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August 2, 1982

PETER SHAPIRO, individually and as County Executive of the County of Essex, State of New Jersey; MICHAEL P. DUFFY, individually and as Director, Essex County Hospital Center; DAVID PASCHAL, individually and as Director, Essex County Department of Health and Rehabilitation; ARTHUR AVELLA, M.D., individually and as Medical Director, Essex County Hospital Center; RALPH SPIRO, individually and as Director, Department of Social Services, Essex County Hospital Center, Defendants

The opinion of the court was delivered by: STERN

 This action was brought pursuant to 42 U.S.C. ยง 1983 by sixteen past and present patients at the Essex County Hospital Center in Cedar Grove, New Jersey, a psychiatric hospital run by Essex County, on behalf of themselves and all others similarly situated. The named defendants were Peter Shapiro, the Essex County Executive; Michael P. Duffy, Director of the Essex County Hospital Center; David Paschal, Acting Director of the Essex County Department of Health and Rehabilitation; Theresa Bielawski, M.D., Acting Medical Director of the Essex County Hospital Center; and Michael Woodman, Director of the Department of Social Services at Essex County Hospital Center. *fn1"

 Plaintiffs sought declaratory relief and an injunction restraining defendants from maintaining conditions and pursuing policies which they alleged deprived them of their right to meaningful treatment; subjected them to inhumane and unsafe environmental factors, such as physical abuse and overcrowded ward conditions; deprived them of effective medical care; confined them in unduly restrictive ward settings; deprived them of their fundamental personal and civil rights; and denied them access to their own funds. Plaintiffs contended that these alleged conditions and policies deprived them of their rights under the First, Fourth, Fifth, Sixth, Eighth, Ninth and Fourteenth Amendments to the Constitution as well as various laws and statutes of the United States and the State of New Jersey.

 On February 25, 1981, upon motion of plaintiffs and after hearing oral argument, the Court entered an Order certifying this action as a class action under Fed. R. Civ. P. 23(b) (2), with the class consisting of all past, present, and future patients at the Essex County Hospital Center.

 On July 20, 1981, the parties entered into a Stipulation of Settlement resolving all of the matters raised by the lawsuit. After a hearing on that same date, the Court entered an Order approving the settlement and dismissing the complaint with prejudice. As part of the settlement, the parties agreed that its terms should be monitored by a Court-appointed Master and the Court appointed John J. Barry, P.C., Gateway One, Newark, New Jersey, an attorney of the Bar of the State of New Jersey, to serve in that capacity. *fn2"

 The parties have requested that the Court issue this opinion so that the terms of the stipulation may be published. The Court is pleased to comply with this request, especially in view of the far-reaching and comprehensive provisions of the agreement. Indeed, the Court wishes to commend counsel for both parties for reaching an agreement that is both fair and equitable and which will undoubtedly be of enormous benefit to the patients at the Essex County Hospital Center.

 The text of the Stipulation of Settlement is therefore set forth as follows:

 Stipulation of Settlement

 WHEREAS, litigation is pending between the Parties relating to the constitutional and statutory rights of the Plaintiff class; and

 WHEREAS, subsequent to the institution of this litigation the Parties to this Agreement have had an opportunity to explore fully the facts and circumstances which relate to the matter; and

 WHEREAS, upon consideration of all relevant facts and circumstances the parties desire to reach an amicable resolution of this litigation; and

 WHEREAS, negotiations between the parties have now resulted in their reaching such an agreement;

 NOW, THEREFORE, the Parties stipulate as follows herein in the Stipulation Agreement attached hereto.

 1. This agreement is entered into in light of the parties' concern that requirements of the federal and state constitutions and of federal and state statutes regarding patients' treatment and patients' rights are satisfied, and in order to provide to patients other guarantees which the parties regard as important as a matter of public policy. No determination or agreement is intended or reached herein regarding the validity or invalidity of the allegations of the complaint in this action.

