The Honorable Pedro J. Rossello
Governor of Puerto Rico
P.O. Box 82
La Fortaleza, San Juan, PR 00901
Re: Center for Integral Services Rio Piedras, Puerto Rico
Dear Governor Rossello:
Last year, we notified you, pursuant to the Civil Rights of Institutionalized
Persons Act, 42 U.S.C. § 1997, that we were initiating an investigation
of conditions at the Center for Integral Services ("CIS") in Rio Piedras,
Puerto Rico. From February 26-28, 1997, we conducted an investigative tour
of the facility accompanied by an expert consultant in behavioral psychology
and psychopharmacology. During our investigation, we toured the facility,
interviewed Department of Health officials, facility administrators and
staff, spoke with residents and their family members, and reviewed pertinent
CIS is a state-operated facility serving approximately 36 men and 17
women with varying levels of developmental disabilities. This facility
is one of six state-operated residential facilities serving persons with
developmental disabilities in Puerto Rico. Most of the CIS clients have
some ability to walk and talk and have either mild or moderate mental retardation.
Most of the clients also have behavior problems, including many who are
mentally ill as well as mentally retarded. There are no children in the
facility (the youngest residents are twenty years old), nor are there any
elderly residents (the oldest client is fifty-four years old).
In investigating CIS, our purpose was to evaluate whether residents
were being afforded their constitutional and federal statutory rights.
All residents of state-operated mental retardation facilities have a Fourteenth
Amendment due process right to adequate food, clothing, shelter, medical
care, reasonably safe conditions, and training. Youngberg v. Romeo,
457 U.S. 307 (1982). In addition, the Commonwealth must provide public
services to individuals with disabilities that represent the most integrated
setting appropriate to their needs. See, e.g., Title II of the Americans
with Disabilities Act ("ADA"), 42 U.S.C. §§ 12132 et seq.;
28 C.F.R. § 35.130(d); and Section 504 of the Rehabilitation Act of
1973, 29 U.S.C. §§ 794 et seq. and the regulations
promulgated pursuant thereto. Further, the Commonwealth must provide services
and programs that are readily accessible to and usable by individuals with
See 28 C.F.R. § 35.150.
Consistent with statutory requirements, we are now writing to inform
you of the findings of our investigation of CIS. Throughout our visit,
representatives from the facility and the Puerto Rico Department of Health
were candid in acknowledging that many service areas at CIS are inadequate
and require remedial attention. During our tour, we found numerous conditions
that violate the constitutional and federal statutory rights of the CIS
residents. A major cause of many of these deficiencies is that the Commonwealth
has not devoted adequate resources to provide essential services and safe
conditions to the CIS residents. In particular, CIS has an insufficient
number of adequately trained staff across all disciplines, including doctors,
nurses, therapy and activity staff, direct care staff, and maintenance
workers to meet the needs of residents. The facts that support our findings
of unlawful and unconstitutional conditions at CIS are set forth below
along with the remedial actions that we believe are necessary to remedy
As a preliminary matter, however, we would like to express our appreciation
for the cooperation and courtesy shown us by Commonwealth officials and
facility administrators and staff during our investigation. We especially
appreciated the assistance we received from Dr. Nayda Negron, the Director
of the Mental Retardation Program in the Puerto Rico Department of Health,
from Ana Rivera Maldonado, the CIS Facility Director, and from Dr. Julian
Irizarry, the CIS primary care physician. While we were at the facility,
Dr. Negron, Ms. Rivera, and Dr. Irizarry made every effort to ensure that
our team had access to whatever information we needed. We hope to be able
to continue working with the Commonwealth in such a cooperative atmosphere.
I. CIS FAILS TO PROVIDE REASONABLE SAFETY TO RESIDENTS AND TO
MEET THEIR BASIC CARE NEEDS
Individuals residing in a state-operated institution have a fundamental
Fourteenth Amendment due process right to basic care and reasonably safe
conditions of confinement. Youngberg v.
Romeo, 457 U.S. 307
(1982). However, CIS fails to provide adequately for the most basic care
needs of its residents and fails to provide reasonable resident safety,
thereby violating the legal rights of its residents.
