Re: Center for Integral Services Rio Piedras, Puerto Rico

Last year, we notified you, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, that we were initiating an investigation of conditions at the Center for Integral Services ("CIS") in Rio Piedras, Puerto Rico. From February 26-28, 1997, we conducted an investigative tour of the facility accompanied by an expert consultant in behavioral psychology and psychopharmacology. During our investigation, we toured the facility, interviewed Department of Health officials, facility administrators and staff, spoke with residents and their family members, and reviewed pertinent documents.
 

CIS is a state-operated facility serving approximately 36 men and 17 women with varying levels of developmental disabilities. This facility is one of six state-operated residential facilities serving persons with developmental disabilities in Puerto Rico. Most of the CIS clients have some ability to walk and talk and have either mild or moderate mental retardation. Most of the clients also have behavior problems, including many who are mentally ill as well as mentally retarded. There are no children in the facility (the youngest residents are twenty years old), nor are there any elderly residents (the oldest client is fifty-four years old).
 

In investigating CIS, our purpose was to evaluate whether residents were being afforded their constitutional and federal statutory rights. All residents of state-operated mental retardation facilities have a Fourteenth Amendment due process right to adequate food, clothing, shelter, medical care, reasonably safe conditions, and training. Youngberg v. Romeo, 457 U.S. 307 (1982). In addition, the Commonwealth must provide public services to individuals with disabilities that represent the most integrated setting appropriate to their needs. See, e.g., Title II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. §§ 12132 et seq.; 28 C.F.R. § 35.130(d); and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. §§ 794 et seq. and the regulations promulgated pursuant thereto. Further, the Commonwealth must provide services and programs that are readily accessible to and usable by individuals with disabilities. See 28 C.F.R. § 35.150.
 

Consistent with statutory requirements, we are now writing to inform you of the findings of our investigation of CIS. Throughout our visit, representatives from the facility and the Puerto Rico Department of Health were candid in acknowledging that many service areas at CIS are inadequate and require remedial attention. During our tour, we found numerous conditions that violate the constitutional and federal statutory rights of the CIS residents. A major cause of many of these deficiencies is that the Commonwealth has not devoted adequate resources to provide essential services and safe conditions to the CIS residents. In particular, CIS has an insufficient number of adequately trained staff across all disciplines, including doctors, nurses, therapy and activity staff, direct care staff, and maintenance workers to meet the needs of residents. The facts that support our findings of unlawful and unconstitutional conditions at CIS are set forth below along with the remedial actions that we believe are necessary to remedy these conditions.
 

As a preliminary matter, however, we would like to express our appreciation for the cooperation and courtesy shown us by Commonwealth officials and facility administrators and staff during our investigation. We especially appreciated the assistance we received from Dr. Nayda Negron, the Director of the Mental Retardation Program in the Puerto Rico Department of Health, from Ana Rivera Maldonado, the CIS Facility Director, and from Dr. Julian Irizarry, the CIS primary care physician. While we were at the facility, Dr. Negron, Ms. Rivera, and Dr. Irizarry made every effort to ensure that our team had access to whatever information we needed. We hope to be able to continue working with the Commonwealth in such a cooperative atmosphere.
 

I. CIS FAILS TO PROVIDE REASONABLE SAFETY TO RESIDENTS AND TO MEET THEIR BASIC CARE NEEDS
 

Individuals residing in a state-operated institution have a fundamental Fourteenth Amendment due process right to basic care and reasonably safe conditions of confinement. Youngberg v. Romeo, 457 U.S. 307 (1982). However, CIS fails to provide adequately for the most basic care needs of its residents and fails to provide reasonable resident safety, thereby violating the legal rights of its residents.
 

A. CIS Fails To Provide Reasonable Resident Safety
 

Throughout our investigation, we uncovered a high level of incidents, injuries and dangerous situations at CIS that have harmed residents or placed them at great risk of harm. Because of poor recordkeeping and lack of aggregate data, it was difficult to determine the exact number of incidents and injuries that occur at the facility on a day-to-day basis. Nonetheless, it was quite clear that the incidents and injuries were widespread and systemic and occurred on a daily basis. Many of these incidents, injuries and dangerous situations were preventable and reflect systemic deficiencies at CIS including lack of adequate staffing, failure to supervise residents, and inadequate assessment and treatment of mental illness, cognitive impairments, and behavior problems.
 

