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Issue Papers - Mental Hygiene [re: closing State Mental Hospitals] (3 of 3)
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Issue Papers - Mental Hygiene [re: closing State Mental Hospitals] (3 of 3)
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Ronald Reagan Presidential Library Digital Library Collections This is a PDF of a folder from our textual collections. Collection: Reagan, Ronald: Gubernatorial Papers, 1966-74: Press Unit Folder Title: Issue Papers - Mental Hygiene [re: closing State Mental Hospitals] (3 of 3) Box: P31 To see more digitized collections visit: https://reaganlibrary.gov/archives/digital-library To see all Ronald Reagan Presidential Library inventories visit: https://reaganlibrary.gov/document-collection Contact a reference archivist at: [email protected] Citation Guidelines: https://reaganlibrary.gov/citing National Archives Catalogue: https://catalog.archives.gov/ Mental HUMAN RELATIONS AGENCY FOR RELEASE 1:30 P.M. Sacramento, California Contact: Spencer Williams JULY 2, 1969 Spencer Williams, secretary of the State Human Relations Agency, today directed the formulation of a master plan to encourage the maximum development of the mental 1y retarded. Williams announced the action at a meeting of a Senate committee consider- ing a report concerning the hospitalization of the mentally retarded which was made at his request. The Secretary urged the committee to back administration efforts to "provide an integrated, modern, effective system of care for California's retarded." Development of the master plan was the Number I recommendation on an action program submitted by the Human Relations Agency Task Force on Mental Retardation services. "While this plan is being formulated we shall proceed to implement the other three major points submitted to me for action by the task force so far as the Legislature will permit," Williams said. He said the state would expand its regional diagnostic and counceling center network to provide residential and other services as close to home as possible, consistent with quality care. "We will encourage innovation in provision of residential care, but always with the best interest of the individual uppermost," Williams said. He said the centers would also provide a single point of entry into the system of mentally retarded care to help each parent learn what his child needs and to secure the necessary resources. Some major recommendations directed to the department of mental hygiene will be implemented at once, but others will require further study and legislative approval. -1- Williams pointed out that substantial progress in the care of the mentally retarded has already been made. He cited new legislation that went into effect yesterday as providing some increases in service. He noted that other legislation, particularly AB 225 supported by the administration, to bring all mental retardation services together is pending. Williams said the number of regional centers authorized was increased from two to six last year and that the administration is supporting an additional increase this year. He said that the number of filled treatment positions in state hospitals for the mentally retarded was increased by 500 persons in the past two years even though there was a slight reduction in the hospital population. He said 200 more positions are requested in the budget for this year. Williams also called attention to increased efforts by the Department of Rehabilitation, the expansion of development centers for handicapped minors and the upsurge in community placement of the retarded from the state hospitals by the Department of Social Welfare. The 72-page report and its 26 recommendations were made by a three-man task force headed by the associate dean of the University of California's College of Medicine at Irvine, Dr. Thomas Nelson. Nine top consultants from throughout the nation and scores of experts participated in the study which extended from July 1968 to June this year. Williams expressed his appreciation to the task force, the consultants and others that assisted them for the report and assured them that all of their recom- mendations will be given full consideration by the administration. "The task force recommendations will probably raise controversy, objections by some, and a few will distort and exploit the report, inflaming rather than illuminating this emotional subject," Williams said. "Opinions as to what, when and how much should be done do vary among different groups, parents, employee, professional and citizen organizations." -3- The task force, consultants, and experts had something to say about the types of facilities needed, the types of employees who should provide the services, the research programs, the types of programs such as medical, rehabilitation, education, and others, and the types of treatment that should be provided certain categories of patients. There was no hesitation by the Department of Mental Hygiene to recommend basic acdeptance of the report. The Department's Director, James V. Lowry, M.D., has always worked for elimination of the "control and custody" principle which the task force states is a predominant policy of the state hospital programs, although the team said there were "noteworthy exceptions to this policy". The Department has been establishing the groundwork to provide hospitaliza- tion only for those mentally retarded requiring it. The last fiscal year, ending Monday, saw the first drop in seven years in the number of mentally retarded patients. The Department of Social Welfare in cooperation of the Department of Mental Hygiene willcontinue to seek placements for patients not requiring hospitalization. The recommendations seek to attain the task force's objective: "To assess present systems of services and recommend needed organizational and program adjustments as well as guidelines for further program development." The members of the task force are Thomas L. Nelson, M.D., Associate Dean, California College of Medicine, University of California, Irvine, Chairman; Richard Koch, M.D., Director, Child Development Division, University of Southern California School of Medicine, Los Angeles; Irving Philips, M.D., Associate Clinical Professor of Psychiatry, University of California Medical Center, San Francisco. The recommendations follow. For Action by Secretary, Human Relations Agency 1. The Secretary of the Human Relations Agency should develop a master plan for achieving the goals set forth in the document referred to earlier in this report, "The Undeveloped Resource, A Plan for the Mentally Retarded in California." This document expressed a philosophical approach which dictates that the general goals of programs for the mentally retarded are to allow for maximum growth, development, and fulfillment for each indi- vidual who is mentally handicapped. The master plan should be updated annually in keeping with changing needs and newer trends of care. 2. A single point of entry should be established in each community, whether it be a Regional Center contract agency, a local public health department, or a Short-Doyle program, to help parents define the specific needs of their child and reach the appropriate service resource. 3. An effort should be made immediately to implement regionalization of care so as to provide residential services for mentaliy retarded individuals at all levels from community to state care and as close as possible to the individual's home consistent with quality care. 4. Experimental and innovative models of community residential care should be encouraged through expansion of present programs for placements from state hospitals into family homes, hostels, cooperative living projects, nurseries, and schools. a For Action by the Director of Mental Hygiene 5. The Departments of Mental Hygiene and Social Welfare should jointly (a) determine the nature and extent of the placement, funding, and staff resources required to effect movement of residents out of the state hospitals who no longer require state operated residential services, (b) mobilize such resources, and (c) expedite placement of the residents. 6. For those persons who require state residential care, services should be organized consistent with broad program goals and sufficient budgetary support to achieve the maximum developmental potential of each resident. 7. DMH residential services for the mentally retarded at any one facility should include no more than 500 residents in a Medical Program for the Multiply Handicapped (Type 1), no more than 150 in a Developmental Program (Type II), and no more than 150 in a Rehabilitation Program (Type III). 8. A type and level of staffing should be developed for mental retardation programs that would permit individual and small group programming in keeping with recommendation No. 7, above. 9. The director of each MR service in a state institution should develop a program for individual residents or groups of residents so that all care and treatment personnel may know at any moment in a resident's institutional stay (a) what stage of development he is in, (b) where he is going, and (c) what is to be anticipated in his eventual development. The program should always be in a state of flux with no ceiling placed on individual potential. 10. There should be greater exchange of resources between state hospital and community; the hospitals should purchase high quality community services where available and state hospitals should develop easily accomplished procedures for short term admissions from the community. b 11. Hospital projects that have proven their worth experimentally, whether supported by federal funds or state research funds, should be continued as part of the ongoing hospital operations budget. Efforts should be made to translate the results of such projects into programs throughout the hospital system wherever appropriate and with sufficient funding. 12. Educational services in DMH facilities should be provided in accordance with standards of the California Department of Education for Special Education programs in public schools. For Action by Secretary, Human Relations Agency 13. Active support should be given toward obtaining substantial increases in salaries. For Action by the Director of Mental Hygiene 14. DMH Headquarters should be reorganized, placing the Director and the two Chief Deputy Directors within the Office of Director. 15. The functions of the Division of Hospitals and Division of Local Programs should be consolidated and redistributed between a Division of Mental Retardation Services and a Division of Mental Health Services. 16. Services to the mentally retarded in state institutions should be headed by a Program Director responsible to the Deputy Director, Mental Retardation Services. There should be three broad program classifications: (a) Medical, (b) Developmental, and (c) Rehabilitation, each headed by a Program Chief responsible to the Program Director. C 17. Development of MR programs in facilities on the grounds of MI hospitals is supported as a temporary expediency and only under certain conditions and guidelines: (a) written plan approved by Deputy Director, MR Services, (b) implementation of plan before admission of residents, (c) transfers by small increments, starting with Rehabilitation Programs, and (d) linkage of MR/MI facility to a parent MR facility. 18. DeWitt State Hospital should be phased out as a facility for the mentally retarded. 19. Parental consent for placement out of state institutions into community facilities should be retained as a normal requirement, with an appeal pro- cedure developed to sources outside of the facility for adjudication of differences between staff and the responsible relative. A consumer repre- sentative (not a relative) should participate in the adjudication process. Personnel Utilization and Development (page 51) 20. Basic care personnel in Medical Programs for the Multiply Handicapped (Type 1) should be licensed vocational nurses (LVN) and registered nurses (RN). 21. Basic care personnel in Developmental Programs (Type 11) should be child development aides and child development specialists. 22. Basic care personnel in Rehabilitation Programs (Type III) should be psychiatric technicians. di 23. Promotion, retention, and merit salary increases for physicians in MR programs should be based primarily on a critical annual review of performance as demonstrated in a clinical setting for the mentally retarded, irrespective of specialty background of the physicians. 24. Basic res dency programs for physicians should be continued for psychiatric programs and extended to pediatrics, emphasizing mental retardation and related hundicapping conditions. 25. More opportunity should be given all basic care personnel for upward mobility into various management and professional classes in order to fill manpower needs. 26. Basic training for the various basic care personnel should occur in junior colleges with DMH providing stipends and field practice settings. e news from the CALIFORNIA STATE EMPLOYEES' ASSOCIATION 1108 o Street, Sacramento Phone: 444-8134 For further information FOR RELEASE TO AM's OF contact: Jim Bald, 444-8134 January 19, 1972 The California State Employees' Association today charged that thousands of mental patients have been released from state hospitals without adequate protection or treatment. In a special study titled, "Where Have All the Patients Gone?" CSEA. urged the legislature to halt plans to close Mendocino, Metropolitan, Patton and Stockton State Hospitals. CSEA also asked a complete legislative review of community mental health programs financed by state funds under the Lanterman-Petris-Short Act of 1969. "CSEA finds evidence that the tragic consequences of this act have been to take thousands of mentally ill patients out of state hospitals and scatter them among counties unequipped to provide adequate care, said Walter W. Taylor, CSEA's general manager. "LPS also has made it difficult to treat mentally disturbed persons--even in a state hospital--for a significant period of time, " Taylor said. "In far too many cases, these patients end up in transient hotels, small board and care homes or in prison. Their illnesses are not being treated. "County and private facilities just are not equipped to handle the flood of patients being released by the state," said Taylor. Taylor also said that "costs under LPS have skyrocketed. = Between fiscal 1965-66 and 1970-71; expenditures at 1971 dollar more 2-2-2-2 value for services to the mentally ill have increased by more than $28 million, the CSEA study reports. There will be a net increase of $9.7 million in the cost of state- financed mental health care during fiscal 1972-73 under the governor's proposed budget, despite plans to close 2 hospitals this year and 2 more within 36 months, states the CSEA study. "We charge," said Taylor, "that the state has distorted the humanitarian aims of Lanterman-Petris-Short and used that law as an excuse to act without adequate planning, without education of either the community or the patient, and without provisions for alternative care." "Complicating the problem is the crazy quilt pattern of state and county licensing laws which permit an estimated 32,000 former mental patients to live in unlicensed board and care homes alongside the geriatric patient, Taylor said. "Obviously, CSEA has more than a passing interest in what happens to our mental hospitals. Thousands of our members are employed there. Their jobs are in danger, along with the health of their patients," said Taylor. "But it should be understood that the very members and non-members of CSEA who urged