 2. The parties hereto agree to have an objective observer monitor this agreement pursuant to the Monitoring Agreement at Section XII herein.

 3. The Parties shall cooperate with the Monitor in his/her efforts to facilitate compliance with this agreement. For this purpose, the County Administration and the Public Advocate shall designate staff persons responsible for coordinating implementation of this agreement 90 days from its signing.

 4. The rights, standards and services set forth herein shall be implemented within the context of the public policy declared in N.J.S.A. 30:4-23, et seq., as well as N.J.A.C. 10:37-1 et seq. as promulgated by the New Jersey Department of Human Services for the New Jersey Division of Mental Health and Hospitals and incorporating the four service concepts, Advocacy, Normalization, Level of Functioning and Unified Services, as the basic framework for the delivery of services.


 "Mental Health Professional": shall be Psychiatrist; or a Medical Doctor (M.D.); or a psychologist who is a member of the therapeutic team; or a Registered Nurse (RN) who is a member of the therapeutic team; or a social worker with a MSW degree.

 "Psychologist": shall have a doctoral degree from an accredited program, or a master's degree from an accredited program with 2 years experience under a licensed clinical psychologist.

 "Activities Therapist": in such categories as vocational rehabilitation, occupational and recreational, music or art therapy, shall be a specialist graduated from an accredited program.

 "Unit Chief": shall be a Board eligible or Board certified psychiatrist who is in charge of a designated area, treatment team, ward or multiple wards or a medical doctor when Medical services are the basic services provided.


 A. The County shall maintain a program of adequate housekeeping and maintenance of buildings and equipment which shall insure a continuous state of good repair and operation in accordance with the needs of the health and safety of the patients. The Hospital center shall maintain the standards as promulgated by the Joint Commission on the Accreditation of Hospitals (hereinafter J.C.A.H.)

1. By June 1982, the County shall correct deficiencies in maintenance, including elimination of backlogs in maintenance procedures.
2. By January 1982, the County shall comply with the provisions of the Life Safety Code of the National Fire Protection Association, and with the functional safety and sanitation requirements of the Joint Commission on the Accreditation of Hospitals, as well as all applicable state and local regulations, except that the Wright Pavilion shall comply by December 1983, and the smoke towers on the Hill Buildings shall comply by December 1981.
3. Special attention shall be paid to the needs of physically handicapped patients.
4. There shall be monthly unannounced fire drills for each shift, except that fire drills for the 11:00 p.m. to 7:00 a.m. shift shall be held quarterly. Staff and residents shall be trained in emergency procedures, particularly for use in case of fire.
5. Adequate heating, air conditioning and/or ventilation systems and equipment shall be afforded to maintain temperatures and air changes which are required for the comfort of patients at all times and for the removal of undesired heat, steam and offensive odors.
6. Thermostatically controlled hot water shall be provided in adequate quantities and maintained at the required temperature for patient or resident use and for mechanical dishwashing and laundry use (180 degrees F at the equipment). The facility water supply system shall not be connected with any other piping systems or with fixtures which could allow contamination of the water supply.
7. Adequate refuse facilities shall be provided so that solid waste, rubbish and other refuse shall 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.
8. Engineering and maintenance personnel shall be adequate in number and in qualification to ensure that the physical facilities meet all fire and safety standards established by the State and that the Hospital meets such provisions of the Life Safety Code of the National Fire Protection Association as are pertinent to the facilities or as are required for accreditation by J.C.A.H.
9. A committee shall be established to maintain surveillance of inadvertent Hospital infection potentials and other hazards to patients and to promote an appropriate preventive and corrective program designed to minimize these hazards.


 The County shall provide patients with living facilities which afford privacy, dignity, comfort and sanitation, consistent with the rights enumerated in N.J.S.A. 30:24.1 and 30:24.2.

