.S.C. f 206 as amended, 1966. 

B. Therapeutic Tasks and Therapeutic Labor 

(1) Patients may be required to perform therapeutic tasks which 
do not involve the operation and maintenance of the hospital, provided the 
specific task or any change In assignment is: 

a. An integrated part of the patient's treatment plan and 
approv«iri as a therapeutic activity by a Qiinllfled MrnrMl 
Health Professional responsible for supervising the patient's 
treatment ; and 

b. Supervised by a staff member to oversee the therapeutic 
aspects of the activity. 

(2) Patients may voluntarily engage in therapeutic labor for which 
the hospital would otherwise have to pay an employee, provided the specific labor 



•12- 



'Or any change in labor assignment is: 

a. An integrated part o£ the patient's treatment plan nnd 
approved as a therapeutic activity by a Qualified Mental Health 
Professional responsible for supervising the patient's 
treatment ; and 

b. Supervised by a staff member to oversee the therapeutic as- 
pects of the activity; and 

c. Compensated in accordance with the minimum wage laws of the 
Fair Labor Standards Act, 29 U.S.C. 3 206 as amended, 1966. 

C. Personal Housekeeping Patients may be required to perform tasks 
of a personal housekeeping nature such as the making of one's own bed. 

D. Payment to patients pursuant to these paragraphs shall not be 
applied to the costs of hospitalization. 

19. Physical Facilities 

A patient has a right to a humane psychological and physical environ- 
ment within the hospital facilities. These facilities shall be designed to 
afford patients with comfort and sdfety, promote dignity, and ensure privacy. 
The facilities shall be designed to make a positive contribution to the efficient 
attainment of the treatment goals of the hospital. 

A. Resident Unit 

The number of patients in a multi-patient room shall not exceed six 
persons. There shall be allocated a minimum of 80 square feet of floor space 
per patient in a multi-patient room. Screens or curtains shall be provided to 
ensure privacy within the resident unit. Single rooms shall have a minimum of 
100 square feet of floor space. Each patient will be furnished with a coin- 
f or table bed with adequate changes of linen, a closet or locker for his personal 
belongings, a chair, and a bedside table. 

B. Toilets and Lavatories 

There will be one toilet provided for each eight patients and one 
lavatory for each six patients. A lavatory will be provided with each toilet 
facility. The toilets will be installed in separate stalls to ensure privacy, 
will be clean and free of odor, and will be equipped with appropriate safety 
devices for th« physically handicapped. 



•13- 



/ir-i 



C. Showcfa 

There will be one tub or ahower for each 15 patlenta. If a central 
bathing area la provided, each ahower area will be divided by curtaina to 
enaure privacy. Showere and tuba will be equipped with adequate aafcty 
acceaaorlca. 

D. Day Room 

The minimum day room area ahall be 40 aquare feet per patient. Day 
rooma will be attractive and adequetely furnished with reading lamps, tables, 
chairs, television and other recreational facilities. They will be conveniently 
located to patients' bedrooms and ahall have outside windows. There shall be at 
least one day room area on each bedroom floor in a multi-story hospital. Areas 
used for corridor traffic cannot be counted as day room apace; nor can a chapel 
with fixed pews be counted as a day room area. 

E. Dining Facilities 

The minimum dining room area shall be ten aquare feet per patient. The 
dining room shall b« separate from the kitchen and will be furnished with 
comfortable chairs and tables with hard, washable surfaces. 

F. Linen Servicing and Handling 

The hospital shall provide adequate facilities and equipment for 
handling clean and soiled bedding and other linen. There must be frequent changes 
of bedding and other linen, no !•■■ than every seven days to sssure patient 
comfort. 

G. Housekeeping 

Regular housekeeping and maintenance procedurea which will ensure that 
the hoapital is maintained in a safe, clean, and attractive condition will be 
developed and implemented. 

H. Geriatric and Other Nonambulatory Mental Patlenta 

There must be special facilltiea for geriatric and other nonambulatory 
patients to assure their safety and comfort, including special fittinga on 
toilets and wheelchairs. Appropriate provision shall be made to permit non- 
ambulatory patients to communicate their needs to staff. 

