Puerto Rican Facilities Findings Letter
The Honorable Pedro J. Rossello
Governor of Puerto Rico
P.O. Box 82
La Fortaleza, San Juan, PR 00901
Re: Centro de Reeducacion para Adultos in Bayamon, Centro de
Servicios Multiples Rosario Bellber in Aibonito, Facilidad de Cuidado Intermedio
in Cayey, Hogar de Grupo Las Mesas in Mayaguez, and Centro de Servicios
de Camaseyes in Aguadilla
Dear Governor Rossello:
On June 11, 1997, 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 Centro de Reeducacion para Adultos in Bayamon ("Bayamon"),
Centro de Servicios Multiples Rosario Bellber in Aibonito ("Aibonito"),
Facilidad de Cuidado Intermedio in Cayey ("Cayey"), Hogar de Grupo Las
Mesas in Mayaguez ("Mayaguez"), and Centro de Servicios Multiples de Camaseyes
in Aguadilla ("Aguadilla"). From September 29 through October 2, 1997,
we conducted an investigative tour of the facilities accompanied by an
expert consultant in mental retardation and behavioral psychology. During
our investigation, we toured each facility, interviewed Department of Health
officials, facility administrators and staff, spoke with residents, and
reviewed pertinent documents. As you may recall, earlier in the year, we
completed our investigation of the Centro Servicios Integrales in Caimito,
and we issued our findings regarding that facility on June 11, 1997.
The five mental retardation facilities in Bayamon, Cayey, Aibonito,
Mayaguez and Aguadilla referenced above, are all state-operated residential
facilities, and in total, they serve approximately 103 individuals with
varying levels of mental retardation and other developmental disabilities.
Most of the residents have mental illness and maladaptive behaviors and
some have physical disabilities. Bayamon serves 24 adult clients (17 men and 7 women), ranging in age from 22 to 50; two-thirds of the clients have severe or profound retardation and one-third have mild or
moderate retardation. The facility is located on one floor of an old building
on a largely abandoned medical facility campus on the outskirts of San
Juan. The Commonwealth is renovating another building on campus to house
the clients that is scheduled to be finished next year. Cayey serves 15
adult male clients in a one-building facility that was renovated in 1990.
The clients range in age from 23 to 61; facility records did not provide
sufficient documentation of the functional levels of all the clients, but
with a few notable exceptions, most appeared to be mildly or moderately
retarded. Aibonito serves 24 children (14 boys and 10 girls) ranging in
age from 6 to 20; all of the children have severe or profound retardation.
The facility is located in the foothills of the mountainous region of the
central part of the island near the local town. The facility's campus includes
one building that serves as the residence with an anteroom kitchen and
dining room, and an adjacent school with three distinct classrooms. Mayaguez
serves 18 adult clients (10 women and 8 men) ranging in age from 24 to
58; virtually all of the clients are listed as having severe or profound
retardation. The one-building facility is small and cramped, located just
off a noisy, busy mountain road near town. The Commonwealth plans to move
these clients to one floor of the local hospital in the near future. Aguadilla
serves 22 clients (8 men, 6 boys, 4 women, and 4 girls) ranging in age
from 6 to 28; approximately half of the clients are mildly or moderately
retarded and the other half are severely or profoundly retarded. The campus
compound is located on the outskirts of town and is surrounded by a high
chain-link fence and barbed wire. There are two buildings housing clients
and one large administration complex.
Consistent with our prior investigation of the facility in Caimito,
in investigating the five additional mental retardation facilities, we
evaluated 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);
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. §§ 794
et seq. and the regulations promulgated pursuant thereto;
and the Individuals with Disabilities Education Act ("IDEA"), 20 U.S.C.
1412(5)(B). Further, the Commonwealth must provide services and programs
that are readily accessible to and usable by individuals with disabilities.
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 the five mental retardation
facilities. During our tour, we found numerous conditions that violate
the constitutional and federal statutory rights of 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 residents. In particular, each facility has an insufficient number
of adequately trained staff across all disciplines, including doctors,
nurses, psychologists, psychiatrists, therapy and activity staff, and direct
care staff to meet the needs of residents. The facts that support our findings
of unlawful and unconstitutional conditions at each facility are set forth
below along with the remedial actions that we believe are necessary to
remedy these conditions.