On our tour of CIS, we generally found a dangerous environment for the clients. We noticed many CIS residents with fresh injuries, including lacerations and bruises, as well as historical remnants of past injuries suffered at CIS, such as disfiguring scars. Many clients had suffered facial injuries or severe injuries on the back of their heads with resulting deep scars and hair loss.
 

The Facility Director, Ana Rivera, readily acknowledged a problem with ensuring client safety, including protecting residents from staff abuse and resident-on-resident aggression. For example, she told us that one CIS staff member had recently been convicted for sodomizing a client. Further, in a February 18, 1997 memorandum to Dr. Nayda Negron, Ms. Rivera expressed concern that serious incidents could occur because CIS does not have the capacity to protect vulnerable residents from other residents who are aggressive and violent.
 

As discussed in greater detail below, many of the injuries that CIS residents suffer are a result of the facility's failure to address the harmful behaviors they exhibit. Other injuries occur due to an inadequate number of staff to supervise residents and protect them from harm. The Director estimated that she does not have her full complement of three staff on both units more than half the time. She acknowledged that when this occurs, staff are not able to supervise residents, placing them at risk of harm. In fact, at least once a month, there is only one staff member working on a given unit, leaving ratios of 1:36 on the men's unit or 1:17 on the women's unit, which our consultant agreed was insufficient to provide reasonable resident safety. The Director has alerted her superiors in the Department of Health about the ongoing staffing problems on a number of occasions. For example, in memoranda dated December 2 and 16, 1996, to Dr. Negron and Auxiliary Secretary Soto, the Director requested additional direct care staff to ensure the safety of CIS residents and to provide them with needed services. Neither of these requests resulted in more staff.
 

Parents and family members of CIS also identified a number of unsafe conditions and injuries suffered by their relatives while residing at CIS. For example, one parent of a CIS client told us that his son has been subjected to physical abuse from an unknown source while at the institution. He showed us recent pictures of his son with a very swollen, bulbous, purple and black eye. The father told us that his son has suffered a host of other injuries at CIS including a broken nose, a severe knee injury, black and blue marks on his torso, an injury over his eyes, and various head injuries, some requiring sutures.
 

Another parent showed us photographs, taken in January of this year, revealing her son with serious injuries he sustained while at CIS, including a swollen black and blue right eye, a bloody left eye socket, bloody swollen lips, and a face marked with fresh lacerations. The mother reported that her son has also suffered a fractured arm, numerous lacerations, bites, broken teeth, and black and blue marks all over his body while living at CIS. She said that because her son has been injured so many times, he is now limited in the use of his hands to one index finger and thumb on each hand. She told us that before placement at CIS, her son had not suffered these types of injuries.
 

The facility generally fails to document and maintain proper records when incidents and injuries occur. Moreover, investigations of injuries at the facility are also inadequate. The few internal investigations of serious incidents that have been conducted were carried out by an overworked social worker at the facility who is not formally trained as an investigator. There are far too many "unexplained" injuries and incidents at CIS, the causes of which are never investigated or identified. In addition, there appears to be a code of silence among the CIS staff where the staff do not report abusive incidents. The Facility Director admitted that some of the unexplained injuries could be the result of staff abuse and that incident investigations are inadequate. Similarly, family members we interviewed are not satisfied with the internal investigations conducted at CIS and they have been frustrated at the facility's non-responsiveness when injuries occur.
 

In sum, CIS is a dangerous and unsafe environment for the individuals who live there. The Commonwealth has failed adequately to protect the CIS residents from harm, in violation of their constitutional rights.
 

B. CIS Often Fails To Provide Sufficient and Adequate Food, Medicine, Basic Care and Shelter To Residents
 

The Commonwealth also violates CIS residents' constitutional rights by failing to meet their most basic and essential needs for food, medicine, shelter, clothing and basic care.
 