I. Physical Plant 

(1) Pursuant to an establiahed routine maintenance and repair 
program, the physical plant shall be kept in a continuous itate of good repair 



•14- 



and operation In accordance with th« naeda of the health, comtort, safety and 
well-being of the patients. 

(2) Adequate heating, air conditioning and ventilation eyateme 
and equipment shall be afforded to maintain temperatures and air changes irhlch 
ara required for the comfort of patlente at all times and the removal of undeeired 
heat, fltean and offensive odors. Such facilities shall ensure that the temperature 
In the hospital shall not exceed 83°F nor fall below 68°F. 

(3) Thermostatically controlled hot water shall be provided in 
adequate quantities and maintained at the required temperature for patient or 

resident use (llO'^F at the fixture) and for mechanlcnl dishwashing and laundry use 

o 
(180 F at the equipment). 

(4) Adequate refuse facilities will be provided bo that solid waste, 
rubbish and other refuse will be collected and disposed of in a manner which will 
prohibit transmission of disease and not create a nuisance or fire hazard or 
provide a breeding place for rodents and insects. 

(5) The physical facilities must meet ell fire and safety standards 
established by the state and locality. In addition, the hospital shall meet such 
provisions of the Life Safety Code of the National Fire Protection Association (2l9t 
edition, 1967) as are applicable to hospitals. 

19A. The hospital shall meet all standards established by the state for 
general hospitals, Insofar as they are relevant Co psychiatric facilities. 
20. Nutritional Standards 

Patients, except for the non-mobile, shall eat or be fed in dining rootaa. 
The diet for patients will provide at a minimum the Recommended Daily Dietary 
Allowances as developed by the National Academy of Sciences. Menus shall be 
satisfying and nutritionally adequate to provide the Recommended Daily Dietary 
Allowances. In developing such menus, the hospital will utilize the Low Cost Food 
Plan of the Department of Agriculture. The hospital will not spend less per patient 
for raw food, including the value of donated food, than the most recent per person 
costs of the Low Cost Food Plan for the Southern Region of the United States, as 
compiled by the United States Department of Agriculture, for appropriate Rronping? 
of pntlpnts, discounted for any savings which might result from institutional 
procurement of such food. Provisions shall be made for special therapeutic diets 
and for substitutes at the request of the patient, or his guardian or next of kinj 



•15- 



/• ►• *■ 



in accordance with the religious requirementa of any patient's faith. Denial of 

a nutritionally adequate diet ahall not be used aa punishment. 

Ill, Qualified Staff in Numbers Sufficient to Administer Adequate Treatment 

21. Each Qualified Mental Health Professional shall meet all licensing and 
certification requirements promulgated by the State of Alabama for pcraona engaged 
in private practice of the same profession elsewhere in Alabama. Other staff 
members shall meet the same licensing and certification requirements as persons who 
engage in private practice of their speciality elsewhere in Alabama. 

22. a. All Non-Profeaaional Staff Members who have not had prior clinical 

experience in a mental institution shall have a substantial 
orientation training, 
b. Staff members on all levels shall hav« regularly scheduled 
in-service training. 

23. Each Non- Professional Staff Member shall be under the direct supervision 
of a Qualified Mental Health Professional. 

24. Staffing Ratios 

The hospital shall have the following minimum numbers of treatment 
personnel per 250 patients. Qualified Mental Health Professionals trained in partic- 
ular disciplines may in appropriate situations perform services or functions 
traditionally performed by members of other disciplines. Changes in staff deploy- 
ment may be made with prior approval of thia Court upon a clear and convincing 
demonstration that the proposed deviation from this staffing structure will 
enhance the treatment of the patients. 

Classification Number of Employees 



Unit Director 


1 


Psychiatrist (3 years' residency training in 




psychiatry) 


2 


MD (RcKlntered physicians) 


4 


Niirson (RN) 


12 


Mconfiod Practical Nursaa 


6 


A (do JH 


6 


Aide 11 


16 


Aide I 


70 


Hospital Orderly 


10 


Clerk Stenographer II 


3 


Clerk Typlat 11 


3 


Unit Administrator 


1 


Administrative Clerk 


1 


Psychologiat (Ph.D.) (doctoral degree from 




accredited program) 


1 


Psychologist (M.A.) 


