Northern Virginia Mental Health Institute Findings Letter
The Honorable George Allen
Governor of Virginia
Commonwealth Capitol Building
Ninth & Grace Streets
Richmond, VA 23212
Dear Governor Allen:
On July 1, 1994, we notified you of our intent to investigate the Northern
Virginia Mental Health Institute ("NVMHI" or "Institute") pursuant to the
Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. §
1997 et seq.
We were initially denied access to the facility, and, as a result, our
April 20, 1995 letter of findings was issued without the benefit of an
on-site investigation. In June 1995, just prior to a meeting between Attorney
General Reno and Virginia Attorney General Gilmore, the Commonwealth finally
agreed to allow a Justice Department inspection of the facility. That inspection
took place on July 25-27, 1995. During the inspection, Justice Department
experts in the areas of psychiatry, psychology, and psychiatric nursing
reviewed documents, interviewed staff, interviewed patients, and toured
the facility. Your staff was cooperative during the tour, and we appreciate
the assistance they provided.
We are now writing to advise you of our supplemental findings, based
on the on-site inspection, that conditions at the NVMHI continue to deprive
NVMHI patients of their constitutional rights and violate the Americans
with Disabilities Act ("ADA"), 42 U.S.C. §§ 12101 et seq.,
and the ADA's implementing regulations.
These continuing violations should be considered in light of this investigation's
long history. Our April 20, 1995 letter previously cited the Commonwealth
for deficiencies in the following areas: 1) mental health treatment; 2)
staffing; 3) medical care; 4) medication practices; 5) protection of patients
from harm; and 6) physical plant. In response to our findings, the Commonwealth
submitted a "Continuous Improvement Plan" ("Continuous Improvement Plan"
or "Plan") on June 7, 1995. This Continuous Improvement Plan details a
number of reforms which the Commonwealth assured us were in the process
of being implemented. At the time of our tour, many of the Commonwealth's
self-imposed deadlines for implementing reforms had either passed or were
fast approaching. Yet, our inspection revealed continued constitutional
violations regarding matters previously identified in our April 20, 1995
letter and supposedly addressed by the Commonwealth's Continuous Improvement
More specifically, our supplemental findings are as follow:
I. Inadequate mental health care, discharge planning, and community
The Commonwealth's Continuous Improvement Plan identifies remedial measures
NVMHI has developed to address our earlier findings and to improve care
and treatment at the Institute. Section A of the Continuous Improvement
Plan calls for "appropriate, comprehensive individualized treatment" based
on adequate evaluations and multidisciplinary assessments. Our consultants
found that the Commonwealth has been unable to meet many of the Plan's
key elements and that the treatment process at NVMHI remains inadequate.
From the point of admissions to the point of discharge, the inadequate
mental health care provided at the facility increases the risk of harm
to patients, fails to provide them with a reasonable opportunity to be
cured and function as independently as their psychiatric conditions permit,
and violates professional standards.
The Continuous Improvement Plan promises that "... NVMHI will evaluate
and assess each patient consistent with generally accepted professional
standards to develop an appropriate, accurate diagnosis.... A new assessment
process will be developed by an interdisciplinary team and will be piloted
in the admissions suite for all new admissions." Accepted professional
standards require that psychological evaluations be part of this assessment.
In the last year, however, only about 10 percent of NVMHI patients received
psychological assessments at the point of admission. The failure to provide
psychological assessments is especially troubling because NVMHI recently
assured the Health Care Financing Administration that staff would provide
all patients with such assessments by July 1, 1995. NVMHI clearly has not
met its own deadline; since at the time of our visit, at least eight individuals
admitted in July had not received a psychological assessment as part of
the admissions process. Even for patients who repeatedly engage in maladaptive
behaviors, the facility fails to complete a psychological assessment or
develop an adequate behavioral plan. For example, one patient had a series
of self-abusive injuries, but received no psychological assessment or intervention.
Psychological assessments, even when done, are often inadequate. Assessments
reiterate symptoms without providing any suggested psychological interventions.
