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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

STERN, District Judge.

 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.

  It is on this 2nd day of July, 1981 stipulated and agreed between and among the parties signatory hereto that:

 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.

  The County shall comply with Section A and B above, one year from the signing of this Agreement unless stated otherwise.


 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.


3. In compliance with N.J.S.A. 30:4-37, or 30:4-38, and 30:4-39, the Hospital shall refuse regular Class B & C commitments that are inappropriate

 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 to deliver prompt and effective evaluative service;


2. to orient the person and the family in a humane manner to the functions, activities, rules, operating policies, rights, services, and treatment programs provided in order to facilitate the person's admission into the Hospital setting if admission is appropriate;


3. if appropriate for admission, to prepare the person for movement to the service area or program that best meets his/her needs, at the time, within the least restrictive environment, and to provide a comprehensive admissions packet and evaluation of the person which may also include data from the referring community service facility for use by treatment teams within the Hospital;


4. to provide short-term emergency crisis intervention, stabilization or short-term treatment to individuals as defined in Section III, 2 herein. Staff training sessions shall be held internally. The written policy shall be widely disseminated, and community education meetings should be held with County and Hospital adminstrative staff, the County Mental Health Administrator and Board, community mental health agencies, and community gatekeeper agencies (police, court personnel general hospital emergency room staff, etc.) to inform referral agencies about the new policy and to urge the use of less restrictive community alternatives.

 2. Acute Psychiatric Care and Intervention

 a) Acute psychiatric care and intervention resulting from crisis and conflict is best treated in the unit which is most familiar to the patient. When a patient is perceived as a danger to him/herself or others, he/she shall be treated by a one to one intervention or other modality. In the event that treatment is not effective, the patient shall be transferred to the male/female hyperactive ward unit which shall handle the crisis.

 b) This acute psychiatric care and intervention shall be available to all patients.

 c) Referral to the hyperactive wards for acute psychiatric care must be made by the sending unit chief or the supervising physician in charge of the unit.

 d) The length of stay for patients transferred to the hyperactive wards shall be temporary and short term based upon the evaluation by the therapeutic team. If any patient being treated for acute psychiatric care and intervention remains on these wards for longer than ten (10) working days, a written progress report specifying reasons for continued stay on the ward must be submitted to the Clinical Director for approval. A similar report shall be prepared for every five (5) days of continued stay. No person shall remain on the ward for more than thirty (30) calendar days except upon a showing of exceptional circumstances which shall be fully documented in the record with specificity.

 e) The major responsibilities of this service are:


1. Internal Management: psychiatric and psychological interventions designed to stabilize the individual toward resuming management of emotions, thoughts and behavior;


2. development of appropriate intervention skills;


3. physical health maintenance;


4. life support skills;


5. vocational-educational-economic skills;


6. return of patients to functionally-oriented units as quickly as possible.

 3. Personal Care Unit

  a) Residents placed in the Personal Care Unit need skills for daily living activities. The basic criteria for placement in this service area are:


1. physical or mental handicap that hinders an individual from functioning independently;


2. inability to care for basic personal needs (such as dressing, toileting, etc.), or


3. mental confusion that prevents an individual from functioning appropriately as well as independently.

  b) The major responsibilities of this service include:


1. Life Support: refamiliarization and reacquisition of skills necessary for life outside the Hospital especially for placement in a long-term care facility;


2. Physical Health: health maintenance and restoration;


3. Internal Management: acquisition of and training in effective habits of coping with the patient's own thoughts and emotions;


4. Interpersonal Skills: acquisition and training in acceptance of everyday relationships with people;


5. Vocational-Economic-Educational: basic economic information, facts and skills required to live outside the Essex County Hospital Center.

  c) Specific programs shall include such activities as reality orientation, bowel and bladder training, feeding skills and good grooming.