the Association to undertake this study are also professional treatment personnel who share a deep concern for the welfare of the men and women they treat. "Our report only scratches the surface of problems relating to community mental health programs. "We hope that by calling this situation to the public's attention we will open a dialogue leading to a more objective and orderly approach to treatment of California's mentally ill," said Taylor. ###### where have all the patients gone? a csea report on the crisis in mental health care in california january 1972 introduction In 1969 there were 9 state hospitals caring for The California State Employees' Association approximately 15,700 mentally ill citizens of represents approximately 16,000 employees of the California. state Department of Mental Hygiene, including Today, in 1972, only 6 state hospitals are treating doctors, nurses, technicians and therapists. mentally ill patients, and their number has shrunk to They are concerned over the state of publicly 7,200. financed mental health care in California. They are Tomorrow-by the end of 1973-it appears 2 more afraid they know what has happened to most of hospitals will close and approximately 2,000 more those 8,500 patients. patients will be released to community-level care. What has happened to the 8,500 patients released As for new patients, what is happening to them is since 1969? known first-hand by CSEA's members who work in Are they cured, and back with their families living the 6 remaining state mental hospitals. And they are happy, healthy lives? upset. If not, are they under professional care, and what A radical change in the state's system of caring for is the level of that care? the mentally ill occurred in 1969 when the And what of new patients, people who experience Lanterman-Petris-Short Act of 1967 went into effect. a mental breakdown which requires institutionalization and treatment? How and where Only now is the full impact of that change are they being cared for? begining to be felt. These are some of the questions which this paper It will be felt even more keenly in the months and attempts to answer. years ahead unless someone applies the brakes. -1- CSEA researcher Richard Funderburg examines trash cans and sink on landing of hotel used by mental patients discharged from state hospitals. At left, hotel exterior. Hospital security officer estimated 50 percent of those staying at the hotel the day these photos were taken were former patients. -2- E (C) to the lanterman-petris-short act What has become known as the Lanterman- In far too many cases these patients end up in Petris-Short Act was passed in the fading hours of transient hotels or small board and care homes in the legislature's 1967 session. run-down neighborhoods where they receive no It combines with the Short-Doyle Act of 1957 to treatment for their illness; form the California Mental Health Act. decrease the number of days a state hospital may As conceived by its architects, this revolutionary hold a mentally ill individual. new system for handling the mentally ill was designed skyrocket the cost of mental health care. mainly to: Before LPS, patients were admitted to state protect the patient from institutionalization mental hospitals on a voluntary basis and kept as long without his consent. as either the patient or his physician felt was needed. remove the stigma of mental illness by holding Patients also were committed involuntarily, all records confidential to the hospital. through the courts, at the request of family or law promote community-level care of the mentally enforcement agencies, the length of their stay disordered, aided by 90-10 state financing-with determined by doctors' judgment. county government paying 10 percent of the cost. Under LPS, state hospital authorities can hold CSEA finds evidence that the tragic consequences patients for only 72 hours, unless they want to stay of this act have been to: longer or unless 2 attending physicians sign a paper take thousands of mentally ill patients out of certifying the person is a danger to others or to state hospitals and scatter them among 58 different himself, whereupon he is committed for 14 days for counties, there to be absorbed by as many different intensive treatment. community mental health programs. After that 14 days, whether or not the patient has -3- improved, he must be released unless he has held counties responsible for providing community physically assualted another person, in which case he treatment facilities, (2) minamized court procedures, may be kept for 90 days. and (3) gave the mentally ill person the right to refuse The Short-Doyle Act of 1957 designated the involuntary treatment unless he was a grave danger to county as the local unit of government to provide himself or others. mental health services and mandated that each county The act protected the civil rights of patients, with a population of 100,000 or more had to provide mandating the right to a hearing before the Superior mental health services. The act also provided that the Court on a writ of habeas corpus, the right to state would fund 75 percent (now 90 percent) of the personal property, the right to see visitors, the right community program and the county would provide to use the telephones, to wear one's own clothing, and the remaining funds. the right to refuse shock treatments or labotomy. The Lanterman-Petris-Short Act was aimed at the In affect, the LPS Act provided a bill of rights for mentally disordered, chronic alcoholic, and user of the mentally ill. narcotics and dangerous drugs. Incorporating findings It also made it increasingly difficult to treat expressed in the 1961 report of the Federal Joint mentally disturbed persons for a significant period of Commission on Mental Illness and Health, LPS: (1) time. -4- a case in point: santa clara county Santa Clara County is a progressive, sprawling "The primary distortion is the present state populous community south of San Franciso Bay. administration's use of LPS philosophy as a rationale Its residents have an active mental health for acting without plan, without prior notice and association, community programs aimed at improving without concern, to remove from the state hospital mental health care, and a small but modern context, and to preclude from entrance to such psychiatric facility-Valley Medical Center. facilities, hundreds of ill persons without provisions There are approximately 1,000 board and care for alternative care. (Emphasis theirs) homes in the San Jose area (San Jose is the county Before Sept. 15, 1971 the usual patient caseload a seat of Santa Clara County) housing geriatric patients month at Valley Medical Center was 60. Since, the and ex-mental patients. C-CAP report states, the caseload has risen to 176 When the Department of Mental Hygiene began average a month. early release of hundreds of mental patients from "The physical plant cannot absorb any more Agnews State Hospital in San Jose, the community patients," the report states. awoke to find their local mental health facilities "In addition, there is little privacy for patients. seriously and dangerously overcrowded. Because of lack of sufficient space, intake, San 'Jose's Council for Community Action counseling, examination, treatment-all take place in Planning (C-CAP) studied the situation and adopted a the midst of hectic, public environment. report on the crisis on Nov. 27, 1971. "The staff and program of Valley Medical Center That report was highly critical of the was reputed as one of the best in the state before the administration of the Lanterman-Petris-Short Act. increase in caseload produced a factory-like Quoting: atmosphere where the press of patients, the "What the outcome of Short-Doyle and uncontrollable noise level and the lack of space Lanterman-Petris-Short might have been is now destroyed the capability of an innovative service to difficult to say, for its provisions have been distorted deliver meaningful patient care," the report states. in practice and misrepresented in policy What of the impact on board and care homes in determinations. Santa Clara County? -5- C-CAP's report found that a large caseload in "would be the destruction of the board and care greater need of assistance, such as will be caused by homes which now provide housing and sheltered care closure of Agnews State Hospital's facilities for the for 1,000 persons." mentally ill, "would defeat recent movements aimed at improved availability of services for the already Another community organization to study the discharged." effects of closing Agnews was Chapter 23 of the Investigators for C-CAP reported many ex-mental California State Employees' Association, most of patients found the board and care home experience whose members work at the hospital. "refreshingly positive." They commissioned a $3,500 study of "The "These facilities," said the report, "provide a Impact of California's Mental Health Act on Mental sheltered environment, a minimal degree of Health Care in Santa Clara County." supervision and assistance with transportation, A San Jose research firm undertook the study and medication, hygiene, etc., to their residents. reached many of the same conclusions as did the Having found that many board and care homes Council on Community Action Planning. were pleasant, well-run environments, C-CAP investigators were forced to report also that "many Dr. John Rieger III, M.D., a consultant employed are negative places, at best, in which to reside." by the San Jose research firm, reported: The report states that the "freedom from restraint "Of_12 facilities (board and care homes) visited, which has fostered uniqueness and responsiveness to one-third rated superior, one-third rated flatly the residents has another face-a picture of inadequate and the remaining third doing a passable unregulated license which provides little protection to job of warehousing mentally ill human beings. residents and leaves to the discretion of the board-and-care operator all conditions and often all "Location of board and care homes, in San Jose as decisions regarding the interests of the resident." in other large metropolitan centers, are mainly in deteriorating neighborhoods. (1) the patients who live in them are too poor to afford residence in more expensive areas of the city, "Persons too sick and to be placed in board and care homes (2) deteriorating neighborhoods frequently possess are already in evidence." large, once-elegant houses appropriate for the purpose." C-CAP researchers reported: "there is no licensing and no means to enforce standards. "board and care clients do not have adequate What will happen counseling, therapy and rehabilitative services at the to psychiatric care facilities present time." in Norwalk? "because of a lack of staffing standards, residences are often ill-staffed for the provision of the appropriate level of supervision "some persons too sick to be placed in board and care facilities are already in, evidence. The dumping of clients in need of specialized and closely The research firm found the average age of such supervised environments, in homes geared to the dwellings in San Jose to be 51 years. client in need of merely a sheltered Santa Clara County is fairly typical of home-away-from-home has already created havoc in metropolitan-suburban California. a few homes and neighborhoods. Problems which come to Santa Clara County will, "for the misplaced patient, the denial of needed in all likelihood, visit other similar communities in the specialized service is unjustifiable and retards or state. negates attempts at rehabilitation." What will happen to psychiatric care facilities in C-CAP researchers concluded that for the Norwalk (Los Angeles County) if Metropolitan State Department of Mental Hygiene to release acute Hospital closes its doors and dumps its mentally ill mental patients from Agnews State Hospital and patients on the doorsteps of hospitals and boarding attempt to locate them in board and care homes homes in southern California? -6- what has happened to the patients? Few persons would dispute the desirability and Most counties in California have a "community value of community-based mental health services. mental health program," as called for under the LPS But CSEA does challenge the wisdom of Act, in name only. dismantling the existing state hospital system. An administrator in a county office oversees We charge: transfers of mental health patients and deals them out Facilities, personnel and programs are to psychiatric wings at county hospitals and to inadequate in most counties. private psychiatric care facilities, which charge the The Department of Mental Hygiene has failed to county (and the state) for this service. plan adequately for the future use of state hospital Others are found to be eligible for "Aid to the facilities. State hospital programs and community Totally Disabled" (ATD) with 50 percent federal facilities are not mutually exclusive. funding, and can be placed in board and care homes. Modesto State Hospital was closed in 1970 and As of September 1, 1971, more than 8,100 turned over to Stanislaus County to be used for mentally ill patients have been placed on ATD by the educational purposes. community services division of the Department of DeWitt State Hospital at Auburn will close its Social Welfare. doors finally late in May of this year, and Agnews State Hospital hear San Jose will close its books on the mentally ill before the end of 1972. " Stockton State Hospital already has closed one they are worried wing devoted to care of the mentally ill. about the cost of keeping them CSEA has learned that DMH plans to close in the hospital." Metropolitan State Hospital and Mendocino State Hospital sometime between June 30, 1972, and June 30, 1973. This information is contained in a memo signed by This method of handling mental patients has Dr. O. L. Gericke, medical director at Patton State become so popular with the state administration that Hospital, of which CSEA has obtained a copy. next year the community services division will be He concludes this memo, dated 11/16/71: moved lock, stock and typewriters to the Department "Other hospitals for the mentally ill, such as of Mental Hygiene, adding $21 million a year to the Patton and Stockton, have uncertain futures with the DMH budget for 1972-73. closing date being possible from 24 to 36 months A Napa State Hospital surgeon blames excessive from now." reliance on ATD, in lieu of proper psychiatric-medical Few new county facilities have been built for the care, for the low percentage of success with patients care of mentally ill since LPS went into effect. under the present program. -7- "Less than 10 percent of all patients admitted to to 6 patients and is located in a poor, deteriorated state hospitals are returned to the cominunity as section of town. productive citizens," he stated. Board and care homes are not psychiatric facilities. "County mental health administrators order Mental patients are commingled with senile patients. patients released long before they are ready because they are worried about the cost of keeping them in Undoubtedly many such homes are operated by the hospital. It is cheaper to put them on ATD and kind and considerate owners who carefully see to the place them in a home at the expense of welfare. The needs of their tenants. procedure is dictated by economics, not But supervision of patients is minimal and the psychiatric-medical judgment." owner need have no training in the care of such Most counties have out-patient psychiatric persons. facilities, but because of the voluntary nature of mental health care under LPS, many