1 



■16- 



Classlftcntlon (Contd.) Hmrber of Employee e (Contd.) 

Psychologist (B.S.) 2 
Social Worker (MSW) (from accredited 

program) 2 

Socinl Worker (D.A.) 5 

Pntlrnt Activity Thrrnpltt (M.S.) 1 

Patient Activity Aide 10 

Mcntnl Health Technician 10 

Dcntnl Hyglcniet 1 
Chnplnln ,5 

Vocational Rehabilitation Counflelor 1 

Volunteer Services Worker 1 

Mental Health Field Representatlv* 1 

Dietitian 1 

Food Service Supervisor 1 

Cook II 2 

Cook 1 3 

Food Service Worker 15 

Vehicle Driver i 

Housekeeper 10 

Messenger 1 

Maintenance Repairman 2 

IV. Individualized Treatment Plans 

25. Each patient shall have a comprehensive physical and mental examination 
and review of behavioral status within 48 hours after admission to the hospital. 

26. Each patient shall have an individualized treatment plan. This plan 
■hall be developed by appropriate Qualified Mental Health Professionals, includ* 
Ing a psychiatrist, and implemented as soon as possible - in any event no later 
than five days after the patient's admission. Each individualized treatment 
plan shall contain: 

a. a statement of the nature of the specific problems and specific 
needs of the patient; 

b. a statement of the least restrictive treatment conditions 
necessary to achieve the purposes of comnitnent; 

c. a description of intermediate and long-range treatment goals, 
with a projected timetable for their attainment; 

d. a statement and rationale for the plan of treatment for achieving 
these intermediate and long-range goals; 

e. a specification of staff responsibility and a description of pro- 
posed staff involvement with the patient in order to attain these 
treatment goals; 

f. criteria for release to less restrictive treatment conditions, snd 
criteria for discharge; 



•17- 



f^WT^mvr^ q;^^^^v^' ■ V* 



/ ^ -r 



g. • notation of any therapeutic taska and labor to b« performed by 
the patient In accordance with Standard 18. 

27. As part of hia treatment plan, each patient ahall have an individualised 
poat-hospitallzation plan. Thia plan shall be developed by a Qualified Hental 
Health Profeaaional as aoon as practicable after the patient's admission to the 
hoapital. 

28. In the interests of continuity of care, whenever possible, one Qualified 
Mental Health Professional (who need not have been involved with the development 
of the treatment plan) shall be responsible for supervising the implementation 

of tho trestmcnt plan, integrating the various aspects of the treatment program 
and recording the patient's progress. This Qualified Mental Health Professional 
shall also be responsible for ensuring that the patient is released, where 
appropriate, into a less restrictive form of treatment. 

29. The treatment plan shall be continuously reviewed by the Qualified Mental 
Health Professional responsible for supervising the Implementation of the plan and 
shall bo modified if necessary. Moreover, at least every 90 days, each patient 
shall receive a mental examination from, and his treatment plan shall be reviewed 
by, a Qualified Mental Health Professional other than the professional reaponsible 
for supervising the implementation of the plan. 

30. In addition to treatment for mental disorders, patients confined at 
mental health institutions also are entitled to and shall receive appropriate 
treatment for physical Illnesses such as tuberculosis.' In providing medical 
care, the State Board of Mental Health shall take advantage of whatever community- 
based facilities are appropriate and available and shall coordinate the patient's 
treatment for mental illness with his medical treatment. 

31. Complete patient records shall be kept on the ward in which the patient 
Is placed and shall be available to anyone properly authorized in writing by the 
patient. These records shall include: 

a. Identification data, including the patient's legal statua; 

b. A patient history, including but not limited to: 

(1) family data, educational background, and employment record; 



1^/ Approximately 50 patients at Bryce-Searcy are tubercular as also are 
approximately four residents at Partlow. 