  4. Socialization Service Unit

  a) Residents placed in the Socialization Unit need skills in socialization and/or acquiring socially acceptable behavior. The basic criteria for placement in this service are:


1. patient has difficulty establishing, maintaining, or developing appropriate interpersonal relationships; or


2. individual may exhibit socially unacceptable habits such as being verbally abusive, physically assaultive, destructive to property, self-destructive or has other behavior problems which limit social acceptability and make return to the community more difficult.

  b) The major responsibilities of this service include:


1. Development of appropriate interpersonal skills;


2. internal self-management;


3. development and maintenance of life support skills;


4. vocational-educational-economic self-maintenance skills; and


5. physical health care.

  c) Specific programs shall include such activities as direct reinforcement, vocational rehabilitation, community re-entry programs such as good grooming, recreational therapy and occupational therapy, and socialization programs such as cooking and remotivation.

  d) The Socialization Unit shall prepare patients for movement either directly to the community or the Community Oriented Unit for preparation for discharge. Living arrangements, daily activities, and use of supportive services shall be as close to the normal patterns of community life as possible. Programs shall be organized to promote dignity, mobility and independence. Special attention shall be paid to the vocational, educational, economic and self-maintenance skills a patient will need to survive in community life.

  5. Community Oriented Unit

  a) Residents placed in the Community Oriented Unit need assistance in developing basic skills that will enable them to live independently in the community. The basic criteria for placement in this service are:


1. Resident has basic socialization and personal care skills but needs assistance in areas such as homemaking, shopping, financial management, self-medication and use of medical and other community services;


2. Resident lacks appropriate work skills or is unable to sustain a meaningful work effort; or


3. Resident lacks ability to find and maintain appropriate community living facility.

  b) The major responsibilities of this unit include:


1. Development and maintenance of community life support skills;


2. Vocational, educational and economic skills required to maintain oneself in the community.


3. Interpersonal skills;


4. Management of internal affairs; and


5. Physical health.

  c) Specific programs shall include such activities as social skills, self-medication, consumerism, decision-making and interpersonal relationships.

  d) Patients in the Community Oriented Unit shall be provided with experience on and off Hospital grounds which promote independence in social, residential, work-related and other life experiences. The social work staff shall establish mechanisms to contact and involve relevant community agencies in the planning and implementation of the unit.

  6. Medical Services

  a) The Medical Services Unit shall function as a modified acute care facility to serve the physical health needs of all Essex County Hospital Center patients. The Hospital shall provide a written plan of organization detailing the provision of physical medical service to meet the needs of patients. Medical services shall be provided by a licensed physician eligible for certification in the relevant medical field, augmented by an adequate, qualified staff.

  b) The Medical Services Unit shall provide the following inpatient service:


1. short term care for patients requiring diagnostic and therapeutic services;


2. nursing and medical care for patients in need of respiratory, pulmonary, or general isolation as a result of a physical illness;


3. the Hospital and Medical Services Unit shall refer all patients in need of surgery to a general hospital where such surgery can be performed. No surgery shall be performed at Essex County Hospital Center with the exception of emergency, life saving procedures.

  c) The medical services provided for patients shall include, but not be limited to:


1. Dermatology;


2. Gynecology;


3. Neurology;


4. Ophthalmology;


5. Orthopedic Clinic (on an on-call basis);


6. Otolarnygology;


7. Podiatry;


8. Surgical;


9. Urology (on an on-call basis);


10. Dental

  d) In providing medical care, the Medical Services Unit shall take advantage of whatever community-based facilities are appropriate and available. The Hospital shall arrange for consultation with community medical experts when required. Whenever possible and clinically indicated, outside consultants shall be contacted within forty-eight (48) hours of development of the condition, except in emergent situations, which require immediate consultation and treatment.

  7. Outreach Unit

  a) This unit shall function to serve the needs of those patients at Essex County Hospital Center who are diagnosed as mentally retarded and assigned to this unit. The purpose of the Unit shall be to provide habilitation and training for these patients to prepare them for community placement or alternative care. The program in the Unit shall be established with the following guidelines proposed by the New Jersey Association of Retarded Citizens, hereinafter NJARC, for the Outreach Program: Staffing patterns shall reflect the needs of a specialized disabled population, i.e., the mentally retarded/mentally disturbed. The nursing staff shall emphasize the medical and health aspects of patient care, such as the administration of medication, first aid, and the monitoring of the physical well-being. The program staff, which would include Outreach personnel as well as Hospital personnel, shall be responsible for the daily programming. The program shall operate at least from 7:00 a.m. to 3:00 p.m. which corresponds to the current Hospital staff work hours. Program positions include: 1 Coordinator; 1 Assistant Coordinator; 5 Outreach Instructors; 1 part time Program Consultant; 1 part time Social Worker and 1 part time Licensed Psychologist.