I. THE COMMONWEALTH FAILS TO PROVIDE ADEQUATE SHELTER AND REASONABLE
SAFETY TO RESIDENTS
Individuals residing in a state-operated institution have a fundamental
Fourteenth Amendment due process right to adequate shelter and reasonably
safe conditions of confinement. Youngberg v. Romeo, 457 U.S.
307 (1982). However, the Commonwealth fails to afford residents these rights.
To begin with, all of the facilities, with the exception of Aibonito,
have structural and environmental deficiencies that pose serious risks
of harm and do not provide adequate shelter to the individuals who live
there. Many of the buildings are dilapidated, decaying, and lack adequate
plumbing and lighting. For example, for years now, the facility at Bayamon
has not had sufficient water pressure to provide adequate running water
for the clients. As a result, the showers do not work, the faucets do not
work, and the toilets do not flush properly. In order to bathe the clients,
staff dump water from water tanks into large movable garbage cans from
which the staff manually extract water using smaller buckets to pour it
on the residents. The Commonwealth has been aware of this unacceptable
condition for years but did not take any steps to remedy it until our recent
tour when officials announced that they would move residents at some point
next year to another building that was being renovated. In the interim,
the lack of running water poses a host of health hazards. For example,
many of the Bayamon clients require diapers and regular diaper changes
by staff; without running water, the staff cannot wash their hands sufficiently
to maintain aseptic conditions. In addition to the plumbing problems at
Bayamon, the overall physical structure of the building is old and dilapidated.
The bathrooms are mildewed with cracked and missing tiles and exposed pipes
and metal objects.
The other facilities face similar problems. At Cayey, the roof leaks
whenever it rains, creating large wet spots all over the facility floor
and posing slippery, hazardous conditions for the residents who walk over
the wet spots. This problem has persisted for many months without repair.
In addition, one of the few toilets available to residents has not worked
for a prolonged period of time, and the showers do not drain properly,
creating additional slippery conditions. One client recently fractured
his arm in a fall due to the water back-up. Mayaguez also has suffered
from chronic and ongoing water pressure problems over the years and the
roof leaks. In addition, the one-building facility at Mayaguez is physically
too small to accommodate the number of clients it presently serves. In
fact, it was designed to serve fewer than half the number of clients currently
residing there. As a result, the bathroom and shower facilities are inadequate
to meet the clients' needs and the bedroom areas are very cramped and overcrowded.
At Aguadilla, one of the residential units is also seriously overcrowded,
with about twice as many clients as it was designed to serve.
At all five facilities, the Commonwealth fails to provide sufficient
direct care staff to protect clients from harm from self-injurious behavior
or the aggression of other clients. Direct care staff absences are routine
at every facility we visited and exacerbate the problem of inadequate staffing
patterns. The staffing problems are particularly serious at Bayamon where
there is sometimes only one direct care staff person on duty on a given
shift. It is also common for Cayey to operate with only half its normal
complement of workers on any given shift. In addition, a sizable number
of clients at each facility require constant supervision due to their behaviors.
When there are staff shortages, the clients who need direct attention suffer,
or the rest of the client population suffers, or both. Each facility director
showed us evidence of unmet, repeated requests they had made to the Department
of Health and the Office of Mental Retardation for additional staff to
meet the basic needs of clients. The one exception to these staffing shortages
was at Aibonito where the children attend school in classrooms that are
staffed with at least one teacher, one or two teacher's aides, and additional
direct care staff for each group of seven or eight clients. However, as
is the case with the other facilities, direct care staff absenteeism in
the residential units is a problem at Aibonito, compromising client safety
In sum, the facilities are generally unsafe environments for the individuals
who live there. The Commonwealth has failed to provide adequate shelter
and protect residents from harm, in violation of their constitutional rights.