A. CIS Fails To Provide Reasonable Resident Safety
Throughout our investigation, we uncovered a high level of incidents,
injuries and dangerous situations at CIS that have harmed residents or
placed them at great risk of harm. Because of poor recordkeeping and lack
of aggregate data, it was difficult to determine the exact number of incidents
and injuries that occur at the facility on a day-to-day basis. Nonetheless,
it was quite clear that the incidents and injuries were widespread and
systemic and occurred on a daily basis. Many of these incidents, injuries
and dangerous situations were preventable and reflect systemic deficiencies
at CIS including lack of adequate staffing, failure to supervise residents,
and inadequate assessment and treatment of mental illness, cognitive impairments,
and behavior problems.
On our tour of CIS, we generally found a dangerous environment for the
clients. We noticed many CIS residents with fresh injuries, including lacerations
and bruises, as well as historical remnants of past injuries suffered at
CIS, such as disfiguring scars. Many clients had suffered facial injuries
or severe injuries on the back of their heads with resulting deep scars
and hair loss.
The Facility Director, Ana Rivera, readily acknowledged a problem with
ensuring client safety, including protecting residents from staff abuse
and resident-on-resident aggression. For example, she told us that one
CIS staff member had recently been convicted for sodomizing a client. Further,
in a February 18, 1997 memorandum to Dr. Nayda Negron, Ms. Rivera expressed
concern that serious incidents could occur because CIS does not have the
capacity to protect vulnerable residents from other residents who are aggressive
As discussed in greater detail below, many of the injuries that CIS
residents suffer are a result of the facility's failure to address the
harmful behaviors they exhibit. Other injuries occur due to an inadequate
number of staff to supervise residents and protect them from harm. The
Director estimated that she does not have her full complement of three
staff on both units more than half the time. She acknowledged that when
this occurs, staff are not able to supervise residents, placing them at
risk of harm. In fact, at least once a month, there is only one staff member
working on a given unit, leaving ratios of 1:36 on the men's unit or 1:17
on the women's unit, which our consultant agreed was insufficient to provide
reasonable resident safety. The Director has alerted her superiors in the
Department of Health about the ongoing staffing problems on a number of
occasions. For example, in memoranda dated December 2 and 16, 1996, to
Dr. Negron and Auxiliary Secretary Soto, the Director requested additional
direct care staff to ensure the safety of CIS residents and to provide
them with needed services. Neither of these requests resulted in more staff.
Parents and family members of CIS also identified a number of unsafe
conditions and injuries suffered by their relatives while residing at CIS.
For example, one parent of a CIS client told us that his son has been subjected
to physical abuse from an unknown source while at the institution. He showed
us recent pictures of his son with a very swollen, bulbous, purple and
black eye. The father told us that his son has suffered a host of other
injuries at CIS including a broken nose, a severe knee injury, black and
blue marks on his torso, an injury over his eyes, and various head injuries,
some requiring sutures.
Another parent showed us photographs, taken in January of this year,
revealing her son with serious injuries he sustained while at CIS, including
a swollen black and blue right eye, a bloody left eye socket, bloody swollen
lips, and a face marked with fresh lacerations. The mother reported that
her son has also suffered a fractured arm, numerous lacerations, bites,
broken teeth, and black and blue marks all over his body while living at
CIS. She said that because her son has been injured so many times, he is
now limited in the use of his hands to one index finger and thumb on each
hand. She told us that before placement at CIS, her son had not suffered
these types of injuries.
The facility generally fails to document and maintain proper records
when incidents and injuries occur. Moreover, investigations of injuries
at the facility are also inadequate. The few internal investigations of
serious incidents that have been conducted were carried out by an overworked
social worker at the facility who is not formally trained as an investigator.
There are far too many "unexplained" injuries and incidents at CIS, the
causes of which are never investigated or identified. In addition, there
appears to be a code of silence among the CIS staff where the staff do
not report abusive incidents. The Facility Director admitted that some
of the unexplained injuries could be the result of staff abuse and that
incident investigations are inadequate. Similarly, family members we interviewed
are not satisfied with the internal investigations conducted at CIS and
they have been frustrated at the facility's non-responsiveness when injuries
In sum, CIS is a dangerous and unsafe environment for the individuals
who live there. The Commonwealth has failed adequately to protect the CIS
residents from harm, in violation of their constitutional rights.
B. CIS Often Fails To Provide Sufficient and Adequate Food, Medicine,
Basic Care and Shelter To Residents
The Commonwealth also violates CIS residents' constitutional rights
by failing to meet their most basic and essential needs for food, medicine,
shelter, clothing and basic care.