.18- 



(2) prior medical history, boCh physical end mental. Including 
prior hospitalisation; 

c. The chief complaints of the patient and the chief coin]:iItilnte of 
others regarding the patient; 

d. An evaluation which notes the onset of illness, Che circumstances 
leading to admission, attitudes, behavior, estimate of intellectual 
functioning, memory functioning, orientation, and an inventory of 
the patient's assets in descriptive, not Interpretative, fashion; 

e. A summary of each physical exaaination which describes the results 
of the examination; 

f. A copy of the individual treatment plan and any modifications thereto; 

g. A detailed aummary of the findings made by the reviewing Qualified 
Mental Health Professional after each periodic review of the treat- 
ment plan. which analyzes the successes and failures of the treatment 
program and directs whatever modifications are necessary; 

h. A copy of the individualized post-hospitalization plan and any modi- 
fications thereto, and a summary of the steps that have been taken 
to Implement that plan; 

i. A medication history and status, which includes the signed orders 
of the prescribing physician. Hurses shall indicate by signature 
that orders have been carried out; 

J, A detailed summary of each significant contact by a Qualified Mental 
Health Professional with the patient; 

k. A detailed summary on at least a weekly basis by a Qualified Mental 
Health Professional involved in the patient's treatment of the 
patient's progress along the treatment plan; 

1. A weekly sumnary of the extent and nature of the patient's work 
activities describod in Standard 16, suprn , and the effect of auch 
activity upon the patient's progress along the treatment plan; 

m. A signed order by a Qualified Mental Health Profeseional for any 
restrictions on visitations and comnmnicatlon, as provided In 
Standards 4 and 5, supra ; 

n. A signed order by a Qualified Mental Health Professional for any 

physical restraints and isolation, as provided in Standard 7, supra; 

-19- 



o, A dec«iled sunnary of any extraordinary incident in the hospital 
Involving the patient to be entered by a staff member noting that 
he has personal knowledge of the Incident or specifying his other 
source of Information, and initialed within 24 hours by a Qualified 
Mental Health Professional; 

p. A Buinnary by the superintendent of the hospital or his appointed 

agent of his findings after the 15- day review provided for in Standard 
33 infra . 

32. In addition to complying with all the other standards herein, a hospital 
shall make special provisions for the treatment of patients who are children and 
young adults. These provisions shall include but are not limited to: 

a. Opportunities for publicly supported education suitable to the 
educational needs of the patient. This program of education must, 

in the opinion of the attending Qualified Mental Health Professional, 
be compatible with the patient's mental condition and his treatment 
program, and otherwise be in the patient's best Interest. 

b. A treatment plan which considers the chronological, maturational, 
and developmental level of the patient; 

c. Sufficient Qualified Mental Health Professionals, teachers, and 
staff members with specialized skills in the care and treatment of 
children and young adults; 

d. Recreation and play opportunities in the open air where possible 
and appropriate residential facilities; 

e. Arrangements for contact between the hospital and the family of the 
patient. 

33. No later than 15 days after a patient is committed to the hospital, the 
superintendent of the hospital or his appointed, professionally qualified agent 
shall cxnmine the conmittcd patient and shall determine whether the pacionc con- 
tinues CO require hospitalization and whether a treatment plan complying with 
Standard 26 has been implemented. If the patient no longer requiree hospitali- 
zation in accordance with the standards for commitment, or if a treatment plan 
has not been implemented, he must be released imnedlately unless he agrees to 
continue with treatment on a voluntary basis. 



.20- 



3'». Th<" Mertrl Health Bo^rd and Its ogcnCs havo ar> afflnnatlve duty to 
provide adequate transitional treatment end cere for all petientei released oftet 
a period o£ involuntery confinement. Trensitlonal cere end treatment poaaibillt '.A'^ 
include, but are not limited to, psychiatric day care, treatment in the hams by 
a visiting therapist, nursing home or extended care, out-patient treatmcn.:, &nd 
treetmenc In the psychiatric ward of « general hospital. 
V. Ml wccllnncouB 

35. Each patient and his family, guardian, or next friend ehall promptly 
upon the patient's admiselon receive written notice, in language he understands, 
of all the above standards for adequate treatment. In addition a copy of ell 
the above standards shall be posted in each %»rd. 



■21. 