II. THE COMMONWEALTH 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 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. Youngberg
v. Romeo, 457 U.S. 307 (1982). The Commonwealth is denying residents
in the five facilities their right to adequate and appropriate training
and related psychological services.
Most of the clients have aberrant, maladaptive behaviors, such as self-injurious
behavior or aggression, that pose a risk of harm to themselves and other
clients. The Commonwealth fails to provide these residents with professional
services to abate or eliminate their maladaptive behaviors and replace
them with appropriate, functional alternative behaviors. For example, none
of the five facilities has a psychologist on staff or even provides contract
psychology hours to address clients' maladaptive behaviors. Oscar Cruz,
the psychologist within the Commonwealth's Mental Retardation Program,
cited lack of funding, resources, and expertise for the Commonwealth's
As a result, clients do not receive psychological assessments or behavior
programs to address their individualized needs. Moreover, the facilities
do not monitor adequately the clients' progress by collecting appropriate
client behavioral data, nor are the staff properly trained in how to respond
to clients' behaviors to ensure clients' safety and the safety of others,
and to teach them more appropriate behaviors. In many cases, this lack
of proper intervention results in undue restraint of clients. As a result,
the clients' maladaptive behaviors are not addressed properly, and the
clients suffer from the negative effects of their behaviors.
Many clients have been harmed due to the Commonwealth's failures in
this regard. At Cayey, Edwin R.O. is perhaps the most glaring example of
the harm that has resulted from allowing a client with maladaptive behaviors
to go untreated for prolonged periods of time. We first observed Edwin
sitting on the floor of the Cayey day room moaning to himself. He was wearing
a soft helmet that covered his entire head. We noticed a stream of blood
trickling down his helmet. We were disturbed that none of the staff --
not even the direct care staff member that was charged with observing him
on a one-to-one basis -- noticed this blood. We asked that the nurse immediately
clean and dress his wound. When the nurse removed his helmet, we discovered
that Edwin's head had been severely damaged due to years of self-abuse
and head banging. Edwin had butted and rammed his head into walls and post
corners so often that he had pushed back completely his hair and skin on
the front half of his head. This hair and skin formed a marked ridge in
the middle of his head. The bleeding we noticed seemed to come from this
Edwin had just arrived at Cayey in April 1997, after having lived at
the Centro Servicios Integrales in Caimito (the facility we investigated
earlier this year). In spite of his ongoing tendency to injure himself,
the tangible injuries that have already stemmed from his self abuse, and
the life-threatening nature of his current condition, the Commonwealth
has failed to provide Edwin with professional psychological or behavioral
services both at Caimito and Cayey. The Commonwealth has not provided him
with a psychology consult, with a behavior program, or with staff properly
trained in how to treat his destructive behaviors.
At Cayey, we also met Juan R.O., whose arms were marked with dozens
of long, deep scars. We learned that over the years, Juan repeatedly had
slit himself with razor blades during various suicide attempts. Juan also
had been transferred recently to Cayey from the deficient conditions at
Caimito. Juan is still at tremendous risk of harm due to self-injury, and
he is in great need of ongoing, intensive professional help to address
his maladaptive behaviors. Yet, as is the case with Edwin, the Commonwealth
has failed to provide him with a psychology consult, with a behavior program,
or with staff properly trained in how to treat his maladaptive behaviors.
At every facility we visited, we noticed a number of other individuals
similarly in need of such intensive ongoing behavioral services for their
maladaptive behaviors who, for years, had received inadequate services
from the Commonwealth.
In addition, with the exception of Aibonito, the Commonwealth does not
provide clients with sufficient daily training and activities that would
prevent many such maladaptive behaviors from occurring in the first place.
Daily, the clients are herded from one room to another by overextended,
untrained staff, who focus on resident control rather than active treatment.
None of the facilities provides adequate, ongoing active training and habilitation
to clients to teach skills, enhance functioning, promote independence,
and prevent client regression and deterioration. As a result, the clients
remain idle all day long. According to our expert consultant, this lack
of meaningful activity encourages maladaptive behaviors stemming from boredom
and leads to regression and deterioration.