1) Food, Medicine and Supplies
During our tour, we discovered that the facility runs out of food monthly
and that it routinely runs out of certain critical drugs. Shortages of
anti-convulsant medications are especially acute, compromising the health
of the many residents with epilepsy who need such medications. As a result,
the Director admitted that recently, she has been forced to buy needed
drugs at the pharmacy with her own money. The Director has repeatedly reported
this dire situation to the Secretary of Health to no avail. For example,
in a December 10, 1996 memorandum to Dr. Negron and a December 10, 1996
memorandum to the Auxiliary Secretary of Health, Dr. Sylvette Soto Colon,
the Director reported that the Center was not receiving needed food, medications
and cleaning products to meet the needs of the residents and that she was
forced to collect money from the staff in order to buy needed food for
the clients. She sent similar memoranda expressing her difficulty in obtaining
needed supplies on November 12, 1996, October 11, 1996, and June 3, 1996.
Parents of CIS residents also advised us that they often have to provide
the medicines their children need because CIS does not provide them.
2) Physical Environment
The physical plant of CIS is in a state of disrepair. Our expert consultant
concluded that it is "grossly inadequate to meet the needs of the residents.
The building and general physical environment are ... dilapidated and neglected."
The paint on the cinder block walls, doors and cement floors is chipped
and/or peeling. The overhead lights do not work in many of the bedrooms
and the bathrooms. All of the bathrooms are neglected, dilapidated, with
peeling paint, and often dirty, with moldy and mildewed tiles. Residents
have to sleep on beds with old, worn mattresses that are dirty and often
wet. Moreover, almost all of the toilets on the men's side of the building
do not work, and many of the toilets on the women's side, do not function
properly. The staff told us that in order to flush the toilets, maintenance
workers must pour a bucket of water into them. As a result, on our tour,
we found that virtually all of the toilets on the men's side had urine
and/or feces in them, producing a health hazard and an unpleasant, malodorous
environment. The Commonwealth has not devoted sufficient resources to keep
the building and the physical plant in proper working order. Moreover,
the CIS physical plant does not conform with ADA accessibility requirements,
despite the fact that some residents must use wheelchairs for mobility.
In addition, offensive smells permeate the environment, residents are
cramped together in small spaces with nothing to do, aggressive residents
run throughout the hallways, attacking other clients, and the noise level
is overpowering. Throughout our visit, we constantly heard residents' screams
and groans of discomfort coming from the residents' rooms and hallways.
In sum, the environment is chaotic and non-therapeutic and violates CIS
residents' rights to adequate shelter.
CIS fails to safeguard clients' personal possessions, particularly their
own clothing. It is quite common for clients to be dressed in other residents'
clothes, simply because the client's own clothes could not be located.
The CIS Director and other staff readily admitted that clients' clothes
often disappear. The parents we interviewed concurred that the clients'
personal effects are frequently missing. More than one parent told us that
they have learned that residents' clothing has been stolen. The parents
have often witnessed their children in strange clothing that does not belong
to them or in the same clothing for several weeks at a time. These conditions
violate CIS residents' rights to be provided with adequate clothing by
4) Basic Care
The Commonwealth is violating the clients' right to basic care and services.
In addition to the issues referenced above, we noticed other areas of neglect.
For example, most of the clients walked around the dirty cement floors
in their bare feet. Staff do not assist clients in proper grooming and
hygiene and during our tour clients' appearances were generally unkempt.
A parent of a CIS client reported that when she visits her son, she often
finds him naked and drenched in his own stool and urine. Moreover, we noticed
that the few wheelchairs that were in use at the facility were in various
states of disrepair. The arm pads or sling backs were ripped and torn or
the footrests were missing.
The staff also fail to respect the clients' right to privacy and dignity.
Staff admitted to us that they routinely bathe the male clients by lining
them up naked and hosing them down in groups in one particular shower stall
outfitted with a garden hose. Typically, three clients are hosed down in
the shower stall, three others wait naked just outside the stall, and three
more are lined up naked outside the bathroom waiting to get in.
II. CIS FAILS TO PROVIDE ITS RESIDENTS WITH ADEQUATE PSYCHOLOGICAL
AND BEHAVIORAL SERVICES AND TRAINING PROGRAMS OR WITH PROPER PSYCHIATRIC
CARE AND SERVICES
A. Psychological and Behavioral Services and Restraints
Individuals residing in a state-operated institution have a fundamental
Fourteenth Amendment due process right to minimally adequate or reasonable
training to ensure their safety and freedom from undue restraint, prevent
regression, and improve their ability to exercise their liberty interests.