Important considerations, such as prior hospitalizations and family background,
are not adequately explored. Our expert consultants found patient diagnoses
that bore no relationship to symptoms identified in the few assessments
Section A of the Commonwealth's Continuous Improvement Plan also requires
that NVMHI "... provide each of its patients an appropriate, comprehensive,
individualized treatment program based on [a] history and physical examination,
psychiatric evaluations, and multidisciplinary assessments designed to
maximize each patient's opportunity for recovery and integration into full
community life." In reality, patient treatment is not appropriate, multidisciplinary,
individualized, or properly managed in accordance with accepted professional
standards. Treatment planning is inadequate. There is little or no evidence
of multidisciplinary thinking in treatment planning, and patients have
little involvement in the process. The process is so disorganized that
our expert consultants were unable to ascertain what the treatment plans
are meant to accomplish. Records show that staff are providing treatment
without an adequate understanding of the patient's problems. Treatment
goals are too vague and fail to provide an objective, measurable basis
for gauging patient progress. Treatment objectives refer to such matters
as whether a patient has attended his "groups," rather than substantive
issues involving patient functioning. Treatment planning is not individualized.
Although patients attend classes or "groups," many of the supposedly "individualized"
treatment schedules are actually standard, preprinted forms that have little
to do with the needs of the patient. For example, some patients who need
to avoid excessive stimulus are assigned to group therapy even though such
therapy is contraindicated by professional standards. Similarly, NVMHI
has patients who are mentally retarded; yet their needs are not met and
they are inappropriately placed at NVMHI.
Treatment is also not adequately coordinated between disciplines. In
particular, master treatment and nursing care plans are inconsistent. Additionally,
nursing care plans suffer similar defects to treatment plans. For instance,
initial nursing care plans are not individualized. Patients are placed
in categories, and then all patients in the same category receive the same
rote nursing care plan without adequate regard to their individual needs.
Thus, one nursing care plan made no mention of a patient's epilepsy, and
another plan failed to address a patient's spastic colon. Because standardized
forms are used, patient problems which are not on the forms, such as sleep
and eating disturbances, are not addressed by nursing care plans.
The defective treatment process results in patients not receiving a
reasonable opportunity to be cured and function as well as possible. NVMHI
policies do not require completion of individualized, comprehensive treatment
plans until ten days have passed, which is a substantial period of the
time that patients stay at NVMHI. The average length of stay at NVMHI is
approximately 40-50 days, an exceptionally long period for stabilizing
patients in an acute care hospital. The treatment process has built-in
delays which prevent prompt treatment and subsequent discharge of patients.
For example, the first review of a patient's stay does not occur until
21 days after admission. This built-in delay means the system is inherently
tilted in favor of excessively long, and often unnecessarily protracted,
hospitalizations. This unnecessary delay places patients at great risk
Behavioral management planning is also grossly inadequate and reflects
the general absence of adequate psychology services at NVMHI. Of the records
reviewed, our expert psychologist found only one patient with recurrent
self-injury who had even been sent to a psychologist for behavioral management
planning. This patient's behavioral plan was not established until nine
months after her admission and occurred at the same time hospital staff
took the extreme measure of having her arrested for assaulting a staff
person. A token economy plan was subsequently put in place for this patient,
but it was not based on any recorded behavioral analysis, psychological
exam, or appraisal of baseline functioning.
The Continuous Improvement Plan assures that "Discharge planning will
continue to be appropriately carried out for all patients who are discharged
from the Institute." Instead, our consultants found that NVMHI's discharge
planning is inadequate and violates professional standards. The discharge
planning fails to ensure that appropriate professional judgments about
the most integrated setting appropriate to meet each patient's needs are
made and implemented. To begin with, NVMHI does not provide adequate discharge
criteria in patient charts. Without such criteria, it is impossible to
exercise professional judgment about readiness for discharge. As a result,
NVMHI's discharge system is arbitrary, with some patients released too
soon while others are hospitalized for too long. Of the 30 records reviewed
by our psychologist, not one contained even a general statement as to the
level of functioning which would demonstrate a patient's readiness for
discharge. Second, discharge planning is given low priority at NVMHI and
discharge plans are often developed only shortly before a patient is about
to be released rather than being incorporated into treatment objectives.
