State Mental Hospital Reforms Ordered

Four years after federal investigators began probing civil rights violations at California’s mental hospitals, prosecutors filed a consent decree in federal court in Los Angeles on Tuesday that lays out a road map for sweeping reform under a court-appointed monitor.

The 90-page decree -- filed simultaneously with a lawsuit that it aims to resolve -- spells out a detailed prescription to prevent suicides and assaults, reduce the use of seclusion and restraints and offer more personalized care to the state’s 5,000 or so mentally ill patients.

The strongly worded lawsuit criticizes the hospitals for “egregiously and flagrantly” depriving patients of their rights by offering services substantially inferior to “generally accepted professional standards of care” and failing to provide “adequate protections from harm.”

Still, along with the stinging rebuke came an acknowledgment that the state has worked to improve its five beleaguered mental hospitals. The decree noted: “California and its officials have acted in good faith and have voluntarily undertaken significant measures to enhance confinement, care, treatment and rehabilitation for residents.”

California Department of Mental Health officials, who have negotiated with U.S. Justice Department officials for several years to resolve the federal concerns, welcomed the decree as a workable compromise that will help bring the state’s system in line with the latest national treatment models.

Selected by both parties to oversee the changes during the next five years was Mohamed El-Sabaawi, a Virginia physician who, as a court-appointed monitor, supervised reforms to Kentucky’s inpatient psychiatric system.

“I think it’s a fair resolution,” said John Rodriguez, deputy director of the Department of Mental Health. “We know exactly what we need to achieve and how to achieve it.”

Rodriguez said he had encouraged federal officials to finish the consent decree before state budget negotiations come to a close later this month. State officials hope to secure about $44 million in additional annual funds to help increase staff at the hospitals, make repairs to aging buildings and pay for the court-appointed monitor, Rodriguez said.

“My expectation is that we’ll have that money in the budget and, when it’s passed, we blast off,” Rodriguez said. “We don’t want to miss this opportunity.”

Despite Rodriguez’s enthusiasm, the agreement was not the more flexible “memorandum of understanding” the state had wanted. Instead, federal officials, who conducted two investigations into civil rights violations of patients and misuse of Medicare and Medi-Cal funds, prevailed in imposing a court-ordered settlement.

The agreement, which the state has five years to carry out, means that two of California’s major bureaucracies -- the prison and mental health systems -- are now under the hammer of a federal judge.

It comes as the state hospitals have struggled to shift to a model of care that involves patients more closely in their own recovery.

However, problems have persisted and in some cases worsened; they include an increase in suicides, assaults and murder, exacerbated by staff shortages and poor training.

Peggy Collins, the lead staffer for the Senate Select Committee on Developmental Disabilities and Mental Health, said the strict mechanism of a consent decree could prove essential to reform.

“Hopefully the changes will be good for the system, good for the people who live there and will improve the ability of people who move out of the state hospitals to stay out,” said Collins, whose committee has helped draft the proposed state budget increase for mental health.

The consent decree spells out reforms in vivid detail, including which kinds of restraints are allowable, which patients should have their medications reviewed and how the hospitals should shift to the so-called “recovery model” of care.

It lays out prescribed timelines for assessments of new patients and calls for timely vision and dental care, as well as infection control.

It also mandates that “potential suicide hazards are identified and prioritized for systematic corrective action” promptly.

“It’s long overdue,” said Linda Russell-Scheet, whose daughter, 20-year-old Cecilia Russell, committed suicide by hanging herself at Metropolitan State Hospital in Norwalk last fall in a manner nearly identical to her roommate’s suicide. Russell had been a patient months before her treatment plan was drafted, her mother said.

The Justice Department began its investigation at Metropolitan in 2002, uncovering wide-ranging violations of the Civil Rights of Institutionalized Persons Act. Findings issued in 2003 and 2004 criticized the juvenile and adult programs for excessive seclusion and restraint and for improper prescription of drugs to control behavior.

Even before the findings were released, the state began moving toward a new approach to care. But a Times investigation found late last year that despite its jump-start on reforms, Metropolitan had seen an increase in escapes, suicides, other self-harm by patients and allegations of physical and sexual abuse.

A report issued by federal investigators last summer on Napa State Hospital in Napa alleged that suicidal patients were not receiving prompt intervention, that patients didn’t get needed medical or psychiatric care and that employees were dealing drugs to patients.

Investigations of Patton State Hospital in San Bernardino and Atascadero State Hospital on the Central Coast followed.

In the last 18 months, two Patton patients have committed suicide and two have been slain.

Atascadero has been plagued by an increase of assaults by patients on staff and other patients. Many nurses and psychiatric technicians, burned out by the conditions, have left over the last year, though a recent systemwide raise for nurses and medical doctors has helped somewhat, officials said.

Meanwhile, federal prosecutors in Los Angeles launched an investigation under the False Claims Act to explore the alleged misuse of Medicare and Medi-Cal funds at Metropolitan.

Assistant U.S. Atty. Howard Daniels, who headed this investigation, said, “This is one of the most meaningful settlements that has ever been achieved under the False Claims Act.” Most cases brought under the act lead to monetary refunds to the federal Treasury but, he said: “With this we will see some tangible benefit to a vulnerable group of people and we’re very happy about that.”

Findings from the recent federal probes of Patton and Atascadero were mailed to state officials Tuesday. Federal officials declined to comment on them, and state officials had not yet seen them. However, the documents filed in federal court in Los Angeles state that the constitutional rights of patients at those two facilities are also being violated.

The lawsuit and consent decree name only Metropolitan and Napa state hospitals, but they will be amended to include Patton and Atascadero.

State officials said California’s other mental hospital -- the newly opened Coalinga State Hospital -- will also participate in the sweeping changes.

Dave Graziani, executive director at Napa State Hospital, said his hospital has been working hard to implement reforms.

“I think all of the hospitals would have moved in this direction anyway. This kind of helped us along a bit,” he said of the consent decree.

“I look at the court master as someone who can assist us and through his monitoring assure that we are doing things in accordance with what cutting edge treatment across the nation is,” he said.