Less than a third of the male clients at Bayamon had been taught to
bathe themselves and a large number of clients had not been trained to
toilet themselves. Only three or four clients at Cayey have been taught
to bathe themselves. Staff at Aguadilla told us that they do not even attempt
to teach the clients to toilet themselves or feed or bathe themselves because
they supposedly lack the potential to acquire this skill. This attitude
runs counter to generally accepted practice in the field. Many clients
who need speech therapy, like Jackeline F.S. at Bayamon, and Jose N. at
Aguadilla, do not receive it.
Restraints are prevalent at many of the institutions we visited and
are related to the lack of behavioral programming, training, and professional
mental health intervention. At Mayaguez, a number of clients are restrained
for much of the day because the staff do not know how to treat their behaviors
properly. For example, staff use a bed sheet to tie client Rosa P.L.'s
waist and torso to a bench and to one of the iron bars at the facility
to keep her from walking around the building and engaging in aggressive,
maladaptive behaviors such as biting and hitting other clients. Staff tie
Nilsa R. up in four-point restraints to her bed for the entire time she
is menstruating. The staff claimed that if they did not tie her up, she
would deeply scratch her face and further injure herself. We noticed Nilsa
in four-point restraints with additional restraints on both of her hands.
Her face was marked with fresh, bloody scratches. While we were in the
room with her, Nilsa was crying and moaning and pleading for help. Moreover,
Mayaguez staff place virtually all the sleeping residents in restraints
by keeping the bed rails up. We witnessed one client in a hazardous situation
because she had caught her leg in-between the bed rails while trying to
emerge from her bed after sleeping. In spite of the obvious potential danger
to her limbs, the staff claimed this was her "normal" way of communicating
to staff that she wanted to be let out of bed.
At Aguadilla, a number of clients are placed in restraints every day.
For example, staff place Rene L. in hand restraints for at least six hours
each day to prevent him from gnawing on his fingers and forcing himself to vomit. Staff restrain Jose N. in
his bed behind bed rails for most of the day. Jose has cerebral palsy,
a condition characterized by marked muscular incoordination and speech
disturbance. However, the staff failed to realize that Jose is higher functioning
than he appears. Not knowing what to do with him, the staff has denied
him educational opportunities with his peers and left him to languish in
The physical environment of all of the facilities, with the exception
of Aibonito, underscores the punitive nature of the facilities, is unduly
restrictive, and not conducive to the habilitation of individuals with
mental retardation. Most buildings are surrounded by high chain-link fences
topped with barbed wire; the entrances and exits to the facilities are
barred and locked with heavy metal gates; the interior corridors of the
buildings are routinely cordoned off by other locked, heavy metal gates.
At Aguadilla, the young men's ward was constructed originally as a juvenile
detention facility with prison mirrors, iron bars on all the windows, iron
gates separating the ward from the outside, and heavy metal doors on each
client bedroom. Virtually nothing was done to normalize this setting to
accommodate the individualized needs of the clients with developmental
disabilities. In contrast, the Aibonito residence is fully functional,
clean and more homelike than any of the other institutions we visited.
There is no high chain-link fence with barbed wire surrounding this facility.
In sum, the Commonwealth is not providing clients with minimally adequate
behavior and training programs. Its failure to do so has resulted in undue
restraint, regression, and injury.
B. Psychiatric Care and Services
The Commonwealth fails to provide residents in the five facilities with
appropriate psychiatric care and services. Although the vast majority of
clients have mental illness, they do not receive a proper psychiatric assessment
and diagnosis and a treatment plan to address the clients' mental health
needs. Moreover, there is no formal mechanism to monitor the clients' progress
or the effect of psychotropic drugs.
Instead, the Commonwealth medicates most of the clients with psychotropic
medications to control them and for staff convenience. This practice produces
a host of dangers, including needlessly medicating the client where there
is no professionally demonstrated need for the medication, needlessly subjecting
the client to the risk of medication side effects and, in most cases, failing
to treat the client's mental illness properly. As a result, the client's
mental illness is left untreated, the behaviors continue unabated, and
the client is unduly medicated with psychotropic drugs.
