US. Department of Justice-

Civil Rights Division

. D C 2

U.S. v. Tennessee

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MR-TN-004-001 . . . ~ ~ w-_JJN 2 2 gf94The Honorable Ned Mc'WherterGovernorState of TennesseeState CapitolNashville, Tennessee 37243-0001

Dear -Governor McVherter:

I as writing to advise you that we intend to investigatethe clover Bottom Developmental Center, Nashville; the C-ieeneValley Developmental Center, Greeneville; and the Nat T. WinstonDevelopmental Center, 3olivar, Tennessee, to deterr-ir.e vfcetherthe constitutional and federal statutory rights ofdevelop-entaliy disabled individuals confined in these facilitiesare being denied. This investigation is pursuant to the: CivilRights of Institutionalized Persons Act, 42 U.S.C. § 19S7 et sea.

The purpose of this investigation will be to determine,ar.cr.g other things, whether adequate care, education, ar.ctraining are being afforded to residents of these facilities.As well, we will be focusing on placement issues, includingthe appropriateness of conr-.unity-based services for thedevelcpr-entally disabled individuals who are presently confinedat these institutions.

The initiation of this investigation does not indicate aprejud.gr.ent en our part that federal constitutional or statutoryrights have been violated. Additionally, if as a resuli. of ourinvestigation any violations are found, we intend to colder withappropriate state officials concerning any appropriate c:c rrectiveaction.

We plan to initiate this investigation as soon as pcssible.In that regard, attorneys fron r.y office will contact tht.Attorney General's office in the near future to arrange tours ofthese facilities by cur consultants and Civil Rights Di^:sicnpersonnel. 7'r.e attorney responsible for this r.atter is j^urie J.Weinstein, (202) 514-6408.

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Your cooperation is appreciated.

Sincerely,

Deval L. PatrickAssistant Attorr.ey General

Civil Rights Division

cc: The Honorable Charles W. BursonAttorney GeneralState of Tennessee

Mr. John ReddittSuperintendentClover 3otton Developmental Center

Kr.~ Robert ErbSuperintendentGreene Valley Developmental Center

V.z. Pete DavidsonActing SuperintendentKar T. Winston Developcental Center

John H. Roberts, EsquireUnited States Attorr.eyMiddle District of Tennessee

Veronica F. Coler.an, EsquireUnited States AttorneyWestern District of Tennessee

i U.S. Department t ustice

Civil Rights Division

Office of the Auis:ant A::cn-,ey General Washington. DC. 20530

January 10, 1995

The Honorable Ned McWherterGovernorState of TennesseeState Capitol

Nashville, Tennessee' 3721S

Re: Greene Valley Developmental Center

Dear Governor McWherter:

On June 23, 19 94, We advised you of this Department's intentto investigate conditions at the Greene Valley DevelopmentalCenter ("GVDC") in Greeneville, Tennessee, pursuant to the CivilRights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C.§ 1997, ej: sea. During the week of September 19, 19 94, we touredthe facility accompanied by consultants in the fields ofmedicine, psychology, nursing and physical therapy. We wish toexpress our appreciation for the cooperation shown by the GVDCstaff and the representatives from the Department of MentalHealth and Mental Retardation and the Attorney General's officeduring this investigation. On September 24, 1994, we conveyed tothe. facility superintendent and other state officials an initialassessment of deficiencies at the facility. Our full assessmentof conditions at GVDC has now been completed.

We regret to advise you that we found numerous conditions atGVDC that violate the constitutional and federal statutory rightsof the residents there. Under the Fourteenth Amendment andrelevant federal statutes, residents of state-operated facilitiesfor the developmentally disabled and mentally retarded have aright to, inter alia, adequate medical care, reasonably safeconditions, and training sufficient to protect each resident'sliberty interests, including training to permit each resident anopportunity to function as independently as possible. Programsmust be provided to teach adaptive skills, including self-help,communication, and social skills. In addition, individuals withdevelopmental disabilities must be provided services incommunity-based programs where appropriate. X/

Act ("ADA"), 42 U.S.C. § 12132, et sea, (and implementingregulations, 23 C.F.R. 35.130(b) (1) , and 28 C.F.R. 35.130(d)3;

(continued . .. .)