released patients The only license needed to operate a 6-bed board never show up. and care home in any county in California is a $10 State and county welfare workers share the business license. responsibility for placing patients released from state Some counties don't even insist on that, and state hospitals, but cannot force them to use their ADT law makes no provision for licensing board and care checks for any particular purpose. homes of 6 beds or less. In Los Angeles County, the mental health subcommittee of the county's Comprehensive Health Planning Association reported in November of 1970 Many of his former patients in a paper on consumer protection: end up in transient hotels "Superficial examination of the present system paying $12 to $15 a week reveals conditions in our residential care facilities for a single room. which (1) undermine attempts to rehabilitate (mental patients) allows far too many proprietors of residential care facilities to exploit those in their care in favor of profit making, and (3) allow most of these Confused, disoriented and often sedated upon facilities to operate without licensing and surveillance their release, many of these patients go off on their by proper authorities. own and end up in transient hotels paying $12 to $15 a week for a single room. This information comes to CSEA from a physician-surgeon at one of the state's hospitals, who asked that his name not be used. He told CSEA "those who benefit investigators that many of his former patients have are not the interested recipients ended up in transient hotels where their money but the proprietors disappears. of the residential care facilities." They have no one to turn to and become police problems, he said. The sheriff of a northern California county told CSEA investigators that since LPS, 2 of the transient hotels in his town have become homes for many "It should also be pointed out that while much of ex-state hospital patients. the financial support for residential care comes from One day early in January 1972 a state hospital the state, those who benefit are not the intended security officer estimated to CSEA investigators that recipients (the client) but the proprietors of the 50 percent of the occupants of one of the hotels were residential care facilities." former state mental patients living on ATD. A Department of Social Welfare official estimated Since 1966, more than 11,000 state mental for CSEA that there are 32,000 mentally ill patients patients age 65 and over have been admitted to housed in unlicensed board and care facilities in nursing homes. California. More than 16,000 younger patients have been As of November 30, 1971, there were 108 licensed placed in the several types of boarding homes whose long-term facilities for treatment of the chronic owners make a living by housing such patients. mental patient scattered across the state. Their beds A typical board and care home accommodates up total 9,416. -8- What other private or public (non-state) facilities made for her because she could not dress herself. A are available to the mental patient discharged from a good supply of these dresses was sent to her after her state hospital? release. The technicians found her in old clothing not psychiatric hospitals for the acutely ill, licensed belonging to her. by DMH. As of July 1, 1971, there were 32 with Another patient in another facility came up to the 2,594 beds. technicians and cried, pleading to be taken back to general hospitals, either private or public, with Mendocino. "They never even talk to us here," she wards for the acute mentally ill, licensed by the said. Department of Public Health. The latest available At still another facility the technicians found a figures date to December 30, 1970, which showed former Mendocino patient who they recalled as a there were 47, with 1,204 beds. constant walker, up early each morning on her own. county hospitals with wards for the mentally ill. "She would take another patient by the hand and As of January 1972, there were 31, with 1,239 beds. walk her," one of the technicians recalled. In 1972-73 the Department of Mental Hygiene is But at the local care facility, they discovered her expected to close state hospitals with 3,267 beds and still in bed at 10:30 a.m. "She appeared to be sedated discharge an estimated 1,900 doctors, nurses, heavily. Her gown and bedding were soiled with-food, technicians and therapists trained in the care of possibly from breakfast. When we inquired as to why psychiatric patients. she was in bed, one of the staff implied that the aide Two CSEA members, both psychiatric technicians probably hadn't got around to getting her up yet.' at Mendocino State Hospital, recently visited several A fourth patient, who the technicians remembered convalescent facilities to see how former patients as ambulatory, was found tied in a chair with a black were being cared for in the community setting. eye and a discolored, swollen elbow, allegedly from a They found one patient, a woman, tied in a chair fall. with a webb strap which was pulled tight and cutting "She begged to come back with us," one of the into her bust. The patient was blind, and while at technicians reported. The patient died a short time Mendocino had been provided with special clothing after the visit, they told CSEA investigators. deaths Where have all the patients gone? report is scheduled for release at the end of this Some of them died, of course. coming June. Among transferred patients, the death rate appears It shows an 18.2 percent mortality rate among to be from 5-10 percent higher than among patients patients transferred when Modesto State Hospital who remained where they were. closed 2 years ago. The death rate among Modesto A study of the effect of transfers on the patients averaged 10.5 percent in the 4 years mortality rate of mental patients is being conducted preceding closure of the hospital. at the Langley-Porter Neuropsychiatric Institute in Among a control group of 100 patients at San Francisco. Stockton State Hospital, the death rate was 5 Called the "Modesto Relocation Project," the percent. -9- HOTEI AFTER STOP Avaura RIGHT TURN PERMITTED ON RED NO Street scene near one hotel assertedly occupied by former patients discharged from state mental hospital under the Lanterman-Petris- Short Act. -10- cost State officials have claimed the closing of state This means a net increase of $9.7 million in the hospitals and shifting care to the local level is saving cost of state-financed mental health care during fiscal tax dollars. 1972-73. In isolated areas of treatment this may be true. Even these figures do not show the real growth in However, in terms of total state expenditures, the total program cost of maintaining mentally ill savings of tax dollars has not materialized. patients at the community level. Other significant costs which are not easily identifiable and therefore Between fiscal 1965-66 and 1970-71, expenditures cannot be priced with a degree of accuracy include: at 1971 dollar value for services to the mentally ill in counties' share of local programs. all programs increased by more than $28 million. cost of services shifted from the Department of Total expenditures for services to the mentally ill Mental Hygiene to other departments (Social Welfare, reached a high of $292,513,477 in the 1970-71 fiscal Rehabilitation, and Public Health). year. Medicare and Medi-Cal contributions. In the current fiscal year, the Department of dentistry, physical therapy, and other Mental Hygiene has budgeted $104.1 million to pay professional services provided locally by charitable its 90 percent share of the cost of community mental organizations. health programs. Most county budgets for mental health have Next year it proposes to spend $123.3 million for increased under LPS. For example, in 1968-69, Los community mental health care, an increase of $19.2 Angeles County's budget for treatment for the million. mentally ill was $16,245,786. In the 1969-70 fiscal In the same time period, the department's budget year, estimates were $22,925,790 and during the for care of the mentally ill in state hospitals will current fiscal year, county mental health officials shrink from $107.1 million to $97.6 million, a drop requested $36,864,304 and received $35,409,953 to of $9.5 million. finance their community mental health programs. -11- In Santa Clara County, the budget in fiscal cases which find their way to county boards of 1969-70 for Health and Sanitation was $10,345,483 supervisors and other local authorities often contain and during this fiscal year the budget increased to evidence that local costs are excessive. $13,065,646. Napa County's entire mental health According to current figures in Sacramento budget in 1965 was $80,000. Today the county has a County, it costs $120 a day. for an average 8 to 10 budget of $1,100,000. days to hospitalize a mentally ill patient-an increase The above figures in themselves do not show the of 70 percent over the February 1970 figures staggering costs related to the community concepts of released by the Department of Mental Hygiene. treating the mentally ill. Various hidden factors are Outpatient care in Sacramento County costs an seldom identified as costs for treating the mentally ill. average $36 an hour. For example, the increased costs to local law Although the county has no current waiting list, enforcement, to our court system and especially the they could still use more money. The county, because increased cost of welfare as thousands of mentally ill of lack of funds, is not able to do as much patients are made eligible for Aid to the Totally consultation as they would like to do. Disabled with 50 percent federal funding. The problem of multiplicity of services within counties is a serious one. The County of Los Angeles for instance operates 37 different facilities for the diagnosis and treatment of mental illness, alcoholism, "I cannot afford it drug addiction, and emotional disturbances of and I doubt that childhood. our taxpayers can." In some treatment areas, costs are possible to measure as evidenced by recent cost accounting figures released by the Department of Mental Hygiene. However, in the important area of continuing One citizen whose wife has been chronically ill for psychiatric care, the comparison shows that it costs over 12 years and has been hospitalized 6 times more to contract out the psychiatric care of patients writes: than it does to treat them in state hospitals. "Sacramento County facilities under the In 1970 the average basic cost for continuing Short-Doyle-Petris system do not provide the psychiatric care in state mental hospitals was $34.35 clinical approach and are the most expensive I a day. Varying widely, costs for similar care in county have experienced. I cannot afford it, and I facilities range from $39 a day at Monterey County doubt that our taxpayers can, either. I had to Hospital to $125.57 a day at Los Angeles fight to get my wife released from Sacramento County-USC Medical Center. County facilities after she was there 10 days at In between these 2 extremes are: a cost of $1,448. My wife is now at Stockton $70 a day at Sacramento County Medical Center State Hospital." $76 a day at San Francisco General Hospital A new cost-reporting data collection system has $47 a day at Kern County General Hospital recently been approved and is expected to permit $68 a day at Santa Barbara General Hospital analysis and comparison of costs in local facilities $62 a day at Orange County Medical Center within a common frame of reference. Until such time $68 a day at Stanford University Hospital as reports become available, relative cost/effectiveness While the total cost picture is admittedly sketchy, analysis of programs will continue to be imcomplete. -12- mental illness and crime CSEA charges that the number of mentally ill department too stopped keeping data on mentally ill persons wandering the streets of California has suspects. increased alarmingly. Prior to 1969, Napa police handled an average of Since Lanterman-Petris-Short went into effect, 10 suicide attempts a year by mental patients. In some law enforcement agencies have experienced a 1970 the number soared to 51. marked and abrupt increase in the number of The Napa Police Department was in the habit of incidents involving former mental patients. keeping track of pedestrians "not in control of themselves." Before 1969 the highest number of such This flood of incidents has been so great that incidents reported in any one year was 15, in 1966. several police agencies have stopped keeping track of In the last 6 months of 1969-right after LPS the number of persons they pick up who are went into effect, 27 such incidents were reported in wandering around acting in a peculiar manner. These include Los Angeles, Santa Clara, Napa and the City of Napa. In 1970 the figure leaped to 74. Mendocino counties. In November of 1969, alarmed at the increase in crime by the mentally ill, the Hon. Goscoe W. Farley, The problem in Los Angeles County has become president of the California Conference of Judges. so acute that a special division of the sheriff's office appointed an 11-member committee of judges to has been formed to handle cases of mental illness. study the effect of the Lanterman-Petris-Short Act. Napa County Sheriff Earl Randol told CSEA They reported back 2 months later. Among their investigators that economic crime, such as many findings: shop-lifting, is his biggest problem with former Commitments of the criminally insane to jail or mental patients. prison terms increased dramatically during the first six months of the act. Compared to the same period a Napa State Hospital, next to the City of Napa, has year earlier (1968), the increases were 298 percent in housed the mentally ill since 1875. Los Angeles County, 66 percent in Alameda County. 