V 



APPENDIX B 

BRYCS HUMAN RIGHTS COMMITTEE 

1. Mr. Bert Bank - Chairman - P. 0. Box 2I&9, Tuacalooaa, Alabama 35A01 

2. Mo. Ruth Cummlngs Bolden • 1414 9th Street, Tuscaloosa, Alabama 35401 

3. Ms. Babs Klein Hellpem - 2526 Jasmine Road, Montgomery, Alabama 36111 

4. Mr. Joseph Malllshan - 3028 20th Street, Tuscaloosa, Alabama 35401 

5. Ms. Alberta Murphy - 13 Hillcrest, Tuscaloosa, Alabama 35401 

6. Mr. Junior Richardson - 17 CM, Bryce Hospital, Tuscaloosa, Alabama 35401 

7. Mr. John T. Uagnon, Jr. - 822 Felder Avenue, Montgomery, Alabama 36106 



SEARCY HUMAN RIGHTS C(»{MITTEE 

1. Dr. E. L. McCafferty, Jr. - Chairman - 1653 Spring Hill Avenue, Mobile, Alabama 36604 

2. Hon. James U. Blacksher - 304 South Monterey, Mobile, Alabama 

3. Hon. Thomaa E. Gilmore - P. 0. Box 109, Eutaw, Alabama 35462 

4. Ms. Consuello J. Harper - 3114 Caffey Drive, Montgomery, Alabama 36106 

5. Hon. Horace McCloud - Mount Vernon, Alabama 

'>. Sister Eileen McLoughlin > 404 Government Street, Mobile, Alabama 36601 

7. Ms. Joyce Nickels • c/o Searcy Hospital, Mount Vernon, Alabama 



1973 REPORT 



LEGISLATIVE RESEARCH COMMISSION 



A STUDY OE THE "GEOGRAPHIC UlNIIT" CONCEPT WITHIN 



NORTH CAROLINA STATE MEt^TiUL HOSPITALS 



CONTENTS 

Page 

INTRODUCTION 1 

BACKGROUND 2 

THE AREA PROGRAM 2 

THE GEOGRAPHIC UNIT . . . ' ^ 

CONCLUSIONS AND RECOMMENDATIONS 5 

APPENDICIES: 

I, Resolution Directing the Study, 

II. Article 20 of G.S. Chapter 122, 

Estahlishnient of Area Mental Health. Programs . 



INTRODUCTION 

On May 14, 197 1-^ "the North Carolina General AssemlDly rati^ie: 
House Joint Resolution 715 as Resolution 66 of th.e 1971 Session. 
This Resolution directed the Legislative Research Commission to 
"stuidy the 'geographical unit' concept within the state mental 
hospitals to evaluate the practicality, the effectiveness and 
the economy of this type of operation. " (A copy of HJR 715 is 
contained in Appendix I.) 

Pursuant to the direction of HJR 715 the Co-Chairmen of 
the Legislative Research Commission appointed Representative 
Carl J. Stewart Chairman of a Committee which was to undertake 
the study and to report its findings "back to the full Commission. 
Representative Stewart is a memher of the Legislative Research 
Commission; other memhers of the Committee on the Geographic 
Unit within State Mental Hospitals were drawn from the General 
Assembly at large. The Committee members are: Representative 
Robert Q. Beard, Representative James T. Beatty, Senator Luther 
J. Britt, Jr., Representative Nancy B. Chase, Senator David T. 
Flaherty, and Representative Joseph B. Raynor, Jr. 

The Committee had a number of meetings and public hearings, 
made individual visits to state mental institutions, and received 
for its consideration a summary of a recent State Bureau of 
Investigation report on North Carolina mental hospitals. Dr. 
Eugene A. Hargrove, Commissioner of the N. C. Department of 
Mental Health, and Dr. Eugene Malony, a practicing psychiatrist 



v/ith experience in the State Hospital system, par-ticipated in 
Committee meetings. Staff assistance was provided by Mr. David 
Wai^ren, Assistant Director of the Institute of Government, and 
Mr. William H, Potter, Jr., Research Director for the Legislative 
Services Office. 