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In addition, GVDC is not in compliance with the Americanswith Disabilities Act of 1990, 42 U.S.C. § 12101, e_t sea. ,Section 504 cf the Rehabilitation Act of 1973, 29 U.S.C. § 794,et seq., the substantive provisions of Title XIX of the SocialSecurity Act, 4 2 U.S.C. § 13 35, .et. sea. , and the Individuals withDisabilities Education Act (IDEA), 20 U.S.C. §§ 1400 - 1485.

The facts disclosed during the course cf our investigationthat support our findings of unconstitutional conditions andviolations of federal statutory rights at GVDC are set forthbelow.

I. Medical Care is Dangerously Deficient.

A. General Medical Care

Due to an inadequate medical care delivery system,especially the failure to provide adequate preventive and chroniccare, GVDC residents are subjected to needless fractures,recurrent aspiration, preventable weight loss, recurringseizures, avoidable injuries, and other direct threats to theirhealth. Records of residents reviewed by our medical consultantindicate, for example, repeated fractures over many years absentpreventive measures; recurrent aspirations, dysphagia andpneumonias without a coherent management plan to treat andotherwise address these life-threatening ailments; significant,rapid weight loss representing a direct threat to health whichwas often not acknowledged or acted upon by professional staff;multiple drug use absent adequate justification; and othermisdiagnosed or untreated injuries. Significantly, the lack ofindividual or facility-wide data with respect to these urgentmedical needs of residents not only compromises the care ofindividual residents, but limits the ability of the medical staffand administration to properly allocate resources, develop plans,

1/(...continued)Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794,et sea.; Title XIX of the Social Security Act, 42 U.S.C. § 1356,et sea, (and implementing regulations, 42 C.F.R. § 483.420 -480); Younabera v. Romeo, 457 U.S. 307 (1982); United States v.Tennessee, No. 92-2062, slip op. (W.D. Tenn. Feb. 17, 1994);Halderman v. Pennhurst State School & Hospital, No. 874-134 5,slip op. (E.D. Pa. March 29, 1994); Jackson v. Fort Stanton Koso.& Training School, 757 F. Supp. 1243 (D.N.M. 1990), rev'd in parton other grounds, 964 F.2d 980 (10th Cir. 1992); Thomas S. bvBrooks v. Flaherty, 699 F. Supp. 1178 (W.D.N.C. 1988), aff'd 902F.2d 250 (4th Cir.), cert, denied, 498 U.S. 951 (1990); Clark v.Cohen. 613 F. Supp. 684 (E.D. Pa. 1985), aff'd, 794 F.2d 79 (3dCir. 1986) cert. denied, 479 U.S. 962 (1986); Gary W. v.Louisiana, 437 F. Supp. 1209 (E.D. La. 1976).

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and ensure critical tr.edical needs are met. In sum, medical carefor the most serious needs of the facility's residents isinadequate and fails to comport with generally accepted medicalstandards.

In addition, medication practices are deficient. There arenumerous residents who have been prescribed multipleanticonvulsant and/or psychotropic medications for years. Ir.view of the potential risks associated with many of thesemedications, including potential for toxicity, tardivedyskir.esia, and reduced cognition, it is generally accepted bymedical professionals that polypharmacy or the prescription ofmultiple medications should be avoided where possible. However,GVDC physicians continue to prescribe such medications absent anyrational justification in violation of medical standards.Indeed, psychotropic medications are used on a routine basis atthe facility absent adequate rationale or a psychiatric orneuropsychiatric diagnosis. The ubiquitous use of anticonvulsantand psychotropic medication also indicates inadequateconsultation with neurologists and psychiatrists. Thesepractices are unacceptable.

The absence of adequate participation of psychiatrists inthe treatment of residents is particularly significant. Forthose dually diagnosed individuals who need both behavioralprogramming and medication for their mental illness, it iscritical that both treatment modalities be integrated properly.The unavailability of adequate psychiatric consultation hasseverely impeded the ability of GVDC to address the needs ofthose residents. The inappropriate use of psychotropicmedication is a direct result of this deficiency.