  The ward for mentally retarded should be set up as a single unit emphasizing a homelike atmosphere. This arrangement would allow for the space which is so critical in creating an environment for the teaching of appropriate social and educational goals. The area should be exclusively used by those residents. The residents shall participate in the existing Hospital services and programs based on their abilities, as determined by program staff. This plan shall stress a consistent, structured and efficient supervised approach to treatment.

  The Hospital shall attempt to have qualifying patients who do not reside in the unit participate in the program.

  8. Adolescent Unit

  a) The Adolescent Unit shall be used as a twenty-four (24) hour care facility for evaluation and short term inpatient care for adolescents, from ages thirteen to seventeen (13-17). Its purpose shall be to provide psychiatric care within the context of community care and education during a specific phase of treatment of the adolescent.

  b) The County and Hospital shall exercise its discretion in admissions procedure to exclude from admission to the Adolescent Unit those patients who do not need intensive psychiatric therapy on an inpatient basis, or who are otherwise inappropriate.

  c) Discharge planning shall begin upon admission to the Unit. At initial family contact, discharge shall be discussed. If the Division of Youth and Family Services (DYFS) is involved, the DYFS worker shall always be consulted with respect to formulation of the Individualized Treatment Plan. If possible, the DYFS worker should assist in formulating the individual treatment plan.

  d) The professional staff shall have training in family intervention in connection with the admission, treatment, and discharge of the individual patient and every effort shall be made to enlist all patients in the form of treatment.

  e) No aspect of the treatment program shall abridge any patient's rights.

  f) Medication shall only be ordered by the qualified psychiatrist or covering physician assigned to the Unit. Medication shall be administered in such a way as to have minimum impact on school attendance and performance.

  g) The procedure to place patients in "Time Out" shall be formalized in the same manner as the procedure for use of seclusion.

  h) School shall parallel the rules and regulations as set forth by the local Board of Education. Each patient shall be enrolled as soon as the local Board of Education has approved the enrollment.

  i) The treatment program shall be problem oriented, with discharge as the ultimate goal. Intermediate goals shall be reviewed and upgraded frequently.

  j) Appropriate activity therapies, opportunities for exercise, levels of education and life skills training shall be available to all patients on the adolescent unit.

  k) Flexible visiting hours designed to encourage maintenance of family and community ties shall be arranged.

  l) Under no circumstances shall any aspect of the adolescent program be administered in a manner which would increase the likelihood of the dissolution of family ties.

  m) Arrangements shall be made to permit and encourage social interaction between adolescents in Essex County Hospital Center and adolescents in local high schools and community organizations.

  n) Diagnostic procedures shall be refined and upgraded to identify and treat the less commonly known physical and psychiatric disorders.

  B. The Hospital shall provide for all patients comprehensive treatment services, including, but not limited to:

  1. General Services

  a) Every patient shall have the opportunity to participate in individual and group psychotherapy.

  b) An activities program shall be provided to meet the needs of each patient. This shall include but not be limited to such activities as recreation and music therapy.

  c) Physical therapy shall be available for all patients as per paragraph (e) below.

  d) Treatment teams which include all or parts of nursing, psychology, occupational therapy, vocational rehabilitation, music therapy, social work and recreation therapy, shall develop written plans within ninety (90) days of this agreement outlining the roles of these services and how they shall be delivered to patients.

  e) The appropriateness of the services shall be determined by the therapeutic team, which shall include the patient. Referrals for therapy shall be made on the basis of a systematic, organized, professional evaluation of the needs of all patients and shall be coordinated by appropriate, qualified staff. The therapeutic teams shall take affirmative steps to actively encourage patients to participate in the various services and programs.

  f) Each member of the therapeutic team shall have the responsibility to recommend appropriate follow-up procedures.

  g) There shall be specific programming appropriate for the needs of deaf, blind, and other multiple-handicapped persons, which programming shall ensure that mental health services provided by the Hospital shall be as accessible to such patients as they are to any other patient served by the Hospital.