There is no staff psychiatrist or contract psychiatrist at any Commonwealth
mental retardation facility. Instead, the Commonwealth retains psychiatrists
in the community, who have little or no training in treating clients with
mental retardation, on an emergency, ad hoc basis, to provide
brief client review, often based upon nothing more than cursory, anecdotal
information about the client from facility staff. This practice departs
substantially from accepted professional standards of care and violates
the clients' right to receive adequate and appropriate treatment for their
III. THE COMMONWEALTH FAILS TO PROVIDE ITS RESIDENTS WITH ADEQUATE
All residents of state-operated institutional facilities have a Fourteenth
Amendment due process right to adequate health care. Youngberg v.
Romeo, 457 U.S. 307 (1982). Nonetheless, the facilities fail to
provide residents with the health care and services they require.
None of the facilities we visited had a physician on staff or a contract
physician to meet the health care needs of clients. Instead, the facilities
are forced to rely on the ad hoc availability of doctors
in the local community, usually at a local hospital, to treat the clients.
This system has produced poor results in terms of meeting clients' health
care needs. Some clients do not see a doctor every year for a routine checkup;
other clients with more chronic health concerns like diabetes and epilepsy,
do not see a doctor at appropriate intervals to monitor and treat these
conditions. Very few clients with seizure disorders at Cayey actually get
to see a neurologist as frequently as their medical conditions warrant.
Some facilities are well-staffed with nurses, while others are grossly
understaffed. At Mayaguez -- which serves clients who are medically involved
such as those with cancer, epilepsy, Hodgkin's disease, heart problems,
and diabetes -- there are no nurses currently on staff. The Commonwealth's
failure in this regard has placed these clients at great risk of harm.
There are residents who need wheelchairs at Aibonito, Mayaguez, and
Aguadilla. Still, the Commonwealth fails to provide the facilities with
funds to purchase and repair wheelchairs. As a result, when a chair needs
to be bought or modified, the facility directors must ask for funds from
family members, or the private community at large. This delays procuring
the chairs or needed modifications and places the clients at risk of harm.
Moreover, the Commonwealth fails to furnish the clients with professional
assessments to determine if their wheelchairs are appropriate. As a result,
the wheelchairs we observed did not fit most of the clients properly and
caused them to slump down in their chairs, promoting scoliosis and contractures
which compromise client breathing, digestion and overall health. In fact,
we noticed three clients at Mayaguez whose wheelchairs were so inadequate,
staff resorted to tying them in their chairs in order to keep them from
The institutions also are in great need of physical therapists, occupational
therapists, and speech therapists. This need was particularly acute at
Bayamon, Aibonito, Mayaguez and Aguadilla. At Aibonito, there is a need
for speech therapy, physical therapy and occupational therapy, and a need
for additional nursing support.
Many facilities, notably Aguadilla, Mayaguez and Bayamon, reported deficiencies
in providing dental care to the clients. We noticed many clients with missing
teeth or poorly cared for teeth during our tours.
IV. THE COMMONWEALTH FAILS TO ENSURE THAT FACILITY 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). Section 504 of the Rehabilitation Act provides
similar protections. Nonetheless, the Commonwealth has failed to assess
each institutionalized client to determine whether the client is residing
in the most integrated setting pursuant to the ADA and Section 504.
Commonwealth officials and the facility directors agreed that many of
the clients currently residing in the institutions are capable of, and
would benefit from, placement in a more integrated setting. Our expert
consultant found that many of the clients are high-functioning and could
move to the community immediately given the proper services and supports.
For example, at Aguadilla, Lecet M.G. is 25 years old, has mild retardation,
and could function well in a community setting. She can speak both Spanish
and English, she can write and draw, and she has the full use of her hands,
limbs and body. She told us that she would like to live outside the institution
because the Aguadilla staff punish her, often locking her up in her small
room. While we were touring the facility, she expressed her dissatisfaction
with her current situation by attempting to elope from the institution
by climbing over the barbed wire fence. At Bayamon, Rafael M.V. spoke to
us in both Spanish and English, and entertained us by singing a medley
of songs that he had memorized and performed with perfect execution. Similarly,
at Aguadilla, a young male client sang a song he had memorized and danced
for us after plugging in his own tape player and inserting the tape. Our
expert consultant found that these and other clients exhibited tremendous
capacity and potential to function more independently in the community.