BACKGROIMD 

The Committee initially found the directive of HJR 715 
ambiguous. The resolution was captioned "A Joint Resolution 
Authorizing and Directing the Legislative Research Commission 
to Study the Area Unit Concept of Treatment of bhe Mentally 
111 ..." (emphasis added) yet the commissioning Section 1 of 
the resolution limits the scope of the directive to an evalua- 
tion of the geographic unit concept. 

THE AREA PROGRAM 

The confusion in the resolution is easily understood. The 
Area Program is a concept clearly articulated in G.S. 122-35-18 
through G.S. 122-35.22. These sections of the General Statutes, 
Article 2C. Establishment of Area Mental Health Programs , were 
enacted by Chapter 470 of the 1971 North Carolina Session Laws. 
(Article 2C of G.S, Chapter 122 is contained in Appendix II.) 
Under G.S. 122-55.19(1), the North Carolina Board of Mental 
Health is given authority to establish area mental health 



programs "to consist of a coin"bining and interrelationshi-) of 
resources, personnel, and facilities of the Department of 
Mental Health, and of the community mental health program to 
serve the population of the area designated pursuant to this 
Article." Other sections of Article 2C provide for Area 
Mental Health Boards, with equitable area-wide representation 
consisting of county commissioners, physicians, attorneys and 
other citizens at large. 

In 1965 the North Carolina Department of Mental Health had 
already been reorganized under four mental health regions, each 
with its own commissioner. Each region contains a mental hospi- 
tal, a mental retardation center, and an alcoholism program. 
The 1971 legislation made possible further decentralization. 
The decentralization under the area program has had the effect 
of shifting authority for mental health programs from elected 
county commissioners to area policy boards appointed by them. 
To date, the area concept has not been fully implemented, nor has 
its ultimate function been fully developed or clarified. 

The Committee quickly concluded that the sponsor of HJR 715 
had no real quarrel with the Area Programs per se but that they 
were largely concerned with another program called the "Geo- 
graphic Unit" concept. 



4 



THE GEOGRAPHIC UNIT 

In 18^8 North Carolina "began a program of institutional 
care for the mentally ill. Hospitals competed for funds under 
this program until the creation of the Hospital Board of Control 
in 19'4-5» The Department of Mental Health was established as a 
state agency in 196'^- and a few years later took over some local 
mental hygiene clinics from the Department of Public Health. 
At this point, North Carolina was providing very limited out- 
patient care to a few people. At the same time, the State was 
providing some acute care and a large amount of custodial care 
at centralized institutions. There was little linkage between 
community programs and institutions, and there was no compre- 
hensive system for the delivery of mental health services. 

Three hospitals were serving white patients and one institu- 
tion was serving black patients. In 1965 all four hospitals 
were racially integrated, and the state was divided into four 
regions — each with a mental hospital for adult patients. This 
change generated much anxiety for hospital staffs within the 
system as well as for families of the patients involved — 
especially at Cherry, the formerly all black institution. 

Shortly following integration, the geographic unit system 
was introduced. It had been widely applauded in professional 
psychiatric and administrative journals throughout the United 
States. Its application involves the decentralization of 
large institutions (North Carolina's four) into what amounts 
to several small hospitals, called units, each with its own pro- 
vision for continuity of care. Patients are grouped according 



to the commuD-ity or geographic catchment area in which they 
reside. Men and women patients are mixed, and no attempt is 
made to segregate them "by symptoms of illness. Admission is 
directly to the unit rather than to a central admissions service. 
It was hoped that the unit system would achieve these goals: 

1. Provide comprehensive and continuous care for 
psychiatric patients "by improving hospital com- 
munity linkage. 

2. Decentralize large state hospitals to provide 
management decisions close to the local situation. 

3. Minimize the concept of "chronic" patients amd to 
provide active treatment for all patients. 

Though lofty in concept, in practice and in application the 
geographic unit program has created strain on the mental health 
system bordering on turmoil. It has also caused staffing dupli- 
cation. 

Back ward patients (long term, chronic, regressed) have been 
thrust together with admission ward patients (less seriously 
disturbed). This does help the back ward patient, but in some 
cases has severely disturbed the admission ward patient (and 
his family!). If they are split into several programs the 
quality of certain specialized services, such as an adolescents' 
program or an alcoholism program, inevitably suffers; the necessary 
specialized skills have simply been spread too thin. 