Quality control, peer review, and coordination mechanismsfor medical care are virtually non-existent. The relationshipsbetween physicians and other personnel such as occupationaltherapists, physical therapists, psychologists, and nurses isill-defined. Although GVDC's policies require that physicians <order certain therapies, there is no mechanism to ensure thatthose needing the various therapies receive such orders. Medicalstaff meetings apparently take place only sporadically. There isno regular morning report among physicians and nurses, and no"on-call" or physician duty logs are regularly kept. Medicalrecords are deficient in that important reports are misfiled andcannot be located. Progress notes are illegible as well. Suchlapses in medical care delivery violate basic medical standards.

In the view of our consultants, most of these deficienciescan be attributed to the absence of adequately trained medicalprofessionals, including physicians and nurses. The currer.:physician staff is inadequately trained, organized and supervisedto provide adequate medical care. Some of the physicians havelittle training or experience in working with developmentally .

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disabled persons and few protocols have been developed to provideguidelines to the staff. For example, no protocols or proceduresare in place cr. the subjects of tracking or managing emergencies,aspirations, weight loss or gain, dysphagia, or seizures.Policies regarding the frequency-and tracking of tardivedyskinesia screenings and hepatitis vaccinations should bedeveloped. Moreover, there has been little effort to providemedical staff with continuing education. The lack of trainedmedical staff has significantly compromised medical care at GVDC.

In sum, the medical care system at GVDC is seriouslydeficient. Serious illnesses are not addressed in a timelymanner. Preventable illnesses, unnecessary injuries, and otherdebilitating conditions occur absent appropriate professionalmedical intervention.

B. Physical and Nutritional Management

Many residents at "GVDC are nutritionally at risk due tophysical disabilities or other medical problems and are notreceiving appropriate assistance and training during meals.Failure to appropriately position residents during meals can leadto aspiration, choking, reflux and other health complications.Staff who assist residents at mealtime must receive specialtraining in order to ensure residents' health and safety.Although we observed one meal at which residents were generallybeing fed appropriately, on many other occasions we observedresidents eating in poor positions and the meal plans ("redcards") that were available were often either not followed or notappropriate for the particular resident for whom the plan wasdeveloped.

C. Physical Therapy and Positioning of' PhysicallyHandicapped Residents

Physical therapy services at GVDC are seriously deficient.One physical therapist for a population of over 600 residents,many of whom have physical disabilities and a related need forphysical therapy services, does not allow the provision ofadequate and appropriate physical therapy services. In fact,only 72 residents are currently receiving such services in spiteof the large number of residents in the GVDC population whorequire such services. Ill-trained physical therapy techniciansfail to fill the void left by the lack of an adequate number ofphysical therapists.

Moreover, our physical therapy consultant identified asignificant number of dangerous practices being conducted bythose few individuals actually engaged in physical therapyactivities. For example, technicians routinely failed to takesimple precautions such as locking wheelchairs from whichresidents were transferred to a position for walking. Review of

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incident reports shows that approximately 13 percent of theinjuries reported resulted from inappropriate handling ofresidents during transfer or in use of their wheelchair. Notechnician ostensibly providing physical therapy was observedendeavoring to teach residents any skills. Technicians used thesame walker for multiple residents with broad differences in gaitand height. Indeed, deficiencies in addressing the needs ofresidents with physical disabilities, especially children, are sosevere as to represent an active threat to their health andsafety.

Appropriate positioning for residents who have multiplephysical disabilities is necessary to prevent deterioration ofresidents' skills, abilities, and health. Our physical therapyconsultant ~ade numerous observations of inadequately andimproperly positioned residents. Many residents were observed inwheelchairs which did not adequately support them. All slingseat and sling back chairs observed were inappropriate. Chairswere also not appropriately designed and constructed to managescoliosis and other spinal malalignments. Other chairs weresimply too small for the residents using them. Physicallydisabled residents not in wheelchairs were likewise observed tobe placed consistently in inappropriate positions.

Furthermore, accurate and useful documentation of anindividual's physical therapy status does not exist, making itimpossible to evaluate whether any intervention was effective,ineffective or in need of modification. In fact, many residentsreviewed were continued for years on the same programs withlittle or no progress noted, which would require a modificationor at least a re-evaluation of the therapy provided.