1) Food, Medicine and Supplies
 

During our tour, we discovered that the facility runs out of food monthly and that it routinely runs out of certain critical drugs. Shortages of anti-convulsant medications are especially acute, compromising the health of the many residents with epilepsy who need such medications. As a result, the Director admitted that recently, she has been forced to buy needed drugs at the pharmacy with her own money. The Director has repeatedly reported this dire situation to the Secretary of Health to no avail. For example, in a December 10, 1996 memorandum to Dr. Negron and a December 10, 1996 memorandum to the Auxiliary Secretary of Health, Dr. Sylvette Soto Colon, the Director reported that the Center was not receiving needed food, medications and cleaning products to meet the needs of the residents and that she was forced to collect money from the staff in order to buy needed food for the clients. She sent similar memoranda expressing her difficulty in obtaining needed supplies on November 12, 1996, October 11, 1996, and June 3, 1996. Parents of CIS residents also advised us that they often have to provide the medicines their children need because CIS does not provide them.
 

2) Physical Environment
 

The physical plant of CIS is in a state of disrepair. Our expert consultant concluded that it is "grossly inadequate to meet the needs of the residents. The building and general physical environment are ... dilapidated and neglected." The paint on the cinder block walls, doors and cement floors is chipped and/or peeling. The overhead lights do not work in many of the bedrooms and the bathrooms. All of the bathrooms are neglected, dilapidated, with peeling paint, and often dirty, with moldy and mildewed tiles. Residents have to sleep on beds with old, worn mattresses that are dirty and often wet. Moreover, almost all of the toilets on the men's side of the building do not work, and many of the toilets on the women's side, do not function properly. The staff told us that in order to flush the toilets, maintenance workers must pour a bucket of water into them. As a result, on our tour, we found that virtually all of the toilets on the men's side had urine and/or feces in them, producing a health hazard and an unpleasant, malodorous environment. The Commonwealth has not devoted sufficient resources to keep the building and the physical plant in proper working order. Moreover, the CIS physical plant does not conform with ADA accessibility requirements, despite the fact that some residents must use wheelchairs for mobility.
 

In addition, offensive smells permeate the environment, residents are cramped together in small spaces with nothing to do, aggressive residents run throughout the hallways, attacking other clients, and the noise level is overpowering. Throughout our visit, we constantly heard residents' screams and groans of discomfort coming from the residents' rooms and hallways. In sum, the environment is chaotic and non-therapeutic and violates CIS residents' rights to adequate shelter.
 

3) Clothing
 

CIS fails to safeguard clients' personal possessions, particularly their own clothing. It is quite common for clients to be dressed in other residents' clothes, simply because the client's own clothes could not be located. The CIS Director and other staff readily admitted that clients' clothes often disappear. The parents we interviewed concurred that the clients' personal effects are frequently missing. More than one parent told us that they have learned that residents' clothing has been stolen. The parents have often witnessed their children in strange clothing that does not belong to them or in the same clothing for several weeks at a time. These conditions violate CIS residents' rights to be provided with adequate clothing by the Commonwealth.
 

4) Basic Care
 

The Commonwealth is violating the clients' right to basic care and services. In addition to the issues referenced above, we noticed other areas of neglect. For example, most of the clients walked around the dirty cement floors in their bare feet. Staff do not assist clients in proper grooming and hygiene and during our tour clients' appearances were generally unkempt. A parent of a CIS client reported that when she visits her son, she often finds him naked and drenched in his own stool and urine. Moreover, we noticed that the few wheelchairs that were in use at the facility were in various states of disrepair. The arm pads or sling backs were ripped and torn or the footrests were missing.
 

The staff also fail to respect the clients' right to privacy and dignity. Staff admitted to us that they routinely bathe the male clients by lining them up naked and hosing them down in groups in one particular shower stall outfitted with a garden hose. Typically, three clients are hosed down in the shower stall, three others wait naked just outside the stall, and three more are lined up naked outside the bathroom waiting to get in.
 

II. CIS FAILS TO PROVIDE ITS RESIDENTS WITH ADEQUATE PSYCHOLOGICAL AND BEHAVIORAL SERVICES AND TRAINING PROGRAMS OR WITH PROPER PSYCHIATRIC CARE AND SERVICES
 

A. Psychological and Behavioral Services and Restraints
 

Individuals residing in a state-operated institution have a fundamental Fourteenth Amendment due process right to minimally adequate or reasonable training to ensure their safety and freedom from undue restraint, prevent regression, and improve their ability to exercise their liberty interests. Youngberg v. Romeo, 457 U.S. 307 (1982). The Commonwealth is denying CIS residents their right to adequate and appropriate training and psychological services.
 