  2. Activities Therapy

  a) Every patient shall have the opportunity to participate in activities therapies, such as occupational therapy, vocational rehabilitation, and/or art/dance/music therapy.

  b) Each patient shall participate in the decision as to which activities therapies best suit his/her needs, and shall be provided activities which permit him/her to function at maximum capability.

  c) The Hospital shall make activities available beyond 3 p.m. and into the early evening hours.

  3. Individualized Treatment Plans

  For every patient an individual treatment plan must exist and be updated every two (2) weeks for the first three (3) months of hospitalization, every two (2) months thereafter up to one (1) year, and then every three (3) months. Individual treatment plans for patients under twenty two (22) years of age shall be reviewed monthly. The patient shall have input into the development of his/her treatment plan in accordance with the provisions of N.J.S.A. 30:4-24.1. The patient must sign the treatment plan and a copy placed in his/her medical records and a copy given to him/her upon the patient's request. The patient shall be advised in writing of his/her right to receive a copy of the treatment plan. The individual treatment plan shall include the patients' schedule.

  a) Each patient shall have a comprehensive physical and mental examination and review of behavioral status within forty-eight (48) hours after admission to the Hospital.

  b) Each patient shall have an individualized treatment plan. This plan shall be developed by an interdisciplinary team including a psychiatrist and the patient, and implemented as soon as possible, but, no later than ten (10) working days after the patient's admission. Each individualized treatment plan shall contain:


1. a statement of the nature of the specific problems and specific needs of the patient;


2. a statement of the level of supervision pursuant to Section XI, g herein;


3. a description of intermediate and long-range service goals, with a projected time table for attainment;


4. a statement and rationale for the plan of treatment for achieving these intermediate and long-range goals;


5. a specification of staff responsibility and a description of proposed staff involvement with the patient in order to attain these services goals;


6. criteria for release to less restrictive treatment conditions, and criteria for discharge.

  c) As part of his treatment plan, each patient shall have an individualized post-hospitalization plan. This plan shall be developed by the treatment team including the patient within five (5) working days after the patient's admission to the Hospital.

  d) In the interests of continuity of care, one mental health professional shall be responsible for supervising the implementation of the treatment plan.

  e) The treatment plan shall be reviewed monthly by the mental health professional responsible for supervising the implementation of the plan and shall be modified if necessary. A patient may request the Monitor to review his/her treatment plan at any time. If the monitor or other outside evaluating agency finds the treatment plan inappropriate, the County shall engage an independent psychiatrist to evaluate the patient and prepare a treatment plan pursuant to the guidelines herein.

  f) Complete patient records shall be kept on the unit in which the patient is placed. Patient records shall be made available to those persons who are properly authorized by law to review same. These records shall include:


1. Identification data, including the patient's legal status;


2. A patient history, including but not limited to:


a. Family data; educational background, and employment record;


b. Prior medical history, both physical and mental, including prior hospitalization;


3. The chief complaints of the patient and the chief complaints of others regarding the patient;


4. An evaluation which notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, physical functioning, vocational functioning, personal functioning, memory functioning, orientation, and an inventory of the patient's qualities in descriptive, not interpretive, fashion;


5. A recorded physical examination;


6. A copy of the latest individual treatment plan and any subsequent modifications thereto;


7. A review of the treatment plan which analyzes the successes and failures of the treatment program and directs whatever modifications are necessary.


8. A copy of the individualized post-hospitalization plan and any modifications thereto.


9. A medication history and status, which includes the signed orders of the prescribing physician. Nurses shall indicate by signature that orders have been carried out;


10. Progress notes of each significant contact by a mental health professional with the patient shall be recorded in the patient's chart.


11. A monthly detailed summary of the patient's progress pursuant to his/her treatment plan prepared by the patients' mental health professional.


12. A formal level of functioning assessment which shall have been completed at least every ninety (90) days.


13. A detailed summary of any extraordinary incident in the Hospital involving the patient. This shall be prepared by a staff member noting personal knowledge of the incident or specifying the source of information and initialed within twenty-four (24) hours by a mental health professional and the Medical Director and Chief Executive Officer; those incidents pursuant to Section XI, g) shall be noted in the patient file.