In sum, physical therapy services, including the positioningof residents, are so deficient as to represent a direct threat ofharm to residents.

II. Residents of GVDC Are Not Adequately Protected From Harm orthe Serious Risks of Harm Due to Lack of Supervision.

Direct care staffing is so deficient that many GVDCresidents are harmed and are at substantial risk of harm becauseof the lack of adequate numbers of competent and qualified staff.Our observations and review of documents reveal that numerousinjuries occur to residents which staff do not observe as theyhappen or do observe and fail to prevent. Residents arerepeatedly "found with blood" on them from injuries that occuroutside of staff supervision. On other occasions, residents'severe injuries are discovered only during bathing or at bedtime.In such instances, the staff report that they are unaware of thecause of the injuries. Such a high degree of unexplainedinjuries is unacceptable.

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Some residents at GVDC repeatedly engage in self-abusive andother self-injurious behavior, such as serious head slapping orgouging their wounds. For instance, one eleven year old boyapparently lest the sight in one eye from repeated headslappir.gwhich resulted in a detached retina. Other residents were notedwith swollen, disfigured features resulting from years ofself-injury. Still others had permanent scars from continualself-mutilation of their faces and arms.

Incident reports detail a variety of unexplained and seriousincidents and injuries at GVDC. Although not all accidents canbe prevented, many of. the injuries suffered by GVDC residents arepreventable products of inadequate staff supervision orintervention. 2./

Over one third of the injuries reported in incident reports-- lacerations, fractures and bruises -- result from residents'behaviors, including sejf-injury and aggression. Many of theseincident/injury reports concluded with the notation that theinjury was "unavoidable due to resident's behavior," reflectingthe facility's lack of confidence in either the residents'ability to learn alternative behaviors or in the facility'scapacity to provide appropriate supervision and training. Themost frequent recommended response to these incidents is forstaff to engage in closer supervision. Such supervision isimpossible given current staffing levels.

The number of unexplained injuries reflected in the incidentreports is particularly disturbing because staff reported thatminor injuries of unknown cause are intentionally not reported.As such, the reported injuries do not reflect the entire range ofinjuries of unknown origin. Out of a sample of ten residentsobserved during the tour as exhibiting recent notable injuries,60 percent of the residents had injuries for which no incidentreport could be located. Several other reports containeddescriptions of injuries that did not accurately reflect theinjury observed.

In sum, there is an unacceptable level of injury at GVDC.The level of injuries of unknown origin is also greatlydisturbing.

2.1 Approximately 40 percent of incident/injury reportsreviewed shewed an injury due to falls. Such injuries can bedivided into falls due to seizure activity, falls due to gait orinstability problems, particularly in cramped areas, oraggression by other residents. While some seizure-related fallsmay be difficult to prevent, GVDC is aware of residents whosegait or behavior problems contribute to their falls and should beable to prevent many more of those injuries.

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III. Programs to Reduce Maladaptive Behavior and to ProvideAdaptive Skills Are Inadequate or Non-existent, SubjectingResidents to Physical and Mental Harm.

Deficiencies in the program services at GVDC, including bothprograms designed to eliminate maladaptive and other anti-socialbehaviors as well as programs to teach residents adaptive andother skills, are significant. Indeed, the deficiencies are sosevere that the absence of necessary programs subjects residentsto harm and unreasonable risks of harm. Furthermore, services donot provide residents with the necessary skills to enhance theirindependence or promote and maintain residents' physical andmental health.

A. Psychology Staff is Inadequate to Provide NecessaryServices

GVDC currently has^ two doctoral level psychologists andeight masters level "psychological examiners." Psychologicalexaminers are responsible for yearly evaluations of residents and-the design and follow-up of individual behavior programs,including the training of direct care staff in the implementationof all programs. At present, each psychological examiner has acaseload of between 80 and 90 residents -- far too many. Inaddition, supervision of the psychological examiners by the Ph.D.psychologists is inadequate. At present, there is insufficientprofessional expertise available at GVDC to develop and implementadequate training and behavior management programs.