CIS does not provide residents with needed psychological assessments or behavior management programs. Our expert consultant concluded that "[t]here is absolutely no semblance of any coordinated psychological services provided to the residents" at CIS. There is no psychologist on staff to provide psychological assessments and to develop behavior management programs that comport with generally accepted practice. Our consultant concluded: "Given that a majority of the residents exhibit behavior problems and are typically not occupied for most of the day, the absence of a well-trained behavioral psychologist to provide the needed psychological services is a very serious concern. Indeed, not providing these services means that the residents are being neglected and are not assisted to live independent lives." Instead of properly treating the clients' maladaptive behaviors, CIS uses restraints and psychotropic medication.
 

There are no appropriate behavior plans to address the clients' maladaptive behaviors despite the prevalence of dangerous behaviors at the facility. Indeed, our consultant concluded that CIS staff are not employing current methods of behavioral care. For example, in a number of client rooms, it was evident that clients had kicked in wooden doors so severely that there were large gaping holes in the doors. Moreover, the staff pointed out that some clients remove floor tiles and eat the dried glue under the tiles. Rather than address these behaviors through appropriate interventions, CIS staff use inappropriate ad hoc measures. They lock the bathroom to stop one particular client from drinking from the toilet, rather than trying to teach the client not to drink from the toilet. More generally, they purposely keep personal belongings, top sheets, blankets and pillows off the beds and away from the clients during the day because they fear that the clients will use them to hurt themselves and other clients. Staff told us that a number of clients have tried to commit suicide and/or suffocate other clients with the items. In addition, residents' beds are bolted to the floor and facility staff have removed most of the doors on client bedrooms to prevent clients from hurting themselves or others. Many of the bathroom sinks have been removed because the clients have broken them. These measures are insufficient to protect CIS residents from harm because they do not address the residents' underlying behaviors.
 

CIS also does not provide residents with skills training programs to prevent regression and assist residents in functioning more independently. During our tour, we never observed any of the clients engaged in meaningful activity. Instead, the residents are left to wander around aimlessly or to sit or lay in bed, idle with nothing to do. It was quite common for us to find clients sitting on the cold, bare cement floor rocking back and forth. Some of them were crying. We also witnessed one client walking around naked and another taking off her clothes in front of others while screaming loudly. The Director acknowledged that she and her staff do not write and implement proper individual habilitation plans for the clients and serve instead as "custodians."
 

As a result of the chronic lack of appropriate psychological and behavioral programs and services, many clients deteriorate markedly while in the Commonwealth's care at CIS. Several parents told us that their children had lost the ability to walk, communicate, and take care of themselves after they were admitted to CIS. One parent told us that her son has continually deteriorated since the day she brought him to the facility approximately ten years ago. She said that her son used to be able to walk but that now he is confined to a wheelchair. Another parent also told us that his son has "deteriorated tremendously" since his transfer to CIS. Once an athletic and strong man, his son lost significant functioning in his ability to walk and speak after he was admitted to CIS.
 

In addition, CIS frequently uses restraints as a substitute for meaningful activity during the day or for appropriate programs to address maladaptive behaviors. These practices depart substantially from accepted professional standards. Because CIS does not properly record its restraint usage, it is impossible to quantify the use of restraints. However, the staff at the facility told us and showed us that to control residents they routinely use mechanical restraints, such as leather cuff belts (which are tied to the heavy metal beds around the limbs of the clients), restraint vests and straight jackets, and restraint nets.
 

The physical environment of CIS underscores the punitive nature of the facility and is unduly restrictive. Surrounding the campus of the facility, there is a high chain-link fence with barbed wire on top of it. Inside the facility, separating the main lobby and the two wings of the building, there are heavy metal doors that are clamped down and locked to confine the clients to their units. In all of the men's rooms and in many of the women's rooms, there are thick prison-like iron bars grafted on top of the windows and many of the doors, including the door at the main entrance to the facility.
 