60 percent in San Francisco County, and 50 percent The Napa Police Department told CSEA in San Diego County. investigators they handled 12 cases involving mentally "Under LPS since July 1, 1969 the mentally ill patients in 1958, a typical year before LPS. disordered defendant remains in jail without medical In 1970 the number jumped to 328. Last year that treatment and is criminally prosecuted. -13- "Because LPS does not involuntarily treat a provide for involuntary treatment of mentally mentally disordered person unless he is a danger to disordered persons who do not fit into the himself or others, or is gravely disabled, the individual classification "dangerous to self or others, or gravely often decompensates and finds himself in a criminal disabled." court. prohibit release back to the community of "Because he is not receiving medical treatment, patients who are a "menance to the health and safety he often further deteriorates to where he is unable to of others." stand trial." So far, both the legislature and the Department of "Many cases involve a mental disorder that is Mental Hygiene have ignored the judges' chronic, where the person is unable to provide food, recommendations. clothing or shelter. After a short-term hospitalization and heavy medication, they go into a period of remission (abatement of symptoms) as soon as the person is out of the treatment facility and off medication he goes into a period of exacerbation "Defective and dangerous where he cannot provide his food, clothing and to the persons most directly shelter." involved." "The urgency of the problem is clearly demonstrated by the cases where the criminal defendants are found to be legally sane and competent to stand trial although they are found to In 1968 Judge Albert H. Mundt of the Sacramento be mentally disordered. The result is they are Superior Court published a critical analysis of the returned to the criminal court to remain in jail, Lanterman-Petris-Short Act. without treatment, for criminal prosecution." In this document he said the statute is, in his "Many individuals certified for 14-day intensive opinion, "defective and dangerous not only to the treatment (in state hospitals) do not fit the definition persons most directly involved, the mentally ill and of gravely disabled, nor do they fit the strict the alcoholic, but to all of the people of the State of requirements (for) 90-day.treatment. California." "Many individuals have to be discharged into the He was particularly critical of a provision which community while still in need of psychiatric prevents detention of a suspected mentally ill person treatment until that person violates a court order. As a consequence the judges' committee "It (the new law) provides for a court-ordered recommended extending the period of involuntary evaluation of a person who is, as a result of mental treatment to 30 days, instead of 14. disorder, a danger to others, or to himself, or gravely disabled, who has refused or failed to accept evaluation voluntarily. So far "The order obtained after the filing of a petition is the Department of Mental Hygiene served on the person by a peace officer, a counselor has ignored the in mental health, or a court appointed official. "The person, after the service of the notice, is judges' recommendations. permitted to remain in his home, or any other place of his choosing, prior to the time of evaluation, without the exercise of any control whatever. Judge Harry Petris of the Los Angeles Superior "It is only when he fails to appear for evaluation Court was chairman of the judges' committee. after having been so notified, that he may be taken Interviewed in Los Angeles recently, he told into custody and placed in the facility. for treatment CSEA: and evaluation for a period not to exceed 72 hours." "Developments in the first 6 months under The old law allowed the court to order detention Lanterman-Petris-Short have become even more pending evaluation, after finding the person pronounced today." dangerous to himself and others. Two years ago that committee recommended that Mundt (who is retired now) wrote: the legislature: "The mentally ill person is not always responsible authorize municipal, superior and federal court for.his conduct and may be very dangerous. The fact judges to suspend criminal proceedings and obtain that it is necessary to get an order for evaluation is in involuntary medical treatment for mentally and of itself indicative of stress and an emotional disordered individuals. condition, because of which he does not cooperate -14- "He often is aware that an evaluation might result "Heavy sedation has been and still is being utilized in his detention for a substantial period of time. A to control their conduct. notice to appear for such evaluation is very likely to "It seems to me that those who have pressed so throw that person into a state of panic, or anger, or hard for this (law) somehow conceive that if you other frenzied conduct that might result in serious ignore these realities and say there is no mentally ill, harm to him or to others. that such sick people will disappear or the illness will "It is ironic," Mundt notes, "that under (LPS) a go away, when such, of course, is not the fact." peace officer may arrest and detain an alleged And sure enough, Judge Mundt was right. mentally ill person while a Superior Court Judge is "Such sick people" have not disappeared nor gone required to wait until a person fails to appear for away. evaluation before he is permitted to order the They have been released from state hospitals. exercise of that power.. They are living in 6-bed board and care facilities, Judge Mundt wrote it is "difficult to conceive why in county hospitals, in long-term treatment homes the legislature seized upon 14 days as the period and in transient hotels. during which all mentally ill people requiring care They are in jail. The judges' report tells us that, have recovered to the point where they no longer and so do police department records. need that care. But how many are in state prisons CSEA has been "Certainly we are...aware that the chronic unable to learn because the LPS Act keeps secret all mentally ill who require treatment over long periods, state mental health records. frequently lack the judgment, because of their illness, The facts, however, suggest that there may be a to understand and appreciate the fact that they do correlation between the effect of LPS on mental need treatment. health care in California and the recent violence in "We find these people resisting treatment. Many California prisons. of them are ill to the point where they need to be At least it would be well for the state legislature to closely confined, under constant surveillance. investigate this possibility. alan post said it in 1970 Legislative Analyst A. Alan Post, in his 1970 problems because the community lacks any effective analysis' of the state spending program, stung machinery to deal with them. operation of the Lanterman-Petris-Short Act with a "In Los Angeles and San Francisco chronically ill series of criticisms: persons are often without friends or relatives. These persons often live in hotels where they frequently "Another result of the fragmented mental health 'act-out.' Many hotel owners, in order to relieve themselves of a problem, will ask the person acting system is the lack of control and supervision of out to move on rather than calling the police or mentally ill individuals living in the community." medical authorities. 0 "As a result these mentally ill individuals end up "A number of chronically ill patients, moving from hotel to hotel until they are eventually particularly in metropolitan areas, are creating jailed or hospitalized again." -15- "A series of visits undertaken by staff of this "Eventually, many of these patients do not again office to state hospitals, Short-Doyle clinics, local become visible to mental health professionals until welfare agencies, community services division offices they deteriorate to the extent that their abnormal and other concerned agencies throughout the state, behavior is brought to the attention of such 'crisis' indicate that the high rate of re-admissions to state agencies as the police." hospitals is the result of insufficient supervision and "There are numerous unlicensed board and care support of patients discharged from the hospitals." homes located throughout California. Many of the "It is clear that to return hospital patients to the persons in these unlicensed homes are ex-mental community without assuring the adequate provision hospital patients or persons with severe emotional of follow-up services constitutes a disservice to the problems. patient, a disservice to the residents of the community into which the patient is placed and a "In the past (the Community Services Division of drain on the fiscal resources of both local and state DMH) and county welfare staff could and did remove agencies. patients from homes with inadequate standards." "Many of the patients released from the state "Since July 1, 1969, mentally ill persons leaving hospitals are not able to make contact with the state hospitals are released without supervision community agencies responsible for assuring the because of the lack of authority, neither CSD nor successful readjustment of former mental patients to county social workers are able to remove patients as community living they did in the past." -16- csea recommends CSEA investigators and researchers spent 4 months coordination of fiscal, psychiatric, social, and 700 man-hours compiling this report on the crisis educational and recreational needs of the mentally that faces publicly-financed care of the mentally ill in ill. California. -development of a uniform treatment program We have attempted to answer the question asked to include establishment of minimum criteria for at the beginning: "Where have all the patients gone?" community-level mental health care programs, In all too many cases they have ended up in avoiding 58 fragmented programs administered by prison, in transient hotels and in unlicensed board 58 counties, but taking into consideration the and care homes. need for flexibility and adaptability. More will make the same hopeless trip unless the -clarification of the functions and administration and legislature act to stop the closure responsibilities of the various agencies dealing with of state mental hospitals and take another look at the mentally ill to avoid leaving mentally ill how we are caring for our mentally ill. individuals living in the community without Therefore, CSEA makes the following supervision and control. recommendations: The Department of Mental Hygiene should hold The legislature should order an evaluation of the its plans to close Mendocino, Metropolitan, Patton effectiveness of state-financed mental health care at and Stockton State hospitals in abeyance until the the community level to include an analysis of: legislature completes its study and makes -quality, availability, cost and social impact of recommendations. local programs as they have evolved under the The legislature should pass emergency legislation Short-Doyle and Lanterman-Petris-Short laws. repealing AB 2648 of 1971, which orders counties to -merit and feasibility of developing use all existing county and private facilities before cooperative programs between state mental admitting patients to state hospitals. hospitals and community facilities. The state should assume full responsibility for -development of a master plan for providing the quality of publicly financed mental health care in mental health services to insure overall California. -17- Light slants through stairway door in transient hotel frequented by mental patients discharged from state hospitals. -18- State of California Department of Mental Hygiene Memorandum To : James M. Hall Date : March 16, 1972 Secretary File No.: Human Relations Agency From : Office of the Director Subject: Plan for State Hospital Closures During Fiscal Year 1972-73 The Legislature has requested a timetable for the closing of state hospitals during the 1972-73 budget year. The budget indicates that closure of two hospitals may be required during the coming year. The latest report on use of state facilities affirms this proposed estimate insofar as one hospital is concerned. It is not possible to report a decision now on a second hospital: geographical considerations, fluctuations in patient referrals, and further inquiries to local program directors require more time before such a decision is made. Accordingly, the Department of Mental Hygiene plans to close Mendocino State Hospital by September 1, 1972. Attachments indicate the rapidly decreasing use of this hospital by community programs. The number of patients in the state-operated hospitals for the mentally disordered continues to decline. Shorter hospital stays and provision of alternate methods of treatment in the community eliminate the need for many referrals to state hospitals. County governments have indicated they can provide service to their citizens. All of these factors contribute to the decline in state hospital bed requirements. Admissions to Mendocino State Hospital will not be necessary after May 1. Patients at this hospital who can be more suitably treated or cared for in community programs or facilities will be placed in the community. Local program directors and relatives or guardians will be consulted. Patients at Mendocino, who in the judgment of community mental health directors continue to require state hospital treatment and care, will be placed in a state hospitalhaving a program suitable to their needs. James M. Hall -2- March 16, 1972 In general, programs at Mendocino State Hospital will be transferred intact together with the current staff to support them to the degree such staff will move to the hospitals that are listed in the attachments to this report and at the times specified. Treatment personnel and support persons not moving with programs will exercise the normal civil service rights to transfer, demotion and/or layoff. The Department's plan for transfers and training is an attachment. The equipment in Mendocino will be redistributed in accordance with state laws and current rules and regulations. Property will be turned over to the Department of General Services for disposition in accordance with law. WD. J. M. Stubblebine, M.D. Director of Mental Hygiene Attachments: 1. County Referrals to State Hospitals 2. Patient Movement Plan 3. Personnel Plan 4. Episode Costs - State Hospital and Community Programs 5. Fiscal Impact Statement MENDOCINO STATE HOSPITAL USE BY COUNTY 1966-67 July 1971 - February 1972 Admissions inpatient Days Admissions inpatient Days Colusa 19 2,477 0 244 Mendocino 363 57,313 480 26,172 Del Norte 19 3,212 4 1,196 Shasta 97 20,196 2 2,119 Humboldt 168 31,660 54 9,695 Siskiyou 22 5,184 21 3,138 San Francisco 1,306 173,291 103 29,020 Marin 277 15,280 24 7,700 Sonoma 515 60,007 51 11,317 Alameda 177 35,121 5 7,072 Lake 80 8,104 117 5,831 Tehama 30 3,625 10 808 Trinity 8 2,326 1 272 Glenn 18 3,306 0 0 Other Counties 336 157,788 388 64,806 Totals 3,435 578,890 1,260 169,370 NUMBER OF PATIENTS MENDOCINO STATE HOSPITAL Fiscal Year Fiscal Year Ending Ending June 30 June 30 1950 2,716 1961 2,261 1951 2,711 1962 2,302 1952 2,607 1963 2,264 1953 2,635 1964 2,061 1954 2,490 1965 1,815 1955 2,378 1966 1,715 1956 2,305 1967 1,590 1957 2,237 1968 1,538 1958 2,456 1969 1,308 1959 2,421 1970 1,115 1960 2,330 1971 821 March 1, 1972 560 June 30, 1972 (Est.) 150 Attachment 2: Patient Movement Plan (Mendocino) Admissions from all counties will be closed by May 1, 1972. Transfers Probable Number Present for Date Program Population Transfer Transfer to May 1 (Penal Code) 74 74 Napa May 1 (Southern Counties) 55 55 Camarillo May 15 Medical-Surgical 31 5-10 Napa May 15 Special Projects 45 45 Stockton (MR) June 1 General Psychiatric 133 100-110 Stockton June 15 Geropsychiatric 60 30-40 Stockton June 15 Alcohol 40 5-10 Napa July 1 Adolescent 83 20-40 Stockton July 1 Drug 24 5-10 Napa July 15 Acute Psychiatric 12 0 I The hospital will be closed on September 1, 1972. Rated Bed Capacity & Present Number of Patients Napa Rated Bed Capacity 2,105 Patients 1,738 Difference 367 Stockton Rated Bed Capacity 1,055 Patients 782 Difference 273 Total No. of Patients to be Transferred to Stockton: 195 - 235 Total No. of Patients to be Transferred to Napa: 89 - 104 Attachment 3: Personnel Plan The Department is able to offer positions to all ward level nursing services personnel. If the employee is willing to transfer, he has 30 days in which to move and all moving expenses will be paid; as well, a per diem allowance for up to 30 days is permitted during relocation. In the case of working couples, every effort is made to transfer spouses in class to the same location and the dates of transfer are coordinated. Where a position in his own class is not available, an employee under certain circumstances may demote in lieu of layoff. Employees with over ten years of satisfactory State service who are displaced in this fashion may be granted a "red circle rate"; that is, they may retain their former salary rates for specified periods depending upon number of years of service. Where employees cannot be placed in an area of their choice and must terminate their State service, they are placed on priority reemployment lists which are good for five years. Through DMH and State Personnel Board programs, employees are placed in other departments, such