14. A summary by the medical director or his/her appointed agent of the findings pursuant to the twenty (20) day review.

  g) None of the services described in this part shall be withheld or otherwise modified or denied for the purpose of punishment.

  h) Predischarge Planning and Aftercare:

  1. The Hospital shall adopt a functional approach to discharge planning, with emphasis on linkage with community mental health and social service agencies;

  2. The social service staff at Essex County Hospital Center shall function in all units of the Hospital, not only in those designated as pre-discharge units.

  3. Just as the Hospital has one clearly stated admissions process, the discharge process shall be standardized for all patients.

  4. Social service department staff should be redeployed in an interdisciplinary unit approach, so that all clients have access to their services; affiliation agreements shall be negotiated and executed with community mental health agencies. The Hospital shall outline the staff responsibility from preadmission screening through discharge planning and follow-up case management after discharge for services, to patients including how, when and where.

  5. The intent of the policies and procedures formally articulated by the Division of Mental Health in its pilot Joint Hospital/Community Discharge Projects should be adopted by the County. The Hospital Administration should translate its already verbally stated commitment to the involvement of community mental health liaisons in treatment and discharge planning into concrete, assertive reinforcement.


a. All Hospital staff should be told that comprehensive discharge planning with the appropriate community health and relevant social service resource agencies is a priority and is considered to be an integral part of the in-hospital treatment process;


b. Formal mechanisms such as the following should be instituted and monitored regularly:


(1) inappropriate admission survey;


(2) admission notification process;


(3) individual service/discharge plan (ISDP);


(4) discharge notification process on all clients.


c. A Discharge Coordinator should be designated with the formal authority to direct the discharge planning process for all clients and to monitor community agency responsiveness;


d. Staff development sessions and training opportunities on available community mental health and related social services in Essex County and the benefits of the community involvement in discharge planning should be organized and offered as soon as possible. The importance of the development of community and natural support service linkages prior to discharge should also be emphasized;


e. Community mental health center liaisons should be accepted as equals in treatment and discharge team planning processes in all programs.


6. Visits of Hospital clients to, and participation in, the day/resident activities of community agencies should be facilitated and accepted as an integral part of comprehensive in-hospital treatment and discharge planning.


7. The discharge planning process should be comprehensive, including, in addition to projected clinical needs, housing arrangements, adequate financial support (such as SSI benefits), appropriate vocational and social opportunities, etc., in an effort to reduce the recidivisim rate.


8. The Hospital should participate in the Division of Mental Health's Bureau of Housing and Policy Development's housing evaluation process to insure that all community residential facilities used by the Hospital and by Bureau of Transitional Services for discharged Essex County Hospital Center client placements are adequate and meet minimal life/safety and normalization standards.


9. The Hospital administration should make every good faith effort to insure that Bureau of Transitional Services becomes an integral part of discharge planning when boarding home placement is appropriate.


10. The Hospital should emphasize the establishment of treatment and rehabilitation programs focused upon a client's level of personal and social functioning. Training efforts should be directed at educating staff in the functional approach to client evaluation, needs assessment, and service planning, including theories of normalization, levels of functioning, and client advocacy.


11. The treatment/discharge planning process shall be reorganized into a multi-discipline team approach.


12. A team evaluation shall be completed within seventy-two (72) hours after admission. A determination should be made as to short-term or long-term patient hospitalization status. When a patient's status is determined to be short-term, a discharge notification form should be completed. Community agencies shall be notified as to the patient and requested to assess his/her community support needs.


13. Appropriate personnel shall be used to expedite unified services record keeping for admission and discharge notification to community mental health agencies, to conduct periodic samplings of records for inclusion of a comprehensive discharge plan, to make telephone contact with community resources, and to follow-up on the action steps outlined in the individual treatment plan.


14. Client involvement in his/her own needs assessment, in-hospital service goal development, and discharge planning should be administratively supported and actively encouraged.