B. Psychiatric Care and Services
 

The Commonwealth has failed to provide CIS residents with appropriate psychiatric care and services. Most of the residents are put on psychotropic medication simply to control their behaviors without appropriate psychiatric assessments, diagnoses, treatment and monitoring. Although many of the residents are both mentally retarded and mentally ill, there is no psychiatrist on staff at CIS and no psychiatrist currently visits the facility. The Director has written to her superiors detailing the problems this causes clients with mental illness. For example, in a November 21, 1995 memo to Dr. Negron, the Director requested that CIS clients be evaluated immediately by a psychiatrist and she requested that a psychiatrist be assigned to the Center. At the time of our tour, more than 15 months later, the evaluations had still not taken place and no psychiatrist had been assigned to CIS.

CIS's monitoring of psychotropic drug side effects substantially departs from generally accepted professional standards. In fact, there is no formal system in place at CIS to monitor the effects of different classes of medication. Instead, the CIS general physician simply makes visual observation of the clients and/or talks to the nurses and direct care staff in assessing whether or not side effects are present. Contrary to accepted professional standards, he utilizes no formalized rating scale to measure side effects, thereby placing the clients at undue risk of adverse side effects of psychotropic medications.
 

III. CIS FAILS TO PROVIDE ITS RESIDENTS WITH ADEQUATE HEALTH CARE
 

All residents of state-operated institutional facilities have a Fourteenth Amendment due process right to adequate health care. Youngberg v. Romeo, 457 U.S. 307 (1982). Nonetheless, CIS is failing to provide the residents with the health care and services they require. Our consultant concluded that "the medical and nursing needs of the residents are not met, and the state of care that can be provided with resources currently available to [CIS] is totally inadequate and fails to meet generally accepted practice."
 

There have been recent, chronic shortages of medicines, sutures, gauze and other needed supplies at the facility. Most notably, the shortages of anti-convulsant medications have directly and adversely affected the clients with epilepsy. CIS provided us with a list of clients who had recently suffered seizures because the facility had run out of needed anti-convulsant medications. For example, CIS resident Marcelino D. did not receive her prescribed seizure medications and had seizures on twenty-one separate days in 1996; Heriberto S. did not receive his prescribed seizure medications and had seizures on ten separate days in 1996; Jorge C. did not receive his prescribed seizure medications and had seizures on eight separate occasions; and Bernaldino de L. had seizures and did not receive his prescribed seizure medications on six separate days. The facility also provided us with an August 5, 1996 letter from the concerned mother of a CIS client who was hospitalized for seizures due to a lack of needed anti-convulsant medication at the facility. Moreover, although a number of CIS residents have epilepsy, the facility does not provide adequate access to needed services by a neurologist.
 

The CIS primary care physician does not treat CIS residents' acute illnesses and injuries on-site. Instead, he makes diagnoses, and then sends the clients off-site for treatment at a local hospital, Centro Medico. The nurses' role is similarly limited. Some clients have suffered injuries and have not been treated in a timely fashion. For example, Inovel O. suffered an injury to his arm, but was not taken to the medical center for several hours even though he needed immediate treatment. Our expert consultant concluded that medical services would improve at CIS "if the physician is able to provide the full spectrum of medical services on campus."
 

In addition to the severely limited nature of the general health and medical care provided to the residents, there is no physical therapy, occupational therapy or other forms of therapy at CIS. Dental care is also inadequate at the facility. It was evident on our tour that many clients' teeth had not been cared for in a prolonged period of time. Many had begun to lose their teeth prematurely due to neglect and injury.
 

Overall, the Commonwealth's failure to provide needed medical supplies and specialized, acute, and routine health care services to CIS residents deprives them of their constitutional right to adequate medical care.
 
 
 

IV. THE COMMONWEALTH FAILS TO ENSURE THAT CIS RESIDENTS ARE BEING SERVED IN THE MOST INTEGRATED SETTING APPROPRIATE TO THEIR NEEDS
 

The Justice Department has promulgated regulations pursuant to the ADA that require public entities to serve individuals in the most integrated setting appropriate to their needs.