as the Department of Corrections, where their skills can best be used. Various training programs for employees are sponsored by DMH in anticipation of shrinking job opportunities in DMH: Training course to prepare for community employment; training of Psychiatric Technicians to become Registered Nurses; one and two year curriculums in work with the mentally retarded and with mentally ill children; demonstration projects where they can show transferability of skills to other settings. State employees separated by layoff or inability to transfer to another location upon hospital closure are now eligible for unemployment insurance. Attachment 4: Episode Costs - State Hospital and Community Programs MENDOCINO SERVICE AREA COUNTIES INPATIENTS COST PER EPISODE * 1971 Total State State Hospital Total Community Hospital Cost Per Community Cost Per Episodes Episode Episodes Episode 17 $3,989.29 38 Del Norte $387.05 Humboldt 174 $ 176.39 590 $118.11 Siskiyou 93 $2,180.81 303 $361.96 Mendocino 943 $1,654.46 NO LOCAL INPATIENTS Marin 851 $1,663.26 759 $252.33 Tehama 45 $2,500.36 174 $611.09 Sonoma 929 $2,328.66 1,718 $182.67 Alameda 5,695 $1,526.50 2,213 $934.31 Lake 193 $1,421.23 NO LOCAL INPATIENTS Trinity 12 $2,565.50 2 $310.50 *These are costs at which each hospital patient from each county is referred to and not necessarily Mendocino. However, the comparisons are about the same no matter which hospital is used. ATTACHMENT 5: FISCAL IMPACT STATEMENT Closure of Mendocino State Hospital by September 1, 1972 will result in a savings of 275.3 positions and $1,860,000 in annual expenditures. MENTAL H46 HUMAN RELATIONS AGENCY HRA #72-4 Sacramento, California Contact: Alex Cunningham IMMEDIATE RELEASE (916) 445-0198 March 23, 1972 Dr. J. M. Stubblebine, Director of the state Department of Mental Hygiene, today announced that Mendocino State Hospital will be closed by September 1, 1972. He said the closure is the result of the successful implementation of the Lanterman-Petris-Short Act. "Never in the history of California have such successful med- ical and social programs been available to Californians who are mentally ill," Stubblebine said. "Because of the increased effect- iveness of the treatment being provided by community mental health programs, fewer Californians need to be cared for in state hospitals. "Community mental health directors are referring fewer patients to state hospitals. The operation of numerous state hospitals for the mentally disordered is fast becoming unnecessary." There are now 9,100 patients in the state hospitals for the mentally ill (see attached chart). There were 10,876 at the start of the fiscal year. In 1966, there were 26,567 patients. The average length of stay in state hospitals has declined steadily days from 223/in 1960 to 75 today. The average stay for first admis- sions is 14.7 days. Mendocino State Hospital now has only 541 patients, down from 821 on July 1, 1971, the start of the fiscal year. The hospital has the capacity to care for 900 patients and has handled in excess of 2,700 prior to 1967 when Governor Reagan adopted new space standards recommended by the American Psychiatric Association. -2- New admissions to the hospital will be halted May 1. Between now and the final closure date, approximately 215 patients will be transferred to Stockton state Hospital and about 100 to the Napa state facility. Other patients will be able to return to their homes or communities by the time Mendocino is closed. Stubblebine said community mental health programs have been especially successful since the Lanterman-Petris-Short Act was approved in 1969. The legislation, introduced by Assembly Frank Lanterman (R-La Canada) and Senators Nicholas Petris (D-Oakland) and Alan short (D-stockton), requires that community mental health programs be established, that counties be reimbursed by the state for 90 percent of the costs of their community programs, and pro- hibits commitment of a Californian unless he is a present danger to himself or others. Community programs will have more than $25 million in additional money available from state, federal, and local funds, and fees and insurance revenues during the 1972-73 fiscal year. Over $250 million will be spent during the same period for the care and treatment of patients who are mentally ill, compared with $151 million in 1966-67. More than $170 million will go to community programs in the coming fiscal year compared to $35 million in 1966-67. The remainder will provide treatment for patients referred by the communities to state hospitals. Governor Reagan said he was extremely pleased with the success the Department of Mental Hygiene has had in implementing the Lanterman-Petris-Short Act. -3- "Dr. Stubblebine and his staff are to be congratulated for the work they have done on behalf of the mentally ill," the Governor said. "There is no question that California is the nation's leader in providing care and treatment for its citizens stricken with mental illness. The department's implementation of the LPS Act is mainly responsible for this success." James M. Hall, secretary of California's Human Relations Agency, whose eight departments include the Department of Mental Hygiene, said: "California's mental health record is outstanding. The measurement is not in numbers or dollars, but rather in the quality of care and treatment of patients. Our citizens have bene- fitted by having mental health programs available that allow them to remain close to home and lead near-normal lives. "Dr. Stubblebine and the entire Department of Mental Hygiene understand the needs of mentally disordered patients. They have held the patients' interests paramount and have provided excellent and positive care and treatment. My appreciation is shared with the families and friends of patients who have their loved ones home again." With the closing of Mendocino, three hospitals for the men- tally ill will have been closed this year--Dewitt, Agnews, and Mendocino. There are currently 607 employees at Mendocino. All ward nursing personnel will be offered positions at other hospitals. (310) Some non-ward treatment employees will have to transfer to other state agencies. Openings exist in several state departments, including the Department of Corrections. 310 Nursing (includes fanitors!) Dept. of F. 100 Non-nursing (but treatment) prob. pr Support (Cooks, Gardiners) other Dept: -4- Mendocino was opened in 1893. For many years it was the state's "security" hospital, where patients were referred from the courts after trial on criminal charges or because they were too mentally disordered to stand trial. The "security" unit was moved to Atascadero in 1954. Mendocino has served North Coast and Bay Area counties since that time as an open hospital. All of the counties affected by the closing have in-patient mental health programs, except Mendocino and Lake Counties. Funds will be made available to the two counties to establish programs. These counties also have the option to contract with other commun- ity programs or refer patients to Napa State Hospital. #### Attached is a chart showing the long term trends in State hospital utilization. LONG-TERM TRENDS IN STATE HOSPITAL UTILIZATION Average Daily Population of Mentally Disordered Population 1950-1972 40,000 Tranquilizing Drugs , ATD Funds for 35,000 Leave Placements Short-Doyle Act 30,000 (50% state funding of county programs) Short-Doyle Act (state reimbursement 25,000 increased to 75%) 20,000 15,000 Lanterman-Petris-Short Act (90% state funding of county programs) 10,000 5,000 0 1950 1955 1960 1965 1970 Fiscal Year Ending June 30 April 10, 1972 Department of Mental Hygiene Office of Information 744 P Street, Room 724 Sacramento, California 95814 #34 Telephone: (916) 445-6921 MEMORANDUM FOR THE PRESS , In late February the Department of Mental Hygiene was apprised that medical records of patients at Atascadero State Hospital may have been altered for purposes at that time unknown. An investigative committee was appointed immediately to determine if the allegations were true. The committee has found many of the allegations to be true. It is an unacceptable situation and will be remedied. A copy of the committee's findings are attached. But with no recommendation as yet. The Department is currently developing new programs, procedures and considering personnel changes. These will be made public as quickly as possible, but not before next Friday. At that time the investigating committee will be in Sacramento to consider the program and procedure suggestions and to make recommendations based on their findings. Because the meeting consistently will be involved with personnel matters, it will be a closed meeting. However, the recommendations will be made public as quickly as approved by the committee and adopted by the Department. The investigation into the problems at Atascadero were initiated by Dr. J. M. Stubblebine, Director of the Department of Mental Hygiene, as promptly as they were called to his attention. The Attorney General is being informed this morning of the findings. Atascadero patients (all males) are: 1. Persons referred by the courts who are too sick to stand trial. These persons are referred back to the court upon certification of competency. MEMORANDUM FOR THE PRESS -2- April 10, 1972 2. Persons found not guilty of a crime because of insanity and sent to Atascadero for treatment and observation. When treatment is completed, these persons are referred back to the court for its disposition. 3. Persons convicted of a crime who are mentally disordered sex offenders and who are hospitalized for treatment. When treatment is completed, these persons are referred back to the court for its disposition. 4. A small group of patients who are too mentally disordered and dangerous to patients and personnel at other open state hospital grounds. There are about 2,400 mentally disordered offenders in hospitals for the mentally ill, of which 1,300 are at Atascadero. About half of the 2,400 were involved in sex offenses. The remainder are not dangerous and have been assigned to other hospitals. The Department has found that the records of these patients have not been tampered with. The following statement is that of Dr. J. M. Stubblebine: I have been concerned about the treatment for and opportunities offered to the mentally disordered offender for a very long period of time. I am concerned about those in prison, on the streets, or in hospitals. They are men, women and youngsters. Since I became Director of the Department last July, a considerable amount of time and thought has gone into developing suggestions toward not only solving a critical public problem but at the same time, aiding the offender to recover his health and return to society as a productive citizen. did not know of these tragic occurrences at Atascadero until recently. I am not yet sure how grave and depriving they have been to any particular person. The degree and consistency of the activity, as found by the special committee, is abhorrent. MEMORANDUM FOR THE PRESS -3- April 10, 1972 The Department has requested funds from the California Council on Criminal Justice to establish an elite "blue ribbon" committee to investigate, take testimony, weigh facts and make recommendations to overhaul the entire structure of the law as it relates to the mentally disordered offender. I am hopeful of approval. In the meantime, this Department will act quickly and effectively to make sure that Atascadero procedures and programs are changed and monitored. These will be in effect by May 1, or sooner. The altering of medical records has, of course, ceased. Personnel changes as are necessary will be made, and I wish to make the first announcement today. I have offered the position of Clinical Director at Atascadero State Hospital to Dr. Michael Serber who was with me today. He is going to consider it and will let us know as quickly as possible. Members of the committee are: John L. Moody, M.D., Northern California Psychiatric Society; Norman Graff, M.D., California Medical Association; Dr. Abe Linn, Napa State Hospital; Dr. Jerry Kayne, Patton State Hospital; Dr. Harold W. Nolen, Agnews State Hospital. #### April 7. 1972 Project #11 Review of Professional Practices at Atascadero State Hospital 1. Charge: A. To determine the validity of a number of charges alleging that treatment and administrative practices at Atascadero State Hospital failed to meet professional, legal and ethical standards. B. To recommend remedial action in any instance where the charges were found to be valid. Specifically, the charges to be investigated alleged that court decisions were given preference to medical standards in determining treatment program, medical records were being altered, and medical care was not being provided to all those patients whose physical conditions warranted additional attention. 11. Recommendations: (to be developed) 111. Findings: In looking into the charges, the task force findings fell into five major areas including: Organization, Court Influence on Treatment Programs, Medical Records, Medical Care and Additional Observations. Although the examination of such items as medical records, statements of policy and operating procedures, administrative directives, as well as interviews with staff resulted in a number of specific findings pertaining to specific cases, only the general conclusions are presented in this report. A. Organization: Atascadero State Hospital has not implemented the program organization used in the other state hospitals. The treatment program is divided into five Sections which serve specific geographic catchment areas. In addition to these five programs there is a Med/Surg. Section which serves the entire hospital population and a Service Section which -2- which houses the coordinators of such services as Professional Education, Research, Nursing, Psychology, etc. All of these Sections report directly to the Associate Medical Director. With this organization the formal chain of command from the top level down is designed as follows: 1. Hospital Medical Director; 2. Associate Medical Director; 3. Section Chief (Staffing Psychiatrist); 4. Ward Physician or Program Coordinator. The major problems that seem to exist at Atascadero in conjunction with this organization are as follows: 1. Although the formal organization would indicate that all unit personnel are responsible to report to the Ward Physician or Program Coordinator, in reality, this organization is frequently bypassed and staff report to the Section Chiefs or Service Coordinators. 2. There is a lack of open two-way communication between the Section Chiefs and the Ward Physicians or Program Coordinators. 3. The organization of all clinical personnel including both physicians and members of other disciplines is unclear in terms of lines of communication, lines of authority and individual responsibilities. 4. Appropriate committees, although identified in the formal organization, are ineffectively utilized. This was particularly true of the Credentials Committee which failed to carry out its assigned functions of: a. Delineation of privileges to be extended to the members of the active medical staff beyond those assignments made by the Section Chiefs, Associate Medical Director and Medical Director. -3- b. Investigation of any breach of ethics that may be reported involving members of the active staff. C. Investigation of the credentials of newly appointed staff members. 