15. A formal administrative audit procedure shall be conducted regularly and be integrated into the Hospital's ongoing Utilization Review and Quality Assurance procedures. The on-site involvement of community liaisons in programming and discharge planning, the inclusion of community liaisons in the team process, the completion and record inclusion of necessary notification forms, service/discharge plans, etc., shall be reviewed.


16. Patients who can function within a community-based setting as based on level of functioning shall be identified so that comprehensive discharge planning is expedited and linkages made.


17. The scope of the relationship between Hospital staff and community agency liaisons shall be mutually defined by the needs of the patients.


18. Admission and discharge planning should be designed to improve the quality of care, reduce inappropriate or unnecessary admissions, effect discharges with more assurances of community service linkages, reduce the Hospital census, and increase a client's chances for successful community reintegration.


19. In the event that the County becomes charged by law with the function of monitoring community agencies and is provided by the State with sufficient funding for that purpose, the County government shall then monitor community agency compliance with unified services mandates requiring services to ex-hospital clients as a condition of funding and shall withhold funds and/or seek and/or organize new sponsor agencies if existing sponsors do not show a willingness to comply with the funding mandates.


  1. Behavior modification shall not be designed to eliminate a particular pattern of behavior unless a physician first certifies that he/she has examined the patient with respect to such behavior and that it is not caused by a physical condition which could be corrected by appropriate medical procedures.

  2. No patient shall be subjected to a behavior modification program which attempts to modify behavior in order to serve any institutional convenience.

  3. Evaluation of the behavior modification programs shall be done by the Department of Human Services which has agreed with the Public Advocate to do the following:

  a) Department of Human Services shall review every behavior modification program (including token economies and the adolescent unit) at least annually.

  b) A Division of Mental Health Advocacy staff member shall accompany the evaluation team at each visit.

  c) The Division of Mental Health Advocacy shall receive thirty (30) days' advance notice of the date of the Department of Human Services team visit.

  d) The Department of Human Services team must include professionals skilled in behavior modification concepts and techniques.

  e) The Department of Human Services team is to pay particular attention to the Patients' Bill of Rights in evaluating the behavior modification programs.

  f) The team report is to be prepared with all due speed after the inspection and is to be furnished to the Division of Mental Health Advocacy and the Monitor at the time it is furnished to the County.

  g) The Hospital must rectify any patients' rights violations noted in the report within twenty (20) days of receipt of the report. Any other deficiencies noted in the report shall be rectified within six (6) months.

  h) In the event that any one or more of these conditions a) to h) herein is not met the Human Services team shall be deemed to no longer be an acceptable evaluation mechanism for behavior modification programs, and an alternative evaluation mechanism shall be agreed upon by the parties.

  V. STAFFING Staffing shall be based on the needs of the individual unit for the patients in the Hospital programs and include the following specific ratios and timetables for meeting these ratios. (The ratios are based on staff position per number of patients.] A. STAFF TO PATIENT RATIO PER UNIT UNITS Compliance ADMISSIONS ACUTE PERSONAL Position: Date: CARE CARE Program Chief * 12/83 1 1 1 Psychiatrist 12/83 1:34 2:39 1:125 Physician 12/82 2:34 2:39 2:125 OT/VR ** 12/82 2:34 2:39 3:125 Activities Therapist 12/81 1:34 1:91 2:125 *** 1:21 Nursing: R.N. 1986 11:34 20:39 12:125 LPN 1986 9:34 18:39 20:125 Para Professional 12/81 18:34 21:39 63:125 Psychologist 12/83 1:35 1:36 1:107 *** 1:21 Social Service 12/83 4:34 5:68 1:68 *** 3:21 Compliance SOCIALIZATION COMMUNITY MEDICAL Position: Date: ORIENTED SERVICES Program Chief* 12/83 1 1 1 Psychiatrist 12/83 2:143 1:79 1:98 Physician 12/82 1:65 1:79 2:98 OT/VR** 12/82 1:39 4:79 3:98 Activities Therapist 12/81 1:76 1:79 2:98 Nursing R.N. 1986 1:10 5:79 26:98 LPN 1986 1:8 6:79 23:98 Para Professional 12/81 1:3 16:79 60:98 Psychology 12/83 4:225 1:79 2:89 Social Service 12/83 1:25 1:25 2:89


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