Discharge planning should be, but is not, an integral part of treatment
at the facility. Third, discharge decisions are not being implemented due
to inadequate community services. One glaring example involves a mentally
retarded NVMHI patient who staff thought should live in a community group
home, but decided that was impractical because it would take several years
before a spot opened up for any patient on the waiting list. Since there
were no community placements available, the staff had to keep the patient
hospitalized instead. Finally, discharge planning is inadequate to ensure
that appropriate aftercare services are provided to help the patient remain
in the community. Our consultant found 36 percent of July 1995 admissions
were readmissions occurring within 76 days of discharge. One of these patients
was discharged with no clear plan to address basic living needs other than
to live with another patient. High readmission rates indicate the State
is not providing integrated hospital and community services in order to
ensure adequate patient transition into the community. Without adequate
follow-through and community treatment options, NVMHI is unable to sustain
patients in the community and prevent their rehospitalization.
II. Deficient staffing and staff supervision.
Section B of the Commonwealth's Continuous Improvement Plan of correction
claims that "NVMHI currently maintains an appropriate number of qualified
staff...." Our consultants found, however, and we concur, that NVMHI does
not have a sufficient number of qualified staff to meet patient needs.
At the time of our tour, virtually the entire management hierarchy,
including the facility director and medical director, was serving in an
acting capacity. The failure to fill these critical positions on a permanent
basis is especially problematic in a facility which already has serious
supervision problems. Additionally, the acting clinical director, who has
recently been placed in charge of the entire psychology department, has
a nursing background, rather than one in psychology. For all practical
purposes, the psychology department is currently functioning without professional
supervision. The problems with leadership at the facility are especially
troubling since NVMHI does not have a clearly defined mission. Although
it is designed as an acute care psychiatric facility, it operates in many
ways like a long-term care facility. Solid leadership is essential if the
facility is to achieve any meaningful reforms.
Direct care, including nursing care, is generally understaffed. Based
upon the hospital's own classification system, our nursing consultant found
that NVMHI is short 18.61 full-time direct care staff. Additionally, much
of the nursing staff's time is spent on ineffective "special observations"
rather than therapeutic activities. In the past year, NVMHI used more than
47 of the 67 direct care staff budgeted for "special observations." In
contrast, direct care staff spend little time working directly with patients
in any meaningful way. NVMHI's practice of relying on one to one interventions
for three to five minutes four times per week is not adequate for supervision
or treatment. Although the understaffing has been reduced in the past year,
it remains troubling. To make up for the lack of direct care coverage,
the facility has had to use at least 4000 hours of overtime in the past
fiscal year. This excessive use of overtime in an acute care mental health
facility is dangerous and does not comport with accepted professional standards.
At NVMHI, psychologist resources are stretched too thin. Patient and
staff interviews show that psychologists see their patients only on rounds
and then for only a few minutes. The psychologists are occupied with a
variety of duties and do not properly address important matters such as
patient admissions, psychotherapy, and treatment. Moreover, psychologists
are not adequately supervised. Some actions by psychologists are highly
questionable. For example, one psychologist recommended restraints for
a patient with an eating disorder. Such an inappropriate recommendation
should not have occurred if there had been adequate supervision.
NVMHI also is not meeting the psychiatrist to patient staffing ratios
outlined in the Continuous Improvement Plan. Presently, one of the five
staff psychiatrist positions is vacant. Given the many, arguably excessive,
number of supervisory responsibilities placed on psychiatrist staff, even
one vacancy seriously increases the workload on the other staff. It is
therefore imperative that psychiatrist staffing operate at full capacity.
Patients rarely see psychiatrists on a one-to-one basis. Instead, psychiatrists
may see patients only during rounds and then just for a few minutes. These
sessions take place in the patient's room, often in the presence of the
patient's roommate. This practice undermines treatment by compromising
NVMHI's close proximity to the Northern Virginia Medical Center provides
good, physical access to emergency medical services. The facility, however,
does not have a full-time internist or family practitioner even though
some patients have chronic medical problems.
More generally, it appears NVMHI sometimes counts administrators as
full-time staff. There is a significant difference between a full-time
doctor, nurse, or other staff person who provides patient services, and
an administrator who provides such services only occasionally.
In sum, NVMHI is not providing adequate direct care and professional
staffing in accordance with its Plan or accepted professional standards.
This failure has directly resulted in deficient patient care.