28 C.F.R. § 35.130(d). Although CIS has taken steps to evaluate some residents to determine whether they could be served in community settings, it has not conducted appropriate professional evaluations of all residents. Moreover, a number of residents who have been referred for community placement remain confined at CIS because of inadequate and limited resources in the community. Our expert consultant concluded that "some of the residents are being neglected, and possibly harmed, as a result of their continued residence in the facility when they are ready for community placement." Removal from the adverse conditions of CIS would help some clients immediately. Finally, for residents who have been transferred to the community, there is no system in place to monitor the adequacy of services. Dr. Negron acknowledged that community services in Puerto Rico need to be expanded and monitored.
 

In each of the areas outlined in this letter, conditions at CIS violate the constitutional or federal statutory rights of residents. As noted earlier, many of the deficiencies result from inadequate resources. Our expert consultant concluded: "Although the Director ... and her staff are valiantly trying to provide the best services they can, they simply do not have the resources to do what is necessary to fully meet the residents' needs." For years, Dr. Negron (a former clinical services coordinator at CIS), Ms. Rivera, and the CIS Directors who preceded Ms. Rivera, have written a series of letters and memoranda to the Department of Health expressing concern about the negative impact on the care and services provided to CIS residents caused by inadequate funding. Despite this knowledge, the Commonwealth has failed to give CIS sufficient funds to provide essential items and services to its residents. Although federal funding is available through the Medicaid system to help provide adequate services at CIS and in the community, the Commonwealth does not receive this funding. In order to address the serious deficiencies outlined in this letter, we are willing to explore ways that we can assist the Commonwealth in obtaining this funding. Due to the nature of the deficiencies and their long-standing duration, we believe that it is necessary to enter into a judicially enforceable agreement to memorialize any agreement we may subsequently reach.

V. MINIMAL REMEDIAL MEASURES
 

In order to remedy these deficiencies and to protect the rights of the CIS residents, the Commonwealth should implement promptly, at a minimum, the following measures:
 

1. Safety and Basic Care
 

The Commonwealth must provide reasonable safety to all CIS residents. The Commonwealth should implement enhanced investigation procedures to ensure that all incidents are properly recorded and reviewed and that all injuries are fully investigated and underlying causes are identified and remedied. The Commonwealth must ensure that CIS residents are provided with sufficient supplies of food, medicine, equipment and staff, and that the residents receive adequate and appropriate basic care. Moreover, the Commonwealth should ensure that the CIS physical building is properly maintained in good working order, including but not limited to the timely repair of toilets and other plumbing, showers and shower stalls, light fixtures, windows, doors, walls, beds and any other furniture. Finally, the Commonwealth should safeguard all clients' personal possessions, especially their clothing, from loss and/or theft.
 

2. Psychological Services, Training Programs, and Restraints
 

The Commonwealth must provide adequate training programs and needed psychological services. In addition, the Commonwealth should provide an adequate array of comprehensive individualized training programs for CIS residents developed by qualified professionals consistent with accepted professional standards to reduce or eliminate risks to personal safety, unreasonable use of bodily restraints, prevent regression, and teach residents basic self-care skills. To this end, the Commonwealth should conduct a comprehensive interdisciplinary evaluation of each CIS resident to determine the individual's need for training and psychological services; develop and implement a professionally based, individually appropriate data collection system to measure relevant information about maladaptive behaviors; have a qualified professional develop and implement and monitor a professionally based, individualized training program for each resident; and provide each individual with an adequate number of hours of training.
 

In addition, the Commonwealth must ensure that CIS residents are not subjected to undue restraint. The Commonwealth should ensure that bodily restraints are used only pursuant to accepted professional standards, and that they are never used as punishment, in lieu of training programs, or for the convenience of staff. The Commonwealth should implement a protocol that has as its goal the elimination of routine use of physical or mechanical restraints.
 

3. Psychiatric Care
 

The Commonwealth must provide adequate and appropriate routine and emergency psychiatric and mental health services in accordance with accepted professional standards to residents who need such services. The Commonwealth should procure adequate psychiatric consult hours to meet the needs of the residents. Psychotropic medication should only be used in accordance with accepted professional standards and only where a psychiatric or neuropsychiatric diagnosis supports the need for such medication. Psychotropic medication should not be used as punishment, in lieu of a training program, for behavior control, or for the convenience of staff. The Commonwealth should conduct a comprehensive assessment of each CIS resident with mental illness, develop an appropriate diagnosis and an overall mental health treatment plan for these residents, and provide on-going monitoring of the treatment, including implementing an adequate system for detecting, reporting, and responding to any drug-induced side effects of psychotropic medication. The Commonwealth should document that, prior to using psychotropic medication for behavior modification, other, less restrictive techniques have been systematically tried as part of a training program and have been demonstrated to be ineffective.
 