The Commonwealth has failed to develop sufficient community services
and supports that would enable clients like these to transition into a
more appropriate environment. The various Commonwealth departments -- Family,
Social Services, Education, Housing, Mental Health, and Health -- have
failed to coordinate efforts to make this a reality.
Again, in contrast to the other facilities, Aibonito stresses the importance
of the clients' involvement with the community. This facility serves only
children and provides residential and educational services for them during
the week. Over the years, the director has stressed that the children remain
connected with the community and with their families where possible. To
that end, he has taken the positive step of insisting that each child return
home to his or her family or to a foster family every weekend (from Friday
afternoon until Sunday afternoon). Moreover, he has actively involved the
families in the lives of their children even when they are residing at
the facility. Largely as a result of this, the children we observed in
school appeared happy and involved. Nonetheless, the clients are not furnished
with an education in an inclusive setting, where appropriate, as required
by the IDEA. The facility provides the children with inclusive activities
only about once a month, and they are limited to recreational, extra-curricular
activities. Moreover, transportation services are inadequate to drive the
clients off-site, especially those clients with physical disabilities.
V. MINIMAL REMEDIAL MEASURES
In order to remedy these deficiencies and to protect the rights of the
facility residents, the Commonwealth should implement promptly, at a minimum,
the following measures:
1. Safety and Adequate Shelter
The Commonwealth must provide reasonable safety to all facility residents.
The Commonwealth must ensure that residents are provided with sufficient
professional and direct care staff and that the residents are protected
from harm and receive adequate and appropriate services. Moreover, the
Commonwealth must provide adequate shelter by ensuring that the physical
buildings are properly maintained in good working order, including repairing
plumbing systems and leaky roofs and ridding the facilities of other environmental
2. Psychological Services, Training Programs, and Restraints
The Commonwealth must provide adequate behavioral and training programs
and needed psychological services. In addition, the Commonwealth should
provide an adequate array of comprehensive individualized training programs
for 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 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 monitor a professionally-based, individualized
training program for each resident and teach direct care staff how to implement
it; and provide each individual with adequate training. The Commonwealth
should procure adequate psychology consult hours to meet the needs of the
residents. Moreover, the Commonwealth should alter the environment of the
facilities to make them less punitive and more conducive to habilitation.
In addition, the Commonwealth must ensure that the 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.
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 diagnosis supports
the need for such medication. Psychotropic medication should not be used
as punishment, in lieu of a training program or for the convenience of
staff. The Commonwealth should conduct a comprehensive assessment of each
resident with mental illness, develop an appropriate diagnosis and an overall
mental health treatment plan for these residents, and provide ongoing 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, and emergency medical care in accordance with generally accepted
standards of care. To this end, the Commonwealth should provide for 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 and emergency
seizure management to all individuals with epilepsy in accordance with
accepted professional standards of care. The Commonwealth should provide
the full range of therapy services to meet the clients' needs, including
physical, occupational and speech therapy.
5. Nursing Care
The Commonwealth must ensure that its residents receive adequate nursing
care. To this end, the Commonwealth should ensure that there are a sufficient
number of nurses to 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.
The Commonwealth should provide the clients who need wheelchairs with
appropriate wheelchairs that meet their individualized needs, as well as
appropriate professional assessments and reassessments to ensure that the
wheelchairs fit the clients properly.
7. Most Integrated Setting
Appropriate professionals should evaluate each 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.
8. 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 the 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 with respect to the five facilities referenced above and at
the Centro Servicios Integrales pursuant to our letter of June 11, 1997.
We would like to integrate the remedial steps needed for all six facilities
into one agreement to provide system-wide relief at all of the Commonwealth's
mental retardation facilities.
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 Bernardi
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