 Such facilities shall include, but not be limited to:

 Bathrooms and Lavatories

 1. Accessible, properly ventilated, private and easily usable toilets and bathing facilities, including specialized equipment for the physically handicapped. There shall be a minimum of one toilet for each eight patients and one lavatory for each six patients and a lavatory with each toilet facility to be attained by January 1982. Toilets are defined to include commodes and/or urinals depending on the sex of the patient using the facility.

 2. Accessible and easily usable sinks and drinking facilities.

 3. Adequate toilet paper, soap and towels available in all bathrooms, at all times. The Hospital administrator shall insist on staff vigilance to replace supplies as often as required.

 4. There shall be one tub or shower for each fifteen patients. If a common bathing area is provided, each shower area shall be divided by curtains to ensure privacy.

 5. Showers and tubs shall be conveniently located so that if staff assistance is needed by a patient the location of the shower does not make assistance difficult. Shower controls shall be within easy reach of all patients. Showers and tubs shall be equipped with adequate safety accessories.

 6. The Hospital shall provide adequate facilities and equipment for handling clean and soiled linen and bedding. There shall be frequent changes of linen and bedding, at least every seven (7) days.

 7. Every building shall be kept clean, odorless and insect-free at all times, and sufficient equipment such as brooms, mops, disinfectants, etc., shall be provided to housekeeping staff for this purpose. In particular, lavatory areas are to be cleaned as often as necessary everyday.


 1. Resident Unit :

 The number of patients in a multi-patient room shall not exceed eight persons (fewer if possible) except for the Medical Services Building. There shall be allocated a minimum of seventy-two (72) square feet of floor space per patient in multi-patient rooms. Single rooms shall have a minimum of ninety (90) square feet of floor space. The space requirement shall be achieved by December 1981, except for the Wright Pavilion, where these standards shall be achieved by December 1982.

 Screens or curtains shall be provided to ensure privacy within the resident unit. Each patient shall be furnished with a comfortable bed with adequate change of linen, a bedside table and a lockable closet or locker for personal belongings. Fifty percent of the required screens, curtains, tables and lockable units shall be in place by June 1982 and all of them shall be in place by December 1983.

 To the maximum extent possible, patients shall be housed in single or two-bed rooms.

 2. Day Room :

 The minimum day room area shall be forty (40) square feet per patient. These areas and the Activity Therapy Building shall provide for a full range of patient activity from two-person conversation to group activities. These rooms shall be attractive and adequately furnished with reading lamps, tables, chairs, television and other recreational facilities. They shall be conveniently located to patients' bedrooms and shall have outside windows. There shall be at least one day room area for each bedroom floor in a multi-story building except for the Hill Buildings where the day rooms are on a different floor. Areas used for corridor traffic shall not be considered as day room areas.

 Furnishings in common areas such as day rooms shall be as homelike as possible and shall be relatively expendable or able to withstand the more destructive patient. Patients shall be encouraged to personalize their sleeping areas by displaying personal possessions.

 3. Dining Facilities :

 a) The minimum dining room area shall be ten (10) square feet per patient. The dining room shall be separate from the kitchen and shall be furnished with comfortable chairs and tables with hard, washable surfaces. These standards shall be achieved by December 1981.

 b) Patients shall not be denied access to dining rooms for regular meals except for valid medical reasons which shall be documented in the event of each denial of access.


 A. As long as the County maintains the Hospital Center, it shall provide direct patient care services as delineated below. Under no circumstances shall the Hospital be operated without an Admissions Unit and an Acute Psychiatric Care and Intervention Unit. If the Hospital should decide to abolish any unit, the Hospital shall continue to provide services as set forth herein to any patient for whom those services would be appropriate. The hospital shall immediately begin the process of implementing the specific services for the units they maintain and shall complete the process no later than December 1982 unless otherwise specified herein.