4. Medical Care
 

The Commonwealth must ensure that its residents receive adequate preventive, chronic, routine, acute, and emergency medical care in accordance with generally accepted standards of care. To this end, the CIS primary care physician should conduct comprehensive evaluations of all residents, identify any needed medical services, and ensure that such services are timely obtained whenever necessary to evaluate or treat the individual's medical problems. In concert with the steps above, the Commonwealth should provide adequate and appropriate routine, chronic, and emergency seizure management to all individuals with epilepsy at CIS in accordance with accepted professional standards of care. Specifically, the Commonwealth should procure a sufficient number of neurology consult hours to meet the needs of the residents.
 

5. Nursing Care
 

The Commonwealth must ensure that its residents receive adequate nursing care. To this end, the Commonwealth should ensure that nurses perform their responsibilities in keeping with accepted professional standards of care by adequately identifying health care problems, notifying physicians of health care problems, monitoring and intervening to ameliorate such problems, and keeping appropriate records of residents' health care status.
 

6. Most Integrated Setting
 

Appropriate professionals should evaluate each CIS resident to determine whether the resident is being served in the most integrated setting appropriate to the resident's needs. Where professionals determine that a resident should be served in a more integrated setting, the Commonwealth should identify appropriate services and take reasonable steps to reallocate resources to meet the resident's needs. The Commonwealth should develop appropriate time lines for placing these residents in the community and develop and implement an adequate system to monitor the adequacy of community placements.
 

7. Recordkeeping and Staffing
 

The Commonwealth should establish and maintain adequate client records to ensure adequate and appropriate care, services and quality assurance for each resident at the facility. The Commonwealth should ensure that a sufficient number of professional and non-professional staff, including outside consultants, are employed to meet the needs of CIS residents. The Commonwealth should ensure that the staff is adequately trained to perform its duties.
 
 

We hope to be able to resolve this matter amicably and cooperatively. Nonetheless, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies at an institution or otherwise to protect the rights of its residents 49 days after receipt of this letter. 42 U.S.C. § 1997b(a)(1). Therefore, we will contact you soon to discuss any actions you may have taken or intend to take to address the deficiencies we have identified herein and to implement the remedies described above.
 

Finally, during the course of our investigation of CIS, we learned that similar conditions may exist at the five other mental retardation facilities operated by the Commonwealth: Centro de Servicios Multiples de Camaseyes in Aguadilla, Hogar de Grupo Las Mesas in Mayaguez, Facilidad de Cuidado Intermedio in Cayey, Centro de Reeducacion para Adultos in Bayamon, and Centro de Servicios Multiples Rosario Bellber in Aibonito. Pursuant to 42 U.S.C. § 1997b(a)(2), we are therefore notifying you that we are expanding our CRIPA investigation to include these facilities. We hope to conclude this investigation on an expedited basis and in the same cooperative spirit as our investigation of CIS.
 

We look forward to working with you to resolve these matters in a reasonable and practical manner. If you or your staff has any questions, please contact Richard Farano at 202-307-3116.
 

Sincerely,
 
 
 

Isabelle Katz Pinzler
Acting Assistant Attorney General
Civil Rights Division

cc: The Honorable Pedro Pierluisi
Secretary
Puerto Rico Department of Justice

The Honorable Carmen Feliciano
Secretary
Puerto Rico Health Department

Ms. Mercedes Perez Rivera
Director, Centro de Reeducacion para Adultos

Ms. Ivette Fernandez
Director, Facilidad de Cuidado Intermedio

Mr. Francisco Espada
Director, Centro de Servicios Multiples Rosario Bellber

Ms. Nilsa Curet
Director, Centro de Servicios Multiples de Camaseyes
Director, Hogar de Grupo Las Mesas

Guillermo Gil, Esquire
United States Attorney
District of Puerto Rico

Ms. Ana I. Rivera Maldonado
Director, Center for Integral Services