III. Inadequate medical care and medication practices.
Section C of the Continuous Improvement Plan seeks to ensure that NVMHI
has taken and will continue to take steps to eliminate intra-class polypharmacy
and generally ensure that medication practices are "professionally justified."
Yet, medication practices at NVMHI remain deficient and violate professional
standards. Intra-class polypharmacy continues to be a serious problem,
with 19 of 76 patients on more than one drug of the same class. In addition,
55 of 76 patients are on benzodiazepines, which are potentially addictive,
sleep-inducing, hypnotics. NVMHI staff are using these powerful drugs for
their sedative effect in a professionally inappropriate manner. In addition,
the rationale for prescribed medications is not specified except in the
most rudimentary and unacceptable terms.
IV. Inadequate protection from harm.
Above all else, a hospital must be safe; yet, NVMHI is an unsafe facility.
When patients and staff are not safe, the hospital environment is not conducive
to treatment. Last year, there were at least 70 patient elopements. In
an average month, there are at least 27 incidents of patient self-injury
and 17 incidents of patient on patient violence. In addition, there were
39 staff injuries last year which were sufficiently serious to require
use of sick leave. Moreover, NVMHI apparently has a contraband problem
which requires close scrutiny. The hospital has conducted drug sweeps,
regularly searches patients after visitation, and has even brought in drug
dogs. Use of such measures in a civilian hospital is highly irregular.
All of these are indications of an unsafe environment. They also help explain
why our consultants concluded that NVMHI has a "siege" or "prison" like
mentality which is inconsistent with professional standards.
Patients are hurt even when they are supposedly under careful supervision.
We found at least five cases where patients engaged in multiple incidents
of self-inflicted injuries, many times even while they were under suicide
watch. One patient committed approximately 12 such acts of self-injury
while on "special observation" status. We even found cases where patients
injured themselves while in both seclusion and restraints. One patient
somehow managed to obtain a knife while in the seclusion room. Another
patient was in full restraints and helmet, yet still managed to pull tape
from his helmet and tie it around his neck. Such severe lapses in supervision
suggest that NVMHI suicide and safety precautions do not meet professional
Even though NVMHI has a practice of arresting patients who assault staff,
there is no attempt to monitor and evaluate this trend or develop a constructive
plan of action to address the issue. Management committee notes make no
mention of the problem. For example, there should be some attempt to evaluate
why some staff seem to call the police more than others, why some aggressive
patients are not responding to treatment, and whether staff are using techniques,
such as "hands on" approaches, which can trigger violent outbursts in some
patients. Instead, the facility has a policy which sanctions the practice
of calling the police when a patient is unruly, which merely encourages
confrontation between patients and staff.
V. Inappropriate use of restraints and seclusion.
Section D of the Commonwealth's Continuous Improvement Plan promises
that "NVMHI will develop and implement seclusion and restraint policies
that comport with generally accepted psychiatric standards by October 1,
1995." At the time of our tour, NVMHI had not made adequate progress in
addressing numerous deficiencies in facility policies and practices.
Restraint and seclusion practices do not meet accepted professional
standards. Seclusion and restraints are used continually over many months
even when they are seemingly ineffective. One patient was secluded/restrained
for 840 hours over an eight-month period. Another patient was secluded/restrained
for 1160 hours over a nine-month period. The inappropriate and excessive
use of restraints and seclusion for patients is related to the facility's
generally inadequate treatment process. As noted earlier, the facility
has had so many problems with some patients, staff have resorted to calling
the police and having patients arrested rather than addressing the underlying
psychological issues. At least one patient has also called 911 in order
to report being injured during physical containment by staff.
Documentation regarding the use of restraints and seclusion is lax.
Patients are kept in restraints and seclusion without any objective, recorded
criteria for their release or explanation of the problem behavior that
is being addressed by the use of restraints. NVMHI has a policy of secluding
and physically restraining a patient at the same time. This policy indicates
a mechanical device (a locked door) is being substituted for a staff member
due to understaffing. Patients are kept in restraints even after they exhibit
sufficient control (e.g., ability to use common bathrooms and eat on the unit) to
VI. Unsafe physical conditions.
Significant physical defects involving "suicide-safe" fixtures exist
at NVMHI, even though the facility's Continuous Improvement Plan calls
for a "safe and sanitary environment." These defects pose a serious risk
of harm to suicidal patients. For example, clothes hangers, which are supposedly
"suicide-safe," are connected so tightly to the closet walls, that they
do not actually break away when someone puts weight on them, thereby posing
a serious risk to patients attempting suicide. Additionally, light fixtures
in housing areas lack institutional safety covers. Thus, patients have
repeatedly been able to injure themselves by removing covers and cutting
themselves with glass shards. There is a long, hand-held shower in one
community bathroom which could be used by a patient to commit suicide.