Romeo, 457 U.S. 307 (1982). The Commonwealth is denying CIS residents
their right to adequate and appropriate training and psychological services.
CIS does not provide residents with needed psychological assessments
or behavior management programs. Our expert consultant concluded that "[t]here
is absolutely no semblance of any coordinated psychological services provided
to the residents" at CIS. There is no psychologist on staff to provide
psychological assessments and to develop behavior management programs that
comport with generally accepted practice. Our consultant concluded: "Given
that a majority of the residents exhibit behavior problems and are typically
not occupied for most of the day, the absence of a well-trained behavioral
psychologist to provide the needed psychological services is a very serious
concern. Indeed, not providing these services means that the residents
are being neglected and are not assisted to live independent lives." Instead
of properly treating the clients' maladaptive behaviors, CIS uses restraints
and psychotropic medication.
There are no appropriate behavior plans to address the clients' maladaptive
behaviors despite the prevalence of dangerous behaviors at the facility.
Indeed, our consultant concluded that CIS staff are not employing current
methods of behavioral care. For example, in a number of client rooms, it
was evident that clients had kicked in wooden doors so severely that there
were large gaping holes in the doors. Moreover, the staff pointed out that
some clients remove floor tiles and eat the dried glue under the tiles.
Rather than address these behaviors through appropriate interventions,
CIS staff use inappropriate ad hoc measures. They lock the bathroom
to stop one particular client from drinking from the toilet, rather than
trying to teach the client not to drink from the toilet. More generally,
they purposely keep personal belongings, top sheets, blankets and pillows
off the beds and away from the clients during the day because they fear
that the clients will use them to hurt themselves and other clients. Staff
told us that a number of clients have tried to commit suicide and/or suffocate
other clients with the items. In addition, residents' beds are bolted to
the floor and facility staff have removed most of the doors on client bedrooms
to prevent clients from hurting themselves or others. Many of the bathroom
sinks have been removed because the clients have broken them. These measures
are insufficient to protect CIS residents from harm because they do not
address the residents' underlying behaviors.
CIS also does not provide residents with skills training programs to
prevent regression and assist residents in functioning more independently.
During our tour, we never observed any of the clients engaged in meaningful
activity. Instead, the residents are left to wander around aimlessly or
to sit or lay in bed, idle with nothing to do. It was quite common for
us to find clients sitting on the cold, bare cement floor rocking back
and forth. Some of them were crying. We also witnessed one client walking
around naked and another taking off her clothes in front of others while
screaming loudly. The Director acknowledged that she and her staff do not
write and implement proper individual habilitation plans for the clients
and serve instead as "custodians."
As a result of the chronic lack of appropriate psychological and behavioral
programs and services, many clients deteriorate markedly while in the Commonwealth's
care at CIS. Several parents told us that their children had lost the ability
to walk, communicate, and take care of themselves after they were admitted
to CIS. One parent told us that her son has continually deteriorated since
the day she brought him to the facility approximately ten years ago. She
said that her son used to be able to walk but that now he is confined to
a wheelchair. Another parent also told us that his son has "deteriorated
tremendously" since his transfer to CIS. Once an athletic and strong man,
his son lost significant functioning in his ability to walk and speak after
he was admitted to CIS.
In addition, CIS frequently uses restraints as a substitute for meaningful
activity during the day or for appropriate programs to address maladaptive
behaviors. These practices depart substantially from accepted professional
standards. Because CIS does not properly record its restraint usage, it
is impossible to quantify the use of restraints. However, the staff at
the facility told us and showed us that to control residents they routinely
use mechanical restraints, such as leather cuff belts (which are tied to
the heavy metal beds around the limbs of the clients), restraint vests
and straight jackets, and restraint nets.
The physical environment of CIS underscores the punitive nature of the
facility and is unduly restrictive. Surrounding the campus of the facility,
there is a high chain-link fence with barbed wire on top of it. Inside
the facility, separating the main lobby and the two wings of the building,
there are heavy metal doors that are clamped down and locked to confine
the clients to their units. In all of the men's rooms and in many of the
women's rooms, there are thick prison-like iron bars grafted on top of
the windows and many of the doors, including the door at the main entrance
to the facility.