B. Behavior Programs Are Not Adequately Designed orImplemented to Train Residents With Maladaptive Behaviors

Significantly, many residents who need behavior programs donot have such programs. Their destructive behaviors remainunaddressed. For example, one resident had large scratches onher face that had been self-inflicted; our consultantpsychologist was informed that there was no program to modify oreliminate this unsafe behavior. Staff described the wound on theforehead of another resident as a wound that the residentfrequently re-opens; there was no program to correct thisbehavior and our consultant was advised that staff "just leave italone." An older gentleman who had a history of pica (eatingforeign objects) documented in his record dating back to 1977 wasobserved eating artificial grass and hitting his face; there isno program to correct these behaviors. The failure ofprofessional staff to develop and implement behavior programs toaddress these and other dangerous behaviors represents a cleardanger to residents, and is unacceptable.

Those behavior programs in place at GVDC, known as "goalplans," fail to comport with generally accepted professionalstandards in that they are not designed to accomplish changes in

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residents' behavior or functional ability. Few of the goal plansare accompanied by a professionally based functional analysis ofthe resident's behavior -- a necessary first step in thedevelopment of a behavior program. Absent an adequateassessment, an adequate behavior program cannot be developed.

In addition, the behavior programs at GVDC are notindividualized to meet the needs of the particular residents forwhom they have been developed. Moreover, although staff reportedthat all behavior programs and skill acquisition programs aremodified in the absence of progress, a review of recordsreflected many programs which had not been modified where noprogress had been shown for protracted periods of time. Ourconsultant also determined that the lack of reliable data or.residents' adaptive and behavioral programs seriously compromisedthe facility's training programs. Finally, direct care staffhave not been adequately trained to implement training programsor to address the self-,injurious behavior exhibited by manyresidents.

C. Adaptive Skills Training is Inadequate

Similar deficiencies also exist in the programs for thedevelopment of functional or adaptive skills. Training programsshould focus on the acquisition of functional skills across arange of settings, people, and target behaviors. Training suchas that at GVDC, which is often related to meaningless orisolated skills, does not enable the individual to acquirecontrol over his/her environment, affect the individual's qualityof life, or promote independence. Communication skills inparticular should receive much more emphasis than is currentlyprovided at GVDC and should be integrated throughout theresidents' activities. While some of the communication boardsand devices were excellent, many individuals who needed such-devices did not have them. Our observation revealed fewinstances where opportunity to work on communication skills waspresented to the residents and even where such skills were beingpresented, the training was not individualized to the residentsinvolved. For example, a staff person was attempting to teachresidents with no verbal skills the word "fork" without either apicture board or an attempt to teach a sign. Also, while atoilet training team has been developed at GVDC, many residentswho could benefit from such training do not receive it.

• •A significant factor to the ineffectiveness of theprogramming at GVDC is the utter lack of reliable data beingcollected on residents' adaptive and behavioral programs. Duringan entire week on-site at GVDC, we observed data being collectedon only two occasions. The lack of reliable data makes itimpossible to determine the efficacy of programs and forces theresidents to lose valuable training time by remaining inineffective programming.

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The inadequacies in the development and implementation ofbehavioral and other training programs at GVDC exacerbatesself-injurious behaviors, leads to needless injury, and otherwiseharms the physical and mental health of residents.

D. Individual With Disabilities Education Act (IDEA)

The school-aged children at the facility fail to receive afree and appropriate public school education as required by theIDEA and its implementing regulations. The IDEA requires thatchildren with disabilities be educated with children who arenon-disabled "to the-maximum extent appropriate." The IndividualEducation Plans (IEPs) at GVDC do not reflect the need for thechildren who are not educated in the public schools to remain atthe institution for educational services. The provision ofservices for students aged 14-21 in a local elementary school isnot an appropriate placement for those individuals. Moreover,physical therapy and other services related to the provision ofspecial education also fall far below accepted professionalpractices. Physical therapy interventions which directly relateto the goals of students' individual education plans are notintegrated into each student's classroom activities.Communication skills are not effectively addressed in currentindividualized habilitation plans (IHPs) and IEPs. Opportunitiesfor training are also limited inappropriately in that objectivesare written to require only limited trials of any particularskill. In addition, many objectives do not appear to have afunctional purpose for the individual student.