The seclusion room on H Unit has a blind spot which prevents adequate
patient observation. There is no seclusion room on F Unit. Thus, a patient
who is acting out has to be moved to H Unit before he or she can be secluded.
This transfer increases the risk of injury.
In addition, there is only a male bathroom on one unit, and only a female
bathroom on the other unit. Since each unit houses both males and females,
this arrangement inhibits necessary access to bathroom facilities, reduces
patient privacy, and increases the risk of untoward sexual events.
In terms of sanitation, NVMHI was clean and appeared adequately maintained
at the time of our tour. There have been limited problems in the past with
vermin, such as dead squirrels in the ceiling.
VII. Quality assurance and recordkeeping.
The Continuous Improvement Plan promises that "NVMHI will implement
an adequate Quality Improvement Plan." Certainly at the time of our tour,
this element of the Plan had not been met. Quality control at NVMHI is
deficient and violates professional standards. The data collected in key
areas is often poor. NVMHI reported six 1995 patient suicide attempts to
the Justice Department. This number appears to be inaccurate. For example,
we found a patient record which showed a patient attempted suicide with
a wire hanger while under 15 minute checks; yet this incident was not reported
to the Department. The failure adequately to track suicide incidents increases
the risk of harm to suicidal patients and is troubling given the other
deficiencies in suicide prevention discussed in previous sections.
The data collected are frequently irrelevant to those who need to use
them. For instance, quality improvement reports regarding seclusion and
restraint usage do not provide the information needed by the nursing department
to evaluate the nursing staff's use of such seclusion and restraints. The
nursing monitoring and evaluation plan is inadequate and is not implemented
as written. Only four of the nine aspects of care identified in the plan
are actually monitored.
Patient records are disorganized. For example, we tried to find one
patient's psychosocial assessment. The present records referred to an older
record, which referred to an even older record, and so forth. Finally,
we learned the assessment was in the state archives. Ad hoc codes are used
to cite to other sections of patient records. Nursing care plans are often
inconsistent with the Master Treatment Plan. Disorganized records exacerbate
supervision and treatment deficiencies.
MINIMUM REMEDIAL MEASURES
We are providing copies of our consultant reports under separate cover.
These reports and our original findings letter detail numerous remedial
measures. A summary of the recommendations follows:
I. Mental health care.
NVMHI must evaluate, diagnose, treat, and discharge patients consistent
with generally accepted professional standards. Individualized patient
psychological assessments must be performed promptly in accordance with
professional standards. In particular, such assessments must be conducted
for patients who repeatedly engage in problem behaviors.
The treatment process must be reformed. Patient treatment must be appropriate,
individualized, coordinated, and properly managed. Such programs must give
each patient a reasonable opportunity to be cured and function as independently
and effectively as possible given his or her individual condition. To that
end, treatment planning should reflect multidisciplinary thinking. Patients
should have input in the treatment process. Treatment must be based on
objective data and clearly established goals. Staff require training on
how to write professionally appropriate behavioral goals and objectives.
Staff must interact therapeutically with patients, and NVMHI should seriously
consider using staff currently assigned to "groups" for providing more
focused, individual treatment. Data collected by staff for treatment decisions
should be adequately incorporated into the treatment planning process.
Master treatment and nursing care plans need to be consistent and adequately
organized for staff review. Special observations should be included in
master treatment and nursing care plans. Mentally retarded patients should
not be admitted to NVMHI, and appropriate alternative placements must be
developed for these patients.