B. Psychiatric Care and Services
The Commonwealth has failed to provide CIS residents with appropriate
psychiatric care and services. Most of the residents are put on psychotropic
medication simply to control their behaviors without appropriate psychiatric
assessments, diagnoses, treatment and monitoring. Although many of the
residents are both mentally retarded and mentally ill, there is no psychiatrist
on staff at CIS and no psychiatrist currently visits the facility. The
Director has written to her superiors detailing the problems this causes
clients with mental illness. For example, in a November 21, 1995 memo to
Dr. Negron, the Director requested that CIS clients be evaluated immediately
by a psychiatrist and she requested that a psychiatrist be assigned to
the Center. At the time of our tour, more than 15 months later, the evaluations
had still not taken place and no psychiatrist had been assigned to CIS.
CIS's monitoring of psychotropic drug side effects substantially departs
from generally accepted professional standards. In fact, there is no formal
system in place at CIS to monitor the effects of different classes of medication.
Instead, the CIS general physician simply makes visual observation of the
clients and/or talks to the nurses and direct care staff in assessing whether
or not side effects are present. Contrary to accepted professional standards,
he utilizes no formalized rating scale to measure side effects, thereby
placing the clients at undue risk of adverse side effects of psychotropic
III. CIS FAILS TO PROVIDE ITS RESIDENTS WITH ADEQUATE HEALTH CARE
All residents of state-operated institutional facilities have a Fourteenth
Amendment due process right to adequate health care. Youngberg v.
457 U.S. 307 (1982). Nonetheless, CIS is failing to provide the residents
with the health care and services they require. Our consultant concluded
that "the medical and nursing needs of the residents are not met, and the
state of care that can be provided with resources currently available to
[CIS] is totally inadequate and fails to meet generally accepted practice."
There have been recent, chronic shortages of medicines, sutures, gauze
and other needed supplies at the facility. Most notably, the shortages
of anti-convulsant medications have directly and adversely affected the
clients with epilepsy. CIS provided us with a list of clients who had recently
suffered seizures because the facility had run out of needed anti-convulsant
medications. For example, CIS resident Marcelino D. did not receive her
prescribed seizure medications and had seizures on twenty-one separate
days in 1996; Heriberto S. did not receive his prescribed seizure medications
and had seizures on ten separate days in 1996; Jorge C. did not receive
his prescribed seizure medications and had seizures on eight separate occasions;
and Bernaldino de L. had seizures and did not receive his prescribed seizure
medications on six separate days. The facility also provided us with an
August 5, 1996 letter from the concerned mother of a CIS client who was
hospitalized for seizures due to a lack of needed anti-convulsant medication
at the facility. Moreover, although a number of CIS residents have epilepsy,
the facility does not provide adequate access to needed services by a neurologist.
The CIS primary care physician does not treat CIS residents' acute illnesses
and injuries on-site. Instead, he makes diagnoses, and then sends the clients
off-site for treatment at a local hospital, Centro Medico. The nurses'
role is similarly limited. Some clients have suffered injuries and have
not been treated in a timely fashion. For example, Inovel O. suffered an
injury to his arm, but was not taken to the medical center for several
hours even though he needed immediate treatment. Our expert consultant
concluded that medical services would improve at CIS "if the physician
is able to provide the full spectrum of medical services on campus."
In addition to the severely limited nature of the general health and
medical care provided to the residents, there is no physical therapy, occupational
therapy or other forms of therapy at CIS. Dental care is also inadequate
at the facility. It was evident on our tour that many clients' teeth had
not been cared for in a prolonged period of time. Many had begun to lose
their teeth prematurely due to neglect and injury.
Overall, the Commonwealth's failure to provide needed medical supplies
and specialized, acute, and routine health care services to CIS residents
deprives them of their constitutional right to adequate medical care.
IV. THE COMMONWEALTH FAILS TO ENSURE THAT CIS RESIDENTS
ARE BEING SERVED IN THE MOST INTEGRATED SETTING APPROPRIATE TO THEIR NEEDS
The Justice Department has promulgated regulations pursuant to the ADA
that require public entities to serve individuals in the most integrated
setting appropriate to their needs.
28 C.F.R. § 35.130(d). Although CIS has taken steps to evaluate
some residents to determine whether they could be served in community settings,
it has not conducted appropriate professional evaluations of all residents.