We note that most states have for many years declined toinstitutionalize children because institutional environmentsrepeatedly have been demonstrated to be harmful to the fullemotional, physical, and intellectual development ofdevelopmentally disabled children. Such harm is particularlyacute in a facility like GVDC where conditions consistently failto meet legal and professional standards.

IV. GVDC's Institutional Environment Fails to Meet the Needs ofthe Residents.

In providing care and services to individuals withdevelopmental disabilities, it is essential to furnish them withan acceptable and responsive environment that ensures safety, andpromotes learning, development, and their overall well-being.Such environments must be functional and serve to enhance thequality of life for the individuals. Currently acceptedprofessional standards require that this environment be the leastseparate, most integrated setting where the individuals needs canbe met. It must be safe, stable, and operate to teach andmaintain functional skills, to reduce or pre-empt the occurrenceof behavior problems, and otherwise promote the independent

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functioning of the individual. GVDC meets none of theserequirements.

The environment at GVDC is not fully functional for itsresidents and may be the cause of some of their problembehaviors. Ironically, it is the presence of these behaviorproblems, the regression in skills experienced by many residentsas the result of inadequate care, and the acuity of theirphysical disabilities produced by other inadequate services thatdecreases or delays the individuals' opportunity to live in andparticipate in community-based programs.

GVDC is an isolated, self-contained environment whichnecessarily separates its residents with disabilities from therest of society. As a result, the facility fails to provide itsresidents treatment in an environment that permits contacts withsociety and its mainstream social institutions, enablesindependent functioning,, and facilitates contact with familymembers. While some few residents enjoy frequent communityoutings, many others have very few opportunities to participatein community activities and still others apparently never leavethe institution at all. The State must provide these disabledresidents an opportunity to participate in or benefit from aids,benefits and services equal to that afforded to others outsidethe institution; more specifically, to those provided to otherindividuals with disabilities in the State's establishedcommunity-based programs. The residents are entitled to aids,benefits and services that are as effective in affording them theequal opportunity to obtain the same result, to gain the samebenefit, or to reach the same level of achievement as thoseserved in community-based programs. By confining residents withdisabilities at GVDC, the State has failed to provide suchservices in the least separate, most integrated setting asrequired by the Americans with Disabilities Act of 1990, 42U.S.C. § 12101, e_t sea. , and section 504 of the RehabilitationAct Of 1973, 29 U.S.C. § 794, et sea.

The cases reviewed by our consultants indicate that all, ornearly all, of GVDC residents could be successfully placed in thecommunity if provided with adequate supports. This view is notdisputed by the professionals at GVDC. Keeping individuals in aninstitution who have been determined to be capable of living inthe community cannot be justified.

V. Remedial Measures

In order to remedy these deficiencies and ensure that therights of GVDC residents are protected, the following remedialmeasures need to be implemented promptly.

a. Hire, train and deploy adequate numbers of competent andqualified medical care staff, including physicians and nurses,-to

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meet the medical needs of the residents. Provide enhancedtraining opportunities to the present physician staff to teachthem skills necessary to care for physically disabled,developmentally disabled persons. Increase the number of hoursof consulting and contract professionals, especially those forneurology and psychiatry, to a level sufficient to provideadequate care. Arrange for a physiatrist to provide regularconsultation. Ensure that enough adequately trained medicalprofessionals, including nurses and pharmacists, are employed toinstitute appropriate quality assurance mechanisms, especially tooversee the prescription, administration, and monitoring ofpsychotropic and anticonvulsant medications, and to providetimely prevention, treatment and follow-up of medical problems.

b. Provide adequate and timely medical care, includingappropriate services to meet the acute, chronic and emergencymedical care needs of residents. Ensure that physicians areimmediately available to GVDC residents at night and on weekends.Develop and implement procedures and protocols for trackingsentinel health events and managing acute and chronic illnesses.