5. The Medical Records Librarian's position of a consultant-advisor with limited knowledge of the mechanics of the hospital's daily routine recording procedures inhibited her effectiveness in carrying out the full range of quality control procedures included in her responsibility. B. Court influence upon treatment program design. Atascadero State Hospital's diagnostic and treatment procedures may be traced by a series of "staffings" which serve as decision points during the patient's course in the hospital. When a patient first arrives at the hospital he is examined by the Ward Physician and an evaluation of his physical and mental status is completed within 72 hours after the examination. At this time a tentative diagnosis is entered in the patient's record. Within five weeks after admission the Ward Team members jointly evaluate the patient and submit their findings through the use of a multidisciplinary staffing form to the Section Chief. The Section Chief then reviews the findings and, after a brief discussion with the Ward Team and brief interview with the patient, confirms or revises the tentative diagnosis and treatment plan. Periodically, the Ward Team reviews the patient's progress through his treatment program. Finally, when the Ward Team feels that the patient has gained maximum benefit from his hospitalization the staffing process is repeated to determine final disposition of the case. In reviewing this decision making process the task force concluded that the treatment program is heavily influenced by the judicial system. This influence is noticeable to the point that court decisions are -4- given preference to medical standards in treatment program determination. The key points leading to his conclusion are as follows: 1. The major determinants for treatment programs for each individual patient are: a. The type of commitment. b. The crime or alleged crime of the patient. C. The probable sentence the patient would have received if convicted and sent to Corrections for a definite period of time. d. The patient's ability to respond to treatment as manifested by his confession of guilt. 2. Arbitrary amounts of time in residence are required of patients according to their type of commitment or offense rather than their progress in the treatment program. Review of the "staffing checklist" as well as statements made during the interviews revealed that: a. Minimum time limits were required for specific types of commitments and offenses. b. Minimum periods of time in residence without ataractic medication were categorically required of some patients as a condition for their return to court in spite of an acknowledgement by some staff that this was inappropriate for many patients. 3. The primary treatment modality used at Atascadero is group therapy on the basis that it seems to be the best means of forcing the patient to acknowledge his guilt. Through peer pressure the patient "learns to be a patient" and submits to the power of the therapist. Individual therapy is minimized as a low-yield, uneconomical treatment modality. -5- 4. The attitude of the Senior Medical Staff (Section Chiefs) established a dictatorial atmosphere which: a. Emphasized physical and legal constraints over psychiatric care. b. Emphasized the necessity of caution in releasing patients so that the hospital and its staff would not receive adverse publicity due to patient "failures" upon return to the community. C. Appeared preoccupied with acting in the function of "judge and jury" rather than providing appropriate psychiatric evaluation and consultation. d. Regarded court decisions which disagreed with hospital recommendations as "losses" on a win-lose basis. 5. In the interest of avoiding criticism from the courts, both written statements as well as unwritten policies emphasized the need for consistency of clinical opinions. Because of this, conflict which arises from disagreements between staff is generally repressed rather than dealt with openly and creatively. Examples of this repression appeared in: a. Statements made in interviews that it was unwritten policy that opinions entered on the multidisciplinary staffing forms must be in agreement with each other and consistent with other notes in the records. b. Statements in the staffing checklist which emphasized the need for consistent notes particularly in cases being returned to court with negative recommendations. C. Statements made in interviews that all disagreements were worked out in team meetings prior to the entry of clinical opinions in the medical records. d. Record review which revealed a remarkable degree of uniformity in the majority of cases. -6- C. Medical Records. The process of making an entry into a medical record at Atascadero State Hospital begins with the professional staff member's initial note either being dictated on tape or written in long hand on a "C-Note" form. The original note is sent to the Section Clerk for transeription while the carbon is maintained on the ward (a carbon of the dictated note is returned to the ward after initial transcription). The Section Clerk then files the initial note in a temporary file until enough entries have been made to complete a type-written page. Once the entries have been typed into the medical record the original notes are destroyed and a carbon copy of the page is sent to the ward to replace the several entries in the ward chart. When the notes are entered in the medical record they are submitted to the authors for their signature. At the desire of the Section Chief, at any point in this process he may review the entries in the medical record and take one of the following actions: 1. Approve the note; 2. Request the author to change the note; 3. Request the author to delete the note; 4. Delete the note without the author's consent; 5. Enter a counter note in the chart. Upon his own initiation, the author of a note may also make changes in his note at any point during this process. One exception to this practice is the entries in the continuous nursing notes in the ward charts. In consultation with the Medical Record Librarian, nursing service has followed the practice of lining out any notes which are in error rather than deleting the notes. In conjunction with the accusations regarding the practice of changing notes the major findings are: -7- 1. The medical records are altered by removal, omission or replacement of staff notes containing clinical opinions. a. This practice was particularly prevalent in Section E during a recent period of several weeks when all notes were reviewed by the Section Chief resulting in the elimination of "conflicting or contradictory" entries. According to information received in the interviews this same practice was commonly used in the other Sections at the discretion of the Section Chiefs. b. Changes made in the notes either by the authors or by the Section Chiefs have been both editorial and substantive. C. Both the Medical Record Librarian and the Chief Clerk disclaimed knowledge of these practices resulting in alteration of the records but, agreed that such practices would be inconsistent with acceptable standards of medical records practice. 2. Entries by professional staff into the medical records are restricted in order to conform to other opinions, particularly those of the Section Chiefs. a. Evidence obtained through interviews and review of the medical records verified that entries made by the professional staff in cited cases were restricted when they failed to conform to ward team recommendations or Section Chief evaluations. This was found primarily in Section E and was not always a uniform practice throughout the other Sections. b. Although there was evidence where divergent opinions were entered in the medical records, it was noted that most of the records revealed a considerable degree of uniformity of opinions and recommendations. d. Staff interviewed cited the team meetings as useful in settling disagreements. While such meetings may account for positive -8- agreement resulting in uniformity of opinion they may also be a subtle means of exerting pressure to eliminate all divergence of opinion prior to making any notations in the charts. D. Medical care. Although it had been alleged that the hospital administration had arbitrarily restricted or limited medical investigation, care and follow-up of clinical somatic problems, there was no evidence to validate this charge. 1. There was no evidence of any deliberate or wanton denial of diagnostic and therapeutic care of patients. 2. There was evidence in a small minority of cases of questionable judgment in terms of appropriate treatment procedure. 3. There was evidence of lack of communication between one ward physician and the Med/Surg. Section Chief which may have resulted in a lack of appropriate referrals for additional diagnostic laboratory procedures. E. Additional observations. 1. The medical staff, particularly the Section Chiefs, exhibited inadequacies and deficiencies in accepting and practicing newer concepts in psychiatric care and administration. Specifically they appeared: a. Unable to communicate effectively with and provide appropriate guidance to their subordinate staff; b. Lacking the technical competence necessary to function in their positions; C. Lacking confidence in their own professional ability particularly in relationship to testifying in court; d. Unable to make creative use of conflict or divergence of opinion. 2. In some records reviewed it appeared that the hospital is not following departmental policy regarding the use of seclusion and restraints. -9- There were instances of patients remaining in seclusion for periods as long as 14 days with no 24-hour reviews recorded in the notes. IV. Methodology A. A Task Force was formed to investigate the charges which included representatives from Psychiatric practice both within the Department of Mental Hygiene as well as from relevant professional organizations. B. The Task Force was provided with background information regarding the charges and also oriented to Atascadero State Hospital's unique function of serving the mentally ill offender. Included in the background material were relevant statements of policy and procedures abstracted from both the Department and the Hospital manuals, records, etc., as well as relevant material from the various legal codes pertaining to Atascadero. C. A site visit was conducted by the Task Force which included: 1. Orientation to the hospital and its administrative practices by the Medical Director and Hospital Administrator. 2. Interviews with staff including both those directly involved in the charges as well as others randomly selected from the Hospital staff roster. 3. Record review of cases including: a. Specific cases cited by both the individuals making the charges as well as other staff defending the hospital's position; b. A sample of cases of patients who had filed writs of habeas corpus; C. A random sample of discharges over the last six months; d. A random sample of the current resident population. D. The findings of the Task Force were summarized and distributed in draft form to the Task Force members for review and comment. E. A follow-up meeting will be scheduled to review the findings and draft the recommendations. mere Mental Hygienc NEWS RELEASE 12 Department of Mental Hygiene Office of Information 744 P Street, Room 724 Sacramento, CA 95814 #42 Telephone: (916) 445-6921 A special commission of judges, a district attorney, and a business executive have concluded that it "is imperative that there be greater liaison between the medical profession and those engaged in the administration of justice in order to attempt to resolve misunderstandings" related to treat- ment of the mentally disordered offender. The commission recommended that the "Department of Mental Hygiene and the Judicial Council sponsor a joint committee to review the laws relating to the confinement of the mentally ill who are charged with or convicted of criminal acts and the administration of these laws so that the law and the practices thereunder may reflect both the current state of learning concerning psychiatric problems and modern concepts of due process of law. If The commission was named by Dr. J. M. Stubblebine, Director of the Department of Mental Hygiene, to review a department document of last May in which it was reported that medical procedures at Atascadero State Hospital were expedient in some cases or preferred by medical and legal entities rather than always in the best interests of patients. The reviewing group found that some practices were true insofar as some procedures involving medical decisions by staff at Atascadero, but the commission said there was no basis in the records they reviewed which indicated judges requested the changes, as had been implied in the original document. The commission also recommended: "Because of questions raised by the material developed in the earlier investigation, there should be further review to determine the extent to which there were any alterations or deletions from any patient's record, and if so, whether it had any appreciable effect on his detention or release. NEWS RELEASE - #42 Page 2 "The Director of the Department of Mental Hygiene should provide to those staff members responsible for reporting to and appearing in court, through a qualified attorney, seminars and other educational materials concerning the state laws and court procedures governing the custody and release of those committed to the institution. H In it's finding the commission found: "On the basis of the evidence reviewed, this committee found no specific case where a patient was detained or released because of an alteration or deletion of a record. "There was no evidence to justify the conclusion that there were illegal or unethical practices among the general staff. In one section of the hospital, it was admittedly the practice of the section chief to remove from the patient record, or omit, or replace, notes made by members of the staff. The section chief characterized those notes as inappropriate, untruthful, contradictory, and conflicting. However, the evidence does not support a finding that this practice occurred in any other sections of the hospital. "There is no evidence that any judge or public prosecutor requested or suggested that any patient of Atascadero State Hospital ready for release or return to court should be kept in confinement in violation of his constitutional rights. There is no evidence that any judge or public prosecutor requested or authorized or was aware of the alteration of any medical record. There is no evidence of court interference with the treatment program design. 11 The commission members reviewed the task force report, the transcript of the interviews of Atascadero State Hospital personnel conducted by the task force, and had available for review all written material, including patient records, considered by the task force. NEWS RELEASE - #42 Page 3 The commission said: "The complaints giving rise to the original investigation and the evidence produced in that investigation focus the spotlight on the inherent difficulty of combining judicially administered restraint with medically administered treatment. The evidence produced indicates that those charged with the treatment of the mentally ill offender may misunderstand the requirements of the legal system and feel improper pressures because of that misunderstanding. It is equally probable that those engaged in the administration of justice are inappropriately seeking and demanding a certainty in diagnosis and prognosis which the medical profession cannot supply. 