Moreover, a number of residents who have been referred for community placement
remain confined at CIS because of inadequate and limited resources in the
community. Our expert consultant concluded that "some of the residents
are being neglected, and possibly harmed, as a result of their continued
residence in the facility when they are ready for community placement."
Removal from the adverse conditions of CIS would help some clients immediately.
Finally, for residents who have been transferred to the community, there
is no system in place to monitor the adequacy of services. Dr. Negron acknowledged
that community services in Puerto Rico need to be expanded and monitored.
* * *
In each of the areas outlined in this letter, conditions at CIS violate
the constitutional or federal statutory rights of residents. As noted earlier,
many of the deficiencies result from inadequate resources. Our expert consultant
concluded: "Although the Director ... and her staff are valiantly trying
to provide the best services they can, they simply do not have the resources
to do what is necessary to fully meet the residents' needs." For years,
Dr. Negron (a former clinical services coordinator at CIS), Ms. Rivera,
and the CIS Directors who preceded Ms. Rivera, have written a series of
letters and memoranda to the Department of Health expressing concern about
the negative impact on the care and services provided to CIS residents
caused by inadequate funding. Despite this knowledge, the Commonwealth
has failed to give CIS sufficient funds to provide essential items and
services to its residents. Although federal funding is available through
the Medicaid system to help provide adequate services at CIS and in the
community, the Commonwealth does not receive this funding. In order to
address the serious deficiencies outlined in this letter, we are willing
to explore ways that we can assist the Commonwealth in obtaining this funding.
Due to the nature of the deficiencies and their long-standing duration,
we believe that it is necessary to enter into a judicially enforceable
agreement to memorialize any agreement we may subsequently reach.
V. MINIMAL REMEDIAL MEASURES
In order to remedy these deficiencies and to protect the rights of the
CIS residents, the Commonwealth should implement promptly, at a minimum,
the following measures:
1. Safety and Basic Care
The Commonwealth must provide reasonable safety to all CIS residents.
The Commonwealth should implement enhanced investigation procedures to
ensure that all incidents are properly recorded and reviewed and that all
injuries are fully investigated and underlying causes are identified and
remedied. The Commonwealth must ensure that CIS residents are provided
with sufficient supplies of food, medicine, equipment and staff, and that
the residents receive adequate and appropriate basic care. Moreover, the
Commonwealth should ensure that the CIS physical building is properly maintained
in good working order, including but not limited to the timely repair of
toilets and other plumbing, showers and shower stalls, light fixtures,
windows, doors, walls, beds and any other furniture. Finally, the Commonwealth
should safeguard all clients' personal possessions, especially their clothing,
from loss and/or theft.
2. Psychological Services, Training Programs, and Restraints
The Commonwealth must provide adequate training programs and needed
psychological services. In addition, the Commonwealth should provide an
adequate array of comprehensive individualized training programs for CIS
residents developed by qualified professionals consistent with accepted
professional standards to reduce or eliminate risks to personal safety,
unreasonable use of bodily restraints, prevent regression, and teach residents
basic self-care skills. To this end, the Commonwealth should conduct a
comprehensive interdisciplinary evaluation of each CIS resident to determine
the individual's need for training and psychological services; develop
and implement a professionally based, individually appropriate data collection
system to measure relevant information about maladaptive behaviors; have
a qualified professional develop and implement and monitor a professionally
based, individualized training program for each resident; and provide each
individual with an adequate number of hours of training.
In addition, the Commonwealth must ensure that CIS residents are not
subjected to undue restraint. The Commonwealth should ensure that bodily
restraints are used only pursuant to accepted professional standards, and
that they are never used as punishment, in lieu of training programs, or
for the convenience of staff. The Commonwealth should implement a protocol
that has as its goal the elimination of routine use of physical or mechanical
3. Psychiatric Care
The Commonwealth must provide adequate and appropriate routine and emergency
psychiatric and mental health services in accordance with accepted professional
standards to residents who need such services. The Commonwealth should
procure adequate psychiatric consult hours to meet the needs of the residents.