 1. Admissions

 a) The Admissions Unit must recognize and deal with the stresses that brought the person to seek treatment and the stresses he/she feels in entering treatment. Since the admission process will have crucial effects that may hinder or facilitate a patient's stay at Essex County Hospital Center, the admission process must be as humane and non-mechanistic as possible so that the patient feels comfortable and reassured. Admissions procedures shall be designed and conducted to inspire a feeling of trust and friendship in the patient and his family.

 b) Whenever possible, attempts shall be made to refer persons to community facilities rather than admitting the person to one of the Hospital's service units.

 c) The major responsibilities of this service include:

1. orientation of the patient and family in a humane manner to the functions, activities, rules, operating policies, services and treatment programs provided in order to facilitate the patient's stay at Essex County Hospital Center;
2. evaluation within a 3 to 5 day period the appropriateness of admissions or of discharge. During that 3 to 5 day period, a reasonable number of diagnostic and treatment programs, including a comprehensive physical examination, must be employed in order to deliver prompt, effective and continuous services to all admissions. There shall be continuous followup and monitoring of treatment found to be necessary by the results of diagnostic procedures and laboratory tests. Medical care shall be made available to the patients throughout his/her Hospital stay;
3. if the patient is appropriate for admission, administration by the staff of the admissions unit of a preliminary level of functioning assessment to determine some of the needs of the individual patient so that treatment teams both within the Hospital and authorized community agencies have useful information. The staff of the Admissions Unit shall then administer a level of functioning assessment to determine all the needs of the individual and shall work with the patients in the development of a preliminary individual treatment plan.

 d) The length of stay of a patient in the Admissions Unit shall not exceed eight (8) working days without approval of the Clinical Director or his/her designee. A written progress note that documents the reason or reasons why any resident must reside in the Admissions Unit for longer than eight (8) working days must be submitted to the Clinical Director or his/her designee for his approval prior to extending the stay beyond eight (8) working days. The designee may not be the patient's treating physician.

 e) The Hospital shall encourage, facilitate and make good faith efforts toward providing citizen and community advocates (including volunteers and others) for individual patients at Essex County Hospital Center for the duration of such patient's stay.

 f) Essex County Hospital Center shall implement diagnostic screening techniques based on a complete range of diagnostic procedures currently available.

 g) The County shall develop a new Hospital admissions policy consistent with the following guidelines in order to survey the current Hospital population and to identify groups traditionally referred and admitted; the following categories of individuals should be seriously considered for exclusion within the new policy: a) persons with major medical problems, with minor mental symptoms; b) persons with chronic brain syndrome; c) persons primarily needing adequate living accommodations, economic or other primary problems such as: alcohol and/or drug abuse without major mental illness, patients who are in acute toxic states due to alcohol abuse and acute toxic states due to drug abuse; e) nursing home care; f) mental retarded.

1. Adolescents shall be screened in accordance with the above stated policy. Screening shall be done in the Admissions Office; the adolescent patient shall then be sent to the Adolescent Unit and shall not be held on the Admissions Unit.
2. The Hospital shall exercise professional judgment in the acceptance of 15 day magistrates' commitments, in compliance with N.J.S.A. 30:4-26.3.

 h) Implementation: The purpose of the Admissions Unit/Service shall be to properly admit, evaluate and refer persons for placement in an appropriate service component of the mental health delivery system, whether that is to be within the Hospital or the community. The rule of the Admissions Unit shall not be to provide extended treatment but to allow for therapeutic intervention and short-term stabilization up to a maximum of eight (8) working days of intensive evaluation and care. In all cases, attempts shall be made to refer persons to appropriate and available community alternatives rather than admitting the person to the Hospital. The Hospital and County administration shall accept responsibility for the implementation of the admission policy by admission office staff and monitor mental health agency staff responsiveness. The major responsibilities of the Admissions Unit shall be:

1. to evaluate the appropriateness for admission, further treatment, referral or discharge. To this end, a wide range of diagnostic and assessment modalities and techniques should be available ...

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