11 The commission consists of: Mr. Ed Bell on the corporate staff of Beckman Instruments, Inc. and a member of the Board of Directors of the California Association for Mental Health Superior Court Judge Arthur L. Alarcon of Los Angeles Justice Richard M. Sims, Jr., First District Court of Appeal, San Francisco Superior Court Judge Jay R. Ballantyne of Tulare County Mr. Robert Tait, District Attorney of San Luis Obispo County September 26, 1972 REPORT OF RECOMMENDATIONS AND CONCLUSIONS OF THE ATASCADERO STATE HOSPITAL REVIEW COMMITTEE Committee Members: Mr. Ed Bell, Chairman Judge Arthur L. Alarcon, Vice-Chairman Justice Richard M. Sims, Jr. Judge Jay R. Ballantyne Mr. Robert Tait The committee was formed at the request of J. M. Stubble- bine, M.D., Director of the State Department of Mental Hygiene, to review the findings set forth in a task force report concerning Atascadero State Hospital, dated May 2, 1972. The purpose of the review is to ascertain if the findings in that report are supported by the evidence considered by the task force which made the report and to make recommendations thereon. The task force report is entitled "Project 11. Review of Professional Practices at Atascadero State Hospital." The committee members reviewed the task force report, the transcript of the interviews of Atascadero State Hospital personnel conducted by the task force, and had available for review all written material, including patient records, considered by the task force. The committee met on June 29 and 30, 1972, in San Francisco. The recommendations and conclusions of the Atascadero State Hospital Review Committee are as follows: Page 2 A. RECOMMENDATIONS 1. The complaints giving rise to the original investigation and the evidence produced in that investigation focus the spot- light on the inherent difficulty of combining judicially administered restraint with medically administered treatment. The evidence produced indicates that those charged with the treatment of the mentally ill offender may misunderstand the requirements of the legal system and feel improper pressures because of that misunderstanding. It is equally probable that those engaged in the administration of justice are inappropriately seeking and demanding a certainty in diagnosis and prognosis which the medical profession cannot supply. It is imperative that there be greater liaison between the medical profession and those engaged in the administration of justice in order to attempt to resolve those misunder- standings. To this end, it is recommended that the Department of Mental Hygiene and the Judicial Council sponsor a joint committee to review the laws relating to the confinement of the mentally ill who are charged with or convicted of criminal acts and the administration of these laws so that the law and the practices thereunder may reflect both the current state of learning concerning psychiatric problems and modern concepts of due process of law. Page 3 2. Because of questions raised by the material developed in the earlier investigation, there should be further review to determine the extent to which there were any alterations or deletions from any patient's record, and if so, whether it had any appreciable effect on his detention or release. 3. There is a continuing, ongoing need for research projects. In the future, such projects must be carefully delineated and personnel selected who are able to work compatibly with other hospital personnel. 4. The Director of the Department of Mental Hygiene should provide to those staff members responsible for reporting to and appearing in court, through a qualified attorney, seminars and other educational materials concerning the state laws and court procedures governing the custody and release of those committed to the institution. 5. With reference to the findings D and E of the May 2, 1972 report, it was this committee's observation that they involved methods of medical treatment and individual competence which we were not qualified to evaluate. B. GENERAL CONCLUSIONS 1. On the basis of the evidence reviewed, this committee found no specific case where a patient was detained or released because of an alteration or deletion of a record. Page 4 2. There is no evidence that any judge or public prosecutor requested or suggested that any patient of Atascadero State Hospital ready for release or return to court should be kept in confinement. There is no evidence that any judge or public prosecutor influenced or authorized the alteration of any medical record. There is no evidence of court inter- ference with the treatment program design. 3. There was no evidence to justify the conclusion that there were illegal or unethical practices among the general staff. In one section of the hospital, it was admittedly the practice of the section chief to remove from the patient record, or omit, or replace, notes made by members of the staff. The section chief characterized those notes as inappropriate, untruthful, contradictory, and conflicting. However, the evidence does not support a finding that this practice occurred in any other sections of the hospital. 4. The generalities contained in the findings of the task force report as a whole were not warranted or supported by the limited scope of the investigation undertaken by the task force making that report. It would be unfortunate if these generalities may have reflected upon the staff members and employees of Atascadero State Hospital whose ability and loyalty have never been questioned. The task force Page 5 which prepared the May 2 report acted quickly because of complaints which indicated a disruptive situation that appeared to threaten the functioning of at least one section of the hospital. It appears that most of the complaints came from one person who had a sincere disagreement with the person to whom he was administratively responsible with respect to the practices reviewed by the earlier task force. C. CONCLUSIONS ON EVIDENCIARY SUPPORT ON SPECIFIC FINDINGS MADE IN MAY 2 REPORT FINDING A; Page 4 The report states: "Atascadero State Hospital has not implemented the program organization used in the other hospitals." This committee has been informed that Atascadero State Hospital was at one time exempt from the program concept concep- tualized in PRU Project #57, "A Study of Patient Treatment Program Organization for State Hospitals." We are also advised that in September, 1971, this exemption was withdrawn and the Superintendent of the hospital was instructed to implement that program. The timing and the full responsibility for implemen- tation for that program is not clear from the record and no opinion is expressed as to what steps should have been taken by Page 6 the time of the original review. The findings are correct in that the recommended program was not implemented and they correctly set forth the practice of geographical distribution in effect at the time. FINDING A, 1 and 2; Page 5 The report states: "1. Although the formal organization would indicate that all unit personnel are responsible to report to the Ward Physician or Program Coordinator, in reality, this organization is frequently bypassed and staff report to the Section Chiefs or Service Coordinators. "2. There is a lack of open two-way communica-, tion between the Section Chiefs and the Ward Physicians or Program Coordinators." The record review shows evidence of lack of communi- cation apparently engendered by the lack of chain of command between the research project and the normal functioning of the hospital. The conclusion that the staff frequently bypassed the Ward Physician or Program Coordinator and that there was a general lack of open two-way communication between Section Chiefs and the Ward Physician or Program Coordinator is not sustained by the limited record before us. Page 7 FINDING A, 3: Page 5 The report states: "3. The organization of all clinical personnel including both physicians and members of other disciplines is unclear in terms of lines of communication, lines of authority and individual responsibilities." We find no support in the record for this finding. FINDING A, 4a and 4b; Page 5 The report states: "4. Appropriate committees, although identified in the formal organization, have been in- effectively utilized in some instances. This was particularly true of the Credentials Committee which failed to carry out a number of its assigned functions, e.g.: a. Investigation of any breach of ethics that may be reported involving members of the active staff. b. Investigation of the credentials of newly appointed staff members." No written records were available to establish whether or not the Credentials Committee met and carried out any of its assigned functions. In the absence of any evidence that any breach of ethics was reported to the Committee, it cannot be assumed that it was derelict in failing to conduct an investigation. Page 8 It should be noted, in reference to Finding 4b, that the by-laws of the medical staff of Atascadero State Hospital provide: "The Credentials Committee shall not be concerned with appointment of physicians to the medical staff since that is the function of the Associate Medical Director, Medical Director, and State Personnel Board." (By-laws, Page 5, Paragraph 3, Section 2) FINDING A, 5: Page 5 The report states: "5. The Medical Records Librarian's position of a consultant advisor with limited knowledge of the mechanics of the hospital's daily routine recording procedures inhibited her effectiveness in carrying out the full range of quality control procedures included in her responsibility." There is evidence to support the conclusion that there was inadequate centralized supervision of the procedures for recording medical records. FINDING B; Pages 6 and 7 The report states: "B. Court influence upon treatment program design. Atascadero State Hospital's diagnostic and treatment procedures may be traced by a series of 'staffings' which serve as decision points during the patient's course in the hospital. When a patient first arrives at Page 9 the hospital he is examined by the Ward Physician and an evaluation of his physical and mental status is completed within 72 hours after the examination. At this time a tentative diagnosis is entered in the patient's record. Within five weeks after admission the Ward Team members jointly evaluate the patient and submit their findings through the use of a multi- disciplinary staffing form to the Section Chief. The Section Chief then reviews the findings and, after a brief discussion with the Ward Team and brief interview with the patient, confirms or revises the tentative diagnosis and treatment plan. Periodically, the Ward Team reviews the patient's progress through his treatment program. Finally, when the Ward Team feels that the patient has gained maximum benefit from his hospitali- zation, the staffing process is repeated to determine final disposition of the case." For reasons set forth below, this Committee considers the title of this finding "Court influence upon treatment program design" unfortunately inappropriate. The report correctly states the general procedure as set forth in the first paragraph under this heading quoted above. Finding B of the report continues as follows: "In reviewing this decision-making process, the Task Force concluded that the treatment program is heavily influenced by the judicial system. This influence is noticeable to the point that court decisions are given preference to medical standards in treatment program determination. The key points leading to this conclusion are as follows: Page 10 "1. The major determinants for treatment programs for each individual patient are: a. The type of commitment. b. The crime or alleged crime of the patient. C. The probable sentence the patient would have received if convicted and sent to Corrections for a definite period of time. d. The patient's ability to respond to treatment as manifested by his confession of guilt." Analysis of key points under this paragraph reflects the following discrepancies: There is no evidence of court interference with the treatment program design. There is some evidence that in a few instances medical decisions were improperly influenced by the following factors: a. To avoid embarrassment in court proceedings because of possible staff disagreement on diagnosis or prognosis. b. To keep a patient in confinement in certain cases for the minimum time the person would serve if sent to prison to avoid further incarceration. C. To justify a failure to recommend release from confinement. Page 11 d. To avoid criticism because of use of medication to tranquilize a patient returned to court. e. To prevent criticism if a person were released and subsequently committed a violent crime. There is no evidence that any prosecutor or judge requested or suggested that any patient ready for release or return to court should be kept in confinement, nor that any prosecutor or judge influenced or authorized the alteration of any medical record. The record does not support that the "major deter- minants for the treatment programs" are those set forth in Finding B, 1, a, b, C, and d. It does show that the treatment program has been influenced with reference to a, b, c, and d and that d applies only to Mentally Disordered Sex Offenders. FINDING B, 2; Page 7 The report states: "2. Arbitrary amounts of time in residence are required of patients according to their type of commitment or offense, rather than their progress in the treatment program. Review of the "staffing checklist" as well as statements made during the interviews revealed that: a. Minimum time limits were generally required for specific types of commit- ments and offenses. Page 12 b. Minimum periods of time in residence without ataractic medication were categorically required of some patients as a condition for their return to court in spite of an acknowledgement by some staff that this was inappropriate for many patients." The Atascadero "Staffing Checklist" suggests that minimum time limits for specific types of commitments and offenses should be considered. There is evidence to support the finding that minimum periods of time in residence without medication are required before return to court. FINDING B, 3; Page 7 The report states: "3. The primary treatment modality used at Atascadero is group therapy. A major reason for employing this treatment, according to the Section Chiefs, is its usefulness in forcing the patient to acknowledge his guilt. This confession is viewed by the Section Chiefs as a pre- requisite to the patient's ability to benefit from further therapy." The record, including the Atascadero State Hospital Staffing Checklist, which suggests this procedure, supports the finding insofar as verbal persuasion may have been used. However, there is insufficient evidence to indicate that this modality was universally applied to all cases. Page 13 FINDING B, 4 and B, 5; Pages 8 and 9 The report states: "4. The attitude of the Senior Medical Staff (Section Chiefs) established a dictatorial atmosphere which: a. Emphasized physical and legal constraints over psychiatric care. b. Emphasized the necessity of caution in releasing patients so that the hospital and its staff would not receive adverse publicity due to patient "failures" upon return to the community. C. Appeared occupied with acting in the function of "judge and jury" at the expense of providing appropriate psychiatric evaluation and consultation. d. Regarded court decisions which disagreed with hospital recommendations as "losses" on a win/lose basis. e. Emphasized potential dangerousness of the patients beyond realistic appraisal. "5. In the interest of avoiding criticism from the courts, both written statements as well as unwritten policies emphasized the need for consistency of clinical opinions. Because of this, conflict which arises from disagreements between staff is generally repressed rather than dealt with openly and creatively. Examples of this