Psychotropic medication should only be used in accordance with accepted
professional standards and only where a psychiatric or neuropsychiatric
diagnosis supports the need for such medication. Psychotropic medication
should not be used as punishment, in lieu of a training program, for behavior
control, or for the convenience of staff. The Commonwealth should conduct
a comprehensive assessment of each CIS resident with mental illness, develop
an appropriate diagnosis and an overall mental health treatment plan for
these residents, and provide on-going monitoring of the treatment, including
implementing an adequate system for detecting, reporting, and responding
to any drug-induced side effects of psychotropic medication. The Commonwealth
should document that, prior to using psychotropic medication for behavior
modification, other, less restrictive techniques have been systematically
tried as part of a training program and have been demonstrated to be ineffective.
4. Medical Care
The Commonwealth must ensure that its residents receive adequate preventive,
chronic, routine, acute, and emergency medical care in accordance with
generally accepted standards of care. To this end, the CIS primary care
physician should conduct comprehensive evaluations of all residents, identify
any needed medical services, and ensure that such services are timely obtained
whenever necessary to evaluate or treat the individual's medical problems.
In concert with the steps above, the Commonwealth should provide adequate
and appropriate routine, chronic, and emergency seizure management to all
individuals with epilepsy at CIS in accordance with accepted professional
standards of care. Specifically, the Commonwealth should procure a sufficient
number of neurology consult hours to meet the needs of the residents.
5. Nursing Care
The Commonwealth must ensure that its residents receive adequate nursing
care. To this end, the Commonwealth should ensure that nurses perform their
responsibilities in keeping with accepted professional standards of care
by adequately identifying health care problems, notifying physicians of
health care problems, monitoring and intervening to ameliorate such problems,
and keeping appropriate records of residents' health care status.
6. Most Integrated Setting
Appropriate professionals should evaluate each CIS resident to determine
whether the resident is being served in the most integrated setting appropriate
to the resident's needs. Where professionals determine that a resident
should be served in a more integrated setting, the Commonwealth should
identify appropriate services and take reasonable steps to reallocate resources
to meet the resident's needs. The Commonwealth should develop appropriate
time lines for placing these residents in the community and develop and
implement an adequate system to monitor the adequacy of community placements.
7. Recordkeeping and Staffing
The Commonwealth should establish and maintain adequate client records
to ensure adequate and appropriate care, services and quality assurance
for each resident at the facility. The Commonwealth should ensure that
a sufficient number of professional and non-professional staff, including
outside consultants, are employed to meet the needs of CIS residents. The
Commonwealth should ensure that the staff is adequately trained to perform
* * *
We hope to be able to resolve this matter amicably and cooperatively.
Nonetheless, the Attorney General may initiate a lawsuit pursuant to CRIPA
to correct deficiencies at an institution or otherwise to protect the rights
of its residents 49 days after receipt of this letter. 42 U.S.C. §
1997b(a)(1). Therefore, we will contact you soon to discuss any actions
you may have taken or intend to take to address the deficiencies we have
identified herein and to implement the remedies described above.
Finally, during the course of our investigation of CIS, we learned that
similar conditions may exist at the five other mental retardation facilities
operated by the Commonwealth: Centro de Servicios Multiples de Camaseyes
in Aguadilla, Hogar de Grupo Las Mesas in Mayaguez, Facilidad de Cuidado
Intermedio in Cayey, Centro de Reeducacion para Adultos in Bayamon, and
Centro de Servicios Multiples Rosario Bellber in Aibonito. Pursuant to
42 U.S.C. § 1997b(a)(2), we are therefore notifying you that we are
expanding our CRIPA investigation to include these facilities. We hope
to conclude this investigation on an expedited basis and in the same cooperative
spirit as our investigation of CIS.
We look forward to working with you to resolve these matters in a reasonable
and practical manner. If you or your staff has any questions, please contact
Richard Farano at 202-307-3116.
Isabelle Katz Pinzler
Acting Assistant Attorney General
Civil Rights Division
cc: The Honorable Pedro Pierluisi
Puerto Rico Department of Justice
The Honorable Carmen Feliciano
Puerto Rico Health Department
Ms. Mercedes Perez Rivera
Director, Centro de Reeducacion para Adultos
Ms. Ivette Fernandez
Director, Facilidad de Cuidado Intermedio
Mr. Francisco Espada
Director, Centro de Servicios Multiples Rosario Bellber
Ms. Nilsa Curet
Director, Centro de Servicios Multiples de Camaseyes
Director, Hogar de Grupo Las Mesas
Guillermo Gil, Esquire
United States Attorney
District of Puerto Rico
Ms. Ana I. Rivera Maldonado
Director, Center for Integral Services