c. Residents on psychotropic or anticonvulsant medicationsshould be evaluated to determine the appropriateness of theirprescriptions and whether these medications are being prescribedand monitored in accordance with accepted professional standards.Psychotropic medications must not be used without an adequaterationale and a psychiatric or neuropsychiatric diagnosis, nor aspunishment, in lieu of a training program for behavior control,nor for the convenience of staff. Residents must not be kept onanticonvulsant medications (or inappropriate doses of thosemedications) that serve no therapeutic purpose or are otherwisecontraindicated. The practice of using standing "PRN" orders forpotent medications such as Ativan should be discontinued.

d. Medical records must be kept in a fashion sufficient toallow medical professionals to provide adequate and timely care.Regular communication among medical staff must be established andenhanced. An adequate system must be developed for tracking andmonitoring seizure disorders, and medical staff, as well asdirect care staff, should be adequately trained in seizuremanagement.

e. GVDC must hire, deploy and train sufficient numbers ofspecialty service providers, including qualified physicaltherapists, physical therapy technicians, occupational therapistsoccupational therapy assistants, and speech pathologists, toensure that residents are provided appropriate physical andoccupational therapy, including positioning, the use of adaptivedevices, eating, and ambulation, and other functional skillstraining, including communication skills.

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f. GVDC must employ and deploy sufficient numbers ofcompetent and trained professional and direct care staff toensure residents are supervised and adequately protected frc~harm and provided appropriate training and other services.

g. All residents must be evaluated to determine theirindividual strengths and weaknesses and to develop appropriateindividualized training programs, including behavior manage~=-tand skill acquisition programs. Immediate attention must begiven to residents with self-injurious, physically abusive andother destructive behaviors by identifying them and providingnecessary training on a priority basis. All interdisciplinaryevaluations should review the individual's training needs,utilizing a written descriptive functional analysis for thoseindividuals with problem behaviors, and emphasize alternatives torestraints. Programs should address and develop appropriatestrategies to promote the physical, mental, behavioral, andsocial skills of each resident and permit each resident tofunction as independently as possible. Such programs must beconsistently implemented and procedures developed to ensureappropriate review and revision.

h. GVDC must develop and implement a professionally based,individually appropriate data collection system to measurerelevant information about problem behaviors and the conditionsunder which they occur, including, where appropriate, thefrequency, intensity, and duration of the behaviors. GVDC mustimplement an appropriate data collection system to ensure thatadaptive and functional skills training is meeting the needs ofthe resident involved. Furthermore, GVDC must review and respondto the data collected relating to either behavior programs orskill acquisition programs in a timely and appropriate manner.

i. GVDC must ensure that each school-aged resident isevaluated and provided educational services, included relatedaids and services, consistent with the requirements of IDEA.Evaluations should be coordinated with the appropriate publicschool district to ensure that each child receives educationalservices in the least restrictive, most appropriate, environmentoutside GVDC. IEPs must be suitably individualized and containfunctional objectives.

j. Immediate steps must be taken to develop and implementan overall plan to significantly reduce the size of the facilityand to place residents in appropriate, less restrictive,community-based programs. There should be an immediate ban onthe admission of children, except in emergency circumstances, andchildren should be prioritized for placement in alternate,properly supported community-based programs. In the meantime,residents should receive training to assist in their placementand transition to community-based living arrangements. Residents

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should also be adequately assessed to identify services necessaryto meet their needs in the community.

Large, congregate residential institutions have beendemonstrated to be ill-equipped to provide the care, educatior.,and training needed to promote the growth and development ofdevelopmentally disabled and mentally retarded persons. See,e.o. , Halderrr.an v. Pennhurst State School & Hospital, No. 74-1345, slip op. at 1, 4-9 (E.D. Pa. March 29, 1994). The nationaltrend is to serve these individuals in appropriate, alternativecommunity-based programs and facilities which can meet theirindividual needs. Given the gravity and scope of our experts'findings regarding the deficient care provided at GVDC, thedevelopment of more appropriate settings and services for theresidents of GVDC is necessary.

Deval L. PatrickAssistant Attorney General

Civil Rights Division

cc: The Honorable Charles W. BursonAttorney GeneralState of Tennessee

Mr. Robert Erb• SuperintendentGreene Valley Developmental Center

Carl K. Kirkpatrick, EsquireUnited States AttorneyEastern District of Tennessee