repression appeared in: a. Satements made in interviews that it was unwritten policy that opinions entered on the multidisciplinary staffing forms must be in agreement with each other and con- sistent with other notes in the records. Page 14 b. Statements in the staffing checklist which emphasized the need for consistent notes particularly in cases being returned to court with negative recommendations. C. Statements made in interviews that all disagreements were worked out in team meetings prior to the entry of clinical opinions in the medical records. While such meetings may account for positive agreement resulting in uniformity of opinion, they may also be a subtle means of exerting pressure to eliminate all divergence of opinion prior to making any notations in the charts. d. Record review which revealed a remarkable degree of uniformity in the majority of cases." The comments set forth above with respect to Find- ings B, 1, B, 2, and B, 3, apply to Findings B, 4 and B, 5. FINDING C; Pages 9 through 11 The report states: "C. Medical Records. The process of making an entry into a medical record at Atascadero State Hospital begins with the professional staff member's initial note either being dictated on tape or written in longhand on a "C-Note" form. The original note is sent to the Section clerk for trans- cription while the carbon is maintained on the ward (a carbon of the dictated note is returned to the ward after initial transcription). The Section Clerk then files the initial note in a temporary file until enough entries have been Page 15 made to complete a typewritten page. Once the entries have been typed into the medical record, the original notes are destroyed, and a carbon copy of the page is sent to the ward to replace the several entries in the ward chart. When the notes are entered in the medical record they are submitted to the authors for their signature. At the desire of the Section Chief, at any point in this process, he may review the entries in the medical record and take one of the following actions: 1. Approve the note; 2. Request the author to change the note; 3. Request the author to delete the note; 4. Delete the note without the author's consent; 5. Enter a counter note in the chart. Upon his own initiation, the author of a note may also make changes in his note at any point during this process. One exception to this practice is the entries in the continuous nursing notes in the ward charts. In consul- tation with the Medical Record Librarian, nursing service has followed the practice of lining out any notes which are in error, rather than deleting the notes. In conjunction with the accusations regarding the practice of changing notes, the major findings are: 1. The medical records are altered by removal, omission, or replacement of staff notes containing clinical opinions. a. This practice was particularly prevalent in Section E during a recent period of several weeks when all notes Page 16 were reviewed by the Section Chief, resulting in the elimination of "conflicting or contradictory" entires. According to information received in the interviews, this same practice was used in the other Sections at the dis- cretion of the Section Chiefs. b. Changes made in the notes either by the authors or by the Section Chiefs have been both grammatical and sub- stantive. C. Both the Medical Record Librarian and the Chief Clerk disclaimed knowl- edge of these practices resulting in alteration of the records, but agreed that such practices would be inconsis- tent with acceptable standards of medical records practice. 2. Entries by professional staff into the medical records are restricted in order to conform to other opinions, particularly those of the Section Chiefs. a. Evidence obtained through interviews and review of the medical records verified that entries made by the professional staff in cited cases were restricted when they failed to conform to ward team recommendations or Section Chief evaluations. This was found primarily in Section E and was not always a uniform practice throughout the other Sections. b. Although there was evidence where divergent opinions were entered in the medical records, it was noted that most of the records revealed a considerable degree of uniformity of opinions and recommendations. Page 17 C. Staff interviewed cited the team meetings as useful in settling disagreements." It was admittedly the practice in Section E to remove, omit, or replace from the medical records some notes made by the staff. The Section Chief acknowledged that he had removed notes which he characterized as inappropriate, untruthful, contradictory, and conflicting. The interviews recorded also reflected that some other Section Chiefs have also deleted notes from the medical records. Nevertheless, the record fails to support a finding that there was a general removal, omission, or replacement of staff notes, or that there was a general restriction of entries in order to conform to other opinions. As to the finding that the Medical Record Librarian and Chief Clerk "agreed that such practices would be inconsistent with acceptable standards of medical record practice," we were unable to find any factual support in the record before us for that opinion. With reference to the factual allegations contained in No. 2 a, b, and C, the record shows that some of the staff cited team meetings as useful, while others felt restricted in the free expression of their professional opinion. Page 18 FINDINGS D and E, Pages 11, 12 and 13 The report states: "D. Medical Care: Although it had been alleged that the hospital administration had arbitrarily restricted or limited medical investigation, care, and follow-up of clinical somatic problems, there was no evidence to validate this charge. 1. There was no evidence of any deliberate or wanton denial of diagnostic and thera- peutic care of patients. 2. There was evidence in a small minority of cases of differing judgment in terms of appropriate treatment procedure. 3. There was evidence of lack of communica- tion between one ward physician and the Med/Surg. Section Chief which may have resulted in a lack of appropriate referrals for additional diagnostic laboratory procedures. The evidence appears to support the finding in D. "E. Additional Observations: 1. The medical staff, particularly the Section Chiefs, exhibited inadequacies and defi- ciencies in accepting and practicing newer concepts in psychiatric care and admini- stration. Specifically, they appeared: a. Unable to communicate effectively with and provide appropriate guidance to their subordinate staff; Page 19 b. Lacking the technical competence. necessary to function in their positions; C. Lacking confidence in their own pro- fessional ability, particularly in relationship to testifying in court; d. Unable to make creative use of conflict or divergence of opinion. 2. In some records reviewed it appeared that the hospital is not following departmental policy regarding the use of seclusion and restraints. There were instances of patients remaining in seclusion for periods as long as 14 days with no 24-hour reviews recorded in the notes. 3. The major positive impact upon the treat- ment program seemed to be provided by the nursing staff." We felt this was medical in nature and outside the scope of our review. With reference to E, it was this committee's obser- vation that it involved medical treatment and individual competence which we were not qualified to review. * STATE OF CALIFORNIA-HEALTH AND WELFARE AGENCY RONALD REAGAN, Governor DEPARTMENT OF MENTAL HYGIENE 744 P STREET CC: EM, JEJ DL, MKD, ACS, RW, SACRAMENTO 95814 HE, NH, EWT, EJG, RG, CEW, JM, WE, TC, TJ, vo, KFH. February 18, 1973 Dear Parents and Friends of the Retarded I want you to know that I share your concern for the good care of the retarded in our State facilities. In the past few days there has been some confusing publicity about the role of the State hospitals. Please be assured that the Health and Welfare Agency and the Department of Mental Hygiene have no plans for mass transfers or sudden closures. Present programs will continue while new goals and services are being planned. At a press conference this past Thursday, the Department of Mental Hygiene presented a "plan for a plan" emphasizing the orderly and gradual improvement of community-based programs. That statement committed us to local agency involvement in the planning of coordi- nated services over the next five years. All of this has been spelled out in a recent submission to the Legislature and will be printed in the next issues of the departmental newspapers that you will receive shortly. Many community and special interest groups will participate in this planning during the next five years. For the retarded persons in the state programs now, only planned changes with family involvement will occur. This administration will continue to meet its financial and legal caretaking responsibilities. All of us in health administration genuinely hope that these facts will reassure you and encourage you to work with us in giving the very best continuing care to every needy retarded person. Sincerely, William mayer,MD. William Mayer, M.D. Director of Mental Hygiene GOVERNOR'S REPLY TO A QUESTION CONCERNING THE CLOSING OF HOSPITALS FOR THE MENTALLY AND PHYSICALLY RETARDED-- Young People's Television Program, February 27, 1973 QUESTION: When the state hospitals are closed what's going to happen to all the patients? ANSWER: Well, here again these are good ones (questions) and I'm glad you're asking because we have some demonstrators here (in Sacramento) right now (February 22). Most of the demonstrators'. presence is based on a total misunderstanding of the facts. They've been fed some propaganda and there's been wild rumors running around that we're going to kick all the patients out of the hospitals. Not truel Several years ago before I became Governor, a piece of legislation was passed called the Lanterman/Petris/Short bill. This was based on a progressive, modern approach to the treatment of the mentally ill. For generations past, in our whole country, and right here in California, you had these giant so-called state hospitals. Once upon a time they called them asylums. Then everybody got self-conscious so they said, "Let's call them hospitals. " But, they were warehouses. You put the people in there because they were mentally ill and basically they never came out. There was no cure, they simply were stored away for the rest of their lives. The other day a story broke in Illinois of a woman who had been in an Illinois state hospital for 40 years. She never had any mental problem at all. She was physically crippled and when her mother died the rest of her family didn't want to take care of her, so they put her in this institution, Everybody in the institution knew that she was mentally sound and it wasn't until just a short time ago that a legal aid group found out about her case and took it to court. She is now living on a pension in an apartment, happy to be out, with no bitterness about it, but she knew all the time that she was mentally sound. The approach under this bill in California is for the state to subsidize county mental health care clinics and hospitals that are closer to the patient's home, where it is easier for the family to visit the patient, rather than having to go half way across the state to one of the big state hospitals, But even more, to treat the patients as hospital patients and, if possible, with our new modern drugs, tranquilizers, and SO forth to cure them and make them able to live a normal life, and to be a hospital in fact as well as in name. It (the law) had been passed, as I said, before I came here. But, it hadn't been really fully implemented, There was some mental health care clinics that weren't getting as full a subsidy as they should. The law called for 75 percent and they were getting, in most cases, 50 percent. We are now subsidizing the development of these clinics at 90 percent. But, no one is being shoved out of a hospital until the county itself says it's ready to take care of him and has the facilities for this care. On this basis, the patients go out and the hospitals are shrinking in population because of this. But, no one is just simply being turned out because we want to close a hospital. Now when you get down to two hospitals and one's got 700 patients and is built for 3, 000, and another one has three or four hundred (patients) and it's built for 3, 000--well, pretty soon you close one of those two and you bring these patients over to the nearest hospital. We've been doing this with the mentally ill. -2- Now we're evolving a plan for the mentally retarded, and this is even more important: To build smaller, more intimate, personalized institutions, near the centers of population and near where the patients come from, to make it easier for their parents to visit them--and this is very important in the mentally retarded cases because they need love and affection. They're retarded, but this simply means that they're like a little child. No matter how old they get physically, their minds remain at an age that can be from a one year old baby. And these are the most pitiful cases, when they get to be an adult physically, to see someone who is mentally one year's old who is as big as we are and yet who has to have the same care that you give a baby that has to be changed and all this. But, the more tragic cases are those who reach a level of, say a small child, and they have the same desire for affection and relationship that any small child has. So the whole program is aimed for the patient's sake: getting them into these personalized smaller institutions closer to home and then simply closing out the big hospitals because they're not needed. In many instances, in the areas near the cities, before the state institution is closed, we offer to local government the institution itself if they can use the facilities for perhaps their own mental health care clinics. And in some cases they do--they start by leasing part of it or taking it over from the state. But with this plan (mental health) right now, with all the concern that had been drummed up for the parents of patients, particularly in the mentally retarded area, it is tragic that some politicians try to further their own purposes and their own partisan goals by causing this distress to the family and parents of a child who is in one of these retarded homes. In the first place, no mentally retarded patient will be moved from one hospital to another without the parents' consent. The plan for change to this more localized treatment will be done with planning, and in coordination with the parents and the local communities, It has actually, so far, made California probably the foremost state in the nation, if not in the world, with regard to the care for the mentally ill. We have people coming here from all over the nation and from all over the world to look at our system and our program. And it makes you a little bitter sometimes, to find this misinformation, this assailing of this program, that is aimed at the best interests of the patient--to hear it assailed as an economy measure. The truth is mental health comes only second to education with regard to state priority. The amount of money we're spending has gone up from less than one hundred million dollars (in 1967) to almost three hundred million dollars I believe. But I know that there has been a tremendous increase in spending for this program to make this transition to this more progressive method of care, (The above was taken from a direct quote of a question and answer period that the Governor had with high school students.) gd