CONCLUSIONS AND RECOMMENDATIONS 

Perhaps as a result of HJR 715 itself, the state regional 
hospitals are retreating markedly from the geographic unit 



6 

emphasis. For example, more than fifty percent of the Dorothea 
Dix population is now back in special units /Admission, Geriatric 
(elderly), Nursing Care, Infirmary, Forensic (criminal), Tiedical 
Surgical, Research, Resocialization and Alcoholi£7 rather than 
geopjraphic units. The department is now exploring revising the 
geographic unit system in two areas (Southeastern and Sandhills) 
and going entirely to special programs. 

Thus we find that the tension and frustration which gave 
rise to House Joint Resolution 715 is already beginning to 
subside. The investigation by your committee has already served 
a great purpose. Our hope is that the analysis of this report 
might hasten the modification of the geographic unit program 
nov/ under way within the system at large. 

In carrying out this modification the Committee feels that 
the following specific recommendations will be useful: 

1. Newly admitted elderly patients should be treated 
in a single geriatric admission and evaluation unit 
no matter what community they come from. 

2. Moderately disturbed or depressed patients should not 
be evaluated or treated in the same ward area as are 
the more chronic or seriously disturbed patients . 

3. As patient census decreases, more specialized 
programs should remain intact. 



Appendix I 



Resolution Directing the Study . 



n«L ASSEMBLY ' 
1971 : 

RATIFic 



RESOLUTION 66 
HOUSE JOINT RESOLUTION 715 

A JOINT RESOLUTION AUTHORIZING AND DIRECTING THE LEGISLA'^"VE 
RESEARCH COMMISSION TO STUDY THE AREA UNIT CONCEPT OF TREATMENT 
OF THE MENTALLY ILL IN THE STATE MENTAL HOSPITALS. 

Whereas, the North Carolina Department of Mental Health 
has implemented a '• geographical unit'* concept for treatment of 
the mentally ill; and 

Mhereas, the State's four mental hospital facilities 
have been divided into units serving patients only from a 
specific county or co\inties; and 

Whereas y each such unit may require fixed staffing and 
supporting services despite the variation in the number of 
patients cared for within each unit; and 

Whereas, there exists under such operations the 
possibility of unequal distribution of patients and staff among 
units; 

Now, therefore, be it resolved by the House of Representatives, 
the Senate concurring: 

Section 1. The Legislative Research Commission with 
advice, direction and assistance of the Advisory Budget 
Commission is hereby authorized and directed to study the 
"geographical unit" concept within the state mental hospitals to 
evaluate the practicality, the effectiveness and the economy of 
this type of operation. 



Sec* 2. The Legislative Research Contxnission s-riall 
report its findings and recommendations to the 19.73 General 
Assembly, 

Sec, 3. This resolution shall become effective upon — ' 
ratification. 

In the General Assembly read three times and ratified, 
this the 14th day of May, 1971. 

H. P. TAYLOR, JR. 



H. P. Taylor, Jr, ^ 
President of the Senate 

PHILIP P. GODWIN 



Philip P. Godwi>n 

Speaker of the House of Representatives 



House Joint Resolution 715 



Appendix II 

Article 2C. 
Establishment of Area Mental Health Pro^ram^ 



Article 2C. 

Establishment of Area Mental Health Programs. 

§ 122-35.18. Definitions. — For purposes of this Article, the following defi- 
nitions shall apply : 

(1) "Area" means a geographic entity consisting of one or more counties, or 

portions of one or more counties, designated by the Board of Mental 
Health as a basic unit for the develojnnent of mental health programs 
to serve the population of that geographic entity. 

(2) "Mental health program" means any services or activities, or combination 

thereof, for the diagnosis, treatment, care, or rehabilitation of mentally 
impaired persons or for the promotion of mental health, which is offered 
by or on behalf of the geographic entity establislied pursuant to this 
Article. (1971, c. 470, s. 1.) 
Editor's Note. — Section 2. c. 470, Session 

L.iws ut71, makes the .Article effective July 

1, 1971. 