NVMHI must provide adequate discharge planning, including appropriately
integrated community-based mental health services, to meet the needs of
patients upon discharge. NVMHI must develop a quality assurance/improvement
system to oversee the discharge process. This system must ensure that patient
discharge plans are implemented and that appropriate aftercare services
in the community are provided. Discharge criteria need to be adequately
developed and discharge planning should be a consideration long before
a patient is about to be discharged. In previous correspondence, the Commonwealth
has taken the position that such requirements are equivalent to a demand
for closure of state institutions. We have never demanded the closure of
any of Virginia's hospitals, and we do not do so in this case. What is
required is individualized, professionally justified placement decisions
which reflect consideration of a patient's needs, rather than just administrative
convenience or inadequate funding of appropriate services.
II. Staffing and staff supervision.
NVMHI must fill vacant management positions with permanent employees
to ensure adequate leadership at the institution. The psychology department
needs to be supervised by a qualified individual with psychology expertise.
NVMHI must hire adequate numbers of additional full-time, qualified, direct
care staff and use them to provide appropriate supervision and treatment.
The vacant psychiatrist's position must be filled as soon as possible.
Direct care and professional staff must spend more time working directly
with patients in an appropriate setting.
III. Medical care and medication practices.
Medical staffing must include at least one full-time internist or family
practitioner. Patients should receive prompt professional evaluation of
medical problems. All use of drugs must be professionally justified, carefully
monitored, documented, and reviewed by qualified staff.
IV. Seclusion and restraint and protection from harm.
Seclusion and restraint policies must comport with professional standards
and be implemented in a safe and appropriate manner. The average hours
per patient in seclusion and restraints should be reduced. All restrained
patients should be on constant observation, rather than being left alone
in a locked seclusion room. Use of seclusion and restraints must be properly
documented and must be reviewed in a timely fashion by qualified staff.
Criteria for release from seclusion and restraints must be clearly identified,
and use of seclusion and restraints as part of any treatment process must
be professionally appropriate and regularly reviewed. NVMHI must provide
adequate supervision of suicidal residents, and mechanical devices should
not be used in order to make up for inadequate staffing.
NVMHI needs to create an environment which ensures reasonable safety
for both staff and patients. The policy allowing the arrest of aggressive
patients should be revamped from a unilateral, confrontational approach
to one which addresses the underlying problems associated with working
with difficult patients. Training must be provided to ensure that only
appropriate interventions are used with patients who are acting out.
V. Unsafe physical conditions.
The facility must be maintained in good physical condition. Suicide
precautions, such as shielded light fixtures and breakaway closet hangers,
need to be installed. NVMHI should consider a new housing system to minimize
the risk of sexual incidents between male and female patients and reduce
the problems associated with moving F Unit patients to the H Unit seclusion
VI. Recordkeeping and quality assurance.
The Commonwealth must keep adequate data and patient records. Data regarding
suicide attempts, use of restraints and seclusion, and patient incidents
are especially important. Data collected should be available in a form
that is useful to appropriate staff.
NVMHI needs to develop an adequate quality improvement mechanism which
collects and distributes useful data. The system developed must encourage
the development and implementation of constructive solutions where data
indicate problems in patient care and treatment. The QA/QI process should
monitor both standardized aspects of care and non-standardized variables
that may indicate potential problems in the delivery of care.
Pursuant to CRIPA, the Attorney General may initiate a lawsuit to correct
deficiencies at an institution 49 days after appropriate officials are
notified of them. 42 U.S.C. § 1997b(a)(1). Our original findings letter generally identified
the same deficiencies as this one. Since that letter was issued in April
1995, the 49 day response period has already passed. We will, however,
give the Commonwealth an opportunity to respond to this findings letter.
We anticipate hearing from you within two weeks with any response you may
have to our findings. If you do not respond within the stated time period,
we will consider initiating an action to remedy the conditions that violate
patients' constitutional and other federal statutory rights. We look forward
to working with you and other Commonwealth officials in an effort to resolve
this matter in a reasonable and expeditious manner.
If you or any member of your staff have any questions, please feel free
to contact attorneys David Deutsch at (202) 514-6270 or Christopher Cheng
at (202) 514-8892.
Deval L. Patrick
Assistant Attorney General
Civil Rights Division
cc: The Honorable James S. Gilmore, III
Commonwealth of Virginia
Dr. David A. Rosenquist
Northern Virginia Mental Health Institute
Helen F. Fahey, Esquire
United States Attorney
Eastern District of Virginia