§ 122-35.19. Area mental health programs. — The North Carolina Board 
of Mental Health is authorized to establish area mental iiealth programs. These 
vhall be joint undertakings of th(' counties or portions thereof, included in the 
designated area, and the Department of Mental Health for the following pur- 
poses : 

(1) To develop area mental lu-alth programs, to consist of a combining and 

interrelationship of resources, j^ersonnel, and facilities of the Depart- 
ment of Mental Health, and of the community mental health program 
to serve the population of the area designated jjuriuant to this Article. 
The area mental health program shall include, lait not be limited to, 
programs for general mental health, mental disorder, mental retardation, 
alcoholism, drug dependence, and mental health education. 

(2) With the approval of the Do])artnient of Administration, to develop and 

test budgeting i^roceduns for combining local and State grants-in-aid 
funds with a ])roportiun,i'; sliare of funds appropriated for the operation 
of departmental facilitie.s serving the population of the area. Provided 
that "local fimds" and "State grants-in-aid" shall be defined and de- 
termined in accordance witli the ])rovisions of G.S. 122-35.11 and G.S. 
122-35.12, and shall be unali'ected by the addition of funds appropriated, 
for the operation of State facilities. 

(3) To evaluate the effectiveness and efficiency of area mental health pro- 

grams. (1971, c. 470. s. 1.) 



§ 122-35.20. Area mental health boards. — (a) In areas wb.ere area 
mental health j^rcgranis are esta!)lishc<l in accordance with this Article, an area 
:. cental health board shall be appointed for each designated area. Th.e area mental 
hcaltl; luiard shall consist of 15 members and shall meet at least six tinies per year. 

(h) In areas consisting of only one coimty, the board of county commissioners 
shall appoint all of the members of the area mental healrh b.oard. In areas consistin':^ 
of more than one county, each lioard of county cn.nmisbioners withm the area shall 
appoint one commissioner as a men-.ber of the area mental health board. These 
members shall appoint the other members of the area mental health board in such a 
manner as to provide equitable area-wide representation. 

(c) The area mental health board shall include: 

( 1 ) At least one commissioiicr from each county ; 

^2) At least two persons duly licensed to practice medicine in North Carolina; 

(3) At least one representative from the professional fields of psychology, or 

social work, or nursing, or religion ; 

(4) At least three representatives from local citizen organizations active in 

mental health, or in mental retardation, or in alcoholism, or in drug 
dependence ; 

(5) At least one representative from local hospitals or area planning organiza- 

tions ; 

(6) At least one attorney practicing in North Carolina. 

(d) Any member of an area mental health board v/ho is a public official shall be 
deemed to be serving on the board in an ex officio capacity to his public office. The 
ex officio members shall serve to the end of their respective terms as public oflicials. 
The other members shall serve four-year terms, except that upon initial formation 
of an area mental health board, three members shall be appointed for one year, twc 
members for two years, three members for three years, and all remaining members 
for fo ur y ears. _ _ 

(C; Subject to the supervision, direction, and control of the State Board of 
Mental Health, the area mental health board shall be responsible for reviewing and 
cvalu.i'.ing the area needs and programs in mental health, mental impairment, 
mental retardation, alcoholism, drug dependence, and related fields, and for develop- 
ing jointly with the State Department of Mental Health an annual plan for the 
effective development, use and control of State and local facilities and resources 
in a comprehensive program of mental liealth services for the residents of the 
area. (1971. c. 470, s. 1.) 

§ 122-35.21. Appointment of area mental health director. — The area 
mental health lioard of each area established pttrsuant to this Article shall appoint, 
with tlie approval of the Commissioner of Mental Health and the State Board of 
Mental Health, an area mental health director. The area mental health director shall 
be the employee of the area tnental health program, responsible to the area mental 
health board for carrying out the ])o!icies and pro.crams of the area mental health 
board, and of the State Hoard of Ment^il Health. ( 1971, c. 470, s. 1.) 

§ 122-35.22. Clinical services. — All clinical services under an area mental 
hcnlth program shall be under the supervision of a person duly hcensed to practice" 
medicine in North Carolina. (1971, c. 470, s. 1.)